Ch 18 Preoperative/Postoperative Care Med Surg
According to the Joint Commission, before a patient is admitted to the OR, which pre op documentation must be attached to the chart? a. an electrocardiogram b. complete physical exam c. lab test findings, including kidney and liver function parameters d. all nursing objectives assessment plan (SOAP) notes for this admission
b. complete physical exam JCo requires that patients admitted to the operating room have a documented physical examination report attached to the chart. This document explains in detail the overall status of the patient for the surgeon and other members of the surgical team. pg 341
Which action would the nurse take to ensure the patient scheduled for surgery is not pregnant? a. Schedule an abdominal x-ray b. check Hct level c. check INR level d. check hCG level
d. check hCG level To check for pregnancy status, hCG levels are measured. X-rays to the abdomen are harmful to a fetus, so they should always be avoided in women of reproductive age if pregnancy is suspected. Hct levels indicte hemoglobin level in blood. INR is used to check for coagulation status. pg 342
5. A patient who is scheduled for a therapeutic abortion tells the nurse, Having an abortion is not right. Which functional health pattern should the nurse further assess? a. Value-belief b. Cognitive-perceptual c. Sexuality-reproductive d. Coping-stress tolerance
ANS: A
7. The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time? a. Auscultate for adventitious breath sounds. b. Obtain the patients blood pressure and temperature. c. Remind the patient about harmful effects of smoking. d. Ask the health care provider about prescribing a nicotine patch.
ANS: A The nurse should first ensure a patent airway and check for breathing and circulation (airway, breathing, and circulation [ABCs]). Circulation and temperature can be assessed after a patent airway and breathing have been established. The immediate postoperative period is not the optimal time for patient teaching about the harmful effects of surgery. Requesting a nicotine patch may be appropriate, but is not a priority at this time. DIF: Cognitive Level: Apply (application) REF: 321
6. A patient undergoing an emergency appendectomy has been using St. Johns wort to prevent depression. Which complication would the nurse expect in the postanesthesia care unit? a. Increased pain b. Hypertensive episodes c. Longer time to recover from anesthesia d. Increased risk for postoperative bleeding
ANS: C St. Johns wort may prolong the effects of anesthetic agents and increase the time to waken completely after surgery. It is not associated with increased bleeding risk, hypertension, or increased pain. DIF: Cognitive Level: Apply (application) REF: 320
The patient scheduled for surgery asks why cefazolin has been prescribed by the health care provider. Which response by the nurse is accurate? a. Cefazolin is an antibiotic given for 2 days to prevent post-op infection b. Cefazolin is an anti-inflammatory drug that will help the surgical site to heal effectively c. Cefazolin will prevent you from getting a stomach ulcer during the time before you are eating a full diet again d. Cefazolin is an analgesic that will make it easier to tolerate the continuous passive-motion machine after surgery on the knee
a. Cefazolin is an antibiotic given for 2 days to prevent post-op infection Cefazolin is a cephalosporin-type antibiotic that reduces the risk of post-op infection. When used as prophylaxis, it commonly is used for 48 hours. pg 345
Which results are expected patient outcomes of the nurse providing thorough preoperative teaching? (Select all that apply.) a. Decreased anxiety b. Reduced postoperative fear c. Diminished patient satisfaction d. Shorter length of hospitalization e. Increased recovery time after discharge f. Decreased development of complications
a. Decreased anxiety b. Reduced postoperative fear d. Shorter length of hospitalization f. Decreased development of complications Preoperative teaching increases patient satisfaction and can reduce postoperative fear, anxiety, and stress. Teaching may decrease thedevelopment of complications, length of hospitalization, and recovery time after discharge.
Which statement by a patient scheduled for surgery is most important to report to the health care provider? a. I had a heart valve replacement last year. b. I had bacterial pneumonia 3 months ago. c. I have knee pain whenever I walk or jog. d. I have a strong family history of breast cancer.
a. I had a heart valve replacement last year. A patient with a history of valve replacement is at risk for endocarditis associated with invasive procedures and may need antibiotic prophylaxis. A current respiratory infection may affect whether the patient should have surgery, but a history of pneumonia is not a reason to postpone surgery. The patients knee pain is the likely reason for the surgery. A family history of breast cancer does not have any implications for the current surgery.
