Ch 13 Care of the Surgical Clients

27. To minimize microorganisms being introduced into the surgical wound, a scrub nurse would be permitted to wear: a. artificial nails b. bracelets c. unchipped nail polish d. rings and watches

ANS: C Microorganisms are often found in the crevices of artificial nails and jewelry. Nurses in the OR should not wear jewelry, nails should be short and neat, but nurses may have unchipped nail polish.

34. For a client who had a craniotomy, postoperative nursing care would give priority to which of these actions? a. assessing respiratory function on a regular schedule b. checking pupillary reactions c. observing for changes in vital signs d. using the Trendelenburg position immediately if shock develops

ANS: B The nurse should monitor the pupillary reactions in a client who had a craniotomy. This assessment can reveal neurological changes that may occur.

9. A client who has a history of angina is scheduled for a hernia repair tomorrow. Which of these nursing interventions is MOST likely to prevent postoperative complications for this client? a. forcing fluids by mouth b. careful monitoring of intravenous (IV) infusions c. resuming food intake as soon as possible d. maintaining a high Fowler's position

ANS: B Clients with a history of cardiovascular disease are prone to developing complications such as dysrhythmias, hypotension, myocardial infarction, congestive heart failure, cardiac arrest, stroke, shock, deep vein thrombosis (DVT), thrombophlebitis, or pulmonary embolism.

16. A client who is scheduled for surgery tells the nurse about an allergy to Demerol. Which of these actions should the nurse take NEXT? a. Apply an allergies alert wristband. b. Ask the client to describe the symptoms experienced when given Demerol. c. Label the client record accordingly. d. Notify the pharmacy and the health care provider.

ANS: B The nurse verifies client allergies to medication, food, and chemicals, and any reactions to blood and blood products, and applies an allergies alert wristband.

22. Which member of the surgical team assists all other team members, coordinates the team's efforts, and is held responsible for all activities during the surgical procedure? a. anesthesiologist or anesthetist b. circulating nurse c. scrub nurse d. surgeon

ANS: B Members of the surgical team each have clearly defined roles and responsibilities; sterile members (surgeon, first assistant, and scrub nurse) work on sterile surfaces (sterile field), and nonsterile team members include the anesthesia provider (anesthesiologist or anesthetist) and the circulating nurse.

11. A client is about to have a cholecystectomy by a surgeon using minimally invasive surgical technique. The most distinct advantage of minimally invasive surgery is: a. decreased need for postoperative therapy b. a smaller incision with less scarring c. no risk of infection d. the likelihoof of an immediate discharge

ANS: B Minimally invasive surgery is replacing much of traditional types of surgery. Advantages of MIS are smaller incisions resulting in less scarring externally and decreased adhesions internally), less postoperative pain, decreased hospital stay, less risk of infection, prompt return to normal activities and work, and less overall postoperative complications.

7. Clients who have nutritional deficiencies before surgery are MORE prone to have which of the following postoperative complications? a. atelectasis b. delayed wound healing c. renal failure d. hepatitis B

ANS: B Nutritional deficiencies place the client at higher risk for fluid and electrolyte imbalance, delayed wound healing, and wound infections.

40. Assessing the postoperative client's level of consciousness is a priority because a change in the level of consciousness may be the first indication that which of these complications has occurred? a. a stroke or increased intracranial pressure b. an adverse reaction to anesthetic agents or postoperative medications c. fluid and electrolyte imbalances or hypoxia d. sleep deprivation or sensory input overload

ANS: A Change in a client's level of consciousness reveals changes in the oxygenation of the brain and may indicate such complications as stroke or myocardial infarction.

8. Surgical clients who have chronic respiratory diseases are MOST likely to develop which postoperative complication? a. atelectasis b. stroke c. hypovolemic shock d. myocardial infarction

ANS: A Client with chronic respiratory problems, such as asthma and COPD, impair the client's gas exchange and increase the client's risk associated with inhalation anesthetic agents. It is because of these factors that the client is more likely to develop atelectasis and pneumonia.

