Fundamentals CH. 39 Perioperative Nursing

Which patient does the nurse classify as facing the highest surgical risk? a)40-year-old with hepatitis secondary to past IV drug use b)83-year-old with medically controlled hypertension c)6-month-old with congenital heart anomaly and early stage liver disease d)28-year-old taking anticoagulants secondary to mitral valve prolapse

c)6-month-old with congenital heart anomaly and early stage liver disease

To promote deep breathing, coughing, and turning by a postoperative patient on the first postoperative day, the best action by the nurse would be to: a)Teach the patient the purpose of respiratory care and ambulation b)Provide constant reinforcement for accomplishing these activities c)Assess the patient's pain level before these activities d)Emphasize the complications of immobility and poor cough effort

c)Assess the patient's pain level before these activities

The nurse is caring for a patient with a Salem sump double lumen nasogastric (NG) tube to suction. The patient complains of nausea and has mild abdominal distention. What is the nurse's priority action? a)Administer an antiemetic. b)Replace the nasogastric tube. c)Check placement of the NG tube. d)Irrigate the NG tube.

c)Check placement of the NG tube.

Surgeries are commonly classified by which of the following? Select all that apply. a)Acuity b)Level of urgency c)Length of surgery d)Organ involved

a)Acuity b)Level of urgency

The nurse is caring for a patient who is wearing antiembolism compression stockings. The patient repeatedly complains of discomfort caused by the stockings. What actions will the nurse take to improve comfort? Select all that apply. a)Assess to determine whether the stockings are the correct size. b)Remove the stockings for the remainder of the shift. c)Ensure there are no wrinkles or rolled areas in the stockings. d)Check that the stockings are on straight and the heel is in the right place. e)Make sure the closed toe is molded to the toes.

a)Assess to determine whether the stockings are the correct size. c)Ensure there are no wrinkles or rolled areas in the stockings. d)Check that the stockings are on straight and the heel is in the right place.

A patient had a colon resection for removal of a cancerous tumor. Postoperatively, on the surgical floor which of the following activities would the nurse perform for the purpose of decreasing the risk of postoperative complications? Select all that apply. a)Assist the patient to turn, breathe deeply, and cough every 2 hours. b)Teach the patient about the type of tumor removed. c)Assess the drainage from the surgical site. d)Monitor vital signs on a regular basis.

a)Assist the patient to turn, breathe deeply, and cough every 2 hours. c)Assess the drainage from the surgical site. d)Monitor vital signs on a regular basis.

The nurse is caring for a patient who had abdominal surgery 3 days ago and will be discharged home later today. The nurse will know that teaching is effective if the patient does which of the following? Select all that apply. a)Describes clinical findings associated with infection b)Performs the dressing change as prescribed c) Demonstrates absence of surgical incision pain d)Completes the regimen of prescribed antibiotics

a)Describes clinical findings associated with infection b)Performs the dressing change as prescribed d)Completes the regimen of prescribed antibiotics

A 2-year-old child is scheduled for a tonsillectomy. When determining the plan of care, the nurse should: a)Include the parents or caregivers in the plan of care b)Explain to the child that she will have a sore throat after surgery c)Tell the child that she can have her favorite foods for the first 24 hours after surgery d)Prepare the child for discharge from the hospital as soon as she is alert

a)Include the parents or caregivers in the plan of care

The preoperative nurse is preparing a patient for surgery. Identify the interventions the nurse will perform. Select all that apply. a)Inform the family to wait in the surgical waiting room. b)Prepare the surgical suite for the operation. c)Remove the patient's dentures and contact lenses. d)Assist the patient to complete a living will.

a)Inform the family to wait in the surgical waiting room. c)Remove the patient's dentures and contact lenses.

The perioperative nurse maintains the safety of the patient during surgery with which of the following goals? Select all that apply. a)Preventing infection b)Improving the accuracy of patient identification c)Preventing mistakes in surgery d)Obtaining signed consent for surgery e)Keeping the family informed of patient's status

a)Preventing infection b)Improving the accuracy of patient identification c)Preventing mistakes in surgery

The nurse is caring for a patient scheduled for repair of a torn rotator cuff. The nurse understands that this surgery will be classified as: a)Reconstructive, minor, elective b)Cosmetic, minor, urgent c)Ablative, major, emergency, d)Reconstructive, major, urgent

a)Reconstructive, minor, elective

The nurse admits a patient to the postoperative unit following gastric bypass surgery for weight loss. Based on the patient's history, the nurse determines that the priority nursing diagnosis for this patient is: a)Risk for infection b)Delayed Surgical Recovery c)Chronic pain d)Risk for Deficient Fluid Volume

a)Risk for infection

The staff RN is assigned to an operation with an operating room LPN. The physician employs another RN who will be first assistant for the operation. What role will the staff RN play? a)Scrub nurse b)Anesthesiologist c)Circulating nurse d)Technician

