ATI Perioperative _ 2020 – Rasmussen College | ATI Perioperative _ 2020

ATI Perioperative _ 2020 – Rasmussen College A circulating nurse is monitoring the temperature in a surgical suite. The nurse should identify that cool temperatures reduce a client's risk for which of the following ...

ATI Perioperative _ 2020 – Rasmussen College A circulating nurse is monitoring the temperature in a surgical suite. The nurse should identify that cool temperatures reduce a client's risk for which of the following potential complications of surgery?

malignant hyperthermia
blood clots
infection
hypoxia Infection

The nurse should identify that a cool room temperature with humidity between 30% and 60%, along with a proper air exchange and filtering system, reduces the risk of infection for clients during surgery. A client had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

Go to the nurses station to seek assitance
Reinsert the organs into the abdominal cavity
Place the client in revere Trendelenburg position
Obtain vital signs to assess for shock Obtain vital signs to assess for shock

The nurse should obtain vital signs to assess the client's current status. A client is transferred from the surgical suite to the PACU following oral surgery. While monitoring the client's vital signs, the nurse finds that the client's tongue has become swollen and is obstructing the airway. Which of the following actions should the nurse take first?

Contact the anesthesiologist
Assist with the endotracheal intubation
Increase the clients flow of oxygen
Use the head-tilt, chin-lift method to open the airway Use the head-tilt, chin-lift method to open the airway

The first action the nurse should take when using the airway, breathing, circulation approach to client care is to establish a patent airway by tilting the client's head back and pushing the lower jaw forward. A nurse in the PACU is assessing a client who is postoperative. Which of the following findings should the nurse report to the provider?

Blood pressure 10% lower than baseline
Pain level of 4/10
Presence of inspiratory stridor
Small amount of sanguineous drainage on dressing Presence of inspiratory stridor

The nurse should report inspiratory stridor to the provider because it is a manifestation of tracheal edema and requires intervention. A nurse is assessing a client's recovery from spinal anesthesia. Which of the following sensations should the nurse expect to return to the client first?

pain
cold
touch
warmth Touch
Following spinal anesthesia, the first sensation the nurse should expect the client to feel is the sense of touch.

The 2nd sensation is pain, 3rd is warmth, and 4th is cold A nurse is assessing a client who is 2 days postoperative following a total prostatectomy. The nurse notes that the client's right calf is red, edematous, and warm to the touch. Which of the following actions should the nurse take?

Apply an ice pack to the clients right calf

Elevate the clients right extremity

Administer testosterone to the client

Gently massage the clients right calf Elevate the clients right extremity

These findings suggest the client has deep-vein thrombosis. The nurse should keep the client's right extremity elevated to promote venous return. A nurse is assessing a client who is 2 hr postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?

Urine output of 20mL/hr
Temp of 36.5
A 2cmX2cm area bloody drainage on the dressing
WBC 9,000 mm3 Urine output of 20mL/hr

The nurse should notify the provider if the client's urine output is less than 30 mL/hr. Decreased output can indicate hypovolemia and decreased perfusion of the kidneys. A nurse is assessing a client who is preoperative. The nurse should identify that which of the following factors reported by the client increases the risk for a postoperative wound infection?

Frequent use of echinacea
Long-term use of corticosteroids
History of osteoporosis
Diet high in Vit C Long-term use of corticosteroids

The nurse should identify that the use of corticosteroids inhibits leukocyte response, which increases the client's risk for infection. A nurse is caring for a client who has a surgical wound with a Penrose drain in place. Which of the following interventions should the nurse plan to perform?

Cut a slit in a 4in quake gauze pad to place around the drain

Use the sterile technique when preforming dressing changes

Establish a clamping schedule prior to removal

Apply negative pressure when emptying the drain The nurse should change the Penrose drain dressing using the surgical aseptic technique.

gauze should never be used as its fibers can become embedded in the wound

clamping can lead to infection

and a Penrose drain is and open system that drains by gravity A nurse is caring for a client who has bradycardia following a surgical procedure using spinal anesthesia. The nurse should plan to administer which of the following medications to the client?

