Fundamentals of Nursing III (Chap 29 Perioperative Nursing Prep U)

A nurse caring for patients in a PACU assesses a patient who is displaying signs and symptoms of shock. What is the priority nursing intervention for this patient?

Placing the patient in a flat position with the legs elevated 45 degrees uses gravity to help direct blood to the vital organs.

Which client in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse?

A client with a crowing sound is exhibiting stridor, which is an indication of an airway obstruction and can be a respiratory emergency. This client needs immediate attention.

The nurse is preparing a client for surgery and asks if the client has an advance directive. The client asks "What is an advance directive?" What is the nurse's best response to this?

"An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so."

Which factors would the nurse consider when assessing surgical clients following surgery? Select all that apply.

-infants are at a greater risk from surgery than are middle-age adults. -Infants experience a slower metabolism of drugs that require renal biotransformation. -Older adults have decreased renal blood flow and a reduced bladder capacity, necessitating careful monitoring of fluid and electrolyte status and input and output. -Older adults have an increased gastric pH and require monitoring of nutritional status during the perioperative period.

A nurse is applying a pneumatic compression device to a client. What is the purpose of a pneumatic compression device?

A pneumatic compression device promotes the circulation of venous blood and relocation of excess fluid into the lymphatic vessels.

In the postoperative phase of abdominal surgery, the client reports severe abdominal pain. In the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect?

A potential complication after surgery is paralytic ileus, a condition in which there is decreased bowel functioning.

A 2-year-old toddler just underwent a tonsillectomy and adenoidectomy surgery. The postanesthesia care unit (PACU) nurse is checking on him. What is the best course of action regarding the developmental care of this child?

Allow the parents into the PACU before the child wakes. Toddlers are prone to separation anxiety. Allowing the child to be with the parents will lower anxiety levels for all members of the family. This will subsequently ease the care for the bedside nurse.

The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. What would be the nurse's most appropriate initial response?

Apply pressure to the surgical site to decrease bleeding. It is essential that the nurse be prepared to address life-threatening needs of the client. Excessive bleeding is a life-threatening issue.

A nurse is caring for an infant who is postoperative following cardiac surgery. What is the most common postoperative complication found in this age group?

According to Dunn (2005), most postoperative complications are related to the respiratory system in infants. After receiving general anesthesia, premature infants are at greater risk for apnea.

A nurse is preparing a client for endotracheal intubation. The anesthesiologist has ordered an anticholinergic medication for this client. What is an action of this medication?

An anticholinergic medication decreases respiratory secretions and prevents vagal nerve stimulation during endotracheal intubation.

A client is undergoing surgery for an appendectomy. This would be considered what type of surgery?

An appendectomy is considered emergency or urgent surgery.

Which nursing action should the PACU nurse take to prevent postoperative complications in clients?

Assist the client to do leg exercises to increase venous return. Leg exercises increase venous return in order to prevent the postoperative complication of clot formation in the lower extremities.

A client had an open cholecystectomy (gall bladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding?

Bowel function does not typically return immediately after surgery, but it can be promoted by encouraging fluid and fiber intake as appropriate to the client and his or her surgery

Which clients would the nurse schedule for surgery based on purpose? Select all that apply.

Breast biopsy, cleft palate repair, bowel resection, and breast reconstructive surgery are procedures based on purpose, and can be scheduled ahead of time. Uncontrolled bleeding and a tracheostomy for respiratory distress are surgeries based on urgency and are considered emergency surgeries.

A pediatric nurse is preparing a child for cleft palate repair surgery. The nurse recognizes that this type of surgery is categorized as which of the following?

Cleft palate repair is considered constructive surgery because the goal is to restore function in congenital anomalies. Reconstructive surgery serves to restore function to traumatized or malfunctioning tissues and includes plastic surgery or skin grafting.

A client has presented to a clinic for a preoperative consult, during which the client has expressed concern about having to fast before surgery. Current recommendations for preoperative fasting include:

Current practice is to allow clients to drink liquids or eat food up to 2 hours before surgery, depending on the type of surgery and with permission of the physician.

The nurse is teaching a client who will undergo abdominal surgery to repair a hernia about deep breathing. When the client asks, "Why am I practicing breathing when I'm having hernia surgery", what is the appropriate nursing response?

Deep breathing after surgery reduces the risk for development of postoperative respiratory complications.

A nurse is reinforcing wound edges and applying a blinder to the separated incisions of a client after a surgery. Which postoperative complication has the client developed?

Dehiscence

A nurse teaches deep breathing exercises to a client scheduled for surgery. In which perioperative phase would this action occur?

Exercises and physical activities occurring in the preoperative phase include deep-breathing exercises, coughing, incentive spirometry, turning, leg exercises, and pneumatic compression stockings.

A client has arrived to the postanesthesia care unit (PACU) and is drowsy with a respiratory rate of 12 breaths per minute. What would be an accurate interpretation by the nurse?

