NCLEX type Questions - Medical Surgical Nursing for competitive exams 2

NCLEX type Questions - Medical Surgical Nursing for competitive exams 2

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1. During the preoperative interview, a patient scheduled for an elective hysterectomy to treat benign tumours of the uterus tells the nurse that she does not know whether she can go through with the surgery because she knows she will die in surgery, as her mother did. What is the most appropriate response?
a. “Tell me more about what happened to your mother.”
b. “Have you discussed these feelings with anyone else?”
c. “I am sure surgical techniques have improved since your mother had surgery.”
d. “Think positively! Positive thoughts have been shown to influence a positive surgical outcome.”

ANS: A
Anxiety can arise from lack of knowledge, which may range from not knowing what to expect during the surgical experience to uncertainty about the outcome of surgery and the potential findings; therefore, it is important that the nurse help explore the patient’s feelings. Also, further assessment may uncover a history of malignant hyperthermia, which will require precautions during the surgery.


2. A 74-year-old man is to have a left inguinal hernia repair at the outpatient surgical clinic. Preoperatively, what is it most important for the nurse to determine?
a. The patient has had outpatient surgery in the past.
b. The patient’s medical plan covers outpatient surgery.
c. The patient plans to stay overnight at the surgical centre.
d. A family member or friend is available for transportation and care at home.

ANS: D
Priority assessment is related to the need to have a responsible adult present for transportation home after surgery. Other preoperative information can include the day-of-surgery events such as patient registration, parking, what to wear, and what to bring, but these are not the priority.

3. A 36-year-old woman has been admitted to the hospital for knee surgery. Which of the following information that was obtained by the nurse during the preoperative assessment should be reported to the surgeon before surgery is performed?
a. Lack of knowledge about postoperative pain control
b. Knowledge of the possibility of an early, unplanned pregnancy
c. History of a postoperative infection following a prior cholecystectomy
d. Concern that she will be physically limited in caring for her children for a period postoperatively

ANS: B
If the patient states that she might be pregnant, information should be immediately given to the surgeon to avoid maternal and subsequent fetal exposure to anaesthetics during the first trimester.

4. Why is it especially important for the nurse to determine the patient’s current use of medications during the preoperative assessment?
a. These medications may alter the patient’s perceptions about surgery.
b. Anaesthetics alter renal and hepatic function, causing toxicity by other drugs.
c. Other medications may cause interactions with anaesthetics, altering the potency and effect of the drugs.
d. Routine medications are usually withheld the day of surgery, requiring dosage and schedule adjustments.

ANS: C
All findings of the medication history should be documented and communicated to the intraoperative and postoperative personnel. Although the anaesthesiologist will determine the appropriate schedule and dose of the patient’s routine medications before and after surgery based on the medication history, the nurse must ensure that all of the patient’s medications are identified, administer the medications as ordered, and monitor the patient for potential interactions and complications.

5. During a preoperative assessment, which of the following reported allergies does the nurse recognize as a risk for latex allergy in the patient?
a. Iodine
b. Penicillin
c. Dairy products
d. Bananas

ANS: D
An allergy to bananas puts the patient at risk for a latex allergy. Additional risk factors include food allergies to papain (meat tenderizer), avocados, kiwis, papayas, chestnuts, potatoes, tomatoes, celery, peaches, and other fruit with stones.


6. Sarah, 46 years old, is in the preoperative assessment area awaiting surgery. She is wringing her hands and perspiring, and she has a worried affect. The nurse’s communication with Sarah is based on the knowledge that the most prevalent fear of patients awaiting surgery is which of the following?
a. Pain
b. Altered body image
c. Potential for death
d. Results of the procedure

ANS: C
Patients fear surgery for many reasons, but the most prevalent are death and permanent disability

7. During the preoperative assessment of a patient scheduled for a cholecystectomy at an outpatient centre, the patient tells the nurse that she uses St. John’s wort to keep her spirits up. Why should the nurse notify the anaesthesiologist about this use of St. John’s wort?
a. It may increase the risk of bleeding.
b. It may prolong the effects of anaesthetics.
c. It may cause serious elevations in blood pressure.
d. It may depress the immune system response, delaying healing.

ANS: B
St. John’s wort may prolong the effects of anaesthetic agents.

8. Which of the following is the meaning of the suffix -ostomy?
a. Excision or removal
b. Creation of opening into
c. Incision or cutting into
d. Repair and reconstruction

ANS: B
The meaning of the suffix -ostomy is creation of an opening into; an example is a colostomy.

9. According to the Canadian Anesthesiologists’ Society, what is the minimum preoperative fasting time period for intake of clear fluids?
a. 30 minutes
b. 1 hour
c. 2 hours
d. 4 hours

ANS: C
According to the Canadian Anesthesiologists’ Society, the minimum preoperative fasting time period for intake of clear fluids is 2 hours.


10. The nurse visits the patient to have him sign the operative permit as directed in the physician’s preoperative orders. The patient tells the nurse that the physician has not really told him what is involved in the surgical procedure. What should the nurse do?
a. Ask family members whether they have discussed the surgical procedure with the physician.
b. Explain what the planned surgical procedure entails before having the patient sign the consent form.
c. Have the patient sign the form, and tell him the physician will visit him before surgery to explain the procedure.
d. Delay the patient’s signature on the consent form, and notify the physician that the informed-consent process is not complete.

ANS: D
The nurse can be a patient advocate, verifying that the patient (or a family member) understands the consent form and its implications and that consent for surgery is truly voluntary. The nurse will contact the surgeon and explain the need for additional information if the patient is unclear about operative plans.

11. What does appropriate preoperative teaching for a patient scheduled for abdominal surgery include?
a. How to care for the wound
b. How to breathe deeply and cough
c. What medications will be used during surgery
d. What drains and tubes will be present after surgery

ANS: B
All abdominal surgery patients are taught deep breathing and coughing exercises in the preoperative period.

12. Which following class of preoperative medications is administered to increase the patients’ gastric pH and decrease gastric volume?
a. Narcotics
b. Benzodiazepines
c. Anticholinergics
d. Histamine H2-receptor antagonists

ANS: D
Histamine H2-receptor antagonists—for example, cimetidine (Tagamet), famotidine (Pepcid), and ranitidine (Zantac)—are used preoperatively to increase gastric pH and decrease gastric volume.

13. An 82-year-old man is admitted to the hospital the evening before a prostatectomy for cancer of the prostate. He is alert and oriented but has difficulty seeing and hearing. His wife is at his bedside and answers most questions directed to the patient. What should the nurse do to accomplish preoperative teaching with the patient?
a. Use printed materials for instruction because the patient does not hear well.
b. Direct the teaching toward the wife because she is the obvious support and caregiver for the patient.
c. Provide additional time for the patient to understand preoperative instructions and carry out procedures.
d. Ask the patient’s wife to wait in the hall in order to focus on preoperative teaching with the patient himself.

ANS: C
Sensory deficits may necessitate that more time be allowed for the older adult to complete preoperative testing and understand preoperative instructions.

14. A patient with diabetes that is well controlled with insulin injections has been on nothing by mouth (NPO) status since midnight before having a mastectomy. The nurse notes that there are no preoperative orders regarding the patient’s daily insulin dose. What is the most appropriate nursing action?
a. Withhold any insulin dose because none is ordered and the patient is on NPO status.
b. Call the physician to clarify whether insulin should be given and at what dosage.
c. Give the patient half of her usual daily insulin dose because she will not be eating in the morning.
d. Give the patient her usual daily insulin dose because the stress of surgery will increase her blood glucose level.

ANS: B
In the case of insulin, it is important to clarify the time and amount of the last dose before surgery.

15. How would the nurse document the preoperative rating of physical status for a patient who has a history of controlled asthma?
a. Healthy patient with no systemic disease
b. Mild systemic disease without functional limitations
c. Severe systemic disease associated with functional limitations
d. Severe systemic disease that is an ongoing threat to life

ANS: B
A patient that has a history of controlled asthma would be rated as a II—a mild systemic disease without functional limitations.

16. As the nurse prepares a patient the morning of surgery, the patient refuses to remove her wedding ring. What should the nurse do?
a. Tape the ring securely to the finger.
b. Note the presence of the ring on the preoperative checklist form.
c. Insist that the patient remove the ring, and take it to the facility’s safe.
d. Tell the patient that the health facility cannot be responsible if something happens to her finger or the ring.

ANS: A
If the patient prefers not to remove a wedding ring, the ring can be taped securely to the finger to prevent loss.

17. Which of the following should be the nurse’s preoperative consideration when the patient states that she takes a garlic pill every day?
a. Garlic may cause inflammation of the liver.
b. Garlic may inhibit platelet activity.
c. Garlic may increase bleeding.
d. Garlic may increase pulse rate.

ANS: C
Garlic may increase bleeding, especially in patients taking anticoagulants.

18. What is the primary reason the perioperative nurse encourages a family member or a friend to remain with a patient in the preoperative holding area until the patient is taken into the operating room (OR)?
a. To ensure the proper identification of the patient before surgery
b. To protect the patient from cross-contamination with other patients
c. To assist the perioperative nurse to perform a complete patient history
d. To help minimize patient anxiety


ANS: D
Some institutions permit the family or a friend to wait with the patient until it is time to be transferred to the OR. It is believed that having a family member stay with the patient helps relieve anxiety.

