Chapter 27: Perioperative Care
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. A nurse is instructing a patient who had surgical removal of a brain tumor on how to
prevent respiratory complications from surgery. The nurse would teach the patient to:
a. turn, cough, and deep breathe.
b. use humidified oxygen.
c. turn gently from side to side.
d. use deep breathing and an incentive spirometer.
ANS: D
Coughing may be contraindicated for patients who have had hernia repair, eye, ear, or
brain surgery. This is because the act of coughing could create increased pressure in
the surgical area, which is contraindicated. Huffing or the use of an incentive
spirometer is effective for postsurgical respiratory health.
DIF: Cognitive Level: Application REF: m 750 OBJ: Clinical Practice #4
TOP: Promoting Respiratory Function KEY: Nursing Process
Step: N/A MSC: NCLEX: Physiological Integrity
2. A post-operative surgical patient asks how the sequential pneumatic compression boots
applied in the operating room will help lower the risk of blood clots forming in the legs.
The nurses most appropriate response would be that the boots:
a. measure pressure in the leg blood vessels and sound an alarm if pressure rises.
b. alternately compress and release to help blood flow through vessels.
c. provide gentle continuous compression at low pressure.
d. provide firm continuous compression at high pressure.
ANS: B
Pneumatic boots alternately compress and release to squeeze the blood vessels and
thus propel blood through the vessels back to the heart.
DIF: Cognitive Level: Comprehension REF: m 751 OBJ: Theory #10
TOP: Promoting Circulation KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
reduction of risk potential
3. A nurse is monitoring the urinary drainage from a patient who returned to the unit a few
hours ago from the post-anesthesia care unit (PACU) following a surgical procedure. The
urine total is 54 mL for the last 2 hours. The most appropriate nursing action is to:
a. increase the flow rate of the IV for 10 to 15 minutes.
b. irrigate the indwelling urinary catheter.
c. apply manual pressure to the patients bladder.
d. notify the surgeon of the findings.
ANS: D
If the urinary flow rate is lower than 60 mL for a 2-hour period, the surgeon is
notified.
DIF: Cognitive Level: Analysis REF: m 751 OBJ: Theory #10
, TOP: Inadequate urine output KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion and
Maintenance: prevention and early detection of disease
4. A patient who had surgery earlier in the day using general anesthesia asks whether he can
have something to eat. The diet order indicates clear liquids can be taken. Before giving a
Jell-O to the patient, the nurse should check for the presence of:
a. clear lung sounds.
b. adequate urinary drainage.
c. bowel sounds in all quadrants.
d. palpable peripheral pulses.
ANS: C
Before allowing a patient to eat or drink after surgery, the nurse must ensure that
bowel sounds are present in all four quadrants. This is because of the risk of paralytic
ileus (lack of return of peristalsis) after surgery.
DIF: Cognitive Level: Analysis REF: m 753 OBJ: Theory #10
TOP: Maintaining Fluid Balance KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
reduction of risk potential
5. A patient who had abdominal surgery is complaining of gas pains and has distention of
the abdomen and flatus. To promote patient comfort, the nurse should advise:
a. early ambulation.
b. turning to the left side.
c. drinking fluids that are very hot.
d. lying supine with knees flexed.
ANS: A
Ambulation is helpful in expelling gas. Taking large amounts of food or liquid at a
time, and drinking fluids that are either very hot or cold, can aggravate the symptoms.
DIF: Cognitive Level: Application REF: m 754 OBJ: Clinical Practice #5
TOP: Promoting Comfort KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity: basic care and comfort
6. A nurse preparing to get a patient out of bed for the first time since surgery will initially:
a. assist the patient to sit and dangle his or her legs on the side of the bed.
b. allow the patient to sit with the head of bed raised to the high-Fowlers position.
c. assist the patient from a supine position to a standing position.
d. place a walker at the side of the bed.
ANS: B
The first step is to raise the head of the bed and let the body adjust to the position
change. After a few minutes, the patient can be assisted to sit on the side of the bed
with his or her legs dangling (with feet on floor). Finally, the patient is assisted to a
standing position.