14. Preoperative client teaching should include the purpose of the surgical site skin preparation, which is to: a. lower the number of microorganisms on or near the operative site b. prevent any wound infection c. remove soil around the operative site d. sterilize the skin

ANS: A Components of the preoperative teaching plan should include an explanation of the activities that will occur before surgery (restriction of food or fluid intake, any intravenous fluids required, premedications prescribed, scheduled time of surgery and approximate length of surgery, transportation to the operating room, preparation of the skin, type of surgical incision involved, and dressings, drains, or similar equipment that may be used); description of the operating room environment or a tour of the facility; explanation of the postanesthesia care unit; explanation and demonstration of postoperative deep breathing, coughing, turning, and incentive spirometry and any special transfer procedures or aids required after surgery; and description of pain management strategies appropriate for the specific surgical procedure.

42. An older adult client had a colon resection 8 days ago. The client experiences a gush of serosanguinous drainage from the wound, feels the abdominal incision "give," and calls the nurse. Viscera are protruding from the wound. Which of these actions must the nurse take FIRST? a. Cover the viscera with sterile saline dressings. b. Notify the surgeon of the situation. c. Place the client on NPO, and begin preparation for emergency surgery. d. Place the client in the semi-Fowler's position.

ANS: A Evisceration occurs when the wound edges separate completely and the viscera protrudes from the wound. The first nursing action is to protect the wound by covering the viscera with sterile saline dressings and notifying the surgeon immediately.

43. Which of the following concepts are part of current trends in surgical health care? a. The majority of clients are admitted through the ambulatory surgery unit on the morning of surgery. b. The invasiveness of many surgeries has increased. c. Clients may stay up to 48 hours in the short-stay surgery unit. d. Clients must assume all responsibility for postoperative care at home.

ANS: A If the client is to have surgery as an outpatient, the client should be instructed when to arrive at the hospital and told where family members can wait. The majority of clients are admitted through the ambulatory surgery unit on the morning of surgery.

26. A scrub nurse thinks aseptic technique may have been broken while setting up the instrument stand in the operating room. Which of these actions should the scrub nurse take NEXT? a. Ask the circulating nurse to remove and replace the instrument setup, rescrub, and set up the area again. b. No action is necessary, because the client is already on preoperative antibiotics. c. Report the possible compromise in private to the anesthesiologist. d. Request a replacement setup and proceed to prepare for the surgery.

ANS: A Members of the surgical team each have clearly defined roles and responsibilities; sterile members (surgeon, first assistant, and scrub nurse) work on sterile surfaces (sterile field) and nonsterile team members include the anesthesia provider (anesthesiologist or anesthetist) and the circulating nurse. If the scrub nurse suspects a break in aseptic technique, the items will be removed by the circulating nurse and the setup procedure redone.

23. Which member of the surgical team monitors the client's oxygenation and gas exchange during surgery? a. anesthesiologist or anesthetist b. circulating nurse c. scrub nurse d. surgeon

ANS: A Members of the surgical team each have clearly defined roles and responsibilities; sterile members (surgeon, first assistant, and scrub nurse) work on sterile surfaces (sterile field), and nonsterile team members include the anesthesia provider (anesthesiologist or anesthetist) and the circulating nurse.

3. The nurse is caring for a client about to undergo surgery. A major nursing role related to preoperative physiologic assessment and diagnostic tests is to: a. ensure the tests ordered by the health care provider have been performed b. inform the client and family of test results c. notify the surgeon that tests have been completed d. make the client's family comfortable while tests are performed

ANS: A Preoperative physiologic assessment includes a physical examination and reports of the client's laboratory and diagnostic studies such as blood components (e.g., hemoglobin, hematocrit, white blood cell count, and typing and crossmatching), serum electrolytes, bilirubin, liver enzymes, blood urea nitrogen (BUN), and urinalysis. Depending on the client's age and type of surgery to be performed, chest X-ray and electrocardiogram may also be included. Preoperative testing is often done several days before the scheduled surgery.

1. When discussing an upcoming surgery with a client, the nurse is aware that which of these statements about the perioperative experience is TRUE? a. To a client, there is no such thing as minor surgery. b. Major surgery creates as much body stress as minor surgery. c. Surgery is performed primarily for curative reasons. d. Surgeons play the major role in the perioperative experience.