19. What is the intraoperative activity that is performed by the perioperative nurse and is specific to the circulating function?
a. Identifying and assessing the patient
b. Counting sponges, needles, and instruments
c. Passing instruments to the surgeon and assistants
d. Preparing the instrument table and organizing sterile equipment

ANS: A
The circulating nurse is responsible for identifying and assessing the physiological and emotional status of the patient. Counting sponges, needles, and surgical instruments is included in both the circulating and scrub roles. Management of sterile instruments and handing instruments to the surgeon are included in the scrub role. Preparation of the instrument table and sterile equipment is included in both the circulating and scrub roles.


20. Which of the following is a principle of basic aseptic technique in the OR?
a. All supplies for the day are opened at the beginning of the shift in the sterile surgical room.
b. Torn items can be used as long as they are opened in the sterile room.
c. Sterile items can be opened and flipped onto the sterile table.
d. Each wrapper should be checked for wrapper integrity and changed chemical indicators.

ANS: D
Ensuring that each wrapper is checked for wrapper integrity and changed chemical indicators before use is a principle of basic aseptic technique in the OR.

21. What are the physical environment and traffic control measures of the OR primarily designed to do?
a. Protect the patient’s privacy.
b. Prevent transmission of infection.
c. Ensure the proper function of electrical equipment.
d. Promote the development of teamwork among the OR staff.

ANS: B
The surgical suite is a controlled environment designed to minimize the spread of infectious organisms and allow a smooth flow of patients, personnel, and the instruments and equipment needed to provide safe patient care.

22. Which one of the following intraoperative patient positions would the nurse anticipate for the patient who is being prepared for abdominal surgery?
a. Prone
b. Supine
c. Trendelenburg
d. Lateral decubitus

ANS: B
The nurse would anticipate a patient that was being prepared for abdominal surgery to be in a supine position for surgery.

23. The nurse would implement postoperative monitoring of a patient’s sedation score when the patient had received which one of the following anaesthetics?
a. Lidocaine (local spinal)
b. Fentanyl (analgesic spinal)
c. Lidocaine (local epidural)
d. Sufentanil (analgesic epidural)

ANS: C
The nurse would implement postoperative monitoring of the patient’s sedation score when the patient had received a local epidural anaesthetic, for example, lidocaine.

24. Which of the following data obtained during the perioperative nurse’s assessment of an older patient in the preoperative holding area would indicate a need for special protection techniques during surgery?
a. A history of spinal and hip arthritis
b. Verbalization of anxiety by the patient
c. The patient asking about the details of the surgical procedure
d. An 8-mm Hg increase in systolic blood pressure from the time of hospital admission

ANS: A
Older adults often have osteoporosis and osteoarthritis. These factors reinforce the need for careful transferring, lifting, and positioning techniques.

25. The nurse notes that a preoperative patient is drowsy, but oriented, in the receiving area. In addition to checking her hospital number and identification band, what should the nurse check?
a. Ask family members to verify the patient’s identity.
b. Check that the operative procedure is noted on the chart.
c. Ask the surgeon to identify the patient and the planned surgical procedure.
d. Ask the patient to state her name, her doctor’s name, and the operative procedure planned.

ANS: D
The identification process in the receiving area includes asking the patient to state her or his name, the surgeon’s name, and the operative procedure and location.

26. The nurse from the general surgical unit brings the patient’s hearing aid to the surgical suite because the patient left the unit without it and it is needed to communicate with the patient. At the surgical suite, what areas can the general surgical unit nurse enter?
a. Clean core
b. Scrub sink areas
c. Information or nursing station
d. Corridors of the ORS

ANS: C
In the OR area, the unrestricted area is where personnel in street clothes can interact with those in scrub clothing. These areas typically include the points of entry for patients (e.g., holding area), staff (e.g., locker rooms), and information (e.g., nursing station).

27. A preoperative patient in the holding area asks the nurse whether he will be “put to sleep” with a mask over his face. What is the most appropriate response?
a. “A drug will be injected through your intravenous line, which will cause you to go to sleep almost immediately.”
b. “Only your surgeon can tell you for sure what method of anaesthesia will be used. Should I ask your surgeon?”
c. “Masks are not used anymore for anaesthesia. A tube will be inserted into your throat to deliver a gas that will put you to sleep.”
d. “You will be so sleepy from the preoperative medication you have received that you will not be aware of the anaesthetic administration.”

ANS: A
Virtually all routine general anaesthetic protocols for use with adults begin with an intravenous (IV) induction agent, such as midazolam (Versed) or propofol (Diprivan).

28. A surgical patient received a volatile liquid as an inhalation anaesthetic during surgery. What would the nurse expect the patient to experience postoperatively?
a. Early onset of pain
b. Nausea and vomiting
c. Respiratory depression
d. Significant cardiac depression

ANS: A
With an inhalation anaesthetic, the nurse needs to assess and treat pain during early anaesthesia recovery.


29. Which assessment finding would the nurse expect to observe in a patient with malignant hyperthermia?
a. Decreased heart rate
b. Low, irregular respirations
c. Decreased temperature
d. Ventricular dysrhythmias

ANS: D
A patient with malignant hyperthermia will exhibit tachycardia, tachypnea, hypercarbia, and ventricular dysrhythmias.

30. A patient with a dislocated shoulder is prepared for a closed, manual reduction of the dislocation with conscious sedation. Which of the following would the nurse anticipate would be administered preoperatively?
a. Inhaled nitrous oxide
b. IV midazolam
c. Intramuscular ketamine (Ketalar)
d. Intramuscular fentanyl–droperidol (Innovar)

ANS: B
Because of its excellent amnestic property, shorter duration of action, and absence of pain on injection, midazolam is presently the most frequently used benzodiazepine for conscious sedation.

31. What is one of the most important goals of the registered nurse first assistant?
a. Safety of the patient
b. Monitoring of the activities of others
c. Documentation of the intraoperative care
d. Admission of the patient to the OR

ANS: A
The registered nurse first assistant’s primary role is to carry out preoperative, intraoperative, and postoperative nursing responsibilities to ensure a safe, efficient patient experience.

32. Which of the following is part of the minimum requirements for the health record in ambulatory surgery facilities?
a. Postoperative checklist
b. Consult request
c. Documentation of consent
d. Detailed surgical procedure report

ANS: C
Minimum requirements for the health record in ambulatory surgery facilities include documentation of informed consent, preoperative checklist, and a history and physical examination.

33. A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anaesthesia. At the completion of the surgery, it is most important that the nurse monitor the patient for which one of the following?
a. Nausea and vomiting
b. Agitation and seizures
c. Laryngospasm or bronchospasm
d. Adequacy of respiratory muscle movement

ANS: D
The patient should be carefully observed for airway patency and adequacy of respiratory muscle movement.

34. On admission of a patient to the postanaesthesia care unit (PACU) from surgery, the nurse should place the highest priority on assessing which of the following?
a. The condition of the surgical site
b. The patient’s level of consciousness
c. The adequacy of respiratory function
d. The status of fluid and electrolyte balance

ANS: C
While the patient is in the PACU, priority care includes monitoring and management of respiratory and circulatory function, pain, temperature, and surgical site, with the priority being the adequacy of respiratory function.

35. A 42-year-old patient is recovering from anaesthesia in the PACU following a hysterectomy. Her preoperative blood pressure was 120/68 mm Hg, and on admission to the PACU, her blood pressure was 124/70 mm Hg. Thirty minutes after admission, her blood pressure is 112/60 mm Hg. Her pulse is 72 beats/min, and her skin is warm and dry. What is the most appropriate nursing action at this time?
a. Administer oxygen therapy per mask.
b. Notify the anaesthesiologist immediately.
c. Increase the rate of the patient’s intravenous (IV) fluid replacement.
d. Continue to monitor the patient, taking vital signs every 15 minutes.

ANS: D
The assessment findings are within the normal range, which directs the nurse to continue to monitor the patient’s status, taking vital signs every 15 minutes.

36. A 70-year-old patient becomes restless and agitated as he begins to regain consciousness in the PACU, and his SpO2 is 88%. What is the most common cause of hypoxemia during anaesthesia recovery that the nurse bases her knowledge on to intervene?
a. Atelectasis
b. Bronchospasm
c. Pulmonary edema
d. Aspiration of gastric contents


ANS: A
The most common cause of postoperative hypoxemia is atelectasis. Atelectasis (alveolar collapse) may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion.


37. During recovery from anaesthesia in the PACU, a patient’s vital signs for the past hour have been as follows: blood pressure 112/82, 110/82, 112/80, and 114/82 mm Hg; pulse 76, 78, 78, and 80 beats/min; and respirations 22, 24, 24, and 26 breaths/min; her SpO2 is 90%. She is sleepy but awakens easily and is oriented when spoken to. Her surgical dressing is dry and intact. What is the most appropriate nursing action?
a. Position the patient in a lateral position.
b. Encourage the patient to take deep breaths.
c. Check the patient’s temperature, and apply warm blankets.
d. Notify the anaesthesiologist that the patient is ready for discharge from the PACU.


ANS: B
Deep breathing and coughing techniques help the patient prevent alveolar collapse and move respiratory secretions to larger airway passages for expectoration. As long as the vital signs are within the normal range, the patient should be assisted to breathe deeply 10 times every hour while awake.

38. When a postoperative patient in the PACU complains of pain at the incision site, what should the nurse do?
a. Administer analgesics as written in the patient’s postoperative orders.
b. Administer half of the postoperative dose of analgesic ordered for the patient.
c. Tell the patient that pain medication cannot be given until transfer to the postoperative clinical unit.
d. Consult with the anaesthesiologist to determine an effective, reduced dose of an analgesic for the patient.


ANS: D
Adequate and regular analgesic medication should be provided because incisional pain often is the greatest deterrent to patient participation in effective ventilation and ambulation; therefore, the nurse should consult with the anaesthesiologist to determine an effective dose in light of the amount of medications that the patient had in the operating room.

