Perioperative Nursing 8.

) Which of the following postop findings should the nurse

report to the M.D.?
1.) Which of the following is most dangerous complication A.) The patient pushes out the oral airway wit h his tounge
during induction of spinal anesthesia? B.) Urine output is 20ml/hr for the past two hours
A.)Tachycardia C.) VS are as follows:
B.)Hypotension BP=110/70;PR=95;RR=19,Temp=36.8C
C.)Hyperthermia D.) Wound drainage is serosanguinous
D.)Bradypnea
Ans: B
2.) Which type of surgery is most likely to predispose a patient
to postoperative atelectasis, pneumonia or respiratory failure? 9.) Which of the following is the earliest sign of poor
A.)Upper abdominal surgery on an obese patient with a respiratory function?
long history of smoking A.) Cyanosis
B.)Upper abdominal surgery on a patient with normal B.) Fast thready pulse
pulmonary function C.) Restlessness
C.)Lower abdominal surgery on a young patient with diabetes D.) Faintness
mellitus
D.)Surgery on the extremities of a nonsmoking football player Ans: C

3.) Which of the following characterizes excitement stage of 10.) If wound eviscerations occurs, the immediate nursing
anesthesia action is:
A.) Occurs from the administration of anesthesia to the loss of A.) Cover the wound with sterile gauze moistened with
consciousness sterile NSS
B.) Extends from the loss of consciousness to the loss of lid B.) Cover the wound with water-soaked gauze
reflex, characterized by struggling and talking C.) Cover the wound with sterile dry gauze
C.) From the loss of lid reflex to the loss of most reflexes D.) Leave the wound uncovered and pull the skin edges
D.) From the loss of most reflexes to respiratory and together
circulatory failure
Ans: A
4.) To prevent headache after spinal anesthesia the patient
should be positioned: 11.) Appendectomy is classified as
A.) Semi-fowler’s A.) Ablative
B.) Flat on bed for 6 to 8 hours B.) Constructive
C.) Prone position C.) Reconstructive
D.) Modified trendelenburg D.) Palliative

5.) Which of the following nursing actions should be given Ans: A

highest priority when admitting the patient into the operating
room? 12.) The worst of all fears among clients undergoing surgery
A.) Level of consciousness is:
B.) Vital signs A.) Fear of financial burden
C.) Patient identification and correct operative consent B.) Fear of death
D.) Positioning and skin preparation C.) Fear of the unknown
D.) Fear of loss of job
6.) What is the primary reason for the gradual change of Ans: C
position of the patient after surgery?
A.) To prevent muscle injury 13.) The best time to provide preoperative teaching on deep
B.) To prevent sudden drop of BP breathing, coughing and turning exercises is:
C.) To prevent respiratory distress A.) Before administration of preoperative medications
D.) To promote comfort B.) The afternoon or evening prior to surgery
C.) Several days prior to surgery
7.) Which of the following assessment data is most important D.) Upon admission of the client in the recovery room
to determine when caring for a patient who has received spinal Ans: B
anesthesia?
A.) The time of return of motion and sensation in the legs 14.) The following are the appropriate nursing actions before
and toes administration of preoperative medications EXCEPT:
B.) The character of respiration A.) Ascertain the consent has been signed
C.) Level of consciousness B.) Ensure that NPO has been maintained
D.) Amount of wound drainage C.) Instruct patient to empty his bladder
D.) Shave the skin at the site of surgery
Ans: A
Ans: D
15.) The patient has been observed pacing along the hallway, 21.) The patient who has undergone TAHBSO complains of
goes to the bathroom frequently and asks questions repeatedly pain. Which of the following is an initial nursing action?
during preoperative assessment. The most likely cause of the A.) Administer the PRN analgesics
behavior is: B.) Instruct to do deep breathing exercises
A.) She is anxious about the surgical procedure C.) Assess the VS
B.) She is worried about separation from the family D.) Change the patient’s position
C.) She has urinary tract infection
D.) She has an underlying emotional problem Ans: C

