HH: Week 2&3: Perioperative Care - Quiz

During the preoperative assessment, the client tells the practical nurse that she uses echinacea, saw palmetto, and glucosamine. What should the practical nurse advise the client? A. Stop the use of all herbs & supplements at this time and follow up with the surgeon's office for further direction. B. There are no known effects of these products that will complicate surgery. C. Bring all products in their original containers the day of surgery. D. She should discuss her use of herbs & supplements with the pharmacist.

A. - Herbal products may interfere with anaesthesia and potentially cause complications during surgery, such as effects on blood pressure, increased sedation, cardiac effects, electrolyte alterations, and inhibition of platelet aggregation. These types of products must be discontinued before surgery, as ordered by the physician.

As the nurse is preparing the client for their scheduled thoracotomy and wedge resection, they say "I'm scared and I don't understand what they're going to do. The doctor was in a rush so I just signed the paper. What's going to happen to me?" What is the best next action by the nurse? A. Contact the HCP to come answer the client's questions and ensure informed consent. B. Explain the procedure for opening the thoracic space and removing a portion of a lung love, including the need for chest drainage, allowing ample time for questions. C. Encourage the client to ventilate their fears about this surgical procedure. D. File an incident report about the situation and the lack of informed consent for this procedure.

A. - Informed consent must be obtained prior to the procedure, and this should be the nurse's priority. Contacting the HCP will provide an opportunity for the procedure to be explained, risks and benefits, alternatives, and to obtain informed consent.

A nurse in the PACU is assessing a client who had abdominal surgery and transferred to the unit 1 hour ago. The nurse would be concerned about which of the following findings? A. Confusion. B. A heart rate of 60 bpm. C. Hypoactive bowel sounds in all 4 quadrants. D. The client has not yet voided 5 hours post-surgery.

A. - Confusion is a sign of respiratory distress and requires immediate attention.

After admission of the post-op client to the clinical unit, which assessment data requires the most immediate attention? A. O2 saturation of 85%. B. Respiratory rate of 13 breaths/min. C. Temperature of 38 C. D. Blood pressure of 95/60 mmHg.

A. - During the initial assessment, identify signs of inadequate oxygenation and ventilation. Pulse oximetry may indicate low oxygen saturation (<90% to 92%) with respiratory compromise. This necessitates prompt intervention.

In planning postoperative interventions to promote ambulation, coughing, deep breathing, and turning, the nurse recognizes that which of the following actions will best enable the client to achieve the desired outcomes? A. Administer adequate analgesics to promote relief or control of pain. B. Ask the client to demonstrate the postoperative exercises every hour. C. Give the client positive feedback when the activities are performed correctly. D. Warn the client about possible complications if the activities are not performed.

A. - Even when a client understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the client has sufficient pain relief to cooperate with the activities.

A client develops a paralytic ileus after abdominal aortic surgery. The nurse suspects the client is experiencing a bowel infarction. Which of the following assessment findings accompany this clinical diagnosis? Select all that apply. A. Absence of bowel sounds. B. Fever. C. Abdominal distension. D. Bloody stools. E. Decreased or absent peripheral pulses.

A., B., C., & D. - Signs of bowel infarction include the absence of bowel sounds, fever, abdominal distension, and bloody stools. The absence of peripheral pulses is a sign of aortic dissection or rupture.

A client notes they are having lower abdominal pain. The nurse suspects urinary retention. Arrange the following nursing interventions in the order in which they should occur: A. Pour warm water over the perineum. B. Contact the HCP and catheterize the client as prescribed. C. Assess for a distended bladder. D. Ask the client when they last voided. E. Assist the client to ambulate to the bathroom.

Correct order: D., C., E., A., B. - Urinary retention is an involuntary accumulation of urine in the bladder because of loss of muscle tone. It can also be caused by medications such as opioid analgesics or anesthetics. A client with this condition will be unable to void and will be restless with a distended bladder, and lower abdominal pain.

The nurse visits the client to have him sign his consent for surgery. The client tells the practical nurse the physician has not told him what is involved in the surgery. What should the nurse do? A. Ask family members if they have discussed the details. B. Explain what the planned surgical procedure entails prior to the signing. C. Have the client sign the consent and tell him the physician will visit before the surgery. D. Delay the signature and notify the physician that the consent is not signed.

