NCLEX Perioperative

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply.

1.Slight redness along the incision
2.The presence of purulent drainage
3.A temperature of 98.8° F (37.1° C)
4.The client states that he feels cold.
5.The client states that the incision itches.
6.Tender firmness palpable around the incision

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply.

1.Slight redness along the incision
2.The presence of purulent drainage
3.A temperature of 98.8° F (37.1° C)
4.The client states that he feels cold.
5.The client states that the incision itches.
6.Tender firmness palpable around the incision

2.The presence of purulent drainage
6.Tender firmness palpable around the incision

Rationale:A wound infection occurs when healing is delayed and pathogens such as bacteria grow in the wound. Signs and symptoms of a wound infection include warmth, redness, swelling, and tenderness of skin around the incision. The client may have fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a wound that was contaminated before surgical exploration; it appears 3 to 6 days after surgery. Slight redness along an incision is a sign of inflammation and should be monitored to determine whether it progresses. A temperature of 98.8° F (37.1° C) is not an abnormal finding in a postoperative client. Itching around a wound may be from irritation or dryness and is not associated with infection. The fact that a client feels cold is not indicative of an infection, although chills and fever are signs of infection. The room temperature may be too cold for client comfort.

Test-Taking Strategy(ies):Focus on the subject, wound infection. Noting the words purulent, tender, and hardness will direct you to the correct options.Review:The signs of a wound infection.Color Key:Cyan = StrategyMagenta = Content Review

The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all that apply.

1.Wound care
2.Personal hygiene
3.Activity restrictions
4.Frequent assessment of vital signs
5.Coughing and deep breathing exercises
6.Pain monitoring and medications to relieve pain

4.Frequent assessment of vital signs
5.Coughing and deep breathing exercises
6.Pain monitoring and medications to relieve pain

Rationale:The type of planning and instruction required varies with each individual and type of surgery. Preoperative education, including rationales related to a client's expected postoperative behavior, has a positive outcome on recovery and prevention of postoperative complications. Postoperatively, the client will be monitored closely with vital signs and the client should understand this is routine. General anesthesia predisposes clients to respiratory problems that can lead to atelectasis and pneumonia in the postoperative period. Therefore, coughing and deep breathing are important exercises to be taught in the preoperative period. Addressing that pain will be monitored and controlled with prescribed analgesia should allay client fears regarding pain. Specific instructions that the client needs to receive before discharge should include wound care, activity restrictions, dietary instructions, postoperative medication instructions, personal hygiene, and follow-up appointments.

Test-Taking Strategy(ies):Focus on the subject, preoperative instructions. Options 1, 2, and 3 refer to information that needs to be taught postoperatively. Options 4, 5, and 6 refer to information that should be taught preoperatively.
Review:Preoperative and postoperative care.Color Key:Cyan = StrategyMagenta = Content Review

The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit after abdominal surgery. The client has an indwelling urinary catheter in place. The vital signs are temperature 99.6° F (37.6° C), pulse 104 beats per minute, respirations 16 breaths per minute, and blood pressure (BP) 100/70 mm Hg. Urinary output is 20 mL for the past hour. Based on this data, which actions should the nurse take before notifying the registered nurse? Select all that apply.

1.Auscultate breath sounds.
2.Review vital signs from previous hour.
3.Observe the urinary catheter for patency and flow.
4.Observe the IV site for patency and correct flow rate.
5.Review when the client last received pain medication

2.Review vital signs from previous hour.
3.Observe the urinary catheter for patency and flow.
4.Observe the IV site for patency and correct flow rate.
5.Review when the client last received pain medication

Postoperative vital signs and urinary output are important parameters to determine how the client is recovering from the surgical procedure. The nurse needs to consider if this data is an early sign of a complication. The nurse should review the previous vital signs to determine whether this is a change from how the vital signs have been trending since the BP is slightly low and the pulse rate is slightly fast. Noting when the last pain medication was administered will help the nurse determine whether the vital signs may be affected from the medication since opioids lower blood pressure. The nurse should determine whether the IV fluid is infusing correctly and whether the catheter is patent. Urine output should be maintained at a minimum of 30 mL/hr for an adult. An output of less than 30 mL for each of 2 consecutive hours should be reported. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Auscultation of breath sounds is not part of determining the significance of the vital signs and urinary output.

Focus on the subject, assessment of a postoperative client. To answer this question correctly, you must know the normal ranges for temperature, blood pressure, and urinary output. The BP must be compared to trends for this particular client. You also need to consider whether fluid is being administered correctly and output is being measured correctly. By checking the situation thoroughly, the nurse can determine whether to report the findings to the registered nurse.

The nurse is preparing a client for surgery. Which should be components of the plan of care? Select all that apply.

1.Verify the preoperative laboratory studies were drawn.
2.Report any increases in blood pressure (BP) on the day of surgery. 3.Verify that the client has received nothing by mouth (NPO) for 24 hours before surgery.
4.Instruct the client not to swallow water with oral hygiene on the morning of surgery.
5.Document that any medications the client was instructed to take before surgery are given.

4.Instruct the client not to swallow water with oral hygiene on the morning of surgery.
5.Document that any medications the client was instructed to take before surgery are given.

The preoperative preparation is important to ensure that the surgery gets done with everything ready to ensure a successful outcome. The client may brush teeth and rinse with mouthwash but must not swallow any water. Any specific medications that the client was instructed to take on the day of surgery need to be administered and documented. This may include insulin or a blood pressure medication. The nurse cannot just verify the preoperative testing was done. The nurse needs to review the results of the preoperative laboratory studies and notify the primary health care provider of any abnormal results. Some increase in both blood pressure and pulse is common because of client anxiety regarding surgery. The client usually has a restriction of food and fluids for 8 hours before surgery instead of 24 hours.

Note the subject, preparing a client for surgery. Read each option carefully and decide whether it promotes client safety when answering the question. Preoperative testing results, NPO status, and medications ordered need to be documented as done. Any concerns regarding laboratory results or the medications should be discussed with the primary health care provider. Recall that surgery can produce anxiety and elevate BP slightly.

Following a surgical procedure, the nurse applies sequential compression devices to both lower extremities and turns the machine on. The nurse implements this intervention for which purpose?

