still be able to have children

https://quizlet.com/426983790/preoperative-nursing-management-n
clex-flash-cards/ 5. The nurse is planning patient teaching for a patient who is
scheduled for an open hemicolectomy. The nurse intends to address
the topics of incision splinting and leg exercises during this teaching
1. A patient is admitted to the ED complaining of severe abdominal session. When is the best time for the nurse to provide teaching?
pain, stating that he has been vomiting coffee-ground-like emesis. The
patient is diagnosed with a perforated gastric ulcer and is scheduled
for surgery. When can the patient most likely anticipate that the ● A) Upon the patient’s admission to the post-anesthesia care
surgery will be scheduled? unit (PACU)
Rationale: The PACU is not an ideal time for patient teaching, as the
patient will still be under the effects of anesthesia and may not be
● A) Within 24 hours fully conscious or alert.
Rationale: A perforated gastric ulcer is a medical emergency due to ● B) When the patient returns from the PACU
the risk of infection (peritonitis) and bleeding. Surgery typically Rationale: After returning from the PACU, the patient is likely still
occurs within 24 hours to manage this life-threatening condition. groggy and might not be able to focus well on instructions.
● B) Within the next week ● C) During the intraoperative period
Rationale: This option is incorrect because waiting this long Rationale: Teaching during surgery is not practical since the patient
increases the risk of complications. is under anesthesia.
● C) Only after the bleed is emergent ● D) As soon as possible before the surgical procedure
Rationale: This statement is misleading. The perforation already Rationale: Preoperative teaching should be done as soon as possible
indicates an emergency that requires immediate surgery. before the procedure while the patient is awake, calm, and can fully
● D) As soon as the day's elective surgeries have been understand and retain the information. This helps in post-surgery
completed recovery, such as incision splinting and leg exercises.
Rationale: Elective surgeries are typically postponed in favor of
emergency cases like this.
Correct Answer: D) As soon as possible before the surgical procedure

Correct Answer: A) Within 24 hours

6. The nurse is caring for a hospice patient who is scheduled for a
surgical procedure to reduce the size of his spinal tumor in an effort
2. The nurse is performing a preoperative assessment on a client who to relieve his pain. The nurse should plan this patient care with the
is going to surgery. The patient informs the nurse that he has drunk knowledge that his surgical procedure is classified as which of the
approximately three martinis daily for the last several years. What following?
postoperative difficulties can the nurse anticipate for this client?

● A) Diagnostic
● A) Alcohol withdrawal syndrome upon administration of Rationale: This procedure is not diagnostic; it is intended to
general anesthesia alleviate pain, not to diagnose a condition.
Rationale: Chronic alcohol consumption can lead to alcohol ● B) Laparoscopic
withdrawal symptoms postoperatively, especially when the intake has Rationale: Laparoscopic refers to a minimally invasive technique
been regular and substantial over several years. used for surgeries on certain organs, but it does not apply here.
● B) Alcohol withdrawal syndrome upon administration of ● C) Curative
spinal anesthesia Rationale: A curative procedure is done to completely remove or
Rationale: This option is less likely because spinal anesthesia cure the underlying condition. This procedure is not curative since it
doesn't affect systemic alcohol withdrawal responses as much as doesn’t remove the tumor entirely but rather alleviates symptoms.
general anesthesia. ● D) Palliative
● C) No complications if the patient agrees to avoid alcohol Rationale: Palliative surgery is aimed at relieving symptoms and
after surgery improving quality of life without curing the disease. Since the goal is
Rationale: This is incorrect because alcohol withdrawal symptoms to reduce the size of the tumor to relieve pain, this is a palliative
can occur even if the patient agrees to abstain after surgery. The procedure.
withdrawal process can happen regardless.
● D) No complications if the patient is permitted an
occasional drink after surgery Correct Answer: D) Palliative
Rationale: Allowing alcohol postoperatively may not be appropriate
or safe.
7. A nurse is providing preoperative teaching to a patient who will
soon undergo a cardiac bypass. The nurse’s teaching plan includes
Correct Answer: A) Alcohol withdrawal syndrome upon exercises of the extremities. What is the purpose of teaching a patient
administration of general anesthesia leg exercises prior to surgery?

3. Immediately after a patient's scheduled surgery, the nurse is ● A) Leg exercises increase the patient’s muscle mass
teaching her to perform deep breathing and coughing exercises. postoperatively.
Which of the following is most accurate? Rationale: While leg exercises may have other benefits, increasing
muscle mass is not the primary goal of preoperative exercises.
● B) Leg exercises help circulation and prevent venous
● A) The patient should take deep breaths and cough three thrombosis.
times, at least every 15 minutes for the first postoperative Rationale: The main purpose of teaching leg exercises is to prevent
day venous stasis and the formation of blood clots (deep vein thrombosis
Rationale: This provides a frequency for encouraging lung or DVT), which can occur postoperatively due to immobility.
expansion and preventing complications like pneumonia. ● C) Leg exercises prevent pressure sores to the sacrum and
● B) The patient should breathe in through the mouth, exhale heels.
carefully and then cough three times Rationale: While exercises can help with mobility and reduce
Rationale: While this suggests some structure, it is not the best pressure, preventing pressure sores is not their primary purpose in
method for maximizing lung expansion. this context.
● C) The patient should take three deep breaths through the ● D) Leg exercise helps increase the patient’s level of
nose and exhale through the mouth, take a fourth deep consciousness after surgery.
breath, and cough forcefully Rationale: Leg exercises do not have a direct effect on consciousness
Rationale: This is the correct technique for preventing respiratory levels post-surgery.
complications like atelectasis and promoting lung clearance
postoperatively.
● D) The patient should slowly inhale, hold for 30 seconds or Correct Answer: B) Leg exercises help circulation and prevent venous
as long as possible, and exhale slowly thrombosis
Rationale: This method may not be practical and doesn’t align with
the typical practice of deep breathing and coughing to mobilize
8. During the care of a preoperative patient, the nurse has given the
secretions.
patient a preoperative benzodiazepine. The patient is now requesting
to void. What action should the nurse take?
Correct Answer: C) The patient should take three deep breaths
through the nose and exhale through the mouth, take a fourth deep
● A) Assist the patient to the bathroom.
breath, and cough forcefully
Rationale: Assisting the patient to the bathroom may pose a fall risk
if the sedative has taken effect.
4. The nurse is preparing a patient for surgery prior to her ● B) Offer the patient a bedpan or urinal.
hysterectomy without oophorectomy. The nurse has instructed the Rationale: This is the safest option because the patient has received
patient to sign a consent form. Which comment by the patient would sedation and may not be fully steady or aware, so offering a bedpan or
best indicate the need for more preoperative teaching? urinal minimizes the risk of falls.
● C) Wait until the patient gets to the operating room and is
catheterized.
● A) I know I’ll be fine because the physician said he has done Rationale: It is not recommended to wait, as the patient may be
this procedure hundreds of times. uncomfortable or unable to void later due to the effects of anesthesia.
Rationale: This reflects a sense of trust, but it does not reveal an ● D) Have the patient go to the bathroom.
understanding of the procedure, indicating the need for clarification. Rationale: This is not safe due to the sedative effects of the
● B) I’ll be fine after the surgery because they aren’t taking benzodiazepine, which may impair the patient's ability to walk safely.
my ovaries.
Rationale: This is incorrect because even with the ovaries left intact,
there can be significant hormonal changes or effects on reproductive Correct Answer: B) Offer the patient a bedpan or urinal
health. It indicates a misunderstanding of the surgery.
● C) I’ll have a large abdominal incision, but it will heal
9. The nurse is preparing a patient for surgery. The patient states that
eventually.
she is very nervous and really does not understand what the surgical
Rationale: This indicates an understanding of the surgical approach
procedure is for or how it will be performed. What is the most
and post-op healing.
appropriate nursing action for the nurse to take?
● D) Because the physician isn’t taking my ovaries, I’ll still be
able to have children.
Rationale: This is incorrect because a hysterectomy involves the ● A) Have the patient sign the informed consent and place it
removal of the uterus, so the patient would no longer be able to carry in the chart.
a pregnancy, even if the ovaries are left intact. Rationale: This is inappropriate, as informed consent should only
be signed when the patient fully understands the procedure.
● B) Call the physician to review the procedure with the
Correct Answer: D) Because the physician isn’t taking my ovaries, I’ll
 patient. Correct Answer: A) Instruct the patient to stop taking St. John’s wort
Rationale: It is the physician's responsibility to explain the surgical at least 2 weeks prior to surgery due to its interaction with anesthetic
procedure thoroughly to the patient to ensure informed consent. agents
● C) Explain the procedure clearly to the patient and her
family.
Rationale: Although nurses play an essential role in patient
education, the physician is responsible for explaining the surgical
procedure. 3. The nurse is creating the care plan for a 70-year-old obese patient
● D) Provide the patient with a pamphlet explaining the who has been admitted to the postsurgical unit following a colon
procedure. resection. This patient’s age and increased body mass index mean that
Rationale: This may help with understanding, but it is not sufficient she is at increased risk for what complication in the postoperative
in addressing the patient's immediate concerns about the surgery. period?

