Exam 1 Practice Questions: Adult 1
. Data obtained during the peri-operative nurse's assessment of a
patient in the preoperative holding area that would indicate a need
for special protection techniques during surgery include
a. a history of spinal and hip arthritis.
b. verbalization of anxiety by the patient.
✅✅-a. history of
c. a stated allergy to cats and dogs.
d. having a sip of water 2 hours previously. -
spinal and hip arthritis
(
The patient with arthritis may require special positioning to avoid
injury and postoperative discomfort. Preoperative anxiety and
having a sip of water 2 to 3 hours before surgery are not unusual
for the preoperative patient. An allergy to cats and dogs will not
impact the care needed during the intraoperative phase.)
1.The nurse from the general surgical unit is asked to bring the
patient's hearing aid to the surgical suite. The nurse will take the
hearing aid to the
a. clean core.
b. scrub sink areas.
✅✅-c. nursing station or
c. nursing station or information desk.
d. corridors of the operating room area. -
information desk
(C. The nurse from the general unit would not be wearing surgical
scrub attire or a head covering and would be restricted to the
nursing station or information desk, which are unrestricted areas.
The clean core, scrub sink area, and corridors are semi-restricted
areas and require that staff members wear surgical scrub attire and
head coverings.)
,3. A surgical patient received a volatile liquid as an inhalation
anesthetic during surgery. Postoperatively the nurse should
monitor the patient for
a. incisional pain.
b. hypertension.
✅✅-a. incisional pain
c. tachypnea.
d. myoclonia. -
(Because volatile liquid inhalation agents are rapidly metabolized,
postoperative pain occurs soon after surgery. Hypertension and
tachypnea are not associated with general anesthetics. Myoclonia
may occur with nonbarbiturate hypnotics but not with the inhaled
inhalation agents.)
A 39-yr-old woman with a history of smoking and oral contraceptive
use is admitted with a venous thromboembolism (VTE) and
prescribed unfractionated heparin. What laboratory test should the
nurse review to evaluate the expected effect of the heparin?
a. Platelet count
b. Activated clotting time (ACT)
c. International normalized ratio (INR)
d. Activated partial thromboplastin time (APTT) - ✅✅-d. Activated
partial thromboplastin time (APTT)
(Unfractionated heparin can be given by continuous IV for VTE
treatment. When given IV, heparin requires frequent laboratory
monitoring of clotting status as measured by activated partial
thromboplastin time (aPTT). Platelet counts can decrease as an
adverse reaction to heparin.)
A circulating nurse is monitoring the temperature in a surgical
suite. The nurse should identify that cool temperatures reduce a
,client's risk for which of the following potential complications of
surgery?
a. malignant hyperthermia
b. blood clots
✅✅
c. infection
d. hypoxia - -c. infection
(The nurse should identify that a cool room temperature with
humidity between 30% and 60%, along with a proper air exchange
and filtering system, reduces the risk of infection for clients during
surgery.)
A client had an open transverse colectomy 5 days ago. The nurse
enters the client's room and recognizes that the wound has
eviscerated. After covering the wound with a sterile, saline-soaked
dressing, which of the following actions should the nurse take?
a. go to the nurses' station to seek assistance
b. reinsert the organs into the abdominal cavity
✅✅
c. place the client in a reverse trendelenburg position
d. obtain vital signs to assess for shock - -d. obtain vital signs
to assess for shock
(The nurse should place the client in a supine position with hips
and knees bent and the head of the bed elevated 15° to 20°. The
nurse should make no attempt to reinsert the eviscerated contents.
The nurse should stay with a client who has experienced a wound
evisceration. The nurse should press the call light to seek
assistance)
A client is transferred from the surgical suite to the PACU following
oral surgery. While monitoring the client's vital signs, the nurse
finds that the client's tongue has become swollen and is
obstructing the airway. Which of the following actions should the
nurse take first?
, a. contact the anesthesiologist
b. assist with ET intubation
✅✅-d.
c. increase the client's flow of oxygen
d. use the head-tilt, chin-lift method to open the airway -
use the head-tilt, chin-lift method to open the airway
(The first action the nurse should take when using the airway,
breathing, circulation approach to client care is to establish a
patent airway by tilting the client's head back and pushing the
lower jaw forward.)
A nurse in the PACU is assessing a client who is postop. Which of
the following findings should the nurse report to the provider?
a. blood pressure 10% lower than the baseline
b. pain level of 4 on a 0-10 scale
✅✅-c.
c. presence of inspiratory stridor
d. small amount of sanguinous drainage on dressing -
presence of inspiratory stridor
(The nurse should report inspiratory stridor to the provider
because it is a manifestation of tracheal edema and requires
intervention.)
A nurse is assessing a client who is 2 days postop following a total
prostatectomy. The nurse notes that the client's right calf is red,
edematous, and warm to the touch. Which of the following actions
should the nurse take?
a. apply an ice pack to the client's right calf
b. elevate the client's right extremity
✅✅
c. administer testosterone to the client
d. gently massage the client's right calf - -b. elevate the
client's right extremity (These findings suggest the client has
deep-vein thrombosis. The nurse should keep the client's right
extremity elevated to promote venous return.)
