Choice A reason:

Ablative surgery is a type of surgery that removes a diseased or abnormal body part, such as a tumor, an appendix, or a tonsil. It does not restore function to a body part, but rather eliminates the source of a problem.

Choice B reason:

Diagnostic surgery is a type of surgery that is done to confirm or rule out a diagnosis, such as a biopsy, an endoscopy, or a laparoscopy. It does not restore function to a body part, but rather provides information for further treatment.

Choice C reason:

Palliative surgery is a type of surgery that is done to relieve symptoms or improve quality of life, such as a colostomy, a shunt, or a nerve block. It does not restore function to a body part, but rather reduces pain or discomfort.

Choice D reason:

Reconstructive surgery is a type of surgery that is done to restore function to a body part that has been damaged by trauma, disease, or congenital defect, such as a skin graft, a breast reconstruction, or a cleft lip repair. This is the correct answer because it matches the definition given by the nurse.

Choice A reason:

Emergency surgery is not the correct answer because this type of surgery is done for an urgent medical condition that may be life threatening, such as acute appendicitis or trauma. Rectal polyps are not an immediate threat to life, limb or organ survival.

Choice B reason:

Urgent surgery is not the correct answer because this type of surgery is done for a condition that requires intervention within hours of decision to operate, such as debridement of fracture or laparotomy for perforation. Rectal polyps do not require such a rapid intervention.

Choice C reason:

Elective surgery is the correct answer because this type of surgery is planned or booked in advance of routine admission to hospital. It may be done for a better quality of life or for a serious condition such as cancer, but not for a life-threatening condition. Rectal polyps fall under this category as they can be scheduled in advance and may be precancerous or cancerous.

Choice D reason:

Optional surgery is not the correct answer because this term is not commonly used to classify surgery by degree of urgency. It may imply that the surgery is not medically necessary, but rather a personal preference, such as cosmetic surgery. Rectal polyps are not optional as they may cause symptoms or complications if left untreated.

Choice E reason:

Routine surgery is not the correct answer because this term is also not commonly used to classify surgery by degree of urgency. It may imply that the surgery is done frequently or regularly, such as cataract surgery or tonsillectomy. Rectal polyps are not routine as they vary in size, number and location.

Choice A reason:

This is the correct answer because the preoperative phase is the period when the nurse prepares the client for surgery and provides education and support. The preoperative phase begins with the decision to have surgery and ends when the client is transferred to the operating room. The nurse assesses the client's health status, identifies potential risks, and plans for the care before surgery.

Choice B reason:

This is incorrect because the intraoperative phase is the period when the nurse monitors the client's vital signs, administers medications, and assists the surgical team during surgery. The intraoperative phase begins when the client is transferred to the operating room and ends when the client is transferred to the postanesthesia care unit (PACU).

Choice C reason:

This is incorrect because the postoperative phase is the period when the nurse evaluates the client's recovery, manages the pain, and prevents complications after surgery. The postoperative phase begins when the client is transferred to the PACU and ends when the client is discharged from the hospital or clinic.

Choice D reason:

This is incorrect because the perioperative phase is not a specific phase but a general term that encompasses all three phases of perioperative nursing: preoperative, intraoperative, and postoperative. The perioperative phase refers to the entire surgical process from preparation to recovery.

Choice A reason:

The standards and guidelines set by the Association of periOperative Registered Nurses (AORN) are based on "the best available evidence from research and expert opinion” This means that the perioperative nursing practice is informed by the most current and reliable sources of knowledge that support quality and safety in the operating room. The AORN guidelines for perioperative practice are the gold-standard in evidence-based recommendations to deliver safe perioperative patient care and achieve workplace safety.

Choice B reason:

The standards and guidelines set by the AORN are not based on "the preferences and values of individual surgeons and nurses” because this would not ensure consistency, quality, or safety in the perioperative nursing practice. The preferences and values of individual practitioners may vary widely and may not reflect the best available evidence or the needs of the patients. Therefore, this choice is incorrect.

Choice C reason:

The standards and guidelines set by the AORN are not based on "the policies and procedures of each health care facility” because this would not ensure uniformity, quality, or safety in the perioperative nursing practice. The policies and procedures of each health care facility may differ depending on their resources, regulations, or goals. They may also be outdated or incomplete. Therefore, this choice is incorrect.

Choice D reason:

The standards and guidelines set by the AORN are not based on "the feedback and satisfaction of patients and families” because this would not ensure validity, quality, or safety in the perioperative nursing practice. The feedback and satisfaction of patients and families may be subjective, biased, or inaccurate. They may also not reflect the best available evidence or the professional standards of nursing. Therefore, this choice is incorrect.

E. Transplant.

Choice A reason:

Ablative surgery is done to remove a diseased or damaged body part, such as an appendix or a tumor. A kidney transplant does not involve removing the original kidney, but adding a new one from a donor.

Choice B reason:

Diagnostic surgery is done to establish or aid a diagnosis, such as taking a biopsy of a suspicious lump. A kidney transplant is not done for diagnostic purposes, but to treat a condition of kidney failure.

Choice C reason:

Palliative surgery is done to relieve symptoms or improve quality of life, but not to cure the underlying disease, such as removing a part of a cancerous organ that causes pain. A kidney transplant is done to cure the condition of kidney failure and restore normal kidney function.

Choice D reason:

Reconstructive surgery is done to restore the appearance or function of a body part that has been damaged by trauma, disease, or birth defect, such as repairing a cleft lip or a burn. A kidney transplant does not involve reconstructing the original kidney, but replacing it with a new one from a donor.

Choice E reason:

Transplant surgery is done to replace a failing or diseased organ with a healthy one from a donor, such as a kidney, liver, or heart. A kidney transplant is done when the original kidney can no longer function properly and causes life-threatening complications.

Choice F reason:

Procurement surgery is done to remove an organ or tissue from a donor for transplantation into another person, such as harvesting a kidney, cornea, or bone marrow. Procurement surgery is not done on the recipient of the transplant, but on the donor.

Informed consent

Preoperative Nursing intervention

Choice A reason:

Incorrect. Explaining the benefits and risks of the surgery to the client is not the nurse's responsibility, but the surgeon's. The nurse should verify that the surgeon has explained these to the client before obtaining the consent.

Choice B reason:

Incorrect. Verifying that the client's signature matches the one on the medical record is not a necessary action for the nurse to take. The nurse should witness the client's signature and confirm that the client is competent and consenting voluntarily.

Choice C reason:

Correct. Ensuring that the surgeon has answered all of the client's questions is an important action for the nurse to take. The nurse should clarify any doubts or concerns that the client might have about the surgery and reinforce the information provided by the surgeon.

Choice D reason:

Incorrect. Documenting the client's level of anxiety and coping strategies is a helpful action for the nurse to take, but it is not directly related to the informed consent process. The nurse should assess the client's emotional state and provide support as needed, but this does not affect the validity of the consent.

Choice A reason:

Hemoglobin and hematocrit are blood tests that measure the amount of red blood cells in the blood. These tests are commonly done before surgery to check for anemia, which is a low level of red blood cells. Anemia can increase the risk of bleeding and infection during and after surgery.

Choice B reason:

Blood glucose is a blood test that measures the amount of sugar in the blood. This test is commonly done before surgery to check for diabetes, which is a high level of sugar in the blood. Diabetes can affect wound healing and increase the risk of infection and complications during and after surgery.