A patient scheduled for an elective hysterectomy tells the nurse, I am afraid that I will die in surgery like my mother did! Which response by the nurse is most appropriate? a. Tell me more about what happened to your mother. b. You will receive medications to reduce your anxiety. c. You should talk to the doctor again about the surgery. d. Surgical techniques have improved a lot in recent years.
a. Tell me more about what happened to your mother. Subjective Data, pg 336, 337- Anxiety The patients statement may indicate an unusually high anxiety level or a family history of problems such as malignant hyperthermia, which will require precautions during surgery. The other statements may also address the patients concerns, but further assessment is needed first.
A patient arrives at the ambulatory surgery center for a scheduled laparoscopy procedure in outpatient surgery. Which information is of most concern to the nurse? a. The patient is planning to drive home after surgery. b. The patient had a sip of water 4 hours before arriving. c. The patients insurance does not cover outpatient surgery. d. The patient has not had surgery using general anesthesia before.
a. The patient is planning to drive home after surgery. After outpatient surgery, the patient should not drive home and will need assistance with transportation and home care. Surgical Settings pg. 336 Ambulatory surgery (aka same-day surgery) are usually minimally invasive such as laparoscopy, however, these procedures can involve the use of general, regional, or local anesthetic.
Which action will the nurse take when the patient going for surgery wants to give their hearing aid to their spouse so it will not be lost during surgery? a. encourage the patient to wear it for the surgery b. tape the hearing aid to the patients ear to prevent loss c. give the hearing aid to the spouse as the patient wishes d. tell the surgery nurse that the patient has the hearing aid out
a. encourage the patient to wear it for the surgery Although jewelry is removed before surgery, hearing aids should be left in place to allow the patient to better follow instructions given in the usrgical suite and the postanesthesia care unit (PACU), as well as the dismissal instructions that will be given before the patient returns home for recovery. pg 345
After signing a witnessed consent for surgery, the patient decides they no longer want to have the procedure. The patient has one adult child but no other immediate family. Which action would the nurse take next? a. inform the surgeon b. inform the adult child c. try to persuade the patient to continue with the procedure d. inform the senior nurse who witnessed the consent from the patient
a. inform the surgeon The patient has the right to revoke the consent at any time; however, this should be reported to the medical staff who obtained the consent because knowing this would help in planning the next steps. pg 344
When teaching a patient about the benefit of ambulatory surgery compared to inpatient surgery, which information is accurate? Select all that apply. a. it involves minimal lab tests b. it requires fewer pre-op medications c. it reduces the risk of hospital acquired infections d. it helps patients recover comfortably in the hospital e. it is more expensive for both patients and insurers
a. it involves minimal lab tests b. it requires fewer pre-op medications c. it reduces the risk of hospital acquired infections Ambulatory surgeries are often preferred over inpatient surgeries. These surgeries are usually minimally invasive, involve minimal laboratory tests, and require fewer pre-op meds. Because the patient recovers at home, there is a lower risk of hospital acquired infections. These surgeries are less costly for both patients and insurers. pg 336
A patient who has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take? a. Notify the dietitian about the food allergies. b. Alert the surgery center about a possible latex allergy. c. Reassure the patient that all allergies are noted on the medical record. d. Ask whether the patient uses antihistamines to reduce allergic reactions.
b. Alert the surgery center about a possible latex allergy. Certain food allergies (e.g., eggs, avocados, bananas, chestnuts, potatoes, peaches) are related to latex allergies. When a patient is allergic to latex, special nonlatex materials are used during surgical procedures, and the staff will need to know about the allergy in advance to obtain appropriate nonlatex materials and have them available during surgery. The other actions also may be ppropriate, but prevention of allergic reaction during surgery is the most important action. pg 339 Allergies
Which topic would the nurse discuss preoperatively with a patient who is scheduled for an open cholecystectomy? a. Care for the surgical incision b. Deep breathing and coughing c. Oral antibiotic therapy after discharge d. Medications to be used during surgery
b. Deep breathing and coughing Preoperative teaching, demonstration, and re-demonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. The patient does not usually need information about medications that are used intraoperatively, and that topic should be discussed with the anesthesia provider.