D. - The nurse can be a patient advocate, verifying that the patient (or a family member) understands the consent form and its implications and that consent for surgery is truly voluntary. The nurse will contact the surgeon and explain the need for additional information if the patient is unclear about operative plans.

The nurse is caring for an older-adult client who is currently undergoing CABG surgery and has just experienced intraoperative vomiting. Which of the following medications should the nurse anticipate for administration at this time? A. Midazolam. B. Fentanyl. C. Meperidine. D. Ondansetron.

D. - Ondansetron is an antiemetic, whereas midazolam is a benzodiazepine, fentanyl and meperidine are opioid analgesics.

Before admitting a client to the operating room, the nurse recognizes that which of the following data must be in the chart of all clients? Select all that apply. A. Electrocardiogram. B. Signed consent form. C. Functional status evaluation. D. Renal and liver function tests. E. A physical examination report

B. & E. - It is essential to have a physical examination report and signed consent form in the chart of a client going for surgery. The physical examination document explains in detail the overall status of the client for the surgeon and other members of the surgical team.

The nurse is preparing to discharge a client home after a laparoscopic procedure on a same-day surgical unit. What should the nurse include in the discharge instructions to the client? Select all that apply. A. The client will need to change their dressing weekly and monitor the surgical site. B. The client cannot have alcohol for 24h after the surgery. C. The client should report a temp. greater than 100 F (38 C). D. The client should report any bleeding through the dressing. E. The client should be aware decreased sensation below the surgical site is expected.

B., C., & E. - Alcohol is not permitted for 24h after a surgical procedure as it is a CNS depressant. They should report a temperature greater than 100 F (38 C) because this may indicate an infection. An increase in bleeding may indicate an internal bleed, stress on the incision, or impending dehiscence of the wound. The client should be changing the dressing daily and decreased sensation below the surgical site is a serious complication.

The nurse is performing preoperative teaching and the client asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the Canadian Anesthesiologists' Society, the nurse should teach the client which of the following timeframes? A. NPO after breakfast. B. NPO after midnight. C. Clear liquids up to 2 hours before surgery. D. Clear liquids up until she is transferred to the OR.

C. - Practice guidelines for preoperative fasting state that the minimum fasting period for clear liquids is 2 hours. Evidence-informed practice no longer supports the longstanding practice of requiring clients to be NPO after midnight.

The nurse is admitting an older-adult client for a bilateral mastectomy and breast reconstruction. Which of the following elements should the nurse include in the client's preoperative teaching? Select all that apply. A. Information about various options for reconstructive surgery. B. Information about the risks and benefits of her particular surgery. C. Information about risk factors for breast cancer and the role of screening. D. Information about where in the hospital she will be taken postoperatively. E. Information about performing postoperative DB&C exercises.

D. & E. - During preoperative teaching, it is important to introduce the role of DB&C exercises and to inform the client about the different locations involved in her hospital stay. The specific risks and benefits of her surgery and reconstruction options should be addressed by her surgeon. Teaching about breast cancer screening would be inappropriate, and likely insensitive, at this point in her disease trajectory.

A 70 kg post-op client has an average urine output of 25 mL/h during the first 8h. Given this assessment, what would the priority nursing intervention be? A. Perform a straight catheterization to measure the amount of urine in the bladder. B. Notify the physician and anticipate obtaining blood work to evaluate renal function. C. Continue monitoring the client as this is a normal finding post-op. D. Evaluate the client's fluid volume status since surgery and obtain a bladder scan.

D. - Due to the possibility of infection associated with catheterization, the nurse should first try to validate that the bladder is full. The nurse should consider fluid intake during and after surgery and should determine bladder fullness by percussion, by palpation, or by a portable bladder ultrasound study to assess the volume of urine in the bladder and avoid unnecessary catheterization.

The nurse is preparing to administer cefazolin 2 g in 100 mL of normal saline to a postoperative client. Which of the following IV rates will infuse this medication over 20 minutes? A. 100 mL/hour. B. 150 mL/hour. C. 200 mL/hour. D. 300 mL/hour.

