Client Having Surgery:Perioperative - Lippincotts ---Incomplete
62. The nurse is to administer flumazenil (Mazi-con) I.V. for reversal of sedation. Which of the fol¬lowing interventions should be included in the care plan? Select all that apply. 1. Administer the medication as a 2-mg bolus. 2. Give the medication undiluted in incremental doses. 3. Be alert for shivering and hypotension. 4. Use only a free-flowing I.V. line in a large vein. 5. Monitor the client's level of consciousness.
62. 2, 3, 4, 5. Flumazenil should be administered in small quantities such as 0.2 mg over 15 to 30 sec¬onds but never as a bolus. Flumazenil may be given undiluted in incremental doses. Adverse effects of flumazenil may include shivering and hypotension. The nurse should monitor the client's level of con¬sciousness while recovering from sedation. Fluma-zenil should be administered through a free-flowing I.V. line in a large vein because extravasation causes local irritation.
102. A client wakes up in the postanesthesia care unit and sees a drain with bright red fluid in it exit¬ing from her total hip incision. She asks the nurse, "Is this the way it is supposed to be?" Which of the following represents the nurse's best response? 1. "The drainage is blood and fluid that must be drained out for healing." 2. "Don't worry about it. I will explain it when you are more awake." 3. "This blood is being kept sterile and will be given back to you." 4. "I will give you something to make you sleep so you will not worry."
102. 1. Blood and serous fluid is drained from the operative site to prevent hematoma formation or a collection of fluid that could become a site for infec-tion. This also minimizes postoperative swelling, which can be painful. A simple explanation such as this is appropriate because the client is just wak¬ing up from surgery. Blood from the operative site can be collected through an autotransfusion system so that it can be transfused to the client during or immediately after surgery. However, strict guide¬lines about volume of blood lost, how quickly the device fills, and how long the blood has been out of the client's body govern whether the blood can be transfused. Therefore, although it is possible that the drainage system to which the client refers is an autotransfusion system, it is more likely that the client has a simple Hemovac drain. It is incorrect to tell a client not to worry about something even if she is in the drowsy state of awakening from anesthesia. It is inappropriate to ignore the client and give her something to make her drowsy instead of addressing his concerns.
112. A client has had a nasogastric tube connected to low intermittent suction. The client is at risk for which of the following complications? 1. Confusion. 2. Muscle cramping. 3. Edema. 4. Tremors.
112. 2. Muscle cramping is a sign of hypokalemia. Potassium is an electrolyte lost with nasogastric suctioning. Confusion is seen with hypercalcemia. Edema is seen with protein deficit or fluid volume overload. Tremors are seen with hypomagnesemia.
48. The nurse should do which of the following to decrease a female client's anxiety about being placed in the lithotomy position for surgery? 1. Explain in detail what will occur in the oper-ating room. 2. 3. Pad the stirrups for comfort. 4. Reassure the client that an all-female surgical team will be present.
48. 2. The nurse should first attempt to find out what the client's concerns are and address them. Providing too much information with details can increase the client's anxiety and does not address specific concerns. Padding the stirrups will provide comfort, but does not address concerns. Having an all-female team may or may not be the source of the client's concerns.
51. The nurse assesses vital signs on a client who has had epidural anesthesia. For which of the fol¬lowing should the nurse assess next? 1. Bladder distention. 2. Headache. 3. Postoperative pain. 4. Ability to move the legs.
51. 1. The last area to regain sensation is the perineal area, and the nurse should check the client for a distended bladder. The client has received a large volume of I.V. fluids since the epidural was inserted, and the client may not feel the urge to void or may be unable to void. In that case, the nurse should obtain an order to catheterize the client before the bladder becomes so distended as to cause bladder spasms. The nurse should assess for a spinal headache, postopera¬tive pain, and the client's ability to move after deter¬mining whether the bladder is distended.