While performing preoperative teaching, the patient asks when to stop drinking water before surgery. Which response by the nurse is accurate? a. nothing by mouth after midnight b. nothing by mouth after breakfast c. you can drink clear liquids up to 2 hours before surgery d. you can drink clear liquids up until you are moved to the OR
c. you can drink clear liquids up to 2 hours before surgery Practice guidelines for pre op fasting state that the minimum fasting period for clear liquids is 2 hours. Evidence based practice no longer supports the long standing practice of requiring patients to have nothing by mouth after midnight. pg 344
The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action would the nurse take? a. Provide a thorough explanation of the planned surgical procedure. b. Notify the surgeon that the informed consent process is not complete. c. Give the prescribed preoperative antibiotics and withhold sedative medications. d. Notify the operating room nurse to give a complete explanation of theprocedure.
b. Notify the surgeon that the informed consent process is not complete. The surgeon is responsible for explaining the surgery to the patient. The nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurse's legal scope of practice to explain the surgical procedure. No preoperative medications should be given until the patient understands the surgical procedure and signs the consent form.
A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take? a. Withhold the usual scheduled insulin dose because the patient is NPO. b. Obtain a blood glucose measurement before any insulin administration. c. Give the patient the usual insulin dose because stress will increase the blood glucose. d. Administer a lower dose of insulin because there will be no oral intake before surgery.
b. Obtain a blood glucose measurement before any insulin administration. Preoperative insulin administration is individualized to the patient, and the current blood glucose will provide the most reliable information about insulin needs. It is not possible to predict whether the patient will require no insulin, a lower dose, or a higher dose without blood glucose monitoring.
Five minutes after receiving the ordered preoperative midazolam (Versed) by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action would the nurse take? a. Perform a straight catheterization. b. Offer the patient a urinal or bedpan. c. Assist the patient to ambulate to the bathroom. d. Tell the patient that a catheter will be placed in the operating room.
b. Offer the patient a urinal or bedpan The patiient will be at risk for a fall after receiving the sedative, so the best nursing action is to have the patient use a bedpan or urinal. Having the patient get up either with assistance or independently increases the risk for a fall. The patient will be uncomfortable and risk involuntary incontinence if the bladder is full during transport to the operating room. There is no need to perform a straight catheterization.
Which information in the preoperative patient's medication history is most important to communicate to the health care provider? a. The patient uses acetaminophen (Tylenol) occasionally for aches and pains. b. The patient takes garlic capsules daily but did not take any on the surgical day. c. The patient has a history of cocaine use but quit using the drug over 10 years ago. d. The patient took a sedative medication the previous night to assist in falling asleep.
b. The patient takes garlic capsules daily but did not take any on the surgical day. Chronic use of garlic may predispose to intraoperative and postoperative bleeding. The use of a sedative the previous night, occasional acetaminophen use, and a distant history of cocaine use will not usually affect the surgical outcome.
Which pre-op patient would the nurse most closely monitor for bleeding as a result of medication being taken? a. woman who takes metoprolol for the treatment of hypertension b. a man who is taking clopidogrel after the placement of a coronary artery stent c. A man whose type 1 diabetes is controlled with insulin injections four times daily d. A man who recently started taking finasteride for the treatment of benign prostatic hyperplasia
b. a man who is taking clopidogrel after the placement of a coronary artery stent Any drug that inhibits platelet aggregation, such as clopidogrel, represents a bleeding risk. Metoprolol, insulin, and finasteride are less likely to contribute to a risk for bleeding. pg 338
While collecting preop history, the patient reports to the nurse a history of diffuse skin rashes when hospitalized in the past as well as food allergies to bananas and avocados. Which action would the nurse take? a. notify the anesthetist to evaluate the patient b. ask additional questions to assess for a possible latex allergy c. no intervention is needed d. notify the OR staff immediately so that latex free supplies can be used
b. ask additional questions to assess for a possible latex allergy The nurse would ask additional screening questions to determine the patient's risk for a latex allergy. Risk factors for latex allergy include a history of contact dermatitis and allergies to certain foods such as eggs, avocados, bananas, chestnuts, potatoes, and peaches. pg 339
Which action will the nurse take for a patient who takes diuretics and is going for surgery? a. administer antibiotic prophylaxis b. have a serum potassium level drawn c. apply a compression device to the legs d. administer vasoactive drugs as advised
b. have a serum potassium level drawn People who take diuretics are at risk of developing low potassium levels due to fluid and sodium loss. Low potassium levels may be detrimental to cardiac health, and surgery may pose additional harm. Antibiotic prophylaxis is given if the patient has valvular heart disease. Compression devices can be applied to the legs if the patient has a risk of DVT. Vasoactive drugs are administered if the patient has hypertension. pg 339
The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. The patient reports use of garlic and Ginkgo biloba. Which action would the nurse take? a. Teach the patient that these products may be continued preoperatively. b. Advise the patient to stop the use of herbs and supplements at this time. c. Discuss the herb and supplement use with the patient's health care provider. d. Reassure the patient that there will be no interactions with anesthetic agents.