1.To promote arterial circulation
2.To prevent muscle cramps in the legs
3.To prevent thrombosis formation in the veins
4.To maintain muscle strength despite inactivity

3.To prevent thrombosis formation in the veins

Compression devices, whether sequential, pneumatic, or intermittent, are external devices applied to the lower extremities to compress the calves of the legs and return blood to the heart similar to the way walking promotes venous return. These compression devices are used for clients who are in bed, especially during surgery and postoperatively, to prevent the complication of venous thrombotic embolism. This embolism can become a pulmonary embolism and cause death during the postoperative recovery period. Heart function determines arterial circulation. The compression devices are not significant in preventing muscle cramps or maintaining muscle strength.

Focus on the subject, purpose of sequential compression devices. Recall they are applied when the client is not walking and that with walking, the calf muscles contract and return blood through the veins to the heart. Note that venous thrombotic embolism disease is a major cause of postoperative deaths.

The nurse is preparing a client for a right below-the-knee amputation. The nurse anticipates that the client is likely to experience which psychosocial problems in the perioperative period? Select all that apply.

1.Pain
2.Anger
3.Grief
4.Anxiety
5.Altered body image

3.Grief
4.Anxiety
5.Altered body image

A client facing an elective amputation of a lower extremity will experience psychosocial as well as physical challenges during the perioperative period. The client is likely to experience grief because of the loss of the extremity as well as an alteration in body image. The client will also experience anxiety since this will be a new experience and life as an amputee is unknown. Pain is a physical problem influenced by psychosocial factors. There are no data in the question to support a problem of anger.

Focus on the subject, a client's psychosocial reaction to an amputation surgery. Noting the word psychosocial will direct you to consider the common reactions to an amputation, loss of a body part, and facing uncertainty. Remember to focus on client concerns as a priority in the perioperative period.

The nurse is caring for a client following a total abdominal hysterectomy. The nurse anticipates that which postoperative outcome will be the priority in the first 24 hours following surgery?

1.Pain
2.Changes in body image
3.Inability to cope with stressors
4.Lack of information about recovery

1.Pain

The client who has had abdominal surgery is most likely to experience pain in the first 24 hours after surgery. The other options identify less important issues during this time frame but could increase in importance later in recovery.

Note the strategic word, priority. Use Maslow's Hierarchy of Needs Theory to answer the question. Option 1 is the only option that addresses a physiological need. Remember that physiological needs are the priority.

Intravenous (IV) lactated Ringer's (LR) solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed. Which student response is correct?

1."The prescribed solution is hypotonic."
2."LR is isotonic to plasma and contains electrolytes"
3."This solution will help prevent further fluid losses."
4."Hypertonic fluids, such as LR, help replace fluid loss from surgery."

2."LR is isotonic to plasma and contains electrolytes"

Lactated Ringer's solution is an isotonic solution. It contains calcium, potassium, sodium, chloride, and lactate in small amounts. Other isotonic solutions include 5% dextrose in water, 0.9% normal saline, and 5% dextrose in 0.225% normal saline. Isotonic solutions are used for fluid replacement in surgical clients. The fluid will remain in the vascular space.

Focus on the subject, lactated Ringer's solution. Knowledge regarding the tonicity of this IV solution is needed to answer the question. Remember that lactated Ringer's solution is isotonic to plasma.

A client with arthritis is scheduled for a surgical knee joint replacement. The client will be admitted to the hospital on the day of the surgical procedure, and the nurse is reinforcing instructions with the client regarding preparation for the surgical procedure. Which client statement indicates an understanding of the preoperative instructions?

1."I cannot drink or eat anything after midnight on the night before surgery."
2."I need to discontinue my prescribed knee exercises at least 1 week before surgery."
3."I need to stop taking my prescribed prednisone 48 hours before the scheduled surgery."
4."My last dose of prescribed acetylsalicylic acid should be taken the evening before surgery."

1."I cannot drink or eat anything after midnight on the night before surgery."

Preoperative instructions are important so that the client is readied adequately for surgery and all has been done to achieve a successful outcome. The client must understand the importance of following the timing of being NPO to lower the risk of aspiration associated with the anesthetic. Antiplatelet medications such as aspirin alter normal clotting factors and increase the risk of hemorrhage. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. Prednisone, a corticosteroid, should not be discontinued abruptly. In fact, additional dosages of the corticosteroid may be necessary before stressful situations, such as surgery. There is no reason to discontinue prescribed exercises, and discontinuing exercises in this client may be harmful.

Focus on the subject, preparation of a client for surgery, and eliminate option 2 first because discontinuing exercises can be harmful to the client. Knowledge regarding the medications that affect the surgical client will assist in eliminating options 3 and 4. General principles related to preparing a client for surgery will direct you to option 1.

A client who had knee surgery 4 days ago reports to the home health nurse that he has not had a bowel movement since before the surgery. Which questions would assist the nurse in the collection of data regarding the client's problem? Select all that apply.

1."How often do you usually move your bowels?"
2."How often do you usually take a laxative?"
3."Have you been eating meat on a daily basis?"
4."What have you been eating and drinking since the surgery?"
5."Have you been experiencing any urge to move your bowels?"
6."What kind and how often have you been taking medications for pain?"

4."What have you been eating and drinking since the surgery?"
5."Have you been experiencing any urge to move your bowels?"
6."What kind and how often have you been taking medications for pain?"

Constipation is marked by difficult or infrequent passage of stools that are hard and dry. Constipation has numerous causative factors, including psychogenic factors, lack of physical activity, inadequate intake of food and fiber, and medication influences. A client recovering from knee surgery may have several factors influencing elimination patterns. The nurse needs to collect data regarding fluid and dietary intake since surgery, whether the client has been responding to the urge to defecate, and whether the pain medication type and frequency is likely to cause constipation. The presurgery bowel frequency and laxative use are not pertinent since the client has not had a bowel movement for 4 days. The intake of meat is unrelated to constipation.

Focus on the subject, the cause of the constipation. Options 1 and 2 can be eliminated first because they are unrelated to the subject of the question. From the remaining options, eliminate option 3 because it will not elicit adequate information that will assist the nurse in determining the cause of the constipation. Select the options that relate directly to bowel function at this time including dietary and fluid intake, client awareness of peristalsis, and pain analgesic use, which may be slowing gastrointestinal function.

