Chapter 30: Perioperative Nursing PrepU

Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? a. "I can have a hamburger and French fries as soon as I wake up." b. "The better I eat before surgery, the more likely I will heal." c. "I might be sick to my stomach and throw up after surgery." d. "When I can eat again, the best meal would include protein and vitamin C"

a. "I can have a hamburger and French fries as soon as I wake up." Oral fluid and food may be withheld until intestinal motility resumes.

A client who is scheduled to undergo coronary bypass surgery in a week asks the nurse whether he should discontinue taking his cholesterol medicine ahead of the surgery. Which should be the nurse's response? a. "I will need to check with your health care provider about that." b. "Yes—you should be off all of your medications for 24 hours before surgery." c. "No—you should stay on your normal medication schedule before the surgery." d. "You should stay on your cholesterol medicine but stop taking all other medications 12 hours before surgery."

a. "I will need to check with your health care provider about that." The client may be permitted to take certain medications before surgery. The health care provider, not the nurse, should provide guidance about which medications should be taken and which ones should be held.

An 83-year-old client who wears glasses is scheduled for surgery. Which action should the nurse take to assure the client remains oriented? a. Allow the client to wear glasses until just before anesthetic is administered. b. Give the glasses to the family until the client is returned to the room. c. Direct the client to leave glasses at home for safety. d. Allow the client to wear glasses until after anesthetic is administered.

a. Allow the client to wear glasses until just before anesthetic is administered. If an adult client is visually impaired, the nurse should allow the client to leave the glasses on until just before an anesthetic is administered. Doing so maintains visual orientation and helps to decrease fear and increase confidence. If a client is having a regional or local anesthetic, operating room personnel may allow the client to wear glasses or contact lenses during the procedure. The nurse should note any visual impairment on the chart so that operating room personnel are aware of this deficit. Glasses should not be given to the family unless the client has requested that action and there is no need for the client to leave glasses at home.

A client has presented to the outpatient surgical center for a scheduled procedure. Which action should the nurse perform prior to the procedure? a. Assess the client's allergy status. b. Encourage the client to create an advance directive. c. Have the client perform leg exercises every 30 minutes. d. Administer analgesia (pain medications).

a. Assess the client's allergy status. The nurse should assess or confirm the client's allergy status prior to surgery. An advance directive may be in place, but one would not be created on the day of surgery if it were not already established. Analgesia is not normally given preoperatively. Leg exercises should be taught and modeled preoperatively, but they do not need to be performed during this phase.

The acute care nurse is preparing a client for surgery. Which action is essential to complete before transferring the client to surgery? a. Assure that diagnostic testing has been completed and results are available. b. Place the client in a side-lying position. c. Remove graduated compression stockings. d. Mark the client's skin to indicate the location of the surgery.

a. Assure that diagnostic testing has been completed and results are available. All prescribed diagnostic tests should be performed, and results made available before the client goes to surgery. Unless otherwise indicated, no special positioning is required preoperatively. Graduated compression stockings, if prescribed, should remain in place. The surgeon, not the nurse, is responsible for marking the skin.

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? a. Food and liquids will be held in the immediate postoperative period. b. You will receive a diet high in vitamin B. c. In the immediate postoperative period, you will receive a soft diet high in carbohydrates. d. You may eat anything you want following surgery.

a. Food and liquids will be held in the immediate postoperative period. Intestinal manipulation, pain medications, and anesthetic agents may result in a decrease in intestinal motility. The client may experience nausea and vomiting. Therefore, after surgery, fluids and food are often withheld until gastric motility returns. A diet with sufficient amounts of protein and vitamins A and C (not vitamin B) helps to rebuild tissues and promotes wound healing. A soft diet with adequate (not high) carbohydrates for energy is started after the client has demonstrated tolerance to liquids well. Clients are not able to eat anything they want following surgery; the diet is usually progressed from NPO, to clear then full liquids, a soft diet, and finally a regular diet.