. Data obtained during the peri-operative nurse's assessment of a
patient in the preoperative holding area that would indicate a need
for special protection techniques during surgery include
a. a history of spinal and hip arthritis.
b. verbalization of anxiety by the patient.
✅✅-a. history of
c. a stated allergy to cats and dogs.
d. having a sip of water 2 hours previously. -
spinal and hip arthritis
(
The patient with arthritis may require special positioning to avoid
injury and postoperative discomfort. Preoperative anxiety and
having a sip of water 2 to 3 hours before surgery are not unusual
for the preoperative patient. An allergy to cats and dogs will not
impact the care needed during the intraoperative phase.)
1.The nurse from the general surgical unit is asked to bring the
patient's hearing aid to the surgical suite. The nurse will take the
hearing aid to the
a. clean core.
b. scrub sink areas.
✅✅-c. nursing station or
c. nursing station or information desk.
d. corridors of the operating room area. -
information desk
(C. The nurse from the general unit would not be wearing surgical
scrub attire or a head covering and would be restricted to the
nursing station or information desk, which are unrestricted areas.
The clean core, scrub sink area, and corridors are semi-restricted
areas and require that staff members wear surgical scrub attire and
head coverings.)
,3. A surgical patient received a volatile liquid as an inhalation
anesthetic during surgery. Postoperatively the nurse should
monitor the patient for
a. incisional pain.
b. hypertension.
✅✅-a. incisional pain
c. tachypnea.
d. myoclonia. -
(Because volatile liquid inhalation agents are rapidly metabolized,
postoperative pain occurs soon after surgery. Hypertension and
tachypnea are not associated with general anesthetics. Myoclonia
may occur with nonbarbiturate hypnotics but not with the inhaled
inhalation agents.)
A 39-yr-old woman with a history of smoking and oral contraceptive
use is admitted with a venous thromboembolism (VTE) and
prescribed unfractionated heparin. What laboratory test should the
nurse review to evaluate the expected effect of the heparin?
a. Platelet count
b. Activated clotting time (ACT)
c. International normalized ratio (INR)
d. Activated partial thromboplastin time (APTT) - ✅✅-d. Activated
partial thromboplastin time (APTT)
(Unfractionated heparin can be given by continuous IV for VTE
treatment. When given IV, heparin requires frequent laboratory
monitoring of clotting status as measured by activated partial
thromboplastin time (aPTT). Platelet counts can decrease as an
adverse reaction to heparin.)
A circulating nurse is monitoring the temperature in a surgical
suite. The nurse should identify that cool temperatures reduce a
,client's risk for which of the following potential complications of
surgery?
a. malignant hyperthermia
b. blood clots
✅✅
c. infection
d. hypoxia - -c. infection
(The nurse should identify that a cool room temperature with
humidity between 30% and 60%, along with a proper air exchange
and filtering system, reduces the risk of infection for clients during
surgery.)
A client had an open transverse colectomy 5 days ago. The nurse
enters the client's room and recognizes that the wound has
eviscerated. After covering the wound with a sterile, saline-soaked
dressing, which of the following actions should the nurse take?
a. go to the nurses' station to seek assistance
b. reinsert the organs into the abdominal cavity
✅✅
c. place the client in a reverse trendelenburg position
d. obtain vital signs to assess for shock - -d. obtain vital signs
to assess for shock
(The nurse should place the client in a supine position with hips
and knees bent and the head of the bed elevated 15° to 20°. The
nurse should make no attempt to reinsert the eviscerated contents.
The nurse should stay with a client who has experienced a wound
evisceration. The nurse should press the call light to seek
assistance)
A client is transferred from the surgical suite to the PACU following
oral surgery. While monitoring the client's vital signs, the nurse
finds that the client's tongue has become swollen and is
obstructing the airway. Which of the following actions should the
nurse take first?
, a. contact the anesthesiologist
b. assist with ET intubation
✅✅-d.
c. increase the client's flow of oxygen
d. use the head-tilt, chin-lift method to open the airway -
use the head-tilt, chin-lift method to open the airway
(The first action the nurse should take when using the airway,
breathing, circulation approach to client care is to establish a
patent airway by tilting the client's head back and pushing the
lower jaw forward.)
A nurse in the PACU is assessing a client who is postop. Which of
the following findings should the nurse report to the provider?
a. blood pressure 10% lower than the baseline
b. pain level of 4 on a 0-10 scale
✅✅-c.
c. presence of inspiratory stridor
d. small amount of sanguinous drainage on dressing -
presence of inspiratory stridor
(The nurse should report inspiratory stridor to the provider
because it is a manifestation of tracheal edema and requires
intervention.)
A nurse is assessing a client who is 2 days postop following a total
prostatectomy. The nurse notes that the client's right calf is red,
edematous, and warm to the touch. Which of the following actions
should the nurse take?
a. apply an ice pack to the client's right calf
b. elevate the client's right extremity
✅✅
c. administer testosterone to the client
d. gently massage the client's right calf - -b. elevate the
client's right extremity (These findings suggest the client has
deep-vein thrombosis. The nurse should keep the client's right
extremity elevated to promote venous return.)