Correct Answer: B) Call the physician to review the procedure with ● A) Hyperglycemia
the patient Rationale: Hyperglycemia can occur, especially if the patient has
diabetes or steroid use. However, the primary concern in older, obese
patients is wound healing and infection risk.
10. The nurse is caring for a patient who is admitted to the ER with
● B) Azotemia
the diagnosis of acute appendicitis. The nurse notes during the
Rationale: Azotemia (elevated urea in the blood) is usually
assessment that the patient's ribs and xiphoid process are prominent.
associated with kidney dysfunction, which is not directly related to
The patient states she exercises two to three times daily and her
the patient’s condition.
mother indicates that she is being treated for anorexia nervosa. How
● C) Falls
should the nurse best follow up these assessment data?
Rationale: While falls are a concern in elderly patients, the primary
risk factor related to obesity and surgery is infection, particularly
● A) Inform the postoperative team about the patient’s risk wound infections.
for wound dehiscence. ● D) Infection
Rationale: While malnutrition could increase the risk for wound Rationale: Obese patients are at higher risk for postoperative
dehiscence, this is not the primary concern at this point. infections due to the increased difficulty in wound healing and higher
● B) Evaluate the patient’s ability to manage her pain level. rates of complications like dehiscence.
Rationale: Pain management is important, but given the additional
history of anorexia nervosa, other issues may take priority.
Correct Answer: D) Infection
● C) Facilitate a detailed analysis of the patient’s electrolyte
levels.
Rationale: Anorexia nervosa often leads to imbalances in
electrolytes, which could complicate surgery and anesthesia.
Monitoring electrolyte levels is crucial in managing patients with this
condition. 4. The nurse is admitting a patient who is insulin-dependent to the
● D) Instruct the patient on the need for a high-sodium diet to same-day surgical suite for carpal tunnel surgery. How should this
promote healing. patient’s diagnosis of type 1 diabetes affect the care that the nurse
Rationale: This is not appropriate without first assessing the plans?
patient's electrolyte balance and nutritional status.
● A) The nurse should administer a bolus of dextrose IV
Correct Answer: C) Facilitate a detailed analysis of the patient’s solution preoperatively.
electrolyte levels Rationale: Administering a dextrose bolus is inappropriate unless
the patient is hypoglycemic. Blood glucose needs to be carefully
monitored to avoid hyperglycemia or hypoglycemia.
1. The nurse is doing preoperative patient education with a ● B) The nurse should keep the patient NPO for at least 8
61-year-old male patient who has a 40-pack-per-year history of hours preoperatively.
cigarette smoking. The patient will undergo an elective bunionectomy Rationale: NPO is necessary to reduce the risk of aspiration during
at a time that fits his work schedule in a few months. What would be anesthesia, but diabetes management requires monitoring of glucose,
the best instruction to give to this patient? not just prolonged fasting.
● C) The nurse should initiate a subcutaneous infusion of
long-acting insulin.
● A) Reduce smoking by 50% to prevent the development of
Rationale: Long-acting insulin may be continued based on the
pneumonia.
physician's orders, but careful monitoring of blood glucose levels
Rationale: While reducing smoking might be beneficial, it does not
preoperatively is more essential.
fully address the risks associated with smoking prior to surgery.
● D) The nurse should assess the patient’s blood glucose
Pneumonia prevention requires complete cessation to allow the lungs
levels vigilantly.
to heal and function properly.
Rationale: Patients with type 1 diabetes are at risk for both
● B) Stop smoking at least 6 weeks before the scheduled
hyperglycemia and hypoglycemia, so close monitoring of blood
surgery to enhance pulmonary function and decrease
glucose levels is essential before and after surgery.
infection.
Rationale: This option is on the right track, as stopping smoking in
advance helps improve pulmonary function and reduces the risk of Correct Answer: D) The nurse should assess the patient’s blood
postoperative complications like pneumonia or infection, but the glucose levels vigilantly
6-week guideline isn't the most widely recommended duration.
● C) Aim to quit smoking in the postoperative period to
reduce the chance of surgical complications.
Rationale: Quitting smoking postoperatively may reduce
complications, but it is more beneficial for the patient to stop 5. The nurse is checking the informed consent for a 17-year-old who
smoking before surgery to enhance pulmonary function and reduce has just been married and is expecting her first child. She is
perioperative risks. scheduled for a cesarean section. She is still living with her parents
● D) Stop smoking 4 to 8 weeks before the scheduled surgery and is on her parent’s health insurance. When obtaining informed
to enhance pulmonary function and decrease infection. consent for the cesarean section, who is legally responsible for
Rationale: Smoking cessation 4 to 8 weeks before surgery is the signing?
most widely recommended guideline. This timeframe allows for
significant improvements in pulmonary function, reduction in
postoperative complications (such as infection), and overall better ● A) Her parents
recovery. Rationale: The patient is legally considered emancipated due to her
marriage and pregnancy, and therefore, her parents do not need to
sign.
Correct Answer: D) Stop smoking 4 to 8 weeks before the scheduled ● B) Her husband
surgery to enhance pulmonary function and decrease infection Rationale: The husband does not have legal responsibility for
signing the consent. The patient, as an emancipated minor, has the
legal right to make her own medical decisions.
● C) The patient
Rationale: Since the patient is married and pregnant, she is
2. You are providing preoperative teaching to a patient scheduled for considered legally emancipated and is responsible for signing her own
hip replacement surgery in 1 month. During the preoperative consent for the procedure.
teaching, the patient gives you a list of medications she takes, the ● D) The obstetrician
dosage, and frequency. Which of the following interventions provides Rationale: The obstetrician’s role is to provide information and
the patient with the most accurate information? obtain consent, not to sign on behalf of the patient.

