Peri-Op NCLEX Questions
The nurse is caring for the postoperative patient who has had spinal anesthesia. The nurse would place highest priority on reporting which of these assessments? a. Complaints of a headache b. Pulse rate of 78 beats per minute c. Voided 300 mL d. Blood pressure of 126/78
Answer 1. One complication of spinal anesthesia is post spinal headache. It is cause by the leaking of cerebrospinal fluid at the puncture site.
A 65-year-old client is having neck surgery. Which nursing diagnosis does the nurse include for this client? a. Risk for Fluid Volume: Deficient b. Ineffective Pain Control c. Risk for Burns d. Risk for Fluid Volume: Excess
Answer A /Rationale:Risk for Fluid Volume: Deficient is related to any blood loss during the client's surgery and NPO status. Risk for Burns is unrelated; there is no indication for Fluid Volume: Excess or Ineffective Pain Control.
After surgery your patient is semi comatose with vital signs within normal limits. As the nurse, what position would be best for the patient? a. Prone b. High- Fowlers c. side position preferably left side d. Lithotomy
Answer: C. A patient who is semi comatose is at risk for aspiration. Placing a patient on their side preferably the left with decrease risk for aspiration and promote cardiovascular circulation
A nurse is preparing to mix and administer dantrolene via IV bolus to a client who has developed malignant hyperthermia during surgery. Which of the following actions should the nurse take? a. Admin the reconstituted medication slowly over 5 min b. Store the reconstituted medication in the fridge c. Use the reconstituted med within 12 hours d. Reconstitute the initial dose with 60 ml of sterile water without a bacteriostatic agent
Answer: D the nurse should dilute the med with 60 ml sterile water without a bacteriostatic agent and inject rapidly
The client receiving preoperative medication tells the nurse that all of the following medications (drugs or herbs) were ingested yesterday. Which one should the nurse report to the surgical team? a. Acetaminophen (Tylenol) b. Vitamin C c. Motherwort d. Diphenhydramine (Benadryl)
ANS: C Motherwort interferes with coagulation, increasing the client's risk for bleeding during and after the surgical procedure.
You are the RN monitoring the status of a postoperative patient in the immediate postoperative period. The nurse would become MOST concerned with which sign that could indicate complications? a. Increasing restlessness b. Pulse 86 c. Blood Pressure 110/60 d. Hypoactive bowel sounds in all 4 quadrants
ANSWER: A Rationale: Increasing restlessness requires continuous/close monitoring. It could indicate a potential complication such as hemorrhage, shock or pulmonary embolism. Blood pressure and pulse are WNL. Hypoactive bowel sounds are a normal occurence in the immediate post-op period.
The nurse is doing preoperative teaching with a patient schedule for surgery in 1 week. The patient has been taking aspirin for arthritis. The nurse determines the patient needs further teaching when the patient states: a. "Aspirin can cause further bleeding after surgery" b. "Aspirin can cause my ability to clot blood to be abnormal" c. "I need to continue to take aspirin until the day of surgery" d. "I need to check with my HCP about the need to stop the aspirin before the scheduled surgery"
ANSWER: D Rationale: Antiplatelets alter normal clotting factors and increase risk of bleeding after surgery. Aspirin should be discontinued at least 48 hours before surgery.
A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. which of the following interventions should the nurse include in the plan of care? a. limit the adolescent's visitors b. select the adolescent's food choices c. allow the adolescent to make decisions regarding his daily routine d. encourage the adolescent's parent to assist with personal hygiene
Answer (C) Rationale: the nurse should allow the adolescent to make decisions regarding his daily routine in order to give him a sense of control
A 48 year-old male client had surgery to correct esophageal varices. Six hours after surgery, his vital signs were pulse 86, respirations 24, blood pressure 142/74, pulse oximetry 92%, temperature 100.2 F. What should the nurse do first? a. Culture the incision b. Consult the attending health care provider for an antibiotic order c. Assess pain level and treat with prescribed narcotic medication d. Reposition the client upright and encourage use of incentive spirometry
Answer 4. Reposition the client upright and encourage use of incentive spirometry An elevation in temperature above 100 F in the first 24 hours after surgery most often indicates pulmonary atelectasis. The client should be instructed to sit up and perform deep breathing exercises. No indication exists for cultures or antibiotics at this time. pain medication may lead to even more shallow breathing.