Choice C reason:

Blood urea nitrogen and creatinine are blood tests that measure the function of the kidneys. These tests are commonly done before surgery to check for kidney disease, which is a low function of the kidneys. Kidney disease can affect the metabolism and elimination of drugs used during and after surgery, and increase the risk of fluid and electrolyte imbalances.

Choice D reason:

Thyroid stimulating hormone is a blood test that measures the function of the thyroid gland. This test is not commonly done before surgery unless there is a specific indication, such as a history of thyroid disease or symptoms of thyroid dysfunction. Thyroid disease can affect the heart rate, blood pressure, and temperature regulation during and after surgery.

Choice E reason:

Prothrombin time and international normalized ratio are blood tests that measure the clotting ability of the blood. These tests are commonly done before surgery to check for bleeding disorders, such as hemophilia or liver disease, or to monitor the effect of anticoagulant drugs, such as warfarin or heparin. Bleeding disorders and anticoagulant drugs can increase the risk of bleeding and hematoma formation during and after surgery.

Choice A reason:

This is incorrect because the nurse should encourage the client to ask questions to the surgeon, as it may help reduce anxiety and increase understanding of the procedure.

Choice B reason:

This is correct because the nurse should suggest the client to bring some personal items, such as music or a book, to help them relax before the surgery. This can provide distraction and comfort for the client who is anxious.

Choice C reason:

This is incorrect because the nurse should not make false reassurances or promises to the client, as it may undermine trust and credibility. The nurse should explain the risks and benefits of general anesthesia and how pain will be managed after the surgery.

Choice D reason:

This is incorrect because the nurse should not focus on the negative outcomes of eating or drinking before surgery, as it may increase anxiety and fear. The nurse should explain the rationale for fasting before surgery, such as preventing aspiration and reducing nausea and vomiting.

Choice A reason:

A heart rate of 72 beats per minute is within the normal range of 60 to 100 beats per minute for an adult. Therefore, this finding does not need to be reported to the surgeon.

Choice B reason:

A temperature of 37.2°C (99°F) is slightly elevated but not considered a fever. A fever is usually defined as a temperature of 38°C (100.4°F) or higher. Therefore, this finding does not need to be reported to the surgeon.

Choice C reason:

A blood pressure of 160/90 mm Hg is considered high and indicates hypertension. High blood pressure before surgery can increase the risk of complications such as heart attack, stroke, or kidney problems. Therefore, this finding should be reported to the surgeon.

Choice D reason:

A respiratory rate of 16 breaths per minute is within the normal range of 12 to 20 breaths per minute for an adult. Therefore, this finding does not need to be reported to the surgeon.

B. Apply sequential compression devices to prevent deep vein thrombosis.

Choice A reason:

Administering an anticholinergic medication to reduce secretions is not a necessary intervention for a client who will undergo surgery. Anticholinergic medications are used to block the action of acetylcholine, a neurotransmitter that stimulates the production of saliva, mucus, and other secretions. Anticholinergics can be used in certain surgical and emergency procedures to help relax the client, decrease salivation, and prevent nausea and vomiting. However, they are not routinely given to all clients who will undergo surgery, and they have side effects such as dry mouth, blurred vision, constipation, and urinary retention. Therefore, this choice is incorrect.

Choice B reason:

Applying sequential compression devices to prevent deep vein thrombosis is a correct intervention for a client who will undergo surgery. Sequential compression devices are pneumatic cuffs that inflate and deflate around the legs to improve blood circulation and prevent blood clots from forming in the deep veins of the lower extremities. Deep vein thrombosis (DVT) is a serious complication that can occur after surgery, especially in clients who are immobile, dehydrated, or have a history of clotting disorders. DVT can lead to pulmonary embolism, which is a life-threatening condition where a blood clot travels to the lungs and blocks the blood flow. Therefore, this choice is correct.

Choice C reason:

Shaving the surgical site with a razor to prevent infection is not a correct intervention for a client who will undergo surgery. Shaving the surgical site with a razor can cause skin irritation, abrasions, and micro-cuts that increase the risk of infection. The current recommendation is to use clippers or depilatory creams to remove hair from the surgical site if necessary. Alternatively, hair can be left intact if it does not interfere with the surgical procedure. Therefore, this choice is incorrect.

Choice D reason:

Inserting a nasogastric tube to decompress the stomach is not a routine intervention for a client who will undergo surgery. A nasogastric tube is a flexible tube that is inserted through the nose and into the stomach to remove gas, fluid, or stomach contents. Nasogastric tubes can be used in some surgical procedures to prevent nausea, vomiting, aspiration, or abdominal distension. However, they are not indicated for all types of surgery, and they have risks such as nasal bleeding, throat irritation, sinusitis, and esophageal perforation. Therefore, this choice is incorrect.

Choice A reason:

This is incorrect because the supine position does not allow optimal exposure of the abdominal cavity. The supine position is used for surgeries involving the anterior surface of the body, such as cardiac, thoracic, and cranial surgeries. For abdominal surgeries, other positions such as Trendelenburg or lithotomy may be used to improve access and visualization of the abdominal organs.

Choice B reason:

This is incorrect because the supine position does not prevent injury to the spinal cord and nerves. In fact, the supine position may cause nerve damage or pressure ulcers if the patient's arms, legs, and head are not properly supported and padded. The patient's arms should be abducted less than 90 degrees and the palms should face up to avoid stretching or compressing the brachial plexus and ulnar nerves. The patient's legs should be uncrossed and the heels should be padded to prevent pressure on the peroneal nerve and the skin. The patient's head should rest on a pad or pillow and the neck should be in a neutral position to avoid injury to the cervical spine and nerves.

Choice C reason:

This is correct because the supine position facilitates drainage of secretions from the mouth and throat. The supine position is commonly used during induction and emergence of anesthesia, which can impair the patient's ability to clear their airway. By lying on their back with their face up, the patient can benefit from gravity-assisted drainage of secretions from the mouth and throat, reducing the risk of aspiration or airway obstruction.

Choice D reason:

This is incorrect because the supine position does not enhance circulation and oxygenation to the brain. The supine position may actually decrease the functional residual capacity (FRC) of the lungs, which is the amount of air remaining in the lungs after a normal expiration. This can lead to reduced oxygenation and ventilation of the blood. Additionally, the supine position may cause venous congestion in the head and neck, which can impair cerebral perfusion and increase intracranial pressure. To enhance circulation and oxygenation to the brain, other positions such as reverse Trendelenburg or sitting may be used.

Choice A reason:

Assisting with surgical procedures is not a function of the circulating nurse, but of the scrub nurse or the surgical assistant. The circulating nurse is responsible for coordinating the care of the patient in the operating room and ensuring a safe environment.

Choice B reason:

Counting instruments and sponges is a function of both the scrub nurse and the circulating nurse. They work together to ensure that no foreign objects are left inside the patient or on the sterile field.

Choice C reason:

Documenting events and interventions is a function of the circulating nurse. The circulating nurse records all relevant information about the patient's condition, the surgical procedure, the anesthesia administration, and any specimens collected.

Choice D reason:

Administering anesthesia and monitoring vital signs is not a function of the circulating nurse, but of the anesthesia care provider (ACP). The ACP is responsible for assessing the patient's health status, selecting and administering the appropriate anesthetic agent, and monitoring the patient's response to anesthesia.