● A) Instruct the patient to stop taking St. John’s wort at least Correct Answer: C) The patient
2 weeks prior to surgery due to its interaction with
anesthetic agents.
Rationale: St. John’s wort can interfere with anesthesia and prolong 16. The nurse is providing preoperative teaching to a patient
its effects, so stopping this supplement before surgery is scheduled for surgery. The nurse is instructing the patient on the use
recommended. of deep breathing, coughing, and incentive spirometry. What
● B) Instruct the patient to continue taking ephedrine prior to rationale for these instructions should the nurse provide?
surgery due to its beneficial effect on blood pressure.
Rationale: Ephedrine can increase blood pressure and heart rate, ● A) To prevent chronic obstructive pulmonary disease
which may cause complications during surgery. It is typically (COPD)
discontinued before surgery. Rationale: COPD prevention is not a reason for teaching these
● C) Instruct the patient to discontinue Synthroid due to its exercises.
effect on blood coagulation and the potential for heart ● B) To promote optimal lung expansion
dysrhythmias. Rationale: Deep breathing, coughing, and using an incentive
Rationale: Synthroid (levothyroxine) is a thyroid replacement spirometer help prevent atelectasis (collapsed lung) and promote
hormone and is usually continued perioperatively because it does not lung expansion.
affect blood coagulation or dysrhythmias. ● C) To enhance peripheral circulation
● D) Instruct the patient to continue any herbal supplements Rationale: These exercises target respiratory function, not
unless otherwise instructed, and inform the patient that circulation.
these supplements have minimal effect on the surgical ● D) To prevent pneumothorax
procedure. Rationale: Pneumothorax prevention requires other medical
Rationale: This is incorrect because many herbal supplements can interventions, not breathing exercises.
interfere with anesthesia and clotting.
Correct Answer: B) To promote optimal lung expansion cause drowsiness but do not guarantee the patient will be asleep.
● D) Take the patient’s vital signs every 15 minutes.
Rationale: Frequent monitoring may be necessary, but safety
measures are the priority.

17. The nurse has taught a patient to have nothing by mouth (NPO) Correct Answer: B) Place the bed in a low position with the side rails
before surgery. The patient asks why this is important. What is the up
most appropriate response?

● A) You will need to have food and fluid restricted before

surgery so you are not at risk for choking.
Rationale: Preventing aspiration, not choking, is the main reason 22. The nurse is performing a preadmission assessment for a patient
for NPO. scheduled for a bilateral mastectomy. What is the primary purpose of
● B) The restriction of food or fluid will prevent the this assessment?
development of pneumonia related to decreased lung
capacity.
● A) Verifies completion of preoperative diagnostic testing
Rationale: Pneumonia is not directly related to eating or drinking
Rationale: Ensuring the completion of tests is a key aspect of
before surgery.
preadmission assessment.
● C) The presence of food in the stomach interferes with the
● B) Discusses and reviews patients' health insurance
absorption of anesthetic agents.
coverage
Rationale: Food does not affect the absorption of anesthetics, but
Rationale: Insurance discussions are important but secondary to
the risk of aspiration is a concern.
clinical assessments.
● D) By withholding food for 8 hours before surgery, you will
● C) Determines the patient's suitability as a surgical
not develop constipation in the postoperative period.
candidate
Rationale: This is not the primary reason for NPO before surgery.
Rationale: Evaluating a patient’s candidacy for surgery is a main
purpose of the assessment.
Correct Answer: A) You will need to have food and fluid restricted ● D) Informs the patient of need for postoperative
before surgery so you are not at risk for choking. transportation
Rationale: Transportation may be discussed but is not the focus.

Correct Answer: C) Determines the patient's suitability as a surgical

candidate
18. A patient is scheduled for a bowel resection, and the nurse
explains the reason for a preoperative cleansing enema. What
therapeutic effect does the enema provide? 23. An OR nurse will be participating in the intraoperative phase of a
kidney transplant. What action should the nurse prioritize during this
phase of nursing care?
● A) Preventing aspiration of gastric contents
Rationale: This is not related to bowel cleansing.
● B) Preventing the accumulation of abdominal gas ● A) Monitoring the patient’s physiologic status
postoperatively Rationale: During surgery, the patient’s physiological status (e.g.,
Rationale: The enema may help reduce gas but is primarily for vital signs, oxygen levels) needs constant monitoring to ensure
cleanliness. patient safety.
● C) Preventing potential contamination of the peritoneum ● B) Providing emotional support to the family
Rationale: Cleansing the bowel reduces the risk of infection or Rationale: Emotional support is important, but during surgery, the
contamination during surgery. nurse’s priority is the patient.
● D) Facilitating better absorption of medications ● C) Maintaining the patient’s cognitive status
Rationale: Medications are not affected by bowel cleansing. Rationale: The patient will likely be under anesthesia, so cognitive
status monitoring is not relevant.
● D) Maintaining a clean environment
Correct Answer: C) Preventing potential contamination of the
Rationale: A sterile environment is crucial, but monitoring the
peritoneum
patient’s physiology takes priority.

