Questions & rationalization

By: GROUP 3
1. Which intervention should the nurse implement first when
beginning preoperative teaching?

A. B. C. D.
Assessing the Using a Describing the Having the
client’s standardized possible risks client read the
knowledge preoperative of the surgical printed
base related teaching plan procedure instructional
to the surgical for booklet
procedure consistency
Answer: A. Assessing the client’s knowledge base related
to the surgical procedure

Rationale:

The key nursing intervention during the preoperative period

is patient and family education. Take every opportunity during
the patient assessment and preparation for surgery, to
provide information that will increase the patient's familiarity
with the procedure, which will decrease anxiety.
2. The primary goal of the circulating nurse during preparation of the
operating room, transferring and positioning the patient, and assisting
the anesthesia team is:

A. B. C. D.
Avoiding any Maintaining a Providing for Preventing
type of injury clean patient breaks in
to the patient. environment comfort and aseptic
for the patient sense of well- technique by
being. the sterile
members of
the team.
Answer: C. Providing for patient comfort and sense of
well-being.

Rationale:

The protection of the patient from injury in the operating

room environment is maintained by the circulating nurse by
ensuring functioning equipment, preventing falls and injury
during transport and transfer, monitoring asepsis, and
being with the patient during anesthesia induction
3. Five minutes after receiving a preoperative sedative
medication by IV injection, a patient asks the nurse to get
up to go to the bathroom to urinate. Which of the
following is the most appropriate action for the nurse to
take?

A. B. C. D.
Assist patient Allow patient to Offer the Ask patient to
to bathroom go to the patient to use hold the urine
and stay next bathroom since the for a short
to door to the onset of the urinal/bedpan period of time
assist patient medication will after explaining since a urinary
be more than 5 the need to catheter will be
back to bed
minutes. maintain safety. placed in the
when done.
operating
room.
Answer: C. Offer the patient to use the urinal/bedpan
after explaining the need to maintain safety.

Rationale:

Sedatives are a type of prescription medication that slows

down your brain activity. They're typically used to make you
feel more relaxed. This is a critical phase with the potential
for several adverse events, such as thrashing or movement,
vomiting.
4. Antibiotic was ordered (cefuroxime); as a nurse what will
be your consideration prior in giving antibiotic medication?

A. B. C. D.

Remove Do skin Check vital Secure

jewelries testing signs consent
ANSWER: B. Do skin testing

Rationale:

This is to determine if the patient has hypersensitivity to

cefuroxime.
5. Metoclopramide may be given as a preoperative
medication in order to

A. B. C. D.
Relieve Reduce risk of Relieve To control
apprehension aspiration discomfort secretion
 Answer: B. Reduce Aspiration

Rationale:

Metoclopramide is an anti emetic. This prevents post operative nausea and

vomiting.

Postoperative nausea and vomiting (PONV) is defined as any nausea, retching, or

vomiting occurring during the first 24–48 h after surgery in inpatients. Although
aspiration of gastric contents, esophageal rupture, and other serious complications
associated with PONV are rare, nausea and vomiting is still an unpleasant and all-
too-common postoperative morbidity that can delay patient discharge from the
post-anaesthesia care unit and increase unanticipated hospital admissions in
outpatients.
6. As the nurse you are getting the patient ready for surgery. You are
completing the preoperative checklist. Which of the following is not
part of the preoperative checklist?

A. B. C. D.
Assess for Ensuring that Conducting Informed
allergies the history the Time Out consent is
and physical signed
examination
has been
completed
 ANSWER: C. Conducting the Time Out

Rationale:

Assessing for allergies, Ensuring Medical history and physical exam, and Signed
informed consent are part of Pre-Operative checklist. Meanwhile, Time Out is one of
the The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and

Wrong Person Surgery. Time Out is usually done before starting an Invasive Procedure
or Making the Incision.
 7. You are completing the history on a patient who is
scheduled to have surgery. What health history increases
the risk for surgery for the patient

A. B. C. D.
Abuse of History of Hyperthyroidism Urinary Tract
street drugs Premature infections
Ventricle Beats
ANSWER: A. Abuse of street drugs

Rationale:

If a patient has a history of street drug abuse this

puts them at risk in surgery. This information is very
important for the anesthesiologist due to the
complications that can arise from the anesthesia. All
of the other options are important to note but not a
risk for surgery
 8. Which of the following items on a client’s presurgery
laboratory results would indicate a need to contact the surgeon?

A. B. C. D.
Platelet count Total Blood urea Hemoglobin 7.5
of cholesterol of nitrogen (BUN)) mg/dl
250,000/cu.mm 325 mg/dl 17 mg/dl
ANSWER: d. Hemoglobin 7.5 mg/dl

Rationale:

The hemoglobin level is low, and the nurse needs to

make sure the surgeon has the most recent laboratory
values before surgery. This client may need a
transfusion before surgery. The cholesterol is elevated
but is not a concern before surgery. The platelets and
the BUN are within normal limits.
9. The client tells the nurse during the preoperative history that
he is a three-pack a day cigarette smoker. This information alerts
the nurse to which potential complication during the
intraoperative and postoperative periods?

a. b. c. d.

A decreased A decreased An increased An increased

tolerance to clotting ability risk for risk for
pain atelectasis and excessive scar
hypoxia tissue
formation
Answer: C. An increased risk for atelectasis and hypoxia

Rationale:

Smoking increases the level of circulating

carboxyhemoglobin, which decreases oxygen delivery to the
tissues. In addition, cigarette smoking damages the cilia of
mucous membranes, decreasing transport of secretions and
increasing the risk of pulmonary infection and atelectasis.
10. When the nurse brings the preoperative medication to the client about to
have abdominal surgery, she tells the nurse that she does not need the
injection because she had a good night's sleep last night. What is the nurse's
best first action?

