Pre-op Nursing Assessment
A 3-year-old child is admitted into day surgery for repair of an inguinal hernia. The child begins to cry when the nurse takes her favorite blanket from her before transferring from her room to the operating room. What is the best nursing action?
a) Explain to the child the blanket will be waiting for her after surgery.
b) Have the mother hold the child and tell her she cannot take her blanket to surgery.
c) Allow the child to take the blanket until she receives the medication for anesthesia.
d) Explain to the mother why the child cannot take the
c) Allow the child to take the blanket until she receives the medication for anesthesia.
According to evidence-based practice, what is the most important nursing action in preventing infections?
a) Isolating infected infants
b) Using separate gown technique
c) Practicing standard precautions
d) Washing hands
d) Washing hands
The nurse has just reassessed the condition of a post-operative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?
a. urinary output of 20mL/hour
b. temperature of 37.6 ° C (99.6 °F).
c. Blood pressure of 100/70 mm Hg
d. Serous drainage on the surgical dressing.
a. urinary output of 20mL/hour
A client is scheduled for major surgery. What is most important for the nurse to do before surgery?
a) Remove all jewelry or tape wedding rings.
b) Verify that all laboratory work is complete.
c) Inform family or next of kin of recovery procedure.
d) Check that consent forms are signed.
d) Check that consent forms are signed
A client with diabetes is being admitted for abdominal surgery. What nursing actions would the nurse implement to promote wound healing for this client?
a) Maintain the client's blood glucose within a normal range.
b) Administer acetaminophen suppository for any temperature above 101° F.
c) Monitor the client's calorie count to validate adequate carbohydrate intake for healing.
d) Maintain a wet to dry dressing to facilitate wound granulation
a) Maintain the client's blood glucose within a normal range.
A client does not want to remove a wedding band before surgery. What is the best nursing intervention?
a) Wrap tape around it to secure it to the finger.
b) Tell the client that the surgery cannot be performed if he does not remove the ring.
c) Tell the operating room staff that the client refused to remove the ring.
d) Remind the client that the hospital will not be liable for any loss.
a) Wrap tape around it to secure it to the finger.
The clinical laboratory notifies the nurse that a client has Clostridium difficile. The nurse should: Select all that apply.
a) Move the client to a private room.
b) Move the client to a negative pressure room.
c) Use gloves and gowns.
d) Use a respirator device.
e) Have hand hygiene supplies available.
a) Move the client to a private room.
c) Use gloves and gowns.
e) Have hand hygiene supplies available.
The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?
a) increasing restlessness
b) a pulse of 86 beats/minute
c) blood pressure of 110/70 mm Hg
d) hypoactive bowel sounds in all 4 quadrants
a) increasing restlessness
The nurse is providing preoperative care for an 18-month-old child who is scheduled for a 10 am procedure. What is a priority intervention in the preoperative preparation?
a) Administer the preoperative on call medication within 1 hour of surgery.
b) Have parents confirm identification information on the child and procedure to be performed.
c) Determine from the nursing history that the client has been NPO since midnight.
d) Determine where the parents will be waiting after procedure
b) Have parents confirm identification information on the child and procedure to be performed.
The nurse is assessing a group of clients who will be having surgery. Which client would be at the highest risk for postoperative complications? The client who:
a) Has been taking birth control pills for the past 5 years
b) Has had difficulty with constipation for the past 6 months
c) Recently completed antibiotic therapy for a streptococcal throat infection
d) Has been on a daily aspirin regimen for his arthritis
d) Has been on a daily aspirin regimen for his arthritis
The preoperative teaching plan for a client scheduled for a right lower lobe (RLL) lobectomy includes deep breathing and coughing. What should the nurse teach the client regarding coughing and deep breathing?
a) "Coughing up large amounts of mucus indicates an effective cough."
b) "Practice deep breathing and coughing from a supine position."
c) "Take a deep breath, exhale through your mouth, and cough."
d) "Take several short breaths, hold the last breath, and cough."
c) "Take a deep breath, exhale through your mouth, and cough."
Infection which spreads from the bloodstream to the musculoskeletal system is known as _____________.
a) contiguous
b) transmissible
c) contagious
d) hematogenous
d) hematogenous
An important nursing responsibility related to pain is to
a. leave the patient alone to rest.
b. help the patient appear to not be in pain.
c. believe what the patient says about the pain.
d. assume responsibility for eliminating the patient's pain.
c. believe what the patient says about the pain.
A 17 year-old patient with a leg fracture who is scheduled for surgery is an emancipated minor. She has a statement from the court for verification. Which intervention is most appropriate?
a) witness the permit after consent is obtained by the surgeon
b) call a parent or legal guardian to sign the permit, since the patient is under 18.
c) obtain verbal consent, since written consent is not necessary for emancipated minors.
d) investigate your state’s nurse practice act related to emancipated minors and informed consent.
a) witness the permit after consent is obtained by the surgeon
What medication would the nurse identify as increasing a client's risk of infection?
a) Beta-blockers
b) Steroids
c) Aspirin
d) Calcium-channel blockers
b) Steroids
(Long-term steroid use depresses the immune system, making the client susceptible to infection. Aspirin may increase bleeding tendencies; beta-blockers and calcium-channel blockers may be used to treat hypertension)
A priority nursing intervention to assist a preoperative patient in coping with fear of postoperative pain would be to
a) inform the patient that pain medication will be available.
b) teach the patient to use guided imagery to help manage pain.
c) describe the type of pain expected with the patient's particular surgery.
d) explain the pain management plan, including the use of a pain rating scale.
d) explain the pain management plan, including the use of a pain rating scale
When should the nurse wash hands with soap and water?
a) Before preparing medications
b) After removing gloves
c) Before entering a client's room
d) When hands are visibly soiled
d) When hands are visibly soiled
A patient is receiving a PCA infusion after surgery to repair a hip fracture. She is sleeping soundly but awakens when the nurse speaks to her in a normal tone of voice. Her respirations are 8 breaths/minute. The most appropriate nursing action in this situation is to
a. stop the PCA infusion.
b. obtain an oxygen saturation level.
c. continue to closely monitor the patient.
d. administer naloxone and contact the physician.
b. obtain an oxygen saturation level.
A client with gastric ulcer is scheduled for surgery. The client can not sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?
a) obtain a court order for the surgery
b) have the charge nurse sign the informed consent immediately
c) sent the client to surgery without the consent form being signed
d) obtain a telephone consent from a family member following agency policy
d) obtain a telephone consent from a family member following agency policy
While discussing a client's scheduled surgery, the nurse notices the client wringing her hands, moving around in her seat, and breathing rapidly. The nurse does a physical assessment and finds a rapid pulse of 128 beats/min with moist, clammy skin. The client states, "I'm so nervous." Which PRN order should the nurse consider administering to the client?
a) Promethazine hydrochloride (Phenergan) 25 mg
b) Lorazepam (Ativan) 0.5 to 1 mg
c) Naproxen (Aleve) 275 mg
d) Cefadroxil (Duricef) 500 mg
b) Lorazepam (Ativan) 0.5 to 1 m