Perioperative Nursing (Test Bank) final for 2024 with updated questions and
answers well analysed/ Perioperative Nursing (Test Bank) final for 2024 with
updated questions and answers well analysed
Accurate recording of intake and output assesses renal and circulatory function.
Measure and record all sources of intake and output. Encouraging copious
amounts of water in a postoperative patient might encourage nausea and
vomiting. In the PACU, it is impractical to weigh the patient while waking from
surgery, but in the days afterward, it is a good assessment parameter for fluid
imbalance. Starting an additional IV is not necessary and is not important at this
juncture. - CORRECT ANSWER-34. The nurse is monitoring a patient in the
postanesthesia care unit (PACU) for postoperative fluid and electrolyte
imbalance. Which action will be most appropriate for the nurse to take?
a. Encourage copious amounts of water.
b. Start an additional intravenous (IV) line.
c. Measure and record all intake and output.
d. Weigh the patient and compare with preoperative weight.
ANS: A
Depending on the surgery, some patients do not regai Accurate recording of
intake and output assesses renal and circulatory function. Measure and record
all sources of intake and output. Encouraging copious amounts of water in a
postoperative patient might encourage nausea and vomiting. In the PACU, it is
impractical to weigh the patient while waking from surgery, but in the days
afterward, it is a good assessment parameter for fluid imbalance. Starting an
additional IV is not necessary and is not important at this juncture. - CORRECT
ANSWER-34. The nurse is monitoring a patient in the postanesthesia care unit
(PACU) for postoperative fluid and electrolyte imbalance. Which action will be
most appropriate for the nurse to take?
,a. Encourage copious amounts of water.
b. Start an additional intravenous (IV) line.
c. Measure and record all intake and output.
d. Weigh the patient and compare with preoperative weight.
ANS: A
Depending on the surgery, some patients do not regain voluntary control over
urinary function for 6 to 8 hours after anesthesia. Palpate the lower abdomen
just above the symphysis pubis for bladder distention. Another option is to use a
bladder scan or ultrasound to assess bladder volume. The nurse must assess
before deciding if the patient can try again. Not everyone feels as if they need to
go but can't after surgery. Calling the health care provider is not the initial best
action. The nurse needs to have data before calling the provider. - CORRECT
ANSWER-35. The nurse is caring for a patient in the postanesthesia care unit.
The patient asks for a bedpan and states to the nurse, "I feel like I need to go to
the bathroom, but I can't." Which nursing intervention will be most appropriate
initially?
a. Assess the patient for bladder distention.
b. Encourage the patient to wait a minute and try again.
c. Inform the patient that everyone feels this way after surgery.
d. Call the health care provider to obtain an order for catheterization.
ANS: B
Before the PACU nurse leaves the acute care area, the staff nurse assuming care
for the patient takes a complete set of vital signs to compare with PACU findings.
Minor vital sign variations normally occur after transporting the patient. The
PACU nurse reviews the patient's information with the medical-surgical nurse,
including the surgical and PACU course, physician orders, and the patient's
,condition. While vital signs may or may not be the first action in a head-to-toe
assessment, this is not the rationale for this situation. While following policy or
ascertaining that the floor nurse checks on the patient are good reasons for safe
care, they are not the best rationale for obtaining vital signs. - CORRECT
ANSWER-36. The postanesthesia care unit (PACU) nurse transports the inpatient
surgical patient to the medical-surgical floor. Before leaving the floor, the
medical-surgical nurse obtains a complete set of vital signs. What is the
rationale for this nursing action?
a. This is done to complete the first action in a head-to-toe assessment.
b. This is done to compare and monitor for vital sign variation during transport.
c. This is done to ensure that the medical-surgical nurse checks on the
postoperative patient.
d. This is done to follow hospital policy and procedure for care of the surgical
patient.
ANS: B
Patients undergoing extensive surgery and requiring anesthesia of long duration
recover slowly. If a patient is undergoing major surgery such as a procedure on
the lung, a stay in the hospital and specifically in the intensive care unit is
required to monitor for potential risks to well-being. This patient would require
more care than can be provided on a medical-surgical unit. It is not appropriate
for this type of patient to go home after the procedure or to stay in an extended
stay area of an ambulatory surgery area because of the complexity and
associated risks. - CORRECT ANSWER-37. The nurse is caring for a patient who
will undergo a removal of a lung lobe. Which level of care will the patient
require immediately post procedure?
a. Acute care—medical-surgical unit
b. Acute care—intensive care unit
, c. Ambulatory surgery
d. Ambulatory surgery—extended stay
ANS: A
For patients who have had eye, intracranial, or spinal surgery, coughing may be
contraindicated because of the potential increase in intraocular or intracranial
pressure. The nurse will need to see this patient first to control the cough and
intraocular pressure. All the rest are normal postoperative patients. Leg exercise
should not be performed on the operative leg with vascular surgery. A patient
after knee surgery should receive heparin and be wearing intermittent
pneumatic compression devices; while the nurse will check on the patient, it
does not have to be first. Monitoring vital signs after surgery is required and this
is the standard schedule. - CORRECT ANSWER-38. The nurse is caring for a group
of patients. Which patient will the nurse see first?
a. A patient who had cataract surgery is coughing.
b. A patient who had vascular repair of the right leg is not doing right leg
exercises.
c. A patient after knee surgery is wearing intermittent pneumatic compression
devices and receiving heparin.
d. A patient after surgery has vital signs taken every 15 minutes twice, every 30
minutes twice, hourly for 2 hours then every 4 hours.
ANS: A
The sequence of exercises is leg exercises, turning, breathing, and coughing. -
CORRECT ANSWER-39. The nurse demonstrates postoperative exercises for a
patient. In which order will the nurse instruct the patient to perform the
exercises?
