Judgments
Perioperative-Care-Nclex-Nursing-Resources.docx
- Course
- Nursing
- Institution
- Central University Of Technology (CUT)
Perioperative-Care-Nclex-Nursing-R
[Show more]
Seller
Follow
Content preview
1. The nurse is performing presurgical assessment of multiple clients. Thenurse determines that which client has the greatest risk for developing an
infection postoperatively?
A. The client with new-onset neutropenia of unknown etiology
B. The client with thrombocytopenia secondary to taking aspirin
C. The child newly diagnosed with type 1 diabetes mellitus (DM)
D. The client who needs assistance with ambulation due to arthritis
ANSWER: A
A. Neutropenia is a reduction in neutrophils, the body’s first line of defense in phagocytosis of
invading microorganisms. Neutropenia predis- poses the client to infection with nonpathogenic
organisms that are present in normal body flora as well as opportunistic pathogens.
B. Thrombocytopenia is a reduction in platelets. Thrombocytopenia predisposes the client to
bleeding.
C. The client with DM is more susceptible to infections because there is a defect in the mobilization
of inflammatory cells and an impairment of phagocytosis by neutrophils and monocytes.
Although at risk, the client with neutropenia has a greater risk.
D. If assistance is provided for activity, there should not be an increased risk.
2. The client being admitted for same-day surgery has inspiratory crackles
and bilateral wheezes, and reports shortness of breath for several days. Which
intervention should the nurse implement first?
A. Notify the surgeon of the findings.
B. Document the assessment findings.
C. Apply 4 liters oxygen by nasal cannula.
D. Instruct on using an incentive spirometer (IS).
ANSWER: A
A. The nurse should notify the surgeon of unanticipated changes in the health status of the
preoperative client. Surgery may need to be postponed.
B. The nurse should first notify the surgeon and then document the findings and the notification.
C. There are no objective data supporting the need for oxygen.
D. Although an IS may be prescribed, notifying the surgeon is the priority.
3. The nurse determines that all of the following must be completed for the
client being prepared for surgery. Which intervention should the nurse
complete first?
A. Complete the preoperative checklist
B. Assess the client’s preoperative vital signs
C. Remove the client’s rings, gold chain, and wristwatch
, D. Give 10 mEq KCL IV for a serum potassium level Of 3.0 mEq/L
ANSWER: D
A. Completing the preoperative checklist ensures that all requirements are completed. This would
be the second intervention.
B. Although important, assessing the client’s preoperative VS is not the priority.
C. Although important, removing the client’s rings, gold chain, and wristwatch is not the priority.
D. Giving KCL is priority. Abnormalities must be corrected before surgery. A low serum potassium
level can induce cardiac dysrhythmias and delay surgery.
4. The nurse is performing a presurgical admission assessment of the client.
Which client statement needs the most immediate follow-up?
A. “I feel very hungry; I haven’t eaten foods or had any fluids for the past 12 hours.”
B. “I donated my own blood in case I need a transfusion; the last donation was 4 days ago-”
C. “I took all my meds including warfarin and atenolol with a sip of water this morning.”
D. “I brought a copy of my health care directive in case my heart stops during surgery.”
ANSWER: C
A. The exact amount of time the client must be NPO before surgery is controversial. Older adults
may have imbalances of fluids, electrolytes, and blood glucose levels from fasting longer.
However, there is no indication in the question that this is a concern.
B. Blood can be donated up to 72 hours before the scheduled surgery.
C. Warfarin (Coumadin) is an anticoagulant. Usually this is stopped a few days before surgery due
to the increased risk of bleeding. The nurse should immediately follow up by notifying the HCP.
D. Clients should be encouraged to bring a copy of the HCD so others are aware of the client’s
wishes. The nurse may want to follow up regarding the client’s statement “in case my heart
stops during surgery,” but this is not the most immediate concern.
5. The nurse is to witness the signature of a surgical consent for multiple
clients scheduled for surgery the following day. After evaluating the health
history of each client, for which client should the nurse plan to obtain a
signature from the next of kin?
A. The 75-year-old client who is legally blind
B. The 60-year-old client who does not understand English
C. The 50-year—old client who is forgetful but fully oriented
D. The 16-year-old client who fully understands the surgery
ANSWER: D
A. The client who is legally blind may sign his or her signature with an “X” as long as the client
under- stands the nature and reason for surgery, who will perform the surgery, available
, options, the benefits and risks of surgery, and the consent form that is read to the client.
Another person besides the nurse should witness the client’s “X” signature.
B. An interpreter should be available to read the consent in the client’s native language. The client
can then provide written consent in the presence of two witnesses.
C. The client is able to sign a consent form unless determined incompetent. If the client is fully
oriented, a signed consent can be obtained from the client.
D. The legal age for consent is 18 years unless the adolescent has emancipated status granted by a
judge.
6 . The nurse receives the written laboratory results of a positive pregnancy
test for the client scheduled for an emergency appendectomy. Which
intervention should the nurse implement first?
A. Call the laboratory to verify the test results.
B. Inform the client of the pregnancy test results-
C. Report the pregnancy test results to the surgeon.
D. Notify the client’s primary care provider of the results.
ANSWER: C
A. Verifying laboratory results is unnecessary. Some hospitals may require repeating critical
laboratory tests.
B. Discussing laboratory results with the client is the HCP’s responsibility.
C. The surgeon should be notified because a positive pregnancy test result could influence the
choice of anesthetic agents, medications, and surgical approach.
D. As a courtesy, the primary care provider should be notified. However, it is more important to
notify the surgeon.
7. During a presurgical admission assessment, the client states, “I’ve told my
surgeon that I am Jehovah’s Witness and I won’t accept a blood transfusion.”
Which statement by the nurse would be most appropriate?
A. “Tell me more about your fear of receiving a blood transfusion.”
B. “Your request not to receive a transfusion would be honored.”
C. “Don’t worry; there is less blood loss with our newer equipment.”
D. “Are you sure you wouldn’t want a transfusion if one is needed?”
ANSWER: B
A. There is no indication that the client is fearful. The client is refusing blood for religious reasons.
B. The client’s consent is needed prior to administering blood or blood products. Even in a life-
threatening situation, the client has the right to refuse blood and blood products for religious
reasons.
C. Telling the client not to worry belittles the client and does not address the client’s statement
about not receiving a blood transfusion.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through EFT, credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying this summary from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Studyabroad. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy this summary for R110,99. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
79223 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy summaries for 14 years now