During preoperative screening, the nurse discovers that the patient is allergic to shellfish. What is the nurse's best first action?

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Perioperative Nursing Care Test Questions Questions

Question 1 of 5

During preoperative screening, the nurse discovers that the patient is allergic to shellfish. What is the nurse's best first action?

Correct Answer: A

Rationale: The nurse's best first action is notifying the surgeon because shellfish allergy may indicate iodine sensitivity, critical for surgical antiseptics or contrast dyes. Developing a safety plan follows notification. A shellfish-free diet is irrelevant preoperatively, and family history is secondary. The rationale prioritizes communication: the surgeon must adjust protocols (e.g., alternative antiseptics) to prevent anaphylaxis, a life-threatening risk. Nursing's role is to escalate allergies immediately, ensuring the surgical team adapts, aligning with safety standards and preventing adverse reactions during the procedure.

Question 2 of 5

Which characteristics are appropriate to the anesthetic agent ketamine HCl?

Correct Answer: D

Rationale: Ketamine HCl causes dissociative reactions and nausea , increases heart rate (not lowers BP, choice B), and is short-acting . It minimally depresses respiration . The rationale clarifies pharmacology: ketamine's dissociative state (hallucinations) and emetic effects are notable; it stimulates cardiovascularly, aiding unstable patients, and wears off quickly. Nursing manages these (e.g., antiemetics), leveraging its benefits, distinct from respiratory-depressing agents.

Question 3 of 5

Which signs/symptoms are considered postoperative complications? (Select all that apply.)

Correct Answer: C

Rationale: Postoperative complications include pulmonary embolism , hypothermia , and wound evisceration (choice E, not listed). Sedation and site pain are expected. The rationale distinguishes normal vs. abnormal: embolism (clot) and hypothermia (low temperature) threaten life; evisceration signals wound failure. Nursing monitors for these, intervening (e.g., anticoagulants, warming), contrasting with manageable sedation or pain, ensuring prompt complication management.

Question 4 of 5

The health care team determines a patient's readiness for discharge from the PACU by noting a postanesthesia recovery score of at least 10. After determining that all criteria have been met, the patient is discharged to the hospital unit or home. Review the patient profiles after 1 hour in the PACU listed below. Which patient should the nurse expect to be discharged from the PACU first?

Correct Answer: D

Rationale: The 42-year-old woman is discharged first, fully awake, voiding, and stable post-sedation. The girl is close but has sore throat; the man with fracture has tachycardia and nausea; the scar patient is drowsy with slow breathing. The rationale uses Aldrete scoring: consciousness, respiration, circulation, and activity favor the colonoscopy patient alert, normal vitals, mobile. Nursing prioritizes stability, ensuring safe transfer, distinct from lingering anesthesia effects.

Question 5 of 5

Which are interventions for the medical-surgical nurse to use in preventing hypoxemia for the postoperative patient? (Select all that apply.)

Correct Answer: C

Rationale: Preventing hypoxemia includes coughing and deep breathing , monitoring SpO2 , and ambulation . Supine position risks atelectasis. The rationale promotes oxygenation: breathing exercises expand lungs, monitoring detects drops, walking enhances circulation. Nursing avoids flat positioning, reducing collapse, ensuring respiratory health, distinct from counterproductive measures.

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