c. Discuss the herb and supplement use with the patient's health care provider. Both garlic and G. biloba increase therisk for bleeding. the nurse should discuss the herb and supplement use with the patient's health care provider. the nurse should not advise thepatient to stop thesupplements or to continue them without consulting with the health care provider and theanesthesia care provider
When caring for a preoperative patient on the day of surgery, which actions included in the plan of care can the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Teach incentive spirometer use b. Explain preoperative routine care c. Obtain and document baseline vital signs. d. Remove nail polish and apply pulse oximeter. e. Transport the patient by stretcher to the operating room.
c. Obtain and document baseline vital signs. d. Remove nail polish and apply pulse oximeter. e. Transport the patient by stretcher to the operating room. Obtaining vital signs, removing nail polish, pulse oximeter placement, and transport of the patient are routine skills that are appropriate to delegate. Teaching patients about the preoperative routine and incentive spirometer use require critical thinking and should be done by the registered nurse.
The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife usually answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching? a. Use printed materials for instruction so that the patient will have more time to review the material. b. Direct the teaching toward the wife because she is the obvious support and caregiver for the patient. c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. d. Ask the patients wife to wait in the hall in order to focus preoperative teaching with the patient himself.
c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. The nurse should allow more time when doing preoperative teaching and preparation for older patients with sensory deficits. Because the patient has visual deficits, he will not be able to use written material for learning. The teaching should be directed toward both the patient and the wife because both will need to understand preoperative procedures and teaching.
A 38-yr-old woman is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment must be communicated to the anesthesiologist and surgeon before surgery? a. The patient's lack of knowledge about postoperative pain control b. The patient's history of an infection following a cholecystectomy c. The patient reports that her last menstrual period was 8 weeks ago d. The patient's concern about being able to resume lifting heavy items
c. The patient's report that her last menstrual period was 8 weeks ago last menstrual period 8 weeks ago in a woman of childbearing age suggests that thepatient could be pregnant and pregnancy testing is needed before administration of anesthetic agents. Although theother data may also be communicated with thesurgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery.
The nurse is preparing to administer a pre op dose of cefazolin prior to an open cholecystectomy. Which explanation by the nurse about why the patient is receiving this medication is accurate? a. it will prevent post op pneumonia b. it will treat your UTI c. it will prevent post op surgical site infection d. it will remove harmful bacteria from your intestines before surgery
c. it will prevent post op surgical site infection Cefazolin has enhanced activity against a wide variety of gram negative organisms and is being used for peri op prophylaxis against infection at the surgical site. The bowel has a wide variety of bacterial flora that could contaminate the abdominal cavity during surgery. pg 345
When signing the consent, a patient states that the health care provider has not really explained what is involved in the surgical procedure. Which action will the nurse take? a. ask family members to clarify the information for the patient b. have the patient sign the form and explain the procedure to the patient c. notify the health care provider about the conversation with the patient and delay the signature d. have the patient sign the consent form and ask the HCP to discuss again before surgery
c. notify the health care provider about the conversation with the patient and delay the signature The patient should not be asked to sign a consent form unless the procedure has been explained to their satisfaction. The nurse should notify the HCP, who has the responsibility for obtaining consent. pg 344
Which patients will require administration of pre-op antibiotics? Select all that apply a. patients undergoing cataract surgery b. patients with known coronary artery disease c. patients undergoing GI surgery d. patients undergoing joint replacement surgery e. patients with a history of valvular heart diseases
c. patients undergoing GI surgery d. patients undergoing joint replacement surgery e. patients with a history of valvular heart diseases GI surgery carries a risk of wound contamination and calls for antibiotic treatment. In joint replacement surgeries, would infections can have serious consequences; therefore it is prudent to give antibiotics. In patients with a history of valvular heart disease, antibiotics may be administered to prevent infective endocarditis. Patients undergoing cataract surgery may reuquire eyedrops, and patients with a history of coronary artery disease may require B-blockers but not antibiotics. pgs 339, 345-346
A patient scheduled for surgery has been using a NSAID for pain. Which effect might the NSAID have postoperatively? a. risk for postoperative infection will increase b. postoperative atelectasis will be a problem c. risk for postoperative bleeding will increase d. DVT is more likely to occur
c. risk for postoperative bleeding will increase Although analgesics are required for surgical patients, the use of NSAIDs should be stopped before surgery because these drugs are associated with increased post op bleeding. pg 338
The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery in a few days. The results are WBC 10.2/L; hemoglobin 15g/dL; hematocrit 45%; platelets 150/L. Which action should the nurse take? a. Call the surgeon and anesthesiologist immediately. b. Ask the patient about any symptoms of a recent infection. c. Discuss the possibility of blood transfusion with the patient. d. Send the patient to the holding area when the operating room calls.