D. - Volume ÷ time in hours = rate in mL/hour. Therefore, 100 mL ÷ 0.33 hour (i.e., 20 minutes) = 300 mL/hour.

A client with a nasogastric tube in situ has an absence of bowel sounds, bowel movement, and flatus eight hours after surgery. Arrange the following nursing interventions in the order in which they should occur before the nurse notifies the HCP. A. Check for patency of the NG tube. B. Monitor intake and output. C. Administer medications as prescribed to increase gastrointestinal motility. D. Maintain NPO status until bowel sounds return. E. Encourage the client to ambulate.

Order: D., A., E., C., B. - A paralytic ileus is a failure of forward movement of bowel contents, this may result from anaesthetic medications or the manipulation of the bowel during surgery. Signs of this condition include vomiting, abdominal distension, and absence of bowel sounds, bowel movement, or flatus.

The nurse is caring for a client who has just returned to the unit following a thyroidectomy. What should the nurse do first immediately for post-op? A. Maintain the client in a semi-Fowler's position with the neck and head supported by pillows. B. Maintain the client in a supine position using sandbags on either side of the head to immobilize head and neck. C. Encourage the client to cough and breathe deeply every 4 hours. D. Encourage the client to tile their head forward to promote drainage of oral secretions.

A. - It's important to place the client in a semi-Fowler's position to prevent aspiration and to reduce swelling that places pressure on the airway, creating an obstruction. Placing a pillow or sandbag behind the neck and head is also done to prevent neck hyperextension as well as to reduce tension on the suture line, preventing wound dehiscence.

The nurse is administering midazolam to a client. Which of the following desired effects is most likely with this medication? A. Monitored anaesthesia care and amnesia. B. Induction and maintenance of anaesthesia. C. Analgesia and prevention of intraoperative vomiting. D. Relaxation of skeletal muscles and facilitation of endotracheal intubation.

A. - Midazolam is a benzodiazepine that is widely used for its ability to induce amnesia and provide conscious sedation.

A preoperative client is informed about a blood transfusion which will be administered during the surgery. The client refuses this intervention based on religious beliefs. Which of the following should the nurse perform first? A. Confirm that the client understands the risks of not having a blood transfusion. B. Try to change the client's mind. C. Accept the refusal and report it to the surgeon immediately. D. Document the refusal of treatment.

A. - Nurses must recognize a client's right to refuse treatments and procedures but should first assess whether the client is well-informed about the risks and consequences of making the decision.

Which of the following events in the surgical suite represents a violation of aseptic technique? A.The circulating nurse remains at least 15 cm from the sterile field. B. The upper arm of the scrub nurse's sterile gown contacts the sterile field. C. The sterile field was established at 0650 and the current time is 0900. D. Bacteria are present in the nares and upper respiratory passages of the nurse.

A. - The circulating nurse is to remain at least 30 cm from the sterile field. The upper arm of a sterile gown is sterile so this does not represent a violation of aseptic technique. The passage of time in and of itself does not necessarily render a field contaminated. Bacteria are inevitable in the respiratory passages of team members, but they present a threat to sterility only if they are not confined by attire.

The nurse is caring for a client 12h post-operative from abdominal surgery. The client has nausea, vomiting, and abdominal distension. Which healthcare provider's order should the nurse complete first? A. Insert nasogastric tube and attach to 20 cm H2O suction. B. Complete an abdominal assessment every hour. C. Administer dimenhydrinate 50 mg IV q4h. D. Complete vital signs every hour.

A. - The client may have a paralytic ileus or an obstruction. An NG tube will help to remove air and stomach secretions in the case of paralytic ileus. The priority is the insertion of an NG tube. The other listed assessments will be completed once the tube is inserted.

Bronchial obstruction by retained secretions has contributed to a postoperative client's recent pulse oximetry reading of 87%. Which of the following health problems is the client experiencing? A. Atelectasis. B. Bronchospasm. C. Hypoventilation. D. Pulmonary embolism.

A. - The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate. Pulmonary emboli do not involve blockage by retained secretions.

Five minutes after receiving a preoperative sedative medication by IV injection, a client asks to get up to go to the bathroom to urinate. Which of the following actions is the most appropriate for the nurse to implement? A. Offer the client to use the urinal/bedpan after explaining the need to maintain safety. B. Assist the client to the bathroom and stay next to the door to assist the client back to bed when done. C. Allow the client to go to the bathroom since the onset of the medication will be more than five minutes. D. Ask the client to hold the urine for a short period since a urinary catheter will be placed in the operating room.

A. - The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the CNS, the client is at risk for falls and should not be allowed out of bed, even with assistance.

