ATI Perioperative _ 2020 – Rasmussen College
A circulating nurse is monitoring the temperature in a surgical suite. The nurse should
identify that
... [Show More] cool temperatures reduce a client's risk for which of the following potential
complications of surgery?
malignant hyperthermia
blood clots
infection
hypoxia
Infection
The nurse should identify that a cool room temperature with humidity between 30% and
60%, along with a proper air exchange and filtering system, reduces the risk of infection
for clients during surgery.
A client had an open transverse colectomy 5 days ago. The nurse enters the client's room
and recognizes that the wound has eviscerated. After covering the wound with a sterile,
saline-soaked dressing, which of the following actions should the nurse take?
Go to the nurses station to seek assitance
Reinsert the organs into the abdominal cavity
Place the client in revere Trendelenburg position
Obtain vital signs to assess for shock
Obtain vital signs to assess for shock
The nurse should obtain vital signs to assess the client's current status.A client is transferred from the surgical suite to the PACU following oral surgery. While
monitoring the client's vital signs, the nurse finds that the client's tongue has become
swollen and is obstructing the airway. Which of the following actions should the nurse
take first?
Contact the anesthesiologist
Assist with the endotracheal intubation
Increase the clients flow of oxygen
Use the head-tilt, chin-lift method to open the airway
Use the head-tilt, chin-lift method to open the airway
The first action the nurse should take when using the airway, breathing, circulation
approach to client care is to establish a patent airway by tilting the client's head back
and pushing the lower jaw forward.
A nurse in the PACU is assessing a client who is postoperative. Which of the following
findings should the nurse report to the provider?
Blood pressure 10% lower than baseline
Pain level of 4/10
Presence of inspiratory stridor
Small amount of sanguineous drainage on dressing
Presence of inspiratory stridor
The nurse should report inspiratory stridor to the provider because it is a manifestation
of tracheal edema and requires intervention.
A nurse is assessing a client's recovery from spinal anesthesia. Which of the following
sensations should the nurse expect to return to the client first?
pain
coldtouch
warmth
Touch
Following spinal anesthesia, the first sensation the nurse should expect the client to feel
is the sense of touch.
The 2nd sensation is pain, 3rd is warmth, and 4th is cold
A nurse is assessing a client who is 2 days postoperative following a total prostatectomy.
The nurse notes that the client's right calf is red, edematous, and warm to the touch.
Which of the following actions should the nurse take?
Apply an ice pack to the clients right calf
Elevate the clients right extremity
Administer testosterone to the client
Gently massage the clients right calf
Elevate the clients right extremity
These findings suggest the client has deep-vein thrombosis. The nurse should keep the
client's right extremity elevated to promote venous return.
A nurse is assessing a client who is 2 hr postoperative following an appendectomy.
Which of the following findings should the nurse report to the provider?
Urine output of 20mL/hr
Temp of 36.5
A 2cmX2cm area bloody drainage on the dressing
WBC 9,000 mm3Urine output of 20mL/hr
The nurse should notify the provider if the client's urine output is less than 30 mL/hr.
Decreased output can indicate hypovolemia and decreased perfusion of the kidneys.
A nurse is assessing a client who is preoperative. The nurse should identify that which of
the following factors reported by the client increases the risk for a postoperative wound
infection?
Frequent use of echinacea
Long-term use of corticosteroids
History of osteoporosis
Diet high in Vit C
Long-term use of corticosteroids
The nurse should identify that the use of corticosteroids inhibits leukocyte response,
which increases the client's risk for infection.
A nurse is caring for a client who has a surgical wound with a Penrose drain in place.
Which of the following interventions should the nurse plan to perform?
Cut a slit in a 4in quake gauze pad to place around the drain
Use the sterile technique when preforming dressing changes
Establish a clamping schedule prior to remova [Show Less]