Correct Answer: A) Monitoring the patient’s physiologic status

19. The nurse is caring for a patient experiencing pain and anxiety
after a prostatectomy. Which intervention will best assist in reducing
the patient’s pain and anxiety?
24. The nurse is doing a preoperative assessment of an 87-year-old
man scheduled for a lung lobe resection. What principle should guide
● A) Administration of NSAIDs rather than opioids
the nurse’s assessment of an elderly patient?
Rationale: Opioids are often required for post-surgical pain, and
anxiety management is needed as well.
● B) Allowing the patient to increase activity ● A) Elderly patients have a smaller lung capacity than
Rationale: Increased activity is not recommended during acute younger patients.
recovery. Rationale: While lung capacity may decrease with age, other factors
● C) Use of guided imagery along with pain medication like physiologic reserve are more significant for surgery.
Rationale: Guided imagery can help relieve anxiety when used ● B) Elderly patients require higher medication doses than
alongside analgesics. younger patients.
● D) Use of deep breathing and coughing exercises Rationale: Elderly patients often require lower doses due to slower
Rationale: These exercises improve lung function but do not directly metabolism and the increased risk of side effects.
address anxiety. ● C) Elderly patients have less physiologic reserve than
younger patients.
Rationale: Elderly patients have reduced physiologic reserve,
Correct Answer: C) Use of guided imagery along with pain medication
meaning their ability to recover from surgery or stress is diminished.
● D) Elderly patients have more sophisticated coping skills
than younger patients.
Rationale: Coping skills vary among individuals and are not
necessarily related to age.
20. A trauma patient in the ED requires emergency surgery and goes
into cardiac arrest. When should the ED nurse perform the
preoperative assessment? Correct Answer: C) Elderly patients have less physiologic reserve than
younger patients.

● A) When he or she has the opportunity to review the

patient's electronic health record
Rationale: This could be useful, but a thorough assessment might
not always be possible in emergencies.
25. When does the postoperative phase of perioperative nursing end
● B) When the patient arrives in the OR
for a patient undergoing coronary artery bypass graft surgery?
Rationale: Ideally, the assessment happens prior to OR, but
emergencies can limit this.
● C) When assisting with the resuscitation ● A) When the patient is returned to his room after surgery
Rationale: Assessing during resuscitation can happen in real-time Rationale: Postoperative care continues long after the patient is
as patient status changes. transferred to the room.
● D) Preoperative assessment is not necessary in this case ● B) When a follow-up evaluation in the clinical or home
Rationale: Some level of assessment is still necessary, even in setting is done
emergencies. Rationale: The postoperative phase extends to follow-up care and
evaluation, which ensures full recovery.
● C) When the patient is fully recovered from all effects of the
Correct Answer: C) When assisting with the resuscitation
surgery
Rationale: Full recovery may take weeks or months, but the
immediate postoperative phase focuses on initial recovery and
follow-up.
● D) When the family becomes partly responsible for the
21. After administering a preoperative medication to a patient, what patient’s care
should the nurse do? Rationale: Family involvement is important, but it does not signal
the end of the postoperative phase.
● A) Encourage light ambulation.
Rationale: The patient should not be encouraged to ambulate after Correct Answer: B) When a follow-up evaluation in the clinical or
receiving sedative medications. home setting is done
● B) Place the bed in a low position with the side rails up.
Rationale: Safety precautions should be taken to prevent falls or
injury.
● C) Tell the patient that he will be asleep before he leaves for
surgery.
26. The admitting nurse in a short-stay surgical unit must verify
Rationale: This is misleading, as preoperative medications may
certain tasks before a patient is taken to the preoperative holding
area. What must the nurse ensure?

31. An 88-year-old woman scheduled for a mastectomy is anxious

● A) That preoperative teaching was performed before surgery. What nursing intervention may best help decrease her
Rationale: Preoperative teaching is essential to ensure the patient anxiety?
understands the procedure and recovery process.
● B) That the family is aware of the length of the surgery
Rationale: While informing the family is important, it is not the ● A) Analgesia
nurse’s priority. Rationale: Pain management is important, but analgesia is not
● C) That follow-up home care is not necessary typically used for anxiety reduction preoperatively.
Rationale: Follow-up care may still be necessary, even for short-stay ● B) Therapeutic touch
surgeries. Rationale: Therapeutic touch can provide comfort and reduce
● D) That the family understands the patient will be anxiety, especially in older patients.
discharged immediately after surgery ● C) Preoperative medication
Rationale: Discharge plans must be clarified, but preoperative Rationale: Preoperative medications can reduce anxiety, but
teaching takes precedence. non-pharmacological methods should be tried first.
● D) Sleeping medication, the night before surgery
Rationale: Sleeping medication may help with rest but does not
Correct Answer: A) That preoperative teaching was performed directly address anxiety before surgery.

Correct Answer: B) Therapeutic touch

27. A clinic nurse is doing a preoperative assessment of a patient

undergoing cataract surgery who had a kidney transplant 8 years ago
and is taking immunosuppressive drugs. For what is this patient at
increased risk during surgery? 32. The preoperative unit is aligning its policies with the Surgical Care
Improvement Project (SCIP). What intervention addresses the
priorities of SCIP?
● A) Rejection of the kidney
Rationale: Kidney rejection is not a direct risk during cataract
surgery. ● A) Actions aimed at increasing participation of families in
● B) Rejection of the implanted lens planning care
Rationale: Immunosuppressive drugs do not typically cause Rationale: SCIP focuses more on clinical outcomes than family
rejection of the lens implant. involvement.
● C) Infection ● B) Actions aimed at preventing surgical site infections
Rationale: Immunosuppressive drugs increase the risk of infection Rationale: SCIP prioritizes preventing surgical site infections
because they lower the body's immune response. through practices like timely antibiotic administration.
● D) Adrenal storm ● C) Actions aimed at increasing interdisciplinary
Rationale: Adrenal storm is related to adrenal gland dysfunction, collaboration
not immunosuppression. Rationale: Interdisciplinary collaboration is important but not the
focus of SCIP.
● D) Actions aimed at promoting the use of complementary
Correct Answer: C) Infection and alternative medicine (CAM)
Rationale: SCIP does not emphasize CAM.

Correct Answer: B) Actions aimed at preventing surgical site

infections
28. An unconscious trauma victim needs emergency surgery. The
patient’s adult son, parents, and fiancé are present. Who should sign
the surgery consent form?