The nurse is caring for a postoperative client who had a pelvic exenteration. The primary health care provider has changed the client's diet from nothing by mouth (NPO) to clear liquids. The nurse checks for which information before administering the clear liquids? Select all that apply.

1.Incision appearance
2.Pain rating of 3 or less
3.Presence of bowel sounds
4.Urinary output of 30 mL per hour
5.Whether the client has passed flatus

3.Presence of bowel sounds
4.Urinary output of 30 mL per hour
5.Whether the client has passed flatus

Pelvic exenteration is a radical surgery for treatment of gynecological cancer involving removal of the uterus, ovaries, fallopian tubes, vagina, bladder, and urethra. Sometimes the descending colon and rectum may also be removed. The client would have a colostomy and ileal conduit created if part of the colon and rectum and bladder are removed. This surgery is done when no metastases have been found outside the pelvis, and the client is agreeable. It is done less often today. The client is kept NPO until peristalsis returns, usually in 4 to 6 days postoperatively. When signs of bowel function return, clear fluids are given. If no distention occurs, the diet is advanced as tolerated. It is most important to monitor for return of peristalsis by the presence of bowel sounds and passing flatus before feeding the client. Before giving the client liquids, the nurse does not need to inspect the incision, assess pain, or monitor the urinary output. These interventions would be done but are not related to beginning the clear liquid diet.

Focus on the subject, the nurse's concern when changing the postoperative client's diet from nothing by mouth (NPO) to clear liquids after a radical surgery such as pelvic exenteration. Select the options that assess for the return of peristalsis.

The nurse is reviewing the preoperative prescriptions of a client with a colon tumor who is scheduled for abdominal perineal resection. The nurse notes that the primary health care provider has prescribed neomycin sulfate orally for the client. Which is the rationale for prescribing this medication?

1.To prevent an infection
2.Because the client has an infection
3.To decrease the bacteria in the bowel
4.Because the client is allergic to penicillin

3.To decrease the bacteria in the bowel

Intestinal anti-infectives such as neomycin are administered to decrease the bacteria in the bowel. To reduce the risk of contamination at the time of surgery, the surgeon may prescribe that the bowel is emptied and cleansed. Laxatives and enemas are given to empty the bowel.

Focus on the subject, abdominal perineal resection surgery. Eliminate options 2 and 4 first because no reference is made to this information in the question. Recalling the concepts related to the flora of the intestinal tract will assist in directing you to option 3 as the primary purpose of this medication.

The nurse is caring for a postoperative client who has been NPO and the primary health care provider (PHCP) has prescribed a clear liquid diet. When planning to initiate this diet, which priority item should the nurse place at the client's bedside?

1.A straw
2.Code cart
3.Blood pressure cuff
4.Suction equipment

4.Suction equipment

In a postoperative client, a concern related to initiating a diet is aspiration. Initiating postoperative oral fluids may lead to distention and vomiting. Suction equipment must be available. A blood pressure cuff may be necessary but is not the priority from the options provided. A code cart is unnecessary. A straw may help the client sip fluids but is not necessary.

Note the strategic word, priority. Use the ABCs—airway, breathing, and circulation—to answer this question. The correct option will maintain airway clearance.

The nurse is reinforcing instructions to a client and family regarding home care following cataract removal with lens implantation in the left eye. The nurse should provide the client with instructions to contact the surgeon promptly for which signs or symptoms? Select all that apply.

1.New floaters
2.Improvement in vision clarity
3.Increasing redness in the eye
4.Sensation of mild grittiness in the eye
5.Pain relieved by acetaminophen 500 mg

1.New floaters
3.Increasing redness in the eye
4.Sensation of mild grittiness in the eye

Following cataract surgery, in which the cloudy lens is removed and a new lens is implanted in the eye, clients are sent home to recover. Clients should contact the surgeon immediately if there is the presence of new floaters (seeing small dots) because this could be a sign of a detached retina. Some redness in the eye may be present but increased redness could indicate bleeding or infection and should also be promptly reported. Clients usually experience improved vision, a sensation of grittiness in the eye, and pain that is controlled with acetaminophen.

Focus on the subject, signs and symptoms to report immediately to the surgeon after cataract surgery. Consider each option and expect that mild symptoms of inflammation are expected as is improved vision. Select options that list signs and symptoms associated with complications.

The nurse is reinforcing instructions to a client following mastectomy who will be discharged with an axillary drain in place. The client will be receiving home care visits from the nurse to monitor drainage and perform dressing changes. Which client statement indicates a need for further teaching?

1."I need to keep my arm elevated when I sit or lie down."
2."I can massage the area with cocoa butter lotion once the incision heals."
3."I may feel pain in the breast area even though my breast has been removed."
4."I need to begin full range-of-motion (ROM) exercises to my upper arm as soon as I get home."

4."I need to begin full range-of-motion (ROM) exercises to my upper arm as soon as I get home."

The client should be instructed to limit upper arm ROM to the level of the shoulder only. After the axillary drain is removed, the client can begin full ROM exercises to the upper arm as prescribed by the primary health care provider. Elevating the arm above the heart level while sitting or lying down, massaging the area with cocoa butter after the incision is completely healed if prescribed by the primary health care provider, and having pain in the absent breast (phantom pain) are correct measures following a mastectomy.

Focus on the subject, client discharge with an axillary drain in place. Note the strategic words, need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Noting the word full in option 4 will direct you to this option.

The nurse is reinforcing instructions to a client about the use of an incentive spirometer in the postoperative period. The nurse should include which information in discussions with the client? Select all that apply.

1.Inhale as rapidly as possible.
2.Keep a loose seal between the lips and the mouthpiece.
3.After maximum inspiration, hold the breath for 10 seconds and exhale.
4.Use the incentive spirometer for 5 to 10 breaths every hour while awake.
5.The best results are achieved when sitting at least halfway or fully upright.

4.Use the incentive spirometer for 5 to 10 breaths every hour while awake.
5.The best results are achieved when sitting at least halfway or fully upright.

An incentive spirometer is a volume- or flow-oriented device used to encourage deep breathing by giving visual feedback to the client during its use. For optimal lung expansion with an incentive spirometer, the client should assume the semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely while the client inhales slowly with a constant flow through the unit. The breath should be held for 2 to 3 seconds before exhaling slowly.

