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Chapter 17: Surgical Care

Linton: Introduction to Medical-Surgical Nursing, 6th Edition
MULTIPLE CHOICE
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 patients family if she is having pain.
d. Determine when the patient last received pain medication.
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
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2. A nurse is caring for a postoperative patient. What should the nurse ask when assessing
for the complication of malignant hyperthermia?
a. Do you think you might have a fever?
b. Do you currently have an infection?
c. Has anyone in your family ever had problems with general anesthesia?
d. Have you ever had any type of malignancy?
ANS: C
Malignant hyperthermia is a life-threatening complication that occurs in response to certain
drugs. Susceptibility to this response is inherited.
TOP: General Anesthesia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk
3. A patient who had a hysterectomy yesterday has not been allowed food or drink by
mouth (NPO). The physician has now ordered the patients diet to be clear liquids. What
should the nurse assess prior to providing this patient with clear liquids?
a. Feelings of hunger
b. Bowel sounds
c. Positive Homans sign
d. Gag reflex
ANS: B
The absence of bowel sounds would contraindicate a diet of clear liquids.
DIF: Cognitive Level: Application REF: p. 283 OBJ: 7 | 8
TOP: Postoperative Nursing Implementations
KEY: Nursing Process Step: Assessment
4. Which technique should a nurse implement when changing a postoperative dressing?

a. Enteric isolation
b. Aseptic technique
c. Clean technique
d. Respiratory isolation
ANS: B
The aseptic technique is important to reduce the risk of infection.
DIF: Cognitive Level: Comprehension REF: p. 281 OBJ: 9
TOP: Postoperative Risk for Infection KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
5. A nurse is caring for a postoperative patient who has had spinal anesthesia. Which
assessment is a priority for this patient?
a. Complaints of a headache
b. Pulse rate of 78 beats/min
c. Voided 300 mL
d. Blood pressure of 126/78 mm Hg
ANS: A
One complication of spinal anesthesia is postspinal headache, which is caused by the
leaking of cerebrospinal fluid at the puncture site.
TOP: Regional Anesthesia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. What should a nurse ensure that a postoperative patient implement to best prevent deep
vein thrombosis (DVT)?
a. Splint the incision.
b. Cough and deep breathe every 2 hours.
c. Regularly remove antiembolism stockings.
d. Ambulate frequently.
ANS: D
DVT is best prevented by early and frequent ambulation of the patient.
TOP: Postoperative Complications KEY: Nursing Process Step: Planning
7. During a nurses preoperative assessment, the nurse notices that a patient is extremely
anxious. The patients blood pressure is 142/92 mm Hg, the heart rate is 104 beats/min,
and respirations are 32 breaths/min. What nursing action should be implemented?
a. Give the preoperative medicine early to help calm the patient.
b. Call the surgical department and cancel the surgery.
c. Notify the anesthesiologist or surgeon.
d. Instruct the patient on possible postoperative complications.
ANS: C
When significant fear is associated with surgical complications, sometimes surgery is

postponed until the anxiety level is reduced.
DIF: Cognitive Level: Analysis REF: p. 259 OBJ: 3
TOP: Preoperative Anxiety KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
8. A nurse is performing a postoperative assessment on a patient who has just returned
from a hernia repair. The patients blood pressure is 90/60 mm Hg, and the apical pulse is
108 beats/min. What should be the nurses first action?
a. Check the dressing for bleeding.
b. Notify the registered nurse (RN).
c. Document the vital signs.
d. Increase the rate of infusion of intravenous fluids.
ANS: A
A decrease in blood pressure and tachycardia could indicate postoperative bleeding. The
first action of the nurse should be to check the dressing and then report to the RN.
TOP: Postoperative Complications KEY: Nursing Process Step: Implementation
9. A postoperative patient who has no previous medical conditions is difficult to arouse
when transferred to the surgical unit from the postanesthesia care unit. A nurse monitors
the pulse oximeter and gets a reading of 85%. What should be the nurses next action?
a. Assess the pulse oximeter reading again in 1 hour.
b. Arouse the patient, have him cough, and encourage deep breathing.
c. Administer a dose of pain medication.
d. Suction fluid from the oral cavity.
ANS: B
If the pulse oximeter reading is less than 90%, the patient should be aroused and
encouraged to take deep breaths. The patients respirations may not be adequate as a
result of the effects of anesthesia.
TOP: Hypoxia KEY: Nursing Process Step: Assessment
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.
ANS: D
The patient should report any signs and symptoms of infection (e.g., fever, redness,
swelling, pain).