39. While assessing patients for complications during recovery from anaesthesia, the nurse recognizes that which of the following patients is at the greatest risk for developing postoperative hypothermia?
a. A 78-year-old female patient undergoing a vaginal hysterectomy under general anaesthesia
b. A 58-year-old male patient undergoing repair of a knee cartilage under general anaesthesia
c. A 68-year-old female patient with diabetes undergoing a great toe amputation under local anaesthesia
d. A 72-year-old male patient undergoing bowel resection for colon cancer under general anaesthesia


ANS: D
Long surgical procedures and prolonged anaesthetic administration lead to redistribution of body heat from the core to the periphery. This places the patient at an increased risk for hypothermia; therefore, the patient at greatest risk is one undergoing a bowel resection because of the length of the surgery.

40. To maintain the airway and promote respiratory function, in which preferred position should the nurse place unconscious patients in the PACU?
a. Prone
b. Lateral
c. Dorsal recumbent
d. Supine with the head of the bed elevated


ANS: B
Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral “recovery” position.

41. A patient’s blood pressure in the PACU has dropped from an admission blood pressure of 138/84 to 110/78 mm Hg, with a pulse change of 68 to 84 beats/min. What is the first nursing action to be performed?
a. Administer oxygen.
b. Assess for a full bladder.
c. Auscultate the patient’s lungs.
d. Check the patient’s temperature.


ANS: A
Treatment of hypotension should always begin with oxygen therapy to promote oxygenation of hypoperfused organs.


42. The nurse is documenting the daily amount that was collected in a patient’s T-tube. Which one of the following daily totals would be considered normal?
a. 100 mL
b. 250 mL
c. 500 mL
d. 1000 mL


ANS: C
The normal daily total for T-tube daily volume is 500 mL.


43. When a patient is transferred from the PACU to the clinical surgical unit, what is the first nursing action on the surgical unit?
a. Assess the patient’s pain.
b. Take the patient’s vital signs.
c. Check the rate of the IV infusion.
d. Check the physician’s postoperative orders.


ANS: B
Vital signs should be obtained, and patient status should be compared with the report provided by the PACU.

44. Which of the following is an ambulatory surgery discharge criterion?
a. Voided at least three times
b. No IV narcotics for last 30 minutes
c. Had at least one bowel movement
d. Oxygen saturation 88%


ANS: B
One of the discharge criteria for ambulatory surgery discharge is that the patient has not received IV narcotics in the past 30 minutes. The patient is only required to have had one void. No bowel movement is required before discharge. Oxygen saturations should be >90%, according to the PACU discharge criteria, which must be met for ambulatory surgery discharge.

45. A patient who had bowel surgery 2 days ago has orders for morphine sulphate 4 mg IV every 2 hours and a clear liquid diet. The patient tells the nurse that she feels distended and has gas pains. What is the most appropriate intervention in response to the patient’s complaint?
a. Obtain an order for a laxative.
b. Withhold all oral fluid and food.
c. Assist the patient to ambulate in the hall.
d. Administer the prescribed morphine sulphate.


ANS: C
Fifty percent of patients who have bowel surgery experience postoperative ileus (POI), a transient cessation of bowel motility that prevents effective passage of intestinal contents and may affect the patient’s tolerance of oral intake. Recent studies suggest starting a clear liquid diet for some types of POI and initiating early ambulation and pharmacological interventions.

46. Postoperatively, a patient is receiving low–molecular weight heparin. What should the nurse do when administering this drug?
a. Explain that the drug will help prevent clot formation in the legs.
b. Administer the dose with meals to prevent gastrointestinal irritation and bleeding.
c. Check the results of the partial thromboplastin time before administration.
d. Inform the patient that blood will be drawn every 6 hours to monitor the prothrombin time.


ANS: A
The use of unfractionated heparin or low–molecular weight heparin is a prophylactic measure for venous thrombosis and pulmonary embolism.

47. Following gallbladder surgery, a patient has a T-tube with thick, dark green drainage. When the patient asks about the tube and the drainage, what is the nurse’s best response?
a. “The tube you see has been placed in the bile duct, and the drainage is normal bile.”
b. “The drainage is from your gallbladder, but it should be bright yellow rather than green.”
c. “The drainage is old blood and fluid that accumulates at the surgical site, and its removal will promote healing.”
d. “The tube is draining secretions from the duodenum and small bowel, and this is normal drainage from this area.”


ANS: A
The assessment indicates normal findings for a T-tube; therefore, the nurse needs to tell the patient that this is normal and that the T-tube is in the bile duct.


48. 15. A postoperative patient has not voided for 7 hours after return to the postsurgical unit. Initially, what should the nurse do?
a. Call the physician.
b. Palpate and percuss the bladder.
c. Ambulate the patient to the bathroom.
d. Check the postoperative orders for catheterization orders.


ANS: B
If no voiding occurs, the abdominal contour should be inspected, and the initial action is to palpate and percuss the bladder for distension.

49. Which of the following is a possible cause for a temperature of 36.1°C in a patient at 8 hours postoperative abdominal surgery?
a. Surgical stress response
b. Lung congestion, atelectasis
c. Effects of anaesthesia
d. Phlebitis

ANS: C
Hypothermia during the first 12 hours after surgery is probably caused by the effects of the anaesthesia or body heat loss during surgical exposure. The other answer options all cause an increase in body temperature, not a decrease.

50. During planning to promote ambulation, coughing, deep breathing, and turning in a postoperative patient, which of the following does the nurse know will help ensure that the desired outcomes will most readily be met?
a. The patient understands the rationale for these activities.
b. The patient receives praise when the activities are completed.
c. The patient receives enough analgesics to promote relative freedom from pain.
d. The patient is warned about complications that can occur without the activities.


ANS: C
Adequate and regular analgesic medication should be provided because incisional pain often is the greatest deterrent to patient participation in effective ventilation and ambulation.

51. Which of the following is an integumentary system clinical manifestation of inadequate oxygenation?
a. Muscle twitching
b. Use of accessory muscles
c. Hypotension
d. Prolonged capillary refill


ANS: D
An integumentary system clinical manifestation of inadequate oxygen is prolonged capillary refill.


52. 19. While caring for a postoperative patient, what should the nurse expect that a physiological response to stress during the first 2 to 5 days postoperatively will result in?
a. Tachycardia
b. Hyperventilation
c. Fluid retention with decreased urinary output
d. An elevation of body temperature to 38.3°C


ANS: C
Fluid retention during the first 2 to 5 postoperative days can be the result of the stress response.

53. A patient is one day postoperative for abdominal surgery and has an indwelling catheter. Which of the following amounts represents the normal daily range of urine volume?
a. 200 to 400 mL
b. 500 to 700 mL
c. 800 to 1000 mL
d. 1500 to 2000 mL


ANS: B
The normal daily range of urine volume expected from a patient with an indwelling catheter 1 to 2 days postoperatively is 500 to 700 mL. After this time period, 1500 to 2500 mL is expected daily.

54. A patient with acute diarrhea of 24 hours’ duration calls the clinic to ask for directions for care. In talking with the patient, what should the nurse do?
a. Ask the patient to describe the character of the stools and any associated symptoms.
b. Advise the patient to use over-the-counter loperamide (Imodium) to slow gastrointestinal motility.
c. Inform the patient that laboratory testing of blood and stool specimens will be necessary.
d. Advise the patient to drink clear liquid fluids with electrolytes, such as Gatorade or Pedialyte.


ANS: A
The nurse’s initial response should be further assessment of the patient. The other responses may be appropriate, depending on what is learned in the assessment.


55. A 78-year-old patient is transferred to the hospital from a nursing home on developing abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of Clostridium difficile. In planning care for the patient, the nurse will do which of the following?
a. Order a diet with no dairy products for the patient.
b. Place the patient in a private room with contact isolation.
c. Explain to the patient why antibiotics are not being used.
d. Teach the patient about proper food handling and storage.


ANS: B
Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used.

56. An older adult man is hospitalized with a diagnosis of Giardia lamblia infection. He frequently has explosive diarrhea stools that he is unable to control. He closes his eyes and will not talk to the nurse when his linens are changed and skin care is performed. To help maintain the patient’s self-esteem, what should the nurse implement?
a. Use incontinence briefs for the patient so that cleaning him is less cumbersome and embarrassing.
b. Request an order for an antidiarrheal drug from the physician to help control the diarrhea episodes.
c. Assure the patient that his lack of control is temporary and will resolve with treatment of the disorder.
d. Acknowledge his behaviour as reflective of a difficult situation for him, and provide privacy during hygiene.


ANS: D
Acknowledging the difficulty of the situation and providing privacy will decrease the patient’s embarrassment about the incontinence.

57. Which of the following is a neoplastic polyp of the large intestine?
a. Familial juvenile polyps
b. Pseudopolyps
c. Hereditary polyposis syndromes
d. Leiomyomas


ANS: C
Hereditary polyposis syndromes are neoplastic polyps of the large intestine. Familial juvenile polyps, pseudopolyps, and leiomyomas are non-neoplastic polyps of the large intestine.

58. Psyllium (Metamucil) is prescribed for a patient with chronic constipation. In teaching the patient about chronic constipation, what should the nurse stress?
a. The use of bulk-forming laxatives is safe, and they do not cause any adverse effects.
b. At least 3000 mL of fluid daily must be taken to prevent impaction or bowel obstruction.
c. Dietary sources of fibre should be eliminated from the diet to prevent excessive gas formation.
d. Supplemental fat-soluble vitamins must be taken because the medication blocks absorption of these vitamins.


