Question 1

Which assessment findings indicate increased risk of infection following hip replacement surgery?

Accepted Answer

Diabetes,urinary catheterization,rheumatoid arthritis,and immunosuppressant medication all increase the risk of infection for the patient.Need for transfusion and normal platelet counts do not increase the risk of infection.

Question 2

Which is the most appropriate outcome for the postoperative patient with the nursing diagnosis ineffective breathing pattern related to side effects of pain medication?

Accepted Answer

The appropriate outcome for ineffective breathing pattern is that the patient's pulse oximetry will stay greater than 94% with at least 12 breaths/minute.Pursed-lip breathing will not be of benefit for respiratory depression due to pain medication.Comfortable breathing is not as measurable as pulse oximetry and respiratory rate.Pain rating is not an appropriate outcome for ineffective breathing pattern.

Question 3

Which is the priority outcome for the patient with the nursing diagnosis fluid volume deficit related to ongoing postoperative bleeding?

Accepted Answer

Urine output is a sensitive indicator of fluid volume.Urine output of at least 30 mL/hour is an indicator that the patient's fluid volume is not significantly low.Temperature and incision appearance are not appropriate outcomes for fluid volume deficit.It is not appropriate to expect the patient to verbalize measures to stop postoperative bleeding.

Question 4

Which nursing diagnosis is the highest priority for a patient who just underwent hip replacement surgery?

Accepted Answer

Risk for injury is the highest priority nursing diagnosis for this patient as the patient could fall or damage the prosthesis.Impaired walking and dressing/grooming self-care deficit are lower-priority nursing diagnoses.Risk for perioperative positioning injury is not applicable as the surgery is complete.

Question 5

The postanesthesia care unit nurse receives a patient from the operating room.Which assessment will the nurse perform first?

Accepted Answer

The priority assessment is airway and oxygenation.Urinary output,intravenous lines,and bowel sounds may be assessed afterward.

Question 6

The nurse is caring for a patient with shallow respirations and diminished breath sounds following abdominal surgery yesterday.Which are the appropriate actions of the nurse?

Accepted Answer

Assisting the patient to sit up in the chair and ambulate in the hallway will facilitate chest expansion for deeper breaths.Incentive spirometry is crucial for prevention of atelectasis and pneumonia.The patient should be taught to splint the incision when coughing to minimize pain.A peaceful environment,privacy,and therapeutic touch will not help prevent atelectasis or pneumonia.

Question 7

Four hours after major abdominal surgery,the nurse notes that the patient does not have any bowel sounds.What is the appropriate action of the nurse?

Accepted Answer

Absence of bowel sounds is common for the first few hours to days following major abdominal surgery.The nurse should keep the patient NPO as any oral intake will lead to nausea and vomiting.The surgeon does not need to be notified and the patient does not require emergency surgery.

Question 8

Which assessment finding indicates that the patient is at high risk for development of pulmonary embolism?

Accepted Answer

Enoxaparin is a low-molecular-weight heparin used to prevent DVT and pulmonary embolism (PE).The refusal of enoxaparin significantly increases the patient's risk of developing DVT or PE.Normal platelet count is 150,000 to 400,000/mm³ so the patient with a 45,000/mm³ platelet count is at risk of hemorrhage.Bowel movement and transfusion do not increase risk of DVT or PE.

Question 9

Which is the priority nursing diagnosis for a patient with shallow respirations following abdominal surgery?

Accepted Answer

Ineffective breathing pattern is the priority nursing diagnosis because the patient's respirations are shallow after surgery.The patient is at risk for developing pneumonia or atelectasis if the nurse does not encourage deep breathing.Deficient diversional activity and readiness for enhanced comfort are not priority diagnoses.Risk for suffocation is not applicable as stress after surgery would not lead to suffocation.

Question 10

Which surgical procedure may be performed using conscious sedation?

Accepted Answer

Conscious sedation may be used for minor surgical procedures such as endoscopy or cataract removal.Major surgeries such as joint replacement,heart bypass,and mastectomy require spinal or general anesthesia.

Question 11

Which assessment finding leads the nurse to question the order to remove the patient's indwelling urinary catheter?

Accepted Answer

The indwelling catheter is usually left in for an extended period of time following radical prostatectomy surgery.The catheter should be removed regardless of the patient's desire to use the toilet.300 mL of clear yellow urine in the last 4 hours is an excellent sign.The patient may be discharged home with a urinary catheter once discharge teaching has been completed.

Question 12

Which type of anesthesia will the patient receive during surgery on the cervical spine?

Accepted Answer

General anesthesia must be used for cervical spinal surgery.Epidural and spinal anesthesia must be placed below the cervical spine.Local anesthesia is not appropriate for spinal surgery.

Question 13

Which surgery is classified as a palliative procedure?

Accepted Answer

Palliative surgeries are performed to make the patient more comfortable.An example of a palliative surgery is a release of bowel obstruction in a patient with end-stage colon cancer.Thoracotomy for biopsy is a diagnostic surgery.Tummy tuck is a cosmetic procedure.Removal of donor organs is termed procurement for transplant.

Question 14

Which assessment finding leads the nurse to include risk for ineffective airway clearance to the surgical patient's care plan?

Accepted Answer

Frequent arousals and waking up every morning with a headache are signs of potential obstructive sleep apnea.Collapse of the patient's upper airway during sleep leads to ineffective airway clearance.Anxiety,language fluency,and local anesthesia do not indicate risk for ineffective airway clearance.

Question 15

Which nursing diagnosis is the highest priority for a patient who had spinal anesthesia for hysterectomy surgery?

Accepted Answer

The priority nursing diagnosis is risk for falls related to impaired motor function from anesthesia because spinal anesthesia causes temporary paralysis of the lower extremities.Nausea,constipation,and impaired oral mucus membranes are all less important nursing diagnoses.

Question 16

The nurse is teaching the patient about postoperative exercises including incentive spirometry.How can the nurse best determine that the teaching was effective?

Accepted Answer

The nurse can best determine that the teaching was effective by having the patient demonstrate the exercises and how to use the spirometer.Statements about anxiety,caring presence,and rationales do not demonstrate that the patient is able to use the spirometer and perform the exercises.

Question 17

The nurse is caring for a patient undergoing a surgical procedure that will take 7 to 8 hours to complete.Which is the appropriate outcome for the diagnosis risk for perioperative positioning injury related to prolonged immobilization?

Accepted Answer

The appropriate outcome for risk for perioperative positioning injury is that the patient's skin will be free of redness or breakdown when surgery is complete.Privacy and dignity is less important than prevention of injury to the skin.Padding bony prominences and assessing the skin are both examples of nursing interventions rather than outcomes.

Question 18

Which is the highest priority nursing diagnosis for the patient undergoing a lengthy surgery in the operating room?

Accepted Answer

The operating room environment is cool,and the patient's depressed level of body function results in a lowering of metabolism and fall in body temperature.Hypothermia is a priority nursing diagnosis for patients undergoing lengthy surgeries.Powerlessness,risk for impaired oral mucus membranes,and risk for caregiver role strain are all less important diagnoses.

Question 19

The nurse is caring for a patient who will be having emergency surgery in a few minutes for appendicitis.Which preoperative teaching is most important?

Accepted Answer

The patient does not have time to learn about exercises and activities to prevent postoperative complications.The nurse should inform the patient about what to expect in the immediate postoperative period.Information about wound care,deep breathing,and ambulation can wait until after surgery is completed.

Quiz 40: Surgical Patient