A. Tell the client that her surgeon has ordered the medication;
therefore, she should go ahead and take the medication because the
surgeon knows what is best.
B. Tell the client that the preoperative medication is ordered to reduce
the risk of some problems during surgery rather than to ensure
adequate rest.
C. Appropriately discard the preoperative medication and notify the
surgeon.
D. Document the client's statement and notify the charge nurse
ANSWER: B. Tell the client that the preoperative medication is
ordered to reduce the risk of some problems during surgery
rather than to ensure adequate rest.

Rationale:

The preoperative medication is prescribed to prevent a vagal

response during intubation and surgery, reduce the amount of
anesthetic needed during induction, and reduce anxiety.
 11. Twenty minutes after the client has received a preoperative injection of
atropine and midazolam (Versed), the client tells the nurse that he must be allergic
to the medication because his mouth is dry and his heart seems to be beating faste
than normal. What is the nurse's best first action?

A. B. C. D.
Document the Document the Prepare to Explain to the
findings as the findings as the administer client that these
only action only action epinephrine symptoms are
and normal
diphenhydramin responses to the
medication.
e (Benadryl).
 Answer: D. Explain to the client that these symptoms are normal
responses to the medication.

Rationale:

Dry mouth and tachycardia (fast heartbeat) are some of the common side effects of
atropine. Some other side effects of atropine include blurred vision, sensitivity to light,
lack of sweating, dizziness, nausea, and loss of balance.While Midozolam has headache,
drowsiness, amnesia or forgetfulness after your procedure, hiccups, nausea, vomiting,
or pain, redness, or tenderness where the medicine was injected, as some of it’s
common side effects. Explain to the patient that when he/she experiences/observes
skin rash, hives, itching, fever, swelling, shortness of breath, wheezing, and runny nose
to report immediately to his/her health care provider as these are the s/sx of allergic
reaction to medications. Explaining what to expect and providing comfort to the client
would ease their tension and anxiety before their procedure.
12. Which nursing action or statement is most likely to reduce
anxiety in a client being brought to the surgical suite?

A. B. C. D.
Asking the Asking the Asking the client Explaining to the
client if he or client what if he or she client that the
she has talked specific surgery wants family surgical area is
with the he or she is members to be the most
hospital having done with them in the technologically
holding area advanced in the
chaplain today
city
ANSWER: C. Asking the client if he or she wants family members
to be with them in the holding area

Rationale:

Most anxious clients would feel some relief by having one or more familiar persons
waiting with them until surgery begins. In addition, asking the client what he or she
wants allows the client to have more control over the situation. Asking the client if he
or she has visited with the hospital chaplain and telling the client about the advanced
technology can imply to the client that the procedure is dangerous. Although the client
must be asked what procedure he or she is having (to ascertain that the client does
know what is to be done), this question may make the client worry about the
competency of the staff.
 13. In the operating room, the client tells the circulating nurse that he is
going to have the cataract in his left eye removed. The nurse notes that the
consent form indicates that surgery is to be performed on the right eye.
What is the nurse's best first action?

A. B. C. D.
Assume that the Check to see if Notify the Ask the client
client is a little the client has surgeon and his name
confused
received any anesthesiologi
because he is
older and has preoperative st.
received medications.
midazolam
intramuscularly.
ANSWER: D. Ask the client his name.

Rationale:

Verifying or asking information such as your name and age is a safety measure to
confirm who you are, and what procedure you are scheduled to receive. These
measures serve as a “double check” for your safety. Many societies and medical
groups recommend that caregivers confirm your identity before caring for you in
order to ensure that each patient receives the right care at the right time.
14. What are the tests to be done before the surgery?

a. b. c. d.
Blood tests such blood sugar Chest x-ray All of the above
as a complete tests
blood count (CBC)
and kidney, liver,
and blood sugar
tests Chest x-ray
Answer: D. All of the above

Rationale:

Complete blood count (CBC). This test checks for a low number of red blood
cells (anemia) and infection.

Chest X-rays. X-rays can help diagnose causes of shortness of breath, chest
pain, cough, and certain fevers. They can also help diagnose heart and lung
problems.
 15. Patient should be checked for presence of
allergies in

a. b. c. d.
Anesthesia Latex Antibiotics all of the
above
Answer: D. All of the above

Rationale:

All these substances (i.e. NMBA, anesthetics,

antibiotics, latex devices) may cause severe systemic
non-IgE-mediated reactions or fatal anaphylactic
events even in the absence of any evident risk
factor in the patient’s anamnesis.
Hysterectomy question & answer with
rationale
Group 2
1. After a hysterectomy, clients may feel incomplete as
women. The statement that should alert nurse Gina to
this feeling would be:
A. “I can’t wait to see all my friends again”
B. “I feel washed out; there isn’t much left”
C. “I can’t wait to get home to see my grandchild”
D. “My husband plans for me to recuperate at our
daughter’s home”
Answer: B. “I feel washed out; there isn’t much left”

Rationale:
The client’s statement infers an emptiness with an
associated loss
2. On a follow-up visit after having a vaginal
hysterectomy, a 32-year-old patient has a
decreased hematocrit level. Which of the
following
A. Hematomacomplications does this suggest?
B. Hypovolemia
C. Infection
D. Pulmonary embolus (PE)
Answer: A. Hematoma

Rationale:
A decreased hematocrit level is a sign of hematoma, a
delayed complication of abdominal and vaginal
hysterectomy. Symptoms of hypovolemia include
increased hematocrit and hemoglobin values. Symptoms
of a PE include dyspnea, chest pain, cough, hemoptysis,
restlessness, and signs of shock.
3. When planning care with a client during the
postoperative recovery period following an
abdominal hysterectomy and bilateral salpingo-
oophorectomy, nurse Frida should include the
explanation that:

A. Surgical menopause will occur

B. Urinary retention is a common problem
C. Weight gain is expected, and dietary plan are needed
D. Depression is normal and should be expected
Answer: A. Surgical menopause will occur

Rationale:
When a bilateral oophorectomy is performed, both
ovaries are excised, eliminating ovarian hormones and
initiating response.
4. Nurse Cecilia is caring for a client who has
undergone a vaginal hysterectomy. The nurse
avoids which of the following in the care of
this client?

