Perioperative Nursing Review C.

) Prone position
Concepts D.) Modified trendelenburg

1.) Which of the following is most Ans: B

dangerous complication during
induction of spinal anesthesia? 5.) Which of the following nursing
A.)Tachycardia actions should be given highest
B.)Hypotension priority when admitting the patient
C.)Hyperthermia into the operating room?
D.)Bradypnea A.) Level of consciousness
B.) Vital signs
Ans: B C.) Patient identification and
correct operative consent
2.) Which type of surgery is most D.) Positioning and skin preparation
likely to predispose a patient to
postoperative atelectasis, pneumonia Ans: C
or respiratory failure?
A.)Upper abdominal surgery on an 6.) What is the primary reason for
obese patient with a long history of the gradual change of position of
smoking the patient after surgery?
B.)Upper abdominal surgery on a A.) To prevent muscle injury
patient with normal pulmonary B.) To prevent sudden drop of BP
function C.) To prevent respiratory distress
C.)Lower abdominal surgery on a D.) To promote comfort
young patient with diabetes mellitus Ans: B
D.)Surgery on the extremities of a
nonsmoking football player 7.) Which of the following
assessment data is most important to
Ans: A determine when caring for a patient
3.) Which of the following who has received spinal anesthesia?
characterizes excitement stage of A.) The time of return of motion
anesthesia and sensation in the legs and toes
A.) Occurs from the administration B.) The character of respiration
of anesthesia to the loss of C.) Level of consciousness
consciousness D.) Amount of wound drainage
B.) Extends from the loss of Ans: A
consciousness to the loss of lid
reflex, characterized by 8.) Which of the following postop
struggling and talking findings should the nurse report to
C.) From the loss of lid reflex to the the M.D.?
loss of most reflexes A.) The patient pushes out the oral
D.) From the loss of most reflexes airway with his tounge
to respiratory and circulatory failure B.) Urine output is 20ml/hr for the
past two hours
Ans: B C.) VS are as follows:
4.) To prevent headache after spinal BP=110/70;PR=95;RR=19,Temp=36.
anesthesia the patient should be 8C
positioned: D.) Wound drainage is
A.) Semi-fowler’s serosanguinous
B.) Flat on bed for 6 to 8 hours Ans: B
9.) Which of the following is the Ans: B
earliest sign of poor respiratory
function? 14.) The following are the
A.) Cyanosis appropriate nursing actions before
B.) Fast thready pulse administration of preoperative
C.) Restlessness medications EXCEPT:
A.) Ascertain the consent has been
D.) Faintness
signed
Ans: C B.) Ensure that NPO has been
maintained
10.) If wound eviscerations occurs, C.) Instruct patient to empty his
the immediate nursing action is: bladder
A.) Cover the wound with sterile D.) Shave the skin at the site of
gauze moistened with sterile NSS surgery
B.) Cover the wound with water-
soaked gauze Ans: D
C.) Cover the wound with sterile dry
gauze 15.) The patient has been observed
D.) Leave the wound uncovered and pacing along the hallway, goes to
pull the skin edges together the bathroom frequently and asks
questions repeatedly
Ans: A during preoperative assessment. The
most likely cause of the behavior is:
11.) Appendectomy is classified as A.) She is anxious about the
A.) Ablative surgical procedure
B.) Constructive B.) She is worried about separation
C.) Reconstructive from the family
D.) Palliative C.) She has urinary tract infection
Ans: A D.) She has an underlying emotional
12.) The worst of all fears among problem
clients Ans: A
undergoing surgery is:
A.) Fear of financial burden 16.) Which of the following nursing
B.) Fear of death actionswould help the patient
C.) Fear of the unknown decrease anxiety during the
D.) Fear of loss of job preoperative period?
A.) Explaining all procedures
Ans: C thoroughly in chronological order
13.) The best time to provide B.) Spending time listening to the
preoperative teaching on deep patient and answering questions
breathing, coughing and C.) Encouraging sleep and limiting
turning exercises is: interruptions
A.) Before administration of D.) Reassuring the patient that the
preoperative medications surgical staff are competent
B.) The afternoon or evening prior professional
to surgery Ans: B
C.) Several days prior to surgery
D.) Upon admission of the client in
the recovery room
17.) Which of the following is the B.) Instruct to do deep breathing
primary purpose of maintaining exercises
NPO for 6 to 8 hours before C.) Assess the VS
surgery? D.) Change the patient’s position
A.) To prevent malnutrition
B.) To prevent electrolyte imbalance Ans: C
C.) To prevent aspiration pneumonia 22.) How frequent should the nurse
D.) To prevent intestinal obstruction monitor the VS of the patient in the
Ans: C recovery room?
A.) Every 15 minutes
18.) The following ensure validity B.) Every 30 mins
of informed written consent C.) Every 45 mins
EXCEPT: D.) Every 60 mins
A.) The patient is of legal age with
proper mental disposition Ans: A
B.) The consent has been secured 23.) Which of the following drugs is
within 24 hours before the surgery given to relieve nausea and
C.) If the patient is unable to write, vomiting?
secure the consent from a relative A.) Mepivacaine
D.) The consent is secured before B.) Aquamephyton
C.) Nubain
administration of any medication
D.) Plasil
that alter the level of consciousness Ans: D
Ans: C 24.) The most important factor in
19.) Which of the following drugs is the prevention of postop infection
administered to minimize is:
respiratory secretions preop? A.) Proper administration of
A.) Valium (Diazepam) antibiotics
B.) Nubain ( Nalbuphine HCL) B.) Fluid intake of 2-3L/day
C.) Phenergan (Promethazine) C.) Practice of strict aseptic
D.) Atropine Sulfate techniques
D.) Frequent change of wound
Ans: D dressings

