Which of the following drugs is administered to minimize respiratory secretions preoperatively?

After surgery your patient starts to shiver uncontrollably. What nursing intervention would you do FIRST?A. Apply warm blankets & continue oxygen as prescribedB. Take the patient's rectal temperatureC. Page the doctor for further ordersD. Adjust the thermostat in the room

Table of Contents

• After surgery your patient starts to shiver uncontrollably. What nursing intervention would you do FIRST?A. Apply warm blankets & continue oxygen as prescribedB. Take the patient's rectal temperatureC. Page the doctor for further ordersD. Adjust the thermostat in the room
• The answer is A. Shivering is an early sign that the patient is starting to experience hypothermia. Immediately, the nurse would need to control the shivering by applying warm blankets and continue oxygen. When the patient starts to experience hypothermia, vital organs are not receiving as much oxygenated blood due to the vasoconstriction. Therefore, oxygen would need to be continued. Then the nurse would take the patient's temperature.
• A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery. Which of the following is not an appropriate nursing intervention?A. Encourage patient intake of 3000 ml/day of fluids if not contraindicated B. Encourage patient to use the incentive spirometer device 10 times every 1-2 hours while awakeC. Encourage early ambulation and patient to eat meals in beside chairD. Repositioning every 3-4 hours
• The answer is D. All options are correct expect for repositioning every 3-4 hours. If the patient is unable to reposition themselves or ambulate, they must be repositioned every 1 to 2 hours minimally.
• To prevent headaches after spinal anesthesia, the patient should be positioned:A. semi-fowlersB. Flat (supine) on bed for 6-8 hoursC. Prone positionD. Modified trandelenburg
• Ans: Brationale:After spinal anesthesia, you lie flat in bed for a few hours. This is to keep you from getting a headache. You may feel sick to your stomach and be dizzy. You may be tired.
• What is the primary reason for the gradual change of position of the patient after surgery?A. to prevent muscle injuryB. to prevent sudden drop in BPC. to prevent respiratory distressD. To promote comfort
• Ans: Brationale:if one were to get up quickly, orthostatic hypotension may occur, causing you to drop BP and feel dizzy. Get up gradually and have your BP monitored while you are lying down, then while on the bed side, and finally while standing up. wait a couple minutes each time you transition.
• The best time to teach deep breathing, coughing and turning exercise to patient would be:A. Before giving preoperative medicationB. The afternoon or evening prior to surgeryC. Several days prior to surgeryD. Upon admission of the client in the recovery room
• Ans: Brationale:Give time for the patient to learn deep breathing so they remember it prior to procedure
• Which of the following drugs is administered to minimize respiratory secretions?A. Valium (Diazepam)B. Nubain (Nalbuphine HCL)C. Phenergan (Promethazine)D. Atropine Sulfate
• Ans: Drationale:Nubaine is used to treat severe pain. Valium is an antianxiety medication. Phenergan is used to treat allergies. Atropine Sulfate treats bradycardia and reduce salivation.
• Which of the following is experienced by a patient who is under spinal anesthesia?A. patient is unconsciousB. Patient is awakeC. Patient experiences amnesiaD. Patient experiences total loss of sensation
• Ans: Brationale:patient is awake when under spinal anesthesia because it is considered a regional anesthesia
• Which of the following drugs is given to relieve nausea and vomiting?A. MepivacaineB. AquamephytonC. NubainD. Plasil
• Ans: DPlasil treats N/V. Mepivacaine treats is an anesthetic. Aquamephyton (vitamin K) which helps blood clot better. Nubain treats severe pain.
• The skin is shaved prior to surgery in order to:A. facilitate skin incisionB. INdicate the site to be drapedC. TO prevent wound infectionD. reduce postop scarring
• Ans: Crationale:to eliminate bacteria that cling to the hair
