Nclex -Perioperative

The nurse assesses a postoperative client who has a rapid, weak pulse; urine output less than 30 mL/hr; and decreased blood pressure. The client's skin is cool and clammy. What complication should the nurse suspect? A. Thrombophlebitis B. Hypovolemic shock C. Pneumonia D. Wound dehiscence

B. Hypovolemic shock Rationale: The symptoms describe decreased cardiac output and not any of the other listed complications.

A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? A. Manage patient pain. B. Control the bleeding. C. Maintain fluid balance. D. Manage oxygenation status.

D. Manage oxygenation status. The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.

What event in the surgical suite represents a violation of aseptic technique? A. A glove contacts the leg of the table that supports the sterile field. B. The cuff 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. A glove contacts the leg of the table that supports the sterile field. Tables are sterile only at tabletop level. Areas below this are considered contaminated. The sterile gown below the point 2 inches above the elbow is considered sterile. 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.

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes? A. Administering adequate analgesics to promote relief or control of pain B. Asking the patient to demonstrate the postoperative exercises every 1 hour C. Giving the patient positive feedback when the activities are performed correctly D. Warning the patient about possible complications if the activities are not performed

A. Administering adequate analgesics to promote relief or control of pain Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.

An alert male patient needs a tracheostomy because he has been intubated for 7 days with an endotracheal tube and cannot be weaned from the ventilator. The patient does not want the tracheostomy, but his family insists that the surgery be performed. What is the best action for the nurse to take? A. Advocate for the patient's rights. B. Try to change the patient's mind. C. Call surgery to cancel the procedure. D. Tell the family they cannot interfere.

A. Advocate for the patient's rights. The nurse must act as the patient's advocate and assist the patient with fulfilling his wishes. However, as the patient's advocate the nurse must be sure he knows the risks and benefits of refusing a tracheostomy. Trying to change the patient's mind is unethical because it is contrary to acting as an advocate. As long as the patient is lucid, he retains the right of self-determination. Canceling the procedure is not indicated until discussion with the patient and surgeon has occurred. Telling the family they cannot interfere can aggravate or escalate the situation.

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

A. Atelectasis 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 or depth. Pulmonary emboli do not involve blockage by retained secretions

The client's postoperative orders state "diet as tolerated." The client has been NPO. The nurse will advance the client's diet to clear liquids based on which assessment? Select all that apply. A. Does not complain of nausea or vomiting. B. Pain level is maintained at a rating of 2-3 out of 10. C. States passing flatus. D. Ambulates with minimal assistance. E. Expresses feeling "hungry."

A. Does not complain of nausea or vomiting. C. States passing flatus. Rationale: Anesthetics, narcotics, fasting, and inactivity all inhibit peristalsis. Oral fluids and food are started after the return of peristalsis. The client may feel hungry but peristalsis may not be present. The other options are important but not related specifically to advancing the client's diet.

A 75-year-old patient is being prepared for surgery. What assessment data needs to be included for this patient (select all that apply)? A. Fluid balance history B. Attitude about surgery C. Foods the patient dislikes D. Current mobility problems E. Current cognitive function F. Patient's opinion about the surgeon

A. Fluid balance history D. Current mobility problems E. Current cognitive function Preoperative fluid balance history is especially critical for older adults as they have reduced adaptive capacity that puts them at greater risk for over- and under-hydration. Mobility problems must be assessed to assist with intraoperative and postoperative positioning and ambulation. Preoperative assessment of the older person's baseline cognition function is especially crucial for intraoperative and postoperative evaluation as they are more prone to adverse outcomes during and after surgery from the stressors of the surgery, dehydration, hypothermia, and anesthesia. Attitude about surgery and opinion or faith in the surgeon is important for all patients. Foods the patient dislikes are not important unless the patient is allergic to them, but this is no more important for older patients than it is for all patients.

The patient is having a mole removed that has changed appearance. What does the nurse teach the patient about the rationale for this surgical procedure? A. It is to prevent malignancy. B. It is to alleviate symptoms. C. It is to cure the malignancy. D. It is to provide cosmetic improvement.

A. It is to prevent malignancy. Removing a mole that is changing is to prevent as well as diagnose malignancy. There are no symptoms to alleviate mentioned or cosmetic problems for this patient.

