InstructiоnsReаd eаch questiоn cаrefully.Answer each questiоn by bubbling your answer on the Scantron answer sheet.After you have finished answering all questions, select TRUE.Click Finish Attempt at the bottom of the page.On the next page, click Submit All and Finish.If a confirmation message appears, click Submit All and Finish again to complete your submission.Once your assessment has been submitted successfully, notify your proctor that you are finished. Please wait for the proctor's instructions before proceeding to the next step.Chapter 50 Key/Version B____ 1. What nursing assessment best identifies a patient’s psychological response to impending surgery? a. Ask the patient to describe feelings, concerns, and expectations about surgery c. Ask the patient to list the vital signs recorded before admission b. Ask the patient to identify preferred foods for postoperative meals d. Ask the patient to select the time for postoperative bathing ____ 2. What outcome is most directly associated with effective preoperative education? a. More realistic expectations about postoperative recovery c. Permission to resume all activities immediately b. Removal of the need for postoperative monitoring d. Complete elimination of postoperative pain ____ 3. What content should the nurse prioritize when preparing a surgical patient for continued self-care after hospitalization? a. Hospital department locations and staff schedules c. Television preferences and visiting hours b. Names of perioperative staff and hospital administrators d. Pain control, wound care, activity, exercises, and diet progression ____ 4. Which nursing action best demonstrates the postoperative phase of perioperative nursing? a. Preparing the operating environment before the procedure c. Continuing assessment to support recovery after transfer to an acute care unit b. Reviewing the patient’s previous anesthetic complications before admission d. Identifying the patient’s nutritional state before surgery ____ 5. What characteristic distinguishes phase II from phase I anesthesia recovery? a. Phase II focuses primarily on securing the airway during anesthesia emergence c. Phase II requires no assessment because immediate recovery is complete b. Phase II begins immediately when the patient leaves the operating room d. Phase II focuses on progressing the patient toward discharge or home care ____ 6. What postoperative outcome is most directly promoted when a patient begins ambulation as tolerated? a. Prevention of all postoperative complications c. Improved circulation, lung expansion, and peristalsis b. Immediate return to unrestricted physical activity d. Elimination of the need for postoperative monitoring ____ 7. What assessment finding indicates that a patient may have limited coping resources before surgery? a. The patient requests information about postoperative exercises c. The patient requests information about postoperative exercises b. The patient asks when the anesthesiologist will visit d. The patient reports difficulty managing current stressors ____ 8. What is the primary rationale for teaching postoperative leg exercises before surgery? a. To prevent all expected discomfort at the surgical site c. To replace prescribed ambulation after surgery b. To prevent all expected discomfort at the surgical site d. To maintain normal dietary intake immediately after surgery ____ 9. What finding most directly supports a patient’s progression from phase I to phase II anesthesia recovery? a. Unstable vital signs compared with preoperative and intraoperative data c. Uncontrolled nausea with impaired fluid and electrolyte balance b. Persistent airway obstruction requiring frequent intervention d. Stabilized physiological status with adequate oxygenation and orientation ____ 10. What perioperative hand-off practice most directly supports continuity and safety of patient care? a. Provide only a brief summary without discussion c. Wait until the receiving unit requests additional information b. Conduct an interactive report in person with time for questions d. Send the medical record without a verbal report ____ 11. What is the primary rationale for teaching diaphragmatic breathing, coughing, and incentive spirometry before surgery? a. To increase the patient’s tolerance for postoperative dietary advancement c. To support lung expansion and reduce pulmonary complications b. To maintain joint alignment during prolonged surgical positioning d. To prevent the need for prescribed postoperative analgesics ____ 12. What nursing action best demonstrates sound clinical judgment during an intraoperative assessment? a. . Delay communication until the patient reaches the postoperative unit c. Document only the procedure name and omit changes in patient condition b. Compare the patient’s current condition with baseline data and report unexpected changes d. Accept the expected surgical response without reviewing baseline information ____ 13. Which action is appropriate when the nurse identifies a previous latex allergic reaction in the surgical history? a. Document the history and provide a latex-free environment c. Remove the allergy information after the patient enters recovery b. Delay documentation until an allergic reaction