• Nursing measures to promote the client's respiratory function during recovery from anesthesia are the following EXCEPT:A. Encourage deep breathing and coughingB. Administer humidified airC. Place in semi-fowlers positionD. Place in supine position with head turned to the side without pillow support
• Ans: Crationale: Make sure to lie flat to prevent headache from occurring. Semi-fowlers is when the head is slightly elevated, which can cause a headache.
• Which of the following criteria must be met before the client is released from the recovery room to the unit?A. Breathe with ease, coughs freelyB. Has regained consciousnessC. Vital signs fluctuate erraticallyD. able to move all four extremities
• Ans: Crationale:vital signs must be stable in order for a patient to be release from the recovery room
• A client in shock must be placed in:A. High-fowlers positionB. Sim's positionC. modified trandelenburgD. Prone position
• Ans: Crationale:legs elevated to improve BP and CO
• A patient is admitted to the PACU. Which of the following action is the most important during the patient's stay in this unit?A. Monitor urine outputB. Assess LOCC. Ensure patency of drainage tubeD. Suction mucus form respiratory passages
• Ans: Drationale:Maintaining a patent airway is always the priority to prevent respiratory distress and hypoxia. This follows ABC's (airway, breathing, circulation) of patients care.
• A postoperative patient is transferred back to the surgical unit with an abdominal dressing and Penrose drain. Which is teh most important nursing action associated with caring for a patient with a Penrose drain?A. remove the external portion until drainage stopsB. Change the soiled dressing carefullyC. Maintain the negative pressureD. Pinning the drain to the dressing
• Ans: Brationale:Changing soiled dressing carefully is necessary to prevent to prevent inadvertent removal of the Penrose drain because it is placed between several layers of gauze to absorb drainage.-A Penrose drain functions by gravity, not negative pressure
• Which factor places a patient at the greatest risk for postoperative N/V after receiving general anesthesia?A. ObesityB. InactivityC. hypervolemiaD. unconsciousness
• Ans: Arationale:Obese people have excess adipose tissue that exerts pressure on the abdominal cavity, which raises intra-abdominal pressure. This Exerts more pressure on the GI tract, increasing the risk of N/V.
• On the second postoperative day after an above-the-knee surgery, the patient's elastic dressing accidentally comes off. Which should the nurse do first?A. Wrap the residual limb with an elastic compression bandageB. Apply saline dressing to the residual limbC. Notify HCPD. place two pillows under the limb
• Ans: Arationale:Gentle compression is desirable because it prevents bleeding and promotes molding and shrinkage of the residual limb.-a saline dressing is unsafe because it breaks down the connective tissue which impedes wound healing by primary intention
• A patient has abdominal surgery for the removal of a gallbladder. Which should the nurse be most concerned if exhibited by the patient?A. constipationB. urinary retentionC. shallow breathingD. inability to provide self-care
• Ans: Crationale: After abdominal surgery patients frequently have shallow respirations becuase when the diaphragm contracts with a deep breath, it increases intra-abdominal pressure, which causes pain at the operative site. Shallow breathing may result in atelectasis and/ or hypostatic pneumonia
• How many days does the nurse expect the patient to exhibit S/S of wound infection if it should occur?A. day 5B. day 3C. day 9d. day 7
• Ans: Brationale:microorganisms introduced to asurgical site take 72 hours to multiply and present local adaptations of painswelling, erythema, warmth and purulent discharge and systematic adaptations of fever and tachcardia
• A nurse is assessing a patient who had spinal anesthesia. For which common response should the nurse assess the patient?A. headacheB. neuropathyC. Lower back discomfortD. increased BP
• Ans: Arationale:leakage of spinal fluid from needle insertion site reduces cerebrospinal fluid pressure, which causes headaches.