57. A client with impaired cardiac functioning is at risk during anesthesia induction with thiopental sodium (Sodium Pentothal) because this drug causes: 1. Bradycardia. 2. Complete muscle relaxation. 3. Hypotension. 4. Tachypnea.
57. 3. Sodium pentothal, a short-acting barbitu¬rate, can cause hypotension, which may be espe¬cially problematic for the client with impaired car¬diac functioning. Sodium pentothal does not cause bradycardia, complete muscle relaxation, hyperten¬sion, or tachypnea.
58. The nurse anticipates that a client who has received propofol (Diprivan) as the induction and maintenance agent for general anesthesia will most likely experience: 1. Minimal nausea and vomiting. 2. Hypotension. 3. Slow induction of anesthesia. 4. Small tremors of the skeletal muscles.
58. 1. Propofol, a nonbarbiturate anesthetic, causes less nausea and vomiting because of a direct antiemetic action. It does not cause hypotension or skeletal muscle movement, and it does not act slowly.
7. The client tells the preoperative nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response? 1. Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken. 2. Tell the client that she will bring the hearing aid to the postanesthesia care unit so that she can have it as soon as she wakes up. 3. Explain to the client that she will have a pre-medication that will make her sleepy before she goes to surgery and she won't need to hear. 4. Call the surgery unit to explain the client's concern and ask if she can wear her hearing aid to surgery.
7. 4. When a client has a concern, it is impor¬tant to decrease her stress as much as possible. The nurse should call the operating room and inform the intraoperative nurse. A special container with correct identification can be prepared so that when the client is anesthetized and her hearing aid is removed, it will not be lost or broken. It is usual policy not to send personal belongings to surgery because they are easily broken or lost in the transfer of an anesthetized client with higher priority needs, but special needs do exist. In some instances the nurse does bring a client's personal belongings to the postanesthesia care unit, but in this case the item involves the client's ability to communicate. Because the trend is to use little pre¬medication, clients are more alert and may want to talk with their surgical team before going to sleep. Decreasing the client's anxieties preoperatively affects the amount of medication used to induce the client and her overall psychological and physi¬ologic status. Telling the client that she won't need to hear is insensitive.
78. A client returns to the medical-surgical floor from the postanesthesia recovery room after a colon resection for adenocarcinoma. The client has comor-bidities of stage 2 hypertension and a previous myo¬cardial infarction. The first set of postoperative vital signs recorded are pulse rate of 110 bpm, respiration rate of 20/minute, blood pressure of 130/86 mm Hg, and temperature of 98° F (36.7° C). The surgeon calls to ask if the client needs a unit of packed red blood cells. The nurse's response should be based on which data? Select all that apply. 1. Cyanotic mucous membrane. 2. Warm, dry skin. 3. Vital sign changes. 4. Oxygen saturation. 5. Intake and output.
78. 1, 3, 4, 5. When assessing a postoperative client for perfusion and the manifestation of shock, nursing assessment should include an inspection for cyanotic mucous membranes; cold, moist, pale skin; and the level of oxygen saturation in relation to hemoglobin. The nurse should also compare the client's postoperative vital signs with his preopera¬tive vital signs to determine how much physiologic stress has occurred during the intraoperative period. A client who is perfusing well would have warm, dry skin. A client well hydrated would have good skin turgor. The nurse would also assess fluid status using the intake and output record. If hemoglobin and hematocrit were available, the values would be included in the assessment.
89. On the fourth day after surgery, a client has a postoperative wound infection. Which of the follow¬ing should the nurse assess? Select all that apply. 1. Total white blood count (WBC) 10,000/mm3. 2. Redness and swelling beyond the incision line. 3. Temperature of 102° F (38.9° C). 4. 89% segmented neutrophils. 5. Incisional pain greater than on day 2.