ANS: B
A high fluid intake is needed to prevent hardened stools leading to impaction or bowel obstruction. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs.

59. A patient is admitted to the emergency department with severe abdominal pain, anorexia, and chills. His vital signs include temperature 38.3°C, pulse 130 beats/min, respiration 34 breaths/min, and blood pressure (BP) 82/50 mm Hg. His pain is more intense in the left lower quadrant but radiates throughout the entire abdomen, with rebound tenderness and abdominal rigidity. The nurse plans care for the patient based on the knowledge that management of his condition initially involves which of the following actions?
a. Intravenous (IV) fluid resuscitation
b. Exploratory laparotomy
c. Administration of IV antibiotics
d. Diagnostic testing with barium studies and endoscopy

ANS: A
The priority for this patient is to treat the patient’s hypovolemic shock with fluid infusion. The other actions should be implemented after starting the fluid infusion.

60. A patient is being evaluated in the emergency department for acute lower abdominal pain with diarrhea and vomiting. During the nursing history, what is the most helpful question to obtain information regarding the patient’s condition?
a. “What do you usually eat?”
b. “Can you tell me about your pain?”
c. “What is your usual elimination pattern?”
d. “When did the diarrhea and vomiting start?”


ANS: B
A complete description of the pain provides clues about the cause of the problem.

61. Two days following an exploratory laparotomy with a resection of a short segment of small bowel, the patient complains of gas pains and abdominal distension. Which nursing action is most appropriate to take at this time?
a. Assisting the patient to ambulate
b. Administering the ordered IV morphine sulphate
c. Giving a return-flow enema
d. Inserting the ordered promethazine (Phenergan) suppository


ANS: A
Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain.

62. Which stool consistency would the nurse expect to see in a patient with a sigmoid colostomy?
a. Semiliquid
b. Semiformed
c. Formed
d. Pasty


ANS: C
A patient with a sigmoid colostomy would be expected to have a formed soot consistency. A semiliquid or semiformed stool consistency would be expected with a transverse colostomy. A pasty stool consistency would be expected with an ileostomy.


63. A patient is brought to the emergency department following an automobile accident in which she suffered blunt trauma to the abdomen. She is splinting her abdomen and complaining of pain, and bowel sounds are decreased. A peritoneal lavage returns brown drainage. Based on the results of the lavage, what should the nurse plan for?
a. Preparation for a paracentesis
b. Administration of pain medications
c. Continued monitoring of the patient’s condition
d. Immediate preparation of the patient for surgery


ANS: D
Return of brown drainage suggests perforation of the bowel and the need for immediate surgery.

64. A patient is brought to the emergency department with a knife impaled in his abdomen following a domestic fight. During the initial assessment of the patient, what is it most important for the nurse to do?
a. Assess the BP and pulse.
b. Remove the knife to assess the wound.
c. Determine the presence of Rovsing’s sign.
d. Palpate the abdomen for distension and rigidity.


ANS: A
The initial assessment is focused on determining whether the patient has hypovolemic shock; therefore, the priority action is to assess the BP and pulse

65. A 20-year-old university student is admitted to the emergency department for evaluation of abdominal pain with nausea and vomiting. She has a white blood cell count of 14,000 cells/microlitre with a shift to the left. Which one of the following actions is appropriate for the nurse to take?
a. Encourage the patient to take sips of clear liquids.
b. Apply an ice pack to the right lower quadrant.
c. Check for rebound tenderness every 30 minutes.
d. Teach the patient how to cough and breathe deeply.


ANS: B
The patient’s clinical manifestations are consistent with appendicitis, and application of an ice pack will decrease inflammation at the area. Heat is never to be applied to the area because it may cause the appendix to rupture.

66. The nurse identifies the collaborative problem of potential complication: hypovolemic shock related to loss of circulatory volume for a patient with bacterial peritonitis resulting from a ruptured appendix. The nurse recognizes that the major loss of circulating fluid volume occurs as a result of which of the following?
a. Nasogastric suctioning
b. Increased production of stress hormones
c. Extracellular fluid shift into the peritoneal cavity
d. Drainage of excessive fluids from the appendix into the peritoneal cavity


ANS: C
The inflammatory process causes the shift of fluids into the peritoneal space.

67. A woman diagnosed with irritable bowel syndrome (IBS) tells the nurse that her friends say her problem is “all in [her] head.” In caring for the woman, what is it most important for the nurse to do?
a. Advise her that new medications are available to treat the condition.
b. Reassure her that IBS has a specific, identifiable cause.
c. Explain that modifications to increase dietary fibre can control the symptoms.
d. Develop a trusting relationship with her to allow for the expression of her concerns.


ANS: D
Because psychological and emotional factors can impact on the symptoms of IBS, encouraging the patient to discuss emotions and ask questions is an important intervention.

68. A patient hospitalized with an acute exacerbation of ulcerative colitis is having 14 to 16 bloody stools a day and crampy abdominal pain associated with the diarrhea. Which of the following will the nurse plan to implement?
a. Place the patient on NPO status.
b. Administer cobalamin (vitamin B12) injections.
c. Start bowel preparation for colonoscopy.
d. Administer IV metoclopramide.


ANS: A
An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest the bowel by making the patient NPO status.


69. While obtaining a nursing history from a patient with IBD, which of the following data leads the nurse to suspect that the patient most likely has ulcerative colitis rather than Crohn’s disease?
a. Weight loss
b. Bloody diarrhea
c. Abdominal pain and cramping
d. Onset of the disease at age 20


ANS: B
Because ulcerative colitis affects the colon, blood in the stools is more common with this form of IBD.

70. Sulphasalazine (Salazopyrin) is prescribed for a patient who has been diagnosed with ulcerative colitis. The nurse recognizes that teaching about this drug has been effective when the patient states which of the following?
a. “The medication will prevent infections that cause the diarrhea.”
b. “The medication suppresses the inflammation in my large intestine.”
c. “I will need lab tests to be sure that I can still fight infections.”
d. “I will take the sulphasalazine as an enema or suppository.”


ANS: B
Sulphasalazine suppresses the inflammatory process that causes the symptoms of ulcerative colitis.

71. The nurse identifies a nursing diagnosis of impaired skin integrity related to diarrhea for a patient with ulcerative colitis. The nurse recognizes that teaching regarding perianal care has been effective when the patient implements which of the following actions?
a. Takes a sitz bath for 40 minutes following each stool
b. Asks for antidiarrheal medication after each diarrhea stool
c. Applies barrier cream after each cleansing of the perianal area
d. Cleans her perianal area with soap and water after each diarrhea stool


ANS: C
The patient should apply barrier cream after cleansing, to protect skin and promote healing.

72. Surgery is recommended by the physician for a patient with severe ulcerative colitis who has not responded to conservative treatment. The patient tells the nurse that she does not know what decision to make about the proposed surgery or how to choose among the surgical alternatives offered by the surgeon. In responding to the patient’s concerns, what should the nurse explain?
a. Surgery for ulcerative colitis involves the formation of a temporary ileostomy to divert fecal contents until the large bowel heals.
b. In a total proctocolectomy with a continent ileostomy, a pouch is created that holds bowel contents and is emptied once a day with the use of a catheter.
c. A total colectomy and ileal reservoir provide the most normal elimination function, but this surgery consists of two procedures, requiring a temporary ileostomy for 8 to 12 weeks.
d. Any proposed surgery for treatment of ulcerative colitis should be given serious consideration because the disease often recurs in previously unaffected parts of the bowel.


ANS: C
The total colectomy and ileal reservoir enable the patient to pass stool rectally but require two procedures 8 to 12 weeks apart.

73. After teaching a patient with IBD about the recommended low-residue diet, the nurse identifies a need for further instruction when the patient chooses which of the following foods from the menu?
a. Boiled shrimp
b. Ham hocks and beans
c. Spaghetti with tomato sauce
d. Poached eggs and crisp bacon


ANS: B
The patient is taught to avoid high-fibre foods such as beans.


74. A total proctocolectomy with a continent ileostomy is performed for a patient with ulcerative colitis. Postoperatively, a catheter is in place in the stoma, and irrigations are performed every 4 hours. The patient is very upset and tells the nurse that the stoma is ugly, and she does not think she can live with all the alterations in her body. What is the best response to the patient’s remarks?
a. Reassure the patient that the stoma will shrink, and she will get used to caring for the ileostomy.
b. Consult with the patient and the surgeon to arrange a visitor from a local ostomy support group.
c. Develop a detailed written plan for the patient, which includes all the information she will need to care for her ileostomy.
d. Recognize that this is a difficult period for the patient, and avoid intervening until she has had time to adjust to her situation.


ANS: B
A visitor from an ostomy support group who has had similar experiences may be helpful to the patient.

75. The nurse identifies a nursing diagnosis of imbalanced nutrition: less than body requirements for a patient who is hospitalized with an acute exacerbation of Crohn’s disease based on which of the following findings?
a. Fatigue and weakness
b. A hemoglobin of 6.2 mmol/L (10 g/dL)
c. A weight loss of 0.9 kg in 2 days
d. A 24-hour diet history that reveals a 1500-calorie intake


ANS: B
A hemoglobin count of 6.2 mmol/L (10 g/dL) indicates that the patient’s iron is low; anemia is a common complication of Crohn’s disease.

76. A 26-year-old woman is diagnosed with Crohn’s disease after having frequent diarrhea and a weight loss of 4.5 kg over 2 months. When the patient asks what will happen, the nurse explains that initial therapy usually includes which of the following treatments?
a. Bed rest
b. Fluid restriction
c. Use of corticosteroids
d. Small, frequent feedings of a high-calorie diet


ANS: C
Corticosteroids are used to achieve remission in IBD, and systemic corticosteroids will be used in Crohn’s disease to affect the small intestine.