TOP: Discharge Planning KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of
Disease
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
ANS: D
An incentive spirometer is used to promote lung expansion, which opens airways, reduces
atelectasis, and stimulates coughing to clear secretions.
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 nurses 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.
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.
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.
ANS: C
There are only a few instances in which coughing is contraindicated. They include surgeries
for hernias, cataracts, and brain surgery.
TOP: Postoperative Complications KEY: Nursing Process Step: Planning
14. When obtaining a patients 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.
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.
TOP: Consent Form KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
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
ANS: A
Conscious sedation uses intravenous drugs to reduce pain intensity or awareness without a
loss of reflexes. A complication may be excessive sedation approaching that of general
anesthesia. The patient should be easily aroused.
TOP: Anesthesia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
16. What is the goal of palliative surgery?
a. Remove and study tissue to make a diagnosis.
b. Relieve symptoms or improve function without correcting the basic problem.
c. Remove diseased tissue or correct defects.
d. Correct serious defects that only affect appearance.
ANS: B
Palliative surgery is performed only to relieve symptoms or to improve function. It is not
curative.
TOP: Types of Surgery KEY: Nursing Process Step: Planning
17. What information should a nurse ask a patient during the preoperative assessment?
a. Current address and telephone number
b. Food preferences
c. Allergies, medications, and past medical conditions

d. Bathing and sleep patterns
ANS: C
If an emergency should arise, any allergies can be promptly managed. Knowledge of the
patients medications can enable the nurse to anticipate possible drug interactions. Past
medical conditions may increase surgical risks or require special attention during the
perioperative period.
DIF: Cognitive Level: Comprehension REF: p. 257-258 OBJ: 2
TOP: Preoperative Assessment KEY: Nursing Process Step: Assessment
18. Which member of the surgical team administers anesthetics and monitors the patients
status throughout the procedure?
a. Surgeon
b. Circulating nurse
c. Perfusionist
d. Anesthesiologist
ANS: D
The anesthesiologist and nurse anesthetist have special training and are the members of
the surgical team that administer anesthesia and are responsible for closely monitoring the
patient during surgery.
DIF: Cognitive Level: Knowledge REF: p. 267 OBJ: 5
TOP: Surgical Team KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
19. A nurse is assisting in the transfer of a postoperative patient from the postanesthesia
care unit to the surgical nursing unit. What action should the nurse implement to ensure
the safety of the patient?
a. Put the side rails up after moving the patient from the stretcher to the bed.
b. Ask the patient to move from the stretcher to the bed.
c. Move the patient rapidly from the stretcher to the bed.
d. Uncover the patient before transferring from the stretcher to the bed.
ANS: A
The patient will probably still be experiencing residual effects of anesthesia; the side rails
should be up to prevent the patient from falling out of bed.
TOP: Postoperative Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
20. A patient who has just undergone a colon resection complains to a nurse that he felt
something pop under his dressing while trying to get out of bed. The nurse removes the
dressing and finds that dehiscence of the wound has occurred. What nursing action should
be implemented first?
a. Replace the dressing; dehiscence is normal.
b. Call the physician.
c. Pull the wound edges together and replace the dressing.

d. Cover the wound with sterile dressings saturated with normal saline.
ANS: D
The first action of the nurse should be to cover the wound with saline-saturated dressings
to prevent damage of the exposed organs from drying and then to call the physician.
TOP: Wound Dehiscence KEY: Nursing Process Step: Implementation
21. A patient has just returned to the surgical unit after varicose vein stripping and ligation.
What is the best technique for a nurse to evaluate pain relief?
a. Check the patients record for the last dose of pain medication administered.
b. Ask the patient to rate the severity of the pain on a scale of 1 to 10.
c. Ask the family if they think that the patient is having pain.
d. Tell the patient to ask for pain medicine when it is needed.
ANS: B
Having the patient rate the pain provides a system for evaluating response to the pain
medication. Pain is controlled better if treated before it becomes severe, and the patient
may not ask for pain medicine soon enough.
TOP: Postoperative Pain Relief KEY: Nursing Process Step: Assessment
22. A patient scheduled for a liver biopsy has given a nurse a list of medications routinely
taken at home. Which medication should the nurse question?
a. Aspirin
b. Multivitamin
c. Furosemide
d. Acetaminophen
ANS: A
Aspirin is an anticoagulant, which can increase the risk of postoperative bleeding. Drugs
that have been taken for a long time may require dose adjustments because of the effects
of surgery or the effect of additional drugs, which may be held or modified.
TOP: Preoperative Assessment KEY: Nursing Process Step: Assessment
23. A patient scheduled for a bronchoscopy is placed on an NPO status after midnight
before the procedure. The patient is complaining of being thirsty and requests some water
on the morning of the procedure. What action should the nurse implement?
a. Deny any oral fluid per order.
b. Allow 8 oz of tap water.
c. Offer limited ice chips.
d. Administer only carbonated drinks.
ANS: C
Patients are given nothing by mouth from midnight before the scheduled procedure to
reduce the risk of vomiting and aspiration during or after the procedure. Recent practice
allows small amounts of fluid or ice chips during the day of surgery.
TOP: Preparation for Surgery KEY: Nursing Process Step: Implementation
24. What should a nurse suggest to a patient to prevent the effects of postoperative
immobility on the gastrointestinal system?
a. Avoid taking antibiotics.
b. Increase her fluid intake.
c. Avoid high-fiber foods.
d. Limit her activity for the first 3 to 4 days.
ANS: B
The intake of oral fluids and ingestion of a normal diet help stimulate peristalsis.
TOP: Postoperative Complications KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Infection Control
25. A postanesthesia care nurse is evaluating a patient for possible transfer to the surgical
unit. Which assessment should prevent the patients transfer?
a. Blood pressure of 126/78 mm Hg
b. Pulse rate of 82 beats/min
c. Pulse oximeter reading of 85%
d. Respirations of 22 breaths/min
ANS: C
The pulse oximeter reading should be 95% to 100%. The patient should not be transferred
from the recovery room until the vital signs are stable, respiratory and circulatory functions
are adequate, pain is minimal, the patient is easily awakened, no complications have been
experienced, and the gag reflex is present.
DIF: Cognitive Level: Analysis REF: p. 281 OBJ: 8
TOP: Postoperative Assessment KEY: Nursing Process Step: Assessment
26. Why should a nurse assess a patients limbs and position the limbs frequently after a
regional anesthesia?
a. Pain is not perceived, although motion is possible.
b. Rashes and skin eruptions would indicate an allergy.
c. Permanent paralysis is a concern.
d. Contracture deformities may occur.
ANS: A
After a regional anesthesia, movement is possible, but pain is not perceived immediately
after surgery, which leaves the patient susceptible to injury.