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? a. If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia. b. If you continue to breathe shallowly or cough ineffectively, this can lead to deep vein thrombosis (DVT) by preventing poor oxygen exchange in the cardiac and peripheral circulatory system. c. If you continue to breathe shallowly or cough ineffectively, this can lead to dizziness, falling, or an inability to ambulate because of shortness of breath. d. If you continue to breathe shallowly or cough ineffectively, this can lead to acute respiratory distress syndrome.

a. If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia. Shallow breathing or an infective cough can lead to mucus plugging, atelectasis, hypoxemia, and pneumonia. Taking deep breaths helps to expand alveoli and an effective cough pushes secretions upward out of the lungs. A client experiencing postoperative pain may be unable or unwilling to take the deep breath needed to cough. Medications used to control pain and splinting the incision by hugging a pillow or blanket increase compliance to deep breathing and coughing exercises. Shallow breathing or ineffective cough does not lead to aspiration pneumonia, inability to ambulate, or DVT. Acute respiratory distress syndrome is caused by sepsis, inhaling harmful substances, injury, and severe pneumonia that has infiltrated all five lobes and is not specific to postoperative-related pneumonia.

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? a. Inability to ambulate b. Inability to see from left eye c. Voiding on a regular basis d. Alert and oriented ×4

a. Inability to ambulate Recovery from anesthesia is usually much quicker when shorter-acting IV anesthetic agents, such used in same-day surgery. Before discharge from an ambulatory surgical unit, the client should: void (after a spinal or epidural anesthetic or after pelvic surgery), be able to ambulate, be alert and oriented, have minimal nausea and vomiting, have adequate pain/comfort control and exhibit no excess bleeding or drainage. The left eye would be covered with a dressing and the client would not be expected to see from that eye immediately.

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? a. Instruct the student to provide the client with a pillow or folded blanket to hug. b. Help the student assist the client into a high Fowler's position. c. Help the client determine whether she is able to dangle at the side of the bed. d. Remind the student to support the client while she performs the exercises.

a. Instruct the student to provide the client with a pillow or folded blanket to hug. Because coughing is often painful, the student should teach the client how to splint the incision (i.e., support the incision with a pillow or folded bath blanket). It is not normally necessary to physically support the client, and it may be unsafe for the client to dangle. The client should not be in a supine or in a low Fowler's position, but the client does not necessarily need to be fully upright.

The preoperative nurse is reviewing the chart of a client whose surgery is scheduled to begin in the next 15 minutes and notices that the consent form is not signed. The nurse contacts the surgeon who states, "We have already reviewed this procedure extensively, so ask the client to sign the consent form and I will verify it in the operating room." Which action by the nurse is appropriate? a. Keep the client in the preoperative area and inform the surgeon that it is the health care provider's responsibility to obtain consent for surgery. b. Ask the client to sign the consent; witness the signature and inform the operating room staff of the modification in the procedure. c. Send the client to the operating room and inform the staff that the consent form needs to be signed. d. Ask the operating room staff to delay the procedure until the consent is signed.

a. Keep the client in the preoperative area and inform the surgeon that it is the health care provider's responsibility to obtain consent for surgery. If a consent form is not signed, the nurse should notify the surgeon. It is the health care provider's responsibility to obtain consent for surgery and anesthesia. Preoperative medications cannot be given until the consent form is signed. The client should not proceed to surgery without a signed consent form (unless it is an emergency).

The nurse cares for a client following surgery to repair an abdominal aortic aneurysm. Which nursing intervention assists with healing and maintaining client comfort? a. Maintaining a calm environment b. Providing solid food during postoperative day 1 c. Allowing family members to visit often d. Keeping the client recumbent

a. Maintaining a calm environment The nurse should plan for adequate periods of rest and sleep and maintain a quiet, restful environment. Nursing interventions that can help promote rest include maintaining a calm environment and limiting interruptions to the client's sleep (including frequent family visits). Providing solid food and keeping the client recumbent will not assist with healing and maintaining client comfort and may be contraindicated.

The nurse is caring for a client who returned from the postanesthesia care unit 3 hours ago. The surgical dressing was dry and intact upon arrival to the postoperative unit, but now it is saturated with fresh blood. Which actions should the nurse take first? a. Reinforce the dressing with more bandages until the bleeding stops. b. Remove the dressing and inspect the wound. c. Measure vital signs. d. Draw a circle around the drainage and note the time.

a. Reinforce the dressing with more bandages until the bleeding stops. In this situation, the nurse should not remove the dressing but should reinforce it with more bandages. Removing the bandage could dislodge any clot that is forming and lead to further blood loss. Measuring vital signs would be of lower priority than reinforcing the dressing to stop the bleeding. Drawing a circle around the drainage and noting the time is not the proper first action.

The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency? a. Respiratory obstruction b. Cardiac distress c. Wound infection d. Dehydration

a. Respiratory obstruction Respiratory obstruction may occur as a result of secretion accumulation, obstruction by the tongue, laryngospasm (a sudden, violent contraction of the vocal cords), or laryngeal edema. Cardiac distress, wound infection, and dehydration are all possible postoperative complications, but respiratory obstruction is most common.

