Test 22: Adult Health: Perioperative Management

863. A nurse plans care for a client and notes that all of ANSWER: 4
the following must be completed for a client being Intravenous potassium is ordered for low serum potassium levels. Low
levels could induce cardiac dysrhythmias and delay surgery. Adminis-
prepared for surgery. Which intervention should the tering the potassium should be the nurse’s priority because abnormal-
nurse complete first? ities must be corrected before surgery. Completing the preoperative
checklist ensures that all requirements are completed. This would be the
1. Complete the preoperative checklist. second priority. Although important, assessing the client’s preoperative vi-
2. Assess the client’s preoperative vital signs. tal signs is not the first priority. Although important, removing the client’s
3. Remove the client’s rings, gold chain, and rings, gold chain, and wristwatch is not the first priority.
wristwatch. ➧ Test-taking Tip: Use the process of elimination and Maslow’s
4. Administer 10 mEq KCL IV for a serum Hierarchy of Needs. Physiological needs would take priority
potassium level of 3.0 mEq/L. over safety needs, unless life threatening. Replacing serum
potassium poses both a physiological and safety need and
could be life threatening.
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Planning; Client Need: Safe and Effective Care Environment/Management
of Care/Establishing Priorities; Cognitive Level: Application
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 301).
St. Louis, MO: Elsevier/Saunders.

864. Which client statement made during a presurgical ANSWER: 3

admission assessment needs the most immediate Warfarin is an anticoagulant. Usually this is stopped a few days before
surgery due to the increased risk of bleeding. The exact amount of time
follow-up? a client must be NPO before surgery is controversial. Older adults may
1. “I haven’t eaten foods or had any fluids for the have imbalances of fluids, electrolytes, and blood glucose levels from fast-
ing longer. However, there is no indication in the question that this is a
past 12 hours.” concern. Blood can be donated up to 72 hours before the scheduled sur-
2. “I donated my own blood in case I need a gery. Clients should be encouraged to bring a copy of the Health Care
transfusion; the last donation was 4 days ago.” Directives so others are aware of the client’s wishes. The surgeon, nurse,
3. “I took my usual dose of warfarin (Coumadin®) and other health-care providers should be aware of the client’s wishes.
and other cardiac meds this morning with a sip of ➧ Test-taking Tip: Note the key words “most immediate.”
water.” Knowledge of the anticoagulant effects of warfarin is needed to
4. “I brought a copy of my Health Care Directives so answer this question.
others will know my wishes should my heart stop Content Area: Adult Health; Category of Health Alteration:
during surgery.” Perioperative Management; Integrated Processes: Nursing Process
Implementation; Client Need: Physiological Integrity/Reduction of Risk
Potential/Potential for Complications from Surgical Procedures and Health
Alterations; Cognitive Level: Application
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., pp. 299, 306).
St. Louis, MO: Elsevier/Saunders.

865. A nurse is to witness the signature of a surgical con- ANSWER: 4

sent for multiple clients scheduled for surgery the fol- The legal age for consent is 18 years unless the adolescent has emanci-
pated status granted by a judge. The client may sign his or her signature
lowing day. In evaluating the health history of each with an “X” as long as the client understands the nature and reason for sur-
client, the nurse should plan to obtain a signature gery, who will perform the surgery, available options, the benefits and risks
from the next of kin for: of surgery, and the consent form that is read to the client. Another person
besides the nurse should witness the client’s “X” signature. An interpreter
1. a 75-year-old client who is blind. should be available to read the consent in the client’s native language. The
2. a 60-year-old client who does not understand client can then provide written consent in the presence of two witnesses.
English. A client is able to sign a consent form unless determined incompetent. If
3. a 50-year-old client who is forgetful, but fully the client is fully oriented, a signed consent can be obtained from the
client.
oriented.
4. a 16-year-old educated client who fully ➧ Test-taking Tip: Note the key words “next of kin.” Focus on the
ages of the clients, and use the process of elimination.
understands the surgery.

399
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400 SECTION II Practice Tests

Content Area: Adult Health; Category of Health Alteration:

Perioperative Management; Integrated Processes: Nursing Process
Planning; Client Need: Safe and Effective Care Environment/Management
of Care/Informed Consent; Cognitive Level: Application
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., pp. 304–306).
St. Louis, MO: Elsevier/Saunders.

866. A nurse receives the written laboratory results of a ANSWER: 3

positive pregnancy test for a client scheduled for an The surgeon should be notified because a positive pregnancy test re-
sult could influence the choice of anesthetic agents, medications, and
emergency appendectomy. The nurse should first: surgical approach. Verifying laboratory results is unnecessary. Some hos-
1. call the lab to verify the results of the test. pitals may require critical laboratory tests repeated. Discussing laboratory
results with the client is the physician’s responsibility.
2. inform the client of the positive results.
3. report the results immediately to the surgeon. As a courtesy, the primary physician should be notified. However, it is
more important to notify the surgeon.
4. notify the client’s primary physician of the results.
➧ Test-taking Tip: Note the key word “first.” Read each stem and
determine what action would be most important.
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Implementation; Client Need: Physiological Integrity/Reduction of Risk
Potential/Potential for Complications from Surgical Procedures and Health
Alterations; Cognitive Level: Application
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 301).
St. Louis, MO: Elsevier/Saunders.

867. During a presurgical admission assessment, a client ANSWER: 2

states, “I’ve told my surgeon that I am a Jehovah’s A client’s consent is needed prior to administering blood or blood
products. Even in a life-threatening situation, the client has the right
Witness and I won’t accept a blood transfusion.” to refuse blood and blood products for religious reasons. There is no in-
Which statement by the nurse would be most dication the client is fearful. The client is refusing blood for religious rea-
appropriate? sons. Telling the client not to worry belittles the client and does not ad-
dress the client’s statement about not getting a blood transfusion. Response
1. “Tell me about your fear of receiving a blood 4 is incorrect. Asking the client if he or she is sure he or she does not want
transfusion.” a transfusion is requesting an explanation and questions the client’s deci-
2. “Your request to not receive a transfusion would be sion. The client has a right to his or her religious beliefs.
honored. Your consent is needed to administer ➧ Test-taking Tip: Use therapeutic communication principles to
blood or blood products.” answer this question. Eliminate a response that belittles the
3. “You don’t need to worry about getting a blood client’s feelings, questions the client’s decision, and
misinterprets the client’s feelings.
transfusion. We have newer equipment that causes
less blood loss during surgery.” Content Area: Adult Health; Category of Health Alteration:
4. “Are you sure you wouldn’t want a blood Perioperative Management; Integrated Processes: Communication and
Documentation; Client Need: Psychosocial Integrity/Religious and
transfusion if one is needed during surgery? You Spiritual Influences on Health; Cognitive Level: Application
can always change your mind after surgery.”
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 299).
St. Louis, MO: Elsevier/Saunders.