Focus on the subject, the procedure for using the incentive spirometer, and visualize this procedure. Understand that the purpose is to promote lung expansion and evaluate the options related to that criterion to select the correct answers.

A client is being advanced to a full liquid diet on the second postoperative day. Which foods are allowed for this client? Select all that apply.

1.Tea
2.Crackers
3.Ice cream
4.Scrambled eggs
5.Cream of tomato soup
6.Cream of wheat cereal

1.Tea
3.Ice cream
5.Cream of tomato soup
6.Cream of wheat cereal
A full liquid diet consists of the foods on a clear liquid diet plus the addition of smooth dairy products, cream soups, and refined cooked cereals. The client's diet would include tea, ice cream, cream of tomato soup, and cream of wheat cereal. Crackers are on a regular diet. Scrambled eggs are included in a pureed diet.

Focus on the subject, foods included in a full liquid diet. Note that all foods on a clear liquid diet (those that are clear at room temperature) are included, as well as smooth foods including dairy. Evaluate the foods according to the criteria to select the correct answers.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

1.Inhale as rapidly as possible.
2.Keep a loose seal between the lips and the mouthpiece.
3.After maximum inspiration, hold the breath for 15 seconds and exhale.
4.The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

4.The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

Focus on the subject, correct use of an incentive spirometer, and visualize the procedure. Note the words rapidly, loose, and 15 seconds in the incorrect options. Options 1, 2, and 3 are incorrect steps regarding incentive spirometer use.

The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activities in the nursing care plan for the client on the day of surgery? Select all that apply.

1.Have the client void before surgery.
2.Avoid oral hygiene and rinsing with mouthwash.
3.Verify that the client has not eaten for the last 24 hours. 4.Determine that the client has signed the informed consent for the surgical procedure.
5.Report immediately any slight increase in blood pressure or pulse from the client's baseline vital signs.

1.Have the client void before surgery.
4.Determine that the client has signed the informed consent for the surgical procedure.
5.Report immediately any slight increase in blood pressure or pulse from the client's baseline vital signs.

The nurse caring for clients who will be having surgery must ensure that the client is properly identified and prepared according to the prescription(s) by the surgeon and anesthesiologist. The nurse should assist the client with voiding before surgery so that the bladder is empty at the beginning of the procedure. The nurse should verify that the client has signed the consent for the procedure. If the client has not signed a consent, no preoperative medications should be given, and the surgeon can obtain the consent before proceeding. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 8 hours before surgery rather than 24 hours (often NPO after midnight). A slight increase in blood pressure and pulse is common during the preoperative period; this is generally the result of anxiety. The nurse should verify what the normal blood pressure and pulse rate are for this client.

Focus on the subject, preoperative care. Recall that the purpose of preoperative preparation is to promote a successful surgical outcome and lower the risk of complications from surgery and anesthesia. Evaluate each option according to that standard and you will select the answers that assure a positive surgical outcome.

A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply.

1.Notify the registered nurse immediately.
2.Document the client's complaint with the exact times.
3.Place a sterile saline dressing and ice packs over the wound.
4.Prepare the client for wound closure by notifying surgery department.
5.Place the client in a supine position without a pillow under the head.
6.Instruct the client to remain quiet and reassure the situation is being taken care of.

1.Notify the registered nurse immediately.
2.Document the client's complaint with the exact times.
4.Prepare the client for wound closure by notifying surgery department.
6.Instruct the client to remain quiet and reassure the situation is being taken care of.

Wound dehiscence is the separation of the wound edges, and wound evisceration is the protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the registered nurse is notified, and he or she then contacts the surgeon immediately. The client is placed in a low-Fowler's position, kept quiet, and instructed not to cough. Protruding organs are covered with a sterile, saline dressing. Ice packs are not applied. The treatment for evisceration is immediate wound closure under local or general anesthesia.

Focus on the subject, a loop of bowel protruding through the incision, to assist you in determining that the client is experiencing wound evisceration. Visualizing this occurrence will assist you with determining that the client should not be placed supine and that ice packs should not be placed on the incision.

The student nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action should be appropriate?

1.Notify the registered nurse.
2.Cover the wound and reassess in 1 hour.
3.Leave the wound open to air to assist in drying.
4.Clean the wound and cover with a dry sterile dressing.

1.Notify the registered nurse.

Sanguineous drainage is bright red and indicates active bleeding. If active bleeding is present, the registered nurse should be notified. Covering the wound and reassessing in 1 hour will delay needed intervention. Leaving a wound open to air can lead to infection, and the blood will not be contained.

Focus on the subject, sanguineous drainage. Use knowledge of the various types of wound drainage to answer this question. Knowing that sanguineous drainage is bright red and indicates active bleeding will direct you to option 1.

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and should be reported to the primary health care provider before the surgery? Select all that apply.

1.Is allergic to penicillin
2.Quit smoking 3 months earlier
3.History of tonsillectomy at the age of 7 years
1.Is allergic to penicillin
2.Quit smoking 3 months earlier
5.Takes daily multivitamin and calcium supplement.
6.History of deep venous thrombosis in right leg 10 years earlier

1.Is allergic to penicillin
2.Quit smoking 3 months earlier
1.Is allergic to penicillin
2.Quit smoking 3 months earlier

The nurse conducts an interview and reviews current health practices and health history preoperatively with clients. Specific client data that are likely to affect a surgery is communicated promptly. The nurse reports any client allergies, especially an antibiotic allergy to avoid an allergic reaction perioperatively. The fact that the client was a smoker until recently is pertinent because it may affect how the client tolerates and recovers from anesthesia. The nurse should communicate any client concerns about the effects of the surgery so that the matter can be discussed and understood clearly before the surgery (informed consent). A history of a deep venous thrombosis (DVT) is pertinent because of an increased risk for DVT after the planned surgery, and precautions should be prescribed. A history of a childhood tonsillectomy and routine vitamin and mineral supplementation are part of the client history but are not pertinent data that needs to be reported specifically.

Focus on the subject, reporting pertinent client data that affects surgery. Considering each option and its effect on the client having the surgery will assist in answering the question.