The nurse is caring for a confused older adult client who requires surgery for a broken hip. What steps does the nurse take to determine if the client has a durable power of attorney for health care and how to contact that person? a. Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact. b. Explain the client's need for hip surgery to visitors and ask them for information about a durable power of attorney for health care. c. Look on the chart for a living will if a durable power of attorney for health care cannot be located. d. Allow the surgeon to handle the issue as part of his or her legal responsibility for explaining the surgical procedure and obtaining the appropriate signature on the consent form.

a. Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact. The client cannot give consent due to confusion. In most cases, the durable power of attorney for health care document is discussed and obtained during the admission process. The nurse should act as a client advocate by seeking someone with durable power of attorney to sign the informed consent form. It is the surgeon's responsibility to explain the surgical procedure and obtain the appropriate signature on the consent form; however, the nurse still acts as the client advocate to locate the designated person. A living will specifies the types of medical treatment the client wants should the client become unable to speak in a terminal or permanently unconscious medical condition, but it does not address matters related to client confusion. Telling visitors about the need for surgery may violate client confidentiality. If the nurse identifies who they have permission to disclose medical information to, they can ask that person about a durable power of attorney for health care.

The nurse is caring for a client who had abdominal surgery yesterday and is reluctant to cough and perform deep breathing. Which strategy will most likely increase the client's willingness to cough and perform deep breathing? a. Teach the client how to splint the abdomen while coughing. b. Remind the client of the serious complications that can result from ineffective coughing and deep breathing. c. Administer respiratory treatments to encourage coughing. d. Assist the client to a side-lying position to cough.

a. Teach the client how to splint the abdomen while coughing. Splinting the abdomen decreases discomfort while coughing. Telling the client about complications will be less effective than teaching splinting techniques. Respiratory treatments are not indicated for cough production. Side-lying position is less effective than upright positioning to clear secretions and expand the lungs.

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? a. The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed. b. After taking a deep breath, the client demonstrates how to exhale into the mouthpiece while in the semi-Fowler position. c. The client explains the procedure should be completed first thing in the morning before rising from the bed. d. The client repeats the explanation and instructions in one's own words to demonstrate understanding.

a. The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed. Incentive spirometry improves lung expansion, helps expel anesthetic gases and mucus from the airway, and facilitates oxygenation of body tissues. The client is positioned in high Fowler or sitting position, inhales slowly and deeply through the mouth with lips tightly sealed around the mouthpiece of the spirometer, and exhales slowly while lips are no longer sealed around the mouthpiece. Spirometry is to be performed in the sitting position so conducting this before rising from the bed is inappropriate. Repeating instructions is a valid tool for verbal instructions, however when procedures and protocols are to be conducted the best method for determining understanding is to have the client return demonstration on how to appropriately perform the spirometry.

The healthy adult client is given an opioid 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? a. Immediately have the client sign the consent form. b. Have the client's family member sign the consent form. c. Ask the client if he still wants to proceed with the procedure. d. Notify the physician of the oversight.

d. Notify the physician of the oversight. Do not administer any medications that might alter judgment or perception before the client signs the consent form because many drugs commonly administered as preoperative medications, such as opioids or barbiturates, can alter cognitive abilities and invalidate informed consent.

A nurse is caring for a postoperative client and preparing to apply a pneumatic compression device. How does the nurse explain the device to the client prior to application? a. The device fills with air and squeezes the legs, which increases blood flow through the veins of the legs and helps to prevent blood clots. b. The device fills with air and squeezes the arms, which increases blood flow through the veins of the arms and helps to prevent blood clots. c. The device fills with air supporting the legs during ambulation so blood flow will not pool in the legs and feet, thus preventing blood clots, and squeezes the legs, which increases blood flow through the veins of the legs. d. The device fills with air and squeezes the legs which increase blood flow through the veins of the legs and should be worn in bed and while ambulating to help prevent blood clots.

a. The device fills with air and squeezes the legs, which increases blood flow through the veins of the legs and helps to prevent blood clots. A pneumatic compression device promotes the circulation of venous blood and relocation of excess fluid into the lymphatic vessels. The device is used on the legs and is worn while the client is in bed.