Choice E reason:

Maintaining surgical asepsis and sterile technique is a function of both the scrub nurse and the circulating nurse. The scrub nurse maintains a sterile field by wearing sterile attire, handling sterile instruments and supplies, and preventing contamination. The circulating nurse maintains asepsis by monitoring the sterile field, checking for breaks in technique, and obtaining additional items as needed.

Choice A reason:

This is the correct definition of general anesthesia, which is a state of controlled unconsciousness, pain relief, memory loss and muscle relaxation that is induced by a combination of medications. It is used for surgical procedures where it is safer or more comfortable to be unaware and not feel pain.

Choice B reason:

This is the definition of regional anesthesia, which is a state of reduced sensation, awareness and movement in a large area of your body such as the lower half or an arm. It is used for surgical procedures that involve a specific region of the body and do not require complete unconsciousness.

Choice C reason:

This is the definition of local anesthesia, which is a state of numbness, tingling and loss of feeling in a small area of your skin such as a finger or a tooth. It is used for minor surgical procedures that involve only a small part of the body and do not require deep pain relief or unconsciousness.

Choice D reason:

This is not a correct definition of any type of anesthesia, but rather a description of natural sleep. General anesthesia is different from sleep because it involves a complete loss of awareness and responsiveness to any stimuli, whereas sleep involves periodic changes in brain activity and responsiveness to certain stimuli such as sounds or light. General anesthesia also requires artificial maintenance of vital functions such as breathing and blood pressure, whereas sleep does not.

Choice A reason:

This is incorrect because the Trendelenburg position does not improve blood pressure or blood flow to the brain. In fact, it may increase intracranial pressure and reduce cerebral perfusion.

Choice B reason:

This is incorrect because the Trendelenburg position does not reduce the risk of bleeding or infection in the lower abdomen or pelvis. It may increase the risk of aspiration, respiratory compromise, and venous congestion.

Choice C reason:

This is incorrect because the Trendelenburg position does not prevent pressure ulcers or nerve damage in the back and legs. It may cause nerve injury due to stretching of the brachial plexus and pressure on the peroneal nerve.

Choice D reason:

This is correct because the Trendelenburg position helps to increase the space and visibility in the upper abdomen or chest by displacing the abdominal organs downward. This may facilitate surgical procedures such as cholecystectomy, hiatal hernia repair, or thoracic surgery.

Choice A reason:

Preparing the surgical instruments and equipment is one of the tasks that the CST performs, but it is not the only one. According to the Mayo Clinic, surgical technologists also assist during and after surgical procedures by passing tools, holding retractors, cutting suture, applying dressings, and counting materials. Therefore, choice A is incomplete and not the best answer.

Choice B reason:

Providing emotional support and education to the patient is not a task that the CST performs. This is usually done by the registered nurse (RN) or the anesthesia care provider before the surgery. The CST does not interact with the patient directly, but rather focuses on preparing and maintaining a sterile environment in the operating room. Therefore, choice B is incorrect.

Choice C reason:

Monitoring the patient's vital signs and oxygen saturation is not a task that the CST performs. This is usually done by the anesthesia care provider or the perioperative nurse during the surgery. The CST does not monitor the patient's condition, but rather assists the surgeon and other members of the surgical team. Therefore, choice C is incorrect.

Choice D reason:

Applying sterile drapes and handing instruments to the surgeon are both tasks that the CST performs. According to WebMD, these are part of the intraoperative duties of the CST, along with keeping the operating room sterile, assisting in retracting tissues, and suctioning and sponging. Therefore, choice D is correct and covers two of the main tasks that the CST performs.

Choice A reason:

Placing a grounding pad on the patient's skin near the surgical site is the correct action to prevent burns to the patient during electrocautery. The grounding pad provides a low-current-density pathway for the high-frequency cautery current to return to the electrosurgical unit, thus avoiding injury to other body areas.

Choice B reason:

Applying petroleum jelly to the patient's skin around the surgical site is not a correct action to prevent burns to the patient during electrocautery. Petroleum jelly is flammable and can ignite during electrocautery, causing fire and thermal injury to the patient.

Choice C reason:

Covering the patient's hair with a wet towel is not a correct action to prevent burns to the patient during electrocautery. A wet towel can create a conductive pathway for the cautery current to flow through, resulting in burns or shocks to the patient or the staff.

Choice D reason:

Removing any metal jewelry from the patient is a correct action to prevent burns to the patient during electrocautery, but it is not sufficient by itself. Metal jewelry can cause electrical arcing or heating, leading to skin burns or fire hazards. However, removing metal jewelry alone does not ensure a safe return pathway for the cautery current, which requires a grounding pad as well.

Choice A reason:

Using a standardized counting method and sequence for each procedure helps to ensure consistency and accuracy in the counting process. It also reduces the risk of confusion or miscommunication among the surgical team members. This is a recommended standard of practice by the Association of Surgical Technologists (AST).

Choice B reason:

Separating sponges into groups of five or ten and counting them as one unit helps to facilitate counting and prevent foreign body retention. It also allows for easier identification of missing sponges in case of an incorrect count. This is another recommended standard of practice by the AST.

Choice C reason:

Keeping instruments and supplies on separate trays according to their function does not necessarily facilitate counting or prevent foreign body retention. It may help to organize the surgical field, but it does not address the issue of counting or documenting the items used during the procedure. Therefore, this is not a correct answer.

Choice D reason:

Using a white board or paper to record the counts and update them as needed helps to facilitate counting and prevent foreign body retention. It provides a visual reference for the surgical team members and allows for easy verification of the counts at any time during the procedure. It also helps to document any discrepancies or changes in the counts. This is another recommended standard of practice by the AST.

Choice E reason:

Discarding any unused items before the final count does not facilitate counting or prevent foreign body retention. It may actually increase the risk of losing track of the items used during the procedure or leaving some items inside the patient. Therefore, this is not a correct answer.

Choice A reason:

This is incorrect because a curved needle with a cutting edge is used for general closure of skin, subcutaneous tissue, and other tissues that are tough or difficult to penetrate A cutting edge needle has a triangular point that can cause more tissue damage and scarring than a tapered point needle.

Choice B reason:

This is incorrect because a straight needle with a tapered point is used for easily accessible tissues, such as mucous membranes, gastrointestinal tract, or blood vessels A tapered point needle has a round body that gradually tapers to a point, allowing it to pierce through tissues without cutting them.

Choice C reason:

This is correct because a half-circle needle with a reverse cutting edge is used for suturing at sites that have limited space and require precise placement of stitches, such as ophthalmic, plastic, or cardiovascular surgery A reverse cutting edge needle has a triangular point with the cutting edge on the outer convex curvature of the needle, which helps prevent the suture from tearing through the tissue.

Choice D reason:

This is incorrect because an eyed needle with a blunt point is used for suturing tissues that are easy to separate, such as liver, kidney, or spleen A blunt point needle has a round body that ends in a blunt tip, which pushes aside the tissue fibers rather than cutting them An eyed needle has an eye at the end of the needle where the suture thread is inserted, which can cause more drag and tissue trauma than a swaged needle that has the suture attached to the end of the needle.

Choice A reason:

This is incorrect because changing the dressing every day and keeping it dry may not be appropriate for all types of wounds. Some wounds may require more frequent dressing changes or moist wound healing environment to promote healing and prevent infection.

Choice B reason:

This is incorrect because showering with the dressing on may cause the dressing to become wet and contaminated, which can increase the risk of infection and delay healing. The dressing should be changed before and after showering, and the wound should be protected from water as much as possible.