ANS: A Surgery is a major stressor for every client. There is no such thing as minor surgery to a client. Anxiety and fear are normal reactions. The nurse should recognize that clients frequently experience some degree of anxiety about surgery, and such feelings can affect coping abilities. The nurse can provide clients with information about the surgical experience and offer appropriate support.

30. Upon admission to the post-anasthetic care unit (PACU), a client's Aldrete score (post-anesthetic recovery score) is 4. Within 30 minutes, it has become 8. The nurse recognizes this score means that the client: a. may be dismissed from the PACU b. must be admitted to a critical care unit c. needs oxygen d. needs to remain in the PACU for further evaluation and care

ANS: A The Aldrete score or post-anesthetic recovery score is a tool PACU nurses use to objectively assess the physical status of clients recovering from anesthesia; to be discharged from the PACU, the client must have an Aldrete score of 8 to 10. Discharge from the PACU is determined by the postanesthesia nurse; if the client's Aldrete score is less than 7, an order for discharge must be written by the client's surgeon or anesthesia provider.

32. A client is returned to the unit from the post-anesthetic care unit (PACU). The client is crying and begging for "something for the pain." Which of these actions should the nurse take NEXT? a. Check the PACU record to see what medications were administered and when. b. Notify the surgeon of the client's complaints of extreme pain. c. Prepare and administer the prescribed postoperative analgesic PRN medication. d. Use comfort measures, and withhold analgesics in the first 3 hours of the postoperative period to allow adequate recovery from the anesthesia.

ANS: A The later phase of postoperative nursing care begins on the clinical unit with preparation of the client's bed and collection of any special equipment required in the client's care prior to the client's arrival from the PACU. When the client arrives on the unit, the receiving nurse assists in the transfer of the client from the stretcher to the bed and assesses the client's vital signs, documenting the client's color, level of consciousness, pain, and dressings. Records of medications given prior to arrival should be checked.

21. Modern operating rooms are designed to prevent wound infections. Which of these characteristics contributes MOST to achieving that goal? a. A cool temperature between 66 and 68 degrees Fahrenheit b. A limit on the supplies and furniture allowed in the room c. Overhead ceiling lights d. Stainless steel furniture

ANS: A The operating room (OR) is environmentally controlled to prevent wound infections. The OR is geographically isolated from other parts of the hospital; clean and contaminated areas within the suite are separated; equipment and supplies needed for each client are centralized within the suite; and there are personnel restrictions as to who may enter certain areas of the surgical suite. Environmental control is also enhanced by constant filtered airflow and positive air pressure within the OR.

2. The nurse is preparing the client for surgery and assisting the client to put on a hospital gown and hair cap. Which of the following articles does the nurse remove? (Select all that apply.) a. hair piece b. glasses c. jewelry d. dentures e. hearing aid f. nail polish

ANS: A, C, D, F Jewelry, makeup, nail polish, hairpins, wigs, dentures, bridgework, and any prostheses are removed; if policy permits, hearing aids, glasses, or contact lenses are left in place and the nurse so informs the operating room nurse.

1. A nurse is caring for a client who has just returned from the post-anesthetic care unit (PACU). Which of the following should the nurse include in her initial assessment upon the client's return? (Select all that apply.) a. color of skin b. time of client's surgery c. time of last meal d. assessment of dressings e. vital signs f. patency of airway

ANS: A, D, E, F Postanesthesia nurses are responsible for managing seven areas of risk: ineffective airway clearance, ineffective breathing patterns, aspiration, decreased cardiac output, fluid volume deficit, sensory or perceptual alterations, injury, and altered thought processes.

25. The most important reason supplemental oxygen in given to even healthy clients when they are recovering from general anesthesia is that: a. it reduces postoperative pain b. it adds significantly to the amount of oxygen in the bloodstream c. to encourage the patient to breathe deeply d. it helps the patient clear their airway

ANS: B Almost all anesthetics and respiratory depressants cause the rate and/or depth of respirations to decrease. The elimination of carbon dioxide is slowed and CO2 builds up in the blood and lungs. Supplemental O2 given to a client with a decreased rate or depth of respirations adds to the amount of oxygen in the bloodstream. Pulse oximetry is used to measure a client's O2 saturation.

33. The nurse should give which of these postoperative instructions to a client who had a cataract removal? a. Drink plenty of fluids. b. Do not cough. c. Avoid head movement. d. Apply ice to the operative area.