A nurse is caring for a client who underwent an abdominal surgery 5 days ago. The HCP orders the dressing to be removed today. Which of the following assessment findings is the most important to report to the HCP that may delay removal of the dressing? Select all that apply. A. Green/yellow drainage is found on the dressing. B. Patient rates their pain 8/10 at incision site. C. There are drops of dried blood around the suture line. D. The client has a a temperature of 39 C. E. The client complains of being constipated.

A., B., & D. - Pain, swelling or redness at incision site, fever > 38 C (100.4 F), and yellow/green purulent drainage from incision are all signs of infection requiring additional follow-up.

The charge nurse on a surgical oncology floor learns that the disaster response plan has been activated. There has been a local mass-casualty event and many admissions are expected. Who should the nurse prioritize for discharge? Select all that apply. A. A client in isolation due to severe neutropenia (120 cells/mcL). B. A stable client whose next chemotherapy session is scheduled the following week. C. An ambulatory client four days post lumpectomy with Jackson-Pratt drain in place. D. A client who had a thyroidectomy this morning. E. A client who had a bowel resection yesterday. Bowel sounds are absent and the client has not yet passed gas.

B. & C. - During a disaster, it is recommended to prioritize discharging clients who are mobile, can perform self-care at home and can use outpatient or community services instead of inpatient care. Clients who are confined to bed, or who need more frequent monitoring, are less suitable for discharge.

The perioperative nurse should recognize the need to monitor the client for hallucinations and agitation after the administration of which of the following anaesthetic agents? A. Nitrous oxide. B. Ketamine. C. Thiopental. D. Halothane.

B. - A disadvantage of ketamine is the associated risk of agitation, hallucinations, and nightmares. These unwanted effects are not associated with the use of thiopental, halothane, or nitrous oxide.

The nurse is caring for a client two days post-craniotomy with a positive halo sign from fluid leaking from their nose. How can the nurse prevent infection in the client? A. Place the client in a supine position. B. Elevate the HOB 30 degrees and apply a mustache dressing. C. Place the client in high Fowler's and encourage them to blow their nose. D. Place the client in a left lateral position and start prescribed antibiotic therapy.

B. - CSF leakage after a craniotomy is a serious complication. The nurse will place the client's HOB at 30 degrees, apply a mustache dressing (under the nose) and call the HCP immediately.

Which of the following best describes the primary purpose of deep breathing and coughing (DB&C) for postoperative clients? A. Prevention of hypotension. B. Prevention of alveolar collapse. C. Prevention of delirium. D. Prevention of hyperventilation.

B. - DB&C help clients prevent alveolar collapse and move respiratory secretions to larger airway passages for expectoration.

The nurse is caring for a client who underwent an abdominal surgery 2-days ago. After straining on the toilet due to being constipated, the clients wound eviscerates. Which of the following interventions is the most appropriate to manage the client's condition? A. Cover the wound with a dry sterile dressing. B. Cover the wound with a sterile soaked dressing. C. Apply an abdominal binder and apply manual pressure. D. Push in the protruding organ and cover with sterile dressing.

B. - Dehiscence or evisceration is considered a medical emergency. The wound should be covered with a sterile soaked dressing immediately and the surgeon must be notified as the client will need to be taken into surgery to close the wound. The nurse must not apply dry sterile dressings as this can dry out the organ. Placing pressure on the wound or reinserting the organ is not a correct action and may cause further complications.

A 36-year-old woman has been admitted for knee surgery. Which of the following information that was obtained during the preoperative assessment should be reported to the surgeon before the surgery? A. Lack of knowledge about pain control. B. Knowledge of the possibility of an early, unplanned pregnancy. C. History of postoperative infection following a prior cholecystectomy. D. Concern that she will be physically limited in caring for her children for a period post-operatively.

B. - If the patient states that she might be pregnant, information should be immediately given to the surgeon to avoid maternal and subsequent fetal exposure to anaesthetics during the first trimester.

Eight hours after surgery, a client has a distended bladder and is unable to void. Which of the following interventions is inappropriate? A. Encourage ambulation. B. Pour water over perineum. C. Insert an indwelling catheter. D. Insert an intermittent catheter.

