Question 20
Type: MCSA
The nurse is preparing a 6-year-old child for a tonsillectomy. Which strategy should the nurse use for teaching
this client?
1. Pamphlets
2. Play
3. Books
4. Videotapes
Question 21
Type: MCSA
The nurse is planning care for a client during the postoperative period. What should the nurse identify as the goal
of care for this client?
1. Provide necessary preoperative teaching.
2. Assist the client to achieve the most optimal health status possible.
3. Ensure client safety.
4. Maintain an aseptic environment.
Question 22
Type: MCMA
The nurse is planning a perioperative client’s needs upon discharge. What should be included when determining
these needs?
Standard Text: Select all that apply.
1. Client’s abilities to provide self-care
2. Date of anticipated discharge
3. Physician performing the surgery
4. Financial resources
5. Need for home health care services
Question 23
Type: MCMA
The nurse has identified the goals of maintaining client safety and homeostasis during the intraoperative phase of
client care. What nursing activities would support these goals?
Standard Text: Select all that apply.
1. Maintain the sterile field.
2. Perform instrument counts.
3. Instruct in postoperative exercises.
4. Position the client appropriately for surgery.
5. Perform preoperative skin preparation.
Question 24
Type: MCMA
A client is anxious about receiving general anesthesia for a surgical procedure. What should the nurse explain are
the advantages of having this type of anesthesia?
Standard Text: Select all that apply.
1. The client remains conscious.
2. Respiratory rate can be regulated easily.
3. It is used for minor surgical procedures.
4. The anesthesia can be adjusted to the length of the operation.
5. It focuses on a single nerve or nerve group.
Question 25
Type: MCSA
During the assessment of a client recovering from surgery, the nurse notes decreased breath sounds in both lower
lobes bilaterally. What should the nurse do?
1. Coach the client to deep-breathe and cough.
2. Restrict fluids.
3. Remind the client to perform leg exercises.
4. Maintain on bed rest.
Question 26
Type: SEQ
The nurse is preparing to change the dressing on a client’s postoperative wound. Place in order the steps the nurse
should perform when removing the soiled dressing.
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Assess the location, type, and odor of wound drainage.
Choice 2. Remove the outer dressing.
Choice 3. Discard the under dressing in a moisture-proof bag, and remove and discard gloves.
Choice 4. Remove the under dressing.
Choice 5. Apply clean gloves.
Choice 6. Place the soiled dressing in a moisture-proof bag.
Question 27
Type: MCMA
The nurse is planning to remove the sutures from a client’s surgical wound. What should the nurse do before
removing the sutures?
Standard Text: Select all that apply.
1. Apply clean gloves.
2. Verify the order for suture removal.
3. Ambulate the client to the bathroom.
4. Read the order to determine whether a dressing is to be applied after removal.
5. Remove the dressing and clean the incision.
Question 28
Type: MCSA
The nurse is evaluating the effectiveness of preoperative instruction regarding leg exercises with a client
recovering from surgery. Which observation indicates that the instructions were effective?
1. The lower extremity is swollen and hot to touch.
2. The vein feels hard.
3. There is no cramping or pain with ambulation.
4. There is pain in the calf with dorsiflexion.
Question 29
Type: MCSA
The nurse determines that interventions to prevent postoperative constipation have been effective in a client
recovering from surgery. What did the nurse assess to make this clinical decision?
1. Abdominal distention present.
2. Gas pains present.
3. Client vomiting.
4. Bowel movement occurred 24 hours after resuming a normal diet.
Question 30
Type: MCMA
The nurse is caring for a postoperative client with an abdominal wound and a drain. What can the nurse delegate
to unlicensed assistive personnel?
Standard Text: Select all that apply.
1. Clean the wound.
2. Assess the skin around the wound.
3. Determine the effectiveness of pain medication.
4. Report if the dressing is soiled.
5. Report if the dressing is loose.
Question 31
Type: MCMA
The nurse is preparing to instruct a client on leg exercises to be used when recovering from abdominal surgery.
What should the nurse determine before beginning this teaching?
Standard Text: Select all that apply.
1. Type of surgery
2. Time of surgery
3. Postoperative diet
4. Preoperative orders
5. Name of the surgeon
Question 32
Type: MCMA
The nurse has removed the sutures from a client’s surgical wound. What should the nurse document about this
procedure?
Standard Text: Select all that apply.
1. Number of sutures removed
2. Appearance of the incision
3. Client teaching
4. Client tolerance of the procedure
5. Name of the surgeon.
Question 33
Type: MCMA
A client in the postanesthesia care unit is to have suction applied through a nasogastric tube. When documenting,
the nurse should include which information?
Standard Text: Select all that apply.
1. The time suction was started
2. Characteristics of wound drainage
3. Pressure on the suction
4. Integrity of the surgical dressing
5. Color and consistency of drainage
Question 34
Type: MCMA
The nurse is completing a preoperative assessment with a client. What should this assessment include?
Standard Text: Select all that apply.
1. Current health status
2. Allergies
3. Current medications
4. Mental status
5. Respiratory rate
Question 35
Type: MCMA
A client is scheduled for lung resection surgery. What should the nurse keep in mind when determining this
client’s degree of risk for this major surgical procedure?
Standard Text: Select all that apply.
1. Age
2. Medications
3. General health
4. Blood pressure
5. Nutritional status