868. A nurse is analyzing serum laboratory results for a ANSWER: 4

73-year-old female client scheduled for surgery in The normal prothrombin time is 11 to 12.5 seconds. Because it is
prolonged, the client is at risk for bleeding. Normal hemoglobin for a
2 hours. The nurse concludes that which result 73-year-old female is 11.7 to 16.1 g/dL. Although a little low, this does
would warrant the most immediate notification of not warrant the most immediate notification. The normal creatinine level
the physician? is 0.6 to 1.2 mg/dL for a 73-year-old female. The normal potassium level
is 3.5 to 5.0 mEq/dL.
1. Hemoglobin 10 g/dL
➧ Test-taking Tip: The nurse would be expected to know ranges
2. Creatinine 1.0 mg/dL
of these essential laboratory values. Analyze each laboratory
3. Potassium 4.5 mEq/dL value against the normal ranges to determine which value is
4. Prothrombin time 22 seconds incorrect.
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CHAPTER 8 Physiological Integrity: Care of Adults and Older Adults 401

Content Area: Adult Health; Category of Health Alteration:

Perioperative Management; Integrated Processes: Nursing Process
Analysis; Client Need: Physiological Integrity/Reduction of Risk
Potential/Laboratory Values; Cognitive Level: Analysis
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., pp. 302–303).
St. Louis, MO: Elsevier/Saunders.

869. A nurse is reviewing preoperative orders for a client ANSWER: 2, 3

who is to have surgery on the large intestine the next Tap water enemas would be administered until the returns are clear.
Stool present in the colon could predispose the client to peritonitis and
day. Which written orders should the nurse question? infection. Antibiotics are administered to sterilize the bowel prior to
SELECT ALL THAT APPLY. surgery but no route is prescribed. The client should be NPO after mid-
night to prevent aspiration of gastric contents during surgery. A clear liquid
1. NPO after midnight diet the day before surgery minimizes roughage in the bowel. IS use allows
2. Erythromycin 500 mg bid for presurgical evaluation of lung capacity.
3. Tap water enemas until hard stool passed
➧ Test-taking Tip: Note the type of surgery and the written
4. Clear liquid diet the day before surgery orders that pose a risk to the client or are incomplete.
5. Begin incentive spirometer (IS) use prior to
Content Area: Adult Health; Category of Health Alteration:
surgery Perioperative Management; Integrated Processes: Nursing Process
Analysis; Client Need: Physiological Integrity/Reduction of Risk
Potential/Potential for Complications from Surgical Procedures and Health
Alterations; Cognitive Level: Application
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 306).
St. Louis, MO: Elsevier/Saunders.

870. A physician writes an order to hold all medications ANSWER: 3

the morning of surgery for a client with a history of The diabetic client who takes insulin should be given a reduced dose of
intermediate or long-acting insulin based on the blood glucose levels.
type 1 diabetes mellitus and hypertension. A nurse Regular insulin in divided doses on the day of surgery or an insulin
should call the physician to clarify the hold order for drip may be initiated for tight glucose control. Aspirin has anticoagulant
what medication? properties and should be discontinued to avoid bleeding complications.
Colace® is a stool softener. It is appropriate to hold this the morning of
1. Acetylsalicylic acid (aspirin) surgery. Antihypertensive medications are often held prior to surgery to
2. Ducosate sodium (Colace®) prevent a hypotension crisis intraoperatively.
3. Regular and NPH insulin (Humulin®) ➧ Test-taking Tip: Focus on the medication actions and use the
4. Clonidine (Catapres®) process of elimination. Remember that stress increases blood
glucose levels.
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Implementation; Client Need: Safe and Effective Care Environment/
Management of Care/Legal Rights and Responsibilities; Cognitive
Level: Analysis
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 306).
St. Louis, MO: Elsevier/Saunders.

871. Which client statement indicates that a client ANSWER: 2

who is scheduled for a 3-hour surgery under general If any shaving of the surgical area is to be done, it should be done im-
mediately prior to surgery in a holding area, treatment room, operat-
anesthesia needs further teaching? ing suite, or the operating room by qualified personnel. The client
1. “A breathing tube will be placed when I am in the should not shave the surgical area. Nicks increase the risk for infec-
tion. Either an endotracheal or nasotracheal tube would be placed for a
operating room.” client under general anesthesia. Postoperatively, the client should cough
2. “I should shave the skin in the surgical area the and deep breathe. The incision can be splinted with a pillow, towel, or
evening prior to surgery.” folded blanket placed over the surgical incision. Because the surgery is
3. “I should splint my incision with a pillow when prolonged (3 hours), a urinary catheter should be inserted and urine output
coughing and deep breathing after surgery.” monitored.
4. “I might need a urinary catheter inserted before ➧ Test-taking Tip: Read the stem carefully and focus on the key
surgery so my urine output can be monitored.” words “needs further teaching.” Select the client statement that
indicates that the nurse needs to provide further instructions.
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402 SECTION II Practice Tests

Content Area: Adult Health; Category of Health Alteration:

Perioperative Management; Integrated Processes: Nursing Process
Implementation; Teaching and Learning; Client Need: Physiological
Integrity/Reduction of Risk Potential/Potential for Complications from
Surgical Procedures and Health Alterations; Cognitive Level:
Application
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., pp. 307–309).
St. Louis, MO: Elsevier/Saunders.
EBP Reference: The Joanna Briggs Institute. (2003). The impact of
preoperative hair removal on surgical site infection. Best Practice, 7(2).
Available at: www.joannabriggs.edu.au/pubs/best_practice.php