A nurse is caring for a client postoperative following colostomy placement. which of the following findings should the nurse report to the provider? a. Stoma appears purple in color b. Protrusion of stoma from the abdomen c. Mucosa of the stoma bleeds slightly when touched d. Red peristomal skin ulcer under the adhesive
Answer A) Rationale: The stoma should appear red and moist. the provider should be notified if the stoma appears dark in color, which is an indication of impaired circulation.
A patient is recovering from surgery. The patient is restless, heart rate 120bpm, blood pressure is 70/53, and skin is cool and clammy. As a nurse, what should you do? a. continue to monitor b. notify MD c. check blood glucose levels d. obtain EKG
Answer B. This is an emergency situation. The patient is more then likely experiencing hemorrhaging of some time. Notifying the MD would be the first line of action and then checking blood glucose and EKG. The patient could possibly require surgical intervention.
Which client statement indicates that a client who is scheduled for a 3-hour surgery under general anesthesia needs further teaching? a. " A breathing tube will be placed when I am in the operating room." b. "I should shave the skin in the surgical area the evening prior to surgery." c. "I should splint my incision with a pillow when coughing and deep breathing after surgery." d. "I might need a urinary catheter inserted before surgery so my urine output can be monitored."
Answer B: If any shaving of the surgical area is to be done, it should be done immediately prior to surgery in a holding area, treatment room, operating suite, or the operation room by qualified personnel. The client should not shave the surgical area. Nicks increase the risk for infection.
A nurse is caring for a postoperative client who reports an inability to void. Which initial action by the nurse is most appropriate? a. Turing on running water b. Inserting a urinary catheter c. Palpating the client's bladder d. Reviewing the client's chart for the time of the last voiding.
Answer C because the bladder should be palpated for distention. The nurse should also observe for other signs of a full bladder such as restlessness or an elevated blood pressure. The nurse should first determine the underlying reason for the client's inability to void. Turning on running water assumes that the client has a full bladder. A urinary catheter should only be inserted if the client has a full and other measures to initiate voiding have been unsuccessful. Though reviewing the chart for the time of the last voiding may assist in determining the underlying problem, client assessment should be the first action.
A nurse plans care for a client and notes that all of the following must be completed for a client being prepared for surgery. Which intervention should the nurse complete first? a. Complete the preoperative checklist b. Assess the client's preoperative vital signs. c. Remove the client's rings, gold chain, and wristwatch. d. Administer 10 mEq KCL IV for a serum potassium level of 3.0 mEq/L.
Answer D: Intravenous potassium is ordered for low serum potassium levels. Low levels could induce cardiac dysrhythmias and delay surgery. Administering the potassium should be the nurse's priority because abnormalities must be corrected before surgery.
The client will receive IV midazolam hydrochloride (Versed) during surgery. Which of the following should the nurse determine as a therapeutic effect? a. Amnesia. b. Antiemetic. c. Mild agitation. d. Blurred vision
Answer a Rationale: Midazolam hydrochloride causes antegrade amnesia or decreased ability to remember events that occurred around the time of sedation. Versed does not provide relief again nausea and vomiting. Mild agitation and blurred vision are adverse effects of Versed
Eight hours following bowel surgery, the nurse observes that the client's urine output has decreased from 50 to 20mL/h. The nurse should assess the client further for which of the following? a. Bowel obstruction. b. Adverse effect of opioid analgesics. c. Hemorrhage. d. Hypertension.
Answer c Rationale: When the urine output is less than 30 mL/h, the nurse should assess for potential causes such as hypovolemia or hemorrhage. The nurse should assess and evaluate the client's vital signs, intake and output, dressing, and available laboratory values and notify the physician. Bowel obstruction, although possible after surgery, is characterized most notably by abdominal distention and absent bowel sounds, not decreased urine output. The nurse would not expect the client to have hypertension , but rather hypotension.
Prior the operation the nurse checks the client receiving warfarin sodium, an anticoagulant, has a prothrombin time of 22 and a partial thromboplastin time of 39. The control values are PT 12.9; and PTT 37. The International Normalized Ratio (INR) is 2.8. Which nursing intervention would be most appropriate? a. Holding the medication and assessing for bleeding b. Administering the medication as ordered c. Preparing to administer protamine sulfate d. Notify the physician immediately
Answer is Give the medication as the values are WNL limits for the patient receiving warfarin (1.5-2 times the control value)and surgical procedures.