TOP: Regional Anesthesia KEY: Nursing Process Step: Assessment
27. A patient who received Penthrane as an inhaled anesthesia complains of a sore throat
and a raspy voice. What should the nurse explain as the probable cause of these
discomforts?
a. Drying effect of the anesthesia
b. Insertion of an endotracheal tube
c. Postsurgical dehydration
d. Possible upper respiratory infection
ANS: B
Inhalant anesthesia is administered via an endotracheal tube that is inserted after the
patient is unconscious.
TOP: Inhalant Anesthesia KEY: Nursing Process Step: Implementation
MULTIPLE RESPONSE
28. Patients with preoperative disorders put them at risk during recovery. What disorders
should a nurse be aware may pose this hazard? (Select all that apply.)
a. Diabetes
b. Warfarin therapy
c. Fungal skin infection
d. Hepatitis C
e. Chronic obstructive pulmonary disease (COPD)
ANS: A, D, E
Diabetes, hepatitis C, and COPD all complicate recovery related to blood-clotting
deficiencies, respiratory problems, or disturbance in the healing process. Warfarin therapy
is not a disorder and should have been discontinued well before surgery, and fungal skin
infections do not pose a threat.
TOP: Conditions That Complicate Recovery
Disease
29. A patient has an extensive bowel preparation of oral laxatives and enemas for a colon
resection. What rationales should the nurse list when asked about the rigorous preparation?
(Select all that apply.)
a. Reduces possibility of fecal contamination of the operative site
b. Flattens the colon
c. Decreases postoperative distention
d. Avoids postoperative constipation
e. Decreases straining at stool
ANS: A, C, D, E
Preoperative bowel prep reduces the risk for infection from bowel contents and decreases
postoperative distention, constipation, and straining at stool.
TOP: Rationale for Bowel Preparation KEY: Nursing Process Step: Implementation
Disease
30. A nurse carefully monitors an obese patient after a hysterectomy for the peculiar
postoperative complications. Which postoperative complications are associated with
obesity? (Select all that apply.)
a. Nausea
b. Wound infection
c. Hypertension
d. Hemorrhage
e. Respiratory difficulties
ANS: B, E
Obese patients are especially prone to postoperative respiratory complications of
pneumonia and atelectasis. Obese patients are at increased risk for infection because of the
amount of adipose tissue.
TOP: Postoperative Complications in the Obese Patient
31. What are the responsibilities of a circulating nurse? (Select all that apply.)
a. Assisting the surgeon with the procedure
b. Setting up the surgical room
c. Scrubbing in to handle instruments
d. Maintaining patient safety
e. Documenting nursing care
ANS: B, D, E
The circulating nurse is in charge of the operating room, monitors asepsis, provides
supplies, and documents patient care. The first assistant helps the surgeon with the
procedure and the scrub nurse handles the instruments.
DIF: Cognitive Level: Knowledge REF: p. 266 OBJ: 5
TOP: Circulating Nurse KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
COMPLETION
32. A nurse discovers on the preoperative assessment that a patient has a condition that
would require increased amounts of general anesthesia. The condition is _____.
ANS:
alcoholism
Individuals who use alcohol excessively usually require greater amounts of anesthesia.
TOP: Conditions That Affect Anesthesia KEY: Nursing Process Step: Assessment
Disease

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Chapter 17: Surgical Care

4. Which technique should a nurse implement when changing a postoperative dressing?

When significant fear is associated with surgical complications, sometimes surgery is

DIF: Cognitive Level: Comprehension REF: p. 284 OBJ: 10

c. Allergies, medications, and past medical conditions

c. Pull the wound edges together and replace the dressing.

DIF: Cognitive Level: Comprehension REF: p. 267 OBJ: 6

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