DETAILED ANSWERS KEY FOR NUR 3401 EXAM 4
1. A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following
surgical procedures places the client at risk for deep-vein thrombosis?
A. Myringotomy
Rationale: A myringotomy is a procedure that takes about 15 min. An incision is made in the tympanic
membrane to reduce pressure and promote fluid drainage. Clients who undergo this procedure
are not at risk for deep-vein thrombosis.
B. Laparoscopic appendectomy
Rationale: Laparoscopic appendectomy is a low risk procedure. Clients who undergo this procedure are not
at risk for deep-vein thrombosis.
C. Hip arthroplasty
Rationale: Clients who are postoperative following orthopedic procedures of the lower extremities and
clients who were placed in the lithotomy position for a procedure, such as for gynecological or
urological surgeries, are at a higher risk of developing deep-vein thrombosis postoperatively.
D. Cataract extraction
Rationale: Clients who are postoperative following cataract extraction are at risk for a number of
complications, including infection and damage to the eye due to increased intraocular pressure,
but are not at risk for deep-vein thrombosis.
2. A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery
and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired
effects of medications should the nurse identify as most important for the client’s recovery?
A. It decreases the client's level of anxiety.
Rationale: The nurse should assess for and manage the client’s anxiety, as this can result in postoperative
delirium. Following the administration of an opioid medication, the nurse should assess the client
for relief of pain and apprehension. Even though opioid analgesics may decrease the client's
level of anxiety (partially from pain reduction alone), there is another effect that is more
important.
B. It facilitates the client's deep breathing.
Rationale: When using the airway, breathing, circulation approach to client care, the nurse should identify
facilitation of deep breathing as the most important desired effect of opioids aside from pain
relief. Following thoracic type surgeries, the client’s has increased pain with moving, deep
breathing and coughing. Opioid medications help minimize the discomfort experienced with
deep breathing and coughing which prevents the development of postoperative pneumonia. The
nurse should also encourage the client to splint his incision to help minimize pain.
C. It enhances the client's ability to sleep.
Rationale: The nurse should take measures to facilitate sleep in the postoperative client such as providing
quiet time that is undisturbed, dimming lights, and ensuring the client is comfortable and not in
pain. Even though opioid analgesics may increase the client’s ability to relax and sleep, another
, effect is more important.
D. It reduces the client's blood pressure.
Rationale: The nurse should closely monitor the cardiac status of the client who is postoperative. The client
who is experiencing pain releases catecholamines which produce vasoconstriction and increase
blood pressure. Even though opioid analgesics may assist in reducing a client’s blood pressure,
another effect is more important.
3. A nursing is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod
instrumentation. Which of the following interventions should the nurse include in the plan of care?
A. Keep the head of the bed at a 30° angle.
Rationale: The nurse should plan to maintain the client in a supine position to prevent bending of the spine.
B. Reposition the client by log rolling every 4 hr.
Rationale: The nurse should plan to log roll the client every 2 hr to promote respiratory status.
C. Place the client in protective isolation.
Rationale: The nurse should use standard precautions for a client who is postoperative following scoliosis
repair.
D. Initiate the use of a PCA pump for pain control.
Rationale: The nurse should initiate the use of a PCA pump for an adolescent who is postoperative
following scoliosis repair. The PCA pump allows the client to control the delivery of pain
medications.
4. A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client's consent form. The
nurse’s signature on the consent form indicates which of the following?
A. Determines the client does not have a mental illness
Rationale: Clients who have a mental illness have the right to make decisions about their health care
unless they have been found to be incompetent by a court of law.
B. Confirms the client appears competent to provide consent
Rationale: By signing as a witness on a procedural consent form, the nurse is confirming the client was the
one who signed the consent form and that he seems to be competent to give consent.
C. Asserts the nurse has explained the risks and benefits of the procedure
Rationale: It is the responsibility of the provider to explain the risks and benefits of the procedure to the
client.
D. Records that the client’s spouse agrees the procedure is necessary
Rationale:
, Although support from the client’s spouse can be a factor when the client considers surgery, the
ethical principle autonomy is a fundamental principle and it supports the client’s right to
self-determination.
5. A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy. Which of the following
actions should the nurse plan to take to prevent aspiration?
A. Place a bedside humidifier at the head of the client's bed.
Rationale: This action does not prevent aspiration.
B. Suction the nasopharynx as needed.
Rationale: This action can cause trauma to the denuded tonsil sockets, leading to hemorrhage. Although
suction equipment should always be available at the client's bedside in case of hemorrhage or
aspiration, it should only be used in an emergency and in the presence of the provider.
C. Withhold fluids until the client demonstrates a gag reflex.
Rationale: Following a tonsillectomy, the client's gag reflex can be suppressed by local anesthetics or
edema. To prevent aspiration, the gag reflex must be present before the client is allowed have
fluids.
D. Perform chest physiotherapy.
Rationale: The purpose of chest physiotherapy is to loosen secretions in the airways; it does not prevent
aspiration.
6. A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in
place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the
suction control chamber. Which of the following actions should the nurse take?
A. Continue to monitor the client as this is an expected finding.
Rationale: The expected finding would be a gentle bubbling of the water in the suction control chamber.
B. Add more water to the suction control chamber of the drainage system.
Rationale: More water should not be added to the closed system.
C. Verify that the suction regulator is on and check the tubing for leaks.
Rationale: A lack of bubbling may indicate that either the suction regulator is turned off or that there is a
leak in the tubing.
D. Milk the chest tube and dislodge any clots in the tubing that are occluding it.
Rationale: Stripping, or milking, can pull too hard on the chest cavity and may cause a tissue injury to the
lung. Stripping is only done when specifically indicated.