A nurse is instructing a client in how to perform leg exercises following surgery. The client asks the nurse, "Why do I have to do these exercises?" Which is the health reason the nurse should mention? a. To increase venous return of blood to the heart b. To strengthen the leg muscles c. To improve the efficiency of the heart d. To increase flexibility in the joints

a. To increase venous return of blood to the heart During surgery, venous blood return from the legs slows. In addition, some client positions used during surgery decrease venous return. Thrombophlebitis, deep vein thrombosis, and the risk for emboli are potential complications from circulatory stasis in the legs. Leg exercises increase venous return through flexion and contraction of the quadriceps and gastrocnemius muscles. Although leg exercises may also strengthen the leg muscles, improve the efficiency of the heart, and increase flexibility, the health reason to perform them following surgery is to increase venous return of blood to the heart.

Which factor is most important in the nurse's decision on assessment data, outcomes, and the monitoring needs of a client in preparing for surgery? a. Type of surgery b. Age of client c. Client's support system d. Type of anesthesia

a. Type of surgery Although all of these factors would need to be taken into account in planning care for a client going to surgery, the type of surgery is the most important influence on what type of care the client will require after surgery. Anesthesia and age play a role in monitoring needs postoperatively. The client needs an adequate support system when leaving the hospital, but the type of surgery influences the client's needs overall.

The nurse knows the term perioperative phase refers to care given to the client: a. before, during, and after the operative phase. b. from the start of surgery until its conclusion. c. immediately before an operative procedure. d. immediately after the operative phase.

a. before, during, and after the operative phase. Perioperative nursing includes three distinct phases: preoperative, intraoperative, and postoperative.

A nurse is caring for a client in the same-day surgery unit. The client asks the nurse, "Do I really need to be put to sleep for this surgery?" Which would be the nurse's best response? a. "You do not have to worry. It will be fine." b. "Tell me what you are most worried about." c. "I will have the anesthesiologist talk to you." d. "Have you ever had surgery before?"

b. "Tell me what you are most worried about." As the client's advocate, the nurse should first assess what the client is most worried about and then provide emotional support. The nurse would not offer false hope, reassurance, nor pass the client off to another team member. Asking if the client had surgery before would not reveal the concerns with this surgery.

A postoperative client states "I don't understand why you are checking my skin on my back. My surgery was on my stomach." What is the nurse's best response? a. "We wanted to be sure we didn't leave any sponges or syringes underneath you." b. "The operating table is a firm surface; we need to be sure your skin looks okay." c. "The covers underneath you need to be straightened out. They look messy." d. "We needed to be sure you didn't have any skin breakdown before surgery."

b. "The operating table is a firm surface; we need to be sure your skin looks okay." The client who has been on the operating table should be examined to ensure skin breakdown hasn't occurred. The client would not be told that his covers looked messy, or that the nurse was concerned about sponges or syringes underneath. The client's skin should be assessed on admission; after surgery would not be the time to do this initial assessment to document skin breakdown.

The nurse is providing education about deep-breathing exercises to a postoperative client whose surgery took place earlier today. Which instruction should the nurse provide? a. "Take off your oxygen nasal prongs during your exercises and replace them as soon as you're done." b. "Try to do your exercises every 1 to 2 hours." c. "It's best to do your exercises before a meal rather than after eating and drinking." d. "If possible, lie flat on your back while you're doing your breathing exercises."

b. "Try to do your exercises every 1 to 2 hours." Instruct the client that deep-breathing exercises should be performed every 1 to 2 hours for the first 24 hours after surgery.

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? a. "Which medications do you take daily?" b. "When was the last time you had anything to eat or drink?" c. "Can you tell me why you are here this morning?" d. "Do you want me to call the hospital chaplain before you have anesthesia?"

b. "When was the last time you had anything to eat or drink?" Determining when the last time the client had anything by mouth is important when undergoing anesthesia. The client ideally should be NPO, nothing by mouth, at least 8 hours prior to a general anesthesia to avoid aspiration during intubation. Assessing daily medications is done before surgery, not in the holding area. Asking the client to verify orientation should have been completed prior to arriving in the holding area. Asking the client if a chaplain should be called is not an appropriate action to take in the holding area.

The nurse needs to evaluate the effectiveness of a preoperative teaching session with a client scheduled for abdominal surgery. Which client statement indicates the need for further clarification? a. "I will splint my incision while I cough." b. "While my pneumatic compression device is on, I don't need to do leg exercises." c. "Every 2 hours while I am awake, I will take deep breaths and cough." d. "I will sit up in bed before using my incentive spirometer."

b. "While my pneumatic compression device is on, I don't need to do leg exercises." Compression stockings and pneumatic compression devices help to decrease the formation of thrombus by helping to promote venous return to the heart. The nurse needs to clarify that the pneumatic compression device does not replace leg exercises because the exercises help keep the joints flexible and help strengthen muscles while the client is in bed. The client is correct that splinting the incision when coughing is important. The client should sit up in bed when using the incentive spirometer, taking deep breaths and coughing. The client should take deep breaths and cough at least every 2 hours while awake to help expand lungs, loosen secretions, and help prevent atelectasis and pneumonia.

