Perioperative Nursing 001
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1.) Which of the following is most dangerous
complication during induction of spinal
anesthesia?
A.)Tachycardia
B.)Hypotension
C.)Hyperthermia
D.)Bradypnea
Ans: B
2.) Which type of surgery is most likely to
predispose a patient to postoperative
atelectasis, pneumonia or respiratory
failure?
A.)Upper abdominal surgery on an obese
patient with a long history of smoking
B.)Upper abdominal surgery on a patient
with normal pulmonary function
C.)Lower abdominal surgery on a young
patient with diabetes mellitus
D.)Surgery on the extremities of a
nonsmoking football player
Ans: A
3.) Which of the following characterizes
excitement stage of anesthesia
A.) Occurs from the administration of
anesthesia to the loss of consciousness
B.) Extends from the loss of consciousness
to the loss of lid reflex, characterized by
struggling and talking
C.) From the loss of lid reflex to the loss of
most reflexes
D.) From the loss of most reflexes to
respiratory and circulatory failure
Ans: B
4.) To prevent headache after spinal
anesthesia the patient should be positioned:
A.) Semi-fowler’s
B.) Flat on bed for 6 to 8 hours
C.) Prone position
D.) Modified trendelenburg
Ans: B
5.) Which of the following nursing actions
should be given highest priority when
admitting the patient into the operating
A.) Level of consciousness
B.) Vital signs
C.) Patient identification and correct
operative consent
D.) Positioning and skin preparation
Ans: C
6.) What is the primary reason for the gradual
change of position of the patient after
surgery?
A.) To prevent muscle injury
B.) To prevent sudden drop of BP
C.) To prevent respiratory distress
D.) To promote comfort
Ans: B
7.) Which of the following assessment data is
most important to determine when caring for
a patient who has received spinal
anesthesia?
A.) The time of return of motion and
sensation in the legs and toes
B.) The character of respiration
C.) Level of consciousness
D.) Amount of wound drainage
Ans: A
8.) Which of the following postop findings
should the nurse report to the M.D.?
A.) The patient pushes out the oral airway wit
h his tounge
B.) Urine output is 20ml/hr for the past two
hours
C.) VS are as follows:
BP=110/70;PR=95;RR=19,Temp=36.8C
D.) Wound drainage is serosanguinous
Ans: B
9.) Which of the following is the earliest sign
of poor respiratory function?
A.) Cyanosis
B.) Fast thready pulse
C.) Restlessness
D.) Faintness
Ans: C
10.) If wound eviscerations occurs, the
immediate nursing action is:
A.) Cover the wound with sterile gauze
moistened with sterile NSS
B.) Cover the wound with water-soaked
gauze
C.) Cover the wound with sterile dry gauze
D.) Leave the wound uncovered and pull the
skin edges together
Ans: A
11.) Appendectomy is classified as
A.) Ablative
B.) Constructive
C.) Reconstructive
D.) Palliative
Ans: A
12.) The worst of all fears among clients
undergoing surgery is:
A.) Fear of financial burden
B.) Fear of death
C.) Fear of the unknown
D.) Fear of loss of job
Ans: C
13.) The best time to provide preoperative
teaching on deep breathing, coughing and
turning exercises is:
A.) Before administration of preoperative
medications
B.) The afternoon or evening prior to surgery
C.) Several days prior to surgery
D.) Upon admission of the client in the
recovery room
Ans: B
14.) The following are the appropriate
nursing actions before administration of
preoperative medications EXCEPT:
A.) Ascertain the consent has been signed
B.) Ensure that NPO has been maintained
C.) Instruct patient to empty his bladder
D.) Shave the skin at the site of surgery
Ans: D
15.) The patient has been observed pacing
along the hallway, goes to the bathroom
frequently and asks questions repeatedly
during preoperative assessment. The most
likely cause of the behavior is:
A.) She is anxious about the surgical
procedure
B.) She is worried about separation from the
family
C.) She has urinary tract infection
D.) She has an underlying emotional problem
Ans: A
16.) Which of the following nursing actions
would help the patient decrease anxiety
during the preoperative period?
A.) Explaining all procedures thoroughly in
chronological order
B.) Spending time listening to the patient and
answering questions
C.) Encouraging sleep and limiting
interruptions
D.) Reassuring the patient that the surgical
staff are competent professional
Ans: B
17.) Which of the following is the primary
purpose of maintaining NPO for 6 to 8 hours
before surgery?