● A) The fiancé 33. A 90-year-old female patient is scheduled for a partial

Rationale: The fiancé does not have legal authority unless specified. mastectomy. What nursing diagnosis should the nurse prioritize in
● B) The son her postoperative care?
Rationale: An adult child is typically the legal next of kin and has
the authority to provide consent.
● C) The physician, acting as a surrogate ● A) Risk for Delayed Growth and Development related to
Rationale: The physician only acts as a surrogate in the absence of prolonged hospitalization
family members. Rationale: This diagnosis applies more to pediatric patients.
● D) The patient’s father ● B) Risk for Decisional Conflict related to discharge planning
Rationale: The father would only sign if the son were not available. Rationale: Decisional conflict is not the most critical issue for
postoperative care in this case.
● C) Risk for Impaired Memory related to old age
Correct Answer: B) The son Rationale: Impaired memory is not the primary concern for this
patient’s surgery.
● D) Risk for Infection related to reduced immune function
Rationale: Elderly patients often have reduced immune function,
making them more susceptible to infections, especially after surgery.
29. An 11-year-old needs emergency surgery, but the parents have not This risk should be prioritized in the patient’s postoperative care to
yet arrived at the hospital. How should informed consent be prevent complications such as surgical site infections (SSI).
addressed?
Correct Answer: D) Risk for Infection related to reduced immune
● A) A social worker should temporarily sign the informed function
consent.
Rationale: Social workers do not have legal authority to sign
consent forms. 34. A clinic nurse is conducting a preoperative interview with an adult
● B) Consent should be obtained from the hospital's ethics patient who will soon be scheduled to undergo cardiac surgery. What
committee. interview question most directly addresses the patient’s safety?
Rationale: The ethics committee is not involved in obtaining
consent for emergencies. ● A) What prescription and nonprescription medications do
● C) Surgery should be done without informed consent. you currently take?
Rationale: In life-threatening emergencies, surgery can proceed Rationale: Medication use, particularly anticoagulants or other
without consent to save the patient’s life. drugs, can significantly impact the patient’s safety during surgery,
● D) Surgery should be delayed until the parents arrive. making it the most direct safety-related question.
Rationale: Delaying surgery in a life-threatening situation would be ● B) Have you previously been admitted to the hospital, either
inappropriate. for surgery or for medical treatment?
Rationale: Relevant but not directly linked to current surgical
Correct Answer: C) Surgery should be done without informed consent safety.
● C) How long do you expect to be at home recovering after
your surgery?
Rationale: Important for discharge planning, but not directly
addressing immediate safety.
● D) Would you say that you tend to eat a fairly healthy diet?
30. A 78-year-old patient is anxious before her brain tumor removal
Rationale: Nutritional status can affect recovery but is not the most
surgery. The preoperative medication is ordered on call to the OR.
direct safety concern.
When should the nurse give this medication?

Correct Answer: A) What prescription and nonprescription

● A) As soon as possible, in order to alleviate the patient’s
medications do you currently take?
anxiety
Rationale: Preoperative medications are given close to surgery to
prevent complications.
● B) As the patient is transferred to the OR bed
Rationale: Medication should be administered before physical
transfer to avoid delays. 35. The nurse is preparing an elderly patient for a scheduled removal
● C) When the porter arrives on the floor to take the patient of orthopedic hardware, a procedure to be performed under general
to surgery anesthetic. For which adverse effect should the nurse most closely
Rationale: The medication should be given prior to transportation monitor the patient?
to the OR.
● D) After being notified by the OR and before other ● A) Hypothermia
preoperative preparations Rationale: Elderly patients are at increased risk for hypothermia
Rationale: The medication should be given "on call," when the OR is due to impaired thermoregulation, especially during surgery under
ready for the patient. general anesthesia.
● B) Pulmonary edema
Correct Answer: D) After being notified by the OR and before other Rationale: Less common than hypothermia in this context.
preoperative preparations ● C) Cerebral ischemia
 Rationale: Possible but less frequent during routine surgeries under Rationale: Gloves are not worn at all times in the restricted zone.
general anesthesia.
● D) Arthritis
Correct Answer: B) Mask covering the nose and mouth
Rationale: Arthritis is not a direct adverse effect of surgery or
anesthesia.

Correct Answer: A) Hypothermia

41. An OR nurse is participating in an interdisciplinary audit of
infection control practices in the surgical department. The nurse
should know that a basic guideline for maintaining surgical asepsis is
what?
36. The OR nurse acts in the circulating role during a patient’s
scheduled cesarean section. For what task is this nurse solely
● A) Sterile surfaces or articles may touch other sterile
responsible?
surfaces.
Rationale: Sterile surfaces can touch other sterile surfaces without
● A) Performing documentation contamination.
Rationale: The circulating nurse is responsible for maintaining ● B) Sterile supplies can be used on another patient if the
documentation during the surgery. packages are intact.
● B) Estimating the patient’s blood loss Rationale: Supplies are for single use only.
Rationale: This is done collaboratively by the entire surgical team. ● C) The outer lip of a sterile solution is considered sterile.
● C) Setting up the sterile tables Rationale: The outer lip is considered contaminated after the initial
Rationale: This is the responsibility of the scrub nurse. pour.
● D) Keeping track of drains and sponges ● D) The scrub nurse may pour a sterile solution from a
Rationale: While the circulating nurse assists, this is a shared nonsterile bottle.
responsibility with the scrub nurse. Rationale: Sterile solutions must be poured from sterile containers.

Correct Answer: A) Performing documentation Correct Answer: A) Sterile surfaces or articles may touch other sterile
surfaces.

42. A patient waiting in the presurgical holding area asks the nurse,
“Why exactly do they have to put a breathing tube into me? My
37. A 21-year-old patient is positioned on the OR bed prior to knee
surgery is on my knee.” What is the best rationale for intubation
surgery to correct a sports-related injury. The anesthesiologist
during a surgical procedure?
administers the appropriate anesthetic. The OR nurse should
anticipate which of the following events as the team’s next step in the
care of this patient? ● A) The tube provides an airway for ventilation.
Rationale: Intubation ensures a secure airway for ventilation,
especially during general anesthesia.
● A) Grounding
● B) The tube protects the patient's esophagus from trauma.
Rationale: Grounding the patient before electrocautery prevents
Rationale: This is a secondary benefit but not the primary reason
electrical injury.
for intubation.
● B) Making the first incision
● C) The patient may receive an antiemetic through the tube.
Rationale: The incision is made after ensuring proper anesthesia
Rationale: While antiemetics can be given, this is not the main
and grounding.
reason for intubation.
● C) Giving blood
● D) The patient's vital signs can be monitored with the tube.
Rationale: Blood transfusions are not routine in elective knee
Rationale: Vital signs are monitored separately, not through the
surgery.
intubation.
● D) Intubating
Rationale: Intubation typically occurs after anesthesia induction,
depending on the anesthesia plan. Correct Answer: A) The tube provides an airway for ventilation.

Correct Answer: A) Grounding

43. The circulating nurse in an outpatient surgery center is assessing

a patient who is scheduled to receive moderate sedation. What
principle should guide the care of a patient receiving this form of
38. A circulating nurse provides care in a surgical department that
anesthesia?
has multiple surgeries scheduled for the day. The nurse should know
to monitor which patient most closely during the intraoperative
period because of the increased risk for hypothermia? ● A) The patient must never be left unattended by the nurse.
Rationale: Patients receiving moderate sedation must be monitored
closely, and they should not be left alone.
● A) A 74-year-old woman with a low body mass index
● B) The patient should begin a course of antiemetics the day
Rationale: Elderly patients with low body mass are at higher risk of
before surgery.
hypothermia during surgery.
Rationale: Not typically necessary unless specifically indicated.
● B) A 17-year-old boy with traumatic injuries
● C) The patient should be informed that he or she will
Rationale: Young patients are typically less at risk for hypothermia.
remember most of the procedure.
● C) A 45-year-old woman having an abdominal hysterectomy
Rationale: Moderate sedation often leads to partial amnesia.
Rationale: Not at particularly high risk for hypothermia.
● D) The patient must be able to maintain his or her own
● D) A 13-year-old girl undergoing craniofacial surgery
airway.
Rationale: Age is less of a factor than in the elderly.
Rationale: While important, the monitoring aspect takes
precedence.
Correct Answer: A) A 74-year-old woman with a low body mass index
Correct Answer: A) The patient must never be left unattended by the
nurse.