During a pre surgical admission assessment, a client states, "I've told my surgeon that I am a Jehovah's Witness and I won't accept a blood transfusion." Which statement by the nurse would be most appropriate? a. "Tell me about your fear of receiving a blood transfusion." b. "your request to not receive a transfusion would be honored. Your consent is needed to administer blood or blood products." c. "You don't need to worry about getting a blood transfusion. We have newer equipment that causes less blood loss during surgery." d. "are you sure you wouldn't want a blood transfusion if one is needed during surgery: You can always change your mind after surgery.
Answer: 2 A client's consent is needed prior to administering blood or blood products. Even in a life- threatening situation, the client has the right to refuse blood and blood products for religious reasons. There is no indication the client is fearful. The client is refusing blood for religious reasons. Telling the client not to worry belittles the client and does not address the client's statement about not getting a blood transfusion. Response 4 asking if the client is sure is wrong.
The nurse is caring for a first day postoperative surgical client. Prioritize the patient's desired dietary progression. Arrange in sequence the dietary progression from 1 to 4: a. 1. Full liquid b. 2. NPO c. 3. Clear liquid d. 4. Soft
Answer: 2, 3, 1, 4 The clients status is NPO immediately after surgery. Desired diet progression advances to clear liquid, full liquid, soft and finally a regular diet as tolerated by the client
A physician writes an order to hold a medication the morning of surgery for a client with a history of type 1 diabetes mellitus and hypertension. A nurse should call the physician to clarify the hold order for what medication? a. Acetylsalicylic acid b. Ducosate Sodium c. Regular and NPH insulin d. Clonidine.
Answer: 3 The diabetic client who takes Insulin should be given a reduced dose of intermediate or long-acting insulin base on the blood glucose levels. Regular insulin in divided doses on the day of surgery or an insulin drip may be initiated for tight glucose control. Anticoagulant, antihypertensive should be discontinued to prevent bleeding and hypotension respectively. Stool softener should be hold.
Which of the following items on a client's presurgery laboratory results would indicate a need to contact the surgeon? a. A platelet count of 250,000 cu/mm b. Total cholesterol of 325 mg/dL c. Blood urea nitrogen 17 mg/dL d. Hemoglobin 9.5 mg/dL
Answer: 4 Explanation: The Hemoglobin 9.5 mg/dL level is low. The nurse needs to make sure that the surgeon has the most recent laboratory values before surgery. This client may need a transfusion before surgery.
A patient returns to the nursing unit after undergoing a cardiac catheterization using the femoral insertion site. After the procedure, the nurse should avoid a. Elevating the head of the bead b. Providing oral fluids c. Assessing the motor function of the patient's foot on the affected side d. Resuming all medications
Answer: A Rationale: After a cardiac catheterization using the femoral artery, the patient should remain on flat bedrest and be reminded not to flex or move the affected extremity. The site is monitored for bleeding or hematoma and kept immobilized for a few hours.
Eight hours after laparoscopic abdominal surgery, a client has a distended bladder and is unable to void in bed using a urinal. The client can be out of bed as tolerated, but has not done so yet. The nurse should first: a. Assist the client to stand at the bedside to use the urinal b. Pour running water over perineum to stimulate emptying of the bladder. c. Encourage the client to ambulate to prevent further bladder distention d. Notify the healthcare provider to request a prescription for catheterization
Answer: A Rationale: The nurse should first try to facilitate the client's ability to void by having the client stand at the bedside and use the urinal. Pouring running water over the perineum is a strategy that could be use if the client cannot void in a standing position. Ambulation will not help the client void. If such conservative methods fail, the nurse should obtain a prescription to catheterize the client, but an indwelling urinary catheter increases the risk of urinary tract infection.
A nurse is providing care for a client who is postop following a open cholecystectomy with the placement of a closed suction drain and is receiving morphine via patient controlled analgesia for pain. Which of the following assessments is the nurses priority? a. Respiratory Rate b. Bowel Sounds c. Drainage amounts d. Wound Appearance
Answer: A Resp Rate When using the ABC's approach to client care, the nurse should determine the priority assessment as the client's airway due to risk of respiratory depression. Morphine and other opioid medications can cause resp depression, constipation and urinary retention
A 65-year-old client is having neck surgery. Which nursing diagnosis does the nurse include for this client? a. Risk for Fluid Volume: Deficient b. Risk for Fluid Volume: Excess c. Ineffective Pain Control d. Risk for Burns
Answer: A Risk for Fluid Volume: Deficient is related to any blood loss during the client's surgery and NPO status. Risk for Burns is unrelated; there is no indication for Fluid Volume: Excess or Ineffective Pain Control.
