Nokea
The nurse is caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock?
- A. Weak and rapid pulse rate
- B. Warm, dry skin
- C. Pooling of secretions in the lungs
- D. Obstructed airway
Correct Answer: A
Rationale: Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock.
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A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants?
- A. Scrub nurse
- B. Circulating nurse
- C. First assistant
- D. Certified registered nurse anesthetist
Correct Answer: A
Rationale: The scrub nurse is sterile and assists the surgical team by handing instruments to the surgeon, preparing sutures, receiving specimens to be sent to the lab, and counting sponges and needles. The circulating nurse is not sterile and obtains and opens sterile equipment, adjusts lights, and keeps records. The first assistant is involved with the client's preoperative care. The certified registered nurse anesthetist assists in the client's anesthesia.
The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed?
- A. If I do not follow the instructions, my surgery could be cancelled.
- B. The nurse will explain the details of the surgery before I sign a consent.
- C. My medical records will be sent to the ambulatory care center prior to my surgery.
- D. The physician will update my family after the procedure and provide specific discharge instructions.
Correct Answer: B
Rationale: Further instruction would be needed to clarify that the physician, not the nurse, explains the details of the surgery and obtains voluntary consent for the procedure. It is correct that preoperative instructions must be followed prior to surgery for the safety of the client, medical records are present for review prior to surgery, and the physician speaks with the family following the procedure and provides instructions for discharge.
The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?
- A. Requirement of intermittent catheterization
- B. Calculus formation
- C. Urine retention
- D. Urinary infection
Correct Answer: C
Rationale: Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus.
The nurse is working in the preoperative area with a client going to surgery for a cholecystectomy. The client has histaminez-receptor antagonists prescribed preoperatively. The client asks the nurse why these medications are needed. What would be the nurse's best answer?
- A. These medications slow motor activity.
- B. These medications decrease the amount of anesthesia you will need.
- C. These medications decrease anxiety before surgery.
- D. These medications decrease gastric acidity and volume.
Correct Answer: D
Rationale: The anesthesiologist frequently prescribes preoperative medications. Common preoperative medications include the following: anticholinergics, which decrease respiratory tract secretions, dry mucous membranes, and interrupt vagal stimulation; anti anxiety drugs, which reduce preoperative anxiety, slow motor activity, and promote induction of anesthesia; histaminez-receptor antagonists, which decrease gastric acidity and volume; narcotics, which decrease the amount of anesthesia needed, help reduce anxiety and pain, and promote sleep; sedatives, which promote sleep, decrease anxiety, and reduce the amount of anesthesia needed; and tranquilizers, which reduce nausea, prevent emesis, and enhance preoperative sedation.
The nurse is caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?
- A. Place pillows under the client's knees or calves.
- B. Encourage the client to move legs frequently and do leg exercises.
- C. Apply pressure on the client's lower extremities.
- D. Maintain the client in a side-lying position.
Correct Answer: B
Rationale: The nurse should encourage the client to move legs frequently and do leg exercises to prevent venous stasis and other circulatory complications. The nurse should not place pillows under the client's knees or calves unless prescribed and should avoid placing pressure on the client's lower extremities. Placing the client in a side-lying position will not help prevent venous stasis and other circulatory complications in a client who has undergone surgery.