39. The anesthetist is coming to the surgical admissions unit to see a

patient prior to surgery scheduled for tomorrow morning. Which of
the following is the priority information that the nurse should provide
44. A nurse is caring for a patient following knee surgery that was
to the anesthetist during the visit?
performed under a spinal anesthetic. What intervention should the
nurse implement to prevent a spinal headache?
● A) Last bowel movement
Rationale: Not crucial for most surgeries unless bowel surgery is
● A) Have the patient sit in a chair and perform deep
involved.
breathing exercises.
● B) Latex allergy
Rationale: Sitting up can worsen a spinal headache.
Rationale: A latex allergy is crucial information to prevent allergic
● B) Ambulate the patient as early as possible.
reactions during surgery.
Rationale: Early ambulation is not directly related to preventing
● C) Number of pregnancies
spinal headaches.
Rationale: Relevant in some contexts, but not the priority.
● C) Limit the patient’s fluid intake for the first 24 hours
● D) Difficulty falling asleep
postoperatively.
Rationale: Not critical for anesthetic planning.
Rationale: Limiting fluid intake may increase the risk of headaches.
● D) Keep the patient positioned supine.
Correct Answer: B) Latex allergy Rationale: Remaining supine can help reduce the risk of a spinal
headache.

Correct Answer: D) Keep the patient positioned supine.

40. An OR nurse is teaching a nursing student about the principles of

surgical asepsis as a requirement in the restricted zone of the
operating suite. What personal protective equipment should the
nurse wear at all times in the restricted zone of the OR?
45. A nurse is caring for a patient following knee surgery that was
performed under a spinal anesthetic. What intervention should the
● A) Reusable shoe covers nurse implement to prevent a spinal headache?
Rationale: Not required at all times.
● B) Mask covering the nose and mouth
● A) Have the patient sit in a chair and perform deep
Rationale: A mask is required in the restricted zone to maintain a
breathing exercises.
sterile environment.
Rationale: As noted previously, this can exacerbate spinal
● C) Goggles headaches.
Rationale: Goggles are used in specific cases but not required at all
● B) Ambulate the patient as early as possible.
times.
Rationale: Early ambulation does not prevent headaches caused by
● D) Gloves spinal anesthesia.
 ● C) Limit the patient’s fluid intake for the first 24 hours ● A) Preventing the risk of hypotension
postoperatively. Rationale: Lying flat helps prevent hypotension after spinal
Rationale: This could actually increase the risk of spinal headaches. anesthesia.
● D) Keep the patient positioned supine. ● B) Preventing respiratory depression
Rationale: The supine position is recommended to minimize Rationale: Not directly relevant to positioning after spinal
headache risk. anesthesia.
● C) Preventing the onset of a headache
Rationale: Lying flat can help reduce the risk of a spinal headache.
Correct Answer: D) Keep the patient positioned supine.
● D) Preventing pain at the lumbar injection site
Rationale: Positioning is not primarily aimed at preventing
injection site pain.

46. The OR will be caring for a patient who will receive a transsacral Correct Answer: A) Preventing the risk of hypotension.
block. For what patient would the use of a transsacral block be
appropriate for pain control?

● A) A middle-aged man who is scheduled for a thoracotomy

51. The nurse is packing a patient’s abdominal wound with sterile,
Rationale: Not appropriate; thoracotomy requires a different
half-inch lodoform gauze. During the procedure, the nurse drops
anesthesia approach.
some of the gauze onto the patient’s abdomen 2 inches (5 cm) away
● B) An older adult man who will undergo an inguinal hernia
from the wound. What should the nurse do?
repair
Rationale: Appropriate use of a transsacral block for this type of
surgery. ● A) Apply povidone-iodine (Betadine) to that section of the
● C) A 50-year-old woman who will be having a reduction gauze and continue packing the wound.
mammoplasty Rationale: This is not appropriate as it could contaminate the gauze.
Rationale: Not the typical use for a transsacral block. ● B) Pick up the gauze and continue packing the wound after
● D) A child who requires closed reduction of a right humerus irrigating the abdominal wound with Betadine solution.
fracture Rationale: Irrigating with Betadine after dropping gauze is not
Rationale: Generally not used for this procedure. appropriate.
● C) Continue packing the wound and inform the physician
that an antibiotic is needed.
Correct Answer: B) An older adult man who will undergo an inguinal
Rationale: This does not address the contamination issue.
hernia repair.
● D) Discard the gauze packing and repack the wound with
new lodoform gauze.
Rationale: This is the safest and most appropriate action to
maintain asepsis.
47. The circulating nurse will be participating in a 78-year-old
patient’s total hip replacement. Which of the following considerations Correct Answer: D) Discard the gauze packing and repack the wound
should the nurse prioritize during the preparation of the patient in with new lodoform gauze.
the OR?
52. The nurse is performing wound care on a 68-year-old postsurgical
● A) The patient should be placed in Trendelenburg position. patient. Which of the following practices violates the principles of
Rationale: Not required for hip replacement. surgical asepsis?
● B) The patient must be firmly restrained at all times.
Rationale: Restraints should be used judiciously.
● A) Holding sterile objects above the level of the nurse's
● C) Pressure points should be assessed and well padded.
waist.
Rationale: Important for preventing pressure injuries, especially in
Rationale: Sterile objects should always be kept above waist level to
elderly patients.
maintain their sterility.
● D) The preoperative shave should be done by the circulating
● B) Considering a 1 inch (2.5 cm) edge around the sterile
nurse.
field as being contaminated.
Rationale: Typically not the circulating nurse's responsibility.
Rationale: This is correct; the edges of sterile fields are considered
contaminated.
Correct Answer: C) Pressure points should be assessed and well ● C) Pouring solution onto a sterile field cloth.
padded. Rationale: This is a common practice as long as the solution is
sterile and poured correctly.
● D) Opening the outermost flap of a sterile package away
from the body.
Rationale: This is a correct practice to maintain sterility.
48. The OR nurse is taking the patient into the OR and the patient
informs the operating nurse that his grandmother spiked a 104°F Correct Answer: A) Holding sterile objects above the level of the
temperature in the OR and nearly died 15 years ago. What relevance nurse's waist.
does this information have regarding the patient?

● A) The patient may be experiencing presurgical anxiety.