A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) a. Encourage use of incentive spirometer every 2 hours b. Instruct the client to splint the incision when coughing and deep breathing c. Reposition the client every 2 hours d. Administer antibiotic therapy e. Assist with early ambulation
Answer: A,B,C,E Rationale: a- Use of the incentive spirometer every 2 hr expands the lungs and prevents atelectasis b- Incisional splinting with a pillow or blanket supports the incision during coughing or deep breathing, which prevents atelectasis. c- Repositioning the client every 2 hr will mobilize secretions and allow the client to deep breathe and expand the lungs to prevent atelectasis d-Antibiotic therapy is used to prophylactically prevent or treat infection and does not prevent atelectasis e- Early ambulation expands the lungs through deep breathing and prevents atelectasis
The nurse is preparing to transfer a client from the operating room to recovery. She knows that adhering to the hospital policy for client handoffs best ensures which of the following? a. Case management b. Continuity of care c. Confidentiality protection d. Collaboration
Answer: B Rationale: A) Case management does not address the issue of handoffs between caregivers. B) Improving handoff communication allows each caregiver to communicate completely, effectively and consistently as the client transitions departments of the hospital. C) Confidentiality protection does not address the issue of handoffs between caregivers. D) Collaboration does not address the issue of handoffs between caregivers.
The nurse is providing pre-procedure education to a patient scheduled to undergo cardiac catheterization. Which of the following statements should the nurse include? a. "You may develop a headache, but this is normal." b. "You may feel various sensations during the procedure, including flushing, warmth, or palpitations." c. "There may be some intense pain at first, but it quickly subsides." d. "The procedure is performed in the operating room."
Answer: B Rationale: The nurse should describe to the patient some of what they should expect in a factual, non-frightening way, giving them a chance to ask questions or express concerns. During a cardiac catheterization, the patient may feel warmth, flushing, palpitations, or a desire to cough. These symptoms are from the injection of contrast dye and the catheter passage. There is very little pain experienced because of the local anesthetic used, headaches are not normal during cardiac catheterization, and the procedure is done in a catheterization lab not in the operating room.
The nurse is monitoring the patient who is 24 hours post-opt from surgery. Which finding requires intervention? a. A. BP 100/80 b. 24-hour urine output of 300 ml c. Pain rating of 4 on 1-10 scale d. Temperature of 99.3' F
Answer: B The nurse needs to watch the patient's urinary output closely. Urinary output within a 24-hour period should be at least 30 ml/hr. In this case, the patient is only urinating 12.5 ml/hr.
1) You are the nurse assigned to an Orthopedic floor, you have a client complaining of pain in varying degrees upon movement of body parts. The client is one day post open reduction and internal fixation (ORIF) of the left hip. Which of the following observation would prompt you to call the doctor? a. Dressing is intact but partially soiled b. Left foot is cold to touch and pedal pulse is absent c. Left leg in limited functional anatomic position d. BP 114/78, pulse of 82 beats/minute
Answer: B, cold limbs and absent pulses are sign of very poor perfusion and should always get the nurses attention, especially for a patient post op day one.
The nurse is caring for a postoperative patient at risk for pneumonia. What interventions can be implemented to reduce the risk of pneumonia? Select all that apply. a. Limiting fluids b. Incentive spirometer c. Early ambulation d. Frequent repositioning e. Bed rest f. Coughing
Answer: B, C, D, F Rationale: To prevent the development of pneumonia, the patient should cough, deep breathe, reposition frequently and ambulate early, and use the incentive spirometer. Bed rest and limiting fluids will increase the risk of pneumonia.
A client is scheduled for an ileostomy. Which would be most helpful in preparing the client psychologically for surgery? a. Include family members in preoperative teaching sessions. b. Encourage the client to ask questions about managing an ileostomy. c. Provide a brief, thorough explanation of all preoperative and postoperative procedures. d. Invite a member of the ostomy association to visit the client.
Answer: C Rationale: Providing explanations of preoperative and postoperative procedures helps the client prepare and understand what to expect. It also provides an opportunity for the client to share concerns. Including family members in the teaching sessions is beneficial but does not focus on the client's psychological preparation. Encouraging the client to ask questions about managing the ileostomy may be rushing the client psychologically into accepting the change in body image and function. The client may need time to first handle the stress of surgery and then observe the care of the ileostomy by others before it is appropriate to begin discussing self-management. The nurse should gently explore whether the client is ready to ask questions about management throughout the hospitalization. The client should have the opportunity to express concerns and to agree to an ostomy association visitor before an invitation is extended.
