Periop- nursing 112

A patient is recovering from surgery. The patient is very restless, heart rate is 120 bpm and blood pressure is 70/53, skin is cool/clammy. As the nurse you would?

notify the MD

The nurse is admitting a patient to the operating room. Which of the following nursing actions should be given highest priority by the nurse?

Checking the patient's identification and correct operative permit

A nurse is preparing the client for transfer to the operating room (OR). The nurse should take which of the following actions in the care of this client at this time?

Ensure that the client has voided.

The nurse reviews the patient's laboratory results prior to surgery. Which finding will the nurse report immediately?

Prothrombin time (PT): 15.2 seconds normal= 11-13.5

The nurse is preparing the preoperative client for surgery. The following statements that indicate the client is knowledgeable about his impending surgery, except:

"After surgery, I will need to wear the pneumatic compression device while sitting in the chair"

A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which of the following responses by the nurse is most likely to stimulate further discussion between the client and the nurse?

"Can you share with me what you've been told about your surgery?"

beta blockers

affect blood pressure

monitor

urinary retention- leads to UTI especially w foley very important to empty bladder so not retention

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?

use of street drugs

The nurse is monitoring the patient who is 24 hours post-opt from surgery. Which finding requires intervention?

24-hour urine output of 300 ml

When assessing your patient who is post-opt, you notice that the patient's right calf vein feels hard, cord-like, and is tender to the touch. The patient reports it is aching and painful. What would NOT be an appropriate nursing intervention for this patient?

Allow the patient to dangle the legs to help increase circulation and alleviate pain

While going through the pre-op checklist the nurse verifies whether the consent is signed. It is signed by the patient and provider but was not witnessed. What action would the nurse NOT need to do?

Ask the patient what date they signed it we do: Ask the patient if the signature is theirs Ask the patient if they understand the procedure Ask the patient is they signed it willingly

The patient had undergone a total hip replacement. He complains of pain in the operative site. Which of the following is the appropriate initial nursing action?

Assess the patient's pain level and vital signs

A patient reports he hasn't had a bowel movement or passed gas since surgery. On assessment, you note the abdomen is distended and no bowel sounds are noted in the four quadrants. You notify the MD. What non-invasive nursing interventions can you perform without a MD order?

Encourage ambulation, maintain NPO status, and monitor intake & output

When performing a surgical dressing change of a client's abdominal dressing, a nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should plan to do which of the following in the initial care of this wound?

Apply a sterile dressing soaked with normal saline.

The patient had undergone thyroidectomy. Which of the following are the earliest signs of poor tissue perfusion and poor respiratory function?

Apprehension and restlessness

A nurse is reviewing the physician's order sheet for the preoperative client, which states that the client must be on nothing per mouth (NPO) status after midnight. The nurse would clarify whether which of the following medications should be given to the client and not withheld?

Atenolol (Tenormin)- beta blockers should not be stopped abruptly

Which of the following drugs is administered to minimize respiratory secretions preoperatively?

Atropine sulfate

Which of the following are not members of the sterile team in the operating room, except:

Circulating nurse

A client is admitted to the surgical unit postoperatively with a wound drain (Hemovac) in place. Which of the following nursing actions would the nurse avoid in the care of the drain?

Curl the drain tightly and tape it firmly to the body.- can cause an obstruction

What is a potential postoperative concern regarding a patient who has already resumed a solid diet?

Failure to pass stool within 48 hours of eating solid foods

The patient had undergone spinal anesthesia for appendectomy. To prevent spinal headache, the nurse should place the patient in which of the following positions?

Flat on bed for 6 to 8 hours

To prevent complications of immobility, which activities would the nurse plan for the first postoperative day after a colon resection?

Get the client out of bed and ambulate to a bedside chair

The nurse is caring for a patient who will be having surgery on his right knee. What is the best method to ensure that the surgery is performed on the correct knee?

Have the surgeon and the patient mark a "yes" and their initials with marker on the knee to be operated on.

Which actions will the nurse include in the surgical time-out procedure before surgery

Have the surgeon identify the patient. Have the patient state name and date of birth. Verify the patient identification band number. Ask the patient to state the surgical procedure.

Which of the following is most dangerous complication during induction of spinal anesthesia?

Hypotension

A nurse is monitoring the status of the postoperative client. The nurse would become most concerned with which of the following signs, which could indicate an evolving complication?