A client has been taking prednisone for 3 years. She is scheduled for abdominal hysterectomy. The nurse plans care realizing that postoperatively the client is at risk for which conditions? Select all that apply.

1.Hypoglycemia
2.Increased risk for dehiscence
3.Excessive bleeding at the surgical incision
4.Increased likelihood of surgical site infection
5.Very early wound healing, causing excessive scarring

2.Increased risk for dehiscence
4.Increased likelihood of surgical site infection

Chronic use of glucocorticoids, such as prednisone, increases the risk of surgical site infections and the potential for dehiscence. Wound healing may be slow. Glucocorticoids increase the blood glucose. Excessive bleeding is not associated with glucocorticoids.

Focus on the subject, the client has been taking prednisone for 3 years. Identify prednisone as a glucocorticoid. Next note the words, at risk for. Recalling the adverse effects of long-term use of glucocorticoids will assist in directing you to the correct options.

After abdominal surgery, a client experiences an evisceration. Which client statement supports this diagnosis?

1."My incision is itching in several places."
2."It felt like something just slit me wide open."
3."My incision is painful, especially when I move."
4."There seems to be some redness along the incision line."

2."It felt like something just slit me wide open."

Wound evisceration is the total separation of the layers of the wound and extrusion of internal organs or viscera (usually abdominal) through the open wound. This disruption in wound healing may be preceded by excessive coughing, not splinting the surgical site, vomiting, or straining. The client may state, "something gave way," or "I feel as if I just split open." Itching, discomfort with moving, and redness along the incision line are not signs and symptoms directly associated with evisceration.

The subject of the question is evisceration. Note that the client in the question underwent abdominal surgery. Consider the meaning of "viscera" (organs) and the prefix "e." Understanding what an evisceration is and noting the relationship between the words abdominal surgery in the question and the statement in the correct option will direct you to option 2.

The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation?

1.A urinary output of 20 mL/hour
2.A temperature of 37.6° C (99.6° F)
3.A blood pressure of 100/70 mm Hg
4.Serous drainage on the surgical dressing

1.A urinary output of 20 mL/hour

Urine output is maintained at a minimum of at least 30 mL/hour for an adult. An output of less than 30 mL/hour for each of 2 consecutive hours should be reported to the surgeon. A temperature more than 37° C (100° F) or less than 36.1° C (97° F) and a falling systolic blood pressure less than 90 mm Hg are to be reported. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

Note the strategic word, most, and focus on the subject, normal assessment data in a postoperative client. Use knowledge of normal expected postoperative ranges to determine that the urinary output is the only finding that is not within normal range.

A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important?

1.Recording that the count was incorrect
2.Informing the surgeon of the situation
3.Looking on the instrument table for the sponge
4.Asking the circulating nurse to look for the sponge

2.Informing the surgeon of the situation

The surgeon has the ultimate responsibility for the safety of the client and can stop the surgery until the sponge is found. Although documenting is necessary, this is not the most important action. Although options 3 and 4 may be appropriate, the surgeon needs to be informed about the missing sponge.

Focus on the subject, a missing surgical sponge. Noting the word, important, and recalling that the surgeon is ultimately responsible for the client will direct you to option 2.

The nurse is caring for a client following an abdominal surgery performed 1 day ago. An intravenous (IV) line is infusing and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse should perform which actions? Select all that apply.

1.Increase the amount of suction on the NG tube.
2.Ask the client whether he has passed any flatus.
3.Encourage the client to take frequent sips of water.
4.Document the finding and continue to check for bowel sounds. 5.Immediately notify the registered nurse or primary health care provider.

2.Ask the client whether he has passed any flatus.
Document the finding and continue to check for bowel sounds.

Bowel sounds may be absent for 3 to 4 postoperative days owing to bowel manipulation during surgery. Passing flatus is another way to determine whether peristalsis is occurring postoperatively. The nurse should document the finding and continue to monitor the client. The suction is not increased on the NG tube, and the client should receive nothing by mouth (NPO) until after the onset of bowel sounds. There is no need to immediately notify the registered nurse.

Focus on the subject, return of peristalsis after abdominal surgery, and note the words, 1 day ago. Recalling that bowel sounds may not return for 3 to 4 postoperative days will direct you to the correct answers.

The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How should the nurse initially address the clients concerns?

1.Tell the client that preoperative fear is normal.
2.Explain all nursing care and possible discomfort that may result. 3.Ask the client to discuss information known about the planned surgery.
4.Provide explanations about the procedures involved in the planned surgery.

3.Ask the client to discuss information known about the planned surgery.

The client is concerned about having surgery and needs to discuss it. This will offer the client the opportunity to verbalize his or her current and specific understanding. Explanations should begin with the information that the client knows. Option 1 is a block to communication and minimizes the client's feelings. Giving unsolicited explanations may produce additional anxiety and not address the real concerns of the client.

Note the strategic word, initially, and realize the question asks for the first response of the nurse. Use therapeutic communication techniques of open-ended questions and active listening, and focus on the client's feelings first. Option 3 is the only option that addresses data collection, which follows the steps of the nursing process.

The nurse is caring for a postoperative client who is wearing an abdominal binder following abdominal surgery. Which interventions should the nurse include in relationship to prescribed dressing change? Select all that apply.

1.Sit up for coughing while splinting the incision.
2.Remove the binder before assisting the client to ambulate. 3.Remove the binder only when the primary health care provider is present.
4.Apply the binder over the abdominal dressing as tight as possible. 5.Remove the binder to change the abdominal dressing as prescribed and reapply.

1.Sit up for coughing while splinting the incision.
5.Remove the binder to change the abdominal dressing as prescribed and reapply.

Binders are large bandages often made of elastic materials that attach together with Velcro and are applied over the abdominal dressing. After abdominal surgery, a binder is used to relieve tension from the suture line and provide support. This maintains the integrity of the incision, helps prevent dehiscence and wound evisceration, and thereby helps prevent infection. Using a binder, however, can hinder chest expansion, promote shallow breathing, and aggravate residual atelectasis and risk of pneumonia from surgery. The client is instructed to sit up to facilitate diaphragmatic excursion and to splint the incision for client comfort and suture line protection while coughing, deep breathing, and using the incentive spirometer. The binder is removed while the client is supine to have the dressing changed and then reapplied. The binder should be worn while the client ambulates. The binder can be removed when the primary health care provider is not present. The binder is applied fairly tight but not so tight as to impair circulation.

