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Perioperative Nursing 001 1.) Which of t he foll owing is most dangerous complication during induction of spinal anesthesi a? A.

)Tach ycardia B.)H ypot ension C.)H yperthermi a D.)Brad ypnea Ans: B 2.) Which t ype of surger y is most likel y to predis pose a patient to postoperative atel ect asis, pneumonia or respirator y failure? A.)Upper abdominal surger y on an obese patient with a long histor y of smoking B.)Upper abdominal surger y on a pati ent with norm al pulm onar y function C.)Lower abdominal surger y on a you ng patient with di abetes mellitus D.)Surger y on the extremities of a nonsmoking football pla yer Ans: A 3.) Which of t he foll owing characterizes excitement stage of anesthesi a A.) Occurs from the administration of anesthesi a to the loss of consciousness B. ) Extends from t he loss of consciousness to the loss of li d refl ex, characterized b y struggling and talking C.) From the loss of lid reflex to the loss of most reflexes D.) From the loss of most refl exes to respi rator y and circulator y fail ure Ans: B

) Level of consciousness D.) To prevent muscle injur y B.) Which of t he foll owing assessm ent data is most import ant to determine when caring for a pati ent who has received spi nal anesthesi a? A.) Amount of wound drainage Ans: A .) Positioni ng and skin preparation Ans: C 6.) Prone position D.) Level of consciousness B.) To prevent respi rator y dist ress D.) Vit al si gns C.) The character of respi ration C.) Fl at on bed for 6 to 8 hours C.) To promote com fort Ans: B 7.) S emi.) Modifi ed trendel enburg Ans: B 5.) To prevent headache aft er spinal anesthesi a the pati ent should be positioned: A.) Which of t he foll owing nursing actions should be given hi ghest pri ori t y when admitting the patient into the operating room? A.) Patient identifi cation and correct operative consent D.) What is the prim ar y reason for the gradual change of position of the pati ent aft er surger y? A.4.) The tim e of return of motion and sensati on in the l egs and toes B.) To prevent sudden drop of BP C.fowler’s B.

RR=19.) Which of t he foll owing is the earliest sign of poor respi rator y function? A.) Urine output is 20ml/hr for the past t wo hours C.8.Temp=36.) If wound eviscerations occurs.) Ablative B.) Cover the wound with sterile dr y gauze D.) Constructive C.) Reconst ructive D.PR=95.) P alliative Ans: A .) Leave t he wound uncovered and pull the skin edges together Ans: A 11.8C D.) Cover the wound with sterile gauz e moistened with st eri le NSS B.) Restl essness D.) Appendectom y i s classi fied as A.) Wound drainage is serosanguinous Ans: B 9.) Cover the wound with water -soaked gauze C.) VS are as follows: BP=110/70.) C yanosis B.D. the immediat e nursing action is: A.) The pati ent pushes out the oral airway wit h his tounge B.) Faintness Ans: C 10.) Fast thread y pul se C.? A.) Which of t he foll owing post op fi nding s should the nurse report to the M.

) Fear of the unknown D.) She has urinar y t ract infection D.) Several da ys pri or to surger y D. The most likel y cause of the behavi or is: A.) The afternoon or evening prior to surger y C.) Ascert ain the consent has been si gned B.) Ensure that NPO has been maint ained C.) She is worri ed about separation from the famil y C.) Fear of financi al burden B.) She has an underl ying emotional problem . coughing and turning exercises is: A.) The followi ng are the appropri ate nursing acti ons before administration of preoperative medications EXCEPT: A.) Fear of loss of j ob Ans: C 13.) The worst of all fears among cli ents undergoing surger y i s: A.) Upon admission of the cli ent in the recover y room Ans: B 14.) The pati ent has been observed paci ng along the hallwa y.) Fear of death C.) Before administ ration of preoperative medications B.) She is anxious about the surgi cal procedure B.12.) The best tim e to provide preoperative teaching on deep breathing.) Shave the sk in at the sit e of surger y Ans: D 15.) Inst ruct pati ent t o empt y hi s bladder D. goes to the bathroom frequentl y and asks questions repeatedl y during preoperative assessm ent.

) Explaini ng all procedures thoroughl y in chronologi cal order B.) To prevent aspi ration pneumoni a D.) R eass uring t he patient that the surgical staff are competent professional Ans: B 17.) To prevent m alnutrition B.) The consent has been secured within 24 hours before the surger y C.) If the pati ent is unabl e to write.) Spending time li stening to the pati ent and answering questions C. secure the cons ent from a relati ve D.Ans: A 16.) The consent is secured before administration of any m edi cation that alt er the level of consciousness Ans: C 19.) Which of the following drugs is administered to mini mize respi rat or y secretions preop? .) The pati ent is of legal age with proper mental di sposition B.) To prevent el ect rol yte im bal ance C.) The followi ng ensure validit y of informed written consent EXC EPT: A.) Which of the following nursing acti ons would help the patient decrease anxiet y during th e preoperat ive period? A.) Which of the following is the primar y purpos e of maint aini ng NPO for 6 to 8 hours before surger y? A.) To prevent int e stinal obst ruction Ans: C 18.) Encouraging sleep and limiting interruptions D.