Increasing restlessness

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: 1. Full liquid; 2. NPO; 3. Clear liquid; 4. Soft

NPO then clear liquid then full liquid then soft

The nurse is completing preoperative teaching for a patient, and it becomes apparent that the patient does not understand the surgery that will be performed. What is the priority action for the nurse?

Notify the surgeon and note the finding in the patient's chart.

A client with a perforated gastric ulcer is scheduled for emergency surgery. The client cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which of the following actions in the care of this client?

Obtain a telephone consent from the family member witnessed by two persons.

diagnostic

PT complains of like belly ache and can't figure out what's going on, X-rays are done, so surgeon goes in laproscopically and try to find what's wrong

A patient is 6 days post-opt from abdominal surgery. The patient is to be discharged later today. The patient uses the call light and asks you to come to his room and look at his surgical site. On arrival, you see that approximately 2 inches of internal organs are protruding through the incision. What intervention would you NOT do?

Put the patient in prone position with knees extended to put pressure on the site You would- cover the site w sterile dressing, monitor for signs of shock, and notify the MD and give antiemetic to prevent vomiting

A nurse is teaching a client about the use of an incentive spirometer in the postoperative period. The nurse should include which of the following pieces of information in discussions with the client?

The best results are achieved when sitting at least halfway or fully upright.

A nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which of the following actions should the nurse plan to take first?

Recheck the vital signs in 15 minutes.

In the recovery room, the postoperative client suddenly becomes cyanotic. What is the most appropriate nursing action?

Reposition the head and determine patency of airway

A nurse is developing a care plan for a patient who is at risk for developing pneumonia after surgery. Which of the following is not an appropriate nursing intervention?

Repositioning every 3-4 hours- if the PT is unable to turn themselves then you have to reposition every 1-2 hours

After surgery your patient is semicomatose with vital signs within normal limits. As the nurse, what position would be best for this patient?

Side positioning preferably on the left side

The nurse will provide preoperative teaching on deep breathing, coughing and turning exercises. When is the best time to provide the preoperative teachings?

The afternoon or evening prior to surgery

You are observing your patient use the incentive spirometry. What demonstration by the patient lets you know the patient understands how to use the device properly?

The patient inhales slowly on the device and maintains the flow indicator between 600 to 900 level

Which of the following is experienced by the patient who is under general anesthesia?

The patient is unconscious

palliative

The patient will be undergoing palliative surgery to debulk an abdominal tumor. The patient's daughter asks why the surgery is considered to be palliative. What is the nurse's best response? "The surgery will relieve the symptoms of the bowel obstruction but will not cure your father."

Which of the following assessment data is most important to determine when caring for a patient who has received spinal anesthesia?

The time of return of motion and sensation in the patient's legs and toes

Which of the following is the primary purpose of maintaining NPO for 6 to 8 hours before surgery?

To prevent aspiration pneumonia

The nurse is transferring the patient from the postanesthesia care unit to the surgical unit. Which of the following is the primary reason for gradual change of position of the patient?

To prevent sudden drop of blood pressure

A nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to most carefully monitor which of the following parameters during the next hour?

Urinary output of 20 mL/hour

The nurse is preparing a client for surgery. What is the most effective method for obtaining an accurate blood pressure reading from the client?

Use a cuff that is wide enough to cover the upper two thirds of the client's arm

The nurse is caring for a patient who will be undergoing surgery. Which information is most important for the nurse to teach the patient at this time?

What to expect in the operating and recovery room

scrub nurse

a nurse who assists surgeons during surgery, wearing sterile attire and handling sterile equipment and supplies

pre op assessment

allergies, previous surgeries, fam history (reaction to anesthesia), contacts? hardware in body? false teeth (everything has to come off before surgery), metal implants- could cause burn w equipment in surgery, culture assessment, communication assessment (get on PT level), drug/ alcohol assessment, open communication w patient, have to have accurate height and weight (anesthesia is based on their weight and height), physical assessment, psychosocial assessment (stress level, coping mechanisms (go to happy place, turn music on), have to report suspected abuse, nutritional assessment, pain assessment, medication review (need to know ahead OTC or prescriptions, supplements, herbs- can counteract anesthesia, informed consent MUST HAVE before surgery- make sure PT understands 100% and if they do not call surgeon to come and explain,