Amiodarone
Propranolol
Methyldopa
Epinephrine Epinephrine

The nurse should plan to administer epinephrine, a vasopressor, to increase the client's heart rate and prevent cardiac arrest. A nurse is caring for a client who is 2 days postoperative following a cholecystectomy. The client has been vomiting for the past 24 hr and reports a pain level of 8 on a scale from 0 to 10. The nurse notes a hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the following actions should the nurse take first?

Draw the clients blood for electrolytes
Insert an NG tube
Administer pain medication
Initiate intake and output Insert an NG tube

The greatest risk to the client is fluid and electrolyte imbalance as a result of accumulated fluid and gas in the gastrointestinal tract. The first action the nurse should take is to insert an NG tube to begin decompression of the bowel. A nurse is caring for a client who is 12 hours postoperative from a gastrectomy and has an NG tube set to continuous low suction. Which of the following findings requires intervention by the nurse?

Gastric distension
Absent bowel sounds
Urine output of 150 mL over the last 4 hrs
Yellow drainage in the NG tube Gastric distension

Gastric distention is an indication that the NG tube is not patent. The nurse should check the tubing for kinks, blockages, and loose connections. The nurse should also reposition the client to facilitate drainage. The nurse should avoid removing or irrigating the tube unless directed to do so by the surgeon. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following nursing interventions should the nurse perform to prevent respiratory complications?

Instruct the client to exhale into the incentive spirometer every 1 to 2 hrs

Minimize the amount of pain medication the client receives to prevent sedation

Advise the client to splint the surgical incision when coughing and deep breathing

Reposition the client very 8hr for the first 48hr Advise the client to splint the surgical incision when coughing and deep breathing

Splinting the incision supports the surgical site and decreases pain during coughing and deep breathing. A nurse is caring for a client who is preoperative and is asking multiple question about risk of the procedure. Which of the following actions should the nurse take?

Explain the risk and benefits of the surgery to the client

Ask the surgeon to speak to the client for clarification

Reassure the client that the procedure is necessary for recovery

Notify the circulating nurse that the client has questions about the procedure Ask the surgeon to speak to the client for clarification

The nurse should notify the surgeon that the client has questions about the procedure. It is the responsibility of the surgeon to explain the risks and benefits of the surgery A nurse is caring for a client who is receiving moderate (conscious) sedation with midazolam. The client's respiratory rate decreases from 16/min to 6/min, and the oxygen saturation decreases from 92% to 85%. Which of the following medicaitons should the nurse administer?

Atropine
Acetylcysteine
Flumazenil
Protamine sulfate Flumazenil

The client's respiratory rate and oxygen saturation level indicate increased sedation caused from a benzodiazepine. The nurse should administer flumazenil, a benzodiazepine agonist, to reverse the sedative effects of the medication. A nurse is creating a plan of care for a client who is preoperative for a total hip arthroplasty, practices Judaism, and adheres to a kosher diet. Which of the following interventions is the nurse's priority?

Listen and allow the client to express feelings about the surgery
Determine if the clients faith conflicts with the treatment plan
Ensure the clients meal plan serves only kosher food following the surgery
Teach the client how to perform various relaxation exercises Determine if the clients faith conflicts with the treatment plan

The nurse's priority intervention when using the nursing process is assessment. By determining if the client's faith, religious practices, or views conflict with the current treatment plan or surgical procedure, the nurse can take the necessary steps to inform the provider and prevent an issue during or after the surgical procedure A nurse is monitoring a client who received succinylcholine during a surgical procedure. Which of the following actions should the nurse take if the client develops manifestations of malignant hyperthermia?

Administer Dantrolene
Institute seizure precautions
Remove endotracheal tube
Give IV atropine Administer Dantrolenea 

The nurse should administer dantrolene by IV bolus at 2 to 5 mg/kg to reverse the manifestations for a client who has malignant hyperthermia. A nurse is planning care for a client who is postoperative and has a closed-wound drainage system in place. Which of the following interventions should the nurse plan to include?

