Chapters 14 & 16 Adaptive Quizzing

During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks?

"I had a heart attack 4 months ago." Cardiac problems increase surgical risks and the risk for a myocardial infarction (MI) during surgery is higher in clients who have heart problems. The type of vitamins the client takes should be assessed, but this is not the highest risk. Moderate alcohol consumption is not considered high-risk behavior. A dislike for latex is not the same as a latex allergy (however, it might be a good idea to ask why the client doesn't like latex balloons).

Which religious group's members will typically not accept blood transfusions because of their religious convictions?

Jehovah's Witnesses Clients who are Jehovah's Witnesses typically will not accept blood transfusions because of their religious convictions. Clients who are Hindus, Muslims, and Buddhists accept blood and blood products.

An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first?

Talk to the client. The nurse should determine the client's wishes and state of mind. The nurse should not call the legal department or document in the client's chart before speaking with the client. Doing nothing is not appropriate.

A client is scheduled for back surgery. Which factors may increase the risk for surgical or postoperative complications? Select all that apply.

- Diabetes - Cardiac disease - Antihypertensive drugs - Age older than 65 years Chronic illnesses increase surgical risks and should be considered when planning care. A diabetic client needs more extensive bowel preparation due to decreased intestinal motility. Cardiac disease impairs the client's ability to withstand hemodynamic changes and alters the response to anesthesia. Antihypertensive drugs are withheld on the day of surgery to reduce adverse effects on blood pressure during surgery. Age also increases the risk for complications because the normal aging process decreases immune system functioning and delays wound healing. In addition, reductions in muscle mass and body water increase the risk for dehydration. Marital status does not play any role in complication risks.

A client is scheduled for surgery. Which laboratory and/or diagnostic tests are routinely carried out before any surgery is performed? Select all that apply.

- Urinalysis - Electrolyte levels - Hemoglobin level - Blood type and screen Laboratory tests before the surgery help to obtain baseline data about the client's health and help to predict potential complications. Urinalysis provides information about any abnormal substances in the urine; any imbalance in electrolyte levels may affect anesthesia and the outcome of surgery. Hemoglobin level is essential to know if the body can tolerate hemodynamic changes during the surgery. Blood type and screen must be known in case a blood transfusion is required. An MRI examination would be performed only based on client need, medical history, and the nature of the procedure; it is not a routine test before surgery.

How often should a postoperative client be repositioned to prevent complications associated with immobility? Record your answer using a whole number. Every ___ hours

2 Factors such as location of the surgical incision and drains, and any client problems such as arthritis and chronic lung disease are considered when positioning the postoperative client. Assisting and repositioning the client every 2 hours reduces the risk for complications related to immobility.

What is the normal range of potassium for adults?

3.5-5.0 mEq/L The normal range of potassium for adults is 3.5-5.0 mEq/L. Potassium increases as a result of dehydration, renal failure, acidosis, cellular or tissue damage, and hemolysis of the specimen. Potassium levels may decrease as a result of excessive use of non-potassium-sparing diuretics, vomiting, malnutrition, diarrhea, and alkalosis.

The RN has just received reports about all of these clients on the inpatient surgical unit. Which client does the nurse care for first?

43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing New drainage on the seventh postoperative day is unusual and suggests a complication that would require further assessment and possible immediate action. A temperature of 100.4° F and pain upon coughing following bladder surgery are normal on the first postsurgical day. The client awaiting discharge teaching is not a priority.

Which client is at greatest risk for slow wound healing?

47-year-old obese man with diabetes Diabetes and obesity significantly contribute to slow wound healing. The healthy 12-year-old would likely heal quickly. The 48-year-old smoker will experience delayed wound healing, but is not as high a risk as an obese client who is diabetic. The healthy 98-year-old is not at risk for delayed wound healing.

A client who works in a warehouse has successfully undergone abdominal surgery. After how many weeks can this client return to work? Record your answer using a whole number. ___ weeks

6 A client whose work involves a moderate amount of physical labor may return to work about 6 weeks after abdominal surgery. Stress due to physical labor may lead to complications or disability if the client resumes work before 6 weeks.

The nurse is caring for a client who underwent abdominal surgery. How does the nurse assist the client with early recovery?

Assist the client to turn every 2 hours and take deep breaths. The nurse can assist the client to turn from one side to the other every 2 hours if the client is unable to get out of bed. The client should also be encouraged to take deep breaths to facilitate lung expansion. The client is generally asked to get out of bed the day or the first day after surgery to help remove secretions. The client is given pain medication 30 minutes before, not after, a walk. The nurse should teach the client to splint the incision when coughing to prevent harm to incisions.

An older adult client who is scheduled for abdominal surgery may have a risk for pulmonary complications. Which appropriate intervention may help the client to reduce pulmonary complications post-surgery?

Coughing and deep-breathing exercises Coughing and deep-breathing exercises can help prevent pulmonary complications in older adults. Changing positions at least every 2 hours helps to prevent reduced blood flow to an area and changes external pressure patterns, reducing the risk of skin-related complications. Turning and positioning help to prevent complications resulting from immobility. Observing urine color is required for the proper assessment of any potential renal or urinary complications.

