Med Surg Perioperative
A nurse is receiving evening shift on four clients who returned from the PACU that morning. Which of the following clients should the nurse assess first? A client who is postoperative following a thoracotomy and has a chest tube with 150 mL of bright-red blood in the collection chamber from the past 1 hr. A client who is postoperative following a small bowel resection and has a temporary colostomy along with absent bowel sounds in all four quadrants. A client who is postoperative following a tonsillectomy and has had one episode of coffee-ground emesis. A client who is postoperative following a total knee arthroplasty and is reporting a pain level of 7 on a scale from 0 to 10.
!!! A client who is postoperative following a thoracotomy and has a chest tube with 150 mL of bright-red blood in the collection chamber from the past 1 hr.When using the airway, breathing, circulation approach to client care, the first client the nurse should assess is the client who has 150 mL of blood in the collection chamber because this finding is above the expected reference range and can be an indication of hemorrhage. A client who is postoperative following a small bowel resection and has a temporary colostomy along with absent bowel sounds in all four quadrants. The nurse should assess the client who is postoperative from a small bowel resection and has absent bowel sounds. However, absent bowel sounds are an expected finding and there is another client the nurse should assess first. A client who is postoperative following a tonsillectomy and has had one episode of coffee-ground emesis. The nurse should assess the client who is postoperative from a tonsillectomy and has coffee-ground emesis. However, postoperative coffee-ground emesis is an expected finding and there is another client the nurse should assess first. A client who is postoperative following a total knee arthroplasty and is reporting a pain level of 7 on a scale from 0 to 10. The nurse should assess the client who is postoperative from a total knee arthroplasty and has postoperative pain of 7 on a scale from 0 to 10. However, this is an expected finding and there is another client the nurse should assess first.
A nurse is monitoring a client who received succinylcholine during a surgical procedure. Which of the following actions should the nurse take if the client develops manifestations of malignant hyperthermia? Administer dantrolene. Institute seizure precautions. Remove the endotracheal tube. Administer IV atropine.
!!! Administer dantrolene. !!! The nurse should administer dantrolene by IV bolus at 2 to 5 mg/kg to reverse the manifestations for a client who has malignant hyperthermia. Institute seizure precautions. Seizures are not a manifestation of malignant hyperthermia. Remove the endotracheal tube. A client who has malignant hyperthermia should have the endotracheal tube maintained for airway management during the crisis. Administer IV atropine. A client who has malignant hyperthermia can develop tachycardia. Therefore, administering atropine is not recommended because tachycardia is an adverse effect of atropine.
A nurse is caring for a client who is 12 postoperative from a gastrectomy and has an NG tube set to continuous low suction. Which of the following findings requires intervention by the nurse? Gastric distention Absent bowel sounds Urine output of 150 mL over the last 4 hr Yellow drainage in the NG tube
!!! Gastric distention !!! Gastric distention is an indication that the NG tube is not patent. The nurse should check the tubing for kinks, blockages, and loose connections. The nurse should also reposition the client to facilitate drainage and avoid removing or irrigating the tube unless directed to do so by the provider. Absent bowel sounds Absent bowel sounds are an expected finding for the first 24 hr after abdominal surgery. Urine output of 150 mL over the last 4 hr A urine output of 150 mL is within the expected reference range. The nurse should report a urine output of less than 30 mL/hr to the provider. Yellow drainage in the NG tube Yellow drainage indicates gastric secretion and is an expected finding after a gastrectomy.
A surgical nurse enters a surgical suite to ensure surgical asepsis is maintained. For which of the following findings should the nurse intervene? The scrub technologist is wearing a watch under their scrubs. The circulating nurse opens dressing packages before applying sterile gloves. The surgeon has their hands folded 5 cm (2 in) above their waist. The holding area nurse is performing client education.