• Which is the most dietary order the nurse can anticipate after a patient who had abdominal surgery exhibits a return of intestinal peristalsis?A. clear liquidB. full liquidC. low fiberD. regular
• Ans: Arationale:They started as NPO and when peristalsis starts, they are prescribed clear liquid because they are easier to digest and process
• A postoperative patient experiences tachycardia, sudden chest pain, and low BP. Which complication associated with the postoperative period should the nurse conclude that the patient most likely experienced?A. pulmonary embolusB. hemorrhageC. heart attackD. pneumonia
• Ans: Arationale:classic symptoms of pulmonary embolus. S/S include chest pain resulting from hypoxia, tachycardia, and hypotension from decreased Cardiac output-embolus lodges (block) a vessel impeding pulmonoary circulation
• A nurse is caring for two patients. One of the patients has a Jackson-Pratt drain and the other patient has a Hemovac drain.Which does the nurse understand is the difference between these two drains?A. The size of the collection containerB. How the pressure within the collection container is reestablishedC. The type of pressure that promotes drainage to the collection containerD. Where the collection container should be placed in relation to the insertion site.
• Ans: Arationale:The size of the collection container. Hemovac is designed to store 100, 400, or even 800 ml. A Jackson-Pratt stores less than 100 ml of drainage.
• A nurse in the operating room is to position a patient for surgery. Which factor is most important for the nurse to consider?A. Allow for skeletal deformitiesB. Prevent pressure on bony prominenceC. Provide for adequate thoracic expansionD. Avoid stretching of neuromuscular tissue
• Ans: Crationale:Facilitating respiratory is always the priority because permanent brain damage can result from cerebral hypoxia in as little as 4-6 hours.
• One hour after the reduction of a compound fracture of the ulna and radius and application of the cast, the nurse observes a centimeter circle of drainage on the patient's cast. Which should the nurse do first?A. inform surgeon immediatelyB. Reinforce the cast with gauze dressingC. Monitor the area frequently for expansionD. Circle the spot with a pen and date, time and initial area.
• Ans: Drationale:locate the area and see if the drainage grows. This is also used to indicate how long the patient would be bleeding and the extent of it.
• A nurse is caring for a patient with an NG tube attached to suction. What is teh most important nursing action in relation to the nasogastric tube?A. use sterile technizue when irrigating the tubeB. record intake and output every 2 hoursC. provide oral hygiene every 4 hoursD. Setting suction at the ordered level
• Ans: Drationale:suction must be maintained continuously to prevent reflux of gastric secretions into the vent lumen which can result in mucosa damage
• A nurse is considering the commonalities and differences of equipment used for gastric depression. Which is the major advantage to using a double-lumen tube?A. minimize risk of bowel obstructionB. Ensure drainage of the intestinesC. Prevents gastric mucosal drainageD. Promotes gastric rest
• Ans: Crationale:one allows the secretions to be removed and the other allows the air to be drawn into the stomach. this makes the outside pressure equal to the inside pressure preventing the tip from attaching to the gastric mucosa when the drainage lumen is attached to the suction, limiting mucosal damage
• A patient has negative pressure wound therapy(vacuum assisted closure) (aka VAC) after the amputation of a toe. The tubing is connected to the intermittent negative pressure. What should the nurse do when the film over the wound collapses when the negative pressure is exerted?A. notify HCPB. decrease extent of negative pressureC. Apply a new transparent film over the woundD. Continue to observe the function of the device.
• Ans: Drationale:The device is functioning appropriately. The transparent film will collapse or wrinkle as negative pressure is applied to the wound. This indicates that there are no leaks in the dressing and the negative pressure is functioning

