ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 14 : Perioperative Care Questions
Question 1 of 5
The surgical unit nurse is developing a postoperative plan of care. In which client's plan of care would the nurse document interventions of deep breathing, gastrointestinal assessment, and effective regulation of temperature?
Correct Answer: A
Rationale: General anesthesia acts on the central nervous system to produce a loss of sensation, reflexes, and consciousness. The anesthesiologist monitors the vital functions of breathing, circulation, and temperature. Following general anesthesia, nurses must closely monitor for effective breathing and oxygenation, temperature regulation, and adequate fluid balance. Nursing interventions for those clients with regional anesthesia, spinal anesthesia, and regional nerve blockades focus on assessing for allergic reactions, neurovascular assessments to specific body regions, and side effects of the medication.
Question 2 of 5
The nurse is caring for a client during an intraoperative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?
Correct Answer: D
Rationale: Intraoperative hyperthermia can indicate a life-threatening condition called malignant hyperthermia. The circulating nurse closely monitors the client for signs of hyperthermia. The pulse rate, respiratory rate, and blood pressure did not indicate a significant concern.
Question 3 of 5
An enterostomal therapy nurse is caring for a postoperative client with a gaping wound. Which nursing measure is most helpful when a wound dressing adheres to the wound bed?
Correct Answer: C
Rationale: When a dressing adheres to the wound bed, using normal saline to moisten the dressing material can loosen the dressing for easier dressing removal without damaging the new tissue or causing discomfort. The transparent dressing and ointment are not helpful in assisting with dressing removal. Allowing the dressing to dry promotes wound adherence.
Question 4 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 5 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.