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1. The post anesthesia care unit (PACU) nurse transports the inpatient surgical patient to
the medical-surgical floor. Before leaving the floor, the medical-surgical nurse obtains a
complete set of vital signs. What is the rationale for this nursing action?
a. This is done to complete the first action in a head-to-toe assessment.
b. This is done to compare and monitor for vital sign variation during transport.
c. This is done to ensure that the medical-surgical nurse checks on the postoperative
d. This is done to follow hospital policy and procedure for care of the surgical patient.
Answer: B
Before the PACU nurse leaves the acute care area, the staff nurse assuming care for the
patient takes a complete set of vital signs to compare with PACU findings. Minor vital sign
variations normally occur after transporting the patient. The PACU nurse reviews the
patient’s information with the medical-surgical nurse, including the surgical and PACU
course, physician orders, and the patient’s condition. While vital signs may or may not be
the first action in a head-to-toe assessment, this is not the rationale for this situation. While
following policy or ascertaining that the floor nurse checks on the patient are good reasons
for safe care, they are not the best rationale for obtaining vital signs.
2. The nurse is caring for a patient who will undergo a removal of a lung lobe. Which level
of care will the patient require immediately post procedure?
a. Acute care—medical-surgical unit
b. Acute care—intensive care unit
c. Ambulatory surgery
d. Ambulatory surgery—extended stay
Answer: B
Patients undergoing extensive surgery and requiring anesthesia of long duration recover
slowly. If a patient is undergoing major surgery such as a procedure on the lung, a stay in
the hospital and specifically in the intensive care unit is required to monitor for potential

risks to well-being. This patient would require more care than can be provided on a
medical-surgical unit. It is not appropriate for this type of patient to go home after the
procedure or to stay in an extended stay area of an ambulatory surgery area because of the
complexity and associated risks.
3. The nurse is caring for a group of patients. Which patient will the nurse see first?
a. A patient who had cataract surgery is coughing.
b. A patient who had vascular repair of the right leg is not doing right leg exercises.
c. A patient after knee surgery is wearing intermittent pneumatic compression devices and
receiving heparin.
d. A patient after surgery has vital signs taken every 15 minutes twice, every 30 minutes
twice, hourly for 2 hours then every 4 hours.
Answer: A
For patients who have had eye, intracranial, or spinal surgery, coughing may be
contraindicated because of the potential increase in intraocular or intracranial pressure. The
nurse will need to see this patient first to control the cough and intraocular pressure. All the
rest are normal postoperative patients. Leg exercise should not be performed on the
operative leg with vascular surgery. A patient after knee surgery should receive heparin and
be wearing intermittent pneumatic compression devices; while the nurse will check on the
patient, it does not have to be first. Monitoring vital signs after surgery is required and this
is the standard schedule.
4. The nurse demonstrates postoperative exercises for a patient. In which order will the
nurse instruct the patient to perform the exercises?
1. Turning
2. Breathing
3. Coughing
4. Leg exercises
a. 4, 1, 2, 3
b. 1, 2, 3, 4
c. 2, 3, 4, 1
d. 3, 1, 4, 2

Answer: A
The sequence of exercises is leg exercises, turning, breathing, and coughing.
1. The nurse is participating in a “time-out.” In which activities will the nurse be involved?
(Select all that apply.)
a. Verify the correct site.
b. Verify the correct patient.
c. Verify the correct procedure.
d. Perform “time-out” after surgery.
e. Perform the actual marking of the operative site.
Answer: A, B, C
A time-out is performed just before starting the procedure for final verification of the
correct patient, procedure, site, and any implants. The marking and time-out most
commonly occur in the holding area, just before the patient enters the OR. The individual
performing surgery and who is accountable for it must personally mark the site, and the
patient must be involved if possible.
2. The nurse is using a forced air warmer for a surgical patient preoperatively. Which goals
is the nurse trying to achieve? (Select all that apply.)
a. Induce shivering.
b. Reduce blood loss.
c. Induce pressure ulcers.
d. Reduce cardiac arrests.
e. Reduce surgical site infection.
Answer: B, D, E
Evidence suggests that pre-warming for a minimum of 30 minutes may reduce the
occurrence of hypothermia. Prevention of hypothermia (core temperature < 36° C) helps to

reduce complications such as shivering, cardiac arrest, blood loss, SSI, pressure ulcers, and
3. The nurse is caring for a postoperative patient with an incision. Which actions will the
nurse take to decrease wound infections? (Select all that apply.)
a. Maintain normoglycemia.
b. Use a straight razor to remove hair.
c. Provide bath and linen change daily.
d. Perform first dressing change 2 days postoperatively.
e. Perform hand hygiene before and after contact with the patient.
f. Administer antibiotics within 60 minutes before surgical incision.
Answer: A, E
Performing hand hygiene before and after contact with the patient helps to decrease the
number of microorganisms and break the chain of infection. Maintaining blood glucose
levels at less than 150 mg/dL has resulted in decreased wound infection. Removing
unwanted hair by clipping instead of shaving decreases the numbers of nicks and cuts
caused by a razor and the potential for the introduction of microbes. The patient is
postoperative; administration of an antibiotic 60 minutes before the surgical incision
supports the defense against infection preoperatively. Providing a bath and linen change
daily is positive but is not necessarily important for infection control. Many surgeons
prefer to change surgical dressings the first time so they can inspect the incisional area, but
this is done before 2 days postoperatively.

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