B. - Inserting an indwelling urinary catheter is not recommended as it increases the client's risk of a urinary tract infection. If catheterization is needed, the nurse should use an intermittent catheter until the client can void on his/her own. Encouraging ambulation and pouring water over the perineum are appropriate techniques to promote urination.

The nurse is admitting a client to the same-day-surgery unit. The client tells the nurse that he was so nervous he had to take kava last evening to help him sleep. Which of the following nursing actions would be most appropriate? A. Tell the client that using kava to help sleep is often helpful. B. Inform the anaesthesiologist of the client's recent use of kava. C. Tell the client that the kava should continue to help him relax before surgery. D. Inform the client about the dangers of taking herbal medicines without consulting his health care provider.

B. - Kava may prolong the effects of certain anaesthetics. Thus the anaesthesiologist needs to be informed of recent ingestion of this herbal supplement.

The nurse is providing intraoperative care for a client. Which of the following findings should alert the nurse to the occurrence of malignant hyperthermia? A. Hypocapnia. B. Muscle rigidity. C. Decreased body temperature. D. Confusion upon arousal from anaesthesia.

B. - Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles occurring as a result of exposure to certain anaesthetic agents in susceptible clients. Hypoxemia, hypercarbia, and dysrhythmias may also be seen with this disorder.

The nurse is caring for a client who recently had chest tubes inserted. The nurse notices that there is no tidaling in the water seal chamber of the drainage system. Which of the following actions should the nurse take first? A. Perform a respiratory assessment. B. Check for kinks in the tubing. C. Inform the health care provider. D. Document the occurrence.

B. - Sudden cessations of tidaling may indicate an obstruction, but gradual reduction occurs as the lung re-expands. The tubing should be checked for kinks as this is a common reason for cessation of tidaling.

The nurse is working on a surgical floor and is preparing to receive a postoperative client from the postanaesthesia unit. Which of the following should be the nurse's initial action upon the client's arrival? A. Assess the client's pain. B. Assess the client's vital signs. C. Check the rate of the IV infusion. D. Check the physician's postoperative orders.

B. - The highest priority action by the nurse is to assess the physiological stability of the client. This is in part accomplished by taking the client's vital signs. The other actions can then take place in rapid sequence.

A nurse is caring for a postoperative client after an exploratory laparotomy. Which of the following nursing interventions decreases the risk of susceptibility for infection for the client? A. Mobilizing the client on post-op day 2. B. Ensuring the client completes DB&C exercises q1h. C. Putting the client on contact isolation precautions. D. Using gloves with all direct client contact.

B. - The nurse can help decrease their risk for infection postoperatively by encouraging deep breathing and coughing exercises hourly.

Unless contraindicated by the surgical procedure, which of the following positions is preferred for the unconscious client immediately postoperative? A. Supine. B. Lateral. C. Semi-Fowler's. D. High Fowler's.

B. - The unconscious client is positioned in a lateral "recovery" position. This position keeps the airway open and reduces the risk of aspiration if vomiting. Once conscious, the client is usually returned to a supine position with the head of the bed elevated.

A client who had an aortic valve repair one year ago comes into the client. The client is having a dental surgery next month and is concerned about the risk of developing infective endocarditis. The client is visibly stressed and states having difficulties sleeping at night due to their worries. Which of the following is the least appropriate response made by the nurse? A. "Tell me more about why you're concerned." B. "I'll ask the doctor to give you some mediations to help you sleep." C. "Prophylactic treatment is available before the procedure." D. "Have you informed your dentist about your previous valve repair surgery?"

B. - This is the least appropriate response as it does not address the client's concerns or encourage communication about the client's feelings. The client is not sleeping well as they are worried about developing endocarditis, and the nurse should validate the client's feelings and provide them with information and resources regarding prevention.

The nurse is educating a group of nursing students on the use of medical aseptic techniques to prevent infection as a complication for post-surgical pediatric cardiology clients. Which of the following statements made by a nursing student indicates that further teaching is required? A. "Gloves must be worn when there is a risk of direct contact with bodily fluids." B. "I should clean the bracelets and rings I plan to wear during client care before client contact." C. "A client's age and nutritional status may affect their susceptibility to infections."' D. "Healthcare-acquired infections are more likely to develop within the urinary and respiratory tracts."

B. - This statement indicates a need for further teaching. Students should be made aware of wearing no jewelry, as it is difficult to clean and becomes a vehicle for infection.