A surgical patient's premedication regimen includes midazolam (Versed). What are the most likely desired effects of this medication? A. Monitored anesthesia care and amnesia B. Potentiates volatile agents to speed induction C. Analgesia and prevention of intraoperative vomiting D. Relaxation of skeletal muscles and facilitation of endotracheal intubation

A. Monitored anesthesia care and amnesia Midazolam is a benzodiazepine that is widely used for its ability to induce amnesia and provide moderate sedation (conscious sedation). Nitrous oxide is a gaseous agent that potentiates volatile agents to speed induction and reduce total dosage and side effects. Antiemetics prevent intraoperative vomiting. Neuromuscular blocking agents facilitate endotracheal intubation.

Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. What is the most appropriate action for the nurse to take? A. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. B. Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done. c. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes. d. Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room.

A. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance. The other options would not be safe for the patient.

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)? A. Vital signs baseline or stable B. Minimal nausea and vomiting C. Wants to go to the bathroom at home D. Responsible adult taking patient home E. Comfortable after IV opioid 15 minutes ago

A. Vital signs baseline or stable B. Minimal nausea and vomiting D. Responsible adult taking patient home Ambulatory surgery discharge criteria includes meeting Phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria includes a responsible adult driving patient, no IV opioid drugs for last 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.

A client who is having a mastectomy expresses sadness about losing her breast. Based on this information, the nurse would identify that the client is at risk for which nursing diagnosis? A. Body Image Disturbance B. Anticipatory Grieving C. Fear D. Ineffective Coping

B. Anticipatory Grieving Rationale: Grieving is the state in which an individual experiences reactions in response to an expected significant loss. The definition for option 1 is "confusion in mental picture of one's self" and is often characterized by negative responses such as shame, embarrassment, guilt, or revulsion. Option 3, fear, is usually characterized by feelings of dread, fright, apprehension, or alarm. Ineffective coping, option 4, is usually characterized by verbalization of inability to cope or ask for help, inappropriate use of defense mechanisms, or inability to meet role expectations.

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? A. Assess the patient's pain. B. Assess the patient's vital signs. C. Check the rate of the IV infusion. D. Check the physician's postoperative orders.

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

The nurse plans to remove the client's sutures. Which action demonstrates appropriate standards of care? Select all that apply. A. Use clean technique. B. Grasp the suture at the knot with a pair of forceps. C. Place the curved tip of the suture scissors under the suture as close to the skin as possible. D. Pull the suture material that is visible beneath the skin during removal. E. Remove alternate sutures first.

B. Grasp the suture at the knot with a pair of forceps. C. Place the curved tip of the suture scissors under the suture as close to the skin as possible. E. Remove alternate sutures first. Option 1 is incorrect because sterile technique is used. The suture material that is visible is in contact with bacteria and must not be pulled beneath the skin during removal (option 4).

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

B. Inform the anesthesiologist of the patient's recent use of kava. Kava may prolong the effects of certain anesthetics. Thus the anesthesiologist needs to be informed of recent ingestion of this herbal supplement. Patients should not take anything before surgery without the health care provider's knowledge.

Which intraoperative nursing responsibilities should 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. Keeping track of irrigation solutions for monitoring of blood loss C. Passing instruments and supplies to the surgeon by anticipating his or her needs E. Performing the count of sponges, needles, and instruments used during the surgical procedure Both the scrub nurse and circulating nurse will participate in the counting of surgical sponges, needles, and instruments, whereas passing instruments to the surgeon and other sterile activities are the exclusive responsibility of the scrub nurse. The circulating nurse takes primary responsibility for the coordination of the surgical suite and documentation.

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

B. Lateral Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated.

The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates what manifestation? A. Hypocapnia B. Muscle rigidity C. Decreased body temperature D. Confusion upon arousal from anesthesia

B. Muscle rigidity Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles from altered control of intracellular calcium occurring as a result of exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercapnia, and ventricular dysrhythmias may also be seen with this disorder.

This will be the patient's first surgical experience and the patient states, "I am nervous about this." The vital signs show BP 158/88, HR 96, RR 24. In the assessment, the nurse finds that the lungs are clear, bowel tones are evident, peripheral pulses are strong, and the patient is fidgeting nervously. The patient took alprazolam (Xanax) at bedtime last night and takes acetaminophen (Tylenol) for tension headaches. Related to this assessment information, what should the nurse do before the patient goes to surgery? A. Review the surgery with the patient. B. Notify the anesthesia care provider (ACP). C. Administer another dose of alprazolam (Xanax). D. Tell the patient that everything will be okay with the surgery.