89. 2, 3, 4. WBC count should be above normal (4,500 to 11,000/mm3) with an acute infection or inflammatory response such as a postoperative wound infection. Redness and swelling beyond the incision line is expected with a wound infection. An elevated temperature such as 102° F (38.9° C) on the third to fourth postoperative day indicates an infection process rather than an inflammatory process. An elevation in the segmented neutrophils demonstrates that the most mature WBCs have responded to the invading bacteria at the incision site, which is an expected response. Typically, post¬operative pain begins to lessen by the fourth day.
97. After surgery, a client was treated for post¬operative nausea and vomiting and now is experiencing hypotension and tachycardia. Which of the following medications would be most likely associated with these findings? 1. Ondansetron hydrochloride (Zofran). 2. Droperidol (Inapsine). 3. Prochlorperazine (Compazine). 4. Promethazine (Phenergan).
97. 2. Hypotension and tachycardia are com-mon adverse effects of droperidol and should be monitored closely by the nurse. Hypotension and tachycardia are not common adverse effects of ondansetron hydrochloride, prochlorperazine, or promethazine.
95. The nurse is teaching a client who has had a laparoscopic cholecystectomy about postoperative pain management. Which of the following statements indicates that the client has deficient knowledge? 1. "My pain is related to the gas used to distend my abdominal cavity." 2. "My diet should include eating bland foods until the gas clears up." 3. "My pain is related to the large incision and manipulation." 4. "My pain should be relieved by walking to eliminate the gas."
95. 3. The client has deficient knowledge when stating that pain from a laparoscopic cholecystec-tomy is related to a large incision and manipulation of tissue. The nurse should explain that there are four puncture sites for the incision and that gas is used to distend the abdominal cavity to keep the abdominal organs away from the operative site. There is no real manipulation of tissue to produce pain. The pain that clients do experience from this procedure is related to the gas, which irritates the diaphragm. The client should start on clear liquids and advance to bland foods until the gas is gone. Walking helps to eliminate the gas from the abdomi¬nal cavity within 12 to 24 hours after surgery.
2. The client has a latex allergy. What should the nurse teach the client to do before having sur¬gery at a free-standing surgery center? Select all that apply. 1. Determine that there will be a latex-safe envi-ronment for surgery. 2. Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing). 3. Notify the health care providers at the surgery center. 4. Wear a stainless steel medical alert bracelet into the surgical suite. 5. Ask to have the surgery at a hospital.
1, 2, 3. Treatment and diagnostic evaluation must be done in a latex-safe environment. Signs/ symptoms may be mild to anaphylaxis. Clients with latex allergy are advised to notify their health care providers and to wear a medical ID; however, all metal and jewelry must be removed prior to sur¬gery as they could conduct an electrical current. The surgery can be safely performed at a free¬standing surgery center as long as latex precautions are observed.
12. A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L. What should be the nurse's first response? 1. Call the surgeon. 2. Send the client to surgery. 3. Make a note on the front of the chart. 4. Notify the anesthesiologist.
12. 4. The nurse should notify the anesthesiolo¬gist because a serum potassium level of 5.8 mEq/L places the client at risk for arrhythmias when under general anesthesia. The surgeon may be notified; however, the anesthesiologist will make the decision about whether to proceed with surgery. The nurse should not automatically send a client with abnor¬mal laboratory findings to surgery because the pro¬cedure may be canceled. Once the client is inside the operating room and sterile supplies have opened up for the procedure, the client is usually charged. The nurse should call ahead of time to communicate the abnormal laboratory result instead of placing a note on the front of the chart. A note would not be seen until after the client has been transported to the operating room and the supplies have been opened.
101. Two days after surgery, a client continues to take hydrocodone 7.5 mg and acetaminophen 500 mg (Lortab 7.5/500). What should the nurse ask the client before administering the pain medication? 1. "Where is your pain located?" 2. "Have you emptied your bladder?" 3. "How long has it been since your last dose?" 4. "Is your pain better than before you had surgery?"