The nurse is assessing a client's abdominal incision when the client sneezes and the incision splits open, exposing the intestines. Which of the following actions should the nurse do first? A. Press the emergency alarm to call the resuscitation team. B. Cover the abdominal organs with sterile dressings. C. Have all visitors and family leave the room immediately. D. Page the surgeon to the client's room.

B. - When wound dehiscence occurs, the nurse should perform the following three steps: (1) Place the client in low Fowler's position with knees bent, (2) Cover the wound with a sterile dressing moistened with normal saline, and (3) Notify the surgeon

A client is experiencing nausea and is refusing to eat after surgery. They have bowel sounds in all four quadrants and are passing flatus. Which of the following are possible alternatives as solutions to this problem? Select all that apply. A. Keep the client NPO until their appetite returns. B. Administer an antiemetic medication. C. Encourage fluid intake with clear fluids. D. Mobilize the client. E. Ensure the client stays on bed rest.

B., C., & D. - For clients experiencing nausea after surgery and normal GI assessment, an antiemetic medication can be administered, along with encouragement to take clear fluids and to mobilize. Keeping the client NPO or maintaining them on bedrest may make nausea worse and put the client at risk for other postoperative complications such as blood clots.

The nurse on the postoperative unit is caring for a client who had a laparoscopic partial colectomy. On postoperative day 2, the client is complaining of abdominal distension and discomfort. Which of the following interventions may be appropriate for this client? Select all that apply. A. Increase the dose of opioids for pain relief. B. Insert a nasogastric tube. C. Reassure the client that this complication should subside in a day or two. D. Monitor the client's abdominal girth by measuring for distension and auscultate the abdomen in all four quadrants.

B., C., & D. - Postoperative ileus is a delay in the return of the GI system's normal peristalsis. Stomach motility returns in 1-2 days, and bowel motility in 3-5 days. Abdominal distension may require insertion of a NG tube for symptomatic relief and the lowering of opioid doses or the provision of pain relief with NSAIDs to reduce inflammation. The nurse should assess the patient regularly to detect the resumption of normal peristalsis, as evidenced by the return of bowel sounds and the passage of flatus.

Which of the following intraoperative nursing responsibilities would be performed by the scrub nurse? Select all that apply. A. Documenting intraoperative care. B. Keeping track of irrigation solutions for monitoring of blood loss. C. Passing instruments and supplies to the surgeon by anticipating his or her needs. D. Coordinating the flow and activities of members of the surgical team in the surgical suite. E. Performing the count of sponges, needles, and instruments used during the surgical procedure.

B., C., & E. - Both the scrub nurse and circulating nurse will participate in the counting of surgical sponges, needles, and instruments. Passing instruments to the surgeon is the exclusive responsibility of the scrub nurse. The circulating nurse takes primary responsibility for the coordination of the surgical suite and documentation.

The nurse is caring for a client with a history of dilated cardiomyopathy who had a heart transplant 12h ago. The nurse is performing an assessment on the client and decides to alert the HCP immediately. Which of the following signs and symptoms may have caused the nurse to be concerned about transplant rejection? Select all that apply. A. Increased ejection fraction. B. Shortness of breath. C. Atrial flutter. D. Hypertension. E. Abdominal bloating.

B., C., & E. - Manifestations of transplant rejection include shortness of breath, fatigue, fluid retention, abdominal bloating, new onset bradycardia, hypotension, atrial fibrillation or flutter.

Which of the following preoperative clients likely faces the greatest risk of bleeding as a result of medication? A. A woman who takes metoprolol (Lopresor) for the treatment of hypertension. B. A man whose type 1 diabetes is controlled with insulin injections four times daily. C. A man who is taking clopidogrel (Plavix) after the placement of a coronary artery stent. D. A man who recently started taking finasteride (Proscar) for the treatment of benign prostatic hyperplasia.

C. - Any drug that inhibits platelet aggregation, such as clopidogrel (Plavix), represents a bleeding risk. Insulin, metoprolol (Lopresor), and finasteride (Proscar) are less likely to contribute to a risk for bleeding.

When a client is admitted to the PACU, what are the priority interventions the nurse performs? A. Assess surgical site, note presence and character of drainage. B. Assess the amount of urine output and presence of bladder distension. C. Assess LOC, airway patency and obtain full set of vital signs. D. Review results of laboratory values, medications received and obtain report from PACU nurse.