872. Which nursing action would be best when a pre- ANSWER: 4

operative client verbalizes fear of postoperative pain? The client should be reassured that there are medications available to
prevent and treat pain. Diversional activities are used to enhance the
1. Providing diversional activities when client reports pharmacological effect. Pharmacological management is the mainstay for
fear of pain acute pain. Although allowing the client to verbalize fears is a therapeutic
communication technique, allaying the fear is best. Informing the client of
2. Encouraging the client to verbalize concerns experiences may heighten the client’s fear. The client needs reassurance
regarding the fear of pain that the pain will be controlled.
3. Informing the client of experiences and the
➧ Test-taking Tip: Note the key word “best.” Look at the verbs
likelihood of pain pre- and postoperatively provide, encourage, inform, explain. Providing diversional
4. Explaining the medications ordered for pain activities does not address the client’s verbalization. Eliminate
control, availability, and treatment goals responses 2 and 3 because they are lower-level verbs.
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Implementation; Client Need: Physiological Integrity/Pharmacological
and Parenteral Therapies/Pharmacological Pain Management; Cognitive
Level: Application
Reference: Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher,
L. (2007). Medical-Surgical Nursing: Assessment and Management of
Clinical Problems (7th ed., pp. 388–389). St. Louis, MO: Mosby.
EBP Reference: Institute for Clinical Systems Improvement (ICSI).
(2008). Assessment and Management of Acute Pain. Available at:
www.guideline.gov/summary/summary.aspx?doc_id=12302&nbr=
006371&string=acute+AND+pain+AND+management+AND+
perioperative+AND+setting.

873. Which statement by a nurse is most effective when ANSWER: 4

collecting data about a preoperative client’s recre- When clients are aware of the potential interactions of drugs with
anesthetics, most clients respond honestly about their drug use. This
ational drug use? statement is nonjudgmental and nonthreatening. Clients are less likely
1. “Describe the drugs you use and the frequency that to respond honestly to drug use if they are unaware of potential drug inter-
actions. Open-ended questions should be used because close-ended ques-
you use these drugs.” tions elicit only a “yes/no” response. Statements and questions made to a
2. “Do you use any over-the-counter medications or patient should be nonthreatening to elicit a more honest answer.
illegal substances?”
➧ Test-taking Tip: Use therapeutic communication techniques to
3. “Tell me about all medications and substances you answer this question.
take because complications can occur if you are
Content Area: Adult Health; Category of Health Alteration:
taking something we do not know about.” Perioperative Management; Integrated Processes: Nursing Process
4. “Because herbs, medications, and recreational Implementation; Communication and Documentation; Client Need:
drugs such as marijuana and cocaine affect the Physiological Integrity/Reduction of Risk Potential/Potential for
type and amount of anesthesia you need, list any of Complications from Surgical Procedures and Health Alterations; Psychosocial
these you take and how often you use them.” Integrity/Therapeutic Communications; Cognitive Level: Analysis
Reference: Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher,
L. (2007). Medical-Surgical Nursing: Assessment and Management of
Clinical Problems (7th ed., p. 354). St. Louis, MO: Mosby.
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CHAPTER 8 Physiological Integrity: Care of Adults and Older Adults 403

874. A nurse evaluates that a preoperative client can prop- ANSWER: 2

erly use a volume incentive spirometer when which Sitting upright promotes lung expansion. With all types of incentive
spirometers, the client must be able to seal the lips tightly around the
client action is noted? mouthpiece and inhale slowly. The client then holds the breath for 3 to
1. Sits upright, inserts the mouthpiece, and blows 5 seconds for effective lung expansion. The client should be inhaling, not
blowing. Coughing will help expel secretions and allow for full lung aera-
until the lungs are emptied of air tion. The client should be inhaling slowly and holding the breath before
2. Sits upright, exhales, seals lips around the exhalation to promote lung expansion.
mouthpiece, inhales, and holds breath for
➧ Test-taking Tip: Visualize a client using an incentive
5 seconds spirometer before trying to answer this question.
3. Sits at the edge of the bed, coughs, inserts the
Content Area: Adult Health; Category of Health Alteration:
mouthpiece, and blows slowly for 10 seconds Perioperative Management; Integrated Processes: Nursing Process
4. Sits at the edge of the bed, breathes deeply five Evaluation; Client Need: Physiological Integrity/Reduction of Risk
times, inserts the mouthpiece, and inhales quickly Potential/Therapeutic Procedures; Cognitive Level: Analysis
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 309).
St. Louis, MO: Elsevier/Saunders.

875. A nurse is teaching a client prior to surgery about ANSWER: 2

the device illustrated. The nurse teaches the client that Sequential compression devices (SCDs) are used postoperatively to
prevent deep vein thrombosis. The device promotes fluid movement by
the primary purpose of the device illustrated is to: simulating leg muscles contraction. The stocking compartments inflate
to 35 to 55 mm Hg, inflating from the ankle, to the calf, and finally the
thigh. Circulation may be improved, but this is not the primary purpose.
SCDs have a cooling and warming option, but this is not the primary
purpose. SCDs will have no effect on wound healing.
➧ Test-taking Tip: Note the key words “primary purpose.”
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Teaching and
Learning; Client Need: Physiological Integrity/Reduction of Risk
1. improve circulation prior to surgery. Potential/Potential for Complications from Surgical Procedures and Health
Alterations; Cognitive Level: Application
2. prevent intra- and postoperative deep vein
thrombosis. Reference: Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., &
Bucher, L. (2007). Medical-Surgical Nursing: Assessment and
3. assist in keeping the client warm during surgery.
Management of Clinical Problems (7th ed., pp. 911–912). St. Louis,
4. promote dehiscence and wound healing MO: Mosby.
postoperatively.
EBP Reference: Blondin, M. (2006). Prevention of Deep Vein Thrombosis.
Iowa City: University of Iowa Gerontological Nursing Research Center,
Research Dissemination Core. Available at: www.guideline.gov/summary/
summary.aspx?doc_id=9266&nbr=004960&string=graduated+AND+
compression+AND+stockings.

