Exam 37: Perioperative Nursing Care

The nurse is caring for a patient who is recovering from bowel resection surgery. Which assessment findings indicate to the nurse that the patient no longer needs to remain NPO and may progress to oral intake of food and fluids? (Select all that apply.)

The nurse is caring for a patient who is recovering from chest surgery. Which action by the patient indicates that additional teaching is needed about how to use the ordered incentive spirometer correctly?

The nurse is caring for a patient who underwent abdominal surgery the previous day. Which assessment findings indicate to the nurse that the patient may be experiencing serious internal bleeding? (Select all that apply.)

The nurse is walking a postoperative patient in the hallway when she notices a large red stain of fresh blood on the patient's gown over the abdominal incision. The patient states, "I felt something just ripped open." What is the priority action of the nurse?

The nurse is caring for a patient who will be having surgery. The patient has just signed the consent form for the operation. What does the patient's signature indicate?

The nurse is caring for a male patient who will soon have open heart surgery. The patient's chest is covered with thick hair so the surgical technician comes in to shave the patient's skin near the operative site. Which action by the technician requires intervention by the nurse to correct the technique?

The nurse is caring for a patient who has a family history of reactions to general anesthesia. Which medication will the anesthesiologist have ready as a precautionary measure before the patient's surgery is started?

The nurse is caring for a patient who requires emergency surgery for injuries sustained in a motor vehicle accident. The patient was on his way back to work after having lunch with colleagues when the accident happened. What is the highest priority nursing diagnosis for this patient?

After general anesthesia is administered, the patient is carefully placed in the prone position. What is the primary consideration of the nursing staff as the patient is positioned?

Which action by the nurse best demonstrates accountability in the operating room?

The nurse is caring for a patient who is about to have surgery. Which intervention will be included in the patient's care to meet the goals for Risk for perioperative positioning injury r/t immobilization during surgical procedure?

The nurse is caring for a postoperative patient on his first day after surgery. The nurse informs the patient that the plan is to sit in the chair and ambulate in the hallway. The patient states that he is in pain and he has no intention of getting out of bed. What is the nurse's best response?

The nurse is caring for a patient who has just been brought to the postoperative unit following major surgery. The patient has many tubes and monitors in place. Which will the nurse assess first?

The nurse is caring for a postoperative patient who is recovering from abdominal surgery. The nurse notes that the patient's breath sounds are clear but diminished, shallow, and slightly labored. The patient's pulse oximetry is 96% on room air. What is the priority action of the nurse?

The nurse is caring for a postoperative patient who has a history of COPD. What is the priority nursing diagnosis for this patient?

The nurse is caring for a patient with advanced colon cancer. The patient is to have surgery to relieve a bowel obstruction that has been causing unrelenting vomiting and abdominal pain. What type of surgery will this patient undergo?

The nurse is obtaining preoperative information for a patient who will be having emergency surgery shortly for a ruptured appendix. Which information is crucial for the nurse to assess? (Select all that apply.)

The nurse is caring for a patient who is headed to the operating room for abdominal surgery. Which goal is appropriate for the nursing diagnosis risk for Perioperative positioning injury?

The nurse is caring for a postoperative patient who is very sleepy following general anesthesia and administration of pain medication. The nurse notes that the patient is making snoring sounds and his pulse oximetry has dropped to 88%. What is the best action of the nurse?

Which of the following patients would benefit from preoperative teaching about splinting of incisions to minimize discomfort? (Select all that apply.)