77. A patient newly diagnosed with Crohn’s disease asks the nurse what to expect in the future. What is the best response?
a. “You need to know that lifelong, unpredictable periods of remissions and recurrences are probable.”
b. “You can expect to lead a normal life and may have long periods without episodes of diarrhea or other symptoms.”
c. “Most patients with Crohn’s disease require an ostomy to control the disease, but you can adjust to that.”
d. “After about 10 years, patients with Crohn’s disease have a high risk for colon cancer unless the colon is removed.”


ANS: A
Crohn’s disease has recurrent acute exacerbations that occur at unpredictable intervals

78. A patient with Crohn’s disease develops a fever and symptoms of a urinary tract infection. The nurse recognizes that this complication may occur as a result of which of the following events?
a. Perianal irritation from frequent diarrhea
b. Fistula formation between the bowel and the bladder
c. Extraintestinal manifestations of the bowel disease
d. Impaired immunological response to infectious microorganisms


ANS: B
Fistulas between the bowel and the bladder occur in Crohn’s disease and can lead to urinary tract infection.

79. A patient is hospitalized with severe vomiting and colicky abdominal pain that is somewhat relieved with the vomiting. The physician suspects an intussusception and orders placement of an nasogastric (NG) tube while determining whether surgery is indicated. What is an appropriate collaborative problem for the nurse to identify for the patient at this time?
a. Potential complication: volvulus
b. Potential complication: thromboembolism
c. Potential complication: renal insufficiency
d. Potential complication: metabolic alkalosis


ANS: D
Metabolic alkalosis is a complication of NG suction resulting from loss of hydrochloric acid from the stomach.

80. An 81-year-old patient has a large bowel obstruction that occurred as a result of a fecal impaction. During nursing assessment of the patient, which of the following findings is consistent with a large bowel obstruction?
a. Metabolic alkalosis
b. Referred pain to the back
c. Bile-coloured vomiting
d. Abdominal distension


ANS: D
Abdominal distension is seen in lower intestinal obstruction.

81. A recent colonoscopy revealed an increased number of polyps in a patient with a history of moderately severe familial adenomatous polyposis (FAP). In planning care for the patient, what does the nurse recognize that the medical recommendation for patients with FAP will include?
a. A total colectomy with ileostomy to prevent colon cancer
b. Annual colonoscopy until the age of 40
c. Routine periodic polypectomies via a colonoscope to remove abnormal growths
d. Biannual colonoscopy for life because of a 50% chance of developing colon cancer


ANS: A
Patients with FAP have a high likelihood of developing colorectal cancer by age 40; therefore, total colectomy with ileostomy is recommended for these patients.

82. While obtaining a nursing history from a patient scheduled for a colonoscopy, what would the nurse be most concerned about?
a. Lifelong constipation
b. Nausea and vomiting
c. History of an appendectomy
d. Recent blood in the stools


ANS: D
Rectal bleeding is associated with colorectal cancer. Recent changes in bowel patterns are a clinical manifestation of colorectal cancer, but lifelong constipation is not an indication.


83. During preoperative teaching for a patient scheduled for an abdominal–perineal resection, which intervention will the nurse perform?
a. Give IV antibiotics starting 24 hours before surgery to reduce the number of bowel bacteria.
b. Teach the patient that activities such as sitting at the bedside will be started the first postoperative day.
c. Instruct the patient that another surgery in 8 to 12 weeks will be used to create an ileal–anal reservoir.
d. Administer enemas and laxatives to ensure that the bowel is empty before the surgery.


ANS: D
A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for infection.

84. Before undergoing a colon resection for cancer of the colon, a patient has an elevated carcinoembryonic antigen (CEA) test result. What should the nurse explain that the test is used to do?
a. Identify the extent of cancer spread.
b. Confirm the diagnosis of colon cancer.
c. Monitor the tumour status after surgery.
d. Identify the need for radiation or chemotherapy.


ANS: C
CEA is used to monitor for cancer recurrence after surgery.

85. A patient returns from surgery following an abdominal–perineal resection with a sigmoid colostomy and abdominal and perineal incisions. The colostomy is dressed with petroleum jelly gauze and dry-gauze dressings. The perineal incision is partially closed and has two drains attached to Jackson-Pratt suction. During the early postoperative period, to what should the nurse give the highest priority?
a. Teaching about a low-residue diet
b. Monitoring drainage from the colostomy stoma
c. Assessing perineal drainage and incision
d. Encouraging acceptance of the colostomy site


ANS: C
Because the perineal wound is at high risk for infection, the initial care is focused on assessment and care of this wound.

86. During the initial postoperative assessment of a patient’s stoma formed with a transverse colostomy, the nurse finds it to be red with moderate edema and a small amount of bleeding. What is the most appropriate nursing action?
a. Document the stoma assessment.
b. Notify the surgeon about the stoma appearance.
c. Monitor the stoma every 30 minutes.
d. Place an ice pack on the stoma to reduce swelling.


ANS: A
The stoma appearance indicates good circulation to the stoma

87. A patient has a newly formed ileostomy for treatment of ulcerative colitis. In teaching the patient about the care of her ileostomy, what should the nurse advise the patient to do?
a. Restrict fluid intake to prevent constant liquid drainage from the stoma.
b. Change the pouch every day to prevent leakage of contents onto the skin.
c. Use care when eating high-fibre foods to avoid obstruction of the ileum.
d. Irrigate the ileostomy daily to avoid having to wear a drainage appliance.


ANS: C
High-fibre foods are introduced gradually and should be well chewed to avoid obstruction of the ileostomy.

88. When teaching a patient to irrigate a new colostomy, the nurse recognizes that additional teaching is needed when the patient indicates which of the following?
a. “I should hang the irrigating container about 46 to 60 cm above the stoma.”
b. “Irrigation will help control and train my bowel.”
c. “I should use a hard plastic catheter for irrigating.”
d. “If resistance is met, force is not to be used.”


ANS: C
A hard plastic catheter is not recommended because of the risk of intestinal perforation.

89. The nurse explains to a patient with a new ileostomy that after her system adjusts to the ileostomy, the usual drainage will be about which following amount?
a. 250 mL
b. 500 mL
c. 800 mL
d. 1400 mL


ANS: C
After the proximal small bowel adapts to reabsorb more fluid, the average amount of ileostomy drainage is about 800 mL daily.

90. When implementing the initial plan of care for a patient admitted with acute diverticulosis, what should the nurse implement for the patient?
a. Administer IV fluids.
b. Order a diet high in fibre and fluids.
c. Give stool softeners.
d. Prepare the patient for colonoscopy.


ANS: A
A patient with acute diverticulitis will be NPO status with parenteral fluids, so the nurse must administer IV fluids.

91. The nurse identifies a nursing diagnosis of acute pain related to edema and surgical incision for a patient who has had a herniorrhaphy performed for an incarcerated inguinal hernia. What is an appropriate nursing intervention for this problem?
a. Apply moist heat to the abdomen.
b. Administer stool softeners as ordered.
c. Provide warm sitz baths several times a day.
d. Apply a scrotal support with application of ice.



ANS: D
Because swelling is likely to affect the scrotum, a scrotal support and ice are used to reduce edema.


92. A 42-year-old patient recently developed abdominal distension, weight loss, steatorrhea, and flatulence. A diagnosis of adult celiac disease is made, and treatment is initiated. The nurse identifies that teaching about the treatment of the disease has been effective when the patient makes which of the following statements?
a. “I must take maintenance folic acid for the rest of my life.”
b. “I must avoid all sources of wheat, rye, and oats in my diet.”
c. “A course of antibiotics is usually effective in treating this disorder.”
d. “To control the fatty, greasy stools, I should eat only very low-fat or fat-free foods.”


ANS: B
Avoidance of gluten-containing foods is the only treatment for celiac disease.

93. In providing discharge teaching for a patient who has undergone a hemorrhoidectomy at an outpatient surgical centre, what should the nurse instruct the patient to do?
a. Maintain a low-residue diet until the surgical area is healed.
b. Use ice packs on the perianal area to relieve pain and swelling.
c. Take prescribed pain medications before a bowel movement is expected.
d. Delay having a bowel movement for several days until healing has occurred.


ANS: C
Bowel movements may be very painful, and patients may avoid defecation unless pain medication is taken before the bowel movement.

94. A patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as illustrated. What should the nurse explain to the patient?
a. This type of colostomy is usually temporary.
b. Soft, formed stool can be expected as drainage.
c. The drainage is liquid at this site but less odorous than at higher sites.
d. Colostomy irrigations can help regulate the drainage from the proximal stoma.

ANS: A
A loop or double-barrel stoma is usually temporary.

95. After being treated for a respiratory tract infection with a 10-day course of antibiotics, a 69-year-old patient calls the clinic and tells the nurse about developing frequent, watery diarrhea. What will the nurse anticipate that the patient will need to do?
a. Prepare for colonoscopy by taking laxatives.
b. Have blood drawn for blood cultures.
c. Bring a stool specimen in to be tested for C. difficile.
d. Schedule a barium enema to check for inflammation.


ANS: C
The patient’s age and history of antibiotic use suggest a C. difficile infection. There is no indication that the patient needs a colonoscopy, blood cultures, or a barium enema.

96. A patient with Crohn’s disease has a megaloblastic anemia. The nurse will anticipate teaching the patient about the ongoing need for which of the following?
a. Oral ferrous sulphate tablets
b. Cobalamin (vitamin B12) injections
c. Iron dextran (Imferon) injections
d. Regular blood transfusions


ANS: B
Crohn’s disease frequently affects the ileum, where absorption of vitamin B12 occurs, and the B12 must be administered regularly by the intramuscular route to correct the anemia.