20.) Which of the following is Ans: C

experienced by the patient who is
under spinal anesthesia? 25.) Which of the following
primarily prevents postop
A.) The patient is unconscious complications?
B.) The patient is awake A.) Adequate fluid intake
C.) The patient experiences amnesia B.) Early ambulation
D.) The patient experiences total C.) Well-balanced diet
loss of sensation D.) Administration of antimicrobials

Ans: B 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
Situation: A female client, 23 y/o A.) Ask patient to empty the bladder
was admitted for the first time at a B.) Do deep breathing and coughing
Hospital with the chief complaint of exercises
Right liac Pain, accompanied by C.) Regulate IVF accurately
nausea and vomiting, chills and D.) Shave the skin
fever. She was diagnosed to have
Ans: A
acute appendicitis. She
was scheduled to have emergency 30.) Immediately following spinal
appendectomy under spinal anesthesia, the greatest risk is:
anesthesia A.) Severe hemorrhage
26.) Pre-op instructions to the client B.) Severe Hypotension
would include the following C.) Severe Hypoglycemia
EXCEPT: D.) Hypertensive crisis
A.) Deep breathing and coughing Ans: B
exercise 31.) Nursing measures to promote
B.) Turning to sides the client’s respiratory function
C.) Foot and leg exercises during recovery from anesthesia are
D.) reassuring her that narcotics the following EXCEPT:
will be given every 4 hours round A.) Encourages deep breathing and
the clock until she is discharged coughing exercises
Ans: D B.) Administer Humidified oxygen
C.) Place in semi-fowlers position
27.) The client gave her consent for D.) Place in supine position with
the surgery. To ensure the legality head turned
of the consent, the following to the side without pillow support
conditions must be
met EXCEPT: Ans: C
A.) She gave her consent freely 32.) Which of the following criteria
B.) She must understand the nature must be met before the client is
of the surgery released from the RR to the unit.
C.) The consent must be signed by a A.) Breathes with ease, coughs
witness freely
D.) Signing should be done after the B.) Has regained consciousness
administration of pre-anesthesia C.) Vital signs fluctuates erratically
meds D.) Able to move four extremities
Ans: D Ans: C
28.) The skin is shaved prior to 33.) Early signs of poor respiratory
surgery in order to: function include which of the
A.) Facilitate skin incision following
B.) Indicate the site to be draped A.) Cyanosis
C.) To prevent wound infection B.) Hypotension
D.) Reduce post op scarring C.) Loss of consciousness
Ans: C D.) Restlessness

29.) The important nursing Ans: D

intervention prior to administration
of pre-anesthetic medication is:
34.) Post operatively, the client within abdomen
must be encouraged to turn, cough C.) Loss of CSF through dural hole
and deep breathe: D.) Administration of large amounts
A.) Every 1-2 hours and heavy concentration of
B.) Every 4 hours anesthetic agents
C.) Every 30 Mins
Ans: C
D.) Every 8 hours