B. Notify the anesthesia care provider (ACP). In determining the psychologic status of the patient, the nurse notes the patient's anxiety, which is supported by the elevated BP and heart rate and fidgeting. The nurse should notify the anesthesia care provider (ACP) after assessing the cause of the anxiety or fear the patient is experiencing. The patient may only need to talk about the surgery related to the situation, concerns with the unknown or body image, or past experiences to relieve the anxiety, but the nurse cannot assume that lack of knowledge is the cause of the anxiety. Medication administration will be prescribed by the ACP if needed, but medications can also be administered during surgery. Reassuring the patient is not taking the patient's needs into account.

The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient? A. Blood administration B. Restoring circulating volume C. An ECG to check circulatory status D. Return to surgery to check for internal bleeding

B. Restoring circulating volume The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, or there is a past history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient's level of consciousness changes or the abdomen becomes firm and distended.

Before admitting a patient to the operating room, which forms or results must the nurse make sure are in the chart of all patients (select all that apply)? A. Electrocardiogram B. Signed consent form C. Functional status evaluation D. Renal and liver function tests E. A history and physical report

B. Signed consent form E. A history and physical report The National Patient Safety Goals (NPSG) require documentation of a history and physical, signed consent form, and nursing and preanesthesia assessment in the chart of a patient going for surgery. The physical examination explains in detail the overall status of the patient before surgery for the surgeon and other members of the surgical team.

The new nursing student is confused about where the patient's family (who are wearing street clothes) can be with the patient in the surgical suite. Which explanation should the perioperative nurse give to the student nurse? A. The family is not allowed to talk to the nurse at the nursing station. B. The family can be with the patient in the preoperative holding area. C. The family cannot be with the patient until the postanesthesia care unit. D. The family is only allowed in the conference room for preoperative teaching.

B. The family can be with the patient in the preoperative holding area. The perioperative nurse should explain to the student nurse that the family can be in the preoperative holding area before the patient goes to surgery, but this includes talking to the nurse at the nursing station. They are also taken to the conference room for preoperative and postoperative meetings with staff, including teaching.

The client is most likely to require the greatest amount of analgesia for pain during which period? A. Immediately after surgery B. 4 hours after surgery C. 12 to 36 hours after surgery D. 48 to 60 hours after surgery

C. 12 to 36 hours after surgery Rationale: Options 1 and 2 are incorrect because the client is still recovering from the anesthesia used during surgery. Option 4 is incorrect because pain usually decreases after the second or third postoperative day.

Which preoperative patient has the greatest risk of bleeding as a result of his or her medication? A. A woman who takes metoprolol (Lopressor) 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. A man who is taking clopidogrel (Plavix) after the placement of a coronary artery stent Any drug that inhibits platelet aggregation, such as clopidogrel (Plavix), represents a bleeding risk. Insulin, metoprolol (Lopressor), and finasteride (Proscar) are less likely to contribute to a risk for bleeding

Which test is the best resource for determining the preoperative status of a client's liver function? A. Serum electrolytes B. Blood urea nitrogen (BUN), creatinine C. Alanine amino transferase (ALT), aspirate amino transferase (AST), bilirubin D Serum albumin

C. Alanine amino transferase (ALT), aspirate amino transferase (AST), bilirubin Rationale: These tests are specific to liver function. Option 1 evaluates fluid and electrolyte status. Option 2 evaluates renal status; option 4 evaluates nutritional status.

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first? A. Recheck in 1 hour for increased drainage. B. Notify the surgeon of a potential hemorrhage. C. Assess the patient's blood pressure and heart rate. D. Remove the dressing and assess the surgical incision.

C. Assess the patient's blood pressure and heart rate. The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)? A. Monitor the patient's pain. B. Do the admission vital signs. C. Assist the patient to take deep breaths and cough. D. Change the dressing when there is excess drainage

C. Assist the patient to take deep breaths and cough. The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The LPN or RN will monitor and treat the patient's pain and change the dressings.

When reviewing the preoperative forms, the nurse notices that the informed consent form is not present or signed. What is the best action for the nurse to take? A. Have the patient sign the consent form. B. Have the family sign the form for the patient. C. Call the surgeon to obtain consent for surgery. D. Teach the patient about the surgery and get verbal permission

C. Call the surgeon to obtain consent for surgery. The informed consent for the surgery must be obtained by the physician. The nurse can witness the signature on the consent form and verify that the patient (or caregiver if patient is a minor, unconscious, or mentally incompetent to sign) understands the informed consent. Verbal consents are not enough. The state's nurse practice act and agency policies must be followed.

