ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 14 : Perioperative Care Questions
Question 1 of 5
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?
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.
Question 2 of 5
A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?
Correct Answer: D
Rationale: A wound evisceration occurs when the wound completely separates, and the internal organs protrude. The first action by the nurse would be to cover the protruding organs with sterile dressings moistened with sterile normal saline. Once the client is safe, the nurse can notify the physician. The client is positioned in a manner that places the least stress on the organs. Dry or pressure dressings are not placed over the protruding organ.
Question 3 of 5
A nurse is assessing the postoperative client on the second postoperative day. What assessment finding requires the nurse to immediately notify the health care provider?
Correct Answer: A
Rationale: A nursing assessment finding of concern on the second postoperative day is the absence of bowel sounds, which may indicate a paralytic ileus. Other assessment findings may include abdominal pain and distention as fluids, solids, and gas do not move through the intestinal tract. Rales in the bases are a frequent finding postoperatively, especially if general anesthesia was administered. Encourage the client to cough and breathe deep. Pain is a common symptom following a surgical procedure. Serous drainage on the postoperative dressing needs to be monitored and brought to the physician's attention when assessing the client.
Question 4 of 5
The nurse is teaching a postoperative client measures to reduce the risk of postoperative complications. Which teaching point would the nurse reinforce to decrease the risk of thrombophlebitis and phlebothrombosis?
Correct Answer: D
Rationale: Venous stasis predisposes the client to venous inflammation and clot formation in the veins (thrombophlebitis) or clot formation with minimal or absent inflammation (phlebothrombosis).
To decrease the risk of venous stasis, the nurse should teach ways to promote blood circulation and limiting trauma to the site. Avoiding leg crossing promotes circulation. Massaging the calves and thighs may cause further swelling and inflammation of the vein. Propping pillows under the knees decreases circulation. Ambulation is stressed each hour while awake.
Question 5 of 5
The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?
Correct Answer: B
Rationale: A bowel movement demonstrates that the nursing outcome of the return to function of the gastrointestinal track has been met.
Tolerating sips of water, breathing calmly, and reports of hunger are components of meeting the outcome of functioning.