An older adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client? a. Dementia b. Delirium c. Opioid overuse d. Boredom

b. Delirium Delirium refers to acute confusion that is reversible. It is common in the acute postoperative period.

A nurse is giving preoperative information to a client scheduled for outpatient surgery. What are recommended education guidelines? Select all that apply. a. Continue with all medications routinely taken. b. Notify the surgeon's office if a cold or infection develops before surgery. c. List allergies and be sure the operating staff is aware of these. d. Wear clothing without buttons or zippers. e. Have someone available for transportation home after recovery from anesthesia.

b. Notify the surgeon's office if a cold or infection develops before surgery. c. List allergies and be sure the operating staff is aware of these. e. Have someone available for transportation home after recovery from anesthesia. The nurse should list medications routinely taken and ask the physician which should be taken or omitted the morning of surgery. The nurse should also have the client notify the surgeon's office if a cold or infection develops before surgery. The nurse should list allergies and be sure the operating staff is aware of these. The nurse should tell the client to wear clothing that buttons in front. The nurse should tell the client to have someone available for transportation home after recovery from anesthesia. The nurse should also inform the client of limitations on eating or drinking before surgery, with a specific time to begin the limitations.

A nurse caring for clients in a PACU assesses a client who is displaying signs and symptoms of shock. What is the priority nursing intervention for this client? a. Remove extra coverings on the client to keep temperature down. b. Place the client in a flat position with legs elevated 45 degrees. c. Do not administer any further medication. d. Place the client in the prone position.

b. Place the client in a flat position with legs elevated 45 degrees. Placing the client in a flat position with the legs elevated 45 degrees uses gravity to help direct blood to the vital organs. Removing extra coverings would cause the client's temperature to drop further during the blood loss occurring during shock. Medications will likely be ordered to help treat the shock. Prone position would be contraindicated.

Which nursing action will assist in pain management for a client in the postoperative phase? a. Client education b. Relaxation techniques c. Dim lighting d. Provide food and medication

b. Relaxation techniques Nursing interventions vital in helping clients cope with pain include administering medications, positioning, relaxation techniques, psychological support, distraction techniques, and appropriate referrals to other health professionals.

Which methods would the nurse anesthetist use when administering regional anesthesia to surgical clients? Select all that apply. a. Inhalation b. Spinal block c. Intravenous d. Oral route e. Nerve block f. Epidural block

b. Spinal block e. Nerve block f. Epidural block Regional anesthesia occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. Regional anesthesia includes spinal blocks, nerve blocks, and epidural blocks. Inhalation and intravenous administration of anesthesia are associated with general anesthesia. Anesthesia is not administered via the oral route.

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. a. increased cardiac output b. decreased peripheral circulation c. increased vascular rigidity d. increased oxygenation of blood e. decreased thermoregulation ability

b. decreased peripheral circulation c. increased vascular rigidity e. decreased thermoregulation ability Older adults have decreased cardiac output, decreased peripheral circulation, decreased oxygenation of blood, decreased thermoregulation ability, and decreased skin moisture and elasticity. Older adults have increased vascular rigidity.

A nurse is reinforcing wound edges and applying a blinder to the separated incisions of a client after a surgery. Which postoperative complication has the client developed? a. hypoxemia b. dehiscence c. evisceration d. shock

b. dehiscence The nurse is taking care of a client with dehiscence. Hypoxemia develops when there is inadequate oxygenation of blood. Evisceration occurs when there is protrusion of abdominal organs through a separated wound. A client has shock when there is inadequate blood flow.

When preparing a client who has diabetes mellitus for surgery, the nurse should be aware of what surgical risk associated with this disease? a. fluid and electrolyte imbalance b. slow wound healing c. respiratory depression from anesthesia d. altered metabolism and excretion of drugs

b. slow wound healing Due to impaired circulation and high glucose levels, the client with diabetes is at an increased risk for slow wound healing. The surgical risk of fluid and electrolyte imbalances is often associated with clients who have kidney and liver disease. The risk of respiratory depression from surgery increases for clients with existing respiratory disorders. Altered metabolism may occur as a result of surgery for clients with kidney and liver diseases.

