Perioperative MS Questions and Answers (ATI) |NURS 320 Perioperative MS Questions and Answers (ATI

Perioperative MS Questions and Answers (ATI) 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 assistance. Reinsert the organs into the abdominal cavity. Place the client in reverse Trendelenburg position. Obtain vital signs to assess for shock. A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain in place. Which of the following interventions should the nurse use to ensure proper functioning of the drain? Secure the drain to the client’s bed sheet. Clamp the drain when the client is ambulating. Empty and compress the drain reservoir as needed. – produces necessary suction Keep the drain higher than the surgical incision. A nurse is completing an initial PACU assessment of a client who is postoperative following a total knee arthroplasty and received spinal anesthesia. Which of the following findings indicates the need to notify the provider? The client states having numbness to the lower extremities bilaterally. –expected finding Spinal anesthesia is at the T10 level. –should still have the spinal anesthetic effect at this time, document motor and sensory function until the pt. function returns The client rouses to tactile stimuli. –moderate sedation is expected finding following surgery The client reports chest pain. –this is an indication of a PE (which total knee arthroplasty increases risk of) A surgical nurse enters the surgical suite to ensure surgical asepsis is maintained. Which of the following observations requires an intervention? The scrub technologist is wearing a watch under his scrubs. –finger and wrist jewelry should be removed due to bacterial harboring The circulating nurse opens dressing packages before applying sterile gloves. –should be opened to maintain surgical asepsis The surgeon has her hands folded 5 cm (2 in) above the waist. –this is maintaining surgical asepsis The holding area nurse is performing client education. –this is a role of the holding area nurse A nurse is caring for a client who is postoperative. To prevent formation of thrombi in the postoperative period, the nurse should do which of the following? Change the client's position every 4 hr. –should change position every 2 hrs. Have the client perform dorsal and plantar flexion of the feet every hour. –exercise helps prevent venous stasis in lower legs and decreases the likelihood of thrombophlebitis Place the client in bed with a pillow under the knees. –can increase thromboembolism formation Assess pedal and posterior tibial pulses every 2 hr. –this is not prevention 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 client's blood for electrolytes. –important action, but not the most important Insert an NG tube. –accumulated fluid and gas in the GI tract. The first action is to insert a NG tube to begin decompression of the bowel Administer pain medication. –this is an important action, but not the most important Initiate intake and output. –important but not the most important 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 20 mL/hr – urine output should be 30mL/Hr., decreased output can indicate dehydration and poor kidney perfusion Temperature 36.5° C (97.7° F) –only slightly lower than normal temperature A 2 cm x 2 cm (0.79 in x 0.79 in) area of bloody drainage on the dressing- a small amount of drainage is expected Jackson-Pratt drainage 30 mL/hr-this is an expected finding following surgery A nurse is completing a preoperative assessment for a client who is a Jehovah’s Witness. Which of the following should the nurse recognize as a situation that could pose special care needs for this client? Having preoperative blood drawn Giving information about sexual history Providing informed consent to receive blood products – in this religion people are not allowed to receive blood or blood products from other people Receiving care from a nurse of the opposite gender –this is not a concern for this religion A nurse is receiving afternoon report on four clients who have returned from the PACU this morning. The nurse should assess which of the following clients first? A client who is postoperative following a thoracotomy has a chest tube with 150 mL bright-red of blood in the collection chamber from the past hour. –ABCs; this is an unexpected finding that may indicate hemorrhage A client who is postoperative following a small bowel resection and has a temporary colostomy has absent bowel sounds in all four quadrants. –this is an expected finding for a pt. who has had intestinal surgery A client who is postoperative following a tonsillectomy has had one episode of coffee-ground emesis. –this is an expected finding for a client who has had a tonsillectomy A client who is postoperative following a total knee arthroplasty and has a PCA pump is reporting a knee pain level of 7 on a scale from 0 to 10. –this is an expected finding in total knee arthroplasty A nurse is providing discharge instructions for a client who is postoperative following abdominal surgery. Which of the following client statements indicates a need for further teaching?