876. A client in an operating room holding area, who is to ANSWER: 1

receive general anesthesia, reports having a dry The client should have nothing by mouth (NPO) for 6 to 8 hours prior
to general anesthesia to prevent vomiting and aspiration. The client
mouth because food and fluids have been withheld may have ordered medications with a sip of water (about 20 mL). Prior to
for 8 hours. Which action by a nurse is most general anesthesia, the client should be NPO for 6 to 8 hours. A full stom-
appropriate? ach putting pressure on the diaphragm and preventing full lung expansion
during surgery is not the primary reason for the NPO status. Telling the
1. Teach the client that the primary reason food and client that the anesthesia will soon cause unawareness of the dry mouth
fluids have been withheld is to prevent vomiting disregards the client’s concerns.
and potential complications ➧ Test-taking Tip: Note the key words “most appropriate.” Client
2. Clarify that food and fluids should have been teaching is most appropriate in the preoperative period.
withheld only for 4 hours and offer a small sip of Content Area: Adult Health; Category of Health Alteration:
water Perioperative Management; Integrated Processes: Nursing Process
3. Explain to the client that a full stomach puts Implementation; Client Need: Physiological Integrity/Reduction of Risk
pressure on the diaphragm and prevents full lung Potential/Potential for Complications from Surgical Procedures and Health
expansion during surgery Alterations; Cognitive Level: Application
4. Tell the client that the general anesthetic will soon Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
make the client sleepy and unaware of the mouth Nursing: Critical Thinking for Collaborative Care (5th ed., p. 306).
St. Louis, MO: Elsevier/Saunders.
dryness
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404 SECTION II Practice Tests

877. A nurse is caring for a client who received conscious ANSWER: 4

sedation during a surgical procedure. Which assess- The rate and depth of breathing should be assessed to determine the
adequacy of air exchange. A respiratory rate of less than 10 breaths
ment of this client is most important for a nurse to per minute indicates drug-induced respiratory depression. The primary
make postoperatively? concern with conscious sedation is the effect of the medications on the
central nervous system (CNS). Lung sounds are assessed to determine the
1. Lung sounds adequacy of ventilation of all lung lobes or the presence of fluid or secre-
2. Amount of urine output tions in the airways and lung tissue. Though assessing the lung sounds is
3. Ability to swallow liquids important postoperatively, assessing the rate and depth of breathing is most
4. Rate and depth of breathing important with conscious sedation. Though urine output should be at least
30 mL/hr and medications administered can potentially be nephrotoxic, it
is more important to assess the rate and depth of respirations with con-
scious sedation. The client swallowing ability should be assessed prior to
administering liquids. However, it is more important to assess the rate and
depth of respirations with conscious sedation.
➧ Test-taking Tip: Note the key words “most important.” Use the
ABCs (airway, breathing, circulation) to identify the correct
response.
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Assessment; Client Need: Physiological Integrity/Reduction of Risk
Potential/System Specific Assessments; Cognitive Level: Application
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 332).
St. Louis, MO: Elsevier/Saunders.

878. Upon arrival to an operating room holding area, a ANSWER: 2

client who is scheduled for abdominal surgery is Because anesthesia and surgery have not yet started, it is safe to ask
the client to remove the tongue ring. If the client refuses, then the sur-
noted to have replaced a tongue ring that was re- geon and anesthesiologist should be notified. Documentation regarding
moved when the operative checklist was completed. finding the tongue ring replaced should occur after the intervention. A vari-
Which is the most appropriate initial action by a ance report should be completed because the item should have been re-
nurse? moved before the client arrived to the holding area. Tongue rings increase
the risk of aspiration, burns, and injury during surgery. Notifying the sur-
1. Document the findings on the client’s medical geon and the anesthesiologist is not the first action. If the client removes
record the tongue ring, the surgeon and anesthesiologist would not need to be
2. Request that the client once again remove the notified.
tongue ring ➧ Test-taking Tip: Note the key word “first.” Use the nursing
3. Complete a variance report, noting that the client process. The nurse has already assessed and analyzed. The next
step is intervention. Decide the priority action.
has replaced the tongue ring
4. Notify the surgeon and the anesthesiologist of the Content Area: Adult Health; Category of Health Alteration:
replacement of the tongue ring Perioperative Management; Integrated Processes: Nursing Process
Implementation; Client Need: Physiological Integrity/Reduction of Risk
Potential/Potential from Surgical Procedures and Health Alterations;
Cognitive Level: Application
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 333).
St. Louis, MO: Elsevier/Saunders.
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CHAPTER 8 Physiological Integrity: Care of Adults and Older Adults 405

879. A nurse is orienting a new nurse to a postanes- ANSWER: 4

thesia care unit (PACU). Which statement by the new The client receiving a spinal anesthetic should remain in the PACU until
feeling and voluntary motor movement of the lower extremities has be-
nurse indicates further orientation is needed? gun to return. Because the client did not receive a general anesthetic
1. “Lactated Ringer’s (LR) and 5% dextrose with LR that depressed the central nervous system, the client may be verbally re-
sponsive immediately after surgery. Both LR and dextrose with LR solu-
are typical IV solutions administered in the PACU.” tions are isotonic and are used for fluid replacement in the PACU. After re-
2. “If a client has an opioid overdose, I should expect turning to the medical-surgical unit, the type and amount of solution are
to administer naloxone hydrochloride (Narcan®).” based on client need. Naloxone hydrochloride (Narcan®) is an antagonist for
3. “I should monitor vital signs and perform a pain opioids and is used for reversing the respiratory-depressive effects of opioid
assessment every 15 minutes or more often if analgesics. Vital sign observations and pain assessment should be completed
every 15 minutes or more frequently based on the client’s condition.
necessary.”
4. “Once a client responds verbally after a spinal ➧ Test-taking Tip: Note the key words “further orientation is
needed.” The correct answer is the wrong statement.
anesthetic, the client can be transferred to the
nursing unit.” Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Teaching and Learning;
Client Need: Safe and Effective Care Environment/Management of Care/
Concepts of Management; Cognitive Level: Analysis
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., pp. 344, 353).
St. Louis, MO: Elsevier/Saunders.
EBP Reference: The Joanna Briggs Institute. (1999). Vital signs. Best Practice,
3(3). Available at: www.joannabriggs.edu.au/pubs/best_ practice.php