Check latency of the drain every 12 hrs
Clamp the drain while the client is ambulating
Cleanse the drain plug with alcohol after emptying
Secure the drain to the clients bed sheet Cleanse the drain plug with alcohol after emptying

After emptying the drain, the nurse should use one hand to compress the top and bottom of the device together and the other to cleanse the plug before replacing it. A nurse is providing discharge instructions for a client who is postoperative following abdominal surgery. Which of the following client statements indicates an understanding of the teaching?

"I will gave an increase in yellow-colored drainage from my incision for 2 weeks"

"I will eat foods that are high in protein and Vitamin C during my recovery"

"I should avoid taking over-the-counter pain medication if my pain is not severe"

"I will remain on bed rest until my follow-up appointment with my doctor" "I will eat foods that are high in protein and Vitamin C during my recovery"

The nurse should instruct the client to increase intake of foods with protein and vitamin C to promote wound healing. A nurse is providing discharge teaching for a client who is postoperative following a rhinoplasty using general anesthesia. Which of the following instructions should the nurse include?

"Lie on your side when resting for the first week after surgery"

"Limit intake to clear liquids for the first 24 hrs after surgery"

"Use cool compresses on your eyes, nose, and face"

"Close your mouth when you are about to sneeze" Use cool compresses on your eyes, nose, and face

The nurse should instruct the client to place cool compresses on his face to reduce swelling and ecchymosis. A nurse is providing preoperative teaching for a client who is about to have a below-the-knee amputation. Which of the following instructions should the nurse include?

"You should avoid lying on your abdomen after surgery"

"Your surgeon might prescribe an antibiotic before surgery."

"It is important for you to sit in a chair at the bedside for several hours every day to reduce the risk of pneumonia"

"to promote would healing it is important for you to reduce your intake of crabs once you are home" "Your surgeon might prescribe an antibiotic before surgery."

A client who has a surgical amputation of an extremity is at risk for infection. Therefore, the provider often prescribes a broad-spectrum, prophylactic antibiotic to reduce the risk of infection. A nurse is providing preoperative teaching to a client who is scheduled for a gastrectomy in 1 week. The client is anxious about the upcoming surgery. Which of the following actions should the nurse take?

Sympathize with the clients feelings
Reassure the client that the surgery will go fine
Change the topic of discussion
Provide concise, factual information Provide concise, factual information

Providing concise, factual information allows for open communication and gives the nurse the opportunity to dispel the client's fears. A nurse is providing preoperative teaching to a client who is scheduled to have a mastectomy with reconstructive surgery. Which of the following statements by the client indicates an understanding of the teaching?

"I should wait to take my pain medication until after i have completed my rang-of-motion exercises"

"I should wait a week after surgery to start my hand-strengthening exercises"

"I will be able to life up and object that weighs 10 lbs 2 weeks after my surgery"


"I will be able to shower after the doctor removes the drain." "I will be able to shower after the doctor removes the drain."

A client who had a mastectomy with reconstructive surgery can shower after the provider removes the drain. A nurse is providing teaching for a client who is in the immediate postoperative period and has a PCA pump. Which of the following statements should the nurse include in the teaching?

"You will receive a dose of medication every time you push the button"

"Do not allow your family to push the PCA button if you are sleeping."

"You cannot receive too much medication by pushing the button"

"Do not push the button until your pain reaches a severe level" "Do not allow your family to push the PCA button if you are sleeping."

The nurse should instruct the client that she should be awake when receiving a dose of the medication and that she is the only authorized user of the PCA pump. Therefore, allowing a family member to push the button is unauthorized and a safety risk for the client. A nurse is providing teaching for a client who is scheduled to undergo moderate sedation for a bronchoscopy. The nurse should verify that the client understands the procedure when the client states which of the following?