Choice C reason:

This is correct because inspecting the dressing for signs of infection, such as redness, swelling, or drainage, is an important part of wound care. The patient should be taught how to recognize and report these signs to the health care provider as soon as possible. Early detection and treatment of infection can prevent complications and promote healing.

Choice D reason:

This is incorrect because removing the dressing after 24 hours and leaving the wound open to air may not be advisable for some wounds, especially those that are deep, large, or at risk of infection. The wound may need to be covered with an appropriate dressing for a longer period of time to protect it from contamination, maintain moisture balance, and support healing.

Choice A reason:

Compressing the drain reservoir before closing the wound creates a vacuum that helps to suction out the fluid from the wound and prevent infection. This is a common practice for bulb-type drains that apply gentle suction.

Choice B reason:

Securing the drain tubing to the patient's skin with tape is not necessary and may cause skin irritation or damage. The drain tubing can be attached to the patient's clothes with a safety pin or secured near the bandage.

Choice C reason:

Emptying the drain reservoir when it is half full and measuring the output is part of the drain care at home, not during the surgical procedure. The patient or caregiver should empty the drain 2 to 3 times a day (or more), depending on the amount of output, and record it in a chart.

Choice D reason:

Flushing the drain tubing with saline solution every 4 hours is not recommended and may introduce infection or clog the tubing. The tubing should be kept clear by squeezing or "milking” it occasionally to prevent clots from forming. : Instructions for Surgical Drain Care - Cleveland Clinic : How to Care for Your Surgical Drain at Home - Verywell Health : Surgical Drain Care: Care Instructions | Kaiser Permanente.

C. Notify the physician or surgeon.

Choice A reason:

Administer oxygen via nasal cannula. This is not the priority action because the patient's oxygen saturation is 92%, which is within the normal range of 90% to 100%. Oxygen therapy may be helpful, but it does not address the underlying cause of the patient's hypotension, tachycardia, and oliguria.

Choice B reason:

Increase the rate of intravenous fluids. This is not the priority action because the patient may have fluid overload or bleeding as a result of the major abdominal surgery. Increasing the rate of intravenous fluids without knowing the patient's fluid status and blood loss may worsen the patient's condition and lead to complications such as pulmonary edema, heart failure, or hemorrhage.

Choice C reason:

Notify the physician or surgeon. This is the priority action because the patient's blood pressure is 90/60 mmHg, pulse is 120 beats/min, respiratory rate is 24 breaths/min, and urine output is 20 mL/h. These are signs of hypovolemic shock, which is a life-threatening condition that occurs when there is inadequate blood volume to maintain tissue perfusion. Hypovolemic shock can be caused by hemorrhage, dehydration, burns, or severe vomiting and diarrhea. The patient needs immediate medical attention and interventions such as blood transfusion, fluid resuscitation, vasopressors, and surgery to stop the bleeding source.

Choice D reason:

Administer pain medication. This is not the priority action because the patient's pain level is not mentioned in the question. Pain medication may be indicated for postoperative pain management, but it does not address the underlying cause of the patient's hypotension, tachycardia, and oliguria. Pain medication may also lower the blood pressure further and mask the signs of shock.

Choice A reason:

Keeping the dressing clean and dry prevents contamination and infection of the wound. It also helps the wound heal faster by protecting it from further injury. This is a standard instruction for wound care after a minor surgical procedure.

Choice B reason:

Changing the dressing every day or as needed helps keep the wound clean and allows the doctor or nurse to monitor the healing process. It also prevents the dressing from sticking to the wound or becoming too wet or soiled. This is another common instruction for wound care after a minor surgical procedure.

Choice C reason:

Washing the wound with soap and water is not recommended for wound care after a minor surgical procedure. Soap can irritate the wound and delay healing. Water can wash away the protective scab and cause bleeding. The wound should be rinsed with sterile water or saline solution instead.

Choice D reason:

Applying antibiotic ointment to the wound is not advised for wound care after a minor surgical procedure unless prescribed by the doctor or surgeon. Antibiotic ointment can cause allergic reactions, increase resistance to bacteria, or interfere with the healing process. The wound should be covered with a sterile dressing and left alone.

Choice E reason:

Reporting any signs of infection to the physician or surgeon is an important instruction for wound care after a minor surgical procedure. Signs of infection include redness, swelling, warmth, pain, pus, fever, or foul odor. Infection can delay healing, cause complications, or spread to other parts of the body.

Choice A reason:

This is not the best response because it does not address the patient's pain experience or offer any empathy. It also implies that medication is the only option for pain relief, which may not be true.

Choice B reason:

This is the best response because it acknowledges the patient's pain and asks them to elaborate on how it affects their daily activities. This can help the nurse assess the impact of pain on the patient's quality of life and plan appropriate interventions.

Choice C reason:

This is not the best response because it focuses on the duration and triggers of pain, which are more relevant for chronic pain than acute pain. It also does not show empathy or validate the patient's pain rating.

Choice D reason:

This is not the best response because it only expresses sympathy but does not ask the patient any questions or offer any solutions. It may also sound patronizing or dismissive to some patients.

Choice A reason:

This is incorrect because wound dehiscence is not normal and expected at this stage of healing. Wound dehiscence is a surgical complication where an incision reopens either internally or externally. It can interfere with wound healing and pose a threat to the individual's overall health. Wound dehiscence can be partial or complete, depending on how many layers of tissue are separated. In rare cases, wound dehiscence can lead to evisceration, which is when internal organs push out through the wound.

Choice B reason:

This is correct because wound dehiscence could be a sign of dehiscence, which is a medical emergency that requires immediate attention. The nurse should call the doctor right away and monitor the patient for signs of infection, bleeding, or evisceration. The nurse should also cover the wound with a sterile dressing moistened with saline to prevent further contamination and keep the patient calm and comfortable.

Choice C reason:

This is incorrect because coughing and deep breathing can increase the abdominal pressure and worsen the wound separation. The nurse should avoid any activities that can strain the stitches or staples used to hold the wound closed while it heals. The nurse should also instruct the patient to avoid vomiting, heavy lifting, or any sudden movements that can cause further damage to the wound.

Choice D reason:

This is incorrect because applying pressure on the wound can cause more bleeding or damage to the tissues. The nurse should not touch the wound or try to close it by themselves. The nurse should only cover the wound with a sterile dressing moistened with saline and wait for the doctor's instructions. Applying pressure on the wound can also increase the risk of infection or evisceration.

D. Infection.

Choice A reason:

Atelectasis is the collapse of alveoli in the lungs, which can impair gas exchange and cause hypoxia. It can occur after surgery due to anesthesia, pain, or immobility. However, atelectasis does not usually cause fever and chills, unless it is complicated by pneumonia.

Choice B reason:

Dehydration is the loss of fluid and electrolytes from the body, which can affect blood pressure, heart rate, and kidney function. It can occur after surgery due to blood loss, vomiting, or inadequate intake. However, dehydration does not usually cause fever and chills, unless it is associated with infection or heat stroke.

Choice C reason:

Inflammation is the body's response to tissue injury or infection, which involves increased blood flow, swelling, pain, and heat. It can occur after surgery as part of the normal healing process. However, inflammation does not usually cause fever and chills, unless it is severe or systemic.