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? a. verbalize absence of pain b. void normally c. eat without nausea d. exhibit no bleeding

b. void normally Before discharge from an ambulatory surgical unit, the client should be able to void normally after a pelvic surgery. It is natural for the client to experience pain after surgery; however, the client should also have the comfort level to control it. The client may not be in a position to eliminate nausea and vomiting completely before discharge, but should suffer minimally from them. The client may have some bleeding or drainage, which should not be excessive at the time of discharge from an ambulatory surgical unit.

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? a. "I have not had anything to eat or drink for 8 hours." b. "My hip pain has prevented me from doing the things I enjoy." c. "I've been taking ibuprofen for my hip pain twice a day." e. "My other hip will probably need to be done eventually."

c. "I've been taking ibuprofen for my hip pain twice a day." The nurse should immediately report the use of ibuprofen twice daily for the hip pain since this medication can cause the complication of postoperative bleeding. The history of hip pain and the inability to perform activities that were previously enjoyed are not relevant in determining complications. The intake of food or fluids is relevant, but the amount of time the client has been NPO is acceptable and reduces the risk of complications from anesthesia.

The nurse is caring for a client after breast augmentation. Before performing a bowel assessment, what education will the nurse provide the client? a. "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By lightly pressing on the abdomen, I can check for a return of peristalsis." b. "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By pressing on the symphysis pubis, I can check for a return of peristalsis." c. "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By listening for bowel sounds, I can check for a return of peristalsis." d. "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By giving you sips of water periodically, I can promote the return of peristalsis."

c. "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By listening for bowel sounds, I can check for a return of peristalsis." A postoperative client can typically have decreased or absent peristalsis because of bowel manipulation and/or administration of anesthetic agents or opioids. Auscultation of bowel sounds will help determine a return of peristalsis. Palpating the abdomen would not help with determining peristalsis return; the nurse may feel distention and firmness of the abdomen with decreased peristalsis, but this is not accurate in determining return of peristalsis. The symphysis pubis would be assessed to determine bladder fullness, not peristalsis. Giving the client sips of water would not help determine or promote the return of peristalsis; this also could be a safety issue if the client has decreased peristalsis due to emesis and subsequent potential aspiration.

A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first? a. Check the client's blood pressure. b. Apply an oxygen saturation monitor. c. Apply warm blankets to the client. d. Notify the health care provider.

c. Apply warm blankets to the client. The nurse should apply warm blankets to the client because the client is hypothermic with a temperature of 96.2°F (35.7°C). The client can be assessed further by checking vital signs and using an oxygen saturation monitor. The health care provider should be notified about the client's temperature but an intervention should be done first to ensure the client begins warming immediately.

A nurse is teaching a client about the rationale for fasting from food and fluids prior to surgery. What condition does this measure attempt to avoid? a. Infection b. Respiratory distress c. Aspiration d. Bowel alterations

c. Aspiration Food and fluid are restricted before surgery to ensure that the stomach contains a minimal amount of gastric secretions. This restriction is important to reduce the risk of aspiration.

A nurse is interacting with a client in the outpatient surgical unit intraoperatively. What is the nurse's priority responsibility? a. Educating the client about postoperative protocols b. Establishing a nurse-client rapport c. Client safety d. Providing emotional support for the client and family

c. Client safety Client safety is the most important nurse responsibility during the intraoperative phase. Safety concerns include equipment, electrical, chemical, radiation, surgical verification, client transport and positioning, and continuous asepsis. Postoperative protocol education is done preoperatively. Establishing a nurse-client rapport and providing emotional support are important, but they are not the most important nursing responsibility during the intraoperative phase.

A nurse teaches deep breathing exercises to a preoperative client. Which action should the nurse perform? a. Assist or place the client in a supine position for the exercises. b. Instruct the client to place the palms of both hands along the upper posterior rib cage. c. Instruct the client to exhale gently and completely before inhaling. d. Instruct the client to breathe in through the nose as deeply as possible and hold the breath for 10 seconds.

c. Instruct the client to exhale gently and completely before inhaling. The nurse should assist the client to sit up and place the palms of both hands along the lower anterior rib cage. The client should then exhale gently and completely inhale through the nose as deeply as possible, holding the breath for 3 seconds.