As the nurse is preparing a patient for outpatient surgery, the patient wants to give his hearing aid to his wife so it will not be lost during surgery. Which action by the nurse should be taken in this situation? A. Give the hearing aid to the wife as he wishes. B. Tape the hearing aid to his ear to prevent loss. C. Encourage the patient to wear it for the surgery. D. Tell the surgery nurse that he has his hearing aid out.

C. Encourage the patient to wear it for the surgery. Although jewelry is removed before surgery, hearing aids should be left in place to allow the patient to better follow instructions given in the surgical suite and the postanesthesia care unit (PACU), as well as the dismissal instructions that will be given before he returns home for recovery.

The nurse is doing a preoperative assessment on a male patient who has type 2 diabetes mellitus, weighs 146 kg, and is 5 feet 8 inches tall. Which patient assessment is a priority related to anesthesia? A. Has hemoglobin A1C of 8.5% B. Has several seasonal allergies C. Has body mass index of 48.8 kg/m2 D. Has history of postoperative vomiting

C. Has body mass index of 48.8 kg/m2 The patient's body mass index is the priority because it indicates the patient is severely obese. The patient's size may impair the anesthesiologist's ability to ventilate and medicate the patient properly, as well as the surgery room staff's ability to position the patient safely. The other factors are not the priority.

What is the primary reason for accurately recording the patient's current medications during a preoperative assessment? A. Some medications may alter the patient's perceptions about surgery. B. Many anesthetics alter renal and hepatic function, causing toxicity of other drugs. C. Some medications may interact with anesthetics, 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. Some medications may interact with anesthetics, altering the potency and effect of the drugs. Drug interactions may occur between prescribed medications and anesthetic 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 anesthesia care provider. Routine medications may or may not be prescribed for use the day of surgery.

While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that A. she must be NPO after breakfast. B. she needs to be NPO after midnight. C. she can drink clear liquids up to 2 hours before surgery. D. she can drink clear liquids up until she is moved to the OR.

C. she can drink clear liquids up to 2 hours before surgery. Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidence-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight

The patient donated a kidney, and early ambulation is included in her plan of care. But the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? A. "Early walking keeps your legs limber and strong." B. "Early ambulation will help you be ready to go home." C. "Early ambulation will help you get rid of your syncope and pain." D. "Early walking is the best way to prevent postoperative complications."

D. "Early walking is the best way to prevent postoperative complications." The best rationale is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and VTE, speeds wound healing, and increases vital capacity and maintains normal respiratory function. These things help the patient be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management should always occur before walking.

Which statement by the client indicates that the preoperative teaching regarding gallbladder surgery has been effective? A. "I cannot eat or drink anything after midnight." B. "I'm not going to cough after surgery because it might open my incision." C. "I might have a stroke if I stop taking my anticoagulant." D. "The nurse showed me how to contract and relax my calf muscles."

D. "The nurse showed me how to contract and relax my calf muscles." Rationale: Option 1 is incorrect because of the ASA guidelines for preoperative fasting. Option 2 is incorrect because clients are taught how to cough and also how to splint their incision to prevent complications. Option 3 is incorrect because anticoagulants are discontinued a few days before surgery to avoid excessive bleeding postoperatively.

An older patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this new patient? A. Check his chart for intraoperative complications. B. Check which medications were used for anesthesia. C. Check the effectiveness of the analgesics he has received. D. Check his preoperative assessment for previous delirium or dementia.

D. Check his preoperative assessment for previous delirium or dementia. If the patient's ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed as these can all contribute to delirium.

A patient having an open reduction internal fixation (ORIF) of a left lower leg fracture will receive regional anesthesia during the procedure. As the patient is prepared in the operating room, what should the nurse implement to maintain patient safety during surgery that is directly related to the type of anesthesia being used? A. Apply grounding pad to unaffected leg. B. Assess peripheral pulses and skin color. C. Verify the last oral intake before surgery. D. Ensure a smooth surface under the patient

D. Ensure a smooth surface under the patient Regional anesthesia decreases sensation to the anesthetized area without impairing level of consciousness, which means the affected leg will be without sensation while the anesthetic is effective. A double tourniquet on the affected leg is used to restrict blood flow. This increases the patient's risk of impaired skin integrity because the patient does not have sensation and cannot identify discomfort or foreign objects and will not be moving during surgery. The nurse's role includes positioning the patient for correct alignment, exposure of the surgical site, and preventing injury. The other options will be occurring but are not directly related to the regional anesthesia.

A 70-year-old woman has been admitted prior to having surgery for a bilateral mastectomy and breast reconstruction. What should the nurse include in the patient'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 deep-breathing and coughing exercises

D. Information about where in the hospital she will be taken postoperatively E. Information about performing postoperative deep-breathing and coughing exercises During preoperative teaching, it is important to introduce the role of deep-breathing and coughing exercises and to inform the patient 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.