1. The nurse should ask the location of the client's pain because Lortab is an opioid, which can be constipating. By the third day, many clients become constipated and are feeling distended, with sharp, cramping pain due to gas, which is treated with ambulation, not more opioids. The client's emptying his bladder should not affect his pain level. The nurse should look at the client's chart to determine when the client's last dose of pain medi¬cation was administered, rather than asking the cli¬ent. The client's statement regarding his pain level before the surgery is not relevant to whether the nurse should administer the Lortab.
28. The nurse receives the preoperative blood work report for a client who is scheduled to undergo surgery. Which of the following laboratory findings should be reported to the surgeon? 1. Red blood cells, 4.5 million/mm3. 2. Creatinine, 2.6 mg/dL. 3. Hemoglobin, 12.2 g/dL. 4. Blood urea nitrogen, 15 mg/dL.
28. 2. The nurse should call the surgeon for a serum creatinine level of 2.6 mg/dL, which is higher than the normal range of 0.5 to 1.0 mg/dL. An elevated serum creatinine value indicates that the kidneys are not filtering effectively and has important implications for the surgical client because many anesthesia and analgesia medications need to be filtered out through the renal system. The red blood cell count, hemoglobin level, and blood urea nitrogen level are within normal limits and do not need to be reported to the surgeon.
66. The physician ordered I.V. naloxone (Narcan) to reverse the respiratory depression from morphine administration. After administration of the naloxone the nurse should: 1. Check respirations in 5 minutes because naloxone is immediately effective in relieving respiratory depression. 2. Check respirations in 30 minutes because the effects of morphine will have worn off by then. 3. Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone. 4. Monitor respirations each time the client receives morphine sulfate 10 mg I.M.
3. The nurse should monitor the client's respirations closely for 4 to 6 hours because naloxone has a shorter duration of action than opioids. The client may need repeated doses of naloxone to prevent or treat a recurrence of the respiratory depression. Naloxone is usually effective in a few minutes; however, its effects last only 1 to 2 hours and ongoing monitoring of the client's respi¬ratory rate will be necessary. The client's dosage of morphine will be decreased or a new drug will be ordered to prevent another instance of respiratory depression.
30. When administering I.V. midazolam hydro¬chloride (Versed) the nurse should? 1. Assess the blood pressure. 2. Monitor the pulse oximeter. 3. Encourage slow, deep breaths. 4. Explain relaxation techniques.
30. 3. The client should be encouraged to take slow, deep breaths because midazolam hydrochlo¬ride is a respiratory depressant. The nurse should assess the client's blood pressure, monitor the pulse oximeter, and keep the client calm and relaxed, but the client will slip into very shallow, ineffective breathing if not encouraged to deep-breathe.
56. Which explanation would be most appropri¬ate for a child when teaching him about general anesthesia induction? 1. "You will be given an injection before you go to surgery to make you sleepy." 2. "You will breathe in oxygen through a facial mask and receive intravenous medication to make you sleepy." 3. "You will receive intravenous medication to make you sleepy." 4. "You will breathe in medication through a facial mask to make you sleepy."
4. Children are induced for general anesthe¬sia by giving them medication through a facial mask to make them sleepy. Children are not induced with a injection. Children usually are not induced by use of a facial mask with I.V. administration started while they are still awake.
45. The nurse teaches a client who had cystos-copy about the urge to void when the procedure is over. What other teaching should be included? 1. Ignore the urge to void. 2. Force fluids. 3. Ask for the bedpan. 4. Ring for assistance to the bathroom.
45. 2. After a scope or catheter has been inserted into the urethra, the mucosal membrane is irritated and the client feels the need to void even though the bladder may not be full. The nurse should encour¬age the client to force fluids to make the urine dilute. The client should not ignore the urge to void. The client should be encouraged to use the bath¬room; there is no need to use the bedpan. The client does not need assistance to the bathroom because this procedure does not require any anesthesia except a topical anesthetic for the male client.
