Chapter 27 PrepU Timby

The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. What would be the nurse's most appropriate initial response?

Apply pressure to the surgical site to decrease bleeding.

Which of these clients in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse?

a client who is pale and diaphoretic with a heart rate of 115 beats/minute

A nurse working in a PACU is responsible for conducting assessments on immediate postoperative clients. What is the purpose of these assessments?

to prevent complications from anesthesia and surgery

A nurse from the ambulatory surgical center is preparing discharge instructions for a client who has had pelvic surgery. Which criterion would the client need to demonstrate to ensure that she is ready for discharge?

void normally

Which statement accurately represents a recommended guideline when providing postoperative care for the following clients?

If vital signs are progressively increasing or decreasing from the baseline, notify the health care provider of possible internal bleeding.

A nurse is caring for an older adult client who had surgery for the removal of a cataract in the left eye. Which issue would prevent the client from being discharged on the day of surgery?

Inability to ambulate

A client states having a latex allergy. Which action does the nurse take to communicate this allergy to hospital staff caring for the client?

Note the allergy on the client's record.

The nurse is providing care for a client who is postoperative day zero following abdominal surgery. Which image demonstrates the correct action the nurse will instruct the postoperative client to take to engage in deep breathing and coughing exercises during the postoperative period?

Patient holding onto pillow image

A nurse is reviewing postoperative protocols with the client, including an explanation and a demonstration of how to use an incentive spirometer. How does the nurse know that the teaching on the use of the incentive spirometer was effective?

The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed.

The nurse is preparing a client for a total hip arthroplasty and is obtaining data preoperatively. Which statement made by the client is most important for the nurse to immediately report to the health care provider?

"I've been taking ibuprofen for my hip pain twice a day."

A client who is in the holding area awaiting knee replacement surgery tells the nurse, "I am afraid of getting HIV if I have to have a blood transfusion during this surgery." What is the appropriate nursing response?

"The risk of acquiring a blood-borne disease from a blood transfusion is very small."

The procedural physician has initiated performance of a time-out in the operating room before surgery. The student nurse asks the operating room nurse why this is important. What is the operating room nurse's best response?

"The time-out checks to be sure that we have the right client and procedure."

A postoperative client asks, "Why is it important to walk and exercise my legs?" Which is the best statement by the nurse?

"Walking and leg exercises will help prevent complications."

The circulating nurse calls for a time-out prior to the surgical procedure and the surgeon states, "I don't have time for this. I have another case to follow and need to get busy." What is the best response by the circulator?

"We all have the same goal and that is the safety of the client, so let's do the time-out."

The nurse working in the holding area is performing an assessment on a client scheduled for surgery. Which question will the nurse ask prior to the client receiving general anesthesia?

"When was the last time you had anything to eat or drink?"

The nurse is caring for a client after breast augmentation. Before performing a bowel assessment, what education will the nurse provide the client?

"You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or narcotics. By listening for bowel sounds, I can check for a return of peristalsis."

A nurse is educating a client about regional anesthesia. Which statement is accurate about this type of anesthesia?

"You will be awake and will not have sensation of the procedure."

When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of:

A partial airway obstruction.

An 83-year-old client who wears glasses is scheduled for surgery. Which action should the nurse take to assure the client remains oriented?

Allow the client to wear glasses until just before anesthetic is administered.

A postoperative home care client has developed thrombophlebitis in the right leg. What new plan of care will need to be added because of this complication?

Anticoagulant treatment and education about the increased risk of bleeding

Which interventions are recommended guidelines for meeting client postoperative elimination needs?

Assess for the return of peristalsis by auscultating bowel sounds every 4 hours when the client is awake.

The nurse is caring for a client who has had abdominal surgery. Which intervention(s) will the nurse include to prevent complications for this client? Select all that apply.

Assist the client with the use of incentive spirometry. Turn the client and change position frequently. Administer analgesic medication as required.

While reviewing the medical record of a client who has had abdominal surgery, the nurse notes that the client has developed a paralytic ileus. The nurse interprets this information as indicative of what?

Bowel functioning is significantly decreased.

A nurse is working as part of an intraoperative team and is involved in the surgical verification process for a client. What would the nurse expect to be performed as the last step?

Complete the "time-out" procedure.

The nurse educates a client about what to expect after abdominal surgery. How will the nurse explain the progression of a client's diet in the postoperative period?

Food and liquids will be held in the immediate postoperative period.

A nurse is giving preoperative information to a client scheduled for outpatient surgery. What are recommended education guidelines? Select all that apply.

Have someone available for transportation home after recovery from anesthesia. List allergies and be sure the operating staff is aware of these. Notify the surgeon's office if a cold or infection develops before surgery.

The nurse has admitted a client to the postoperative unit following a bowel resection and is providing postoperative health education on coughing and deep breathing. What does the nurse explain to the client about why these actions are important?

If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia.

After conducting a preoperative health assessment, the nurse documents that the client has physical assessments supporting the medical diagnosis of emphysema. Based on this finding, which is the priority risk of complications in the postoperative period?

Impaired gas exchange

A male client is postoperative day 2 following hip replacement surgery. The nurse's morning assessment reveals that the client's bowel sounds are absent, but the client has asked for "some real food" since he has been receiving only clear fluids since his surgery. How should the nurse respond to the client's request?

Inform the care team that the client has inactive bowel sounds and ensure that further assessment is conducted.

The nurse is preparing to send a client to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the client's chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature from the client. What is the nurse's best action to the physician's request?