Choice D reason:

Infection is the invasion and multiplication of microorganisms in the body, which can trigger an immune response and cause inflammation, fever, and chills. It can occur after surgery due to contamination of the surgical site, catheters, or intravenous lines. Infection is the most likely cause of fever and chills in a postoperative patient.

Choice A reason:

Administering an antiemetic as ordered can help prevent postoperative nausea and vomiting by blocking the receptors in the brain that trigger the vomiting reflex. This is a common intervention for clients who have undergone laparoscopic cholecystectomy, as they may experience nausea and vomiting due to the effects of anesthesia, pain, or the carbon dioxide gas used to inflate the abdomen during the procedure.

Choice B reason:

Encouraging the client to drink carbonated beverages is not a good intervention to prevent postoperative nausea and vomiting, as carbonated beverages can increase gastric distension and pressure, which can worsen nausea and vomiting. Carbonated beverages can also cause belching, which can introduce air into the stomach and increase the risk of aspiration.

Choice C reason:

Placing the client in a supine position is not a good intervention to prevent postoperative nausea and vomiting, as supine position can decrease gastric emptying and increase the risk of aspiration. Supine position can also impair respiratory function and cause hypoxemia, which can trigger nausea and vomiting. The client should be placed in a semi-Fowler's position or on their side with their head elevated to facilitate gastric emptying and prevent aspiration.

Choice D reason:

Applying pressure to the client's abdomen is not a good intervention to prevent postoperative nausea and vomiting, as pressure can cause pain and discomfort, which can worsen nausea and vomiting. Pressure can also interfere with wound healing and increase the risk of infection or bleeding. The client's abdomen should be assessed for distension, tenderness, or signs of complications, but not pressed.

Choice A reason:

Tingling in the fingers and toes is a sign of paresthesia, which is a common symptom of hypocalcemia. Hypocalcemia occurs when the blood calcium level is too low, which can happen after a thyroidectomy if the parathyroid glands are damaged or removed. The parathyroid glands produce parathyroid hormone, which regulates calcium balance in the body. Without enough parathyroid hormone, calcium levels drop and cause neuromuscular irritability and numbness or tingling sensations.

Choice B reason:

Difficulty swallowing and speaking is not a specific sign of hypocalcemia, but rather a possible complication of a thyroidectomy due to injury to the recurrent laryngeal nerve. This nerve innervates the muscles of the larynx, which control voice production and swallowing. Damage to this nerve can cause hoarseness, weak voice, or vocal cord paralysis.

Choice C reason:

Dry mouth and increased thirst are not signs of hypocalcemia, but rather signs of dehydration. Dehydration can occur for various reasons, such as fluid loss, inadequate fluid intake, or increased fluid needs. Dehydration can affect the electrolyte balance in the body, but it does not directly cause hypocalcemia.

Choice D reason:

Muscle weakness and fatigue are not specific signs of hypocalcemia, but rather general signs of malaise. Malaise can occur for various reasons, such as infection, inflammation, stress, or chronic illness. Malaise can affect the physical and mental well-being of a person, but it does not directly cause hypocalcemia.

Choice A reason:

This is incorrect because gentle shoulder shrugs and circles are not enough to prevent lymphedema and promote mobility. The client needs to perform more active and progressive exercises that involve the full range of motion of the shoulder joint.

Choice B reason:

This is incorrect because lifting the arm above the head several times a day is too aggressive and may cause swelling and pain. The client should gradually increase the elevation of the arm over several weeks, starting with 90 degrees and then progressing to 120 degrees.

Choice C reason:

This is correct because using the affected arm for normal activities as much as possible helps to restore function and prevent stiffness. The client should avoid heavy lifting, tight clothing, blood pressure measurements, and injections on the affected arm, but otherwise should use it for daily tasks such as combing hair, dressing, and eating.

Choice D reason:

This is incorrect because wearing a compression sleeve on the affected arm is not recommended for routine use after a mastectomy. Compression sleeves are only indicated for clients who have developed lymphedema and need to reduce the swelling. They may also be used for air travel or strenuous exercise, but only with a physician's prescription.

A. Notify the provider of the findings.

Choice A reason:

The client has signs of a possible infection, such as low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. These are complications of hysterectomy that require immediate attention from the provider. The provider may order further tests, such as a wound culture or blood tests, and prescribe antibiotics or other treatments. Therefore, notifying the provider is the first action the nurse should take.

Choice B reason:

Obtaining a wound culture from the surgical site may be necessary to identify the type of infection and the appropriate antibiotic therapy. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and follow their orders.

Choice C reason:

Administering an antibiotic as ordered may help treat the infection and reduce the risk of further complications. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and obtain a wound culture if ordered to determine the best antibiotic for the client.

Choice D reason:

Increasing the frequency of perineal care may help prevent or reduce infection by keeping the area clean and dry. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and administer an antibiotic as ordered to treat the infection.

Choice A reason:

This is a correct statement by the client. Using a pillow between the legs when sleeping helps to maintain the hip in abduction and prevent dislocation of the prosthesis.

Choice B reason:

This is also a correct statement by the client. Avoiding crossing the legs or bending forward prevents excessive flexion of the hip and reduces the risk of dislocation.

Choice C reason:

This is another correct statement by the client. Reporting any signs of infection or bleeding to the doctor is important to prevent complications such as wound infection, hematoma, or sepsis.

Choice D reason:

This is an incorrect statement by the client that indicates a need for further teaching. Resuming normal activities as soon as the client feels better is not advisable, as it may cause excessive stress on the joint and lead to loosening or fracture of the prosthesis. The client should follow a gradual rehabilitation program and avoid activities that involve high impact, twisting, or lifting.

Choice E reason:

This is also an incorrect statement by the client that indicates a need for further teaching. Taking anticoagulant medication as prescribed is not enough to prevent thromboembolic events after a total hip replacement. The client should also wear compression stockings, use intermittent pneumatic compression devices, and perform ankle and foot exercises as instructed. The client should also monitor for signs of bleeding or bruising and report any abnormal findings to the doctor.

Choice A reason:

A wound infection is the most likely diagnosis for a client who has redness, warmth, swelling, and purulent drainage at the incision site 24 hours after an appendectomy. These are signs of inflammation and infection that indicate the wound is not healing properly. A wound infection can delay wound healing, increase pain, and cause fever and systemic symptoms. A wound infection requires treatment with antibiotics and wound care.

Choice B reason:

A wound dehiscence is a partial or complete separation of the edges of a surgical incision. It usually occurs later than 24 hours after surgery, when the wound is still fragile and weak. A wound dehiscence can be caused by stress on the wound, such as coughing, vomiting, or straining, or by poor wound closure, infection, or malnutrition. A wound dehiscence may present with increased drainage, a visible gap in the incision, or a popping sensation. A wound dehiscence requires immediate medical attention and may need surgical repair.

Choice C reason:

A wound evisceration is a rare but serious complication of a wound dehiscence, where the abdominal organs protrude through the open incision. It is a surgical emergency that requires immediate intervention to prevent organ damage, infection, and shock. A wound evisceration may present with sudden pain, a gush of blood or serous fluid, and visible organs through the wound. The client should lie down with knees bent and cover the wound with a sterile dressing moistened with warm saline until help arrives.

Choice D reason:

A wound hematoma is a collection of blood under the skin or in the deeper tissues that results from bleeding at the surgical site. It usually occurs within the first few hours after surgery and may cause swelling, pain, bruising, and pressure on nearby structures. A wound hematoma can increase the risk of infection and impair wound healing. A small hematoma may resolve on its own, while a large hematoma may need drainage or surgery.