DIF: Cognitive Level: Application REF: m 754 OBJ: Clinical Practice #6
TOP: Rest and Activity KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity: reduction of
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. A nurse is instructing a patient who had surgical removal of a brain tumor on how to
prevent respiratory complications from surgery. The nurse would teach the patient to:
a. turn, cough, and deep breathe.
b. use humidified oxygen.
c. turn gently from side to side.
d. use deep breathing and an incentive spirometer.
ANS: D
Coughing may be contraindicated for patients who have had hernia repair, eye, ear, or
brain surgery. This is because the act of coughing could create increased pressure in
the surgical area, which is contraindicated. Huffing or the use of an incentive
spirometer is effective for postsurgical respiratory health.
DIF: Cognitive Level: Application REF: m 750 OBJ: Clinical Practice #4
TOP: Promoting Respiratory Function KEY: Nursing Process
Step: N/A MSC: NCLEX: Physiological Integrity
2. A post-operative surgical patient asks how the sequential pneumatic compression boots
applied in the operating room will help lower the risk of blood clots forming in the legs.
The nurses most appropriate response would be that the boots:
a. measure pressure in the leg blood vessels and sound an alarm if pressure rises.
b. alternately compress and release to help blood flow through vessels.
c. provide gentle continuous compression at low pressure.
d. provide firm continuous compression at high pressure.
ANS: B
Pneumatic boots alternately compress and release to squeeze the blood vessels and
thus propel blood through the vessels back to the heart.
DIF: Cognitive Level: Comprehension REF: m 751 OBJ: Theory #10
TOP: Promoting Circulation KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
reduction of risk potential
3. A nurse is monitoring the urinary drainage from a patient who returned to the unit a few
hours ago from the post-anesthesia care unit (PACU) following a surgical procedure. The
urine total is 54 mL for the last 2 hours. The most appropriate nursing action is to:
a. increase the flow rate of the IV for 10 to 15 minutes.
b. irrigate the indwelling urinary catheter.
c. apply manual pressure to the patients bladder.
d. notify the surgeon of the findings.
ANS: D
If the urinary flow rate is lower than 60 mL for a 2-hour period, the surgeon is
notified.
DIF: Cognitive Level: Analysis REF: m 751 OBJ: Theory #10
, TOP: Inadequate urine output KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion and
Maintenance: prevention and early detection of disease
4. A patient who had surgery earlier in the day using general anesthesia asks whether he can
have something to eat. The diet order indicates clear liquids can be taken. Before giving a
Jell-O to the patient, the nurse should check for the presence of:
a. clear lung sounds.
b. adequate urinary drainage.
c. bowel sounds in all quadrants.
d. palpable peripheral pulses.
ANS: C
Before allowing a patient to eat or drink after surgery, the nurse must ensure that
bowel sounds are present in all four quadrants. This is because of the risk of paralytic
ileus (lack of return of peristalsis) after surgery.
DIF: Cognitive Level: Analysis REF: m 753 OBJ: Theory #10
TOP: Maintaining Fluid Balance KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
reduction of risk potential
5. A patient who had abdominal surgery is complaining of gas pains and has distention of
the abdomen and flatus. To promote patient comfort, the nurse should advise:
a. early ambulation.
b. turning to the left side.
c. drinking fluids that are very hot.
d. lying supine with knees flexed.
ANS: A
Ambulation is helpful in expelling gas. Taking large amounts of food or liquid at a
time, and drinking fluids that are either very hot or cold, can aggravate the symptoms.
DIF: Cognitive Level: Application REF: m 754 OBJ: Clinical Practice #5
TOP: Promoting Comfort KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity: basic care and comfort
6. A nurse preparing to get a patient out of bed for the first time since surgery will initially:
a. assist the patient to sit and dangle his or her legs on the side of the bed.
b. allow the patient to sit with the head of bed raised to the high-Fowlers position.
c. assist the patient from a supine position to a standing position.
d. place a walker at the side of the bed.
ANS: B
The first step is to raise the head of the bed and let the body adjust to the position
change. After a few minutes, the patient can be assisted to sit on the side of the bed
with his or her legs dangling (with feet on floor). Finally, the patient is assisted to a
standing position.
DIF: Cognitive Level: Application REF: m 754 OBJ: Clinical Practice #6
TOP: Rest and Activity KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity: reduction of