Rationale: Anxiety could be a factor, but it’s not the primary
concern. 53. A patient is scheduled for surgery the next day and the different
● B) The patient may be at risk for malignant hyperthermia. phases of the patient's surgical experience will require input from
Rationale: Family history of temperature issues can indicate a risk members of numerous health disciplines. How should the patient's
for this serious condition. care best be coordinated?
● C) The grandmother's surgery has minimal relevance to the
patient's surgery.
● A) By planning care using a surgical approach.
Rationale: Family history is relevant, particularly with anesthesia
Rationale: While important, this approach may not fully encompass
concerns.
the interdisciplinary aspect.
● D) The patient may be at risk for a sudden onset of
● B) By identifying the professional with the most knowledge
postsurgical infection.
of the patient.
Rationale: Infection risk is common but not directly related to the
Rationale: This may not ensure comprehensive care as it limits
family history.
input from other disciplines.
● C) By implementing an interdisciplinary approach to care.
Correct Answer: B) The patient may be at risk for malignant Rationale: This approach ensures that all aspects of the patient’s
hyperthermia. care are addressed by various professionals.
● D) By using the nursing process to guide all aspects of care
and treatment.
Rationale: The nursing process is vital, but it should be integrated
with interdisciplinary input.
49. While the surgical patient is anesthetized, the scrub nurse hears a
member of the surgical team make an inappropriate remark about the Correct Answer: C) By implementing an interdisciplinary approach to
patient’s weight. How should the nurse best respond? care.

● A) Ignore the comment because the patient is unconscious. 54. D) Evidence-based practice
Rationale: Ignoring it is unprofessional and does not address the
issue.
● B) Discourage the colleague from making such comments. Organizing patient care around collaboration among diverse health
Rationale: Directly addressing it can be effective, but a report may disciplines is primarily based on evidence-based practice. This
be necessary. ensures that the patient's care is informed by the latest research and
● C) Report the comment immediately to a supervisor. best practices, leading to better outcomes. Historical precedence,
Rationale: Reporting inappropriate remarks is important for patient requests, or physicians' needs are less reliable or objective
maintaining professionalism. justifications.
● D) Realize that humor is needed in the workplace.
Rationale: This approach is inappropriate and unprofessional. 55. B) Informed consent
Before surgery, verifying that informed consent is complete is crucial, as it is a
Correct Answer: C) Report the comment immediately to a supervisor. legal and ethical requirement. Discharge planning, analgesia prescriptions, and
educational resources are important but not as critical in the preoperative phase
as ensuring that the patient has consented to the procedure.

50. You are caring for a male patient who has had spinal anesthesia.
The patient is under a physician's order to lie flat postoperatively.
56. C) Ensure that the patient has had a current cross-match
When the patient asks to go to the bathroom, you encourage him to
In the event of a possible blood transfusion, the most important safety measure is
adhere to the physician's order. What rationale for complying with
ensuring a current cross-match. This ensures compatibility between the
this order should the nurse explain to the patient?
patient and donor blood, which is essential for preventing serious transfusion
reactions. Priming IV tubing or keeping blood warmed is not as vital without
confirming compatibility first.
70. A) Ensure that IV fluids are warmed to the patient's body
temperature
Preventing hypothermia involves warming IV fluids to the patient's body
temperature. This helps maintain normothermia during surgery, which is critical
57. D) Use a tone that decreases the patient's anxiety
in patients with a low BMI who are more prone to heat loss.
In therapeutic communication, reducing patient anxiety is a key objective. Using
a calm and reassuring tone can help alleviate stress. Waiting for the patient to
initiate dialogue or giving preoperative medication before communication doesn't
necessarily promote comfort and understanding.
71. D) Airway patency
After surgery, the priority is ensuring airway patency, as compromised airway
could lead to respiratory distress. Although heart rate and temperature are
important, airway management is the first and most urgent assessment.
58. C) Dorsal recumbent
The dorsal recumbent position (lying on the back) is most appropriate for
many types of abdominal surgeries, such as bowel resection, as it provides
optimal access to the surgical site. Other positions like prone or Trendelenburg
are less suitable for this type of surgery.
72. D) Turn the patient completely to one side
To prevent aspiration when a patient is vomiting or retching, the priority is to
turn the patient to one side. This helps prevent the inhalation of vomitus into
the lungs, which could lead to aspiration pneumonia.
59. B) Anaphylaxis
When using tissue adhesives, the greatest concern would be anaphylaxis, a
severe allergic reaction. While infection and hypothermia are risks, anaphylaxis is
an immediate life-threatening reaction that must be addressed.
73. A) The patient should not drive herself home
After anesthesia, patients should not drive themselves due to the lingering effects
of the anesthetic, which can impair reflexes and judgment. Recommendations
like staying in bed for 48 hours are excessive unless otherwise indicated.
60. C) By maintaining each of your patient’s privacy
As a patient advocate, protecting the patient's privacy is central to ensuring
respect and dignity. While encouraging deep breathing or maintaining informed
consent is important, privacy is a direct aspect of patient advocacy in the
74. C) Stand upright for 2 to 3 minutes prior to ambulating
operating room.
To prevent orthostatic hypotension after surgery, it’s recommended for patients
to stand upright for a few minutes to allow the body to adjust, reducing the
risk of dizziness and falls.

61. D) Paravertebral block

A paravertebral block is a conduction block used to anesthetize the chest area
by blocking nerves near the spinal cord, making it appropriate for a pleura
75. A) Atelectasis
biopsy. Other blocks like the brachial plexus or pudendal blocks are for different
The patient's reluctance to ambulate increases the risk of atelectasis (lung
regions of the body.
collapse) postoperatively. Anemia, dehydration, and peripheral edema are less
directly linked to immobility in the immediate postoperative period.

62. B) Hypoxia
Vomiting during surgery increases the risk of hypoxia, as the patient could
76. C) Red, warm, tender incision
aspirate vomit into the lungs, leading to airway obstruction or respiratory
Signs of infection include redness, warmth, and tenderness at the incision
complications. Skin integrity, malignant hyperthermia, and hypothermia are less
site. While an indwelling catheter or mildly elevated temperature can be
directly related to vomiting.
concerning, local signs of inflammation around the incision are more indicative
of infection.

63. C) Tachycardia
Tachycardia is one of the earliest signs of malignant hyperthermia, a
77. B) During the dressing change, I will provide privacy...
life-threatening complication during surgery. Increased temperature may develop
This response is the most appropriate because it ensures privacy, involves the
later, but tachycardia is often the first clinical indication.
patient in their care, and reassures them that the dressing change should not be
painful, which is both informative and respectful.

64. C) Reduce the incidence of health care-associated infections

In the operating room (OR), preventing health care-associated infections is
78. B) Notify the physician and continue to monitor the hourly urine
critical for patient safety. Goals related to medication safety or falls are
output closely
important, but infection control is the most directly relevant to the OR
If the Foley catheter output is concerning, the best action is to notify the
environment.
physician and continue monitoring. Irrigating the Foley should only be done if
there is a clear indication of obstruction, and massaging the abdomen is not a
recognized intervention.

65. A) Hypervolemia
In elderly patients, changes in the cardiovascular system, such as reduced cardiac
efficiency, increase the risk of hypervolemia, or fluid overload. Conditions like
79. C) Pulmonary embolism
hyponatremia or hyperkalemia are less common cardiovascular concerns
Refusing to wear pneumatic compression stockings increases the risk of
postoperatively.
pulmonary embolism by contributing to venous stasis, which can lead to clot
formation in immobile patients.