"I will need to complete a bowel prep the day before the procedure"

"I will drink plenty of fluids the morning of the procedure"

"I can eat as soon as the procedure is over"

"I can expect to feel sleepy for several hours after the procedure" "I can expect to feel sleepy for several hours after the procedure"

Following moderate sedation, the client should expect to feel drowsy for several hours and should avoid all activities requiring concentration. A nurse is receiving evening shift report on four clients who returned from the PACU that morning. The nurse should assess which of the following clients first?

A client who is postoperative following a thoracotomy and has a chest tube with 150mL of bright-red blood in the collection chamber from the past 1 hr

A client who is postoperative following a small bowel resection and has a temporary colostomy along with absent bowel sounds in all 4 quadrants

A client who is postoperative following a tonsillectomy and has had one episode of coffee-sound emesis

A client who is postoperative following a total knee arthroplasty and is reporting a knee pain of 7/10 A client who is postoperative following a thoracotomy and has a chest tube with 150mL of bright-red blood in the collection chamber from the past 1 hr

When using the airway, breathing, circulation approach to client care, the nurse should first assess the client who has 150 mL of blood in the collection chamber because this finding is above the expected reference range and can be an indication of hemorrhage A nurse is reviewing the medical record of a client who is scheduled for an elective surgery. Which of the following medications should the nurse expect the provider to discontinue prior to surgery to minimize the risk of complications?

Cefazolin
Digoxin
Ondansetron
Warfarin Warfarin

The nurse should anticipate that the provider will instruct the client to discontinue warfarin, an anticoagulant, because it increases the risk of bleeding during and following surgery. A nurse is reviewing the medical record of a client who is to undergo general anesthesia for surgery. The nurse should report which of the following findings to the provider?

Serum potassium 2.8 mEq/L
Serum sodium 140 mEq/L
INR 1.5
BUN 12 mg/dL Serum potassium 2.8 mEq/L

The nurse should recognize that the client's potassium level is below the expected reference range of 3.5 to 5 mEq/L, which places the client at risk for cardiac dysrhythmias. Therefore, this finding should be reported to the provider immediately. A nurse is reviewing the medication administration record for a client who is scheduled for surgery the next day. The nurse should identify that which of the following medications places the client at risk for complications during surgery and should be reported to the provider?

Clopidogrel
Atorvastatin
Ranitidine
Alendronate Clopidogrel

The nurse should identify that clopidogrel is an oral antiplatelet medication used to prevent coronary artery stenosis and other vascular incidents. Therefore, the mediation should be discontinued 5 days prior to surgery because it acts similarly to aspirin and can cause the client to experience increased bleeding during and after surgery. A surgical nurse enters a surgical suite to ensure surgical asepsis is maintained. Which of the following findings requires intervention by the nurse?

The scrub technologist is wearing a watch under his scrubs
The circulating nurse opens dressing packages before applying sterile gloves
the surgeon has her hands folded 5 cm above her waist
The holding area nurse is preforming client education The scrub technologist is wearing a watch under his scrubs

Finger and wrist jewelry are likely contaminated with microorganisms and bacteria. Therefore, the scrub technologist should remove jewelry before handling sterile objects A nurse is assessing a client who received a preoperative IV dose of metoclopramide 1 hr ago. For which of the following findings should the nurse notify the provider? a) dry mouth b) muscle rigidity c) tinnitus d) diarrhea b) Muscle rigidity. Explanation: • Metochlopromide is used a drug of choice for GERD,vomiting,heartburn etc. • Muscle rigidity is a serious side effect of metochlopromide which leads to problems in body positioning and movement. • So the nurse should notify the physician if muscle rigidity occurs after metochlopromide administration. A client had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

A. Go to nurses' station to seek assistance
B. Reinsert the organs into the abdominal cavity.
C. Place client in reverse Trendelenburg position
D. Obtain V/S to assess for shock. D. Obtain V/S to assess for shock.

Rationale: Nurse should obtain V/S to assess pts current status.