Having drowsiness and a respiratory rate of 12 breaths/minute are normal findings in the immediate postoperative period. The client needs to be monitored to ensure that there is no deterioration in respiratory status, and the client awakens readily. As the anesthetics wear off, the client should return to a normal level of consciousness

A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client?

Implement leg exercises and turn the client in bed every 2 hours. Ambulation and leg exercises increase circulation, which prevents cardiovascular complications.

Which postoperative exercise promotes venous return and decreases complications related to venous stasis?

Leg exercises assist in preventing muscle weakness, promote venous return, and decrease complications related to venous stasis.

A client is undergoing conscious sedation for an endoscopy. When the client becomes overly sedated, which medication does the nurse anticipate will be required?

Naloxone is a reversal drug, as it is the antagonist for opiates like morphine.

Which nursing action will best promote pain management for a client in the postoperative phase?

Performing relaxation techniques is the best nursing action to promote pain management for a client in the postoperative phase.

The nurse knows the term perioperative phase refers to care given to the client:

Perioperative nursing includes three distinct phases: preoperative, intraoperative, and postoperative.

The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency?

Respiratory obstruction may occur as a result of secretion accumulation, obstruction by the tongue, laryngospasm (a sudden, violent contraction of the vocal cords), or laryngeal edema.

The nurse is talking with a client who wishes to have a tattoo removed. Which client statement indicates that the client understands how the procedure will be accomplished?

Tattoos are often removed via laser surgery in an ambulatory setting. This type of outpatient procedure does not commonly require anesthesia, nor hospitalization.

A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice?

The RN's role is a supportive one for the client, monitoring vital signs and positioning the client on the operating room table. The RN also helps maintain safety by counting sponges and instruments that may have been used during the surgery.

A client who came in through the emergency department with a severely fractured leg will be transported to surgery within the hour. When the client asks how long hospitalization will occur after surgery, what is the appropriate nursing response?

With a severe fracture, the client will be considered as having inpatient surgery, and will be hospitalized at least a day. The nurse should not give a definitive period of time for hospitalization, and the surgeon (not the anesthesiologist) will give the best predictor of length of stay.

Which client would a nurse monitor most closely for postoperative respiratory complications?

a 55-year-old client with a history of asthma who had a colon resection. The client who has had abdominal surgery and has preexisting respiratory disease would be at the greatest risk for observation of any respiratory complications (due to having two factors instead of only one).

Which client most likely requires special preoperative assessment and treatment as a result of the existing medication regimen?

a woman who takes daily anticoagulants to treat atrial fibrillation. Anticoagulants present a risk of hemorrhage

A client has been taking aspirin since his heart attack in 1997. The client is at risk for:

hemorrhage.

A nurse is caring for a client who is admitted to the health care facility for surgery. Which activities take place before inpatient surgery? Select all that apply.

prior laboratory tests diagnostic tests meet anesthesiologist

Which of the following factors is most important in the nurse's decision on assessment data, outcomes, and the monitoring needs of a client in preparing for surgery?

the type of surgery is the most important influence on what type of care the client will require after surgery.

Which nursing intervention is most likely to prevent respiratory complications such as pneumonia and atelectasis in a postoperative client?

use of incentive spirometry. Incentive spirometry improves lung expansion, helps expel anesthetic gases and mucus from the airway, and facilitates oxygenation of body tissues.

What is the nurse's role in the informed consent process for a surgical procedure?

witnessing the signed informed consent document

The nurse has entered the room of a client who is postoperative day 1 and finds the client grimacing and guarding her incision. The client refuses the nurse's offer of p.r.n. analgesia and, on discussion, states that this refusal is motivated by his fear of becoming addicted to pain medications. How should the nurse respond to the client's concerns?

"Research has shown that there is very little risk of clients becoming addicted to painkillers after they have surgery."

A client who is in the holding area awaiting knee replacement surgery tells the nurse, "I am afraid of getting HIV if I have to have a blood transfusion during this surgery." What is the appropriate nursing response?

"The risk of acquiring a blood-borne disease from a blood transfusion is very small."

Which factors should the nurse consider when assessing patients for postsurgical risks? (Select all that apply.)

-Patients with respiratory disease may experience alterations in acid-base balance after surgery. -Kidney and liver diseases influence the patient's response to anesthesia. -Endocrine diseases increase the risk for slow surgical wound healing. Acid-base balance alterations are more likely to occur in patients with respiratory diseases because of the effects of anesthesia. Kidney and liver diseases negatively influence the patient's ability to metabolize and excrete anesthesia. Endocrine diseases, such as diabetes, increase the risk for slow wound healing and hypoglycemia.

A nurse asks a preoperative patient what medications he is currently taking. Which of the following is an accurate guideline for patient teaching regarding these medications?

Adjustments in taking medications may be needed before surgery. Anticoagulants are stopped days before surgery. Certain cardiac and respiratory drugs may be taken the day of surgery per physician's order. If the patient is diabetic and takes insulin, the insulin dosage may be reduced.

The nurse is preparing for a client for laser procedure. Which nursing intervention is appropriate?