You are completing the history on a patient who is scheduled to have surgery. What health history increases the risk for surgery for the patient? a. Urinary Tract infections b. History of Premature Ventricle Beats c. Abuse of street drugs d. Hyperthyroidism
Answer: C If a patient has a history of street drug abuse this puts them at risk in surgery. This information is very important for the anesthesiologist due to the complications that can arise from the anesthesia. All of the other options are important to note but not a risk for surgery.
Following a thyroidectomy, the client experiences hemorrhage. The nurse would prepare for which emergency intervention? a. IV administration of calcium b. Insertion of an oral airway c. Creation of a traceostomy d. Administration of thyroid hormone
Answer: C Hemoorhage in the neck area will creat much pressure on the trachea and th need to keep airway patent is priority.
\The nurse is educating a client who is scheduled for surgery in the near future about autologous blood donation. Which of the following statements by the clients indicates that the teaching was successful? a. "I cannot donate blood for myself because of my age." b. "I will not need a transfusion after surgery." c. "I can be an autologous blood donor 6 weeks before my surgery in the event that I may need a transfusion." d. "I will not get a transfusion reaction with my own blood."
Answer: C Rationale: A)The client's age does not disqualify him/her from autologous donation. B) You cannot assume that the client will not need a transfusion. C) Autologous donation should take place 4-6 weeks prior to surgery and when blood counts are within normal limits. D) Though it is rare, it is possible for the client to have a reaction to his/her own blood.
A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take? (Select all that apply) a. Explain to the client the purpose of having the procedure b. Inform the client of risks to having the procedure c. Ensure the client understands information about the procedure d. Determine if the client is capable of understanding the reason for the procedure
Answer: C,D,E Rationale: a-The provider should explain the purpose of the procedure b-The provider should inform the client of risks to having the procedure c-The nurse should ensure understanding d. The nurse should witness the client signing informed consent e. The nurse should determine if client is capable of understanding the reason for the procedure
The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? a. Avoid oral hygiene and rinsing with mouthwash b. Verify that the client has not eaten for the last 24 hours c. Have the client void immediately before going into surgery d. Report immediately any slight increase in blood pressure or pulse
Answer: C. The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, without swallowing water. The client usually has is NPO 6-8 hours before surgery, not 24. A slight increase in BP and pulse is usually the result of anxiety.
1) A 26-year-old client comes into the clinic prior to a tonsillectomy. Which action is priority during this phase of surgery? a. Intraoperative medication b. Intraoperative consent signed c. Postoperative assessment d. Preoperative assessment
Answer: D Rationale: The client is in the preoperative phase of surgery and must be assessed and prepared for surgery. The client may have labs drawn, medication administered, and consent forms signed. The intraoperative phase is the actual surgery; the client is anesthetized, prepped, draped, and surgery performed. The postoperative phase is the recovery phase of surgery where the client continues to recover until maximum health is achieved.
A patient scheduled to undergo a left femoral-popliteal bypass graft has poor perfusion to the left lower extremity. Due to poor perfusion, which of the following interventions should the nurse complete before the procedure? a. Complete the preoperative checklist b. Obtain baseline coagulation studies c. Check vital signs to establish a baseline d. Assess for and mark the location of the posterior tibial and dorsal pedal pulses
Answer: D Rationale: Due to poor perfusion, the nurse assesses and marks weak peripheral pulses before the surgery to establish baseline findings for after surgery comparison.
A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? a. Obtain a court order for the surgery b. Have the charge nurse sign the informed consent immediately c. Send the client to surgery without the consent form signed and have client sign after d. Obtain a telephone consent from a family member, following agency policy. Eight hours following bowel surgery, the nurse observes that the client's urine output
Answer: D. Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent from. Usually, two witnesses must hear the oral consent. Consent is not informed if the client is confused, unconscious, mentally incompetent, or under influence of sedatives. In an emergency, a health care provider is permitted to legally perform surgery without consent, but this is not the case in this situation
The nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? a. Assess the patency of the airway. b. Check tubes or drains for patency. c. Check the dressing to assess for bleeding. d. Assess the vital signs to compare with preoperative measurements.
Option 1 is correct answer Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.
The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? a. Red, hard skin b. Serous drainage c. Purulent drainage d. Warm, tender skin
Option 2 is correct answer Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.