A. Elevating the knee gatch on the bed

B. Assisting with range-of-motion leg exercises
C. Removal of antiembolism stockings twice daily
D. Checking placement of pneumatic compression boots
Answer: A. Elevating the knee gatch on the bed

Rationale:
The client is at risk of deep vein thrombosis or thrombophlebitis
after this surgery, as for any other major surgery. For this reason,
the nurse implements measures that will prevent this complication.
Range-of-motion exercises, antiembolism stockings, and pneumatic
compression boots are helpful. The nurse should avoid using the
knee gatch in the bed, which inhibits venous return, thus placing the
client more at risk for deep vein thrombosis or thrombophlebitis.
5.Nurse Betty is assigned to the following clients. The
client that the nurse would see first after endorsement?

A. 34 year-old post operative appendectomy client of five hours

who is complaining of pain.
B. 44 year-old myocardial infarction (MI) client who is complaining
of nausea.
C. A 26 year-old client admitted for dehydration whose intravenous
(IV) has infiltrated.
D. A 63 year-old post operative’s abdominal hysterectomy client of
three days whose incisional dressing is saturated with
serosanguinous fluid.
Answer: B. 44 year-old myocardial infarction (MI)
client who is complaining of nausea.

Rationale:
Nausea is a symptom of impending myocardial infarction
(MI) and should be assessed immediately so that
treatment can be instituted and further damage to the
heart is avoided.
6. A patient with endometriosis is treated with
medroxyprogesterone (Depo-Provera). The nurse
explains that this therapy
A. Suppresses the menstrual cycle by mimicking pregnancy.
B. May cause symptoms such as vaginal atrophy and hot
flashes.
C. Is associated with loss of bone density and increased
fracture risk.
D. Will lead to permanent suppression of abnormal
endometrial tissues.
Answer: a. suppresses the menstrual cycle by
mimicking pregnancy.

Rationale:
Depo-Provera induces a pseudopregnancy, which suppresses
ovulation and causes shrinkage of endometrial tissue. Vaginal
atrophy and hot flashes are caused by synthetic androgens such as
danazol or gonadotropin-releasing hormone agonists (GNRH) such
as leuprolide. Although hormonal therapies will control
endometriosis while the therapy is used, endometriosis will recur
once the menstrual cycle is reestablished. Depo-Provera use is not
associated with bone loss.
7. A 58-year-old woman is one-day
postoperative following an abdominal
hysterectomy. Which intervention should the
nurse perform in order to prevent deep vein
thrombosis (DVT)?

A. Place the patient in a high Fowler's position.

B. Provide pillows to place under the patient's knees.
C. Encourage the patient to change positions frequently.
D. Teach the patient deep breathing and coughing exercises.
Answer: c. Encourage the patient to change positions
frequently.

Rationale:
The patient should be encouraged to change positions
frequently and ambulate to prevent venous stasis. The
high Fowler's position and pressure under the knees
should be avoided in order to prevent DVT. Deep
breathing and coughing are therapeutic exercises but do
not directly address the risk of DVT.
8. Which condition would prevent the use of a vaginal
hysterectomy?

A. A woman with more than four pregnancies

B. Large uterine fibroids
C. Menorrhagia for over 6 months
D. Women over the age of 50
Answer: b. Large uterine fibroids

Rationale:
In the case of large uterine fibroids, a vaginal
hysterectomy is not an option.
9. The young husband of a patient who has been scheduled
for a hysterectomy because of the discovery of ovarian
cancer in both ovaries says to the nurse, Please go talk to my
wife. She is real upset and says she wont be a woman
anymore. What is the nurses most therapeutic response?

A. Dont be concerned. All young women get upset before this kind of surgery.
B. Certainly, I will be glad to tell her about hormone replacement.
C. She will get over this feeling soon.
D. No matter what I may say to her, it is you that needs to listen to her
concerns and assure her.
Answer: d. No matter what I may say to her, it is you
that needs to listen to her concerns and assure her.

Rationale:
Assisting patients with recognizing and clarifying fears
and with developing coping strategies for those fears by
listening is helpful.
10. The uterus and the cervix are removed along
with the tissue on both sides of the cervix and
the upper part of the vagina. What kind of
hysterectomy procedure is this?

A. Partial or supracervical hysterectomy

B. Total hysterectomy
C. Radical hysterectomy
D. Hysterectomy with bilateral salpingo-oophorectomy
Answer: C. Radical hysterectomy

Rationale:
In a radical hysterectomy, the uterus, the cervix and neighboring
tissues are removed, usually because there is a cancer present. If
only the uterus is removed, but not the cervix, then it is called a
partial or supracervical hysterectomy. In a total hysterectomy,
your doctor will take out the cervix and the body of the uterus
together. In hysterectomy with bilateral salpingo-oophorectomy,
the uterus, cervix, and fallopian tubes are removed.
11. Which are the following conditions may need for
hysterectomy?

A. Gynecologic cancer
B. Fibroids
C. Endometriosis
D. All of the choices
Answer: D. All of the choices

Rationale:
Gynecologic cancer. If you have a gynecologic cancer such as
cancer of the uterus or cervix a hysterectomy may be your best
treatment option. Depending on the specific cancer you have and
how advanced it is, your other options might include radiation or
chemotherapy. A hysterectomy is the only certain, permanent
solution for fibroids — benign uterine tumors that often cause
persistent bleeding, anemia, pelvic pain or bladder pressure.
Nonsurgical treatments of fibroids are a possibility, depending on
your discomfort level and tumor size. In endometriosis, the tissue
12. A male patient undergoes a total abdominal
hysterectomy. When assessing the patient 10
hours later, the nurse identifies which finding as
an early sign of shock?