Focus on the subject, abdominal binder. Recall the binder is used to give support to the abdominal incision. Remember that abdominal restriction is likely to hinder chest expansion. The binder is removed to inspect and change the dressing as prescribed. Consider each option and select the answers that relate to giving the client care and providing support while ambulating.

A client has returned to the nursing unit following abdominal hysterectomy. To gather data on the client's postoperative bleeding, the nurse should implement which interventions? Select all that apply.

1.Observing perineal pad drainage
2.Observing the abdominal dressing
3.Rolling the client to one side to view bedding
4.Monitoring output from the Jackson-Pratt drain
5.Auscultation of bowel sounds, especially lower quadrants 6.Observing for abdominal distention and presence of ecchymosis

1.Observing perineal pad drainage
2.Observing the abdominal dressing
3.Rolling the client to one side to view bedding
4.Monitoring output from the Jackson-Pratt drain

The nurse should roll the client to one side after checking the perineal pad and abdominal dressing. This allows the nurse to check the rectal area, where blood may pool by gravity, particularly if the client is lying supine. The nurse should also observe the output from the Jackson-Pratt drain. Auscultation of bowel sounds is related to return of peristalsis. Abdominal distention may occur with air in the bowels not necessarily bleeding. Ecchymosis from the surgical bleeding would not be apparent so soon after surgery.

Focus on the subject, determining postoperative bleeding after an abdominal hysterectomy. Consider the intervention described in each option and select the options that relate to bleeding, both observable and measureable.

The nurse receives a client in the surgical unit who was transferred from the postanesthesia care unit. The nurse checks the client for which data first?

1.A patent airway
2.Surgical dressing
3.Adequate urine output
4.Orientation to the surroundings

1.A patent airway

After transfer from the postanesthesia care unit, the nurse performs an assessment on the client. Airway must be established first. Urine output, surgical dressing, and orientation to the surroundings also may be checked, but these are not the first actions.

The nurse has admitted a client to the clinical nursing unit following a right mastectomy. Which interventions should be included in the plan of care? Select all that apply.

1.Elevate the right arm on one or two pillows.
2.Do not check the radial pulse in the right arm.
3.Use small-gauge needles if the IV is initiated in the left arm. 4.Instruct the client to avoid bending the fingers of the right hand. 5.Ensure that no venipunctures or blood pressures (BPs) are done in the right arm.

1.Elevate the right arm on one or two pillows.
5.Ensure that no venipunctures or blood pressures (BPs) are done in the right arm.

The client, who has undergone a mastectomy (removal of the breast) procedure, is at risk for developing lymphedema due to disruption of the lymph circulation. The client's operative arm should be positioned so that it is elevated on one or two pillows and does not exceed shoulder elevation. This will facilitate the flow of fluids through the lymph and venous routes and prevent lymphedema (accumulation of lymph in soft tissue). Placing a sign stating no venipunctures or BPs in the operative arm will inform all health care workers of the precautions needed to prevent infection or blockage of lymph channels in the arm. Checking the radial pulse in the right arm will not block lymph circulation. The left arm needs no precautions because the lymph circulation is intact on that arm. The client may bend the fingers and not bending them will likely promote edema.

Focus on the subject, interventions to prevent lymphedema in the postmastectomy client. Use principles of infection prevention, circulation, and gravity to answer this question.

The nurse is monitoring the status of the postoperative client after abdominal surgery earlier in the day. Which signs or symptoms noted by the nurse would indicate an evolving complication associated with hypovolemia? Select all that apply.

1.Increasing restlessness
2.Capillary refill of 3 seconds in all extremities
3.Hypoactive bowel sounds in all four quadrants
4.White blood cell (WBC) count 9,500 mm3 (9.5 × 109/L)
5.Blood pressure of 104/66 mm Hg with a pulse of 106 beats per minute

1.Increasing restlessness
5.Blood pressure of 104/66 mm Hg with a pulse of 106 beats per minute

Hypovolemia is decreased circulating blood volume. In a postoperative client, this often is associated with inadequate fluid replacement or hemorrhage. Increasing restlessness is a sign that requires continuous and close monitoring because it could forecast a complication such as shock. A low and dropping BP with an increased pulse rate could be early compensation for a decrease in circulating blood volume. The WBC count is normal at 5000 to 10,000 mm3 (5 to 10 × 109/L). Hearing hypoactive bowel sounds in all four quadrants is a normal occurrence, as is a capillary refill of 3 seconds in all extremities.

Focus on the subject, an evolving complication associated with hypovolemia. Evaluate each option and determine whether it is associated with blood volume and is a normal or abnormal finding.

The nurse monitors a postoperative client who had abdominal surgery for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication? Select all that apply.

1.Increasing restlessness
2.A temperature of 98.9° F (37.7° C)
3.Unrelieved pain despite receiving analgesics
4.Faint bowel sounds heard in all four quadrants
5.A blood pressure of 114/66 mm Hg with a pulse of 96 beats per minute

1.Increasing restlessness
3.Unrelieved pain despite receiving analgesics

Increasing restlessness and unrelieved pain despite receiving analgesics are signs that require continuous and close monitoring because they could be potential indications of a complication, such as hemorrhage or shock. A temperature of 98.9° F is normal. Faint bowel sounds heard in all four quadrants is a normal occurrence. A blood pressure of 114/66 mm Hg with a pulse of 96 beats per minute is a relatively normal sign.

Focus on the subject, presence of a complication. Evaluate each option and consider whether it is an early sign of a potential complication.

The nurse, caring for a client with a postoperative abdominal wound, observes that the dressing has Montgomery ties in place. The nurse determines this intervention will decrease the risk of which complication?

1.Dehiscence
2.Paralytic ileus
3.Wound infection
4.Skin irritation surrounding the wound

4.Skin irritation surrounding the wound

The use of Montgomery ties, also called Montgomery straps, is a means of securing a dressing without removing and reapplying tape on the skin surrounding the incision. The ties consist of a long strip of material, half of which contains an adhesive backing to apply to the skin, and the other half folds back and contains a cloth tie or a safety pin/rubber band combination that you fasten across a dressing and untie at dressing changes. Montgomery ties are often used with wounds requiring frequent dressing changes and prevent irritation to the skin surrounding the incision. The ties do not lower the risk of dehiscence, paralytic ileus, or wound infection.