occurs d. Place latex supplies at the bedside for rapid access ____ 14. What nursing priority has the greatest importance during the first 24 hours of postoperative recovery from general anesthesia? a. Restore the complete preoperative routine immediately c. Monitor the surgical wound without assessing other systems b. Maintain respiratory, circulatory, and neurological status d. Begin discharge planning before assessing recovery status ____ 15. Which patient factor requires focused preoperative assessment because it can increase the risk for postoperative complications? a. The patient’s preferred time for routine bathing c. The patient’s preferred hospital television channel b. The patient’s preferred meal after discharge d. A co-morbid condition affecting the patient’s surgical risk ____ 16. What principle should guide education for a surgical patient during the restorative phase of recovery? a. Use identical teaching materials for every surgical patient c. Provide routine care without requiring patient participation b. Advance teaching according to the patient’s progress toward preoperative function d. Postpone all self-care teaching until discharge day ____ 17. What preoperative teaching approach most effectively confirms a patient’s understanding of the surgical experience? a. Ask the patient to sign the teaching handout c. Ask the patient to watch a surgical video without discussion b. Ask the patient to repeat the names of hospital departments d. Ask the patient to explain expected events before and after surgery ____ 18. What sequence best represents effective instruction for a postoperative exercise? a. Ask the family to perform the exercise while the patient observes c. Provide written directions, postpone practice, and evaluate at discharge b. Explain the exercise, demonstrate it, guide practice, and use teach-back d. Demonstrate the exercise once, omit practice, and document completion ____ 19. What information belongs in the Situation component of an SBAR perioperative hand-off? a. The nurse’s interpretation of current assessment findings c. The requested action or anticipated change in care b. The patient’s immediate clinical concern or current condition d. The patient’s relevant history and recent treatment ____ 20. Which nursing activity represents the preoperative phase of perioperative nursing? a. Screening the patient for risks and organizing data before surgery c. Monitoring the patient’s response during the surgical procedure b. Evaluating the patient’s convalescence on an acute care unit d. Assessing recovery-room responses immediately after anesthesia ____ 21. What patient outcome is most directly supported by postoperative education about early mobility? a. Complete prevention of all postoperative complications c. Immediate resumption of unrestricted activity b. Removal of the need for postoperative monitoring d. Improved participation with less hospital-acquired deconditioning ____ 22. What nursing action most effectively promotes safety when early mobility is initiated? a. Require independent walking before assessing balance or weight-bearing ability c. Explain the activity plan, use appropriate assistance, and progress activity according to tolerance b. Advance the walking distance rapidly to achieve the protocol immediately d. Avoid mobility aids to encourage faster development of strength ____ 23. What information from the intraoperative hand-off enables the recovery nurse to anticipate immediate postoperative risks? a. The patient’s discharge destination without postoperative assessment findings c. The patient’s preferred television program and usual bathing schedule b. Anesthesia type, vital-sign trends, medications, fluid losses, and wound devices d. The patient’s preferred meal and planned family visitation time ____ 24. What conclusion should the nurse draw when a postoperative patient tolerates range-of-motion exercises and sitting at the bedside without concerning changes? a. The patient no longer requires monitoring during subsequent activity c. The patient can immediately ambulate independently without further assessment b. The patient should remain on bed rest until the next postoperative day d. The patient may be appropriate for gradual progression to assisted ambulation ____ 25. What information should the nurse place in the Background component of an SBAR report before transferring a patient to the operating room? a. Relevant history, diagnosis, allergies, and treatments c. The immediate concern requiring attention b. The nurse’s interpretation of current findings d. The action requested from the receiving team ____ 26. What activity most specifically characterizes the intraoperative phase of perioperative nursing? a. Teaching the patient about expected postoperative recovery c. Assessing the patient at regular intervals in the PACU b. Obtaining the patient’s initial surgical history before admission d. Maintaining patient safety during the surgical procedure ____ 27. Which assessment finding should prompt the nurse to conduct additional screening for obstructive sleep apnea before surgery? a. A history of loud snoring and repeated apnea during sleep c. A history of reading before going to sleep b. A history of awakening