) Valium (Di azepam) Nubain ( Nalbuphine HC L) Phenergan (Prom ethazine) Atropine Sul fat e Ans: D 20.) The pati ent sensati on Ans: B 21.A.) Ever y 60 mins Ans: A 23.) The pati ent who has undergone TAHBSO complains of pain.) Ass ess the VS D.) D.) The patient C.) Change the pati ent’s position Ans: C 22.) Aquameph yton C.) Which of the following is experi enced b y the patient who is under spinal anesthesia? A.) Which of the following drugs is given to relieve nausea and vomiting? A.) The pati ent B.) M epivacaine B.) Ever y 15 minutes B.) Nubain is unconscious is awake experiences amnesia experiences total loss of .) Inst ruct to do deep breathing exercises C.) Administer the P RN anal gesi cs B.) C.) The patient D.) Ever y 45 mins D.) B. Which of t he followi ng is an initial nursi ng act ion? A.) How frequent should the nurse monitor the VS of the patient in the recover y room? A.) Ever y 30 mins C.

chills and fever. 23 y/o was admitted for the first time at t he Fatima Hospital with the chief compl aint of Ri ght Ili ac Pain.) Fl uid int ake of 2 -3L/da y C.) Frequent change of wound dressings Ans: C 25.) reassuring her t hat narcotics will be given ever y 4 hours round the clock until she is discharged Ans: D . She was diagnos ed to have acute appendicitis.) Pl asil Ans: D 24. She was s cheduled to have em ergenc y appendectom y under spinal anesthesi a 26. accompanied b y nausea and vomiting.) Pre-op inst ructi ons to the cli ent would include the following EXCEPT: A.) Which of the following primaril y prevents postop com plications? A.) Administration of antimi crobials Ans: B Situation: A fem ale client.) Proper administration of antibiotics B.) Well-b alanced di et D.) Practi ce of st rict aseptic t echniques D.) Turning to sides C.) Earl y ambul ation C.) Deep breathing and coughing exercise B.D.) Foot and l eg exercises D.) Adequat e flui d i ntake B.) The most important fact or in t he prevention of postop infection is: A.

) Do deep breathing and coughing exercis es C.) She gave her consent freel y B. To ensure t he legalit y of the cons ent.) Severe H ypogl yc emia D.) Ask patient to empt y t he bl adder B.) Shave the skin Ans: A 30.) R educe post op scarring Ans: C 29.) The skin is shaved prior to surger y i n order to: A.) The import ant nursing int ervention prior to administ ration of pre -anesthetic medication is: A.) Si gning should be done aft er the administration of pre -anest hesi a meds Ans: D 28.27.) H ypertensive cri sis Ans: B . the greatest risk is: A.) She m ust underst and the nature of the surger y C.) Severe H ypotension C.) The consent must be si gned b y a witness D.) Indicate the sit e to be draped C.) To prevent wound infection D.) Immedi atel y fol lowing spinal anest hesia. the followi ng conditions must be met EXCEPT: A.) Facilitat e ski n i ncision B.) S evere hemorrhage B.) Regul ate IVF accuratel y D.) The client gave her consent for t he surger y.

) Nursing measures to promot e the client ’s respi rator y function during recover y from anesthesi a are t he following EXCEP T: A.) Able t o move four extremities Ans: C 33. A.) Encourages deep breathing and coughing exercises B.) C yanosis B.) Post operativel y.) Ever y 1 -2 hours B.) Breathes with ease.) R estlessness Ans: D 34.) Place in semi -fowlers position D. cough and deep breathe: A.) Has regained consciousness C.) Which of the following criteria must be met before the client is rel eased from the RR to the unit .) H ypotension C.) Vit al si gns fluct uates erraticall y D.) Ever y 30 Mins D.) Ever y 8 hours Ans: A 35. coughs fre el y B. the client must be encouraged to turn.) Loss of consciousness D.) Earl y si gns of poor respi rator y funct ion include whi ch of the following A.) Sim’s position .) Hi gh-fowl ers position B.) A cli ent in shock must be placed in: A.) Ever y 4 hours C.31.) Pl ace in supine position with head t urned to the side wit hout pillow support Ans: C 32.) Administ er Hum idified ox ygen C.