Use knowledge of basic concepts related to the subject, the purpose of Montgomery ties with care of an abdominal dressing. Eliminate dehiscence and wound infection because they are comparable or alike options. Eliminate paralytic ileus because it is not related to the incision or abdominal wound. Use your knowledge of wound care materials to select the correct answer.

A client's preoperative vital signs are temperature 98.6° F (37° C) orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which action should the nurse take first?

1.Recheck the blood pressure in 5 minutes.
2.Take an apical-radial pulse for a full minute.
3.Compare these values to those recorded previously.
4.Report the vital signs immediately to the registered nurse.

3.Compare these values to those recorded previously.

Preoperative assessment of vital signs provides important baseline data with which to compare following surgery. Anxiety and fear commonly cause elevations in the heart rate and blood pressure. The nurse should review and compare the vital signs to those recorded previously. The vital signs as stated in the question do not need to be reported to the registered nurse immediately. The apical pulse is not above the normal range and an apical radial pulse for a full minute is not required. Rechecking the blood pressure in 5 minutes is likely to show an unchanged blood pressure measurement.

Note the strategic word, first. Focus on the data in the question and note that the client is preoperative. Recalling the normal ranges for vital signs and the effects of anxiety and fear on the vital signs in the preoperative client will direct you to option 3. The first action should be to compare the values to those recorded previously.

The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action?

1.Leave the incision open to the air.
2.Apply a dry sterile dressing to the wound.
3.Ask the client to cough to verify the presence of dehiscence. 4.Apply a sterile dressing soaked with sterile normal saline to the wound.

4.Apply a sterile dressing soaked with sterile normal saline to the wound.

Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. It usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and to avoid coughing or straining. The client should be placed in semi-Fowler's position to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The primary health care provider needs to be notified immediately.

Note the strategic word, initial, and focus on the subject, wound dehiscence. Eliminate option 1 because this action would expose the open wound and underlying tissues to infection. Eliminate option 2 because a dry dressing will irritate the exposed body tissues. Eliminate option 3 because coughing will disrupt the exposed underlying tissue and organs.

A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

1."If it's any help, everyone is nervous before surgery."
2."I will be happy to explain the entire surgical procedure to you."
3."Can you share with me what you've been told about your surgery?"
4."Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

3."Can you share with me what you've been told about your surgery?"

In assisting clients to deal with anxiety related to medical treatments, it is important that the nurse focus on the client and promote the expression of feelings. An open-ended question will assist the client to express emotions and concerns. Explanations should begin with the information that the client knows. By providing the client with an individualized explanation of care and procedures, the nurse can assist the client in handling fears and providing a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. The nurse should not trivialize the client's expression of anxiety or cut off communication by giving excessive information and focusing on the surgery and not the client.

Note the strategic words, most likely. Use of therapeutic communication skills and interviewing techniques will direct you to the correct option.

Which types of nourishment should the nurse include when initiating a prescribed clear liquid diet for a postoperative client who has a gag reflex after surgery under general anesthesia? Select all that apply.

1.Coffee
2.Ice chips
3.Beef broth
4.Plain yogurt
5.Tea with milk
6.Lemon flavored gelatin

1.Coffee
2.Ice chips
3.Beef broth
6.Lemon flavored gelatin

A clear liquid diet includes fluids or frozen fluids that are clear at room temperature. These food sources are easy to digest and less likely to cause vomiting in a postoperative client. The nurse should assess for the return of the gag reflex first before initiating any oral intake. Coffee, ice chips, beef broth, plain tea, and gelatins are included in a clear liquid diet. Dairy products such as milk or yogurt are included in a full liquid diet.

Focus on the subject, nourishments included in a clear liquid diet. Recall the definition of clear liquids and evaluate each option.

The nurse is taking care of a client preoperatively. The client is NPO and an intermediate and short-acting insulin are scheduled for 0700 daily. The client's surgery is scheduled for 0900. Which is the best action for the nurse to take?

1.Administer both medications.
2.Obtain and document the client's finger stick glucose level.
3.Call the primary health care provider (PHCP) for clarification. 4.Withhold both medications and document surgery as a reason for withholding the medication.

3.Call the primary health care provider (PHCP) for clarification.

The diabetic client who is going to surgery will not have the usual diet and will not require the routine prescribed insulins. The primary health care provider should be notified to prescribe an adjusted insulin dosage for the day of surgery. The nurse must contact the PHCP for clarification of the prescription and should not give the medication because it might lead to hypoglycemia during surgery. The nurse should not withhold the insulin because this might lead to hyperglycemia during surgery and can cause increased risk for infection and impaired wound healing. The nurse may obtain the finger stick glucose reading but this should be reported to the PHCP when seeking clarification.

Focus on the strategic word, best. Think about the preoperative care for clients with diabetes mellitus. Recalling the effects of insulin and the nurse's legal responsibilities and role will assist in directing you to the correct option.

The nurse is caring for a postoperative client who is being monitored by pulse oximetry. Which is an expected measurement determined by the pulse oximeter?

1.Oxygen liter flow 2 liters
2.Oxygen saturation 95% to 100%; blood pressure 120/80 to 130/80 mm Hg
3.Oxygen partial pressure 80 to100 mm Hg; respiration rate 18 to 22 breaths per minute
4.End tidal carbon dioxide 35 to 45 mm Hg; temperature 98° F to 99° F (36.7° C to 37.2° C):

2.Oxygen saturation 95% to 100%; blood pressure 120/80 to 130/80 mm Hg

Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2). The pulse oximeter does not replace arterial blood gases, but it is an effective tool to monitor the client for subtle or sudden changes in oxygen saturation. It is not the oxygen liter flow that may be prescribed for a client, the oxygen level from arterial blood gases, or the end tidal carbon dioxide, which is measured on exhalation and is more sensitive to hypoxemia that oxygen saturation.

Focus on the subject, pulse oximetry. Recalling the purpose of the pulse oximeter and that it is a method of monitoring the oxygen saturation will direct you to option 2.

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should plan to place the client in which position?