!!! The scrub technologist is wearing a watch under their scrubs. !!! Finger and wrist jewelry are likely contaminated with micro-organisms and bacteria. Therefore, the scrub technologist should remove jewelry before handling sterile objects. The circulating nurse opens dressing packages before applying sterile gloves. The outside wrapping of dressing packages is nonsterile. Touching the outside of the wrapper maintains the sterility of the contents inside the wrapper. It is acceptable for the nurse to open packages before applying sterile gloves. Therefore, this action does not require intervention by the nurse. The surgeon has their hands folded 5 cm (2 in) above their waist. The surgeon should hold their hands above the waist to maintain surgical asepsis. Any items held below the waist are deemed unsterile or contaminated. Therefore, this action does not require intervention by the nurse. The holding area nurse is performing client education. The role of the holding area nurse includes verifying that the preoperative checklist is complete and performing client education. Therefore, this action does not require intervention by the nurse.
A nurse is assessing a client who is 2hr postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?
!!! Urine output of 20 mL/hr !!! The nurse should notify the provider if the client's urine output is less than 30 mL/hr. Decreased urine output can indicate hypovolemia and decreased perfusion of the kidneys. Temperature of 36.5° C (97.7° F) The client's temperature is within the expected reference range. The nurse should report a temperature lower than 36° C (96.8° F), which is an indicator of hypothermia, or a temperature higher than the expected reference range, which is an indicator of an infection. A 2 cm x 2 cm (0.79 in x 0.79 in) area of bloody drainage on the dressing The nurse should expect the client to have a small amount of bloody drainage on the dressing following an appendectomy. However, the nurse should report an increased amount of bloody or purulent drainage. WBC count 9,000 mm3 The client's WBC count is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. However, the nurse should report a WBC count below or above the expected reference range.
A nurse is providing preoperative teaching to a client who is scheduled to have a mastectomy with reconstructive surgery. Which of the following statements by the client indicates an understanding of the teaching? "I should wait to take my pain medication until after I have completed my range-of-motion exercises." "I should wait until a week after surgery to start my hand-strengthening exercises." "I will be able to lift an object that weighs 10 pounds 2 weeks after my surgery." "I will be able to shower after the doctor removes the drain."
"I should wait to take my pain medication until after I have completed my range-of-motion exercises." If the client experiences pain while doing range-of-motion exercises, they should take pain medication 30 min prior to exercise. "I should wait until a week after surgery to start my hand-strengthening exercises." The nurse should encourage the client to begin hand-strengthening exercises, such as squeezing a ball, the first day after surgery. "I will be able to lift an object that weighs 10 pounds 2 weeks after my surgery." The client should avoid lifting objects that weigh 2.26 to 4.54 kg (5 to 10 lb) for at least 4 weeks after surgery. !!! "I will be able to shower after the doctor removes the drain." !!! A client who has had a mastectomy with reconstructive surgery can shower after the provider removes the drain.
A nurse is providing discharge instructions for a client who is postoperative following abdominal surgery. Which of the following client statements indicates an understanding of the teaching? "I will have an increase in yellow-colored drainage from my incision for 2 weeks." "I will eat foods that are high in protein and vitamin C during my recovery." "I should avoid taking over-the-counter pain medication if my pain is not severe." "I will remain on bed rest until my follow-up appointment with my doctor."
"I will have an increase in yellow-colored drainage from my incision for 2 weeks." The nurse should instruct the client to report an increase in serous drainage after the first few days following surgery because an increase in drainage can indicate infection. !!! "I will eat foods that are high in protein and vitamin C during my recovery." !!! The nurse should instruct the client to increase intake of foods with protein and vitamin C to promote wound healing. "I should avoid taking over-the-counter pain medication if my pain is not severe." The nurse should instruct the client to use over-the-counter analgesics for mild to moderate pain unless contraindicated by the provider. "I will remain on bed rest until my follow-up appointment with my doctor." The nurse should instruct the client to increase activity gradually to reduce the risk for infection and development of deep-vein thrombosis.
A nurse is providing teaching for a client who is scheduled to undergo moderate sedation for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching? "I will need to complete a bowel prep the day before the procedure." "I will drink plenty of fluids the morning of the procedure." "I can eat as soon as the procedure is over." "I can expect to feel sleepy for several hours after the procedure."