Ans: A 22.) How frequent should the nurse monitor the VS of the
patient in the recovery room?
16.) Which of the following nursing actions would help the A.) Every 15 minutes
patient decrease anxiety during the preoperative period? B.) Every 30 mins
A.) Explaining all procedures thoroughly in chronological C.) Every 45 mins
order D.) Every 60 mins
B.) Spending time listening to the patient and answering
questions Ans: A
C.) Encouraging sleep and limiting interruptions
D.) Reassuring the patient that the surgical staff are competent 23.) Which of the following drugs is given to relieve nausea
professional and vomiting?
A.) Mepivacaine
Ans: B B.) Aquamephyton
C.) Nubain
17.) Which of the following is the primary purpose of D.) Plasil
maintaining NPO for 6 to 8 hours before surgery?
A.) To prevent malnutrition Ans: D
B.) To prevent electrolyte imbalance
C.) To prevent aspiration pneumonia 24.) The most important factor in the prevention of postop
D.) To prevent intestinal obstruction infection is:
A.) Proper administration of antibiotics
Ans: C B.) Fluid intake of 2-3L/day
C.) Practice of strict aseptic techniques
18.) The following ensure validity of informed written consent D.) Frequent change of wound dressings
EXCEPT:
A.) The patient is of legal age with proper mental disposition Ans: C
B.) The consent has been secured within 24 hours before the
surgery 25.) Which of the following primarily prevents postop
C.) If the patient is unable to write, secure the consent complications?
from a relative A.) Adequate fluid intake
D.) The consent is secured before administration of any B.) Early ambulation
medication that alter the level of consciousness C.) Well-balanced diet
D.) Administration of antimicrobials
Ans: C
Ans: B
19.) Which of the following drugs is administered to minimize Situation: A female client, 23 y/o was admitted for the first
respiratory secretions preop? time at the Fatima Hospital with the chief complaint of Right
A.) Valium (Diazepam) Iliac Pain, accompanied by nausea and vomiting, chills and
B.) Nubain ( Nalbuphine HCL) fever. She was diagnosed to have acute appendicitis. She was
C.) Phenergan (Promethazine) scheduled to have emergency appendectomy under spinal
D.) Atropine Sulfate anesthesia

Ans: D 26.) Pre-op instructions to the client would include the

following EXCEPT:
20.) Which of the following is experienced by the patient who A.) Deep breathing and coughing exercise
is under spinal anesthesia? B.) Turning to sides
A.) The patient is unconscious C.) Foot and leg exercises
B.) The patient is awake D.) reassuring her that narcotics will be given every 4
C.) The patient experiences amnesia hours round the clock until she is discharged
D.) The patient experiences total loss of sensation
Ans: D
Ans: B
27.) The client gave her consent for the surgery. To ensure the
legality of the consent, the following conditions must be met 34.) Post operatively, the client must be encouraged to turn,
EXCEPT: cough and deep breathe:
A.) She gave her consent freely A.) Every 1-2 hours
B.) She must understand the nature of the surgery B.) Every 4 hours
C.) The consent must be signed by a witness C.) Every 30 Mins
D.) Signing should be done after the administration of pre- D.) Every 8 hours
anesthesia meds
Ans: D Ans: A

28.) The skin is shaved prior to surgery in order to: 35.) A client in shock must be placed in:
A.) Facilitate skin incision A.) High-fowlers position
B.) Indicate the site to be draped B.) Sim’s position
C.) To prevent wound infection C.) Modified trendelenburg
D.) Reduce post op scarring D.) Prone position
Ans: C
Ans: C
29.) The important nursing intervention prior to administration
of pre-anesthetic medication is: 36.) The most important factor in the prevention of post op
A.) Ask patient to empty the bladder wound infection is:
B.) Do deep breathing and coughing exercises A.) Adequate fluid intake
C.) Regulate IVF accurately B.) Proper administration of antibiotics
D.) Shave the skin C.) Practice of strict aseptic technique
Ans: A D.) Frequent cleaning of the wound

30.) Immediately following spinal anesthesia, the greatest risk Ans: C

is:
A.) Severe hemorrhage 37.) When the patient vomits, the most important nursing
B.) Severe Hypotension objective is to prevent:
C.) Severe Hypoglycemia A.) Dehydration
D.) Hypertensive crisis B.) Aspiration
C.) Rupture of suture line
Ans: B D.) Met. Alkalosis

31.) Nursing measures to promote the client’s respiratory Ans: B

function during recovery from anesthesia are the following
EXCEPT: 38.) Post operatively, a patient is expected to void after:
A.) Encourages deep breathing and coughing exercises A.) 6-8 hours
B.) Administer Humidified oxygen B.) 2-4 hours
C.) Place in semi-fowlers position C.) 12-24 hours
D.) Place in supine position with head turned to the side D.) 10-12 hours
without pillow support
Ans: A
Ans: C
39.) Headache after spinal anesthesia is due to:
32.) Which of the following criteria must be met before the A.) Paralysis of vasomotor nerves
client is released from the RR to the unit. B.) Traction placed on structures within abdomen
A.) Breathes with ease, coughs freely C.) Loss of CSF through dural hole
B.) Has regained consciousness D.) Administration of large amounts and heavy concentration
C.) Vital signs fluctuates erratically of anesthetic agents
D.) Able to move four extremities
Ans: C
Ans: C
40.) Nursing measures for post-op thrombophlebitis include
33.) Early signs of poor respiratory function include which of the following EXCEPT:
the following A.) Maintain bedrest
A.) Cyanosis B.) Elevate affected leg with pillow support
B.) Hypotension C.) Massage the painful extremities
C.) Loss of consciousness D.) Apply antiembolic stockings
D.) Restlessness
Ans: C
Ans: D
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
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
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”
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