880. Which information is most important for a postanes- ANSWER: 4

thesia care unit nurse to include in a report on a post- Pain is the fifth vital sign. Time and dose is the reference for imple-
menting the pain protocol or developing a plan for the client’s pain
operative client to a surgical unit nurse? control. The hand-off of the client to another area is the ideal time to
1. Location of the relatives insure the continuation of care, as well as the transfer of responsibility.
The nurse should check for the presence of family or significant others.
2. Review of the surgical consent However, this is not the most important. Reviewing the consent is unneces-
3. Placement of client belongings sary postoperatively. If the client needs a blood transfusion, the nurse may
4. Last dose and type of pain medication need to review the consent for a blood transfusion prior to administering
blood or blood products. This may be a part of the surgical consent but
varies by institution. The nurse should note where the client’s belongings
are placed if the client was not previously on the surgical unit. However,
this is not the most important.
➧ Test-taking Tip: Use Maslow’s Hierarchy of Needs to identify
the correct option. Note the physiological need.
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Implementation; Client Need: Safe and Effective Care Environment/
Management of Care/Continuity of Care; Cognitive Level: Application
Reference: Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., &
Bucher, L. (2007). Medical-Surgical Nursing: Assessment and Management
of Clinical Problems (7th ed., pp. 378, 388). St. Louis, MO: Mosby.

881. A nurse evaluates that a client has achieved an ex- ANSWER: 1

pected outcome for the second postoperative day fol- Passing flatus indicates increased gastrointestinal motility and the re-
turn of bowel function. The urine output should be at least 30 mL per
lowing abdominal surgery under general anesthesia. hour or at least 720 mL in 24 hours. Crackles indicate atelectasis or fluid
Which finding supports the nurse’s conclusion? accumulation in the lungs. Incisional pain is the most intense in the first
48 hours. An expected outcome should be a pain level of 3 or less.
1. Passing flatus
2. Urine output 680 mL in 24 hours ➧ Test-taking Tip: Focus on the key words “achieved an
expected outcome.” Look for an indication that the client’s
3. Crackles in bilateral lung bases
status is improving.
4. Rates incisional pain at 4 out of 10 on a 0 to 10
rating scale 60 minutes after analgesic given Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Evaluation; Client Need: Physiological Integrity/Physiological
Adaptation/Alterations in Body Systems; Cognitive Level: Analysis
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 345).
St. Louis, MO: Elsevier/Saunders.
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406 SECTION II Practice Tests

882. A nurse is planning the discharge of a client follow- ANSWER: 1

ing recovery from an exploratory laparotomy. The Because the client has limited ability to ambulate, the client should
continue to wear the TED stockings at home to prevent deep vein
client has a history of chronic back pain and limited thrombosis until the client increases ambulation. The TEDS should be
ability to ambulate. The nurse plans for further removed one to two times daily for skin care and inspection. Clients
discharge teaching when the client states: provided with preoperative teaching pamphlets learn proper exercise tech-
niques or skills faster than those provided the information postadmission.
1. “I can leave my elastic antiembolic (TEDS®) A diet high in protein, calories, and vitamin C will promote wound
stockings off once I get home.” healing. A nonpharmacological method to reduce postoperative pain and
2. “I should be eating a diet high in protein, calories, promote comfort includes ice application. Specific volume goals are usu-
and vitamin C now and when I get home.” ally set based on the client’s ability and the type of incentive spirometer.
Achievement of the volume goal is an expected postoperative outcome that
3. “An alternative method to control pain and reduce should be met prior to discharge.
swelling is applying ice to my incision.”
➧ Test-taking Tip: Focus on the key words “limited ability to
4. “I use my incentive spirometer every 2 hours so I
ambulate.” Both TEDS and ambulation promote venous return.
can reach my volume goal before discharge.”
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Planning; Client Need: Physiological Integrity/Reduction of Risk
Potential/Potential for Complications from Surgical Procedures and Health
Alterations; Cognitive Level: Application
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 354).
St. Louis, MO: Elsevier/Saunders.

883. A nurse is reviewing a plan of care for a postopera- ANSWER: 4

tive client with a history of sickle cell disease. Which An open airway is a physiological need that is priority. Ineffective air-
way clearance in a postoperative client is often due to an ineffective or
nursing diagnosis, documented on the client’s care absent cough and the accumulation of secretions that compromise the
plan, should the nurse address first? airway. Anxiety is a psychosocial need and is not the priority. Impaired
skin integrity is a physiological need, but of lower priority than an open
1. Anxiety airway. Deficient fluid volume is a physiological problem, but of lower
2. Impaired skin integrity priority than an open airway.
3. Deficient fluid volume
➧ Test-taking Tip: Note the key word “first.” Use Maslow’s
4. Ineffective airway clearance Hierarchy of Needs theory to identify that physiological needs
are the first priority. Then use the ABCs (airway, breathing,
circulation) to further prioritize the physiological needs.
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Planning; Client Need: Physiological Integrity/Physiological
Adaptation/Alterations in Body Systems; Cognitive Level: Application
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 348).
St. Louis, MO: Elsevier/Saunders.

884. A nurse is caring for a postoperative client who re- ANSWER: 3

ports an inability to void. Which initial action by the The bladder should be palpated for distention. The nurse should also
observe for other signs of a full bladder such as restlessness or an ele-
nurse is most appropriate? vated blood pressure. The nurse should first determine the underlying
1. Turning on running water reason for the client’s inability to void. Turning on running water as-
sumes that the client has a full bladder. A urinary catheter should only be
2. Inserting a urinary catheter inserted if the client has a full bladder and other measures to initiate void-
3. Palpating the client’s bladder ing have been unsuccessful. Though reviewing the chart for the time of the
4. Reviewing the client’s chart for the time of the last last voiding may assist in determining the underlying problem, client as-
voiding sessment should be the first action.
➧ Test-taking Tip: Use the steps in the nursing process to
identify the correct answer. Assessment should be completed
before interventions are implemented.
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Assessment; Client Need: Physiological Integrity/Basic Care and
Comfort/Elimination; Cognitive Level: Application
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 344).
St. Louis, MO: Elsevier/Saunders.
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CHAPTER 8 Physiological Integrity: Care of Adults and Older Adults 407