"I will need to complete a bowel prep the day before the procedure." The nurse should inform the client that bowel preparation is not necessary prior to a bronchoscopy. "I will drink plenty of fluids the morning of the procedure." The nurse should instruct the client to be NPO for 4 to 8 hr prior to a bronchoscopy to reduce the risk of aspiration. "I can eat as soon as the procedure is over." The nurse should instruct the client to avoid eating until their gag reflex returns to prevent the risk of aspiration. !!! "I can expect to feel sleepy for several hours after the procedure." !!! The nurse should instruct the client to expect to feel drowsy for several hours following moderate sedation and to avoid any activities which require concentration.
A nurse is providing discharge teaching for a client who is postoperative following a rhinoplasty using general anesthesia. Which of the following instructions should the nurse include? "Lie on your side when resting for the first week after surgery." "Limit intake to clear liquids for the first 24 hours after surgery." "Use cool compresses on your eyes, nose, and face." "Close your mouth when you are about to sneeze."
"Lie on your side when resting for the first week after surgery." The nurse should instruct the client to maintain a semi-Fowler's position when resting at home. "Limit intake to clear liquids for the first 24 hours after surgery." The nurse should instruct the client that he can eat soft foods after his gag reflex has returned. !!! "Use cool compresses on your eyes, nose, and face." !!! The nurse should instruct the client to place cool compresses on his face to reduce swelling and ecchymosis. "Close your mouth when you are about to sneeze." The nurse should instruct the client to avoid sneezing with his mouth closed until after the surgical packing is removed.
A nurse is providing preoperative teaching for a client who is scheduled to have a below-the-knee amputation. Which fo the following instructions should the nurse include? You should avoid lying on your abdomen after surgery." "Your surgeon might prescribe an antibiotic before surgery." "It is important for you to sit in a chair at the bedside for several hours every day to reduce the risk of pneumonia." "To promote wound healing, it is important to reduce your intake of carbohydrates once you return home."
"You should avoid lying on your abdomen after surgery." The nurse should instruct the client that she will be assisted into the prone position every 3 to 4 hr after surgery to prevent a hip flexion contracture. !!! "Your surgeon might prescribe an antibiotic before surgery." A client who has a surgical amputation of an extremity is at risk for infection. Therefore, the provider often prescribes a broad-spectrum, prophylactic antibiotic to reduce the risk of infection. "It is important for you to sit in a chair at the bedside for several hours every day to reduce the risk of pneumonia." The client should avoid sitting for long periods of time to reduce the risk of a hip flexion contracture. "To promote wound healing, it is important to reduce your intake of carbohydrates once you return home." A client who is postoperative should increase their intake of carbohydrates and protein. Calories from carbohydrates are used for energy and ensure that adequate proteins are available for wound healing.
A nurse is teaching a client who is in the immediate postoperative period about the use of a PCA pump. Which of the following statements should the nurse include in the teaching? "You will receive a dose of medication every time you push the button." "Do not allow visitors to push the PCA button if you are sleeping." "You cannot receive too much medication by pushing the button." "Do not push the PCA button until your pain reaches a severe level."
"You will receive a dose of medication every time you push the button." The nurse should teach the client that the size and interval between each dose is set by the PCA device. However, the provider can adjust the device to maintain a therapeutic level of pain control. The PCA also has a lock-out period to decrease the risk of opioid overdose. !!! "Do not allow visitors to push the PCA button if you are sleeping." !!! The nurse should instruct the client that they should be awake when receiving a dose of the medication and that they are the only authorized user of the PCA pump. Allowing visitors to push the button is a safety risk for the client. "You cannot receive too much medication by pushing the button." Clients have different tolerance levels for opioid analgesics. The nurse should instruct the client to report nausea, dizziness, and other adverse effects indicating excessive sedation. Opioid analgesia places the client at risk for respiratory depression. Therefore, the nurse should monitor the client closely for indications of sedation and respiratory depression. "Do not push the PCA button until your pain reaches a severe level." The nurse should inform the client that frequent, lower doses of opioids can provide effective pain relief if the client uses the PCA pump before the pain becomes severe. If the client waits to take the medication until after their pain is severe, it will require more medication to reduce their pain to a manageable level.