1. A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following
surgical procedures places the client at risk for deep-vein thrombosis?
A. Myringotomy
Rationale: A myringotomy is a procedure that takes about 15 min. An incision is made in the tympanic
membrane to reduce pressure and promote fluid drainage. Clients who undergo this procedure
are not at risk for deep-vein thrombosis.
B. Laparoscopic appendectomy
Rationale: Laparoscopic appendectomy is a low risk procedure. Clients who undergo this procedure are not
at risk for deep-vein thrombosis.
C. Hip arthroplasty
Rationale: Clients who are postoperative following orthopedic procedures of the lower extremities and
clients who were placed in the lithotomy position for a procedure, such as for gynecological or
urological surgeries, are at a higher risk of developing deep-vein thrombosis postoperatively.
D. Cataract extraction
Rationale: Clients who are postoperative following cataract extraction are at risk for a number of
complications, including infection and damage to the eye due to increased intraocular pressure,
but are not at risk for deep-vein thrombosis.
2. A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery
and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired
effects of medications should the nurse identify as most important for the client’s recovery?
A. It decreases the client's level of anxiety.
Rationale: The nurse should assess for and manage the client’s anxiety, as this can result in postoperative
delirium. Following the administration of an opioid medication, the nurse should assess the client
for relief of pain and apprehension. Even though opioid analgesics may decrease the client's
level of anxiety (partially from pain reduction alone), there is another effect that is more
important.
B. It facilitates the client's deep breathing.
Rationale: When using the airway, breathing, circulation approach to client care, the nurse should identify
facilitation of deep breathing as the most important desired effect of opioids aside from pain
relief. Following thoracic type surgeries, the client’s has increased pain with moving, deep
breathing and coughing. Opioid medications help minimize the discomfort experienced with
deep breathing and coughing which prevents the development of postoperative pneumonia. The
nurse should also encourage the client to splint his incision to help minimize pain.
C. It enhances the client's ability to sleep.
Rationale: The nurse should take measures to facilitate sleep in the postoperative client such as providing
quiet time that is undisturbed, dimming lights, and ensuring the client is comfortable and not in
pain. Even though opioid analgesics may increase the client’s ability to relax and sleep, another
, effect is more important.
D. It reduces the client's blood pressure.
Rationale: The nurse should closely monitor the cardiac status of the client who is postoperative. The client
who is experiencing pain releases catecholamines which produce vasoconstriction and increase
blood pressure. Even though opioid analgesics may assist in reducing a client’s blood pressure,
another effect is more important.
3. A nursing is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod
instrumentation. Which of the following interventions should the nurse include in the plan of care?
A. Keep the head of the bed at a 30° angle.
Rationale: The nurse should plan to maintain the client in a supine position to prevent bending of the spine.
B. Reposition the client by log rolling every 4 hr.
Rationale: The nurse should plan to log roll the client every 2 hr to promote respiratory status.
C. Place the client in protective isolation.
Rationale: The nurse should use standard precautions for a client who is postoperative following scoliosis
repair.
D. Initiate the use of a PCA pump for pain control.
Rationale: The nurse should initiate the use of a PCA pump for an adolescent who is postoperative
following scoliosis repair. The PCA pump allows the client to control the delivery of pain
medications.
4. A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client's consent form. The
nurse’s signature on the consent form indicates which of the following?
A. Determines the client does not have a mental illness
Rationale: Clients who have a mental illness have the right to make decisions about their health care
unless they have been found to be incompetent by a court of law.
B. Confirms the client appears competent to provide consent
Rationale: By signing as a witness on a procedural consent form, the nurse is confirming the client was the
one who signed the consent form and that he seems to be competent to give consent.
C. Asserts the nurse has explained the risks and benefits of the procedure
Rationale: It is the responsibility of the provider to explain the risks and benefits of the procedure to the
client.
D. Records that the client’s spouse agrees the procedure is necessary
Rationale:
, Although support from the client’s spouse can be a factor when the client considers surgery, the
ethical principle autonomy is a fundamental principle and it supports the client’s right to
self-determination.
5. A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy. Which of the following
actions should the nurse plan to take to prevent aspiration?
A. Place a bedside humidifier at the head of the client's bed.
Rationale: This action does not prevent aspiration.
B. Suction the nasopharynx as needed.
Rationale: This action can cause trauma to the denuded tonsil sockets, leading to hemorrhage. Although
suction equipment should always be available at the client's bedside in case of hemorrhage or
aspiration, it should only be used in an emergency and in the presence of the provider.
C. Withhold fluids until the client demonstrates a gag reflex.
Rationale: Following a tonsillectomy, the client's gag reflex can be suppressed by local anesthetics or
edema. To prevent aspiration, the gag reflex must be present before the client is allowed have
fluids.
D. Perform chest physiotherapy.
Rationale: The purpose of chest physiotherapy is to loosen secretions in the airways; it does not prevent
aspiration.
6. A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in
place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the
suction control chamber. Which of the following actions should the nurse take?
A. Continue to monitor the client as this is an expected finding.
Rationale: The expected finding would be a gentle bubbling of the water in the suction control chamber.
B. Add more water to the suction control chamber of the drainage system.
Rationale: More water should not be added to the closed system.
C. Verify that the suction regulator is on and check the tubing for leaks.
Rationale: A lack of bubbling may indicate that either the suction regulator is turned off or that there is a
leak in the tubing.
D. Milk the chest tube and dislodge any clots in the tubing that are occluding it.
Rationale: Stripping, or milking, can pull too hard on the chest cavity and may cause a tissue injury to the
lung. Stripping is only done when specifically indicated.
