Angela DeVarso

Angela DeVarso

Perioperative Nursing 001

1.) Which of the following is most dangerous

complication during induction of spinal
anesthesia?
A.)Tachycardia
B.)Hypotension
C.)Hyperthermia
D.)Bradypnea

Ans: B

2.) Which type of surgery is most likely to

predispose a patient to postoperative
atelectasis, pneumonia or respiratory
failure?
A.)Upper abdominal surgery on an obese
patient with a long history of smoking
B.)Upper abdominal surgery on a patient
with normal pulmonary function
C.)Lower abdominal surgery on a young
patient with diabetes mellitus
D.)Surgery on the extremities of a
nonsmoking football player

Ans: A

3.) Which of the following characterizes

excitement stage of anesthesia
A.) Occurs from the administration of
anesthesia to the loss of consciousness
B.) Extends from the loss of consciousness
to the loss of lid reflex, characterized by
struggling and talking
C.) From the loss of lid reflex to the loss of
most reflexes
D.) From the loss of most reflexes to
respiratory and circulatory failure
Angela DeVarso

Ans: B

4.) To prevent headache after spinal

anesthesia the patient should be positioned:
A.) Semi-fowler’s
B.) Flat on bed for 6 to 8 hours
C.) Prone position
D.) Modified trendelenburg

Ans: B

5.) Which of the following nursing actions

should be given highest priority when

admitting the patient into the operating

room?
A.) Level of consciousness
B.) Vital signs
C.) Patient identification and correct
operative consent
D.) Positioning and skin preparation

Ans: C

6.) What is the primary reason for the gradual

change of position of the patient after
surgery?
A.) To prevent muscle injury
B.) To prevent sudden drop of BP
C.) To prevent respiratory distress
D.) To promote comfort

Ans: B

7.) Which of the following assessment data is

most important to determine when caring for
a patient who has received spinal
anesthesia?
A.) The time of return of motion and
sensation in the legs and toes
B.) The character of respiration
C.) Level of consciousness
D.) Amount of wound drainage
Angela DeVarso

Ans: A

8.) Which of the following postop findings

should the nurse report to the M.D.?
A.) The patient pushes out the oral airway wit
h his tounge
B.) Urine output is 20ml/hr for the past two
hours
C.) VS are as follows:
BP=110/70;PR=95;RR=19,Temp=36.8C
D.) Wound drainage is serosanguinous

Ans: B

9.) Which of the following is the earliest sign

of poor respiratory function?
A.) Cyanosis
B.) Fast thready pulse
C.) Restlessness
D.) Faintness

Ans: C

10.) If wound eviscerations occurs, the

immediate nursing action is:
A.) Cover the wound with sterile gauze

moistened with sterile NSS

B.) Cover the wound with water-soaked
gauze
C.) Cover the wound with sterile dry gauze
D.) Leave the wound uncovered and pull the
skin edges together

Ans: A

11.) Appendectomy is classified as

A.) Ablative

B.) Constructive
C.) Reconstructive
D.) Palliative

Ans: A
Angela DeVarso

12.) The worst of all fears among clients

undergoing surgery is:
A.) Fear of financial burden
B.) Fear of death
C.) Fear of the unknown
D.) Fear of loss of job

Ans: C

13.) The best time to provide preoperative

teaching on deep breathing, coughing and
turning exercises is:
A.) Before administration of preoperative
medications
B.) The afternoon or evening prior to surgery
C.) Several days prior to surgery
D.) Upon admission of the client in the
recovery room

Ans: B

14.) The following are the appropriate

nursing actions before administration of
preoperative medications EXCEPT:
A.) Ascertain the consent has been signed
B.) Ensure that NPO has been maintained
C.) Instruct patient to empty his bladder
D.) Shave the skin at the site of surgery

Ans: D

15.) The patient has been observed pacing

along the hallway, goes to the bathroom
frequently and asks questions repeatedly
during preoperative assessment. The most
likely cause of the behavior is:
A.) She is anxious about the surgical
procedure
B.) She is worried about separation from the

family
C.) She has urinary tract infection
D.) She has an underlying emotional problem
Angela DeVarso

Ans: A

16.) Which of the following nursing actions

would help the patient decrease anxiety
during the preoperative period?
A.) Explaining all procedures thoroughly in
chronological order
B.) Spending time listening to the patient and
answering questions
C.) Encouraging sleep and limiting
interruptions
D.) Reassuring the patient that the surgical
staff are competent professional

Ans: B

17.) Which of the following is the primary

purpose of maintaining NPO for 6 to 8 hours
before surgery?
A.) To prevent malnutrition
B.) To prevent electrolyte imbalance
C.) To prevent aspiration pneumonia
D.) To prevent intestinal obstruction

Ans: C

18.) The following ensure validity of informed

written consent EXCEPT:
A.) The patient is of legal age with proper
mental disposition
B.) The consent has been secured within 24
hours before the surgery
C.) If the patient is unable to write, secure the
consent from a relative
D.) The consent is secured before
administration of any medication that alter
the level of consciousness

Ans: C

19.) Which of the following drugs is

administered to minimize respiratory
secretions preop?
Angela DeVarso

A.) Valium (Diazepam)

B.) Nubain ( Nalbuphine HCL)
C.) Phenergan (Promethazine)
D.) Atropine Sulfate

Ans: D

20.) Which of the following is experienced by

the patient who is under spinal anesthesia?