A nurse is caring for a client who has bradycardia following a surgical procedure using spinal anesthesia. The nurse should plan to administer which of the following medications to the client? Amiodarone Propranolol Methyldopa Epinephrine
Amiodarone Amiodarone is an antiarrhythmic medication and has the adverse effect of bradycardia. Therefore, this medication is contraindicated for this client. Propranolol Propranolol is an antiarrhythmic medication and has the adverse effect of bradycardia. Therefore, this medication is contraindicated for this client. Methyldopa Methyldopa is an antihypertensive medication and has the adverse effect of bradycardia. Therefore, this medication is contraindicated for this client. !!! Epinephrine !!! The nurse should plan to administer epinephrine, a vasopressor, to increase the client's heart rate and prevent cardiac arrest.
A nurse is assessing a client who is 2 days postoperative following a total prostatectomy. The nurse notes that the client's right calf is red, edematous, and warm to the touch. Which of the following actions should the nurse take? Apply an ice pack to the client's right calf. Elevate the client's right extremity. Administer testosterone to the client. Gently massage the client's right calf.
Apply an ice pack to the client's right calf. Applying an ice pack to the client's right calf can result in injury because it can cause vasoconstriction. The nurse should apply warm, moist packs to the client's right calf. !!! Elevate the client's right extremity. !!! These findings suggest the client has deep-vein thrombosis. The nurse should keep the client's right extremity elevated to promote venous return. Administer testosterone to the client. This client does not require testosterone. The nurse should use anticoagulants to treat deep-vein thrombosis. Gently massage the client's right calf. The nurses should avoid massaging the client's right calf because it could dislodge the thrombus and result in injury.
A nurse is caring for a client who is receiving moderate (conscious) sedation with midazolam. The client's respiratory rate decreases from 16/min to 6/min, and their oxygen saturation decreases from 92% to 85%. Which of the following medications should the nurse administer? Atropine Acetylcysteine Flumazenil Protamine sulfate
Atropine Atropine is an anticholinergic that is used to treat cholinesterase inhibitor toxicity. Acetylcysteine Acetylcysteine is an antidote that is used to treat acetaminophen toxicity. !!! Flumazenil!!! The client's respiratory rate and oxygen saturation level indicate increased sedation caused by a benzodiazepine. The nurse should administer flumazenil, a benzodiazepine agonist, to reverse the sedative effects of the medication. Protamine sulfate Protamine sulfate is administered to treat heparin toxicity.
A nurse in a PACU is assessing a client who is postoperative. Which of the following findings should the nurse report to the provider? Blood pressure 10% lower than baseline Pain level of 4 on a 0 to 10 scale Presence of inspiratory stridor Small amount of sanguineous drainage on dressing
Blood pressure 10% lower than baseline The nurse should report a change in blood pressure of 25% above or below baseline to the provider. Pain level of 4 on a 0 to 10 scale Pain is an expected finding following surgery. The nurse should report pain that is not controlled by the administration of analgesic medication. !!! Presence of inspiratory stridor !!! The nurse should report inspiratory stridor to the provider because it is a manifestation of tracheal edema and requires intervention. Small amount of sanguineous drainage on dressing A small amount of sanguineous drainage is an expected finding following surgery. The nurse should note the amount of sanguineous drainage on the dressing and notify the provider if there is a large amount of drainage.
A nurse is reviewing the medical record of a client who is scheduled for an elective surgery. Which of the following medications should the nurse expect the provider to discontinue prior to surgery to minimize the risk for complications? Cefazolin Digoxin Ondansetron Warfarin
Cefazolin Cefazolin is an antibiotic that can be used prophylactically to reduce the risk of infection for some types of surgical procedures. Digoxin Digoxin is an antiarrhythmic that does not increase the client's risk for surgical complications. Ondansetron Ondansetron is a serotonin receptor antagonist that is used to treat postoperative nausea and vomiting, which could place the client at risk for aspiration of gastric secretions. !!! Warfarin !!! The nurse should anticipate that the provider will instruct the client to discontinue warfarin, an anticoagulant, because it increases the risk of bleeding during and following surgery.
A nurse is planning care for a client who is postoperative and has a closed-wound drainage system in place. Which of the following interventions should the nurse plan to include? Check the patency of the drain every 12 hr. Clamp the drain while the client is ambulating. Cleanse the drain plug with alcohol after emptying. Secure the drain to the client's bed sheet.