The patient is going to have a colonoscopy. Which type of anesthesia should the nurse expect to be used? A. Local anesthesia B. Moderate sedation C. General anesthesia D. Monitored anesthesia care (MAC)

D. Monitored anesthesia care (MAC) The nurse should expect monitored anesthesia care (MAC) to be used for the patient having a colonoscopy because it can match the sedation level to the patient needs and procedural requirements. Local anesthesia would not be used because the area affected by a colonoscopy is larger than loss of sensation could be provided for with topical, intracutaneous, or subcutaneous application. Moderate sedation is used for procedures performed outside the OR, and the patient remains responsive. General anesthesia is not needed for a colonoscopy, and it requires advanced airway management.

A 71-year-old male patient who is currently undergoing coronary artery bypass graft (CABG) surgery has just experienced intraoperative vomiting. The nurse should consequently anticipate the use of which drug? A. Midazolam (Versed) B. Fentanyl (Sublimaze) C. Meperidine (Demerol) D. Ondansetron (Zofran)

D. Ondansetron (Zofran) Ondansetron (Zofran) is an antiemetic, whereas midazolam (Versed) is a benzodiazepine, and fentanyl (Sublimaze) and meperidine (Demerol) are opioid analgesics.

In which surgical area will the patient's skin be prepped for surgery, and what clothing will the person doing the prepping be wearing? A. Surgical suite wearing a lab coat B. Preoperative holding area wearing street clothes C. Postanesthesia care unit (PACU) wearing scrubs D. Operating room wearing surgical attire and masks

D. Operating room wearing surgical attire and masks Surgical attire includes pants and shirts (or scrubs), a cap or hood, masks, and protective eyewear. All surgical attire is worn when the patient's skin is being prepped in the operating room to avoid contamination of the site. The surgical suite includes all unrestricted, semirestricted, and restricted areas of the controlled surgical environment. A lab coat is usually worn by the staff over their scrubs when they leave the surgical area. The staff will not wear street clothes in the preoperative holding area, although the family may. The holding area and PACU will not include prepping the patient for surgery.

Which National Patient Safety Goal (NPSG) requirement is enacted immediately before surgery with a surgical time-out? A. Prevention of infection B. Improved staff communication C. Identify patients at risk for suicide. D. Patient, surgical procedure, and site are checked.

D. Patient, surgical procedure, and site are checked. During the surgical time-out the Universal Protocol is used to verify the patient's identity, surgical procedure, and site to prevent mistakes in surgery. Prevention of infection is to be done at all times. Improved staff communication relates to getting important test results to the right staff on time. Identifying patient's safety risks for suicide is not usually vital before surgery and does not occur during the time-out.

A semiconscious client in the postanesthesia care unit (PACU) is experiencing dyspnea (difficulty breathing). Which action should the nurse perform first? A. Place a pillow under the client's head. B. Remove the oropharyngeal airway. C. Administer oxygen by mask. D. Reposition the client to keep the tongue forward.

D. Reposition the client to keep the tongue forward. Rationale: The tongue can obstruct the airway in a semiconscious client. Repositioning in the side-lying position with the face slightly down will help prevent occlusion of the pharynx and also allow drainage of mucus out of the mouth. Option 1 is incorrect because a pillow under the head increases the risk of aspiration or airway obstruction. Because the problem is airway obstruction, actions to promote an open airway are most appropriate. The nurse would want to keep the airway in place (option 2). The problem is obstruction, not percentage of available oxygen (option 3).

A 78-year-old patient is having surgery. What risk areas will the nurse need to be especially aware of for this patient during surgery? A. Sterility B. Paralysis C. Urine output D. Skin integrity

D. Skin integrity Skin of older adults has lost elasticity and is at increased risk for injury from tape, electrodes, warming or cooling blankets, and dressings. Pooling cleansing solution may create skin burns or abrasions. The nurse is responsible for monitoring patient safety and adjusting patient position as necessary to prevent pressure or misalignment. Sterility and urine output would be monitored for all patients. Paralysis would not be unusual during some types of surgery but would have an impact on any patient's skin integrity.

The overall goal of nursing care during the intraoperative phase is the client's ...... _______________________________

Safety

A postop client who had abdominal surgery is holding a pillow against his abdomen during deep-breathing and coughing exercises. What term does the nurse use to describe this technique? ___________________

Splinting