A.) The patient is unconscious

B.) The patient is awake
C.) The patient experiences amnesia
D.) The patient experiences total loss of
sensation

Ans: B

21.) The patient who has undergone TAHBSO

complains of pain. Which of the following is
an initial nursing action?
A.) Administer the PRN analgesics
B.) Instruct to do deep breathing exercises
C.) Assess the VS
D.) Change the patient’s position

Ans: C

22.) How frequent should the nurse monitor

the VS of the patient in the recovery room?
A.) Every 15 minutes
B.) Every 30 mins
C.) Every 45 mins
D.) Every 60 mins

Ans: A

23.) Which of the following drugs is given to

relieve nausea and vomiting?
A.) Mepivacaine

B.) Aquamephyton

C.) Nubain
Angela DeVarso

D.) Plasil

Ans: D

24.) The most important factor in the

prevention of postop infection is:
A.) Proper administration of antibiotics
B.) Fluid intake of 2-3L/day
C.) Practice of strict aseptic techniques
D.) Frequent change of wound dressings

Ans: C

25.) Which of the following primarily

prevents postop complications?
A.) Adequate fluid intake
B.) Early ambulation
C.) Well-balanced diet
D.) Administration of antimicrobials

Ans: B

Situation: A female client, 23 y/o was

admitted for the first time at the Fatima

Hospital with the chief complaint of Right
Iliac Pain, accompanied by nausea and
vomiting, chills and fever. She was
diagnosed to have acute appendicitis. She
was scheduled to have emergency
appendectomy under spinal anesthesia

26.) Pre-op instructions to the client would

include the following EXCEPT:
A.) Deep breathing and coughing exercise
B.) Turning to sides
C.) Foot and leg exercises
D.) reassuring her that narcotics will be
given every 4 hours round the clock until she
is discharged

Ans: D
Angela DeVarso

27.) The client gave her consent for the

surgery. To ensure the legality of the
consent, the following conditions must be
met EXCEPT:
A.) She gave her consent freely
B.) She must understand the nature of the
surgery
C.) The consent must be signed by a witness
D.) Signing should be done after the
administration of pre-anesthesia meds

Ans: D

28.) The skin is shaved prior to surgery in

order to:
A.) Facilitate skin incision
B.) Indicate the site to be draped
C.) To prevent wound infection
D.) Reduce post op scarring

Ans: C

29.) The important nursing intervention prior

to administration of pre-anesthetic
medication is:
A.) Ask patient to empty the bladder
B.) Do deep breathing and coughing
exercises
C.) Regulate IVF accurately
D.) Shave the skin

Ans: A

30.) Immediately following spinal anesthesia,

the greatest risk is:
A.) Severe hemorrhage
B.) Severe Hypotension

C.) Severe Hypoglycemia

D.) Hypertensive crisis

Ans: B
Angela DeVarso

31.) Nursing measures to promote the

client’s respiratory function during recovery
from anesthesia are the following EXCEPT:
A.) Encourages deep breathing and
coughing exercises
B.) Administer Humidified oxygen
C.) Place in semi-fowlers position
D.) Place in supine position with head turned
to the side without pillow support

Ans: C

32.) Which of the following criteria must be

met before the client is released from the RR
to the unit.
A.) Breathes with ease, coughs freely
B.) Has regained consciousness
C.) Vital signs fluctuates erratically
D.) Able to move four extremities

Ans: C

33.) Early signs of poor respiratory function

include which of the following
A.) Cyanosis
B.) Hypotension
C.) Loss of consciousness
D.) Restlessness

Ans: D

34.) Post operatively, the client must be

encouraged to turn, cough and deep breathe:
A.) Every 1-2 hours
B.) Every 4 hours
C.) Every 30 Mins
D.) Every 8 hours

Ans: A

35.) A client in shock must be placed in:

A.) High-fowlers position
B.) Sim’s position
Angela DeVarso

C.) Modified trendelenburg

D.) Prone position

Ans: C

36.) The most important factor in the

prevention of post op wound infection is:
A.) Adequate fluid intake

B.) Proper administration of antibiotics C.) Practice of strict aseptic technique