107. How often should the postoperative client's temperature be assessed during the first 24 hours after surgery? 1. Every 2 hours. 2. Every 4 hours. 3. Every 6 hours. 4. Every 8 hours.
107. 2. The client's body temperature should be assessed every 4 hours during the first 24 hours because the client is still at risk for hypothermia or malignant hyperthermia. The client does not need to be checked every 2 hours unless indicated by an abnormal finding.
81. A client had a total abdominal hysterectomy and bilateral oophorectomy for ovarian carcinoma yesterday. She received 2 mg of morphine sulfate I.V. by patient-controlled analgesia (PCA) 10 min¬utes ago. The nurse was assisting her from the bed to a chair when the client felt dizzy and fell into the chair. The nurse should: 1. Discontinue the PCA pump. 2. Administer oxygen. 3. Take the client's blood pressure. 4. Assist the client back to bed.
3. The nurse should take the client's blood pressure. She is likely experiencing orthostatic hypotension. The PCA pump does not need to be discontinued because, as soon as the blood pres-sure stabilizes, the pain medication can be resumed. Administering oxygen is not necessary unless the oxygen saturation also drops. The client should sit in the chair until the blood pressure stabilizes.
33. What therapeutic outcome does the nurse expect for a client who has received a premedica¬tion of glycopyrrolate (Robinul)? 1. Increased heart rate. 2. Increased respiratory rate. 3. Decreased secretions. 4. Decreased amnesia.
33. 3. Glycopyrrolate is an anticholinergic given for its ability to reduce oral and respiratory secre¬tions before general anesthesia. Increased heart rate and respiratory rate would be adverse effects of the drug. Amnesia should not be an effect of the drug.
82. A nurse is instructing a client who had abdominal surgery that day to do deep-breathing exercises. In which order should the nurse teach the client to perform diaphragmatic breathing and coughing? 1. Inhale through the nose. 2. Cough deeply from the lungs. 3. Exhale through pursed lips. 4. Splint the incisional site.
4. Splint the incisional site. 1. Inhale through the nose. 3. Exhale through pursed lips. 2. Cough deeply from the lungs. The client must first splint the incision to avoid increased intolerable pain or he may not cooperate with the pulmonary ventilation. The next step is to inhale oxygen to expand the alveoli for a few sec¬onds and then exhale carbon dioxide in successive steps 5 to 10 times. The client should try to cough on the end of the exhalation to remove retained secretions from the larger airways.
72. A client requests a narcotic analgesic shortly after the oncoming nurse receives change-of-shift report. The nurse who is leaving reported that the client had received morphine 10 mg (IM) within the past hour. In what order from first to last should the oncoming RN do the following actions? 1. Validate with the outgoing RN that morphine 10 mg (IM) had been administered. 2. Assess the client for manifestations of pain. 3. Check the medication documentation as to when morphine 10 mg (IM) was dispensed and to whom. 4. Check to ascertain if any discrepancy had been documented with accompanying reason/s.
72. 2, 3, 1, 4. The oncoming nurse should first assess the client for pain. Next, the nurse should check the documentation and then validate with the nurse who reported giving the medication that the medication had been given. Finally, the nurse should determine if there is a discrepancy between administration and documentation.
85. A client who had a left thoracoscopy sustained an injury secondary to the surgery position. The nurse should assess the client for: 1. Footdrop. 2. Knee swelling and pain. 3. Tingling in the arm. 4. Absence of the Achilles reflex.
85. 3. A client who had a left thoracoscopy is placed in the lateral position, in which the most common injury is an injury to the brachial plexus. Numbness and tingling in the arm suggests a bra¬chial plexus injury. There is no undue pressure on the ankles or knees during thoracic surgery.
110. Which of the following nursing interventions does not aid in meeting the goal of clear breath sounds? 1. Offering pain relief before having the client cough. 2. Providing a minimum of 1,500 mL of fluid per day. 3. Monitoring breath sounds. 4. Assisting with early ambulation.