The answer is A. Shivering is an early sign that the patient is starting to experience hypothermia. Immediately, the nurse would need to control the shivering by applying warm blankets and continue oxygen. When the patient starts to experience hypothermia, vital organs are not receiving as much oxygenated blood due to the vasoconstriction. Therefore, oxygen would need to be continued. Then the nurse would take the patient's temperature.

A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery. Which of the following is not an appropriate nursing intervention?A. Encourage patient intake of 3000 ml/day of fluids if not contraindicated B. Encourage patient to use the incentive spirometer device 10 times every 1-2 hours while awakeC. Encourage early ambulation and patient to eat meals in beside chairD. Repositioning every 3-4 hours

The answer is D. All options are correct expect for repositioning every 3-4 hours. If the patient is unable to reposition themselves or ambulate, they must be repositioned every 1 to 2 hours minimally.

To prevent headaches after spinal anesthesia, the patient should be positioned:A. semi-fowlersB. Flat (supine) on bed for 6-8 hoursC. Prone positionD. Modified trandelenburg

Ans: Brationale:After spinal anesthesia, you lie flat in bed for a few hours. This is to keep you from getting a headache. You may feel sick to your stomach and be dizzy. You may be tired.

Ans: Brationale:if one were to get up quickly, orthostatic hypotension may occur, causing you to drop BP and feel dizzy. Get up gradually and have your BP monitored while you are lying down, then while on the bed side, and finally while standing up. wait a couple minutes each time you transition.

The best time to teach deep breathing, coughing and turning exercise to patient would be:A. Before giving preoperative medicationB. The afternoon or evening prior to surgeryC. Several days prior to surgeryD. Upon admission of the client in the recovery room

Ans: Brationale:Give time for the patient to learn deep breathing so they remember it prior to procedure

Which of the following drugs is administered to minimize respiratory secretions?A. Valium (Diazepam)B. Nubain (Nalbuphine HCL)C. Phenergan (Promethazine)D. Atropine Sulfate

Ans: Drationale:Nubaine is used to treat severe pain. Valium is an antianxiety medication. Phenergan is used to treat allergies. Atropine Sulfate treats bradycardia and reduce salivation.

Which of the following is experienced by a patient who is under spinal anesthesia?A. patient is unconsciousB. Patient is awakeC. Patient experiences amnesiaD. Patient experiences total loss of sensation

Ans: Brationale:patient is awake when under spinal anesthesia because it is considered a regional anesthesia

Which of the following drugs is given to relieve nausea and vomiting?A. MepivacaineB. AquamephytonC. NubainD. Plasil

Ans: DPlasil treats N/V. Mepivacaine treats is an anesthetic. Aquamephyton (vitamin K) which helps blood clot better. Nubain treats severe pain.

The skin is shaved prior to surgery in order to:A. facilitate skin incisionB. INdicate the site to be drapedC. TO prevent wound infectionD. reduce postop scarring

Ans: Crationale:to eliminate bacteria that cling to the hair

Ans: Crationale: Make sure to lie flat to prevent headache from occurring. Semi-fowlers is when the head is slightly elevated, which can cause a headache.

Which of the following criteria must be met before the client is released from the recovery room to the unit?A. Breathe with ease, coughs freelyB. Has regained consciousnessC. Vital signs fluctuate erraticallyD. able to move all four extremities

Ans: Crationale:vital signs must be stable in order for a patient to be release from the recovery room

A client in shock must be placed in:A. High-fowlers positionB. Sim's positionC. modified trandelenburgD. Prone position

Ans: Crationale:legs elevated to improve BP and CO

A patient is admitted to the PACU. Which of the following action is the most important during the patient's stay in this unit?A. Monitor urine outputB. Assess LOCC. Ensure patency of drainage tubeD. Suction mucus form respiratory passages

Ans: Drationale:Maintaining a patent airway is always the priority to prevent respiratory distress and hypoxia. This follows ABC's (airway, breathing, circulation) of patients care.

A postoperative patient is transferred back to the surgical unit with an abdominal dressing and Penrose drain. Which is teh most important nursing action associated with caring for a patient with a Penrose drain?A. remove the external portion until drainage stopsB. Change the soiled dressing carefullyC. Maintain the negative pressureD. Pinning the drain to the dressing

Ans: Brationale:Changing soiled dressing carefully is necessary to prevent to prevent inadvertent removal of the Penrose drain because it is placed between several layers of gauze to absorb drainage.-A Penrose drain functions by gravity, not negative pressure

Which factor places a patient at the greatest risk for postoperative N/V after receiving general anesthesia?A. ObesityB. InactivityC. hypervolemiaD. unconsciousness

Ans: Arationale:Obese people have excess adipose tissue that exerts pressure on the abdominal cavity, which raises intra-abdominal pressure. This Exerts more pressure on the GI tract, increasing the risk of N/V.