C. - Assessment in the PACU begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient, LOC, vital signs, pain, and surgical site and the assessment of the patient's response to the reversal of anaesthetic, such as sedation score and level of spinal block.

Which of the following statements is the primary reason for accurately recording the client's current medications during a preoperative assessment? A. Some medications may alter the client's perceptions about surgery. B. Many anaesthetics alter renal and hepatic function, causing toxicity of other drugs. C. Some medications may interact with anaesthetics, altering the potency and effect of the drugs. D. Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery.

C. - Drug interactions may occur between prescribed medications and anaesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that they have been communicated to the anaesthesia care provider.

A client is admitted to the PACU after major abdominal surgery. During the initial assessment, the client tells the nurse he thinks he is "going to throw up." What would be the priority nursing intervention? A. Increase the rate of IV fluids. B. Obtain vital signs including O2 sat. C. Position the client in the lateral recovery position. D. Administer antiemetic medications as prescribed.

C. - If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs.

The nurse is preparing a client for surgery and the client refuses to remove a wedding ring. Which of the following actions is the most appropriate for the nurse to implement? A. Insist the client remove the ring for safety purposes. B. Explain that the hospital will not be responsible for the ring. C. Tape the ring securely to the finger and document this on the preoperative checklist. D. Note the presence of the ring in the nurse's notes of the chart and on the preoperative checklist.

C. - It is customary policy to tape a client's wedding band to the finger and make a notation on the preoperative checklist that the ring is taped in place.

The nurse is caring for a 65-year-old client following a myocardial infarction. The client had a coronary artery bypass surgery three days ago. The following considerations need to be made when caring for older adults after CABG, except for: A. Older adults are more likely to have side effects from antihypertensives. B. The older adult is at high risk for transient neurological deficits. C. Older adults are less likely to have toxic effects from inotropes. D. Older adults are more likely to have dysrhythmias.

C. - Older adults are MORE likely to experience toxic effects from inotropes, so the nurse should pay attention to any side effects the client is experiencing. The remaining choices are all important considerations for the older adult following CABG surgery.

The nurse is monitoring a client who had abdominal surgery that morning. Which of the following symptoms best suggest that the client is hemorrhaging? A. Blood pressure is 115/80 and heart rate is 80 bpm. B. Skin is warm to the touch. C. The client is restless. D. Sudden dyspnea and chest pain.

C. - Restlessness and anxiety are early clinical manifestations of hemorrhage. These symptoms occur due to the hypo-perfusion of the brain. Additionally, hypotension, tachycardia, tachypnea, pale, cold and clammy skin are symptoms commonly observed with hemorrhage.

The nurse is caring for a client with a history of Crohn's disease who is day one post-op after a bowel resection. The nurse notices evisceration of the wound. Which of the following actions should the nurse take first? A. Assess the client's bowel sounds. B. Apply an abdominal pad over the area. C. Lower the HOB to reduce pressure on the abdomen. D. Place gauze soaked with sterile saline over the area.

C. - The client's HOB should be lowered to help reduced pressure on the abdomen. Then the wound should be assessed and a gauze soaked in sterile saline should be placed over the wound to keep the area from drying out. The nurse should await orders from the physician once the wound has been appropriately covered.

When assessing a client's surgical dressing on the first postoperative day, the nurse notes new, bright red drainage about 5 cm in diameter. Which of the following actions should the nurse implement? A. Recheck in 1 hour for increased drainage. B. Notify the surgeon of a potential hemorrhage. C. Assess the client's blood pressure and heart rate. D. Remove the dressing and assess the surgical incision.

C. - The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report the findings as a whole.

A client with a postoperative paralytic ileus has a nasogastric tube to suction in situ. What should the nurse do to promote an accurate assessment for this client? A. Assess bowel sounds q4h in all abdominal quadrants. B. Ensure the client is kept NPO while the nasogastric tube is in situ. C. Turn off the suction and clamp the tube while auscultating bowel sounds. D. Observe for signs of abdominal distension or tenderness on palpation.

C. - The nasogastric tube must be clamped or the suction turned off when the abdomen is auscultated. If the tube remains on suction the nurse may mistake the suction sounds for bowel sounds, this may cause the nurse to miss important assessments and put the client at risk.