A patient is taking Aspirin 325 mg PO by mouth daily. The patient is scheduled for surgery in a week. What education do you provide the patient with before surgery? a. Educate the patient to take the scheduled dose of Aspirin the day of surgery to help prevent blood clots b. To hold his morning dose of Aspirin because the nurse will give it to him before surgery c. None of the above are correct d. The medication should be discontinued for 48 hours prior to the scheduled surgery date
The answer is D. Aspirin alters the normal clotting factors and increases the patient's chances of hemorrhaging. Therefore, it should be held for at least 48 hours prior to surgery.
The client tells the nurse during the preoperative history that he is a three-pack a day cigarette smoker. This information alerts the nurse to which potential complication during the intraoperative and postoperative periods? a. A decreased tolerance to pain b. A decreased clotting ability c. An increased risk for atelectasis and hypoxia d. An increased risk for excessive scar tissue formation
ANS: C Smoking increases the level of circulating carboxyhemoglobin, which decreases oxygen delivery to the tissues. In addition, cigarette smoking damages the cilia of mucous membranes, decreasing transport of secretions and increasing the risk of pulmonary infection and atelectasis.
The nurse is preparing the preoperative client for surgery. The following statements that indicate the client is knowledgeable about his impending surgery, except: a. After surgery, I will need to wear the pneumatic compression device while sitting in the chair b. The skin prep area is going to be longer and wider than the anticipated incision c. I cannot have anything to drink or eat after midnight on the night before the surgery d. To ensure my safety, a time out will be conducted in the operating room
Answer A. After surgery, I will need to wear the pneumatic compression device while sitting in the chair The pneumatic compression device is worn during bed rest, not during ambulation
A postoperative client who received a spinal anesthetic is experiencing a headache, photophobia, and double vision. A nurse's initial intervention should be to: a. immediately notify the surgeon. b. position the client flat in bed. c. limit the client's fluid intake. d. administer steroid medications.
Answer B because the client is experiencing a postdural puncture headache caused by leakage of cerebrospinal fluid (CSF) from the needle insertion made in the dura for the spinal anesthetic. Placing the client in the flat position minimizes the leakage of CSF. The surgeon should be notified of the development as well as the anesthesiologist if the headache persists despite interventions or there is noticeable leakage of CSF. Fluids should be increased to hydrate the client and replace fluids lost from the CSF leakage. If the headache persists, steroids may be ordered to decrease inflammation, but this is not an initial intervention.
A client is rushed into surgery following an MVA. The client must receive a blood transfusion to sustain life but is a Jehovah's Witness. What priority intervention by the nurse is the most appropriate? a. Do nothing; the family will not change their minds. b. Tell the family the client will die without the blood. c. Do not ask for consent; give the blood anyway. d. Obtain consent for an autologous blood transfusion.
Answer: D Many Jehovah's Witness clients, due to their beliefs, do not receive blood, even if it is a life saving measure. Some Jehovah's Witness clients sign only the consent to receive autologous blood. The perioperative nurse needs to understand and accept this belief. Therefore, when the nurse presents the Jehovah's Witness client with the blood consent to sign, the nurse cannot ask questions or try to persuade the client.
Surgery schedules are communicated to the OR usually a day prior to the procedure by the nurse of the floor or ward where the patient is confined. For orthopedic cases, what department is usually informed to be present in the OR? a. Rehabilitation department b. Laboratory department c. Maintenance department d. Radiology department
Answer: D, radiology must be informed for orthopedic cases so they can ensure the procedure was performed properly and that all bones/implants are placed correctly
Which of the following is the primary purpose of maintaining NPO for 6 to 8 hours before surgery? a. To prevent malnutrition b. To prevent electrolyte imbalance c. To prevent aspiration pneumonia d. To prevent intestinal obstruction
Answer C. To prevent aspiration pneumonia. NPO for 6 to 8 hours before surgery prevents vomiting, regurgitation of gastric content. Therefore, this prevents aspiration pneumonia. The primary purpose for maintaining NPO before surgery is to prevent aspiration pneumonia
You are completing the history on a patient who is scheduled to have surgery. What health history increases the risk for surgery for the patient? a. Urinary Tract infections b. History of Premature Ventricle Beat c. Abuse of street drugs d. Hyperthyroidism
The answer is C. If a patient has a history of street drug abuse this puts them at risk in surgery. This information is very important for the anesthesiologist due to the complications that can arise from the anesthesia. All of the other options are important to note but not a risk for surgery.