66. C) The elderly patient has impaired thermoregulatory

mechanisms, which increase susceptibility to hyperthermia
80. B) Hypovolemic shock
Elderly patients often have impaired thermoregulation, making them more
The patient’s drop in blood pressure, rapid pulse, and pale, moist skin are signs of
susceptible to temperature fluctuations, including hyperthermia. This
hypovolemic shock, a condition that results from a significant loss of blood or
thermoregulatory impairment is a primary concern in the intraoperative period.
fluids.

67. C) Incorporate cultural and religious considerations, as

81. D) Pain, hypoxia, or bladder distention
appropriate
Postoperative hypertension can often be caused by pain, hypoxia, or bladder
Culturally and religiously sensitive care can enhance a patient's emotional
distention. These factors increase sympathetic nervous system activity, raising
well-being and positively affect surgical outcomes. Strategies like distraction or
blood pressure.
antianxiety medications do not directly address the patient's holistic needs.

82. C) The patient is in pain

68. C) 1 foot
Given the stable oxygen saturation, the most likely cause of increased restlessness
Maintaining a 1-foot distance from the sterile field is standard to avoid
and elevated blood pressure postoperatively is pain. Hypothermia or shock
contamination in the operating room. Closer proximity increases the risk of
would present with more critical signs.
compromising the sterility of the field.

83. A) Postoperative delirium

69. C) Anesthesia complication
Confusion, disturbed sleep patterns, and impaired psychomotor skills in an
Given the trauma and the complexities involved in surgery, the patient is at
elderly patient postoperatively are indicative of postoperative delirium, which
increased risk for anesthesia complications. Factors like respiratory
is common in older adults following surgery.
depression and hypothermia are also possible, but anesthesia-related
complications are more common in major trauma.
84.
Answer: C) Postoperative confusion is common in the older adult 96.
patient, but it could also indicate a significant issue such as impaired Answer: B) Adequate respiratory function
oxygenation or blood loss.
● Rationale: Adequate respiratory function is the most critical
● Rationale: Postoperative confusion, restlessness, and agitation are short-term goal after surgery to ensure that the patient can breathe
common in older adults but may signal serious issues such as effectively and prevent complications like pneumonia. Pain relief (A)
impaired oxygenation or blood loss, which require further assessment is important but secondary to respiratory function.
and intervention. Options A and B downplay the potential
seriousness, and D assumes an underlying cognitive deficit that may
97.
not be present.
Answer: D) Encourage the patient to use the incentive spirometer
every 2 hours.
85.
Answer: A) Hemorrhage and shock
● Rationale: Using an incentive spirometer helps clear secretions and
prevent pneumonia by encouraging deep breathing. Options A, B, and
● Rationale: Cold, moist, and pale skin, along with restlessness, are C do not directly address this goal.
signs of shock, which is commonly caused by hemorrhage in the
postoperative period. The other options (B, C, D) do not directly
98.
explain these symptoms.
Answer: B) The patient has vomited three times in the past 12 hours.

86.
● Rationale: Vomiting increases intra-abdominal pressure, which can
Answer: B) The PACU allows the patient to recover from the effects of
lead to wound dehiscence. The other options (A, C, D) are not as likely
anesthesia, and the patient stays in the PACU until he or she is
to cause this complication.
oriented, has stable vital signs, and is without complications.

99.
● Rationale: The PACU is designed for close monitoring immediately
Answer: D) Dehydration is a contributory factor to the formation of
after surgery while the patient recovers from anesthesia and
deep vein thrombi.
stabilizes. Option A is incorrect because the PACU is not intended as a
stimulating environment. Option C is inaccurate, and D is rarely the
reason patients stay in the PACU. ● Rationale: Dehydration increases blood viscosity, contributing to
DVT formation. Hypervolemia (B) is the opposite of dehydration, and
there is no genetic link (A) that is the primary factor for DVTs.
87.
Answer: B) Treat the possible airway obstruction by tilting the head
back and pushing forward on the angle of the lower jaw. 100.
Answer: B) Encourage early ambulation.
● Rationale: In the case of apnea and cyanosis, airway obstruction is a
priority, and a jaw thrust maneuver can help relieve obstruction. ● Rationale: Early ambulation is a key intervention to reduce the risk
Checking oxygen saturation (A) is not the first priority. Reintubation of venous thromboembolism by promoting circulation. Options A, C,
(D) would only be done if simpler measures fail. and D are helpful but not as effective in preventing this complication.

88.
Answer: D) I'll eat plenty of fruits and vegetables

● Rationale: Proper nutrition, including vitamins and minerals from

fruits and vegetables, promotes tissue repair and wound healing.
Option A suggests limiting protein, which is counterproductive.
Options B and C suggest harmful practices.

89.
Answer: B) Maintaining a patent airway

● Rationale: In the immediate postoperative period, ensuring the

patient has a patent airway is the highest priority to ensure adequate
oxygenation. Pain management (C) and vital sign monitoring (D) are
important but secondary to airway patency.

90.
Answer: B) Quickly attempt to determine the cause of hemorrhage.

● Rationale: When hemorrhage is suspected, it is crucial to identify

the source and address it. Leaving the patient to notify the physician
(A) is unsafe. Resuscitation (C) and the Trendelenburg position (D)
may be needed later but not before identifying the cause.

91.
Answer: C) Keeping the patient warm

● Rationale: Hypothermia is common postoperatively, especially in

older adults, and maintaining warmth is essential. Sterility (A) is not
the priority once the patient has left the OR. Restraints (B) are rarely
used, and hydration (D) is important but not the first priority.

92.
Answer: B) Patients admitted to the hospital for surgery usually have
multiple health needs.

● Rationale: Hospital-based surgeries often involve patients with

complex health conditions that require closer monitoring.
Ambulatory surgical centers are more appropriate for healthier
patients undergoing less complex procedures. The other answers are
less accurate.

93.
Answer: C) Close monitoring of neurologic status

● Rationale: After hip replacement surgery in an elderly patient,

monitoring neurologic status is critical due to the risk of
complications such as confusion or delirium. Ambulation (A) and oral
intake (D) are secondary in the immediate postoperative period.

94.
Answer: D) Flash pulmonary edema

● Rationale: The symptoms of tachypnea, crackles, and frothy pink

sputum are classic signs of flash pulmonary edema, a life-threatening
condition. Pulmonary embolism (A) or atelectasis (B) are less likely to
present this way, and laryngospasm (C) would not cause these
symptoms.

95.
Answer: A) Assess the patient's oxygen levels.

● Rationale: Anxiety can be a symptom of hypoxia, so checking

oxygenation is the first step. Administering medications (B) or calling
the physician (C) would follow after assessment. A social work
referral (D) is not relevant in this acute scenario.