Apply goggles to client. The client, and all who are involved in the procedure, will wear goggles.

Ames is an 87-year-old man who underwent a hip replacement today. He is telling the nurse that his parents, who are deceased, are coming to visit him today. He continues to tell the nurse that he needs to cut the lawn and run errands. The last time the nurse entered the room, Ames was trying to climb over the bed rail. Which term best describes Ames' condition?

Delirium refers to acute confusion that is reversible. It is common in the acute postoperative period.

The nurse is assessing an obese client scheduled for heart surgery. Which surgical risk related to obesity should the nurse monitor?

Fatty tissue has a poor blood supply and, therefore, has less resistance to infection. As a result, postoperative complications of delayed wound healing, wound infection, and disruption in the integrity of the wound are more common.

The preoperative nurse is reviewing the chart of a client whose surgery is scheduled to begin in the next 15 minutes and notices that the consent form is not signed. The nurse contacts the surgeon who states, "We have already reviewed this procedure extensively, so ask the client to sign the consent form and I will verify it in the operating room." Which action by the nurse is most appropriate?

Keep the client in the preoperative area and inform the surgeon that it is the physician's responsibility to obtain consent for surgery.

After a client receives morphine sulfate for pain in the postanesthesia care unit (PACU), which assessment finding would the nurse obtain as a priority?

Measure respiratory rate. The client who is receiving morphine sulfate for pain has a potential for decreased respiratory effort because of the side effect of respiratory depression

The nurse recognizes that palliative surgery is performed for what purpose?

Palliative surgery is performed to help lessen the intensity of an illness; it is not meant to be curative but will help improve the client's quality of life.

A nurse is assessing a client who is experiencing pulmonary embolus. What would be the priority nursing intervention for this client?

Place the client in semi-Fowler's position.

Which methods would the nurse anesthetist use when administering regional anesthesia to surgical clients? Select all that apply.

Spinal block Nerve block Epidural block Regional anesthesia occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. Regional anesthesia includes spinal blocks, nerve blocks, and epidural blocks. Inhalation and intravenous administration of anesthesia are associated with general anesthesia.

A nurse is assigned to be the circulating nurse during a surgical procedure. The nurse would be responsible for which activity?

The circulating nurse identifies and assesses the client on admission to the operating room, collaborates with multiple surgical team members to provide safe client care, including carefully positioning the client on the OR bed, using an approved antimicrobial agent to prepare the skin at the surgical site (prep), placing a Foley catheter (if indicated), assisting with monitoring the client during surgery, providing additional supplies, anticipating needs of the surgical team to facilitate the procedure, maintaining environmental safety, and counting the number of instruments, sharp items such as needles, and soft goods such as sponges used during the surgery to prevent the accidental loss of an item in the surgical site.

A postoperative client states "I don't understand why you are checking my skin on my back. My surgery was on my stomach." What is the nurse's best response?

The client who has been on the operating table should be examined to ensure skin breakdown hasn't occurred.

A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which characteristic applies to this type of surgery?

The client will be admitted the day of surgery and return home the same day.

A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first?

The nurse should apply warm blankets to the client because the client is hypothermic with a temperature of 96.2°F (35.7°C).

A nurse teaches deep-breathing exercises to a preoperative client. What accurately describes a step in this exercise?

The nurse should assist the client to sit up and place the palms of both hands along the lower anterior rib cage. The client should then exhale gently and completely and breathe in through the nose as deeply as possible, holding the breath for 3 seconds.

A client is scheduled for surgery within the hour. Which assessment data requires immediate nursing intervention?

The nurse will immediately intervene if any portion of preoperative instructions have not been followed. Consuming a soda thirty minutes ago violated diet and fluid restrictions.

The nurse is caring for a confused elderly client who requires surgery for a broken hip. Which nursing intervention regarding consent is appropriate?

The nurse will seek someone with durable power of attorney to sign the informed consent form, which is required. The client cannot give consent due to confusion

An operating room nurse is bringing a client to the nurse in the postanesthesia care unit (PACU). Which information would the operating room nurse provide during a hand-off report? Select all that apply.

The operating room nurse should give a hand-off report when bringing the client from the operating room and must include several critical pieces of information: medications given, the length of surgery, and any drains inserted.

As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site?

The procedural pause (time-out) must be done prior to any procedure to ensure client safety and to verify the client identity, staff roles, and procedure being performed.

The procedural physician has initiated performance of a time-out in the operating room before surgery. The student nurse asks the operating room nurse why this is important. What is the operating room nurse's best response?

The time-out is a safety measure performed before any surgical procedure and allows the operating room staff to determine they have the right client, procedure, and side (if appropriate).

A client is undergoing a knee replacement tomorrow morning. She is ordered nothing by mouth (n.p.o.) prior to surgery. She asks the nurse how long she can drink water prior to the procedure. Based on the nurse's knowledge of standard protocols, what is the nurse's best response?

Two hours is a standard n.p.o. time for clear liquids, though the nurse should always check with the institution's policy.