five minutes after receiving a preoperative sedative medication by iv injection
a patient asks the nurse to get up to go to the bathroom to urinate which of the following is the most appropriate act
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Centre for Nursing Studies (CNS
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Nursing
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NCLEX Examination Review Questions
Submitted by kharris401 on 4/16/2019 12:46:19 PM
Points Awarded 13
Points Missed 0
Percentage 100%
1. Five minutes after receiving a preoperative sedative medication by IV injection, a patient
asks the nurse to get up to go to the bathroom to urinate. Which of the following is the most
appropriate action for the nurse to take?
A. Assist patient to bathroom and stay next to door to assist patient back to bed when
done.
B. Allow patient to go to the bathroom since the onset of the medication will be more than 5
minutes.
C. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety.
D. Ask patient to hold the urine for a short period of time since a urinary catheter will be
placed in the operating room.
The prime issue after administration of either sedative or opioid analgesic medications is safety.
Because the medications affect the central nervous system, the patient is at risk for falls and
should not be allowed out of bed, even with assistance.
Points Earned: 1/1
Correct Answer: C
Your Response: C
2. Which of the following is the primary reason for prioritizing the determination of the
patient's current medications during a preoperative assessment?
A. Routine medications are usually withheld the day of surgery, requiring dosage and
schedule adjustments.
B. Some medications may alter the patient’s perceptions about surgery.
C. Some medications may interact with anesthetics, altering the potency and effect of the
drugs.
D. Anesthetics alter renal and hepatic function, causing toxicity by other drugs.
Drug interactions may occur between prescribed medications and anesthetic agents used during
surgery. For this reason, it is important to take a careful medication history and check that they
have been communicated to the anesthesiologist.
Points Earned: 1/1
Correct Answer: C
Your Response: C
3. As the nurse is preparing a patient for surgery, the patient refuses to remove a wedding
ring. Which of the following is the most appropriate action by the nurse?
A. Note the presence of the ring in the nurse’s notes of the chart.
B. Insist the patient remove the ring.
C. Explain that the hospital will not be responsible for the ring.
, D. Tape the ring securely to the finger.
It is customary policy to tape a patient's wedding band to the finger and make a notation on the
preoperative checklist that the ring is taped in place.
Points Earned: 1/1
Correct Answer: D
Your Response: D
4. While performing preoperative teaching, the patient asks when she needs to stop drinking
water before the surgery. Based on the most recent practice guidelines established by the
American Society of Anesthesiologists, the nurse tells the patient that:
A. She must be NPO after breakfast.
B. She needs to be NPO after midnight.
C. She can drink clear liquids up to 2 hours before surgery.
D. She can drink clear liquids up until she is taken to the OR.
Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2
hours. Evidenced-based practice no longer supports the long-standing practice of requiring
patients to be NPO after midnight.
Points Earned: 1/1
Correct Answer: C
Your Response: C
5. The nurse is admitting a patient to the same day surgery unit. The patient tells the nurse
that he was so nervous he had to take kava last evening to help him sleep. Which of the
following nursing actions would be most appropriate?
A. Inform the anesthesiologist of the patient’s ingestion of kava.
B. Tell the patient that using kava to help sleep was a good idea.
C. Tell the patient that the kava should continue to help him relax before surgery.
D. Inform the patient about the dangers of taking herbal medicines without consulting his
health care provider.
Kava may prolong the effects of certain anesthetics. Thus the anesthesiologist needs to be
informed of recent ingestion of this herbal supplement.
Points Earned: 1/1
Correct Answer: A
Your Response: A
6. The nurse would be alerted to the occurrence of malignant hyperthermia when the patient
demonstrates:
A. Hypocapnia
B. Muscle rigidity
C. Decreased body temperature
D. Confusion upon arousal from anesthesia
Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of
skeletal muscles occurring secondary to exposure to certain anesthetic agents in susceptible
patients. Hypoxemia, hypercarbia, and dysrhythmias may also be seen with this disorder.
Points Earned: 1/1
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