An RN and an LPN/LVN are working together in caring for a client who needs all of these interventions after orthopedic surgery. Which actions would be best for the RN to accomplish?

Develop the discharge teaching plan in conjunction with the client. Education and preparation for discharge are within the scope of practice of the RN. Reinforcing the need to cough and deep-breathe and monitoring the client are within the scope of the LPN/LVN nurse. LPN/LVNs can also administer pain medications.

Which condition can cause increased pain in postoperative clients?

Excretion of anesthetic Postoperative pain usually increases on the second day after surgery. The anesthetic introduced during the surgery has been excreted and the client's pain reaches a peak. Sweating, confusion, and increased pulse rate do not result in increased pain; they are the primary assessments included in acute pain management.

A client has developed a pulmonary embolism. Which measurement is essential when ordering an antiembolism stocking size for the client?

Leg length Antiembolism stockings must be an accurate fit for the client's leg. Therefore, measurement of the client's leg length and circumference is essential before ordering the stocking size. A correct size is required for maximum benefit. Measuring the foot length, and client's height and weight is not useful for stocking size.

The nurse is attending to a client scheduled for prostate surgery. What intervention does the nurse perform for this client?

Monitor intake and output of fluids. Intake and output of fluids should be monitored in the client scheduled for prostate surgery; the client may have urine retention or incontinence. Coughing and deep-breathing exercises should be taught to the client with a loss of lung elasticity. The client with musculoskeletal complications related to osteoporosis or arthritis is taught turning and positioning. The client with sensory deficits may need to be oriented to his or her surroundings.

Which type of airway may be used in a postoperative client who has had oral surgery?

Nasal airway Airway maintenance is essential to prevent obstruction and facilitate easy passage of air. A nasal airway may be used in clients who have undergone oral surgeries. An oral airway would be used in clients who have undergone non-oral-type surgeries. A resuscitation bag is normally used for tracheotomy clients, not for clients who have just undergone oral surgery. Mechanical ventilators are used when clients are unable to breathe spontaneously.

After gastric surgery, a client arrives in the postanesthesia care unit (PACU). Which nursing action is most appropriate for the RN to delegate to an experienced nursing assistant?

Position the client on the left side. Positioning the client on the left side can be delegated to an unlicensed care provider. Airway patency requires the care of a nurse in case of emergency management requirements. Irrigating the nasogastric tube with saline is a nursing skill and care by a nurse would be required. Pain assessment is also within the scope of a nurse.

A client has an allergy to shellfish. Which other substance may the client be allergic to in conjunction with the shellfish allergy?

Povidone-iodine If the client has allergy of shellfish, the client may also have an adverse reaction to povidone-iodine. Povidone iodine used for skin cleansing contains the same allergens found in shellfish. The client with an allergy to bananas and other fruits may also have a latex sensitivity or allergy. Morphine and folic acid do not contain the same allergens as shellfish so they will likely not cause an allergic reaction in this client.

In the postanesthesia care unit (PACU), the nurse is caring for a postsurgical client. Which type of assessment is most important for the client who was given general anesthesia?

Respiratory The respiratory assessment is the most important assessment for the client who was given general anesthesia, moderate sedation, or has received sedative or opioid drugs. Skin assessment, kidney or urinary assessment, and wound assessment can be done after the client's respiratory assessment has been performed and is all clear.

Which assessment finding in a postoperative client after general anesthesia requires immediate intervention?

Respiratory rate of 6 The most important postoperative assessment is respiratory assessment, and a rate of 6 is too low. A heart rate of 58, pale and cool extremities, and a suppressed gag reflex are all normal postoperative findings.

The nurse is attending to a client who had an appendectomy. What nursing intervention does the nurse perform for this client?

Teaches the client to splint the wound when turning in bed. The client should be taught to splint the wound when turning in bed; pain drugs will be given as needed to reduce anxiety and pain during this activity. The client is generally encouraged to get out of bed the day after surgery; the nurse can assist the client into a chair or with ambulation. The client should be taught to perform leg exercises with the head of the bed elevated to 45 degrees, and instructed to turn at least every 2 hours after surgery when confined to bed.

A client is scheduled for emergency abdominal surgery. The client is unable to give consent and has no family. Who can appoint a legal guardian for the client?

The court If the client is not capable of giving consent and has no family, then the court appoints a legal guardian to represent the client's best interests. The client's friend, an attorney, or the health care provider does not have the right to appoint a legal guardian for the client.

The nurse is caring for a Jehovah's Witness client with a Foley catheter. The client had abdominal surgery under general anesthesia. What finding does the nurse report to the health care provider at the end of the 8-hour shift?

The total urine output is 160 mL/8 hr. The nurse should report to the health care provider that the client's total urine output is 160 mL/8 hr which is 10 mL/hr less than an expected 30 mL/hr. A client with an allergy to bananas will also have an allergy to latex; the client's allergy should be identified and recorded before the client is sent for surgery. The client does not agree to a blood transfusion because this is a practice against Jehovah's Witness beliefs. An estimated blood loss of 100 mL is not a cause for worry.