A.) To prevent malnutrition
B.) To prevent electrolyte imbalance
C.) To prevent aspiration pneumonia
D.) To prevent intestinal obstruction
Ans: C
18.) The following ensure validity of informed
written consent EXCEPT:
A.) The patient is of legal age with proper
mental disposition
B.) The consent has been secured within 24
hours before the surgery
C.) If the patient is unable to write, secure the
consent from a relative
D.) The consent is secured before
administration of any medication that alter
the level of consciousness
Ans: C
19.) Which of the following drugs is
administered to minimize respiratory
secretions preop?
A.) Valium (Diazepam)
B.) Nubain ( Nalbuphine HCL)
C.) Phenergan (Promethazine)
D.) Atropine Sulfate
Ans: D
20.) Which of the following is experienced by
the patient who is under spinal anesthesia?
A.) The patient is unconscious
B.) The patient is awake
C.) The patient experiences amnesia
D.) The patient experiences total loss of
sensation
Ans: B
21.) The patient who has undergone TAHBSO
complains of pain. Which of the following is
an initial nursing action?
A.) Administer the PRN analgesics
B.) Instruct to do deep breathing exercises
C.) Assess the VS
D.) Change the patient’s position
Ans: C
22.) How frequent should the nurse monitor
the VS of the patient in the recovery room?
A.) Every 15 minutes
B.) Every 30 mins
C.) Every 45 mins
D.) Every 60 mins
Ans: A
23.) Which of the following drugs is given to
relieve nausea and vomiting?
A.) Mepivacaine
B.) Aquamephyton
C.) Nubain
D.) Plasil
Ans: D
24.) The most important factor in the
prevention of postop infection is:
A.) Proper administration of antibiotics
B.) Fluid intake of 2-3L/day
C.) Practice of strict aseptic techniques
D.) Frequent change of wound dressings
Ans: C
25.) Which of the following primarily
prevents postop complications?
A.) Adequate fluid intake
B.) Early ambulation
C.) Well-balanced diet
D.) Administration of antimicrobials
Ans: B
Situation: A female client, 23 y/o was
admitted for the first time at the Fatima
Hospital with the chief complaint of Right
Iliac Pain, accompanied by nausea and
vomiting, chills and fever. She was
diagnosed to have acute appendicitis. She
was scheduled to have emergency
appendectomy under spinal anesthesia
26.) Pre-op instructions to the client would
include the following EXCEPT:
A.) Deep breathing and coughing exercise
B.) Turning to sides
C.) Foot and leg exercises
D.) reassuring her that narcotics will be
given every 4 hours round the clock until she
is discharged
Ans: D
27.) The client gave her consent for the
surgery. To ensure the legality of the
consent, the following conditions must be
met EXCEPT:
A.) She gave her consent freely
B.) She must understand the nature of the
surgery
C.) The consent must be signed by a witness
D.) Signing should be done after the
administration of pre-anesthesia meds
Ans: D
28.) The skin is shaved prior to surgery in
order to:
A.) Facilitate skin incision
B.) Indicate the site to be draped
C.) To prevent wound infection
D.) Reduce post op scarring
Ans: C
29.) The important nursing intervention prior
to administration of pre-anesthetic
medication is:
A.) Ask patient to empty the bladder
B.) Do deep breathing and coughing
exercises
C.) Regulate IVF accurately
D.) Shave the skin
Ans: A
30.) Immediately following spinal anesthesia,
the greatest risk is:
A.) Severe hemorrhage
B.) Severe Hypotension
C.) Severe Hypoglycemia
D.) Hypertensive crisis
Ans: B
31.) Nursing measures to promote the
client’s respiratory function during recovery
from anesthesia are the following EXCEPT:
A.) Encourages deep breathing and
coughing exercises
B.) Administer Humidified oxygen
C.) Place in semi-fowlers position
D.) Place in supine position with head turned
to the side without pillow support
Ans: C
32.) Which of the following criteria must be
met before the client is released from the RR
to the unit.