ANS: B Clients who have experienced cataract surgery are given discharge instructions to prevent changes in intra-abdominal pressure such as lifting, straining, coughing, sneezing, and bending.

6. Which of these postoperative complications is MORE likely to occur in older adult clients? a. deep vein thrombosis b. dehydration c. pneumonia d. unpredictable responses to medications and anesthetics

ANS: B Older adult clients experience many physiologic changes associated with aging and are more likely to become dehydrated and thus less able to adapt to fluid loss during surgery.

15. Preoperative teaching should include how to perform postoperative leg exercises, which are done to prevent which complication of surgery? a. ankylosis of the joints b. atrophy of the muscles c. thrombosis formation d. pneumonia

ANS: C Although the specific postoperative nursing care provided depends on the client's surgical procedure and postoperative status, there are several important general nursing measures related to the preceding risks. One of these measures is prevention of deep vein thrombosis, thrombophlebitis, and pulmonary embolism by application of antiembolism stockings or a sequential compression device to the lower extremities; if the client's condition permits, early ambulation also improves peripheral vascular status and helps prevent emboli.

41. A client who is 24 hours postoperative has an oral temperature of 101.8 degrees Fahrenheit. Which of these actions is indicated FIRST? a. Administering antipyretics as ordered. b. Lowering the room temperature and providing cool washcloths. c. Notifying the surgeon. d. Providing light covers and clothing.

ANS: C An elevation in a client's temperature the first 48 hours postoperatively may indicate that a source of infection is present. The nurse would notify the surgeon of the change in the client's status.

12. Clients who have diabetes mellitus are prone to what postoperative complications? a. atelectasis b. hemorrhage c. infection d. pressure sores

ANS: C Besides hyperglycemia and hypoglycemia, the client who is diabetic is prone to fluid and electrolyte imbalances, infection, neurogenic bladder, impaired wound healing, deep vein thrombosis (DVT), thrombosis, thrombophlebitis, and pulmonary embolism.

10. A client who has diabetes mellitus is scheduled for surgery tomorrow. Which of the following accommodations will be made? a. The dose of insulin for the morning of the surgery will be reduced. b. IV fluids will be omitted. c. Surgery will be scheduled as early in the morning as possible. d. Serum glucose will be carefully monitored immediately after surgery.

ANS: C Clients with diabetes are scheduled as early in the morning as possible, and a fasting glucose is drawn immediately before surgery.

4. What is the primary reason that electrocardiograms (EKGs) are routinely performed in middle-aged and older adult clients undergoing surgery? a. Most insurance coverage dictates that they be performed. b. The client's cardiac health must be evaluated because of the physical stress of surgery. c. Ischemic heart disease is prevalent in these age groups. d. A baseline study for comparison is needed should subsequent EKGs be needed.

ANS: C Depending on the client's age and type of surgery to be performed, chest X-ray and EKG may also be included. Middle-aged and older adult clients have an increased risk for ischemic heart disease. Preoperative testing is often done several days before the scheduled surgery.

5. Infants who undergo surgery are at greater risk than adults for which of these possible complications? a. hyperthermia b. cardiac arrest c. fluid overload d. prolonged wound healing

ANS: C Infants easily become dehydrated or experience fluid overload with resultant electrolyte imbalances.

31. Criteria for discharge of the postoperative client from the post-anesthetic care unit (PACU) includes which of the following? a. The client has been in the PACU at least 30 minutes. b. The client's dressing is in place. c. The client is fully awake. d. The client is able to stand up.

ANS: C The Aldrete score or post-anesthetic recovery score is a tool PACU nurses use to objectively assess the physical status of clients recovering from anesthesia; to be discharged from the PACU, the client must have an Aldrete score of 8 to 10 (fully awake). Discharge from the PACU is determined by the postanesthesia nurse; if the client's Aldrete score is less than 7, an order for discharge must be written by the client's surgeon or anesthesia provider.

18. An anesthesiologist is meeting with a client prior to total hip replacement. In addition to assessing the client's health status and the plan for anesthesia, what will the anesthesiologist do? a. Review postoperative incentive spirometry instructions. b. Review the client's occupation. c. Discuss the risks and benefits of anesthesia. d. Discuss the client's postoperative surgical instructions.