A. Restlessness
B. Pale, warm, dry skin
C. Heart rate of 110 beats/minute
D. Urine output of 30 ml/hour
Answer: a. Restlessness

Rationale:
Early in shock, hyperactivity of the sympathetic nervous
system causes increased epinephrine secretion, which
typically makes the patient restless, anxious, nervous, and
irritable. It also decreases tissue perfusion to the skin,
causing pale, cool clammy skin. An above-normal heart rate
is a late sign of shock. A urine output of 30 ml/hour is within
normal limits.
13. A 49-year-old obese diabetic patient has had a total
abdominal hysterectomy. On the second post-operative day, the
patient complains of increased pain in the operative site. She
states, "It feels like something suddenly popped." With the
symptoms presented, it would be likely that when the nurse
removes the abdominal dressing she may note that:

A. The wound has purulent exudate

B. Dehiscence has occurred
C. The wound is indurated and tender
D. The wound is well approximated
Answer: B. dehiscence has occurred

Rationale:
Dehiscence is a partial or total separation of previously
approximated wound edges, due to a failure of proper
wound healing. This scenario typically occurs 5 to 8 days
following surgery when healing is still in the early stages
14. Following a total abdominal hysterectomy Ms. Sarah
Princesa develops a slightly elevated temperature and
swelling in the right calf of her leg. The physician prescribes
warm moist compresses for the client’s affected leg. Which
of the following nursing actions is correct when applying the
warm moist compress? The nurse:

A. Heats the water to 120°F

B. Uses a sterile technique
C. Inspect the skin every 4 hours
D. Covers the wet gauze with a towel
Answer: D. Covers the wet gauze with a towel

Rationale:
Covers the wet gauze with a towel. A warm compress or
soak helps improve blood flow to tissues and relieve pain
and swelling.
15. Choose the correct statement about the different
types of hysterectomy:

A. Total hysterectomy – the uterus and cervix are

removed along with structures around the uterus. This
surgery may be recommended if cancer is diagnosed
or suspected
B. Supravercical hysterectomy – the upper part of the
uterus is removed, but the cervix is left in place
C. Radical hysterectomy - uterus and cervix are removed
Answer: b. Supravercical hysterectomy – the upper part
of the uterus is removed, but the cervix is left in place

Rationale:
Total hysterectomy is when the uterus and cervix are
removed. While radical hysterectomy is when the uterus
and cervix are removed along with structures around
the uterus. This surgery may be recommended if cancer
is diagnosed or suspected.
16. What other organ/s besides cervix and uterus may
be removed during a hysterectomy?

A. Ovaries
B. Fallopian tubes
C. Both a and b
D. Neither a and b
Answer: c. Both a and b

Rationale:
If needed, the ovaries and fallopian tubes may be
removed if they are abnormal (for example, they are
affected by endometriosis). This procedure is called:
salpingo-oophorectomy if both tubes and ovaries are
removed, salpingectomy if just the fallopian tubes are
removed, oophorectomy if just the ovaries are removed
17. What are the different ways hysterectomy can be
performed?

A. Through the vagina

B. Through the abdomen
C. With laparoscopy
D. All of the above
Answer: d. All of the above

Rationale:
A hysterectomy can be done in different ways: through
the vagina, through the abdomen, or with laparoscopy.
The choice will depend on why you are having the
surgery and other factors. Sometimes, the decision is
made after the surgery begins and the surgeon is able
to see whether there are other problems.
18. Are all women at the same risk of complications?

A. Yes
B. No
Answer: b. No

Rationale:
No, some women are at greater risk of complications
than others. For example, if you have an underlying
medical condition, you may be at greater risk of
problems related to anesthesia.
 MASTECTOMY
QUESTIONS WITH RATIONALE

GROUP 1
1. A client who has had a mastectomy tells the nurse, “My
husband will leave me now that I am not a whole woman
anymore.” Which response is therapeutic?

A. Are you afraid that your husband will not find you
sexually appealing?

B. Your husband should be grateful that you will be able

to live and be with him.

C. Maybe your husband would like to attend a support

group for spouses.

D. You don’t know that’s true. Give him a chance.

A. Are you afraid that your husband will not find
you sexually appealing?

This is restating her feelings and is

therapeutic.
2. The client is being discharged after a left modified radical
mastectomy. Which discharge instructions should the nurse
include?
Select all that apply.
A. Notify the HCP of temperature of 100 F
B. Carry large purses and bundles with the right hand.
C. Do not go to church or anywhere with crowds.
D. Try to keep arm as still as possible until seen by HCP.
E. Have a mammogram of the right and left breast yearly.
 A. Notify the HCP of temperature of 100 F
B. Carry large purses and bundles with the right
hand.
E. Have a mammogram of the right and left breast
yearly.

A – possible infection
B – risk of lymphedema. Protect arm from injury.
E – risk for more cancer is high in both breasts.
3. The client who had a right modified radical mastectomy 4 years
before is being admitted for a cardiac workup for chest pain.
Which intervention is most important?

A. Determine when client had chemo last.

B. Ask client if she received Adriamycin, an antineoplastic agent.
C. Post a message at the head of the bed not to use the right arm.
D. Examine the chest wall for cancer sites.
C. Post a message at the head of the bed not to use the
right arm.

C – risk for lymphedema

4. The client is 4 months pregnant and finds a lump in her breast
and the biopsy is positive for stage 2 BC. Which treatment
should the nurse anticipate?

A. A lumpectomy to be performed after the baby is born.

B. A modified radical mastectomy.
C. Radiation therapy to chest wall only.
D. Chemo only until baby is born.
 B. A modified radical mastectomy.