) Traction pl aced on structures within abdom en C.) Administration of large amounts and heav y concentration of anesthetic agents Ans: C .) Prone position Ans: C 36.) When the pati ent vomits.) Headache after spinal anest hesi a is due to: A.) Deh ydration B.) 10-12 hours Ans: A 39.) Loss of CS F through dural hole D.) Aspi ration C.) 12 -24 hours D. the most important nursi ng objective is to prevent: A.) 2-4 hours C.) P aral ysis of vasomotor nerves B.) M et.) Post operativel y.) 6 -8 hours B.) Rupture of suture line D.) Modi fied t rendel enburg D.) Frequent cleaning of the wound Ans: C 37. Alkalosis Ans: B 38.) Proper administ ration of antibiotics C.C. a patient is expected to void after: A.) Adequat e flui d i ntake B.) Practi ce of st rict aseptic t echnique D.) The most important fact or in t he prevention of post op wound infection is: A.

) R emoval of t he entire breast but ni pple rem ains int act Ans: A 43.) Appl y antiem bol ic stockings Ans: C 41.) Which of the following is not appropriat e nursing int ervention aft er modifi ed ra di cal mastectom y? A.) Monitor output from wound suction drainage .) Appl y pressure over the e yeball through closed e ye lids C.) Modifi ed radi cal mastectom y involves: A.) Removal of the entire breast. pect oralis muscl e B.40.) Administer hi gh concent ration of ox ygen Ans: D 42. i ncluding pectoralis muscles D.) Check behind the cli ent for bl eeding C.) Exhal e and inhal e through a paper bag B.) M aintai n bedrest B.) Hold breath whil e taki ng a large pulp of water D.) Removal of the l ump of t he breast C.) R emoval of t he entire breast. axillar y and neck l ymph nodes.) Elevat e affect ed leg with pillow support C.) Pl ace in semi fowler’s position and elevate arm on the affect ed side with pil low support B.) Mas sage the painful extremities D.) Nursing measures for post -op thrombophl ebitis include the following EXCEPT: A.) Nursing measures to reli eve hiccups include the following EXCEPT: A. axillary l ymph nodes.

) Blood pressure and api cal rat e checks C.) Prevent the transmission of pain impulses Ans: A 46.) The wall of the jejunum cont ains no intestinal villi D.) A cli ent is scheduled for a subtotal gastrectom y.) Lung soun ds and art eri al blood gases D. creatinine results Ans: A 45.) A fluid challenge is begun with a post -op gastri c surger y client.) The head of the pancreas is adherent to the duodenal wall B. In anti cipation of cl arif yi ng inform ation for client education.) Increase bl ood suppl y to the jej unum D.) El ectrol yt es.) Which of the following facts b est explains wh y the duodenum is not removed during a subt otal gastrectom y? A.) CVP readings and hourl y urine out put B.) The common bil e duct empti es into t he duodenal lum en C. Which assessm ent will give the best indi cat ion of client response to this treatment? A.) Improve the tone of the G I muscles C.) The j ejunum receives its blood suppl y through t he duodenum .D.) Immobilize the arm on affected side in adduction Ans: D 44. the nurse knows that vagotom y is done as part of t he surgic al t reatment for peptic ul cers in order to A.) Decrease secreti on of h ydrochloric acid B. BUN.

) Pri or to havi ng a subtot al gastrectom y.) Form ation of an ulcer at the m argin of the gastroj ejunal anastomosis C.) “ I pl an to eat a diet hi gh in CHO and low in CHON and fat” .) Obst ructi on of venous flow from the stomach into the portal s ystem D.) The hi gh abdominal incision will l ead to shallow breathing to avoid pain C.) Which of the following st atem ents by a client recovering from a subtot al gastrectom y would i ndicat e a need for additional teaching about the di et protocol for dumping s yndrome? A.) R apid empt ying of food and fluid from the stomach into the jej unum Ans: D 49.) “I plan t o eat a diet low in carboh ydrates and hi gh in protein and fat” B.) The phreni c nerve will have been perm anentl y damaged during the surgi cal procedure D.) De ep-breathing will prevent post op vomiting and intesti nal dist ention Ans: B 48. The nurs e explains t hat it is: A.) The bod y’s absorption of toxins produced by li quefaction of dead tissue B.) During the immediat e postoperative period following gastric surger y. a client is told about t he dumping s yndrom e.Ans: B 47. wh y m ust the nurse be particul arl y conscientious about encouraging a client to cough and deep -breathe at regular in t ervals? A.) M arked changes in intrat horaci c pressure will stimulat e gastri c drainage B.

) Place her in a semi .fowl er’s position C. int ermittent sucti on for her NGT Ans: B .) S et up low.) Appl y a warm bl anket to her bod y B.) Att ached her T -t ube to gravit y drainage D.) “I will tr y to assume a recumbent position aft er m eals for 30 m ins to 1 hour to enhance digestion and reli eve s ymptoms Ans: B 50.) A 40 y/ o femal e client has arrived in the post anesthesia room following a cholec yst ectom y and a common bil e duct exploration. She is semi conscious.) “ I will eat slowl y and avoid drinking fluids during m eals” D. Which of the following nursi ng actions would be inappropri ate? A.C. Her vital signs are within normal limits.