Inform the physician that it is their responsibility to obtain the signature.

A nurse teaches deep breathing exercises to a preoperative client. Which action should the nurse perform?

Instruct the client to exhale gently and completely before inhaling.

The nurse is supervising a nursing student who is providing postoperative education to a client with an abdominal incision. The nurse sees the student coaching the client to perform coughing exercises, as pictured above. What is the nurse's best action?

Instruct the student to provide the client with a pillow or folded blanket to hug.

A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding?

Monitor the client closely and promote fluid intake.

The healthy adult client is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first?

Notify the physician of the oversight.

A client comes to the postoperative area and reports chest pain and palpitations. What priority intervention(s) will the nurse perform? Select all that apply.

Obtain vital signs, especially heart rate and blood pressure Give sublingual nitroglycerin as prescribed Ask the client to rate pain on a scale from zero to ten

Which measure would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client?

Place graduated compression stockings on the client.

A nurse is caring for a client with a chest incision. Which action should the nurse ask the client to perform to induce forced coughing?

Pull the abdomen inward.

A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which characteristic applies to this type of surgery?

The client will be admitted the day of surgery and return home the same day.

A client has arrived to the postanesthesia care unit (PACU) and is drowsy with a respiratory rate of 12 breaths per minute. What would be an accurate interpretation by the nurse?

This is an expected finding in the immediate postoperative period.

Which client would a nurse monitor most closely for postoperative respiratory complications?

a 55-year-old client with a history of asthma who had a colon resection

Which client in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse?

a 26-year-old client who is exhibiting a crowing sound

The nurse is conducting a preoperative assessment with a client who is having abdominal surgery on the same day. When reviewing the client's medication list, the nurse recognizes the client has a higher risk of bleeding during the intra- and postoperative periods if which medication was taken?

acetylsalicylic acid

Which nursing intervention occurs in the postoperative phase of the surgical experience?

airway/oxygen therapy/pulse oximetry

Surgery can lead to hypothermia. Which client is at greatest risk for hypothermia?

an older adult man with a fractured hip

A client has been admitted to the postanesthesia care unit (PACU) after a bunionectomy. Which assessment should the PACU nurse prioritize during the client's immediate recovery from surgery?

assessing the patency of the client's airway

The nurse knows the term perioperative phase refers to care given to the client:

before, during, and after the operative phase.

The telemetry unit nurse is reviewing laboratory results for a client who is scheduled for an operative procedure later in the day. The nurse notes on the laboratory report that the client has a serum potassium level of 6.5 mEq/L (6.5 mmol/L), indicative of hyperkalemia. The nurse informs the health care provider of this laboratory result because the nurse recognizes hyperkalemia increases the client's operative risk for:

cardiac problems.

A nurse preparing an older adult client for hip replacement surgery is aware of the surgical risks related to the client's age. Which of the following accurately describes these risks? Select all that apply.

decreased thermoregulation ability decreased peripheral circulation increased vascular rigidity

The nurse is providing preoperative education to a client who is about to undergo an inguinal hernia repair. The nurse will provide education about which intervention to prevent atelectasis?

deep-breathing and coughing

The recovery nurse is caring for a surgical client in the PACU. The client's blood pressure is dropping and the heart rate is increasing. The nurse suspects the client is:

developing shock.

A client is undergoing surgery for an appendectomy. This would be considered what type of surgery?

emergency surgery

Which intervention is of major importance during preoperative education?

encouraging the client to identify and verbalize fears

Which client is most likely to see the greatest permanent changes in lifestyle following surgery?

ileostomy

Upon assessment, a client reports that he drinks five to six bottles of beer every evening after work. Based upon this information, the nurse is aware that the client may require:

larger doses of anesthetic agents and larger doses of postoperative analgesics.

An operating room nurse is bringing a client to the nurse in the postanesthesia care unit (PACU). Which information would the operating room nurse provide during a hand-off report? Select all that apply.

medications given in operating room length of surgery drains inserted in surgery

In the postoperative phase of abdominal surgery, the client reports severe abdominal pain. In the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect?

paralytic ileus

A nurse is caring for an older adult following hip surgery. Which serious complication would the nurse attempt to avoid by encouraging use of the incentive spirometer?

pneumonia

A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice? Select all that apply.

positioning the client on the operating table counting sponges before and after surgery monitoring the client's vital signs

As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site?

procedural pause (time-out)

Following a successful coronary artery bypass graft (CABG), a 71-year-old male client has been transferred to the postanesthesia care unit (PACU). What is the priority for the client's nursing care during this stage of his recovery?

protecting and maintaining the client's airway

A client scheduled for major surgery will receive general anesthesia. Why is inhalation anesthesia often used to provide the desired actions?

rapid excretion and reversal of effects

A nurse is assessing an older adult client who has undergone major bypass surgery at the health care facility. When developing the plan of care for this client in the postoperative period, what would the nurse identify as a priority assessment in the immediate period and for the first few days after the surgery?

respiratory function

A nurse has been asked to ensure informed consent for a surgical procedure. What might be a role of the nurse?

signing the consent form as a witness

A client who is being treated in the hospital has just been informed that the client's bowel obstruction will require immediate surgery, which has been scheduled for later the same morning. During the immediate preoperative period, what task must the nurse prioritize?

teaching exercises that will reduce the risk of postoperative complications

Who is legally responsible for obtaining the client's informed consent for a surgical procedure?

the surgeon

The nurse recognizes that palliative surgery is performed for what purpose?

to lessen the intensity of an illness