B – Can’t do radiation/chemotherapy which would

also be required for lumpectomy. Tumor should
be removed ASAP.
5. The client has a mastectomy and asks nurse about a Tram Flap
procedure. Which info should nurse provide?
A. The surgeon will insert a saline filled sac under the skin to
stimulate a breast.
B. The surgeon will pull the client’s own tissue under the skin to
create a breast.
C. The surgeon will use tissue from inside the mouth to make a
nipple.
D. The surgeon can make the breast any size the client wants.
B. The surgeon will pull the client’s own tissue under the
skin to create a breast.

B – the tissue remains attached to its original site,

retaining its blood supply. The flap, consisting of
the skin, fat, and muscle with its blood supply, is
tunneled beneath the skin to the chest, creating a
pocket for an implant—or in some cases, creating
the breast mound itself.
6. The nurse is caring for a 39-year-old woman with a family history
of breast cancer. She requested a breast tumor marking test and
the results have come back positive. As a result, the patient is
requesting a bilateral mastectomy. This surgery is an example of
what type of oncologic surgery?
A. Salvage surgery
B. Palliative surgery
C. Prophylactic surgery
D. Reconstructive surgery
 C. Prophylactic surgery

C – prophylactic surgery is used when there is an

extensive family history and nonvital tissues are
removed.

https://quizlet.com/31490738/nclex-breast-cancer-flash-cards/
https://www.easynotecards.com/notecard_set/75474
7. Mastectomy performed to manage breast cancer should be
accompanied by radiation therapy if the primary tumor is ≥ 5
cm and/or Axillary nodes are involved.

A. True
B. False
 A. TRUE

Radiation therapy after breast-conserving surgery

significantly reduces incidence of local
recurrence in the breast and in regional lymph
nodes and may improve overall survival.
8. In skin-sparing mastectomy. .________________.
A. Axillary lymph nodes are spared
B. Enough skin remains after the procedure to cover the wound
C. The pectoral muscles are spared
D. A and B
E. A, B, and C
 E. A, B, AND C

Skin-sparing mastectomy spares the pectoral

muscles and enough skin to cover the wound,
making breast reconstruction much easier, and
spares axillary lymph nodes.
9. True or False.
The regions that are conserved in skin-sparing mastectomy are also
conserved in nipple-sparing mastectomy.

A. True
B. False
 A. TRUE

Nipple-sparing mastectomy is the same as skin-

sparing mastectomy plus spares the nipple and
areola.
 
 10. involves removal of the pectoral muscles.

A. Simple mastectomy
B. Modified radical mastectomy
C. Radical mastectomy
D. B and C
E. A, B, and C
 C. RADICAL MASTECTOMY

Simple mastectomy spares the pectoral muscles and

axillary lymph nodes, modified radical
mastectomy spares the pectoral muscles and
removes some axillary lymph nodes, while
radical mastectomy removes axillary lymph
nodes and the pectoral muscles.
11. A 72-year-old patient who had a mastectomy for breast cancer 6
months ago wants to have breast reconstructive surgery. The
nurse knows that what is the most likely motivation for this
patient seeking this surgery?

A. Improve the woman's self-image

B. Be able to experience sexual arousal
C. To get a tummy tuck as well as the breast mound
D. Restore the pre-mastectomy appearance of the breast
 
 A. IMPROVE THE WOMAN'S SELF-IMAGE

The most likely motivation for this patient to seek breast

reconstructive surgery is to improve her self-esteem.
With this surgery, she will not be able to experience
sexual arousal or restore the pre-mastectomy appearance
of the breast. The abdominoplasty (tummy tuck) effect
will only be a possibility with the transverse rectus
abdominis musculocutaneous (TRAM) flap, not with a
breast implant or tissue expansion.
12. Following a modified radical mastectomy, the health care provider
recommends chemotherapy even though the lymph nodes were
negative for cancer cells. The patient tells the nurse that she does not
know what to do about chemotherapy because she has heard that she
may not even need chemotherapy and that the side effects are
uncomfortable. The nursing diagnosis that best reflects the patient's
problem is:

A. Anxiety related to prospect of additional cancer therapy.

B. Fear related to uncomfortable side effects of chemotherapy.
C. Decisional conflict related to lack of knowledge about prognosis and
treatment options.
D. Risk for ineffective health maintenance related to reluctance to consider
additional treatment.
 C. DECISIONAL CONFLICT RELATED TO LACK OF
KNOWLEDGE ABOUT PROGNOSIS AND TREATMENT
OPTIONS.

The patient's statements indicate that she is having difficulty

making a decision about treatment because of a lack of
understanding about prognosis and treatment. Although she
may have some anxiety and fear, these are not the priorities at
this time. The patient expresses concerns about chemotherapy
rather than reluctance to consider additional treatment.
13. A 62-year-old patient complains to the nurse that mammograms
are painful and a source of radiation exposure. She says she does
breast self-examination (BSE) monthly and asks whether it is
necessary to have an annual mammogram.
The nurse's best response to the patient is:
A. "If your mammogram was painful, it is especially important that
you have it done annually.“
B. "An ultrasound examination of the breasts, which is not painful or a
source of radiation, can be substituted for a mammogram.“
C. "Because of your age, it is even more important for you to have
annual mammograms.“
D. "Unless you find a lump while examining your breasts, a
mammogram every 2 years is recommended after age 60."
C. "Because of your age, it is even more important for
you to have annual mammograms.“

Annual mammograms are recommended for women over

age 40 as long as they are in good health. The incidence
of breast cancer increases in women over 60. Pain with a
mammogram does not indicate any greater risk for breast
cancer. Ultrasound may be used in some situations to
differentiate cystic breast problems from cancer but is not
a substitute for annual mammograms.
14. While the nurse is obtaining a nursing history from a 55-year-
old patient who has found a small lump in her left side breast,
which question is most pertinent?