Choice A reason:

Hypothermia, bradycardia, and hypotension are not signs of malignant hyperthermia, but rather signs of hypovolemia, shock, or anesthesia overdose. Malignant hyperthermia is a rare but life-threatening condition that occurs when a patient is exposed to certain anesthetic agents and develops a hypermetabolic response that leads to high fever, muscle rigidity, tachycardia, hypertension, acidosis, and rhabdomyolysis.

Choice B reason:

Hyperthermia, tachycardia, and hypertension are the classic signs of malignant hyperthermia. The patient may also experience increased carbon dioxide production, decreased oxygen saturation, dysrhythmias, cyanosis, muscle breakdown, and organ failure. The nurse should monitor the patient's vital signs, temperature, blood gases, electrolytes, and urine output closely and notify the anesthesia care provider immediately if malignant hyperthermia is suspected. The treatment involves stopping the anesthetic agent, administering 100% oxygen, cooling the patient with ice packs and cold intravenous fluids, and giving dantrolene sodium intravenously to relax the muscles.

Choice C reason:

Hypothermia, tachypnea, and hypertension are not consistent with malignant hyperthermia. Hypothermia may occur due to exposure to cold operating room environment or intravenous fluids. Tachypnea may be caused by pain, anxiety, hypoxia, or acidosis. Hypertension may be related to stress, pain, or sympathetic stimulation. These signs are not specific to malignant hyperthermia and do not indicate a hypermetabolic state.

Choice D reason:

Hyperthermia, bradypnea, and hypotension are not typical of malignant hyperthermia. Hyperthermia may occur due to infection, inflammation, or dehydration. Bradypnea may be a result of oversedation, opioid administration, or respiratory depression. Hypotension may be due to blood loss, dehydration, or vasodilation. These signs do not reflect a hypermetabolic state or muscle rigidity that are characteristic of malignant hyperthermia.

Choice A reason:

Wearing tight-fitting clothing or jewelry on the affected arm is not recommended, but it is not something to avoid completely. Tight-fitting clothing or jewelry can cause swelling (lymphedema) or infection in the arm, but wearing them for short periods of time may be acceptable. The client should be advised to wear loose-fitting clothing and jewelry most of the time and to monitor the arm for any signs of swelling, pain, or redness.

Choice B reason:

Elevating the affected arm above the level of the heart is not something to avoid, but rather something to do frequently. Elevating the arm can help reduce swelling and improve blood flow. The client should be instructed to elevate the arm several times a day for 15 to 30 minutes at a time.

Choice C reason:

Applying moisturizer or sunscreen to the affected arm is not something to avoid, but rather something to do regularly. Moisturizer can help prevent dryness and cracking of the skin, which can increase the risk of infection. Sunscreen can help protect the skin from sun damage, which can also increase the risk of infection and skin cancer. The client should be advised to apply moisturizer daily and sunscreen whenever exposed to the sun.

Choice D reason:

Having blood pressure or blood draws on the affected arm is something to avoid. This is because these procedures can cause injury or infection to the arm, which can lead to lymphedema or other complications. The client should be instructed to inform all health care providers that they had a mastectomy with lymph node dissection and to request that blood pressure or blood draws be done on the other arm or on another part of the body.

Choice E reason:

Performing range-of-motion exercises on the affected arm is not something to avoid, but rather something to do gradually and carefully. Range-of-motion exercises can help restore mobility and flexibility to the arm and prevent stiffness and contractures. The client should be instructed to start doing gentle exercises as soon as possible after surgery and to increase the intensity and duration as tolerated. The client may be referred to a physical therapist for additional guidance and support.

Choice A reason:

General anesthesia will make you unconscious and unable to feel any pain during the surgery. This is true because general anesthesia affects the whole body and brain, blocking the sensation of pain and awareness of the surroundings. General anesthesia is used for almost all laparoscopic hysterectomies and is often used for abdominal and vaginal hysterectomies. General anesthesia also impairs your breathing, so a breathing tube, ventilator, and inhalation anesthetic may be used.

Choice B reason:

General anesthesia will numb your lower body and allow you to remain awake during the surgery. This is false because general anesthesia does not numb only a part of the body, but rather affects the whole body and brain. Numbing only a part of the body is called regional anesthesia, which involves injecting an anesthetic near a cluster of nerves to block pain signals from that area. Regional anesthesia can be used for some types of hysterectomies, but not for abdominal hysterectomy.

Choice C reason:

General anesthesia will block pain signals from reaching your brain and make you sleepy during the surgery. This is partially true but incomplete. General anesthesia does block pain signals from reaching your brain, but it also makes you unconscious, not just sleepy. You will not be aware of anything that is happening during the surgery or remember anything afterwards. General anesthesia also affects other functions of your body, such as breathing, blood pressure, and heart rate.

Choice D reason:

General anesthesia will relax your muscles and reduce your awareness of what is happening during the surgery. This is also partially true but incomplete. General anesthesia does relax your muscles and reduce your awareness, but it also makes you completely unconscious and unable to feel any pain. You will not have any memory of the surgery or be able to respond to any stimuli. General anesthesia also has other effects on your body, such as lowering your body temperature and slowing down your digestion.

D. All of the above.

Choice A reason:

Removing dentures, glasses, contact lenses, jewelry and nail polish is part of the physical preparation of the client before surgery. These items can interfere with the anesthesia, cause injury, or be lost during the procedure.

Choice B reason:

Administering a sedative or anxiolytic medication as prescribed is part of the preoperative medication of the client before surgery. These medications can help reduce anxiety, pain, nausea, and vomiting, and facilitate induction of anesthesia.

Choice C reason:

Marking the surgical site with an indelible marker is part of the patient identification and verification process before surgery. This helps prevent wrong-site, wrong-procedure, or wrong-person surgery by ensuring that the correct site is marked and confirmed by the client, surgeon, and nurse.

Choice D reason:

All of the above. All of these items should be completed before transferring the client to the operating room as part of the preoperative checklist. The checklist ensures that necessary documentation, admission assessment, physical preparation, and client education have been completed before the client enters the surgical suite.

Choice A reason:

This statement is correct and does not indicate a need for further teaching. The client should use a walker or crutches to avoid putting too much weight on the new hip and prevent dislocation or damage to the prosthesis.

Choice B reason:

This statement is incorrect and indicates a need for further teaching. The client should not keep the legs crossed when sitting or lying down, as this can cause dislocation of the new hip joint. The client should keep the affected leg in abduction at all times.

Choice C reason:

This statement is correct and does not indicate a need for further teaching. The client should avoid bending the hip more than 90 degrees when getting dressed or using the toilet, as this can also cause dislocation of the new hip joint. The client should use assistive devices such as a long-handled reacher or a raised toilet seat.

Choice D reason:

This statement is correct and does not indicate a need for further teaching. The client should take antibiotics as prescribed to prevent infection, which can be a serious complication of hip replacement surgery. The client should also report any signs of fever, chills, or increased pain.

Choice E reason:

This statement is correct and does not indicate a need for further teaching. The client should report any signs of bleeding, swelling, redness or drainage from the incision, as these can also indicate infection or hematoma formation. The client should keep the incision clean and dry and change the dressing as instructed.