Ans: A 40.) Nursing measures for post-op

thrombophlebitis include the
35.) A client in shock must be following EXCEPT:
placed in: A.) Maintain bedrest
A.) High-fowlers position B.) Elevate affected leg with pillow
B.) Sim’s position support
C.) Modified trendelenburg C.) Massage the painful extremities
D.) Prone position D.) Apply antiembolic stockings

Ans: C Ans: C

36.) The most important factor in 41.) Nursing measures to relieve

the prevention of post op wound hiccups include the following
infection is: EXCEPT:
A.) Adequate fluid intake A.) Exhale and inhale through a
B.) Proper administration of paper bag
antibiotics B.) Apply pressure over the eyeball
C.) Practice of strict aseptic through closed eye lids
technique C.) Hold breath while taking a large
D.) Frequent cleaning of the wound pulp of water
Ans: C D.) Administer high concentration
of oxygen
37.) When the patient vomits, the
most important nursing objective is Ans: D
to prevent:
A.) Dehydration 42.) Modified radical mastectomy
B.) Aspiration involves:
C.) Rupture of suture line A.) Removal of the entire breast,
D.) Met. Alkalosis axillary lymph nodes, pectoralis
Ans: B muscle
B.) Removal of the lump of the
38.) Post operatively, a patient is breast
expected to void after: C.) Removal of the entire breast,
A.) 6-8 hours axillary and neck lymph nodes,
B.) 2-4 hours including pectoralis muscles
C.) 12-24 hours D.) Removal of the entire breast but
D.) 10-12 hours nippleremains intact

Ans: A Ans: A

39.) Headache after spinal

anesthesia is due to:
A.) Paralysis of vasomotor nerves
B.) Traction placed on structures
43.) Which of the following is not 46.) Which of the following facts
appropriate nursing intervention best explains why the duodenum is
after modified radical not removed during a subtotal
mastectomy? gastrectomy?
A.) Place in semi fowler’s position A.) The head of the pancreas is
and elevate arm on the affected side adherent to the duodenal wall
with pillow support
B.) Check behind the client for B.) The common bile duct empties
bleeding into the duodenal lumen
C.) Monitor output from wound C.) The wall of the jejunum contains
suction drainage no intestinal villi
D.) Immobilize the arm on affected D.) The jejunum receives its blood
side in adduction supply through the duodenum

Ans: D Ans: B

44.) A fluid challenge is begun with 47.) During the immediate

a post-op gastric surgery client. postoperative period following
Which assessment will give the best gastric surgery, why must
indication of client response to the nurse be particularly
this treatment? conscientious about encouraging a
A.) CVP readings and hourly urine client to cough and deep-breathe at
output regular intervals?
B.) Blood pressure and apical rate A.) Marked changes in intrathoracic
checks pressure will stimulate gastric
C.) Lung sounds and arterial blood drainage
gases B.) The high abdominal incision
D.) Electrolytes, BUN, creatinine will lead to shallow breathing to
results avoid pain
C.) The phrenic nerve will have
Ans: A been permanently damaged during
the surgical procedure
45.) A client is scheduled for a D.) Deep-breathing will prevent
subtotal gastrectomy. In anticipation post op vomiting and intestinal
of clarifying information for client distention
education, the nurse knows that
vagotomy is done as part of the Ans: B
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
48.) Prior to having a subtotal 50.) A 40 y/o female client has
gastrectomy, a client is told about arrived in the post anesthesia room
the dumping syndrome. The nurse following a cholecystectomy and a
explains that it is: common bile duct exploration. She
A.) The body’s absorption of toxins is semi conscious. Her vital
produced by liquefaction of dead signs are within normal limits.
tissue Which of the following nursing
B.) Formation of an ulcer at the actions would be inappropriate?
margin of the gastrojejunal A.) Apply a warm blanket to her
anastomosis body
C.) Obstruction of venous flow from B.) Place her in a semi-fowler’s
the stomach into the portal system position
D.) Rapid emptying of food and C.) Attached her T-tube to gravity
fluid from the drainage
stomach into the jejunum D.) Set up low, intermittent suction
for her
Ans: D NGT
49.) Which of the following Ans: B
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