A. "Are you currently smoking cigarettes?“

B. "Have you ever had past any breast injuries?“
C. "Is there any family history of fibrocystic breast changes?“
D. "At what age did you start having menstrual periods?"
 D. "At what age did you start having menstrual
periods?”
 
  
Early menarche and late menopause are risk factors
for breast cancer because of the prolonged
exposure to estrogen that occurs. Cigarette
smoking, breast trauma, and fibrocystic breast
changes are not associated with increased breast
cancer risk.
15. A 52-year-old patient has ductal cell carcinoma of the left breast.
Adter a modified radical mastectomy, a Jackson Pratt drain is in
place in the left axillary region. The main purpose of this drain is
to:

A. Control numbness of her left incisional site

B. Improve her ability to perform range-of-motion exercises on her
affected side
C. Facilitate drainage and prevent formation of a hematoma
D. Prevent postoperative phlebitis in her affected arm
 C. Facilitate drainage and prevent formation of a
hematoma

Jackson Pratt drain is used to help empty excess

fluid from the body after surgery. Use of a drain
can help in the healing process.
16. The first lymph node most likely to drain the cancerous site in a
breast cancer patient is known as the:

A. Axillary node
B. Contaminated node
C. Primary node
D. Sentinel node
 D. Sentinel node

It is a hypothetical first lymph node or group of

nodes draining a cancer. In case of established
cancerous dissemination it is postulated that the
sentinel lymph node/s is/are the target organs
primarily reached by metastasizing cancer cells
from the tumor.
17. Postoperatively the nurse teaches the patient with a modified
radical mastectomy to prevent lymphedema by:

A. Using a sling to keep the arm flexed at the side.

B. Exposing the arm to sunlight to increase circulation.
C. Wrapping the arm with elastic bandages during the night.
D. Avoiding unnecessary trauma (e.g. venipuncture, blood pressure) to
the arm on the operative side.
D. Avoiding unnecessary trauma (e.g. venipuncture, blood
pressure) to the arm on the operative side.

Blood pressure readings, venipunctures, and injections

should not be done on the affected arm. Elastic bandages
should not be used in the early postoperative period
because they inhibit collateral lymph drainage. The
affected arm should be elevated above the heart, and
isometric exercises are recommended and gradually
increased starting in the recovery room to reduce fluid
volume in the arm.
 31-45
QUESTIONS WITH
RATIONALES
GROUP 1
31. You are the circulating nurse. Which tasks are
you solely responsible for?

A. The patient and documents throughout the

perioperative period.
B. Maintaining satisfactory degrees of relaxation of
the patient for the duration of the surgical procedure
C. Setting up the sterile tables
D. Ultimately responsible for the surgery
 A. The patient and documents throughout the perioperative
period.

Main responsibilities include verifying consent; coordinating the

team; and ensuring cleanliness, proper temperature, humidity,
lighting, safe function of equipment, and the availability of
supplies and materials. The circulating nurse monitors aseptic
practices to avoid breaks in technique while coordinating the
movement of related personnel (medical, x-ray, and laboratory),
as well as implementing fire safety precautions. The circulating
nurse also monitors the patient and documents specific activities
throughout the operation to ensure the patient's safety and well-
being.
https://quizlet.com/351953279/brunner-19-20-intra-op-postop-flash-cards/
32. You are the circulating nurse in an operating room
that has several surgeries scheduled. You would
know how to monitor which patient during the
intraoperative period because he or she is at
increased risk for hypothermia?

A. Woman
B. A 72-year-old-woman
C. A 45-year-old-woman
D. A 12-year-old-girl
 
 B. A 72-year-old-woman

Elderly patients are at greatest risk during

surgical procedures because they have an
impaired ability to increase their metabolic
rate and impaired thermoregulatory
mechanisms, which increase susceptibility
to hypothermia.
 
https://quizlet.com/351953279/brunner-19-20-intra-op-postop-flash-cards/

 
33. General Anesthesia consists of four stages,
which of these present that the patient may
have a ringing, roaring or buzzing in the ears
and though still conscious?

A. Stage 1 C. Stage 3
B. Stage 2 D. Stage 4
 A. Stage 1

Stage I: Onset or Induction or Beginning anesthesia. 

This stage extends from the administration of
anesthesia to the time of loss of consciousness. The
patient may have a ringing, roaring or buzzing in the
ears and though still conscious, is aware of being
unable to move the extremities easily. Low voices or
minor sounds appear distressingly loud and unreal
during this stage.
Reference: https://nurseslabs.com/intraoperative-phase/
34. As an intraoperative nurse, you know that
the patient's emotional state can influence the
outcome of his or her surgical procedure. How
would you best reinforce the patient's ability to
influence their outcome?

A. Teach the patient guided imagery

B. Assess the patient's coping strategies
C. Incorporate cultural, ethnic, and religious
considerations as appropriate
D. Give him or her anti-anxiety medication
 C. Incorporate cultural, ethnic, and religious
considerations as appropriate

Respecting the beliefs and values of your client is

an important part of establishing an effective
relationship between the care giver and the client.
Failure to take those beliefs seriously can
undermine the client's ability to trust you
as her/his care giver. All clients participate in care
that is respectful and non-judgmental.
Reference: https://www.homecareaustralia.com.au/post/respecting-clients-spiritual-beliefs-1
35. A part of the intraoperative nurse’s role is
being a patient advocate. What is an
advocacy activity of the intraoperative
nurse?
 
A. Maintaining the patient’s privacy while he or
she is awake
B. Checking the patient’s armband against his or
her medical record
C. Respecting the patient’s cultural values
D. Dehumanizing the patient
 C. Respecting the patient’s cultural values
 
Cultural respect is critical to reducing health
disparities and improving access to high-
quality health care, health care that is
respectful of and responsive to the needs of
diverse patients.
 