ANS: C The anesthesiologist meets with the client prior to administering an anesthetic to assess the client's health status, discusses the risks and benefits of anesthesia with the client and makes a plan for an anesthetic appropriate for the client and the surgical procedure to be performed. Other members of the healthcare team will perform the preoperative and postoperative surgical instructions.

39. A client who had surgery 4 hours ago has not yet voided. Of the following nursing measures to facilitate voiding, which one would be done LAST? a. asking visitors to wait in the lounge area for a few minutes b. assisting the client to ambulate to the bathroom c. catheterizing the client d. pouring warm water over the perineum

ANS: C The client is at risk for urinary retention related to anesthesia, immobility, and pain. Interventions include the placement of a catheter to facilitate voiding.

24. The entire surgical team is responsible for prevention of infection, and maintaining the sterile field in the operating room in the area that includes: a. all members of the sterile team b. all members of the surgical team c. the client and the surgical site itself d. the entire operating room

ANS: C The entire surgical team is responsible for prevention of infection; for this reason, sterile team members perform a surgical scrub before gowning and gloving for the procedure, wear sterile gowns and gloves, use sterile drapes, place sterilized equipment on a sterile field, and are alert to breaks in technique that may harm the client. The skin over the client's operative site is also specially cleansed in the OR.

29. The endotracheal tube of a postoperative client transferred to the post-anesthesia care unit (PACU) was removed for five minutes. The client develops acute inspiratory stridor with sternal retractions. Which of these actions should the nurse take immediately? a. Reinsert the endotracheal tube. b. Reassure the client. c. Prepare to initiate cardiopulmonary resuscitation. d. Start oxygen via mask.

ANS: C When a client experiences acute inspiratory stridor with sternal retractions, it is an indication of respiratory distress. The nurse cannot replace the endotracheal tube and must be prepared to initiate cardiopulmonary resuscitation (CPR). The surgeon or anesthesiologist should be notified immediately.

3. The physiologic nursing assessment is completed before surgery. Which of the following are the focus of this assessment? (Select all that apply.) a. living arrangements b. insurance c. nutritional status d. fluid and electrolyte balance e. respiratory status f. family status g. age h. medications

ANS: C, D, E, F, G, H The physiologic nursing assessment is completed before surgery and includes health data obtained from the client, the family, and health care providers, and from previous health records. The focus of this assessment is identification of risk factors and possible complications of each; these data provide the basis for establishing the client's nursing diagnoses. The assessment addresses age, nutritional status, fluid and electrolyte balance, respiratory and cardiovascular status, neurological and musculoskeletal status, renal and hepatic status, integumentary status, and the client's current medications. Preoperative psychosocial health assessment includes identifying the client's perceptions and expected outcomes of the scheduled surgery, coping mechanisms and ability to understand the procedure, and cultural and spiritual beliefs.

36. Postoperative nursing measures to prevent the development of deep vein thrombosis, thrombophlebitis, and pulmonary embolism include which of the following? a. using an alternating pressure pad on the bed b. administering antibiotics every 12 hours as ordered c. massaging the calves of the legs for complaints of "cramping" d. performing postoperative leg exercises each hour

ANS: D Although the specific postoperative nursing care provided depends on the client's surgical procedure and postoperative status, there are several important general nursing measures related to the preceding risks. One of these measures is prevention of deep vein thrombosis, thrombophlebitis, and pulmonary embolism by application of antiembolism stockings or a sequential compression device to the lower extremities; if the client's condition permits, early ambulation also improves peripheral vascular status and helps prevent emboli.

17. Before beginning to implement preoperative medical orders for a surgical client, it is MOST important that the nurse: a. ask the visitors to leave the client's room b. be sure that the surgical consent form has been signed c. complete the preoperative checklist d. verify the identity of the client verbally and by viewing the name band

ANS: D Before any specific physical preparation for surgery is initiated, the nurse must verify the client's identity verbally by checking the identification band and by asking the client what surgical procedure is scheduled.