A client is admitted to the ED following a motor vehicle accident. The client has lost a profound amount of blood and is going in and out of consciousness. The client is prescribed 3 units of whole blood stat to replenish the blood volume. Prior to the administration of blood products, the client tells the nurse that she is a Jehovah's Witness, and thus refuses to accept the treatment. Which of the following actions is appropriate for the nurse to take next? A. Find a substitute decision maker for the client. B. Explain to the client that they are required to accept treatment if they wish to receive subsequent care in the hospital. C. Communicate the client's wishes to the healthcare team and explore alternative treatment options. D. Obtain a prescription for packed red blood cells instead of whole blood.

C. - This client has the right to self-determination. As a member of Jehovah's Witness, this client is refusing a blood transfusion because it goes against their spiritual beliefs. This scenario is ethically challenging because the administration of blood may save the client's life or prevent them from further harm. The nurse must recognize that the spiritual well-being of the client may be of equal importance, and ensure that the client is well-informed of the implications of their decision, to enable them the capability of making an informed decision. Working with the client and the healthcare team to incorporate spirituality into healthcare is the most appropriate action.

Discharge criteria for the Phase II client include which of the following? Select all that apply. A. No nausea or vomiting. B. Ability to drive himself or herself home. C. No respiratory depression. D. Written discharge instructions understood. E. Opioid pain medication given 45 min ago.

C., D., & E. - Phase II discharge criteria that must be met include the following: all PACU discharge criteria (Phase I) met; no intravenous opioid drugs administered for the past 30 minutes; patient's ability to void (if appropriate with regard to surgical procedure or orders); patient's ability to ambulate if it is not contraindicated; presence of a responsible adult to accompany or drive patient home; and written discharge instructions given and understood.

The new graduate nurse is working with the nurse on the unit to care for clients who are stable after myocardial infarction. Which of the following complications does the new nurse recognize as the most common among MI clients? A. Heart failure. B. Pericarditis. C. Cardiogenic shock. D. Dysrhythmias.

D. - Dysrhythmias are caused by a lack of oxygen supply to the myocardium and are the most common complication of MI.

The nurse is caring for a 7 year-old client who has undergone a valve replacement for a congenital heart defect. The client has returned from the PACU 1h prior. The nurse notes the client appears anxious with laboured respirations. Chest tube in situ and appears clean and dry with no drainage/output since previous assessment. The nurse obtains the following vitals, HR of 137 bpm, RR of 34/min, temp. of 37 C, and O2 sat. of 99%. What is the nurse's immediate next action? A. Assess peripheral pulses for symmetry and strength. B. Flush the chest tube with normal saline to maintain patency. C. Administer an opioid analgesic for pain relief. D. Call the physician.

D. - The nurse has sufficient evidence to believe that the client may be experiencing a cardiac tamponade. Specifically, the abrupt stop of chest tube drainage, tachycardia and dyspnea are findings consistent with this condition. This complication should be immediately reported as failing to provide immediate treatment will lead to death.

A nurse is caring for a post-operative client that just received CABG surgery. The nurse plans to change the dressing on the client's chest incision. Which of the following is true when performing a dressing change for this client? A. Hand hygiene and clean gloves are required when applying a new dressing. B. Prepare the sterile field ahead of time to ensure it's ready to be used at any time. C. A sterile dressing can still be used if it is out of the range of vision. D. Solutions are poured slowly into receptacles on the sterile field.

D. - This is done to avoid splashing which can cause strike-through or splash-back from nonsterile surfaces to the sterile field. When performing a dressing change at the client's bedside, hand hygiene and the application of sterile gloves are required, prepare the sterile field as close to the time of use as possible, and keep objects above the waist in the range of vision.

A client is being discharged after undergoing hernia repair surgery 5 days ago. The nurse receives an order to remove the Jackson-pratt drain. Which action(s) should be avoided during drain removal? Select all that apply. A. Removing the sutures around the drain. B. Emptying the drain before removal. C. Releasing the suction on the bulb. D. Using both hands to grasp the tube and pull. E. Examining the tip of the drainage tube.

D. - This should be avoided. When removing the tube, one hand should be applying counter pressure to the insertion site while the dominant hand grasps and pulls. This helps to avoid excess trauma to the skin. A nurse should not have to pull with both hands, if excess resistance is felt you should stop and contact the HCP. The other options are appropriate actions and would be performed by the nurse.