The nurse is caring for a client postoperatively. The vital signs are blood pressure 88/50 mm Hg, heart rate 110 beats/min, respiratory rate 24 breaths/min. The client stated the pain in the abdomen will not stop. The abdominal dressing is saturated with fresh blood. Along with notifying the surgeon, what is the nurse's priority in this situation? a. Reinforce the abdominal dressing. b. Provide prescribed pain medication. c. Place in supine position. d. Assess urine output.

c. Place in supine position. The client is hemorrhaging from the abdominal incision and has symptoms of shock: hypotension, tachycardia, increased respirations. The nurse's priority is to place the client in supine position to help increase the blood pressure by increasing the blood return to the heart. The supine position will also decrease intra-abdominal pressure and help take pressure off the incision. The nurse can quickly assess urine output, which may be decreased due to hypovolemia from the blood loss and subsequent shock. The nurse can reinforce the abdominal dressing to absorb drainage. The nurse should not remove the dressing because this would lead to removal of the clot formation and increase bleeding. Because the client is hypotensive, the nurse would need to reassess blood pressure before administering certain prescribed opioid analgesics since the med could lower the blood pressure more. The nurse would stay with the client until the client is stable.

A nurse is assessing a client who is experiencing pulmonary embolus. What would be the priority nursing intervention for this client? a. Attempt to overhydrate the client with fluids. b. Instruct the client to perform Valsalva maneuver. c. Place the client in semi-Fowler's position. d. Assist the client to ambulate every 2 to 3 hours.

c. Place the client in semi-Fowler's position. Nursing interventions include notifying the physician immediately, calling the medical intervention team, maintaining the client on bed rest in the semi-Fowler's position, assessing vital signs frequently, administering oxygen, administering medications (e.g., anticoagulants, analgesics), and instructing the client to avoid Valsalva maneuver (this prevents increased intrathoracic pressure and, possibly, increased emboli).

The nurse is caring for a client who had a procedure under moderate sedation at the ambulatory surgical center. Which assessment finding indicates to the nurse that the client may be ready for discharge to home? a. The client is alert and oriented with a blood pressure 122/74 mm Hg and respirations 18 breaths/min, able to ambulate, is not nauseated or vomiting, reports a pain level of 5 on a 0-10 scale, and has no excessive bleeding or drainage. b. The client is alert and oriented with a blood pressure 102/60 mm Hg and respirations 18 breaths/minute, is slightly dizzy, but not nauseated or vomiting, denies pain, and has no excessive bleeding or drainage. c. The client is alert and oriented with a blood pressure 118/70 mm Hg and respirations 18 breaths/minute, is able to ambulate, is not nauseated or vomiting, pain is controlled with medication, and has no excessive bleeding and drainage is as expected. d. The client is alert and oriented with a blood pressure of 136/90 mmHg and respirations 18 breaths/minute, states mild nausea but no vomiting, pain under control with pain medication, able to void and pass gas, and has mild expected drainage.

c. The client is alert and oriented with a blood pressure 118/70 mm Hg and respirations 18 breaths/minute, is able to ambulate, is not nauseated or vomiting, pain is controlled with medication, and has no excessive bleeding and drainage is as expected. Stable vital signs, being alert and oriented, ability to ambulate, minimal nausea and vomiting, adequate pain control, and no excessive bleeding or drainage may indicate that the client is ready for discharge to home. The ability to void is a criterion after a spinal anesthesia or after pelvic surgery. Dizziness or inadequate pain control indicate that the client still needs to be monitored before discharge. Elevated blood pressure should be monitored and the client should not be discharged until stable.

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. the effects of anesthesia. b. the normal return of reflexes. c. a partial airway obstruction. d. the type of surgery.

c. a partial airway obstruction. Loud, irregular respirations may indicate obstruction of the airway, possibly from emesis, accumulated secretions, or client positioning that allows the tongue to fall to the back of the throat.

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? a. operative site marking b. preoperative checklist c. procedural pause (time-out) d. informed consent

c. procedural pause (time-out) The procedural pause (time-out) must be done prior to any procedure to ensure client safety and to verify the client identity, staff roles, and procedure being performed.

A nurse is preparing a client for endotracheal intubation. The anesthesiologist has ordered an anticholinergic medication for this client. What is an action of this medication? a. It promotes induction of anesthesia. b. It decreases gastric acidity and volume. c. It promotes sleep or conscious sedation. d. It decreases respiratory secretions.

d. It decreases respiratory secretions. An anticholinergic medication decreases respiratory secretions and prevents vagal nerve stimulation during endotracheal intubation. Antianxiety drugs slow motor activity and promote the induction of anesthesia. Histamine-2 receptor antagonists decrease gastric acidity and volume. Sedatives promote sleep or conscious sedation.