once during the night to void d. A history of preferring to sleep with one pillow ____ 28. What teaching method best confirms that a surgical patient understands a postoperative exercise? a. Ask the patient to watch a demonstration silently c. Ask the patient to repeat the exercise name b. Ask the patient to sign the written instructions d. Ask the patient to explain or demonstrate the exercise ____ 29. What action demonstrates the Identify step when an unfamiliar nurse gives an ISBAR hand-off? a. State the nurse’s name, location, and role in the patient’s care c. Summarize the patient’s current physiological assessment b. Request a specific intervention from the receiving nurse d. Review the patient’s relevant diagnoses and treatments ____ 30. What assessment comparison should the receiving nurse complete after a postoperative patient arrives on the inpatient unit? a. Compare the surgical dressing with the preoperative checklist c. Compare the family’s observations with the discharge instructions b. Compare the patient’s complete vital signs with the PACU findings d. Compare the patient’s meal preference with the diet order ____ 31. Which preoperative history finding most directly alerts the nurse to prepare preventive measures for a possible anesthesia-related emergency? a. Previous malignant hyperthermia during surgery c. Previous request for a quiet recovery room b. Previous preference for family visitation d. Previous mild thirst after a procedure ____ 32. What nursing priority characterizes the convalescent phase during the first 24 hours after general anesthesia? a. Maintain respiratory, circulatory, and neurological status while advancing recovery c. Resume the patient’s full preoperative routine immediately b. Focus exclusively on wound drainage and omit functional recovery d. Limit activity until discharge regardless of patient tolerance ____ 33. What teaching intervention best prepares a patient to participate in postoperative pain management? a. Tell the patient to avoid analgesics to prevent medication dependence c. Explain that pain is abnormal after every surgical procedure b. Teach pain-scale use and explain the prescribed pain-relief plan d. Instruct the patient to wait until pain becomes severe before reporting it ____ 34. What is the defining priority during phase I anesthesia recovery? a. Evaluating long-term functional status after discharge c. Close monitoring of airway, cardiovascular, fluid, temperature, and neurological b. Planning independent home activities without recovery assessment d. Advancing the diet before evaluating orientation and oxygenation ____ 35. What nursing action best supports a patient who expresses fear related to an upcoming surgical procedure? a. Tell the patient that anxiety is unnecessary before surgery c. Listen attentively and encourage the patient to express concerns b. Limit discussion until the patient arrives in the operating room d. Provide only written instructions about the surgical procedure ____ 36. Which finding is included in the preoperative component of the Munro scale? a. Type of anesthesia c. Nutritional state b. Length of the surgical procedure d. Occurrence of hemorrhage ____ 37. What postoperative benefit is most directly supported by early ambulation and prescribed exercises? a. Reduced deconditioning and improved circulation c. Elimination of the need for wound-care instruction b. Prevention of every possible postoperative complication d. Immediate restoration of unrestricted physical activity ____ 38. Which assessment tool is specifically designed to evaluate pressure-injury risk across the perioperative phases? a. Munro Pressure Ulcer Risk Assessment Scale for Perioperative Patients c. Standard Braden Scale b. Scott Triggers Risk Assessment Tool d. STOP-Bang sleep apnea assessment tool ____ 39. What is the primary purpose of assessing surgical risk factors before a procedure? a. To select the patient’s postoperative activity schedule independently c. To determine whether postoperative assessment will be necessary b. To identify risks and plan precautions that reduce perioperative complications d. To replace the physical assessment performed after surgery ____ 40. What assessment should the nurse complete before assisting a postoperative patient to ambulate for the first time? a. Assess range of motion, bed mobility, weight-bearing ability, gait, and balance c. Assess only the patient’s stated willingness to walk b. Assess only the condition of the surgical dressing d. Assess only the patient’s ability to consume a regular diet
The nurse nоtes the feet аre cооl to the touch, the skin is pаle, no notаble edema, and unable to palpate the pedal pulses bilaterally. What does the nurse suspect to be the cause of the client’s current condition?
A nurse аssesses а client's tempоrоmаndibular jоint (TMJ) and documents: "Jaw protracts and retracts easily. No pain, no crepitus. Mouth opens 1-2 in." How should this finding be interpreted?
A nurse is reviewing heаlth histоries fоr severаl clients during а cоmmunity health screening. She is identifying individuals who may be at increased risk for developing osteoporosis and may benefit from education or further screening.Which client is at the highest risk?