1. A postoperative patient is complaining of incisional pain. An
order has been given for morphine every 4 to 6 hours as needed
(PRN). What should the nurse assess first?
a. Assess for the presence of bowel sounds.
b. Assess pupillary reaction.
c. Ask the patient's family if she is having pain.
d. Determine when the patient last received pain medication.
Correct Answers ANS: D
Verifying the time of the last dose decreases the risk of a dose of
medication being given too soon.
DIF: Cognitive Level: Application REF: p. 277 OBJ: 9
TOP: Acute Pain KEY: Nursing Process Step: Assessment
1. The thyroid gland is located in the __________.
a. apex of the lung
b. brain
c. anterior neck
d. abdomen Correct Answers c. anterior neck
10. A nurse has completed giving discharge instructions to a
patient after a hernia repair. What verbalization by the patient
should lead the nurse to determine that the patient understands
the instructions?
a. Go back to work tomorrow.
,b. Do not change the dressing until he sees his physician in 2
weeks.
c. Ignore changes in the size of his abdomen.
d. Report fever, redness, swelling, or increased pain at the
incision site. Correct Answers ANS: D
The patient should report any signs and symptoms of infection
(e.g., fever, redness, swelling, pain).
DIF: Cognitive Level: Comprehension REF: p. 284 OBJ: 10
TOP: Discharge Planning KEY: Nursing Process Step:
Evaluation
11. A nurse should include the proper use of an incentive
spirometer in teaching a preoperative patient. What
postoperative assessment of this patient would reveal that the
incentive spirometry teaching has been effective?
a. Adventitious breath sounds
b. Expiratory wheezing
c. Thick, green respiratory secretions
d. Clear breath sounds Correct Answers ANS: D
An incentive spirometer is used to promote lung expansion,
which opens airways, reduces atelectasis, and stimulates
coughing to clear secretions.
DIF: Cognitive Level: Comprehension REF: p. 281 OBJ: 8
TOP: Impaired Gas Exchange KEY: Nursing Process Step:
Evaluation
12. The suprapubic area of a postoperative patient is distended.
The patient states that he has not voided since surgery
,approximately 9 hours ago. What should be the nurse's first
action?
a. Notify the head nurse or physician.
b. Insert a catheter and document insertion.
c. Seat the patient on the side of the bed to try to void.
d. Prepare the patient to return to surgery. Correct Answers
ANS: C
The patient should be encouraged to try to void in a natural
position before other measures are taken. Seated on the bedside
or on a bedside commode may make urination easier.
DIF: Cognitive Level: Application REF: p. 283 OBJ: 9
TOP: Postoperative Urinary Retention KEY: Nursing Process
Step: Implementation
13. Which modification should the nurse implement when
caring for a postoperative patient after cataract surgery?
a. Early ambulation is not necessary.
b. Remove the dressing immediately.
c. Omit instructions relative to coughing.
d. Omit use of an incentive spirometer for deep breathing.
Correct Answers ANS: C
There are only a few instances in which coughing is
contraindicated. They include surgeries for hernias, cataracts,
and brain surgery.
DIF: Cognitive Level: Application REF: p. 282 OBJ: 7
TOP: Postoperative Complications KEY: Nursing Process Step:
Planning
, 14. When obtaining a patient's signature on the surgical consent
form, the patient seems confused about the procedure to be
performed. What is the most appropriate response by the nurse?
a. Tell the patient to talk to the physician after he or she gets to
the surgical department.
b. Ask the patient to go ahead and sign the consent.
c. Ask the patient what the physician told him and then call the
physician if necessary.
d. Encourage the patient to ask his family what the physician
told them. Correct Answers ANS: C
The patient may not understand some of the medical terms used
by the physician, and the nurse may be able to explain them. If
the patient needs further information, notify the physician. The
physician is responsible for explaining the procedure and the
risks to the patient.
DIF: Cognitive Level: Application REF: p. 260 OBJ: 3
TOP: Consent Form KEY: Nursing Process Step:
Implementation
15. A nurse is doing an assessment of a patient who has returned
from a cardiac catheterization and had conscious sedation.
Which finding should the nurse report?
a. Difficulty arousing the patient
b. Blood pressure of 124/72 mm Hg
c. Oxygen saturation of 96%
d. Patient complaints of the need to void Correct Answers
ANS: A
Conscious sedation uses intravenous drugs to reduce pain
intensity or awareness without a loss of reflexes. A complication
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