102. 2. The client should drink a minimum of 2,500 mL of fluid per day (not 1,500 mL) to keep secretions liquefied and easier to cough up and eliminate from the upper respiratory tract. The cli¬ent should use pain medication before coughing. The nurse should monitor the client's breath sounds and temperature to detect early signs of infection. The nurse should assist with early ambulation.
105. A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which of the following indicates this client is ready to be discharged? 1. The client voids 500 mL of urine. 2. The client tolerates eating a hamburger. 3. The client is pain-free. 4. The client walks in the hallway unassisted.
105. 1. Urinary elimination in the first 8 hours postoperatively is a requirement before the client who has had an inguinal hernia repair can be dis¬charged from same-day surgery. Ingestion of fluids without nausea and vomiting is important, but eating solid foods is not a requirement for discharge from same-day surgery. Being completely pain-free is an unrealistic expectation for the time frame and is not a requirement for leaving same-day surgery. However, the client should be comfortable and his pain should be controlled. It is not a requirement for the client to ambulate in the hallway, but the cli¬ent should be able to sit up and go to the bathroom without assistance.
108. A nurse is assessing a surgical client's blood pressure 8 hours after surgery. The client's blood pressure before surgery was 120/80 mm Hg and on admission to the postsurgical nursing unit, it was 110/80 mm Hg. The client's blood pressure is now 90/70 mm Hg. What should the nurse do first? 1. Notify the health care provider. 2. Elevate the head of the bed. 3. Administer pain medication. 4. Check the intake and output record.
108. 1. The client's systolic blood pressure is drop-ping and the pulse pressure is narrowing, indicating impending shock. The nurse should notify the sur¬geon. Elevating the head of the bed will not increase the blood pressure. Administering pain medication could cause the blood pressure to drop further. The intake and output record may indicate decreased urine output related to shock but the nurse should first contact the health care provider.
31. When the nurse administers I.V. midazolam hydrochloride (Versed), the client demonstrates signs of an overdose. The nurse should next collabo¬rate with the surgical team to: 1. Ventilate with an oxygenated Ambu bag. 2. Shock the client with ECG paddles. 3. Administer 0.5 mL 1:1000 epinephrine. 4. Titrate flumazenil (Romazicon).
31. 1. The nurse should have an Ambu bag in the client's room because midazolam hydrochloride can lead to respiratory arrest if it is administered too quickly. The client does not need to be shocked back into a normal rhythm or to receive epineph¬rine unless cardiac compromise developed after the respiratory arrest. The client would receive titrated dosing of flumazenil to reverse the Versed, but first the nurse should ventilate the client.
47. A client who had a gastrectomy has been in the postanesthesia recovery room for 30 minutes when his vital signs suddenly change. The nurse checks the recovery room record (see chart). In addi¬tion to notifying the physician, what other action should the nurse take immediately? 1. Administer dantrolene. 2. Elevate the head of the bed 30 degrees. 3. Administer a bolus of I.V. fluids. 4. Insert an indwelling urinary catheter.
47. 1. The client is demonstrating signs of malignant hyperthermia. Unless the body is cooled and the influx of calcium into the muscle cells is reversed, lethal cardiac arrhythmia and hypermetab-olism occur. The client's body temperature can rise as high as 109° F (42.8° C) as body muscles contract. Dantrolene, an I.V. skeletal muscle relaxant, is used to reverse muscle rigidity. Elevating the head of the bed will not reverse the hyperthermia. Adding fluids and inserting an indwelling urinary catheter are not immediately beneficial steps in reversing the progression of malignant hyperthermia.
69. Which of the following systems is not blocked by spinal anesthesia? 1. The sympathetic nervous system. 2. The sensory system. 3. The parasympathetic nervous system. 4. The motor system.
69. 3. Spinal anesthesia does not cause para¬sympathetic blockage. The spinal anesthetic agent usually is injected into the L2 subarachnoid space, where it produces sympathetic, sensory, and motor blockade.