36. As an aseptic nurse, you know that
maintaining an aseptic environment in the
operating room is essential. When moving
around surgical areas, what distance must
be kept from the sterile field?
 
A. 2 Feet
B. 18 Inches
C. 1 Foot
D. 6 Inches
 C. 1 Foot or 12 inches
 
This square footage minimum is intended to
accommodate the equipment and personnel
necessary for one surgical field. For unsterile
personnel, such as the circulator, to move
around the sterile field without contaminating it, he
or she should maintain a distance of at least 12
inches from the sterile field. 
https://opentextbc.ca/clinicalskills/chapter/entering-the-operating-room/#:~:text=Non%2Dsterile%20person%2Farea,reach%20over
%20the%20sterile%20field.
37. You are the nurse performing wound care
on a 68 year old patient. Which of the
following practice violates surgical asepsis?

A. Holding sterile objects above the waist

B. Considering a 1 inch ( 2.5cm ) edge around the
sterile field as being contaminated
C. Pouring solution into a sterile cloth
D. Opening the outermost flap of a sterile package
away from the body
 C. Pouring solution into a sterile cloth

Whenever a sterile barrier is breached, the

area must be considered contaminated.
Pouring solution onto a sterile field cloth
violates surgical asepsis because moisture
penetrating the cloth can carry
microorganisms to the sterile field via
capillary action. The other options are
practices that help ensure surgical asepsis.
38. The physical environment of a
surgery suite is designed primarily to
promote

A. Electrical safety
B. Medical and surgical asepsis
C. Comfort and privacy of the patient
D. Communication among the surgical team
 B. Medical and surgical asepsis

Although all of the factors listed are important

to the safety and well-being of the patient,
the first consideration in the physical
environment of the surgical suite is
prevention of transmission of infection to the
patient.
39. Goals for patient safety in the operating
room (OR) include the Universal Protocol, in
which;
A. All surgical centers of any type must submit reports on patient
safety infractions to the accreditation agencies
B. The members of the surgical team stop whatever they are
doing to check that all sterile items have been properly
prepared
C. A surgical timeout is performed just before the procedure is
started to verify patient identity, surgical procedure, and
surgical site
D. All members of the surgical team pause right before surgery to
medicate for 1 minute to decrease stress and possible errors
C. A surgical timeout is performed just before the
procedure is started to verify patient identity,
surgical procedure, and surgical site

The Universal Protocol supported by The Joint

Commission is used to prevent wrong site, wrong
procedure, and wrong surgery in view of a high rate
of these problems nationally. It involves pausing just
before the procedure starts to verify identity, site,
and procedure.
40. A break in sterile technique during surgery
would occur when the scrub nurse touches.

A. The mask with gloved hands

B. Gloves hands to the gown at chest level
C. The drape at the incision site with gloved
hand
D. The lower arms to the instruments on the
instrument tray
 A. The mask with gloved hands

The mask covering the face is not considered

sterile, and if in contact with sterile gloved
hands, contaminates the gloves. The gown
at chest level and to 2 inches above elbows
is considered sterile, as is the drape placed
at the surgical area.
41. During surgery, a patient has a nursing
diagnosis of risk for perioperative position
injury. A common rick factor for this nursing
diagnosis is?

A. Skin lesions
B. Break in sterile technique
C. Musculoskeletal deformities
D. Electrical or mechanical equipment failure
 C. Musculoskeletal deformities

Musculoskeletal deformities can be

a risk factor for positioning injuries
and require special padding and
support on the operating table.
42. The primary advantage of the use of
midazolam (versed) as an adjunct to
general anesthesia is it’s;

A. Amnestic effect
B. Analgesic effect
C. Antiemetic effect
D. Prolonged action
 B. Analgesic effect

Midazolam (Versed) is a medication, which is generally

used for anesthesia, in patients who have troubled sleep,
and in cases of severe agitation. It is a short-acting
benzodiazepine. This drug has not been shown to
induce analgesic effects in the patient, who have been
administered this drug. Since, it is a short acting drug, it
does not show prolonged effects in the patients who
have received this drug One of the side effects of this
drug is vomiting in the patient. So, this drug does not
exert antiemetic effects on the patients.
 
43. During epidural and spinal
anaesthesia, the nurse should monitor
the patient for:

A. Spinal head ache

B. Hypotension and bradycardia
C. Loss of consciousness
D. Downward extension of nerve block
 B. Hypotension and Bradycardia

Hypotension and bradycardia are commonly

observed after the spinal anesthesia and
various mechanisms have been postulated
for these hemodynamic changes. In
addition, surgical manipulation of different
neural structures also causes similar
changes.
44. What is the primary goal of the circulating nurse
during preparation of the operating room,
transferring and positioning the patient, and
assisting the anesthesia team?

A. Avoiding any type of injury to the patient

B. Maintaining a clean environment for the patient
C. Providing for patient comfort and sense of well-
being
D. Preventing breaks in aseptic technique by the
sterile members of the team
A. Avoiding any type of injury to the patient
 
The protection of the patient from injury in the
operating room is maintained by the
circulating nurse, who ensures functioning
equipment; prevents falls and injury during
transport, transfer, and positioning; monitors
asepsis; and provides supportive care for
the anesthetized patient.
45. Because of the rapid elimination of volatile
liquids used for general anesthesia, the
nurse should anticipate that early in the
anesthesia recovery period, the patient will
need.

A. Warm blankets
B. Analgesic medication
C. Observation for respiratory depression
D. Airway protection in anticipation of vomiting
 B. Analgesic Medication

The volatile liquid inhalation agents have very little

residual analgesia, and patients experience early
onset of pain when the agents are discontinued.
They are associated with a low incidence of nausea
and vomiting.
Prolonged respiratory depression is not common
because of their rapid elimination.
Hypothermia is not related to use of these agents, but
they may precipitate malignant hyperthermia in
conjunction with neuromuscular blocking agents.
THANKS
18. A 55-year-old woman has recently had a unilateral, right total
mastectomy and axillary node dissection for the treatment of
breast cancer. What nursing intervention should the nurse
include in the patient's care?

