Exam 4: Surgery Review

The nurse in the primary health care providers office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client ?

"These sensations lessen over several months and usually are gone after 1 year."

A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, "I don't feel any better than I did before surgery." Which response by the nurse is most appropriate?

"You are concerned that you don't feel any better after surgery?"

A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions would the nurse take? Select all that apply.

-Notify the registered nurse. -Document the client's complaint. -Instruct the client to remain quiet. -Prepare the client for wound closure.

The nurse is asking the pt who will be having surgery today about the use of taking any herbal medication. The nurse knows that all herbal medications to be d/cd within which time frame?

1-2 weeks before surgery

The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How would the nurse initially address the client's concerns?

Ask the client to discuss information known about the planned surgery.

A client arrives to the surgical nursing unit after surgery. What would be the initial nursing action after surgery?

Assess patency of the airway.

During the shift hand off, a postoperative patient reportedly has a paralytic ileus. The nurse should anticipate which of the following? SATA

An NG tube and suction may be in place Bowel sounds should be auscultated

An older adult who is scheduled for a surgical procedure expresses fear that. He is too old for surgery and asks what you think. Your response should be based on the knowledge that?

An older adult in good health is likely to do just as well in surgery as a younger person

The nurse will be caring for several older adults who will be undergoing general anesthesia. Which older adult will require the closest monitoring for a prolonged effect of anesthesia?

An older adult with increased amount of fatty tissue

The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions would the nurse take to deal with this event? Select all that apply.

Apply a sterile dressing soaked with normal saline to the wound. Notify the registered nurse (RN) and primary health care provider (PHCP) at once.

The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action?

Apply a sterile dressing soaked with sterile normal saline to the wound.

A patient with an abdominal incision reports that his dressing is soaked with drainage and that he felt a pulling sensation when getting out of bed. On Inspection, the nurse observes that a loop of intestine is protruding from the open wound. The appropriate actions is to?

Apply saline soaked gauze and cover with a sterile dry dressing

The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which actions would the nurse take? Select all that apply.

Ask how the client feels and inquire about any feelings of dizziness. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU). Review the client record to determine time and type of analgesia last received.

The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound. Which actions would the nurse take in the care of the drain? Select all that apply.

Check the drain for patency. Check that the drain is decompressed. Observe for bright red, bloody drainage. Maintain aseptic technique when emptying. Empty the drain when it is half full and every 8 to 12 hours.

The patient c/o a bad headache following spinal anesthesia. Which interventions should the nurse try first?

Lie the patient flat if not contraindicated

New LPNS are being oriented to an ambulatory surgical center. The educator should explain that the nurses responsibility when obtaining a patients signature on a surgical consent form includes?

Obtaining the signature before the patient is given sedatives

In the PACU a pts vital signs are Temp: 98 HR: 66 RR:14 BP: 100/56. Which other pieces of information is most important to allow the nurses to evaluate these vital signs?

Patients preoperative vital signs

Before surgery, the nurse knows that the pt must sign a legal form called informed consent. The nurse knows that explaining the procedure and risks to the pt is the responsibility of which member of the health care team?

Physician

Guidelines to prevent Wong site surgery include?

Confirm that the operative site is marked before giving sedating drugs Verify that the appropriate equipment is available for the procedure Confirm the surgical consent form has been signed and witnessed Verify with the pt the procedure that is expected to be performed Conduct a time out before the first incision to resolve any concerns

The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse would include which activities in the nursing care plan for the client on the day of surgery? Select all that apply.

Determine that the client has signed the informed consent for the surgical procedure. Have the client void before surgery.

The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Vital signs are: temperature: 37.9° C (100.2° F), pulse 104 beats per minute, respirations 22 breaths per minute, blood pressure 128/74 mm Hg. Oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem?

Pneumonia

The nurse is preparing preoperative medications for a patient who will be undergoing abdominal surgery. The nurse is aware that an anticholinergic drug is most likely ordered for which reason?

Reduce Salivation

Pre operative medications typically include? SATA

Sedative hypnotic agent Opioid Analgesic Antiemetic Agent Anticholinergic

A nurse is changing the postoperative dressing for a pt who had surgery 2 days ago. The wound drainage is a light pinkish color. This is documented as which type of drainage?

Serosanguineous

Complications that are most likely to occur during the immediate postoperative period include which of the following? SATA

Shock Hypoxia

The nurse is caring for a postoperative client who has been NPO, and the primary health care provider (PHCP) has prescribed a clear liquid diet. When planning to initiate this diet, which priority item would the nurse place at the client's bedside?

Suction equipment

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse would plan to place the client in which position?

Supine, with the residual limb supported with pillows

The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is nonreddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 mm3 (7.5 × 109/L). Which interpretation does the nurse make of these findings?

The incision line is slightly edematous but shows no active signs of infection.

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply.

The presence of purulent drainage Tender firmness palpable around the incision

The nurse admitted a patient with a Hx of chronic alcoholism who is scheduled for surgery in the morning. The nurse anticipates that this pts Hx will affect anesthesia in which way?

The pt will require more general anesthesia

The nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action?

The surgeon marking the area of the operative procedure

The nurse is explaining the concept of a time-out in the perioperative area. Which statement best describes the purpose of a time-out?

To allow the surgical team a chance to verbally verify its agreement about the client's name, the surgical procedure, and the site

Following a surgical procedure, the nurse applies sequential compression devices to both lower extremities and turns the machine on. The nurse implements this intervention for which purpose?

To prevent thrombosis formation in the veins

The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation?

Urinary output of 20 mL/hour

After surgery, a patient voids 10-20mL of urine at frequent intervals. You should suspect?

Urinary retention with overflow

A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, the nurse observed the client has a patent airway. Which is the next nursing assessment?

Vital signs

The nurse is caring for a patient in the preoperative area who will be undergoing palliative surgery. Which is an example of palliative surgery?

creation of an ostomy for a patient with malignant metastatic tumor of the intestine

The nurse is caring for a client following a total abdominal hysterectomy. The nurse anticipates that which postoperative outcome will be the priority in the first 24 hours following surgery?

pain

The nurse is assisting with data collection for a patient who is scheduled to have abdominal surgery requiring general anesthesia. Which finding would alert the nurse that the patient may be at increased risk for a postoperative complication?

smokes 1 to 2 packs of cig per day

A patient is recovering from a surgical procedure that was done using spinal anesthesia. The PACU nurse assesses whether the patient has sensation and movement in his legs. Why is this data especially important?

the extremities are susceptible to injury because movement returns before sensation

A patient who has had a surgical procedure is at risk for development of a postoperative wound infection. Which interventions by the nurse are appropriate for prevention? SATA

Follow aseptic technique when performing dressing changes Report increasing redness to the PCP

The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all that apply.

Frequent assessment of vital signs Coughing and deep breathing exercises Pain monitoring and medications to relieve pain

The nurse monitors a postoperative client who had abdominal surgery for signs of complications. Which signs/symptoms would the nurse determine to be indicative of a potential complication? Select all that apply.

Increasing restlessness Unrelieved pain despite receiving analgesics

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and would be reported to the primary health care provider before the surgery? Select all that apply.

Is allergic to penicillin Quit smoking 3 months earlier Wonders if the surgery could cause incontinence History of deep venous thrombosis in right leg 10 years earlier

A nurse is caring for an obese patient who had an abdominal surgical procedure 3 days ago. The patient reported a sudden "popping" feeling in the abdomen during ambulation and now can see something protruding from the surgical site. Which action by the nurse is appropriate?

Keep patinet calm with legs and knees flexed