97. A patient presents at the emergency department with complaints of diarrhea and weight loss. Upon further assessment, steatorrhea is noted and the patient is found to have oxalate kidney stones. The nurse knows that these signs and symptoms are common with which following condition?
a. Intestinal obstruction
b. Short-bowel syndrome (SBS)
c. Lactase deficiency
d. Colorectal cancer


ANS: B
The predominant manifestations of SBS are diarrhea, steatorrhea, and weight loss. Oxalate kidney stones may form from increased colonic absorption of oxalate.

98. Which of the following is a clinical manifestation of an obstruction in the small intestine as opposed to the large intestine?
a. Gradual onset
b. Immediate and frequent vomiting
c. Low-grade cramping abdominal pain
d. Complete constipation


ANS: B
Clinical manifestations of a small intestine obstruction include a rapid onset, frequent and copious vomiting, colicky, cramplike, intermittent pain, feces for a short time, and minimal abdominal distension.

99. When planning care for a surgical patient, the nurse recognizes that surgical site infections account for what percentage of hospital-acquired infection?
a. 22% to 40%
b. 5% to 10%
c. 45% to 70%
d. 75% to 100%

ANS: A
The National Nosocomial Infections Surveillance (NNIS) system of the Centers for Disease Control and Prevention (CDC) reports that surgical site infections (SSIs) account for up to 16% of hospital-acquired infections. Current research indicates that 38% of hospital-acquired infections are surgical site infections.


100. The goal of prophylactic antibiotic therapy is to protect the patient from infection with as little risk as possible. To achieve this goal, the nurse recognizes that antibiotics should be administered when they will be most beneficial. When would that be?
a. Twenty-four hours before surgery
b. For 2 weeks after surgery
c. For no longer than 24 hours after surgery
d. When signs of infection first appear

ANS: C
Overall, it is recommended that prophylactic antibiotics be given as close to the time of incision as possible (within 30 to 60 minutes) and not be given for longer than 24 hours postoperatively. However, vancomycin and fluoroquinolones may be given up to 2 hours before incision because of their longer infusion times. The goal of prophylactic antibiotic therapy is to protect the patient from infection with as little risk as possible. To achieve this goal, antibiotics must be administered when they will be most beneficial.

101. While planning care for a surgical patient, the nurse recognizes that which of the following effects of hyperglycemia is seen in the immediate postoperative period?
a. Increases risk for infection in the diabetic patient only
b. Decreases risk for surgical site infection
c. Increases risk for infection in diabetic and nondiabetic patients
d. Has no effect on the body’s ability to fight infection


ANS: C
The presence of hyperglycemia in the immediate postoperative period increases the risk for infection in both diabetic and nondiabetic patients. The higher the serum glucose, the greater the potential for infection in both patient groups. Hyperglycemia has been shown to inhibit the body’s ability to fight infection. Immediate postoperative glucose control also has been correlated with a reduction in surgical infection.

102. The nurse is to obtain an informed consent for a patient before surgery is performed. The nurse recognizes that which of the following statements is true?
a. Informed consent is required by law to protect the surgeon in case of an adverse outcome.
b. Only the patient can sign a surgical consent.
c. The nurse’s legal responsibility is to ensure that the patient understands the information presented.
d. The surgeon should give the patient information about the surgery.


ANS: D

103. The nurse is planning care for a preoperative patient. Which intervention is implemented to ensure safe nursing care?
a. Allowing the patient to have ice chips
b. Always keeping the patient NPO for 12 to 14 hours before
c. Allowing the patient to brush teeth and swallow water
d. Allowing the patient to take specifically ordered oral medications with small amounts of water


ANS: D
Patients may take oral medications with sips of water (30 mL) if they are specially ordered to be taken preoperatively (e.g., antiarrhythmic or seizure medications). All other oral medications are withheld. The nurse must later check postoperative orders to ensure that scheduled medications unrelated to surgery are not forgotten. In general, food and fluids are withheld for 4 to 8 hours before surgery requiring general anesthesia, to minimize the risk for aspiration. Patients may brush their teeth but should not swallow water.

104. The nurse is providing the patient with preoperative education. When the nurse informs the patient that she will not be able to wear makeup, the patient states, “But I never go anywhere without my makeup.” The nurse’s response is based on what rationale?
a. She will speak with the surgeon to see if he will make an exception.
b. The patient may wear makeup if she insists.
c. Makeup makes it difficult for the surgeon to assess the patient.
d. Makeup impedes circulation.


ANS: C
Instruct the patient to remove hairpins, clips, wigs, hairpieces, jewelry, including rings used in body piercings, and makeup (including nail polish and acrylic nails). Makeup, nail polish, and false nails impede the assessment of skin and oxygenation. In addition, acrylic nails harbor pathogenic organisms. Makeup does not impede circulation.


105. The patient is in the hospital awaiting surgery. When asked to remove her jewelry, the patient asks why she needs to remove her navel ring. What explanation should the nurse provide?
a. The navel ring may impede assessment of the skin.
b. The navel ring may decrease circulation.
c. She may leave it in place if she chooses.
d. The navel ring may cause injury.


ANS: D
Hair appliances and jewelry anywhere on the body may become dislodged and cause injury during positioning and intubation. Navel rings probably would not impede assessment or decrease circulation. Due to the risk of injury if left in place, allowing the patient to leave the ring in place is not an option.

106. A patient who is scheduled for colon surgery is wearing a simple wedding band that he cannot remove. Which intervention is implemented to provide safe patient care?
a. Get the ring cutter from the emergency department and cut the ring off.
b. Call the physician and cancel the surgery.
c. Tape the wedding ring in place.
d. Call the physician for an order for extra antibiotics.


ANS: C
Tape in place wedding rings that cannot be removed. Be careful not to create a tourniquet effect with tape around the finger.

107. The nurse is helping the patient prepare for surgery. The patient has removed her jewelry and glasses. Which action should the nurse take to keep the jewelry safe?
a. Put these items in the patient’s bedside stand.
b. Inventory the items and give them to the family.
c. Place the items in a plastic bag and send them to the OR with the patient.
d. Keep these items with her until the patient returns.


ANS: B
Inventory the items and give them to family members, or have security lock them up. Document a list of items and their locations in a preoperative checklist and/or in the nurses’ notes per agency policy. Valuables left in the patient’s room may be lost or stolen. Items not secured could be misplaced or lost. Keeping the items with the nurse creates a liability for the nurse.

108. 10. In planning care for a surgical patient, the patient asks the nurse what may be “left on” during the surgery. Understanding patient safety, the nurse tells the patient that which item may remain in place?
a. Hearing aid
b. Artificial limb
c. Pair of eyeglasses
d. Pair of contact lenses

ANS: A
The only item the might be left in place is a hearing aid. If the patient will be required to follow instructions in the operating room, allow the patient to keep the hearing aid in place. Otherwise remove prostheses, including dentures and oral appliances, glasses and contact lenses, artificial limbs and eyes, and artificial eyelashes. Prostheses can be lost or damaged during surgery and could cause injury. Oral appliances may occlude the airway.

109. In planning surgical care for an older adult patient, the nurse recognizes which of the following as causing the greatest risk for surgery?
a. Increased tactile sense
b. Decreased glomerular filtration rate
c. Increased numbers of red blood cells
d. Decreased rigidity of arterial walls

Ans B
Reduced glomerular filtration rate and excretory times limit the ability to remove drugs or toxic substances. Assess for adverse effects of medications. Older adults usually will have sensory losses, reduced numbers of red blood cells, and increased rigidity of the arterial walls.

110. When providing care for an ambulatory surgical patient, the nurse recognizes that which assessment indicates that the patient meets discharge criteria?
a. The patient is able to drive home alone.
b. Some respiratory depression is evident.
c. The oxygen saturation level is at 85%.
d. No intravenous (IV) narcotics have been given in the past 30 minutes.

ANS: D
An ambulatory surgical patient meets discharge criteria when no IV narcotics have been administered for the past 30 minutes, a responsible adult is present to accompany the patient home, respiratory depression is not present, and oxygen saturation is greater than 90%.

111. As a patient is prepared for surgery, which finding indicates that the nurse should inform the surgeon that the surgery may need to be postponed?
a. The patient has a history of smoking.
b. The patient is experiencing calf pain, redness, and swelling.
c. The patient has an increased hemoglobin level.
d. The patient experienced an upper respiratory infection a month ago.

Ans B
Observe the calves for redness, warmth, and tenderness. Palpate pedal pulses. If a thrombus is suspected, notify the physician and refrain from manipulating the extremity any further. Surgery usually will be postponed. Any condition that affects chest wall movement such as obesity, advanced pregnancy, thoracic or abdominal surgery, history of smoking, or presence of reduced hemoglobin level can increase the risk for postoperative complications but will not necessarily require postponement of surgery. Assess and report to the physician and/or the anesthesiologist if the patient has had a cold or an upper respiratory infection within the past week.


112. The patient has been taught how to use diaphragmatic breathing. When the patient returns from surgery, however, he cannot be placed upright and must remain flat. What does the nurse tell the patient about performing the diaphragmatic exercises?
a. Diaphragmatic breathing cannot be done in this position.
b. Alternative breathing exercises need to be found.
c. Diaphragmatic breathing exercises still can be performed.
d. Diaphragmatic breathing exercises may be postponed.