885. A postoperative client who received a spinal anesthetic ANSWER: 2

is experiencing a headache, photophobia, and double The client is experiencing a postdural puncture headache caused
by leakage of cerebrospinal fluid (CSF) from the needle insertion
vision. A nurse’s initial intervention should be to: made in the dura for the spinal anesthetic. Placing the client in
1. immediately notify the surgeon. the flat position minimizes the leakage of CSF. The surgeon should
be notified of the development as well as the anesthesiologist if the
2. position the client flat in bed. headache persists despite interventions or there is noticeable leakage
3. limit the client’s fluid intake. of CSF. Fluids should be increased to hydrate the client and replace
4. administer steroid medications. fluids lost from the CSF leakage. If the headache persists, steroids
may be ordered to decrease inflammation, but this is not an initial
intervention.
➧ Test-taking Tip: Note the key word “initial.” Also note
that positioning the client flat in bed is an intervention
that the nurse could accomplish quickly to reduce the
client’s headache.
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Implementation; Client Need: Physiological Integrity/Physiological
Adaptation/Unexpected Response to Therapies; Cognitive Level:
Application
References: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 942). St.
Louis, MO: Elsevier/Saunders; Williams, L., & Hopper, P. (2007).
Understanding Medical-Surgical Nursing (3rd ed., p. 189). Philadelphia:
F. A. Davis.

886. A physician documents in a client’s postoperative ANSWER: 2

progress notes that the client is experiencing a respi- An early indication of infection is an increase in the band cells, which
are immature neutrophils in the WBC differential count. The increase
ratory infection with a shift to the left in the white is termed a shift to the left. The total WBC count should be elevated, not
blood cell (WBC) differential count. Which finding decreased. However, this does not describe the shift to the left. Decreased
by a nurse reviewing the client’s laboratory report hemoglobin in a postoperative client is usually due to blood loss. An
would support the physician’s documentation? increased C-reactive protein indicates nonspecific inflammation and
is not part of the WBC differential count.
1. Decreased WBC count
➧ Test-taking Tip: Note the key words “shift to the left” and “WBC
2. Increased band cells differential.” Decreased hemoglobin and increased C-reactive
3. Decreased hemoglobin protein do not pertain to the WBC. Increased C-reactive protein is
4. Increased C-reactive protein opposite of what is expected with infection.
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Evaluation; Client Need: Physiological Integrity/Reduction of Risk
Potential/Laboratory Values; Cognitive Level: Analysis
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 347).
St. Louis, MO: Elsevier/Saunders.

887. In reviewing a physician’s orders for a postop- ANSWER: 2

erative client who underwent gynecological surgery, Enoxaparin is an anticoagulant that potentiates the inhibitory effect of
antithrombin on factor Xa and thrombin. Early postoperative ambula-
which order should a nurse determine is specifically tion instead of dangling is a major preventive technique for throm-
written with the intent to prevent postoperative bophlebitis. Hydromorphone is a narcotic analgesic for pain control.
thrombophlebitis and pulmonary embolism? Coughing and deep breathing promote lung expansion and prevent
atelectasis and pneumonia.
1. Have the client dangle the legs the evening of
➧ Test-taking Tip: Note the key words “specifically written,” and
surgery
then eliminate options 1, 3, and 4 because they are not specific
2. Administer enoxaparin (Lovenox®) 40 mg to preventing postoperative thrombophlebitis and pulmonary
subcutaneously daily embolism. Knowledge of medications is needed to answer this
3. Administer hydromorphone (Dilaudid®) 1 to 4 mg question.
IV every 3 to 4 hours as needed (prn)
4. Encourage coughing and deep breathing (C&DB)
every hour while awake
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408 SECTION II Practice Tests

Content Area: Adult Health; Category of Health Alteration:

Perioperative Management; Integrated Processes: Nursing Process
Analysis; Client Need: Physiological Integrity/Reduction of Risk
Potential/Therapeutic Procedures; Cognitive Level: Analysis
Reference: Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher,
L. (2007). Medical-Surgical Nursing: Assessment and Management of
Clinical Problems (7th ed., pp. 911–912). St. Louis, MO: Mosby.
EBP Reference: American College of Obstetricians and Gynecologists.
(2007). Prevention of deep vein thrombosis and pulmonary embolism.
Available at: www.guideline.gov/summary/summary.aspx?doc_id=
11429&nbr=005947&string=postoperative+AND+care

888. A nurse assesses that a client on the second postoper- ANSWER: 1

ative day following abdominal surgery has dimin- Atelectasis is a common finding in smokers after abdominal surgery
due to the accumulation of secretions. It is caused from collapsed alve-
ished breath sounds in both lung bases, is taking shal- oli or mucus that prevents some alveoli from opening and manifests
low breaths, is able to achieve only 500 mL on an with diminished breath sounds, diminished vital capacity, and de-
incentive spirometer, and has been smoking one pack creased oxygen saturation. There is no indication, such as elevated tem-
of cigarettes per day prior to surgery. The nurse’s best perature or increased white blood cells, that the client has an infection. It
interpretation of these findings is that the client is should also be noted that the client is experiencing abnormal findings for
the second postoperative day. Smoking can cause COPD, but the dimin-
experiencing: ished lung bases suggest alveoli are not expanding.
1. atelectasis. ➧ Test-taking Tip: Note that the client is 2 days postabdominal
2. pneumonia. surgery. Eliminate the options that occur over time.
3. a normal postoperative course. Content Area: Adult Health; Category of Health Alteration:
4. chronic obstructive pulmonary disease (COPD). Perioperative Management; Integrated Processes: Nursing Process
Analysis; Client Need: Physiological Integrity/Physiological
Adaptation/Alterations in Body Systems; Cognitive Level: Analysis
Reference: Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., &
Bucher, L. (2007). Medical-Surgical Nursing: Assessment and Management
of Clinical Problems (7th ed., pp. 511–512, 597). St. Louis, MO: Mosby.