D.) Frequent cleaning of the wound

Ans: C

37.) When the patient vomits, the most

important nursing objective is to prevent:
A.) Dehydration

B.) Aspiration

C.) Rupture of suture line

D.) Met. Alkalosis

Ans: B

38.) Post operatively, a patient is expected to

void after:
A.) 6-8 hours
B.) 2-4 hours
C.) 12-24 hours
D.) 10-12 hours

Ans: A

39.) Headache after spinal anesthesia is due

to:
A.) Paralysis of vasomotor nerves
B.) Traction placed on structures within
abdomen
C.) Loss of CSF through dural hole
D.) Administration of large amounts and
heavy concentration of anesthetic agents

Ans: C
Angela DeVarso

40.) Nursing measures for post-op

thrombophlebitis include the following
EXCEPT:
A.) Maintain bedrest
B.) Elevate affected leg with pillow support
C.) Massage the painful extremities
D.) Apply antiembolic stockings

Ans: C

41.) Nursing measures to relieve hiccups

include the following EXCEPT:
A.) Exhale and inhale through a paper bag
B.) Apply pressure over the eyeball through
closed eye lids
C.) Hold breath while taking a large pulp of
water
D.) Administer high concentration of oxygen

Ans: D

42.) Modified radical mastectomy involves:

A.) Removal of the entire breast, axillary
lymph nodes, pectoralis muscle
B.) Removal of the lump of the breast
C.) Removal of the entire breast, axillary and
neck lymph nodes, including pectoralis
muscles
D.) Removal of the entire breast but nipple
remains intact

Ans: A

43.) Which of the following is not appropriate

nursing intervention after modified radical
mastectomy?
A.) Place in semi fowler’s position and
elevate arm on the affected side with pillow
support
B.) Check behind the client for bleeding
C.) Monitor output from wound suction
drainage
Angela DeVarso

D.) Immobilize the arm on affected side in

adduction

Ans: D

44.) A fluid challenge is begun with a post-op

gastric surgery client. Which assessment will
give the best indication of client response to
this treatment?
A.) CVP readings and hourly urine output
B.) Blood pressure and apical rate checks
C.) Lung sounds and arterial blood gases
D.) Electrolytes, BUN, creatinine results

Ans: A

45.) A client is scheduled for a subtotal

gastrectomy. In anticipation of clarifying
information for client education, the nurse
knows that vagotomy is done as part of the
surgical treatment for peptic ulcers in order
to
A.) Decrease secretion of hydrochloric acid
B.) Improve the tone of the GI muscles
C.) Increase blood supply to the jejunum
D.) Prevent the transmission of pain
impulses

Ans: A

46.) Which of the following facts best

explains why the duodenum is not removed
during a subtotal gastrectomy?
A.) The head of the pancreas is adherent to
the duodenal wall

B.) The common bile duct empties into the

duodenal lumen
C.) The wall of the jejunum contains no
intestinal villi
D.) The jejunum receives its blood supply
through the duodenum
Angela DeVarso

Ans: B

47.) During the immediate postoperative

period following gastric surgery, why must
the nurse be particularly conscientious
about encouraging a client to cough and
deep-breathe at regular intervals?
A.) Marked changes in intrathoracic pressure
will stimulate gastric drainage
B.) The high abdominal incision will lead to
shallow breathing to avoid pain
C.) The phrenic nerve will have been
permanently damaged during the surgical
procedure
D.) Deep-breathing will prevent post op
vomiting and intestinal distention

Ans: B

48.) Prior to having a subtotal gastrectomy, a

client is told about the dumping syndrome.
The nurse explains that it is:
A.) The body’s absorption of toxins produced
by liquefaction of dead tissue
B.) Formation of an ulcer at the margin of the
gastrojejunal anastomosis
C.) Obstruction of venous flow from the
stomach into the portal system
D.) Rapid emptying of food and fluid from the
stomach into the jejunum

Ans: D

49.) Which of the following statements by a

client recovering from a subtotal
gastrectomy would indicate a need for
additional teaching about the diet protocol
for dumping syndrome?
A.) “I plan to eat a diet low in carbohydrates
and high in protein and fat”
B.) “I plan to eat a diet high in CHO and low
in CHON and fat”
Angela DeVarso

C.) “I will eat slowly and avoid drinking fluids

during meals”
D.) “I will try to assume a recumbent position
after meals for 30 mins to 1 hour to enhance
digestion and relieve symptoms

Ans: B

50.) A 40 y/o female client has arrived in the

post anesthesia room following a
cholecystectomy and a common bile duct
exploration. She is semi conscious. Her vital
signs are within normal limits. Which of the
following nursing actions would be
inappropriate?
A.) Apply a warm blanket to her body
B.) Place her in a semi-fowler’s position
C.) Attached her T-tube to gravity drainage
D.) Set up low, intermittent suction for her
NGT

Ans: B