A client states having a latex allergy. Which action does the nurse take to communicate this allergy to hospital staff caring for the client? a. Inform the client to tell the anesthesiologist. b. Obtain latex-free gloves for the client's room. c. Place a sign on the client's bed. d. Note the allergy on the client's record.

d. Note the allergy on the client's record. Assessing the client for allergies to medications, food, and latex when in a health care facility is an important task of the nurse. Clearly marking the client's allergies on the client's record will communicate to all health care personnel who interact with the client. It is not the client's responsibility to notify the anesthesiologist; the allergy should be clearly noted on the medical record. Obtaining latex-free gloves for the client's room is an appropriate intervention, but it will not communicate to all hospital staff the client's allergy. Placing a sign on the client's bed will inform bedside caregivers of the allergy, but clearly marking the medical record will inform all health care staff of the client's allergy.

Which measure would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client? a. Educate the client about the use of an incentive spirometer. b. Encourage the client to elevate the head of the bed. c. Elevate bilateral legs when the client is lying in bed. d. Place graduated compression stockings on the client.

d. Place graduated compression stockings on the client. Use of graduated compression stockings and/or pneumatic compression devices on the client will help with prevention of DVT, which is a risk for clients after surgery. Elevating the client's legs will passively improve venous return but not prevent DVT if a client is not up and walking (to more actively promote the venous return). Elevating the head of the bed and using the incentive spirometer help prevent postoperative complications of atelectasis or pneumonia.

The nurse is teaching the client who recently experienced abdominal surgery to deep breathe and cough effectively. What observable action serves to best minimize pain that may result from the intervention? a. Supporting the head and shoulders effectively to prevent muscle strain b. Exhaling through the mouth with lips pursed to slowly empty the lungs c. Offering emotional support to help minimize concern of abdominal pain d. Providing support to abdominal and accessory respiratory muscles

d. Providing support to abdominal and accessory respiratory muscles Coughing and deep breathing uses abdominal and accessory respiratory muscles, which may have been cut during surgery. Splinting, in this case with a pillow, supports the incision and surrounding tissues and reduces pain during coughing and deep breathing exercises. While providing emotional support is appropriate, doing so will not affect physiological pain resulting from the intervention. Exhaling with lips pursed increases resistance in the airways, which helps them stay open during exhalation. Supporting the head and shoulders adds to the client's comfort, but doing so does not address the primary source of pain produced by therapeutic coughing and deep breathing.

The nurse is taking a history on Kumar, who informs her that he has an allergy to adhesive tape. When the nurse asks Kumar to describe his reaction to the tape, he describes it as "blotchy and reddened." What type of allergic reaction is this? a. Type I b. Type II c. Type III d. Type IV

d. Type IV A type IV reaction is characterized by local inflammation, pruritus and erythema.

Which client in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse? a. a 30-year-old client who is drowsy and reporting pain b. a 6-year-old client who is crying for a parent to visit c. an 80-year-old client who is disoriented to place and time d. a 26-year-old client who is exhibiting a crowing sound

d. a 26-year-old client who is exhibiting a crowing sound A client with a crowing sound is exhibiting stridor, which is an indication of an airway obstruction and can be a respiratory emergency. This client needs immediate attention. The client with disorientation needs to be frequently reoriented and observed for safety reasons but is not a priority over respiratory distress. The client who needs pain medication or the pediatric client requesting a parent are also not priority over a client in respiratory distress.

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: a. overmedicated. b. experiencing normal adaptation to the postoperative period. c. allergic to the anesthesia. d. developing shock.

d. developing shock. Decreasing blood pressure and an increased pulse rate in the postoperative client are significant because they may signify hemorrhage or shock.

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? a. normal response b. abdominal infection c. hernia development d. paralytic ileus

d. paralytic ileus A potential complication after surgery is paralytic ileus, a condition in which there is decreased bowel functioning.

The nurse has been waiting until after the administration of a toddler's anesthesia before removing the child's clothing and applying monitoring equipment. Doing these actions after the administration of anesthesia will: a. minimize blood loss. b. enhance thermoregulation. c. provide more accurate baseline vital signs. d. prevent anxiety.

d. prevent anxiety. Relaxation can be enhanced by removing the child's clothing, applying the grounding pad, and applying monitoring devices after the child is anesthetized. This action has no effect on vital signs, thermoregulation, or blood loss.