1. Turning
answers well analysed/ Perioperative Nursing (Test Bank) final for 2024 with
updated questions and answers well analysed
Accurate recording of intake and output assesses renal and circulatory function.
Measure and record all sources of intake and output. Encouraging copious
amounts of water in a postoperative patient might encourage nausea and
vomiting. In the PACU, it is impractical to weigh the patient while waking from
surgery, but in the days afterward, it is a good assessment parameter for fluid
imbalance. Starting an additional IV is not necessary and is not important at this
juncture. - CORRECT ANSWER-34. The nurse is monitoring a patient in the
postanesthesia care unit (PACU) for postoperative fluid and electrolyte
imbalance. Which action will be most appropriate for the nurse to take?
a. Encourage copious amounts of water.
b. Start an additional intravenous (IV) line.
c. Measure and record all intake and output.
d. Weigh the patient and compare with preoperative weight.
ANS: A
Depending on the surgery, some patients do not regai Accurate recording of
intake and output assesses renal and circulatory function. Measure and record
all sources of intake and output. Encouraging copious amounts of water in a
postoperative patient might encourage nausea and vomiting. In the PACU, it is
impractical to weigh the patient while waking from surgery, but in the days
afterward, it is a good assessment parameter for fluid imbalance. Starting an
additional IV is not necessary and is not important at this juncture. - CORRECT
ANSWER-34. The nurse is monitoring a patient in the postanesthesia care unit
(PACU) for postoperative fluid and electrolyte imbalance. Which action will be
most appropriate for the nurse to take?
,a. Encourage copious amounts of water.
b. Start an additional intravenous (IV) line.
c. Measure and record all intake and output.
d. Weigh the patient and compare with preoperative weight.
ANS: A
Depending on the surgery, some patients do not regain voluntary control over
urinary function for 6 to 8 hours after anesthesia. Palpate the lower abdomen
just above the symphysis pubis for bladder distention. Another option is to use a
bladder scan or ultrasound to assess bladder volume. The nurse must assess
before deciding if the patient can try again. Not everyone feels as if they need to
go but can't after surgery. Calling the health care provider is not the initial best
action. The nurse needs to have data before calling the provider. - CORRECT
ANSWER-35. The nurse is caring for a patient in the postanesthesia care unit.
The patient asks for a bedpan and states to the nurse, "I feel like I need to go to
the bathroom, but I can't." Which nursing intervention will be most appropriate
initially?
a. Assess the patient for bladder distention.
b. Encourage the patient to wait a minute and try again.
c. Inform the patient that everyone feels this way after surgery.
d. Call the health care provider to obtain an order for catheterization.
ANS: B
Before the PACU nurse leaves the acute care area, the staff nurse assuming care
for the patient takes a complete set of vital signs to compare with PACU findings.
Minor vital sign variations normally occur after transporting the patient. The
PACU nurse reviews the patient's information with the medical-surgical nurse,
including the surgical and PACU course, physician orders, and the patient's
,condition. While vital signs may or may not be the first action in a head-to-toe
assessment, this is not the rationale for this situation. While following policy or
ascertaining that the floor nurse checks on the patient are good reasons for safe
care, they are not the best rationale for obtaining vital signs. - CORRECT
ANSWER-36. The postanesthesia care unit (PACU) nurse transports the inpatient
surgical patient to the medical-surgical floor. Before leaving the floor, the
medical-surgical nurse obtains a complete set of vital signs. What is the
rationale for this nursing action?
a. This is done to complete the first action in a head-to-toe assessment.
b. This is done to compare and monitor for vital sign variation during transport.
c. This is done to ensure that the medical-surgical nurse checks on the
postoperative patient.
d. This is done to follow hospital policy and procedure for care of the surgical
patient.
ANS: B
Patients undergoing extensive surgery and requiring anesthesia of long duration
recover slowly. If a patient is undergoing major surgery such as a procedure on
the lung, a stay in the hospital and specifically in the intensive care unit is
required to monitor for potential risks to well-being. This patient would require
more care than can be provided on a medical-surgical unit. It is not appropriate
for this type of patient to go home after the procedure or to stay in an extended
stay area of an ambulatory surgery area because of the complexity and
associated risks. - CORRECT ANSWER-37. The nurse is caring for a patient who
will undergo a removal of a lung lobe. Which level of care will the patient
require immediately post procedure?
a. Acute care—medical-surgical unit
b. Acute care—intensive care unit
, c. Ambulatory surgery
d. Ambulatory surgery—extended stay
ANS: A
For patients who have had eye, intracranial, or spinal surgery, coughing may be
contraindicated because of the potential increase in intraocular or intracranial
pressure. The nurse will need to see this patient first to control the cough and
intraocular pressure. All the rest are normal postoperative patients. Leg exercise
should not be performed on the operative leg with vascular surgery. A patient
after knee surgery should receive heparin and be wearing intermittent
pneumatic compression devices; while the nurse will check on the patient, it
does not have to be first. Monitoring vital signs after surgery is required and this
is the standard schedule. - CORRECT ANSWER-38. The nurse is caring for a group
of patients. Which patient will the nurse see first?
a. A patient who had cataract surgery is coughing.
b. A patient who had vascular repair of the right leg is not doing right leg
exercises.
c. A patient after knee surgery is wearing intermittent pneumatic compression
devices and receiving heparin.
d. A patient after surgery has vital signs taken every 15 minutes twice, every 30
minutes twice, hourly for 2 hours then every 4 hours.
ANS: A
The sequence of exercises is leg exercises, turning, breathing, and coughing. -
CORRECT ANSWER-39. The nurse demonstrates postoperative exercises for a
patient. In which order will the nurse instruct the patient to perform the
exercises?
1. Turning