Check the patency of the drain every 12 hr. The nurse should check the amount, color, and type of drainage at least every 8 hr. Clamp the drain while the client is ambulating. The purpose of a closed-wound drainage system is to provide continuous suction. Therefore, the nurse should not clamp the drain while the client is ambulating. !!! Cleanse the drain plug with alcohol after emptying. !!! After emptying the drain, the nurse should compress the top and bottom of the device together with one hand, while cleansing the plug with the other. Secure the drain to the client's bed sheet. The nurse should secure the drain to the client's gown to prevent dislodgement.
A client is transferred from the surgical suite to the PACU following oral surgery. While monitoring the client's vital signs, the nurse finds that the client's tongue has become swollen and is obstructing the airway. Which of the following actions should the nurse take first? Contact the anesthesiologist. Assist with endotracheal intubation. Increase the client's flow of oxygen. Use the head-tilt, chin-lift method to open the airway.
Contact the anesthesiologist. (The nurse should contact the anesthesiologist to provide emergency treatment. However, there is another action the nurse should take first.) Assist with endotracheal intubation. (The nurse might need to assist with intubation. However, there is another action the nurse should take first.) Increase the client's flow of oxygen. (The nurse might need to increase the client's flow of oxygen to maintain oxygen saturation at 90% or higher. However, there is another action the nurse should take first.) !!! Use the head-tilt, chin-lift method to open the airway. (The first action the nurse should take when using the airway, breathing, circulation approach to client care is to establish a patent airway by tilting the client's head back and pushing the lower jaw forward.)
A nurse is caring for a client who has a surgical wound with a Penrose drain in place. Which of the following interventions should the nurse plan to perform? Cut a slit in a 4-inch square gauze pad to place around the drain. Use the sterile technique when performing dressing changes. Establish a clamping schedule prior to removal. Apply negative pressure when emptying the drain.
Cut a slit in a 4-inch square gauze pad to place around the drain. A drain sponge should be used around a Penrose drain. A gauze pad should never be cut and used around a drain due to the risk of dressing fibers becoming embedded in the wound. !!! Use the sterile technique when performing dressing changes. !!! The nurse should change the Penrose drain dressing using the surgical aseptic technique. Establish a clamping schedule prior to removal. Clamping a Penrose drain can lead to infection. Apply negative pressure when emptying the drain. A Penrose drain is an open system and drains by gravity.
A nurse is caring for a client who is 2 days postoperative following a cholecystectomy. The client has been vomiting for the past 24 hr and reports a pain level of 8 on a 0-10 scale. The nurse notes a hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the following actions should the nurse take first? Draw the client's blood for electrolytes. Insert an NG tube. Administer pain medication. Initiate intake and output.
Draw the client's blood for electrolytes. Drawing the client's blood for electrolytes is an important action because electrolyte imbalance is a possible cause of paralytic ileus. However, there is another action the nurse should take first. !!! Insert an NG tube. !!! The greatest risk to the client is fluid and electrolyte imbalance as a result of accumulated fluid and gas in the gastrointestinal tract. The first action the nurse should take is to insert an NG tube to begin decompression of the bowel. Administer pain medication. Administering pain medication is an important action to promote comfort. However, there is another action the nurse should take first. Initiate intake and output. Initiating intake and output is an important action because it provides information about the client's fluid balance. However, there is another action the nurse should take first.
A nurse is assessing a client who received a preoperative IV dose of metoclopramide 1 hr ago. For which of the following findings should the nurse notify the provider? Dry mouth Muscle rigidity Tinnitus Diarrhea
Dry mouth Dry mouth is an expected adverse effect of metoclopramide. Other expected adverse effects include drowsiness, restlessness, and nausea. !!!Muscle rigidity !!! Muscle rigidity is a manifestation of neuroleptic malignant syndrome, which is a potentially life-threatening adverse effect of metoclopramide. Other manifestations include hyperthermia, blood pressure irregularities, tachycardia, and diaphoresis. The nurse should report this finding to the provider. Tinnitus Tinnitus is not an adverse effect of metoclopramide, nor is it an urgent finding that requires notification of the provider. Diarrhea Diarrhea or constipation are expected adverse effects of metoclopramide. Other expected adverse effects include drowsiness, restlessness, and irritability.
