C HAPTER 37: C ARE OF THE S URGICAL
P ATIENT
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. The circulating nurse is responsible for:
a. preparing the sterile field.
b. assisting with sterile d raping of the patient.
c. maintaining an accurate count of sponges.
d. pointing out the observation of contamination immediatel y to the
personnel involved.
ANS: D
Any break in sterile technique in the operating room should be
immediatel y pointed out and remedi ed.
DIF: Cognitive Level: Comprehension REF: p. 748
OBJ: Theory #9 TOP: Circulating Nurse KEY: Nursing
Process Step: Planning MSC: NCLEX: Safe, Effective
Care Environment: Safet y and Infection Control
2. When the patient is ready to return from the postanesthesia care unit
(PACU), a minimal Aldrete score of ______ is an indicator that the patient
is ready to return to the floor.
, a. 2 to 4
b. 4 to 8
c. 9 to 10
d. 11 to 12
ANS: C
Using an Aldrete scoring system of activity, respiration, circulation,
consciousness, and skin color being scored from 1 to 3, a score of 9 to
10 is the minimal ready to return to the floor. indicator that the patient
is
DIF: Cognitive Level: Comprehension REF: p. 748
OBJ: Theory #10 TOP: Postanesthesia Care KEY:
Nursing Pro cess Step: Assessment MSC: NCLEX:
Physiological Integrity: Physiological Adaptation
3. A patient who has returned to the surgical nursing unit from the
postanesthesia care unit (PACU) is drowsy and requires verbal stimulation
to remain aroused. The best p osition to maintain an airway for this patient
is:
a. supine.
b. side l ying.
c. head of bed at 30 degrees with head and neck midline.
d. head of bed at 45 degrees with head and neck midline.
ANS: B
, The patient should be positioned on the side or with the head turned to
the side to prevent aspiration. Maintaining an open airway is a priorit y
measure.
DIF: Cognitive Level: Application REF: p. 751 OBJ:
Theory #10 TOP: Safet y: Airway KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion
and Maintenance: Prevention and Earl y Detection of Disease
4. The nurse is assessing the surgical dressing of a patient who arrived on
the unit an hour ago.
a. The surgical dressing has serosanguineous drainage on the dressing.
The nurse should:
b. make a note of the d rainage on the worksheet to report it at the end
of shift.
c. change the surgical dressing immediatel y to prevent infection.
d. outline the area of drainage with a pen and mark it with the date and
time.
e. reinforce the dressing with clean gauze sponges and tape.
ANS: C
The area should be outlined, dated, and timed for future reference and
comparisons.
DIF: Cognitive Level: Application REF: p. 751 OBJ:
Theory #2 TOP: Safet y: Bleeding KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrit y: Reduction of Risk
P ATIENT
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. The circulating nurse is responsible for:
a. preparing the sterile field.
b. assisting with sterile d raping of the patient.
c. maintaining an accurate count of sponges.
d. pointing out the observation of contamination immediatel y to the
personnel involved.
ANS: D
Any break in sterile technique in the operating room should be
immediatel y pointed out and remedi ed.
DIF: Cognitive Level: Comprehension REF: p. 748
OBJ: Theory #9 TOP: Circulating Nurse KEY: Nursing
Process Step: Planning MSC: NCLEX: Safe, Effective
Care Environment: Safet y and Infection Control
2. When the patient is ready to return from the postanesthesia care unit
(PACU), a minimal Aldrete score of ______ is an indicator that the patient
is ready to return to the floor.
, a. 2 to 4
b. 4 to 8
c. 9 to 10
d. 11 to 12
ANS: C
Using an Aldrete scoring system of activity, respiration, circulation,
consciousness, and skin color being scored from 1 to 3, a score of 9 to
10 is the minimal ready to return to the floor. indicator that the patient
is
DIF: Cognitive Level: Comprehension REF: p. 748
OBJ: Theory #10 TOP: Postanesthesia Care KEY:
Nursing Pro cess Step: Assessment MSC: NCLEX:
Physiological Integrity: Physiological Adaptation
3. A patient who has returned to the surgical nursing unit from the
postanesthesia care unit (PACU) is drowsy and requires verbal stimulation
to remain aroused. The best p osition to maintain an airway for this patient
is:
a. supine.
b. side l ying.
c. head of bed at 30 degrees with head and neck midline.
d. head of bed at 45 degrees with head and neck midline.
ANS: B
, The patient should be positioned on the side or with the head turned to
the side to prevent aspiration. Maintaining an open airway is a priorit y
measure.
DIF: Cognitive Level: Application REF: p. 751 OBJ:
Theory #10 TOP: Safet y: Airway KEY: Nursing Process
Step: Implementation MSC: NCLEX: Health Promotion
and Maintenance: Prevention and Earl y Detection of Disease
4. The nurse is assessing the surgical dressing of a patient who arrived on
the unit an hour ago.
a. The surgical dressing has serosanguineous drainage on the dressing.
The nurse should:
b. make a note of the d rainage on the worksheet to report it at the end
of shift.
c. change the surgical dressing immediatel y to prevent infection.
d. outline the area of drainage with a pen and mark it with the date and
time.
e. reinforce the dressing with clean gauze sponges and tape.
ANS: C
The area should be outlined, dated, and timed for future reference and
comparisons.
DIF: Cognitive Level: Application REF: p. 751 OBJ:
Theory #2 TOP: Safet y: Bleeding KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrit y: Reduction of Risk