On the second postoperative day after an above-the-knee surgery, the patient's elastic dressing accidentally comes off. Which should the nurse do first?A. Wrap the residual limb with an elastic compression bandageB. Apply saline dressing to the residual limbC. Notify HCPD. place two pillows under the limb

Ans: Arationale:Gentle compression is desirable because it prevents bleeding and promotes molding and shrinkage of the residual limb.-a saline dressing is unsafe because it breaks down the connective tissue which impedes wound healing by primary intention

A patient has abdominal surgery for the removal of a gallbladder. Which should the nurse be most concerned if exhibited by the patient?A. constipationB. urinary retentionC. shallow breathingD. inability to provide self-care

Ans: Crationale: After abdominal surgery patients frequently have shallow respirations becuase when the diaphragm contracts with a deep breath, it increases intra-abdominal pressure, which causes pain at the operative site. Shallow breathing may result in atelectasis and/ or hypostatic pneumonia

How many days does the nurse expect the patient to exhibit S/S of wound infection if it should occur?A. day 5B. day 3C. day 9d. day 7

Ans: Brationale:microorganisms introduced to asurgical site take 72 hours to multiply and present local adaptations of painswelling, erythema, warmth and purulent discharge and systematic adaptations of fever and tachcardia

A nurse is assessing a patient who had spinal anesthesia. For which common response should the nurse assess the patient?A. headacheB. neuropathyC. Lower back discomfortD. increased BP

Ans: Arationale:leakage of spinal fluid from needle insertion site reduces cerebrospinal fluid pressure, which causes headaches.

Which is the most dietary order the nurse can anticipate after a patient who had abdominal surgery exhibits a return of intestinal peristalsis?A. clear liquidB. full liquidC. low fiberD. regular

Ans: Arationale:They started as NPO and when peristalsis starts, they are prescribed clear liquid because they are easier to digest and process

A postoperative patient experiences tachycardia, sudden chest pain, and low BP. Which complication associated with the postoperative period should the nurse conclude that the patient most likely experienced?A. pulmonary embolusB. hemorrhageC. heart attackD. pneumonia

Ans: Arationale:classic symptoms of pulmonary embolus. S/S include chest pain resulting from hypoxia, tachycardia, and hypotension from decreased Cardiac output-embolus lodges (block) a vessel impeding pulmonoary circulation

Ans: Arationale:The size of the collection container. Hemovac is designed to store 100, 400, or even 800 ml. A Jackson-Pratt stores less than 100 ml of drainage.

A nurse in the operating room is to position a patient for surgery. Which factor is most important for the nurse to consider?A. Allow for skeletal deformitiesB. Prevent pressure on bony prominenceC. Provide for adequate thoracic expansionD. Avoid stretching of neuromuscular tissue

Ans: Crationale:Facilitating respiratory is always the priority because permanent brain damage can result from cerebral hypoxia in as little as 4-6 hours.

Ans: Drationale:locate the area and see if the drainage grows. This is also used to indicate how long the patient would be bleeding and the extent of it.

A nurse is caring for a patient with an NG tube attached to suction. What is teh most important nursing action in relation to the nasogastric tube?A. use sterile technizue when irrigating the tubeB. record intake and output every 2 hoursC. provide oral hygiene every 4 hoursD. Setting suction at the ordered level

Ans: Drationale:suction must be maintained continuously to prevent reflux of gastric secretions into the vent lumen which can result in mucosa damage

Ans: Crationale:one allows the secretions to be removed and the other allows the air to be drawn into the stomach. this makes the outside pressure equal to the inside pressure preventing the tip from attaching to the gastric mucosa when the drainage lumen is attached to the suction, limiting mucosal damage

A patient has negative pressure wound therapy(vacuum assisted closure) (aka VAC) after the amputation of a toe. The tubing is connected to the intermittent negative pressure. What should the nurse do when the film over the wound collapses when the negative pressure is exerted?A. notify HCPB. decrease extent of negative pressureC. Apply a new transparent film over the woundD. Continue to observe the function of the device.

Ans: Drationale:The device is functioning appropriately. The transparent film will collapse or wrinkle as negative pressure is applied to the wound. This indicates that there are no leaks in the dressing and the negative pressure is functioning