A nurse is caring for a client who is preoperative and is asking multiple questions about the risks of the procedure. Which of the following actions should the nurse take? Explain the risks and benefits of the surgery to the client. Ask the surgeon to speak to the client for clarification. Reassure the client that the procedure is necessary for recovery. Notify the circulating nurse that the client has questions about the procedure.
Explain the risks and benefits of the surgery to the client. (It is not the nurse's responsibility to explain the risks and benefits of the surgery. The nurse should verify that the client signs the consent form prior to transfer to surgery.) !!! Ask the surgeon to speak to the client for clarification. (The nurse should notify the surgeon that the client has questions about the procedure. It is the responsibility of the surgeon to explain the risks and benefits of the surgery.) Reassure the client that the procedure is necessary for recovery. (This response dismisses the client's concerns and is an example of false reassurance.) Notify the circulating nurse that the client has questions about the procedure. (The nurse should verify that the client signs the consent form prior to transfer to surgery. The circulating nurse is not responsible for explaining the risks and benefits of the procedure to the client. This action is the responsibility of the surgeon.)
A nurse is assessing a client who is preoperative. The nurse should identify that which of the following factors reported by the client increases the risk for postoperative wound infection? Frequent use of echinacea Long-term use of corticosteroids History of osteoporosis Diet high in vitamin C
Frequent use of echinacea The nurse should identify that echinacea is a dietary supplement used to stimulate immune function. Therefore, it does not increase the client's risk for infection. !!! Long-term use of corticosteroids The nurse should identify that the use of corticosteroids inhibits leukocyte response, which increases the client's risk for infection. History of osteoporosis The nurse should identify that a history of osteoporosis increases the client's risk for bone fracture. However, it does not increase the client's risk for infection. Diet high in vitamin C The nurse should identify that a diet high in vitamin C promotes wound healing. Therefore, it does not increase the client's risk for infection.
A nurse is caring for a client who had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take? Go to the nurses' station to seek assistance. Reinsert the organs into the abdominal cavity. Place the client in a reverse Trendelenburg position. Obtain vital signs to assess for shock.
Go to the nurses' station to seek assistance. The nurse should stay with a client who has experienced a wound evisceration. The nurse should press the call light to seek assistance. Reinsert the organs into the abdominal cavity. The nurse should make no attempt to reinsert the eviscerated contents. Place the client in a reverse Trendelenburg position. The nurse should place the client in a supine position with hips and knees bent and with the head of the bed elevated 15° to 20°. !!! Obtain vital signs to assess for shock. !!! The nurse should obtain vital signs to assess the client's current status.
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following interventions should the nurse perform to prevent respiratory complications? Instruct the client to exhale into the incentive spirometer every 1 to 2 hr. Minimize the amount of pain medication the client receives to prevent sedation. Advise the client to splint the surgical incision when coughing and deep breathing. Reposition the client every 8 hr for the first 48 hr.
Instruct the client to exhale into the incentive spirometer every 1 to 2 hr. The nurse should instruct the client to inhale deeply from the incentive spirometer and hold her breath to expand the lungs. Minimize the amount of pain medication the client receives to prevent sedation. The nurse should administer pain medication as needed to allow the client to increase depth of breathing. An increased pain level increases the risk of altered gas exchange and can lead to respiratory complications. !!! Advise the client to splint the surgical incision when coughing and deep breathing. !!! Splinting the incision supports the surgical site and decreases pain during coughing and deep breathing. Reposition the client every 8 hr for the first 48 hr. The nurse should reposition the client at least every 2 hr until the client is ambulating frequently.
A nurse is creating a plan of care for a client who is preoperative for a total hip arthroplasty. The client informs the nurse that they practice Judaism and adhere to a kosher diet. Which of the following interventions is the nurse's priority? Listen and allow the client to express feelings about the surgery. Determine if the client's faith conflicts with the treatment plan. Ensure the client's meal plan serves only kosher food following surgery. Teach the client how to perform various relaxation exercises.