A. Immobilize the patient's right arm until postoperative day 3.

B. Maintain the patient's right arm in a dependent position when at rest.
C. Administer diuretics prophylactically for the prevention of
lymphedema.
D. Promote gradually increasing mobility as soon as possible following
surgery.
D. Promote gradually increasing mobility as soon as possible
following surgery.

Mobility should be encouraged beginning in the post

anesthesia care unit (PACU) and increased gradually
throughout the patient's recovery. Immobilization is
counterproductive to recovery, and the limb should not be
in a dependent position. Diuretics are not used to prevent
lymphedema but may be used in active treatment of the
problem.
19. When teaching a 22-year-old patient about breast self-
examination (BSE), the nurse will instruct the patient that:

A. BSE will reduce the risk of dying from breast cancer.

B. Performing BSE right after the menstrual period will improve
comfort.
C. BSE should be done daily while taking a bath or shower.
D. Annual mammograms should be scheduled in addition to BSE.
B. Performing BSE right after the menstrual period will
improve comfort.

Performing BSE at the end of the menstrual period will

reduce the breast tenderness associated with the
procedure. The evidence is not clear that BSE
reduces breast cancer mortality. BSE should be done
monthly. Annual mammograms are not routinely
scheduled for women under age 40
20. While the nurse is obtaining a nursing history from a 52-year-
old patient who has found a small lump in her breast, which
question is most pertinent?

A. "Do you currently smoke cigarettes?“

B. "Have you ever had any breast injuries?“
C. "Is there any family history of fibrocystic breast changes?“
D. "At what age did you start having menstrual periods?"
 D. "At what age did you start having menstrual periods?“

Early menarche and late menopause are risk factors for

breast cancer because of the prolonged exposure to estrogen
that occurs. Cigarette smoking, breast trauma, and
fibrocystic breast changes are not associated with increased
breast cancer risk.
21. A patient with a small breast lump is advised to have a fine
needle aspiration (FNA) biopsy. The nurse explains that an
advantage to this procedure is that:

A. Only a small incision is necessary, resulting in minimal breast pain

and scarring.
B. If the specimen is positive for malignancy, the patient can be told at
the visit.
C. If the specimen is negative for malignancy, the patient's fears of
cancer can be put to rest.
D. FNA is guided by a mammogram, ensuring that cells are taken from
the lesion.
B. If the specimen is positive for malignancy, the patient
can be told at the visit.

An FNA should only be done when an experienced

cytologist is available to read the specimen immediately.
If the specimen is positive for malignancy, the patient can
be given this information immediately. No incision is
needed. If the specimen is negative for malignancy, the
patient will require biopsy of the lump. FNA is not
guided by mammography.
22. A 33-year-old patient tells the nurse that she has fibrocystic
breasts but reducing her sodium and caffeine intake and other
measures have not made a difference in the fibrocystic condition.
An appropriate patient outcome for the patient is:

A. Calls the health care provider if any lumps are painful or tender.
B. States the reason for immediate biopsy of new lumps.
C. Monitors changes in size and tenderness of all lumps in relation to
her menstrual cycle.
D. Has genetic testing for BRCA-1 and BRCA-2 to determine her risk
for breast cancer.
C. Monitors changes in size and tenderness of all lumps in relation
to her menstrual cycle.
Because fibrocystic breasts may increase in size and
tenderness during the premenstrual phase, the patient is
taught to monitor for this change and to call if the changes
persist after menstruation. Pain and tenderness are typical of
fibrocystic breasts, and the patient should not call for these
symptoms. New lumps may be need biopsy if they persist
after the menstrual period, but the biopsy is not done
immediately. The existence of fibrocystic breasts is not
associated with the BRCA genes.
23. A 20-year-old student comes to the student health center after
discovering a small painless lump in her right breast. She is
worried that she might have cancer because her mother had
cervical cancer. The nurse's response to the patient is based on
the knowledge that the most likely cause of the breast lump is:

A. Fibrocystic complex.
B. Fibroadenoma.
C. Breast abscess.
D. Adenocarcinoma.
 B. Fibroadenoma.

Fibroadenoma is the most frequent cause of breast

lumps in women under 25 years of age.
Fibrocystic changes occur most frequently in
women ages 35 to 50. Breast abscess is
associated with pain and other systemic
symptoms. Breast cancer is uncommon in women
younger than 25.
 
24. The nurse is working on a surgical floor and is preparing to
receive a postoperative patient from the postanesthesia care unit
(PACU). What should the nurse's initial action be upon the patient's
arrival?

A. Assess the patient's pain.

B. Assess the patient's vital signs.
C. Check the rate of the IV infusion.
D. Check the physician's postoperative orders.
 B. Assess the patient's vital signs.

The highest priority action by the nurse is to assess

the physiologic stability of the patient. This is
accomplished in part by taking the patient's vital
signs. The other actions can then take place in
rapid sequence.
 
25. A patient is recovering from a mastectomy. Which answer is
incorrect in regards to positioning?

A. Place the patient in semi-Fowler's position

B. Place the affected arm on a pillow
C. Place the patient in a side-lying position on the unaffected side to
promote lymphatic drainage
D. Every 2 hours turn the patient on the prone position on the affected
side 
C. Place the patient in a side-lying position on the
unaffected side to promote lymphatic drainage

You would not place the patient in a side-lying

position on the unaffected side to promote
lymphatic drainage. The patient needs to be in
semi-Fowler's (head of the bed 30 degrees) with
the affected arm on the pillow to promote
lymphatic fluid return.
Thanks!
Please keep this slide for attribution