1.Prone
2.Reverse Trendelenburg's
3.Supine, with the residual limb flat on the bed
4.Supine, with the residual limb supported with pillows

4.Supine, with the residual limb supported with pillows

The residual limb is usually supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema. After the first 24 hours, the residual limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check the surgeon's prescription(s) regarding positioning following amputation.

Focus on the subject, positioning following amputation, and note that the client has just returned from surgery. Using basic principles related to immediate postoperative care and preventing edema will assist in directing you to the correct option.

The nurse in the primary health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client?

1."These sensations are signs of a complication."
2."These sensations probably will be permanent."
3."These sensations lessen over several months and usually are gone after 1 year."
4."It is nothing to worry about because women who have this type of surgery experience this problem."

3."These sensations lessen over several months and usually are gone after 1 year."

Numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow occurs in women after mastectomy. It is a result of injury to the nerves that provide sensation to the skin in those areas. These sensations may be described as heaviness, pain, tingling, burning, or "pins and needles." These sensations dissipate over several months and usually resolve 1 year after surgery.

Focus on the subject, numbness along the incision and inner upper arm after mastectomy. Use therapeutic communication techniques and address the client's concerns using clear understandable terms. Explain the postoperative situation truthfully and accurately. Telling the client it is nothing to worry about is incorrect because it is not therapeutic and dismisses the client's complaint.

The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A wound drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change?

1.Advancing the drain by ¼ inch
2.Omitting gloves during the procedure
3.Securing the drain by taping it firmly to body
4.Checking the wound site for drainage from the drain

4.Checking the wound site for drainage from the drain

The wound site needs to be checked for drainage from the drain; the drainage can excoriate the skin. Usually the drainage from the wound is pale, red, and watery. Active bleeding is bright red. Aseptic technique must be used when changing the dressing to avoid contamination of the wound, and sterile gloves are worn. The drain should be checked for patency to provide an exit for the fluid and blood to promote healing. The drainage needs to flow freely, and there should be no kinks in the drains. Curling, folding, or taping the drain prevents the flow of drainage. The tube is not advanced.

Focus on the subject, abdominal dressing change after a suprapubic prostatectomy. Knowledge of the care of drains is necessary to answer this question. Read each option carefully and visualize each option. Note that option 4 is the only option that is a data collection action, which is the first step in the nursing process.

A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, "I don't feel any better than I did before surgery." Which response by the nurse is most appropriate?

1."You will feel better in a week or two."
2."It's only the second day postop. Cheer up."
3."This is a normal frustration. It'll get better."
4."You are concerned that you don't feel any better after surgery?"

4."You are concerned that you don't feel any better after surgery?"

Paraphrasing is restating the client's message in the nurse's own words. Paraphrasing may be in the form of a question. Option 4 uses the therapeutic communication technique of paraphrasing. The client is frustrated and is searching for understanding. Options 1, 2, and 3 are inappropriate communication techniques. Option 1 belittles the client's concerns. Options 2 and 3 offer false reassurance by the nurse.

Note the strategic words, most appropriate. Use therapeutic communication techniques to answer the question. Option 4 focuses on the client's feelings.

A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery?

1.Assess patency of the airway.
2.Check tubes or drains for patency.
3.Check dressing for bleeding or drainage.
4.Obtain vital signs to compare with those recorded preoperatively.

1.Assess patency of the airway.

If the airway is not patent, immediate measures must be taken for the survival of the client. After checking the client's airway, the nurse would then check the client's vital signs, followed by the dressings, tubes, and drains.

The nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which action should the nurse plan to take first?

1.Shake gently to arouse.
2.Call the surgeon immediately.
3.Cover the client with a warm blanket.
4.Recheck the vital signs in 15 minutes.

4.Recheck the vital signs in 15 minutes.

A drop in blood pressure slightly below a client's preoperative baseline reading is common after surgery. The nurse should recheck the vital signs. There are no data in the question suggesting that the client is unarousable or requiring a warm blanket. Warm blankets are applied to maintain the client's body temperature or in the case of shivering. Level of consciousness can be assessed by the evaluation of the client's response to light touch and verbal stimuli. It is not necessary to contact the surgeon immediately.

Use principles of priority setting and the ABCs—airway, breathing, and circulation—to answer this question. Note the strategic word, first in the question. Checking vital signs takes priority over warming the client and arousing the client. The vital signs are within normal limits following this surgical procedure; therefore, the surgeon does not need to be notified immediately.

The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is nonreddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 mm3 (7.5 × 109/L). Which interpretation does the nurse make of these findings?

1.The incision line is slightly edematous but shows no active signs of infection.
2.The incision line shows no sign of infection, although the WBC count is elevated.
3.The incision line shows early signs of infection supported by an elevated WBC count.
4.The incision line shows early signs of infection, although the temperature is near normal.operative

1.The incision line is slightly edematous but shows no active signs of infection.

Sternotomy incision sites are assessed for signs and symptoms of infection, such as redness, swelling, and induration. An elevated temperature and elevated WBC count after 3 to 4 days usually indicate infection. A WBC count of 7500 mm3 (7.5 × 109/L) is within the normal range. Normal WBC is 5000 to 10,000 mm3 (5 to 10 × 109/L).

Focus on the subject, condition of the sternotomy incision. Eliminate the two options indicating the WBC count is elevated because a value of 7500 cells/mm3 is normal. Additionally, the lack of drainage and redness helps you choose the option that indicates that there are no signs of infection.

When positioning for a surgical procedure, the nurse understands that the client's respiratory system is most at risk for dysfunction in which position?

1.Sims'
2.Supine
3.Lateral
4.Lithotomy

4.Lithotomy

The thoracic cage normally expands in all directions except posteriorly. In a lithotomy position, the expansion of the lungs is restricted at the ribs or sternum, and there is a reduction in the ability of the diaphragm to push down against the abdominal muscles. Respiratory function is impaired because of this interference with normal movements. The volume of air that can be inspired is reduced. Sims', supine, and lateral positions will not compromise lung expansion as much as the lithotomy position would.

Note the strategic word, most. Visualize each of these positions and their effect on the process of respiration. Options 1 and 3 are comparable or alike; therefore, eliminate these options. Consider the expansion of the lungs with each position, and this will lead you to select the correct answer.