ATI Assessment for Caring for the Surgical Client

A transplant nurse is part of a multidisciplinary care team creating a documented plan of care for a client in need of a heart transplant. Which of the following standards of professional performance for transplant nursing is the nurse demonstrating by being part of the team?

Collaboration

A surgical nurse receives additional training to become a transplant nurse. When the nurse administers postoperative care to a transplant client for the first time, which element of care will be new for that nurse?

Monitoring for signs of organ rejection

A transplant nurse is providing care related to a client's kidney transplant. Which priority nursing action would be most likely to take place during the preoperative phase?

Educating the client's caregivers about the transplant process.

An experienced transplant nurse is describing the transplant nursing process to a student nurse. Which statement should the experienced nurse make?

Transplant nursing is similar to other type of perioperative nursing.

A nurse teaches a surgical client about breathing and relaxation exercises during the preoperative phase. Which of the following postoperative complications would breathing and relaxation exercises help?

Pain

A nurse is preparing a client scheduled for right knee arthroplasty surgery. Which of the following interventions should be the priority for the nurse to address to ensure client safety?

Have the surgeon mark the surgical site.

A nurse administers IV medication and reviews breathing and relaxation techniques with a client recovering from a mastectomy. Which element of postoperative care is the nurse performing?

Managing postoperative pain.

A nurse observes a client signing their informed consent for surgery. The client says to the nurse, “I am not sure why I have to have this surgery.” Which of the following actions should the nurse take first?

Contact the provider and notify them that the informed consent process is not complete, then notify the perioperative staff that the surgery is on hold.

A nurse is providing information to a client being admitted to the surgical clinic for a right knee arthroscopy. The nurse explains to the client that they will be receiving perioperative care. The client asks, "When does that care occur?" Which of the following statements made by the nurse is correct?

Perioperative care occurs before, during, and after surgery.

A nurse is using the SBAR communication tool when handing off a client to the PACU nurse. Which of the following sections of the tool is the nurse using when describing the client's comorbidities?

Background

A nurse is caring for a client in the PACU following a surgical procedure during which they received moderate sedation. Which of the following interventions should the nurse implement?

Monitor level of consciousness

A nurse is preparing a client for a surgical procedure. During which of the following timeframes should the nurse initiate the prescribed antibiotic to help decrease surgical site infections?

60 minutes before performing the surgical incision

A nurse is caring for a client who is having a total abdominal hysterectomy. The nurse prepares to teach the surgical client about minimizing the pain and discomfort postoperatively. Which of the following priority instructions should the nurse give the client?

Ensure the client understands splinting the incision and performing deep breathing exercises.

A nurse is using the "I Pass the Baton" hand-off tool when transferring a client to the operating room. Which of the following steps of the tool should the nurse use when reporting the client has allergies to latex and penicillin?

Safety

A nurse is preparing to admit a client to an outpatient surgical center. Which of the following will assist in collecting data that can be used to plan care during the preoperative phase?

Physical assessment

A nurse is completing a preassessment for a surgical client. The nurse asks the client whether they or anyone in their family has a history of complications from anesthesia. Which of the following assessment findings is most concerning?

Malignant hyperthermia

A nurse transfers a client to the PACU postoperatively. During the hand-off report, the nurse states that, "Dr. Jones performed a bowel resection." Which of the following sections of the SBAR communication tool does this statement address?

Situation

A nurse is preparing a client for surgery when the client expresses how nervous and anxious they are about the surgery. Which of the following responses by the nurse would help initiate assessment of the client's need for further preoperative instruction?

"Tell me what you have already been told about the surgery."

A nurse documents how much solution is administered to a postoperative client intravenously, as well as how much output is collected in the client's catheter bag. Which of the following elements of postoperative care is the nurse directly performing?

Maintain adequate fluid balance

A nurse is admitting a client to the surgical clinic for an elective surgery. Which of the following is the priority focus during the preoperative phase?

Prepare the client mentally and physically for surgery

A nurse is teaching a client how to perform deep breathing exercises postoperatively. Which of the following instructions should the nurse include in her demonstration?

Breathe in through your nose for four seconds.

A transplant nurse is identifying client risk factors during the preoperative phase. Which of the following potential complications should the nurse recognize puts the client at a higher risk level due to the medications and procedures for organ transplants?

Acquiring a secondary infection

A nurse is preparing a client for total hip surgery. The client has been on anticoagulant therapy for the last few months. During which of the following periods in the surgical checklist is the risk of greater than 500 mL blood loss assessed and recorded?

SIGN-IN

A nurse is preparing a client for a surgical appendectomy. The nurse identifies an appendectomy as which of the following types of surgical classification?

Urgent

A nurse is providing preoperative education to a client scheduled for an elective surgery. Which of the following is the best time for the nurse to provide preoperative teaching?

The afternoon or evening prior to surgery.

A nurse is caring for a client who is scheduled for a laparotomy. The client states that they are concerned about the possibility of postoperative infection. Which of the following actions should the nurse take to address the client's concern and decrease the risk of infection?

Educate the client during the preoperative phase about wound care

A nurse is preparing a client for a surgical procedure, explaining that perioperative nursing care is primarily focused on the client to provide high quality care. The nurse is demonstrating knowledge of the Perioperative Patient Focused Model. Which of the following domains of this model has more emphasis on structural standardized data elements and analytical reporting?

Health system

For each assessment finding, click to specify if the assessment finding is a normal finding, an expected abnormal finding, or an unexpected abnormal finding in a client who is about to undergo surgery. Each finding may support more than one.

White blood count: expected abnormal

Extremity assessment: expected abnormal

Platelet count: normal finding

Temperature: expected abnormal

Positive HCG: unexpected abnormal

Pain level: expected abnormal

A nurse is assessing a client in the preoperative area. Which of the following preoperative finding(s) should the nurse relay to the surgeon immediately?

Select all that apply.

- Platelet count

- Urinalysis results

Complete the following sentence by using the lists of options.

The client is at highest risk for developing _________________ as evidenced by the client's __________________.

- Hypoxemia

- Hematology labs