Complex Exam 3 Perioperative

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incision site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? SATA 1. contact the surgeon 2. instruct client to remain quiet 3. prepare the client for wound closure 4. document the findings and actions taken 5. place a sterile saline dressing and ice packs over the wound 6. place the client in a supine position without a pillow under the head

1, 2, 3, 4 Organs are covered with sterile saline dressing but NO ICE d/t vasoconstriction. Patient is put in low fowlers, kept quiet, instructed not to cough.

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a CBC, coagulation studies and electrolytes and creatinine levels. Which lab result should be reported to the surgeon's office by the nurse, knowing it could cause the surgery to be postponed? 1. Hemoglobin 8.0 2. Sodium 145 3. Serum Creatinine 0.8 4. Platelets 210,000

1. Hemoglobin 8.0

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is MOST appropriate for the nurse to make to the client at this time as it relates to techniques? 1. Use of an incentive spirometer will help prevent pneumonia 2. Close monitoring of your oxygen saturation will detect hypoxemia 3. Administration of IV fluids will prevent or treat fluid imbalance 4. Early ambulation and administration of blood thinners will prevent pulmonary embolism

1. Use of an incentive spirometer will help prevent pneumonia

The nurse receives a telephone call from the postanesthesia care unit stating that the client is being transferred to the surgical unit. The nurse plans to take which action FIRST on arrival of the client? 1. assess patency of airway 2. check tubes or drains for patency 3. check dressing to assess for bleeding 4. assess the vital signs to compare with the preoperative measurements

1. assess patency of airway ABC

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become MOST concerned with which sign that could indicate an evolving complication? 1. increased restlessness 2. pulse of 86 bpm 3. BP of 110/70 mmHG 4. Hypoactive bowel sounds in all 4 quadrants

1. increased restlessness could indicate shock, hemorrhage or PE

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states the client must be NPO after midnight. The nurse should call the surgeon to clirfy that which medications should be given to the client and NOT withheld? 1. prednisone 2. ferrous sulfate 3. cyclobenzaprine 4. conjugated estrogen

1. prednisone body is under stress

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter MOST carefully during the next hour? 1. urinary output of 20 ml/hr 2. temperature of 37.6 C (99.6F) 3. BP of 100/70mm HG 4. Serous drainage on the surgical dressing

1. urinary output of 20 ml/hr min of 30 ml/hr

The nurse is monitoring a client admitted to the hospital with a dx of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended an bowel sounds are diminished. Which is the most appropriate intervention? 1. administer prescribed pain medications 2. notify the provider 3. call and ask the operating room to perform surgery ASAP 4. Reposition the client and apply heating pad on the warm setting to client's abdomen

2. notify the provider

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. red, hard skin 2. serous drainage 3. purulent drainage 4. warm, tender skin

2. serous drainage

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is MOST likely to stimulate further discussion between the client and the nurse. 1. If it's any help, everyone is nervous before surgery 2. I will be happy to explain the entire surgical procedure to you 3. Can you share with me what you've been told about your surgery? 4. Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate

3. Can you share with me what you've been told about your surgery?

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash 2. Verify that the client has not eaten for the last 24 hours 3. Have the client void immediately before going to surgery 4. Report immediately any slight increase in BP or pulse

3. Have the client void immediately before going to surgery

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritus and has been taking acetylsailicylic acid. The nurse determines the the client needs additional teaching if the client makes which statement? 1. Aspirin can cause bleeding after surgery 2. Aspirin can cause my ability to clot to be abnormal 3. I need to continue to take the aspirin until the day of surgery 4. I need to check with my doctor about the need to stop the aspirin before the scheduled surgery

3. I need to continue to take the aspirin until the day of surgery

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which MOST appropriate action in the care of this client? 1. Obtain a court order before surgery 2. Have the charge nurse sign the informed consent immediately 3. Send the client to surgery without the form signed 4. Obtain a telephone consent from a family member, following agency policy

4. Obtain a telephone consent from a family member, following agency policy

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. Inhale as rapidly as possible 2. Keep a loose seal between the lips and the mouthpiece 3. After maximum inspiration, hold breath for 15 seconds and exhale 4. The best results are achieved when sitting up or with the head of the bed elevated 45-90 degrees

4. The best results are achieved when sitting up or with the head of the bed elevated 45-90 degrees #3 hold breath for at least 3 seconds repeat 10 -12 times every hour when awake