22. The nurse assesses a patient on the second postoperative day after abdominal
surgery to repair a perforated duodenal ulcer. Which finding is most important for the
nurse to report to the surgeon?
a. Tympanic temperature 99.2° F (37.3° C)
b. Fine crackles audible at both lung bases
c. Redness and swelling along the suture line
d. 200 mL sanguineous fluid in the wound drain
Give this one a try later!
, d. 200 mL sanguineous fluid in the wound drain
- Wound drainage should decrease and change in color from sanguineous
to serosanguineous by the second postoperative day. The color and
amount of drainage for this patient are abnormal and should be reported.
Redness and swelling along the suture line and a slightly elevated
temperature are normal signs of postoperative inflammation. Atelectasis is
common after surgery. The nurse should have the patient cough and deep
breathe, but there is no urgent need to notify the surgeon.
14. A postoperative patient has not voided for 8 hours after return to the clinical unit.
Which action should the nurse take first?
a. Perform a bladder scan.
b. Insert a straight catheter.
c. Encourage increased oral fluid intake.
d. Assist the patient to ambulate to the bathroom.
Give this one a try later!
a. Perform a bladder scan.
4. A patient who has not had any prior surgeries tells the nurse doing the
preoperative assessment about allergies to avocados and bananas. Which action is
most important for the nurse to take?
a. Notify the dietitian about the specific food allergies.
b. Alert the surgery center about a possible latex allergy.
c. Reassure the patient that all allergies are noted on the health record.
d. Ask whether the patient uses antihistamines to reduce allergic reactions.
Give this one a try later!
, b. Alert the surgery center about a possible latex allergy.
- Certain food allergies (e.g., eggs, avocados, bananas, chestnuts,
potatoes, peaches) are related to latex allergies. When a patient is allergic
to latex, special nonlatex materials are used during surgical procedures.
The staff will need to know about the allergy in advance to obtain
appropriate nonlatex materials and have them available during surgery.
The other actions also may be appropriate, but prevention of allergic
reaction during surgery is the most important action.
7. A patient scheduled to undergo total knee replacement surgery under general
anesthesia asks the nurse, "Will the doctor put me to sleep with a mask over my face?"
Which response by the nurse is most appropriate?
a. "Only your surgeon can tell you what method of anesthesia will be used."
b. "I will check with the anesthesia care provider to find out what is planned."
c. "General anesthesia is now given by injecting drugs into your veins, so you will not
need a mask over your face."
d. "Masks are no longer used for anesthesia. A tube will be inserted into your throat to
deliver gas that will put you to sleep."
Give this one a try later!
b. "I will check with the anesthesia care provider to find out what is
planned."
8. A postoperative patient has a nursing diagnosis of ineffective airway clearance. The
nurse determines that interventions for this nursing diagnosis have been successful if
which is observed?
a. Patient drinks 2 to 3 L of fluid in 24 hours.
b. Patient uses the spirometer 10 times every hour.
c. Patient's breath sounds are clear to auscultation.
d. Patient's temperature is less than 100.2°F orally.
Give this one a try later!
surgery to repair a perforated duodenal ulcer. Which finding is most important for the
nurse to report to the surgeon?
a. Tympanic temperature 99.2° F (37.3° C)
b. Fine crackles audible at both lung bases
c. Redness and swelling along the suture line
d. 200 mL sanguineous fluid in the wound drain
Give this one a try later!
, d. 200 mL sanguineous fluid in the wound drain
- Wound drainage should decrease and change in color from sanguineous
to serosanguineous by the second postoperative day. The color and
amount of drainage for this patient are abnormal and should be reported.
Redness and swelling along the suture line and a slightly elevated
temperature are normal signs of postoperative inflammation. Atelectasis is
common after surgery. The nurse should have the patient cough and deep
breathe, but there is no urgent need to notify the surgeon.
14. A postoperative patient has not voided for 8 hours after return to the clinical unit.
Which action should the nurse take first?
a. Perform a bladder scan.
b. Insert a straight catheter.
c. Encourage increased oral fluid intake.
d. Assist the patient to ambulate to the bathroom.
Give this one a try later!
a. Perform a bladder scan.
4. A patient who has not had any prior surgeries tells the nurse doing the
preoperative assessment about allergies to avocados and bananas. Which action is
most important for the nurse to take?
a. Notify the dietitian about the specific food allergies.
b. Alert the surgery center about a possible latex allergy.
c. Reassure the patient that all allergies are noted on the health record.
d. Ask whether the patient uses antihistamines to reduce allergic reactions.
Give this one a try later!
, b. Alert the surgery center about a possible latex allergy.
- Certain food allergies (e.g., eggs, avocados, bananas, chestnuts,
potatoes, peaches) are related to latex allergies. When a patient is allergic
to latex, special nonlatex materials are used during surgical procedures.
The staff will need to know about the allergy in advance to obtain
appropriate nonlatex materials and have them available during surgery.
The other actions also may be appropriate, but prevention of allergic
reaction during surgery is the most important action.
7. A patient scheduled to undergo total knee replacement surgery under general
anesthesia asks the nurse, "Will the doctor put me to sleep with a mask over my face?"
Which response by the nurse is most appropriate?
a. "Only your surgeon can tell you what method of anesthesia will be used."
b. "I will check with the anesthesia care provider to find out what is planned."
c. "General anesthesia is now given by injecting drugs into your veins, so you will not
need a mask over your face."
d. "Masks are no longer used for anesthesia. A tube will be inserted into your throat to
deliver gas that will put you to sleep."
Give this one a try later!
b. "I will check with the anesthesia care provider to find out what is
planned."
8. A postoperative patient has a nursing diagnosis of ineffective airway clearance. The
nurse determines that interventions for this nursing diagnosis have been successful if
which is observed?
a. Patient drinks 2 to 3 L of fluid in 24 hours.
b. Patient uses the spirometer 10 times every hour.
c. Patient's breath sounds are clear to auscultation.
d. Patient's temperature is less than 100.2°F orally.
Give this one a try later!