ANS: C
Although performing the diaphragmatic exercises in the upright position is ideal, the patient can still benefit from performing the exercises while laying flat. The upright position is preferred because it facilitates diaphragmatic excursion by using gravity to keep abdominal contents away from the diaphragm. It prevents tension on the abdominal muscles, which allows for greater diaphragmatic excursion.

113. When teaching the patient about positive expiratory pressure therapy (PEP) and “huff” coughing, the nurse incorporates which of the following in the plan of care?
a. Instruct the patient to remain flat in bed.
b. Place a nose clip on the patient’s nose.
c. Instruct the patient to breathe through his nose.
d. Instruct the patient to exhale with long slow breaths.


ANS: B
Instruct the patient to assume semi-Fowler’s or high-Fowler’s position, and place a nose clip on the patient’s nose. Have the patient place his lips around the mouthpiece. Instruct the patient to exhale in quick, short, forced “huffs.” “Huff” coughing, or forced expiratory technique, promotes bronchial hygiene by increasing expectoration of secretions.

114. When providing teaching to a patient, which action is important to help the patient in performing controlled coughing?
a. Repeat the breathing exercises twice.
b. Cough two to three times and inhale between coughs.
c. Place a pillow over the incisional site for splinting.
d. Use the chest and shoulder muscles while inhaling during diaphragmatic breathing.


ANS: C
If the surgical incision is to be thoracic or abdominal, teach the patient to place a pillow over the incisional area and to place his hands over the pillow to splint the incision. The patient should begin by taking two or three slow, deep breaths inhaling through the nose and exhaling through the mouth. On the third inhale he should hold the breath to a count of 3. The patient will then cough fully for two to three consecutive coughs without inhaling between coughs. Teach the patient to avoid using chest and shoulder muscles while inhaling.. The patient will do this 2 to 3 times every hour he is awake.

115. When providing care for a postoperative patient, it is important for the nurse to include which postoperative exercise?
a. Turning every 4 hours
b. Completing leg exercises once daily
c. Repeating individual leg exercises 20 times
d. Performing exercises with the unaffected extremities


ANS: D
A leg unaffected by surgery can be exercised safely unless the patient has preexisting phlebothrombosis (blood clot formation) or thrombophlebitis (inflammation of the vein wall).
Instruct the patient to turn every 2 hours from side to back to the other side while awake. Have the patient continue to practice exercises at least every 2 hours while awake and repeat exercises 5 times. Instruct the patient to coordinate turning and leg exercises with diaphragmatic breathing, incentive spirometry, and coughing exercises.

116. When planning care for a PACU or recovery room patient, how often should the nurse plan to assess the patient?
a. Every 5 minutes
b. Every 15 minutes
c. Every 30 minutes
d. Hourly


ANS: B
Conduct complete assessment of all vital signs. Compare findings with the patient’s normal baseline. Continue assessing vital signs at least every 15 minutes until the patient’s condition stabilizes.

117. When providing care for a patient who has received spinal anesthesia, the nurse recognizes that which position prevents spinal headaches?
a. Prone
b. Lying on the side
c. Supine, with the head flat
d. Trendelenburg’s position


ANS: C
Position patients with spinal anesthetic supine, without elevation of the head, for up to 24 hours to prevent spinal headache from loss of cerebrospinal fluid. Increased IV or PO fluids aid the body in replacing cerebrospinal fluid.

118. While providing care for a postsurgical patient who has not received spinal anesthesia, the nurse recognizes that which position is required to maintain a patent airway in the recovery phase?
a. On his side with head facing down and neck slightly extended
b. On his side with head facing down and neck slightly flexed
c. On his back with hands over the chest
d. On his side with head facing up and neck slightly extended


ANS: A
Position the patient on his side with head facing down and neck slightly extended. Extension prevents occlusion of the airway at the pharynx. A downward position of the head moves the tongue forward, and mucus or vomitus can drain out of the mouth, preventing aspiration. Never position the patient with hands over the chest (reduces chest expansion).

119. The nurse is providing care for a patient who is recovering in the postanesthesia care unit (PACU). Given that the patient is restricted to the supine position, which intervention provides the patient with adequate chest expansion?
a. Keeping the bed flat during recovery
b. Positioning the patient’s hands over his chest
c. Flexing the neck and turning the head to the side
d. Extending the neck and turning the head to the side


ANS: D
If the patient is restricted to a supine position, elevate the head of the bed approximately 10 to 15 degrees, extend the neck, and turn the head to the side. Never position the patient with his hands over his chest (reduces chest expansion).

120. A patient is being transferred to a room from the PACU. What should the nurse do upon transfer?
a. Remove the indwelling urinary catheter.
b. Turn off the nasogastric tube suction.
c. Use a black pen to note drainage on the dressing.
d. Change the dressing immediately when the patient reaches the room.


ANS: C
Mark the dressing with a circle around the drainage using a black pen. Never use a felt tip marker to mark the dressing because ink can bleed into the gauze, contaminating the incision site. Once the patient is transferred to the bed, immediately attach any existing oxygen tubing, hang IV fluids, check the IV flow rate, attach a nasogastric (NG) tube to suction, and place an indwelling catheter in drainage position. Reinforce the pressure dressing, or change a simple dressing as ordered and needed. First dressing changes most often occur 24 hours postoperatively and usually are done by the physician.

121. The nurse explains to the patient that the incentive spirometer is used to promote which of the following outcomes?
a. Lung expansion
b. Reduce likelihood of vascular complications
c. Incisional healing
d. Expectoration of mucus

ANS: A
The use of the incentive spirometer promotes lung expansion. The visual incentive provided by the device encourages the patient to breathe as deeply as possible. Huff coughing is used to promote expectoration of mucus. Repositioning the patient regularly reduces the risk for vascular complications. While adequate oxygenation is needed for wound healing, the use of the incentive spirometer is not recommended for that outcome.


122. When assessing a postoperative patient, the nurse notes tenderness, redness, and swelling in the left calf. What should the nurse do next?
a. Massage the lower leg.
b. Contact the surgeon and prepare for heparin therapy.
c. Keep the leg in a dependent position.
d. Have the patient exercise that extremity.

ANS: B
Calf tenderness, redness, and edema in the lower extremity are signs and symptoms of venous thrombosis or thrombophlebitis. Notify the surgeon and anticipate orders for bed rest, leg elevation, and initiation of anticoagulation (e.g., heparin intravenous drip). Do not massage the affected leg. Continue to have the patient do leg exercises with the unaffected leg, not the affected leg.

123. The nurse understands that paralytic ileus is a possible postoperative complication. Which assessment provides the nurse with information about this postoperative complication?
a. Auscultating for bowel sounds every 4 hours
b. Checking blood pressure while sitting and standing
c. Observing the patient’s performance of leg exercises
d. Palpating the suprapubic region for distention


ANS: A
Paralytic ileus can develop as a common complication after bowel or abdominal surgery. Intestinal motility may return slowly, depending on anesthetic effects.

124. Upon entering a patient’s room, the nurse finds that the abdominal surgical wound has eviscerated. Which intervention is safest for the nurse to implement?
a. Cover the site with dry sterile dressings.
b. Report the incident to the oncoming shift.
c. Attempt to replace the organs.
d. Cover the site with saline-soaked sterile gauze.


ANS: D
Report wound dehiscence and/or evisceration to the surgeon immediately because it could be life threatening. If evisceration has occurred, cover abdominal contents with sterile gauze saturated with sterile normal saline, and prepare the patient for emergency surgery.

125. Which of the following have been identified as evidence-based guidelines to reduce surgical site infections (SSIs)? (Select all that apply.)
a. Prepping the surgical site with a razor followed by an antiseptic scrub
b. Giving antibiotics immediately after the procedure
c. Maintaining blood glucose levels
d. Maintaining normal body temperatures
e. Maintaining proper positioning


ANS: C, D

126. Therapies and regimens designed to prevent venous thromboembolism (VTE) include which of the following? (Select all that apply.)
a. Pneumatic compression stockings
b. Venous foot pump
c. Low-molecular-weight heparin
d. Fondaparinux
e. Elspar


ANS: A, B, C, D
Mechanical therapies include the use of graduated compression stockings along with intermittent pneumatic compression (IPC) or a venous foot pump (VFP). The VFP is limited primarily to when IPC cannot be used, as when surgery or injury occurs to the affected lower extremity. Pharmacological regimens that include the administration of low-dose unfractionated heparin, low-molecular-weight heparin, factor Xa inhibitor (fondaparinux), or warfarin are recommended. Elspar is a chemotherapeutic drug used to treat which can increase the risk for clot formation.

127. Being overweight or obese increases the risk for many diseases and health conditions, including which of the following? (Select all that apply.)
a. Hypertension
b. Coronary heart disease
c. Sleep apnea
d. Respiratory problems
e. Hypotension

ANS: A, B, C, D
Being overweight or obese increases the risk for many diseases and health conditions, including hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, sleep apnea, and respiratory problems. These conditions increase risks for postoperative complications. Hypotension is not a complication of obesity.

128. The charge nurse is assigning duties in the surgical arena. Which member of the surgical team should be assigned to the role of circulating nurse?
a. Registered nurse (RN)
b. Licensed practical nurse (LPN)
c. Certified surgical technologist (CST)
d. Licensed nursing assistant


ANS: A
The circulating nurse is always an RN who is the charge nurse in the operating room.

129. Which of the following is true about the circulating nurse’s primary responsibility?
a. She is a “sterile” member of the surgical team.
b. She provides the surgeon with instruments.
c. She is a “nonsterile” member of the surgical team.
d. She performs delegated medical functions or skills.