c)Circulating nurse

In the emergency department (ED), the patient is diagnosed with a dislocated humerus. What type of anesthesia would the nurse anticipate will be used to repair the dislocation in the ED? a)General b)Epidural c)Conscious sedation d)Local

c)Conscious sedation

The focus of nursing care in the intraoperative phase is to: a)Prepare the patient for surgery b)Maintain the sterile field c)Ensure patient safety during the surgery d)Obtain a signed informed consent

c)Ensure patient safety during the surgery

A patient is scheduled for abdominal surgery tomorrow. While gathering preoperative data, the nurse learns that the patient takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E. The patient reports that he stopped taking the anticoagulant 4 days ago as instructed by the surgeon. He has continued to take the multivitamin and vitamin E. Based on the information given, the nurse notifies the surgeon because she: a)Needs an order to restart the anticoagulant b)Is concerned about continued use of the multivitamin c)Is concerned about the vitamin E d)Has canceled the surgery so more lab tests can be done.

c)Is concerned about the vitamin E

Identify the type of surgery a terminally ill patient will undergo if the purpose is removal of tissue to relieve pain. a)Procurement b)Ablative c)Palliative d)Diagnostic

c)Palliative

The intraoperative nurse observes the anesthesiologist administer general anesthesia, insert the endotracheal tube, and take control of the airway. The nurse understands that the next important nursing intervention for this patient is to: a)Prepare the surgical site b)Shave the surgical site c)Position the patient d)Pad bony prominences

c)Position the patient

The nurse admits a patient who is scheduled for surgery tomorrow morning. The nursing admission assessment indicates that the patient is mildly anxious about the procedure, does not drink alcohol or smoke, is married with two children, and is allergic to kiwi, avocados, and penicillin. The nurse identifies the priority nursing diagnosis for this patient as: a)Fear b)Anxiety c)Risk for Latex Allergy Response d)Ineffective Airway Clearance

c)Risk for Latex Allergy Response

Which of the following describes the Perioperative Nursing Data Set? Select all that apply. a) A standardized tool for assessing high-risk surgical patients b) A standardized vocabulary encompassing all surgical patient outcomes c)The first specialized nursing language recognized by the ANA d)A standardized language designed to describe the care of perioperative patients

c)The first specialized nursing language recognized by the ANA d)A standardized language designed to describe the care of perioperative patients

The postoperative patient is admitted to the postanesthesia care unit (PACU) with an oral airway in place, an indwelling urinary catheter, IV fluid infusing via two different sites, and a Jackson-Pratt drain pinned to the gown near the wound dressing. What is the nurse's priority action after the patient is moved to the bed? a)Check the wound dressing. b)Obtain vital signs. c)Turn the patient's head to the side. d)Hang the urinary drainage bag on the bed frame.

c)Turn the patient's head to the side.

A patient has chronic confusion secondary to dementia. As a result, he is unable to sign an informed consent for surgery. In this situation: a)An informed consent is not needed b)Two nurses may sign the informed consent for the patient c)The surgeon must sign the informed consent d)A family member will be asked to sign the informed consent

d)A family member will be asked to sign the informed consent

A patient is to have a sequential compression device (SCD) applied on the postoperative unit. The patient is wearing knee-high elastic (antiembolism) stockings. When applying the SCD, what should the nurse do? a)Remove the antiembolism stockings and not replace them. b)Replace the knee-high stockings with thigh-high stockings. c)Notify the surgeon that the patient is wearing antiembolism stockings. d)Apply the SCD over the knee-high antiembolism stockings.

d)Apply the SCD over the knee-high antiembolism stockings.

The student nurse is assigned to a patient through the entire perioperative period and identifies the time when the preoperative phase ends and the intraoperative phase begins as when the patient: a)Receives the preoperative medication b)Is taken to the holding area c)Leaves the holding area d)Enters the operating room

d)Enters the operating room

The postoperative patient returned to the surgical nursing unit at 1:30 p.m. The evening shift nurse receives the report and begins working at 3:30 p.m. How often will the evening shift nurse take this patient's vital signs? a)Immediately, then every 30 minutes for the next 2 hours b)Immediately, then every hour for the next 4 hours c)Every hour beginning 30 minutes from now until end of shift d)Immediately, then every 30 minutes 2 more times, then hourly

d)Immediately, then every 30 minutes 2 more times, then hourly

Which of the following is the most appropriate nursing goal for a 2-year-old who is to have a tonsillectomy? a)Separation anxiety will be minimal. b)The child will verbalize understanding of expected pain. c)The child will tolerate a normal diet 24 hours after surgery. d)The parent will indicate readiness to assume the child's care.

a)Separation anxiety will be minimal.