Listen and allow the client to express feelings about the surgery. The nurse should listen and allow the client to express feelings about the surgery to provide support and comfort to the client prior to the surgery. However, another intervention is the nurse's priority. !!! Determine if the client's faith conflicts with the treatment plan. !!! The nurse's priority intervention when using the nursing process is assessment. The nurse should determine if the client's faith, religious practices, or views conflict with the current treatment plan or surgical procedure so that they can take the necessary steps to inform the provider and prevent issues during or after the surgical procedure. Ensure the client's meal plan serves only kosher food following surgery. The nurse should ensure the client's meal plan serves only kosher food following surgery because it is important to be knowledgeable and respectful of the client's dietary restrictions. However, another intervention is the nurse's priority. Teach the client how to perform various relaxation exercises. The nurse should teach the client how to perform various relaxation exercises, including meditation and guided imagery, because these methods are associated with improved physiological and psychological outcomes. However, another intervention is the nurse's priority.
A circulating nurse is monitoring the temperature in a surgical suite. The nurse should identify that cool temperatures reduce a client's risk for which of the following potential complications of surgery? Malignant hyperthermia Blood clots Infection Hypoxia
Malignant hyperthermia Malignant hyperthermia is a genetic condition that can cause a reaction to the surgical anesthetic. The nurse should identify that a cool room temperature does not reduce the risk for malignant hyperthermia. Blood clots Decreased mobility during a surgical procedure can increase the risk for a blood clot. The nurse should identify that a cool room temperature does not reduce the risk for blood clots. !!! Infection The nurse should identify that a cool room temperature with humidity between 30% and 60%, along with a proper air exchange and filtering system, reduces the risk of infection for clients during surgery. Hypoxia Hypoxia is caused by the surgical anesthetic and inadequate ventilation. The nurse should identify that a cool room temperature does not reduce the risk for hypoxia.
A nurse is assessing a client who is recovering from spinal anesthesia. Which of the following sensations should the nurse expect to return to the client first? Pain Cold Touch Warmth
Pain Following spinal anesthesia, the second sensation the nurse should expect the client to feel is the sense of pain. Cold Following spinal anesthesia, the fourth sensation the nurse should expect the client to feel is the sense of cold. !!! Touch !!! Following spinal anesthesia, the first sensation the nurse should expect the client to feel is the sense of touch. Warmth Following spinal anesthesia, the third sensation the nurse should expect the client to feel is the sense of warmth.
A nurse is providing preoperative teaching to a client who is scheduled for a gastrectomy in 1 week. The client expresses anxiety about the upcoming surgery. Which of the following actions should the nurse take? Sympathize with the client's feelings. Reassure the client that the surgery will go fine. Change the topic of discussion. Provide concise, factual information.
Sympathize with the client's feelings. Sympathizing with the client's feelings is a nontherapeutic communication technique because it can lead the nurse to over-identify with the client and lose objectivity. This can impair the nurse's judgment and prevent problem solving. Reassure the client that the surgery will go fine. Giving the client false reassurance is a nontherapeutic communication technique because it discourages continued communication and does not address the client's anxiety. Change the topic of discussion. Changing the topic shows a lack of empathy for the client and blocks further communication, which can increase the client's anxiety. !!! Provide concise, factual information. !!! Providing concise, factual information allows for open communication and gives the nurse the opportunity to address the client's anxiety.
A nurse is reviewing the medical record for a client who has a prescription for general anesthesia prior to surgery. Which of the following findings should the nurse report to the provider? Potassium 2.8 mEq/L Sodium 140 mEq/L INR 1.5 BUN 12 mg/dL
!!! Potassium 2.8 mEq/L !!! The nurse should identify that the client's potassium level is below the expected reference range of 3.5 to 5 mEq/L, which places the client at risk for cardiac dysrhythmias. Therefore, the nurse should report this finding to the provider. Sodium 140 mEq/L The nurse should identify that the client's sodium level is within the expected reference range of 136 to 145 mEq/L. INR 1.5 The nurse should identify that the client's INR is within the expected reference range of 0.7 to 1.8. BUN 12 mg/dL The nurse should identify that the client's BUN level is within the expected reference range of 10 to 20 mg/dL.