d. Send the patient to the holding area when the operating room calls. The CBC count results are normal. With normal results, the patient can go to the holding area when the operating room is ready for the patient. There is no need to notify the surgeon or anesthesiologist, discuss blood transfusion, or ask about recent infection. Normal Ranges: WBC 5000- 10,000 hemoglobin- 14-18 (M), 12-16 (F) hematocrit 42-52 (M), 37-47 (F) platelets 150k- 400k
A patient who takes a diuretic and a B-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the healthcare provider before surgery? a. Hematocrit 36% b. Blood pressure 144/82 c. Pulse rate 58 beats/minute d. Serum potassium 3.2 mEq/L
d. Serum potassium 3.2 mEq/L Normal range for potassium is 3.5-5 The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of anxiety. The lower heart rate would be expected in a patient taking a b-blocker. The hematocrit is in the low normal range but does not require any intervention before surgery.
As the nurse prepares a patient the morning of surgery, the patient refuses to remove a wedding ring, saying, I have never taken it off since the day I was married. Which response by the nurse is best? a. Have the patient sign a release and leave the ring on. b. Tape the wedding ring securely to the patients finger. c. Tell the patient that the hospital is not liable for loss of the ring. d. Suggest that the patient give the ring to a family member to keep.
d. Suggest that the patient give the ring to a family member to keep. Jewelry is not allowed to be worn by the patient, especially if electrocautery will be used. There is no need for a release form or to discuss liability with the patient.
A patient has received atropine before surgery and complains of dry mouth. Which action by the nurse is best? a. Check for skin tenting. b. Notify the health care provider. c. Ask the patient about any dizziness. d. Tell the patient dry mouth is an expected side effect
d. Tell the patient dry mouth is an expected side effect Anticholinergic medications decrease oral secretions, so the patient is taught that a dry mouth is an expected side effect. The dry mouth is not a symptom of dehydration in this case. Therefore there is no immediate need to check for skin tenting. The health care provider does not need to be notified about an expected side effect. Weakness, forgetfulness, and dizziness are side effects associated with other preoperative medications such as opioids and benzodiazepines.
18. The nurse interviews a patient scheduled to undergo general anesthesia for a hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery? a. The patient drinks 3 or 4 cups of coffee every morning before going to work. b. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. c. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital. d. The patients father died after receiving general anesthesia for abdominal surgery.
d. The patients father died after receiving general anesthesia for abdominal surgery. The information about the patients father suggests that there may be a family history of malignant hyperthermia and that precautions may need to be taken to prevent this complication. Current research indicates that having clear liquids 3 hours before surgery does not increase the risk for aspiration in most patients. Patients are instructed to discontinue aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative implications.
The nurse needs to administer pre-op meds for a patient scheduled for surgery at 0730, cefazolin IV to be infused 30 minutes prior to surgery, midazolam IV before surgery, and a scopolamine patch behind the ear. Which mediation would the nurse administer first? a. cefazolin b. fentanyl c. midazolam d. scopolamine
d. scopolamine The scopolamine patch will be administered first to allow enough time for the serum level to become therapeutic. The cefazolin will be given in the OR 30 minutes prior to surgery. Fentanyl is a narcotic and was not prescribed preoperatively. The midazolam, a short acting benzodiazepine, is used as a sedative. pg 345
Which statement is accurate regarding the hydration status of an older adult being prepared for surgery? a. it is difficult to find IV access in older patients b. skin turgor assessment is a reliable measure for dehydration in this patient c. there is an increased loss of water and electrolytes through sweating in older adults d. there is a narrow margin of safety between overhydration and underhydration in elderly patients.
d. there is a narrow margin of safety between overhydration and underhydration in elderly patients. The capacity to adapt to changes in fluid levels is low in older adult patients. The safety margin is very low between dehydration and overhydration, so the nurse should focus on the preoperative fluid balance history of this patient. pg 340