A.) Breathes with ease, coughs freely
B.) Has regained consciousness
C.) Vital signs fluctuates erratically
D.) Able to move four extremities
Ans: C
33.) Early signs of poor respiratory function
include which of the following
A.) Cyanosis
B.) Hypotension
C.) Loss of consciousness
D.) Restlessness
Ans: D
34.) Post operatively, the client must be
encouraged to turn, cough and deep breathe:
A.) Every 1-2 hours
B.) Every 4 hours
C.) Every 30 Mins
D.) Every 8 hours
Ans: A
35.) A client in shock must be placed in:
A.) High-fowlers position
B.) Sim’s position
C.) Modified trendelenburg
D.) Prone position
Ans: C
36.) The most important factor in the
prevention of post op wound infection is:
A.) Adequate fluid intake
B.) Proper administration of antibiotics
C.) Practice of strict aseptic technique
D.) Frequent cleaning of the wound
Ans: C
37.) When the patient vomits, the most
important nursing objective is to prevent:
A.) Dehydration
B.) Aspiration
C.) Rupture of suture line
D.) Met. Alkalosis
Ans: B
38.) Post operatively, a patient is expected to
void after:
A.) 6-8 hours
B.) 2-4 hours
C.) 12-24 hours
D.) 10-12 hours
Ans: A
39.) Headache after spinal anesthesia is due
to:
A.) Paralysis of vasomotor nerves
B.) Traction placed on structures within
abdomen
C.) Loss of CSF through dural hole
D.) Administration of large amounts and
heavy concentration of anesthetic agents
Ans: C
40.) Nursing measures for post-op
thrombophlebitis include the following
EXCEPT:
A.) Maintain bedrest
B.) Elevate affected leg with pillow support
C.) Massage the painful extremities
D.) Apply antiembolic stockings
Ans: C
41.) Nursing measures to relieve hiccups
include the following EXCEPT:
A.) Exhale and inhale through a paper bag
B.) Apply pressure over the eyeball through
closed eye lids
C.) Hold breath while taking a large pulp of
water
D.) Administer high concentration of oxygen
Ans: D
42.) Modified radical mastectomy involves:
A.) Removal of the entire breast, axillary
lymph nodes, pectoralis muscle
B.) Removal of the lump of the breast
C.) Removal of the entire breast, axillary and
neck lymph nodes, including pectoralis
muscles
D.) Removal of the entire breast but nipple
remains intact
Ans: A
43.) Which of the following is not appropriate
nursing intervention after modified radical
mastectomy?
A.) Place in semi fowler’s position and
elevate arm on the affected side with pillow
support
B.) Check behind the client for bleeding
C.) Monitor output from wound suction
drainage
D.) Immobilize the arm on affected side in
adduction
Ans: D
44.) A fluid challenge is begun with a post-op
gastric surgery client. Which assessment will
give the best indication of client response to
this treatment?
A.) CVP readings and hourly urine output
B.) Blood pressure and apical rate checks
C.) Lung sounds and arterial blood gases
D.) Electrolytes, BUN, creatinine results
Ans: A
45.) A client is scheduled for a subtotal
gastrectomy. In anticipation of clarifying
information for client education, the nurse
knows that vagotomy is done as part of the
surgical treatment for peptic ulcers in order
to
A.) Decrease secretion of hydrochloric acid
B.) Improve the tone of the GI muscles
C.) Increase blood supply to the jejunum
D.) Prevent the transmission of pain
impulses
Ans: A
46.) Which of the following facts best
explains why the duodenum is not removed
during a subtotal gastrectomy?
A.) The head of the pancreas is adherent to
the duodenal wall
B.) The common bile duct empties into the
duodenal lumen
C.) The wall of the jejunum contains no
intestinal villi
D.) The jejunum receives its blood supply
through the duodenum
Ans: B
47.) During the immediate postoperative
period following gastric surgery, why must
the nurse be particularly conscientious
about encouraging a client to cough and
deep-breathe at regular intervals?
A.) Marked changes in intrathoracic pressure
will stimulate gastric drainage
B.) The high abdominal incision will lead to
shallow breathing to avoid pain
C.) The phrenic nerve will have been
permanently damaged during the surgical
procedure
D.) Deep-breathing will prevent post op
vomiting and intestinal distention
Ans: B
48.) Prior to having a subtotal gastrectomy, a
client is told about the dumping syndrome.
The nurse explains that it is:
A.) The body’s absorption of toxins produced
by liquefaction of dead tissue
B.) Formation of an ulcer at the margin of the
gastrojejunal anastomosis
C.) Obstruction of venous flow from the
stomach into the portal system
D.) Rapid emptying of food and fluid from the
stomach into the jejunum
Ans: D
49.) Which of the following statements by a
client recovering from a subtotal
gastrectomy would indicate a need for
additional teaching about the diet protocol
for dumping syndrome?
A.) “I plan to eat a diet low in carbohydrates
and high in protein and fat”
B.) “I plan to eat a diet high in CHO and low
in CHON and fat”
C.) “I will eat slowly and avoid drinking fluids
during meals”
D.) “I will try to assume a recumbent position
after meals for 30 mins to 1 hour to enhance
digestion and relieve symptoms
Ans: B
50.) A 40 y/o female client has arrived in the
post anesthesia room following a
cholecystectomy and a common bile duct
exploration. She is semi conscious. Her vital
signs are within normal limits. Which of the
following nursing actions would be
inappropriate?
A.) Apply a warm blanket to her body
B.) Place her in a semi-fowler’s position
C.) Attached her T-tube to gravity drainage
D.) Set up low, intermittent suction for her
NGT

Ans: B