Choice A reason:

The client reports numbness in his right leg. This is not a cause for immediate intervention by the nurse, because numbness is an expected effect of spinal anesthesia. Spinal anesthesia blocks the nerve impulses from the lower extremities, lower abdomen, pelvic, and perineal regions, resulting in loss of sensation and movement.

Choice B reason:

The client has a blood pressure of 90/60 mm Hg. This is not a cause for immediate intervention by the nurse, because mild hypotension is a common side effect of spinal anesthesia. Spinal anesthesia causes vasodilation and decreases the sympathetic tone, leading to reduced blood pressure. The nurse should monitor the client's vital signs and fluid status, and administer vasopressors if needed.

Choice C reason:

The client complains of a headache when sitting up. This is a cause for immediate intervention by the nurse, because it may indicate a post-dural puncture headache (PDPH). PDPH is a complication of spinal anesthesia that occurs when the dura mater is punctured by the needle, causing cerebrospinal fluid (CSF) to leak and create a pressure gradient between the intracranial and spinal compartments. The nurse should assess the client's pain level, position the client flat or with a slight head elevation, administer analgesics and fluids, and notify the anesthesiologist.

Choice D reason:

The client has difficulty voiding after surgery. This is not a cause for immediate intervention by the nurse, because urinary retention is a common problem after spinal anesthesia. Spinal anesthesia affects the bladder function by inhibiting the micturition reflex and impairing the sensation of bladder fullness. The nurse should monitor the client's urine output, bladder distension, and fluid intake, and assist with catheterization if needed.

Choice A reason:

Placing a pillow under the dependent axilla is a proper technique for lateral positioning because it helps to prevent brachial plexus injury by reducing the pressure on the neurovascular structures in the axilla. It also helps to maintain the alignment of the shoulder and prevent shoulder drop.

Choice B reason:

Flexing both knees at a 90-degree angle is not a proper technique for lateral positioning because it can cause excessive pressure on the knees and ankles, leading to nerve injury or skin breakdown. It can also impair venous return and increase the risk of deep vein thrombosis (DVT). Only the dependent leg should be flexed at the hip and knee, while the upper leg should be straight and supported by pillows between the legs.

Choice C reason:

Aligning the shoulders directly over each other is not a proper technique for lateral positioning because it can cause compression of the dependent shoulder and compromise the blood supply to the arm. It can also cause shoulder drop and brachial plexus injury. The lower shoulder should be pulled slightly forward and supported by a pad under the chest wall.

Choice D reason:

Elevating the dependent arm on an arm board is not a proper technique for lateral positioning because it can cause excessive abduction of the arm and stretch the brachial plexus. It can also interfere with surgical access to the thorax or kidney. Both arms should be supported on parallel arm boards with abduction less than 90 degrees.

Choice A reason:

This statement is correct. Regional anesthesia blocks the sensation of pain and other sensations from a specific part of the body, such as below the waist for spinal or epidural anesthesia. The client will not be able to move or feel anything in the affected area during the surgery.

Choice B reason:

This statement is incorrect. Regional anesthesia does not require the client to stay awake during the surgery, unless the client prefers to do so. The client can also receive sedation or general anesthesia along with regional anesthesia, depending on the type and duration of the surgery and the client's preference.

Choice C reason:

This statement is incorrect. Regional anesthesia can have residual effects on the client's motor and sensory function, as well as blood pressure and heart rate, for several hours after the surgery. The client will need someone to drive them home after the surgery and monitor them for any signs of complications.

Choice D reason:

This statement is correct. Regional anesthesia has some advantages over general anesthesia, such as less risk of nausea and vomiting, less blood loss, less stress response, and better postoperative pain control.

Choice E reason:

This statement is correct. Regional anesthesia does not affect the client's ability to swallow or protect their airway, unlike general anesthesia. However, the client will still have to fast for at least 8 hours before the surgery to prevent aspiration of stomach contents in case general anesthesia or sedation is needed or administered.

A. Notify surgeon immediately.

Choice A reason:

This is the correct answer. This is to prevent the risk of leaving a foreign object inside the patient, which can cause serious complications such as infection, abscess, bowel obstruction, or perforation.

Choice B reason:

This is incorrect. Notifying anesthesia personnel is not the priority action when an incorrect sponge count is reported. Anesthesia personnel are not responsible for counting or searching for sponges, and they cannot intervene in the surgical procedure without the surgeon's consent. The surgeon is the one who needs to be informed first, as they have the authority and ability to search the wound and decide whether to continue or stop the surgery.

Choice C reason:

This is incorrect. Notifying risk management is not the priority action when an incorrect sponge count is reported. Risk management is a department that deals with identifying, assessing, and minimizing potential hazards in health care settings. While it is important to report any adverse events or errors to risk management, this should be done after ensuring the patient's safety and resolving the issue. The priority is to notify the surgeon and search for the missing sponge.

Choice D reason:

This is incorrect. Notifying operating room supervisor is not the priority action when an incorrect sponge count is reported. The operating room supervisor is a person who oversees the daily operations of the surgical suite, such as staffing, scheduling, equipment, and supplies. While they may be involved in addressing any problems or conflicts that arise in the OR, they are not directly responsible for counting or searching for sponges, and they cannot interfere with the surgical procedure without the surgeon's consent. The priority is to notify the surgeon and search for the missing sponge.

Choice A reason:

Double gloving is a recommended precaution for health care workers who are exposed to blood or body fluids of clients who have a positive HIV test result. Double gloving can reduce the risk of needlestick injuries and transmission of HIV or other bloodborne pathogens.

Choice B reason:

Placing instruments in closed containers at completion of surgery is not a specific precaution for clients who have a positive HIV test result. It is a standard practice for all surgical procedures to prevent contamination and infection. Placing instruments in closed containers does not protect the health care workers from exposure to blood or body fluids during surgery.

Choice C reason:

Wearing shoe covers in addition to personal protective equipment is not a specific precaution for clients who have a positive HIV test result. It is a standard practice for all surgical procedures to prevent contamination and infection. Wearing shoe covers does not protect the health care workers from exposure to blood or body fluids during surgery.

Choice D reason:

Using instruments only from specially marked trays is not a specific precaution for clients who have a positive HIV test result. It is a standard practice for all surgical procedures to prevent contamination and infection. Using instruments only from specially marked trays does not protect the health care workers from exposure to blood or body fluids during surgery.

Choice A reason:

This response is not appropriate because it does not acknowledge the patient's pain or offer any pain relief. It also sounds dismissive and unsympathetic to the patient's feelings. A better response would be to empathize with the patient and explain the benefits and risks of early mobilization in a respectful way.

Choice B reason:

This response is not appropriate because it does not address the patient's pain or provide any pain relief. It also sounds demanding and authoritarian, which may increase the patient's anxiety and resistance. A better response would be to collaborate with the patient and set realistic and individualized goals for mobility.

Choice C reason:

This response is appropriate because it acknowledges the patient's pain and offers a solution to reduce it. It also shows respect for the patient's autonomy and readiness by suggesting rather than ordering to get up. It also implies that the nurse will assist and support the patient during the activity.

Choice D reason:

This response is appropriate because it provides positive reinforcement and education to the patient. It explains how early mobilization can enhance wound healing and decrease pain by improving blood circulation, preventing complications, and restoring function.

Choice E reason:

This response is not appropriate because it sounds accusatory and judgmental. It may make the patient feel defensive or guilty for expressing their pain or reluctance. A better response would be to explore the patient's concerns and fears in a non-threatening way and provide reassurance and information as needed.