20. A client undergoing quadruple bypass surgery would be anesthetized using: a. spinal block anesthesia b. local anesthesia c. topical anesthesia d. general anesthesia

ANS: D General anesthesia involves unconsciousness, complete insensibility to pain, amnesia, and muscle relaxation and is a combination of IV and inhaled drugs. Local anesthesia is used to block nerves. Topical anesthesia is an ointment, lotion, solution or spray applied directly to the skin for local anesthetic (ie: before insertion of an IV). A spinal block is where a local anesthetic is injected into the cerebrospinal fluid to anesthetize a significant area of the body.

37. A client complains of a warm, tender, reddened, hardened area in the right calf on the second postoperative day and has a positive Homans' sign. Which of these actions should the nurse take NEXT? a. Assist the client to ambulate. b. Recheck for Homans' sign and chart the results. c. Massage the calf vigorously to relieve the pain. d. Report finding to the client's surgeon.

ANS: D Homans' sign indicates thrombophlebitis and should be reported to the surgeon.

35. Nursing care of a client for the first 48 hours after surgery includes all of the following interventions. Which action would enable the client to better participate in the other activities? a. Assist the client to sit up and ambulate as soon and as often as possible. b. Encourage coughing and deep breathing every 2 hours. c. Monitor use of the incentive spirometry every waking hour. d. Provide adequate pain-relief measures.

ANS: D Measures taken to control a client's pain can allow for participation in other activities.

19. A nurse is assessing a client admitted to the ambulatory surgery unit. The client has diaphoresis with rapid pulse and respirations, elevated blood pressure, and dilated pupils. When the nurse attempts to reinforce preoperative teaching, the client cannot remember anything about previous instructions. Which of these nursing actions is MOST appropriate? a. Administer the prescribed preoperative medication now. b. Ask the client to describe what is wrong. c. Slowly repeat all preoperative instructions. d. Notify the surgeon of the client's emotional status.

ANS: D Mildly anxious clients should receive the most complete instructions. Moderately anxious clients receive less information but more attention to specific areas of concern. Severely anxious clients receive only basic information but are encouraged to verbalize their concerns. Clients in a state of panic are unable to learn; in such cases, no instructions are given and the surgeon is notified.

28. Which of the following assessments of a client transferred to the post-anesthesia care unit (PACU) from the operating room would NOT necessarily indicate a postoperative complication to the nurse? a. acute inspiratory stridor with sternal retractions b. labored chest movement c. snoring d. peripheral cyanosis

ANS: D Postanesthesia nurses are responsible for managing seven areas of risk: ineffective airway clearance, ineffective breathing patterns, aspiration, decreased cardiac output, fluid volume deficit, sensory or perceptual alterations, injury, and altered thought processes. Peripheral cyanosis may be a sign of hypothermia rather than respiratory distress.

13. When a nurse conducts preoperative teaching for a client, which of these educational principles is MOST important? a. Focus on correct medical terminology. b. Begin the sessions the day before surgery. c. Give the client and family a test following the sessions. d. Use more than one teaching medium.

ANS: D Teaching methods selected in a preoperative teaching situation depend on the nursing assessment of the client. The instruction should begin as early as possible, usually as soon as the procedure is scheduled. For most clients, a one-to-one session that includes the clients' family is preferable because the nurse can personalize the information (e.g., include information about some of the sights, sounds, or feelings that the client is likely to experience). Using a variety of teaching materials (e.g., charts, pictures, brochures) reinforces the verbal information; simple written instructions can also be useful.

2. Of the common fears that clients have related to surgery, which fear is MOST prevalent and most easily addressed by nurses? a. anesthesia b. disruption of life patterns c. pain and discomfort d. the unknown

ANS: D The most common fears related to surgery are fear of the unknown, of pain and discomfort, of mutilation and disfigurement, of anesthesia, of disruption of life patterns, of death, and of not being in control. The one most easily addressed by nurses is the fear of the unknown. The nurse can provide clients with information about the surgical experience and offer appropriate support.

38. A client experiences dyspnea, chest pain, cyanosis, cough, hemoptysis, and tachycardia on the second postoperative day. Vital signs confirm the client is in shock. The nurse should recognize that the client has MOST likely developed which of these complications? a. atelectasis b. myocardial infarction c. pneumothorax d. pulmonary embolism

ANS: D The signs and symptoms of pulmonary embolism are dyspnea, chest pain, cyanosis, cough, hemoptysis, and tachycardia.