889. A nurse notes redness, swelling, and warmth of and ANSWER: 3

around the incision when assessing a client’s leg inci- Redness, swelling, and warmth are signs of inflammation and could
indicate the presence of an infection. Other signs of an infection in-
sion 48 hours after femoral popliteal bypass surgery. clude excessive pain or tenderness on palpation and purulent or odor-
The nurse’s best analysis should be that the incision is: ous drainage. Slight crusting, a pink color to the incision line, and slight
swelling under the sutures or staples are normal findings for the second
1. healing normally for the second postoperative day. postoperative day due to inflammation from the surgical procedure.
2. showing signs of rejection of the suture materials. Though these findings could indicate rejection of the sutures, rejection oc-
3. inflamed and could indicate the presence of an curs less frequently than a wound infection. If the wound is dehiscing,
infection. bloody or serosanguineous drainage would also be present.
4. infected and showing signs of wound dehiscence. ➧ Test-taking Tip: Use the process of elimination and focus on
the findings (redness, swelling, and warmth).
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Analysis; Client Need: Physiological Integrity/Reduction of Risk
Potential/Potential for Complications from Surgical Procedures and Health
Alterations; Cognitive Level: Analysis
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 346).
St. Louis, MO: Elsevier/Saunders.
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CHAPTER 8 Physiological Integrity: Care of Adults and Older Adults 409

890. Which outcome should indicate to a nurse that a post- ANSWER: 2

surgical client’s coughing and deep breathing The purpose of postoperative C&DB is to expel secretions, keep the
lungs clear, allow full aeration, and prevent pneumonia and atelectasis.
(C&DB) is most effective? Auscultating for clear and audible lung sounds is a definitive means
1. Respirations are 16 per minute and unlabored. for evaluating the effectiveness of C&DB. Secretions could still be pres-
ent in the lungs with normal respirations and nonlabored breathing.
2. Lung sounds are audible and clear on auscultation. Coughing clear secretions and a productive cough indicates that secretions
3. Coughs include small amount of clear secretions. are still present.
4. Cough effort is strong and productive.
➧ Test-taking Tip: Note the key words “most effective,” and
eliminate options that include abnormal data.
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Evaluation; Client Need: Physiological Integrity/Physiological
Adaptation/Illness Management; Cognitive Level: Application
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 309).
St. Louis, MO: Elsevier/Saunders.

891. A client is to receive a second dose of oxycodone/ ANSWER: 2

acetaminophen (Percocet®) for postoperative incisional The nurse is using the therapeutic communication technique, known
as clarifying, to determine the effects of the medication on the client.
pain. When a nurse brings the medication to the client, This focuses on the client’s feelings. Simply offering new medication
the client says, “Why bring this medication again? It avoids the client’s feelings. Also, without questioning the client, the nurse
makes me feel sick.” Which statement is the most would have insufficient information to give to the physician regarding the
appropriate initial nurse response? client’s reaction to the medication. Offering an antacid also avoids the
client’s concerns and assumes that the client has a gastrointestinal reaction
1. “I can call the doctor to see what else can be to the medication. Even though option 4 focuses on the client’s nausea,
ordered for your pain.” incorrect information is provided. Oxycodone/acetaminophen does not
2. “Describe what you feel when you say that the contain aspirin.
medication makes you feel sick.” ➧ Test-taking Tip: Use therapeutic communication techniques
3. “The doctor has ordered an antacid. I can give you and focus on the client’s feelings, concerns, fears, or anxieties.
Eliminate options that provide incorrect information.
this along with the medication.”
4. “Many people say the same thing. The aspirin in Content Area: Adult Health; Category of Health Alteration:
the medication is hard on your stomach.” Perioperative Management; Integrated Processes: Communication and
Documentation; Client Need: Psychosocial Integrity/Therapeutic
Communications; Cognitive Level: Application
References: Berman, A., Snyder, S., Kozier, B., & Erb, G. (2008). Kozier
& Erb’s Fundamentals of Nursing: Concepts, Process, and Practice
(8th ed., pp. 469–471). Upper Saddle River, NJ: Pearson Education;
Wilson, B., Shannon, M., Shields, K., & Stang, C. (2008). Prentice Hall
Nurse’s Drug Guide 2008 (p. 1656). Upper Saddle River, NJ: Pearson
Education.

892. A nurse evaluates that the drainage from a client’s na- ANSWER: 2
sogastric (NG) tube, inserted for gastric decompres- Normal NG drainage fluid is greenish yellow in color. Brown liquid or
drainage with a “coffee-ground” appearance indicates old bleeding. The
sion during emergency surgery, would be normal if it: pH of gastric secretions would be acidic. In emergency surgery, large
1. returns brown-liquid in color. amounts of output would be expected because the client’s stomach
was unlikely to be empty.
2. returns greenish-yellow in color.
3. has an alkalotic hydrogen level (pH). ➧ Test-taking Tip: Note the key word “normal.”
4. measures less than 25 mL in volume. Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Evaluation; Client Need: Physiological Integrity/Physiological Adaptation/
Fluid and Electrolyte Imbalances; Cognitive Level: Application
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 345).
St. Louis, MO: Elsevier/Saunders.
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410 SECTION II Practice Tests

893. A nurse notifies a physician after assessing a client ANSWER: 1

5 days after an exploratory laparotomy and noting a Paralytic ileus results from a neuromuscular disturbance and does not
involve a physical obstruction in or outside the intestine. Peristalsis is
distended abdomen, abdominal pain, absence of decreased or absent, resulting in a slowing of the movement or a
flatus, and absent bowel sounds. Which typical backup of intestinal contents. In addition to the symptoms the client is
complication of abdominal surgery should the nurse experiencing, nausea and vomiting may be present. The client would
conclude may be occurring? not have any signs or symptoms with silent peritonitis. The distended
abdomen could indicate that fluid may have shifted into the abdomen.
1. Paralytic ileus However, fluid volume deficit would then occur and not excess. There is
2. Silent peritonitis an interference with absorption of nutrients in malabsorption syndrome.
3. Fluid volume excess Typical signs and symptoms include weight loss, bloating and flatus,
edema, bone pain, anemia, easy bruising, and decreased libido.
4. Malabsorption syndrome
➧ Test-taking Tip: Note the key words “typical complication of
abdominal surgery” and eliminate options that occur over a
longer period of time.
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Analysis; Client Need: Physiological Integrity/Reduction of Risk
Potential/Potential for Complications from Surgical Procedures and Health
Alterations; Cognitive Level: Analysis
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., pp. 345,
1326–1327). St. Louis, MO: Elsevier/Saunders.