C. Calling for assistance and notifying the surgeon.

Choice A reason:

Covering the wound with sterile gauze moistened with normal saline is a correct nursing intervention for wound evisceration, but it is not the priority action. The priority is to get immediate help and inform the surgeon of the situation.

Choice B reason:

Placing the patient in low Fowler's position with knees bent is another correct nursing intervention for wound evisceration, as it reduces tension on the abdominal muscles and prevents further protrusion of the bowel. However, it is not the priority action either.

Choice C reason:

Calling for assistance and notifying the surgeon is the priority nursing intervention for wound evisceration, as this is a surgical emergency that requires prompt intervention to prevent complications such as infection, necrosis, or shock. The nurse should also monitor the patient's vital signs and prepare for possible surgery.

Choice D reason:

Applying pressure to the wound edges is an incorrect nursing intervention for wound evisceration, as it can cause further damage to the bowel and increase the risk of infection. The nurse should avoid touching or manipulating the wound or the bowel.

Choice A reason:

Applying sequential compression devices (SCDs) to the lower extremities is the most effective nursing intervention in preventing DVT in a patient who had spinal surgery and is at risk for DVT. SCDs are pneumatic devices that inflate and deflate around the legs to promote venous return and prevent stasis of blood, which can lead to clot formation.

Choice B reason:

Massaging the calves and thighs gently is not recommended for a patient who had spinal surgery and is at risk for DVT. Massaging the affected area can dislodge a clot and cause a pulmonary embolism, which is a life-threatening complication of DVT.

Choice C reason:

Elevating the foot of the bed by 15 degrees is not an effective nursing intervention in preventing DVT in a patient who had spinal surgery and is at risk for DVT. Elevating the foot of the bed can increase venous stasis and impair circulation, which can increase the risk of clot formation.

Choice D reason:

Encouraging early ambulation and leg exercises is an effective nursing intervention in preventing DVT in a patient who had spinal surgery and is at risk for DVT, but not as effective as applying SCDs. Early ambulation and leg exercises can improve blood flow and prevent venous stasis, but they may not be feasible or safe for some patients who had spinal surgery, depending on their level of injury and mobility.

Choice A reason:

This statement is correct and does not indicate a need for further teaching. The client can resume normal activities in a week after a laparoscopic cholecystectomy.

Choice B reason:

This statement is correct and does not indicate a need for further teaching. The client can take acetaminophen for pain relief after a laparoscopic cholecystectomy.

Choice C reason:

This statement is correct and does not indicate a need for further teaching. The client can shower the day after surgery and pat the incisions dry to prevent infection.

Choice D reason:

This statement is correct and does not indicate a need for further teaching. The client can eat a low-fat diet for the first month to avoid stimulating the gallbladder and causing pain.

Choice E reason:

This statement is incorrect and indicates a need for further teaching. The client should not expect any drainage from the incisions, as this could indicate infection or leakage of bile. The client should report any drainage to the provider immediately. A) “I can resume my normal activities in a week.” B) “I can take acetaminophen for pain relief.” C) “I can shower tomorrow and pat my incisions dry.” D) “I can eat a low-fat diet for the first month.” E) “I can expect some drainage from my incisions.”

Choice A reason:

Shivering is a sign of hypothermia because it is the body's way of generating heat when the core temperature drops below normal. Shivering can be uncontrollable in mild hypothermia and may stop in moderate to severe hypothermia as the body conserves energy.

Choice B reason:

Tachycardia is not a sign of hypothermia. In fact, hypothermia can cause bradycardia, which is a slow heart rate, as the body tries to reduce heat loss through the blood vessels.

Choice C reason:

Pallor is a sign of hypothermia because it indicates reduced blood flow to the skin as the blood vessels constrict to preserve core temperature. Pallor can also be accompanied by cyanosis, which is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood.

Choice D reason:

Diaphoresis is a sign of hypothermia because it is the result of excessive sweating that can occur after exposure to cold or wet environments. Sweating can increase heat loss through evaporation and lower the body temperature further.

Choice E reason:

Hypotension is a sign of hypothermia because it reflects decreased cardiac output and blood pressure as the heart muscle becomes less efficient and responsive to stimuli. Hypotension can also lead to shock, organ failure, and death if not treated promptly.

Choice A reason:

The nurse should call for assistance and stay with the client because the client is likely experiencing wound evisceration, which is a surgical emergency that requires immediate intervention. Wound evisceration is the protrusion of bowel through an abdominal incision, and it can occur 4 to 5 days postoperatively following an increase in strain on the incision, such as from turning, coughing, sneezing, or vomiting. Clients often report feeling something has "popped” or opened in the wound, followed by severe pain and a sensation of wetness. The nurse should not leave the client alone or attempt to reinsert the bowel.

Choice B reason:

The nurse should not remove the dressing to assess the wound because this could increase the risk of infection and further injury to the wound. The nurse should cover the wound with a nonadherent dressing moistened with warm sterile normal saline to protect the wound from contamination and drying. Removing the dressing could also cause more pain and bleeding to the client.

Choice C reason:

The nurse should not cover the wound with sterile towels soaked in sterile saline because this could cause maceration of the skin and increase the risk of infection. The nurse should use a nonadherent dressing moistened with warm sterile normal saline to prevent adherence to the wound and allow for drainage. Sterile towels could also be too bulky and heavy for the wound.

Choice D reason:

The nurse should not assess vital signs as the first action because this would delay the urgent care needed for the client. The nurse should call for assistance and stay with the client while covering the wound with a nonadherent dressing moistened with warm sterile normal saline. Assessing vital signs can be done after securing help and stabilizing the wound. Vital signs may show signs of shock, such as hypotension, tachycardia, tachypnea, and pallor. A) Call for assistance and stay with client. B) Remove dressing to assess wound. C) Cover wound with sterile towels soaked in sterile saline. D) Assess vital signs.

Choice A reason:

Fat embolism is a possible complication of ORIF of a fractured hip. A fat embolism occurs when fat droplets from the bone marrow enter the bloodstream and block small blood vessels in the lungs, brain, or other organs. This can cause serious symptoms such as shortness of breath, chest pain, confusion, seizures, or coma. Fat embolism syndrome is more common with fractures of long bones such as the femur.

Choice B reason:

Pulmonary edema is not a likely complication of ORIF of a fractured hip. Pulmonary edema is a condition where fluid accumulates in the lungs, making it difficult to breathe. Pulmonary edema can be caused by heart failure, kidney failure, lung infections, or high altitude. It is not directly related to bone fractures or surgery.

Choice C reason:

Deep vein thrombosis (DVT) is a possible complication of ORIF of a fractured hip. DVT is a blood clot that forms in a deep vein, usually in the leg. DVT can cause pain, swelling, redness, or warmth in the affected area. DVT can also break off and travel to the lungs, causing a pulmonary embolism, which is a life-threatening emergency. DVT is more likely to occur after surgery or prolonged immobility.

Choice D reason:

Myocardial infarction (MI) is not a likely complication of ORIF of a fractured hip. MI is a heart attack that occurs when the blood supply to the heart muscle is interrupted, causing damage or death of the heart tissue. MI can be caused by coronary artery disease, which is the buildup of plaque in the arteries that supply the heart. MI can also be triggered by stress, physical exertion, or other factors. MI is not directly related to bone fractures or surgery. A) Fat embolism B) Pulmonary edema C) Deep vein thrombosis D) Myocardial infarction