Which of the following members of the operative team use sterile technique during the surgical procedure? Select all that apply. a)Surgeon b) Anesthetist c)Scrub nurse d)Registered nurse first assistant

a)Surgeon c)Scrub nurse d)Registered nurse first assistant

A patient returns from surgery with a nasogastric tube and intermittent gastric suction to provide abdominal decompression. Which of the following are correct nursing activities for managing the equipment and drainage? Select all that apply. a)Wear nonsterile procedure gloves when emptying the drainage container. b)When irrigating the nasogastric tube, use sterile water. c)Wear sterile gloves when irrigating the nasogastric tube. d)Apply water-soluble lubricant if the patient's lips are dry.

a)Wear nonsterile procedure gloves when emptying the drainage container.

Identify the desired effects of general anesthesia. Select all that apply. a)Reduction of risk b)Analgesia c)Amnesia d)Muscle relaxation

b)Analgesia c)Amnesia d)Muscle relaxation

The patient tells the nurse, "I'm so nervous. I want to be knocked out for the surgery so that I don't know what is going on." When the nurse communicates with the surgeon and anesthetist, she tells them that the patient desires which type of anesthesia? a)Conscious sedation b)General anesthesia c)Local anesthesia d)Regional anesthesia

b)General anesthesia

A patient is admitted from a local skilled nursing facility to the outpatient surgery center for surgical debridement of a stage IV sacral pressure ulcer. The perioperative nurse discovers that the patient does not have a signed consent form for the surgery on the chart or in the surgery center. The patient says that she has not talked to the surgeon and that she has many questions regarding her surgery. When informed of this, the surgeon tells the nurse to have the patient sign the informed consent form, and he will review it prior to the surgery. What should the nurse do? a)Follow the surgeon's orders, and ask the patient to sign the surgical consent form. b)Inform the surgeon that she will have the patient sign after he discusses the surgery with the patient. c)Ensure that the signed surgical consent is witnessed by two nurses, because the surgeon is not available. d)Cancel the surgery and transfer the patient back to the long-term care facility.

b)Inform the surgeon that she will have the patient sign after he discusses the surgery with the patient.

A patient had a hiatal hernia repair earlier today and is now in the postanesthesia care unit (PACU). The family asks the nurse why the patient is in the PACU rather than back in his room on the postsurgical unit. The nurse should inform the family that: a)Patients who have had surgical complications are observed in the PACU until they are stable enough to return to the floor b)Patients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care c)The PACU is a holding area for patients awaiting a surgical unit bed or awaiting adequate staff to provide care on the postsurgical unit d)The nurse will ask the surgeon to explain to them why the patient is not on the postsurgical unit as per usual procedure

b)Patients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care

The focus of nursing activities in the preoperative phase is to: a)Admit the patient to the surgical suite b)Prepare the patient mentally and physically for surgery c)Set up the sterile field in the operating room d)Perform the primary surgical scrub to the surgical site

b)Prepare the patient mentally and physically for surgery

When asked to sign the surgical consent form, the patient has questions. The nurse notifies the surgeon, who talks with the patient again and then tells the nurse the questions have been answered. When the nurse again explains the purpose of the consent form to the patient, the patient says, "The doctor says this surgery is necessary. Do you think it is really necessary?" What is the nurse's best response? a) "The doctor wouldn't schedule the surgery if it wasn't necessary." b) "There are probably nonsurgical treatments, but they may not be as effective." c)"This is a decision only you can make. What concerns do you have?" d) "I think it is necessary, but I can call the doctor back if you want further information."

c)"This is a decision only you can make. What concerns do you have?"

A patient is admitted for hip surgery. The patient usually takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E. He stopped taking his anticoagulant 4 days ago as instructed by his surgeon, but has continued to take the multivitamin and vitamin E. An important collaborative problem or nursing diagnosis for this patient is which of the following? a)Potential complication: anemia b)Risk for infection related to inadequate anticoagulant dosage c)Risk for noncompliance related to inability to follow instructions d)Potential complication: increased bleeding

d)Potential complication: increased bleeding

The patient is scheduled for an outpatient cholecystectomy (gall bladder removal) in 2 weeks. Based on the patient's history, the nurse includes which of the following in the preoperative plan of care? a)Tell the patient to avoid smoking on the day of surgery. b)Use a safety razor to shave the abdomen the day before surgery. c)Ask the surgeon to prescribe antibiotics to be given preoperatively. d)Tell the patient to inform the surgeon of allergies and chronic health conditions.

d)Tell the patient to inform the surgeon of allergies and chronic health conditions.

The preoperative phase encompasses which period of time? a)Entry to the operating suite until admission to postanesthesia care b)Entry into the operating suite until discharge from the hospital c)The decision to have surgery until admission to postanesthesia care d)The decision to have surgery until entry to the operating suite

d)The decision to have surgery until entry to the operating suite