894. Which statement should a nurse include when teach- ANSWER: 2

ing a client prior to discharge following abdominal In addition to vitamins and iron, supplemental vitamin C and a diet
high in protein and calories will promote wound healing. Surgery stresses
surgery? the body, and time and rest are needed for healing. The client should return
1. “Return to work in about 4 weeks because working to work only after consulting with the surgeon. If work involves a moderate
amount of physical labor, up to 6 weeks time off may be needed for recov-
increases your physical activity gradually.” ery. Daily walking should be encouraged, but carrying 10-pound weights or
2. “The ordered iron and vitamins tablets will lifting heavy objects stresses the incision. Although the wound may appear
promote wound healing and red blood cell to be healed in 2 to 3 weeks, it takes up to 2 years for complete wound heal-
growth.” ing and strengthening of the scar. A referral to a home-care agency should be
3. “Daily walking carrying 10-pound weights will made if skilled nursing care such as complex dressing changes is needed.
Nursing service does not include household help.
help to strengthen your incision.”
4. “Home-care nursing service is usually paid by ➧ Test-taking Tip: Note the key words “should . . . include.” Read
each option carefully noting key words that would make an
insurance if you need help around the house.”
option incorrect.
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Teaching and
Learning; Client Need: Health Promotion and Maintenance/Self-Care;
Cognitive Level: Analysis
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., pp. 354–355).
St. Louis, MO: Elsevier/Saunders.

895. A nurse is calculating nasogastric (NG) tube ANSWER: 305

drainage for a postoperative client. At 0700 hours, 575 mL – 150 mL = 425 mL of drainage in the container
30 mL  4 = 120 mL of irrigation solution
the client’s drainage container was marked at 425 mL – 120 mL = 305 mL of actual drainage
150 mL. At 1500 hours, there was 575 mL in the
➧ Test-taking Tip: Focus on the information in the question and
container. During the nursing shift, the nurse in-
use the on-screen calculator. Verify your response especially if
stilled 30 mL of saline irrigation into the tube four it seems like an unusual amount.
times as prescribed by the physician. The nurse
Content Area: Adult Health; Category of Health Alteration:
calculates that the actual NG tube drainage for the Perioperative Management; Integrated Processes: Nursing Process
client from 0700 to 1500 hours is _____ mL. Implementation; Client Need: Physiological Integrity/Physiological
Adaptation/Alterations in Body Systems; Cognitive Level: Analysis
Reference: Ignatavicius, D., & Workman, M. (2006). Medical-Surgical
Nursing: Critical Thinking for Collaborative Care (5th ed., p. 345).
St. Louis, MO: Elsevier/Saunders.
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CHAPTER 8 Physiological Integrity: Care of Adults and Older Adults 411

896. A nurse assesses that two areas of a client’s postoper- ANSWER:

ative leg incision are not approximated. Place an X
on the two areas in the illustration that correctly de-
pict the nurse’s wound assessment.

A nonapproximated incision is one in which wound edges are not

closed. The wound will close by secondary intention healing.
➧ Test-taking Tip: Read the stem carefully, noting the words
“not approximated.”
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
Assessment; Client Need: Health Promotion and Maintenance/
Techniques of Physical Assessment; Cognitive Level: Application
Reference: Lewis, S., Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L.
(2007). Medical-Surgical Nursing: Assessment and Management of Clinical
Problems (7th ed., p. 392). St. Louis, MO: Mosby.

897. A nurse is interpreting the serum laboratory report il- ANSWER: 2

lustrated for a postoperative client. The nurse, notify- A low serum potassium (K) level can cause cardiac dysrhythmias.
Potassium is lost through nasogastric (NG) suctioning and tissue de-
ing a physician of the laboratory results, should ex- struction. The potassium needs to be replaced immediately. Unless the
pect the physician to order which stat order? client is showing symptoms of inadequate tissue perfusion, blood would
not be replaced with a hemoglobin (Hgb) level of 11.0. The nurse should
Serum be alert for the development of hyperkalemia, not hypokalemia, with an-
giotensin-converting enzyme (ACE) inhibitors such as enalapril (Vasotec®)
Laboratory Test Client’s Value Normal Values
especially with clients who have diabetes mellitus, impaired kidney func-
BUN 40 5–25 mg/dL tion, or congestive heart failure (CHF). Calcium gluconate is administered
in acute hypocalcemia to replace calcium. It is also administered when a
Creatinine 1.4 0.5–1.5 mg/dL
client’s serum potassium level is elevated to raise the threshold for cardiac
Na 140 135–145 mEq/L muscle excitation, thereby preventing life-threatening dysrhythmias.
K 3.2 3.5–5.3 mEq/L
Cl 99 95–105 mEq/L ➧ Test-taking Tip: Use the ABCs (airway, breathing, circulation)
CO2 16 22–30 mEq/L to determine the priority intervention. Both the serum K level
and the hemoglobin/hematocrit (Hgb/Hct) affect oxygenation
Phosphate 1.9 1.7–2.6 mEq/L
and circulation. However, the low serum K level is more critical
Calcium 9 9–11 mg/dL than the low Hgb/Hct level because the serum K level affects
Hgb 11 13.5–17 g/dL cardiac muscle function.
Hct 38% 40%–54%
Content Area: Adult Health; Category of Health Alteration:
Perioperative Management; Integrated Processes: Nursing Process
1. Administer 1 unit packed red blood cells (RBCs). Analysis; Client Need: Physiological Integrity/Physiological
2. Administer potassium chloride 10 mEq in 100 mL Adaptation/Fluid and Electrolyte Imbalances; Cognitive Level: Analysis
0.9% NaCl via intravenous piggyback (IVPB). Reference: Wilson, B., Shannon, M., Shields, K., & Stang, C. (2008).
3. Hold the ACE inhibitor enalapril (Vasotec®). Prentice Hall Nurse’s Drug Guide 2008 (pp. 221–223, 543–545,
4. Administer calcium gluconate 10 mEq in 100 mL 1243–1245). Upper Saddle River, NJ: Pearson Education.
0.9% NaCl via IVPB.