ANS: C
The circulating nurse is a “nonsterile” member of the surgical team who assumes responsibility and accountability for maintaining patient safety and continuity of quality care. This includes supervising the conduct of the scrub technician and delegating tasks to licensed and unlicensed nursing assistive personnel (NAP) as appropriate. The circulating nurse is also an assistant to the first assistant, the scrub nurse/technician, and the surgeon. The scrub nurse/technician provides the surgeon with instruments and supplies. The registered nurse first assistant (RNFA) performs a combination of nursing and delegated medical functions and/or skills.


130. The scrub nurse’s hands are being washed in preparation for a surgical procedure. As the nurse finishes, the scrub nurse accidentally touches the faucet with one hand. Which action should the nurse take next?
a. Apply sterile gloves.
b. Apply a sterile gown.
c. Apply a sterile mask.
d. Wash her hands.


ANS: D
The scrub nurse/technician who accidentally touches the faucet with one hand while rinsing will rescrub. This is an example of following a sterile conscience and being committed to safe, quality patient care.

131. The nurse recognizes that evidence-based care is appropriate when the nurse witnesses the surgeon take which step?
a. Washing hands for a minimum of 15 minutes with soap and water
b. Using alcohol hand scrub for 15 minutes
c. Using alcohol combined with chlorhexidine gluconate hand scrubs
d. Using a combination of soap and alcohol as a scrub


ANS: C
Recent research demonstrates that hand scrub preparations containing 50% to 90% alcohol combined with chlorhexidine gluconate are just as effective as the traditional scrubbing method in preventing SSI.

132. When planning care for a surgical patient, the nurse implements which technique to maintain sterility in the operating room?
a. Keeps the hands below the waist
b. Tucks the hands under the axilla
c. Uses sterile gloved hands to move a sterile drape under a table
d. Has anyone who is unscrubbed stay at least 1 foot away from the sterile field

ANS: D
Unscrubbed persons should always stay at least 1 foot away from the sterile field while keeping it in constant view and should contact only unsterile areas. Sterile persons must keep their hands in view, above waist level and below the neckline, to avoid contamination. When wearing a sterile gown, do not fold the arms with hands tucked in the axillary region. This area is not considered sterile once operating room personnel have donned gowns. Sterile-draped tables are sterile only at table level. The sides of the drape extending below table level are unsterile.

133. When one prepares to enter the operating room, which technique demonstrates the safest outcome?
a. Keeping the hands below the elbows
b. Applying surgical gloves before the scrub
c. Scrubbing for at least 3 to 5 minutes with an antimicrobial
d. Drying the hands and arms, starting at the elbow and moving toward the fingers


ANS: C
The Association of periOperative Registered Nurses (AORN) recommends a 3- to 5-minute hand and arm scrub with an approved antimicrobial agent for all surgical procedures. Rinse hands and arms thoroughly under running water. Grasp one end of the sterile towel to dry one hand thoroughly, moving from fingers to elbow in a rotating motion. Use the opposite end of the towel to dry the other hand.

134. When evaluating a health care team member’s ability to put on a sterile gown and perform closed gloving, it is most important for the nurse to assess for which outcome?
a. Opening the sterile gown pack on a sterile surface
b. Holding the gown close to the body before applying
c. Having the circulating nurse tie the gown at the hip
d. Keeping the hands inside the sleeves of the gown until the gloves are applied


ANS: D
Apply gloves using the closed-glove method, with hands covered by gown cuffs and sleeves. Open the sterile gown and glove package on a clean, dry, flat surface. This can be done by the scrub nurse (before scrubbing hands) or the circulating nurse. While keeping it at arm’s length away from the body, allow the gown to unfold with the inside of the gown toward the body. Do not touch the outside of the gown, and do not allow it to touch the floor. Have the circulating nurse tie the gown at the neck and waist. If the gown is wraparound style, the sterile front flap is not touched until the scrub nurse has gloved.

135. The charge nurse is assigning members of the surgical team; the nurse recognizes that which member is responsible for ensuring preoperative and postoperative patient management in collaboration with other health care providers?
a. RN
b. LPN
c. Circulating RN
d. RNFA


ANS: D

136. When planning care for a surgical patient, which nursing diagnosis has the highest priority?
a. Risk for infection
b. Risk for constipation
c. Risk for falls
d. Risk for knowledge deficit


ANS: A
Surgical patients are at risk for surgical site infection from the stress of surgery and their procedure. Studies have found that surgical staff may transmit pathogens via contact with patients and contaminated items.

137. While supervising the surgical team, the charge nurse notices that a team member’s nails are long and chipped. Which action should the nurse take next?
a. Allow the team member to complete the task.
b. Remove the team member to have the nails cut.
c. Turn the team member in to the RNFA.
d. Ask the team member why the nails are long and chipped.


ANS: B
The team member must be removed immediately to allow cutting of the nails. Long nails and chipped or old polish harbor greater numbers of bacteria. Long fingernails can puncture gloves, causing contamination.

138. Who of the following can assume the role of the scrub nurse/assistant? (Select all that apply.)
a. RN
b. LPN
c. CST
d. Licensed nursing assistant
e. Medical transcriptionist


ANS: A, B, C
RNs, LPNs, and CSTs may assume the scrub nurse role.

139. The consequences of double gloving during surgery include which of the following? (Select all that apply.)
a. Decreased need for handwashing
b. Decreased risk for exposure to bloodborne pathogens
c. Increased perforations to the innermost glove
d. Decreased risk for surgical wound infection
e. Increased patient cost


ANS: B, D


140. Which of the following are principles of sterile procedure? (Select all that apply.)
a. Gowns are sterile from the chest and shoulder to table level.
b. Sterile persons must keep hands in view and above the waist and below the neck.
c. Sterile persons must fold arms across chest with hands tucked into the axillary region.
d. Unscrubbed persons must stay at least 6 inches away from the sterile field.
e. Sterile persons may position themselves with their back to the sterile field.


ANS: A, B
Once in place, gowns are sterile from the front chest and shoulders to table level and on the sleeves to 2 inches (5 cm) above the elbow. Sterile persons must keep their hands in view, above waist level and below the neckline, and must not turn their back to the sterile field to avoid contamination. When wearing a sterile gown, do not fold arms with hands tucked into the axillary region. This area is not considered sterile once operating room personnel have donned gowns. Perspiration can lead to strike through, or contamination that occurs when moisture permeates a sterile barrier. Unscrubbed persons always stay at least 1 foot away from the sterile field while keeping it in constant view; they touch only unsterile areas.

141. Through the use of an antimicrobial agent and sterile brushes or sponges, which of the following occurs? (Select all that apply.)
a. Debris and transient microorganisms are removed from the nails, hands, and forearms.
b. The resident microbial count is reduced to a minimum.
c. The skin is sterilized.
d. Rapid/rebound growth of microorganisms is inhibited.
e. The need to wash between patients is reduced.

ANS: A, B, D
Although the skin cannot be sterilized, operating room personnel can greatly reduce the number of microorganisms by chemical, physical, and mechanical means. Through the use of an antimicrobial agent and sterile brushes or sponges, the surgical hand scrub removes debris and transient microorganisms from the nails, hands, and forearms, and inhibits rapid/rebound growth of microorganisms.

142. Which of the following are sources of contamination in the operating room? (Select all that apply.)
a. A wristwatch
b. Chipped nail polish
c. Artificial fingernails
d. Abrasions on the hands
e. Tattoos to the arms


ANS: A, B, C, D
Jewelry harbors and protects microorganisms from removal. Allergic skin reactions may occur as a result of scrub agent or glove powder accumulating under jewelry. Long nails and chipped or old polish harbor great numbers of bacteria. Long fingernails can puncture gloves, causing contamination. Artificial nails harbor gram-negative microorganisms and fungus. Cuts, abrasions, exudative lesions, and hangnails tend to ooze serum, which may contain pathogens. Broken skin permits microorganisms to enter various layers of the skin, providing deeper microbial breeding.

143. The surgeon is about to finish surgery and requests a sponge count. Who would normally perform this task? (Select all that apply.)
a. Scrub nurse
b. Registered nurse first assistant
c. Circulating nurse
d. Certified registered nurse anesthetist
e. Surgical technician


ANS: A, C
Part of the role of the scrub nurse is to perform sponge, sharps, and instrument counts with the circulating nurse before an incision is made, at the beginning of wound closure, and at the end of the surgical procedure.

144. While the patient is in the OR and the OR team is gowned and gloved, the nurse recommends completion of a safety checklist. The nurse understands that the checklist verifies which of the following? (Select all that apply.)
a. Patient identity
b. Patient allergies
c. Accurate marking of surgical site
d. Patient cultural preferences
e. Questions posed by the patient

ANS: A, B, C
While the patient is in the OR and the OR team is gowned and gloved, it is recommended that a surgical safety checklist or the World Health Organization (WHO) checklist be conducted. The WHO checklist verifies the patient’s identity, ascertains whether the patient has any allergies, checks if the surgical site is marked and reverifies the site marking, and asks the patient if he or she has any questions

145. The _______________ phase begins when the patient enters the operating room suite and ends with admission to the post anesthesia care unit (PACU).

ANS:intraoperative
The intraoperative phase begins when the patient enters the operating room suite and ends with admission to the PACU.

146. The _________________ is a nurse with advanced education who assists the surgeon with the surgical procedure, performing a combination of nursing and delegated medical functions and/or skills.

ANS:registered nurse first assistant (RNFA)
The RNFA is a nurse with advanced education who assists the surgeon with the surgical procedure, performing a combination of nursing and delegated medical functions and/or skills.


147. The ________________ is a “sterile” team member who provides the surgeon with instruments and supplies, disposes of soiled sponges, and accounts for sponges, sharps, and instruments in the surgical field.


ANS: scrub nurse/technician

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