Post op pain

antiemetic meds- nausea or vomiting decreased or increased BP= pain also pulse grimacing= pain

Nursing diagnosis for pre-op

anxiety, anticipatory grieving- impending surgery (knowing they will lose something), knowledge deficit- surgical experiences

Nursing Diagnosis for intra- op

anxiety, risk for infection, risk for fluid volume deficit (incision & blood & seriousgenus fluid), risk for injury, risk for electrolyte imbalance (w fluid volume deficit or excess leads to the electrolyte imbalance), ineffective breathing pattern (rapid respirations or slow)

class 2- clean contaminated

appendectomy- pt never had surgery- puss spills out from rupture

post- op

begins w/ admission to surgical recovery area- concludes upon hospital unit or discharge PACU- to recover then to ICU, then to medical surgical floor then home

class 4- dirty

black scar- surgeon cleans pus out ALL THESE PREDICT RISK FOR INFECTION if higher risk- pump w antibiotics

elective

boob job, plastic surgery, get rid of fat in stomach, weight reduction surgery,

emergency

car accident, ovarian cyst (ovary twisted), mans testicles twisted, needs emergent action done

intra- op

during the surgery in the operating room- constant monitoring of OR and client

Pre-op nursing care

early client teaching, we want PT to understand what is going on, what side of the body, if there will be any lines or drains, length, whether to stop or change meds, how to care for wound, deep breathing, pain scale (level 4 tell someone), prevention of clot formation, discharge planning begins at admission

circulating nurse

everything that happens during the surgery is documented- output, blood loss, instruments used, foley, every single supply used, time outs, time incision was made, changes in monitors, changes in color of urine, ANY changes that occur deviated from assessment, watch entire team process, baseline assessment- so important need to know all these

A postoperative client receives a dinner tray with gelatin, pudding, and vanilla ice cream. Based on the foods on the client's tray, what would the nurse anticipate the client's current diet order to be:

full liquid diet

increased surgery time =

greater complications, greater time in operating room also makes complications greater

transplant

heart, lungs, liver, any type of transplant

Which of the following items on a client's presurgery laboratory results would indicate a need to contact the surgeon?

hemoglobin of 9.5 (For men, 13.5 to 17.5, For women, 12.0 to 15.5) BUN limit: 7-20 Platelet count: 150,000-450,000 PT time: 11 to 13.5 seconds

post op documentation

history and physical, body systems, pain assessment, sedation assessment, psychosocial assessment, med review, care of lines, drains, I&O, blood work, dressing changes, labs, discharge education, teach to increase fluids, educate about narcotics and general anethesia

Intra-op complications

hypothermia, hypo & hypervolemia, hypo and hypernatremia, hypo and hyperkalemia, increased intracranial pressure, hyperthermia, malignant hyperthermia- in PT genes- reacted badly to anethesia

complications in OR

hypothermia- freezing and naked on table, SCDs if surgery is greater than 30min- for DVT to try and reduce risk for it, greater risk for blood loss

Patient is in the operating room what phase is this?

intra-op

As a nurse, which statement is incorrect regarding an informed consent signed by a patient?

it is the nurses job to obtain the informed consent- wrong it is the surgeons job

The best position for kidney, chest, or hip surgery is:

lateral

constructive

limb back on, finger back on, putting something back on body

infections

little kids, elderly, tiny malnourished PT, immunocompromised at highest risk, aseptic environment at all times

Airway

most clients are extubated or put on ventilator to be intubated intubated helps PT rest and heal

class 1- clean

no spillage within cavity

open vs laparoscopic

open: completely open (emergency) Lapro- robotic surgery- make small little incisions, bars in abdominal area

nursing diagnosis post op

pain, risk for impaired gas exchange (02 stat), anxiety, capillary refill, mucous membranes, any cyanosis- gas exchange, risk for decreased cardiac output, risk for deficient fluid volume or also excess fluid volume

cumaudin (blood thinners)

risk for bleeding out, have to have been stopped before surgery Ask for order to stop from surgeon even hold aspirin

how to clean

start at incision point and go outward

class 3- contaminated

surgery- stitches popped open- back to OR- reopen area this is considered contaminated

The time out is conducted by the OR nurse prior to surgery.

this is not done by the nurse getting the patient ready for surgery, this nurse assess for allergies, makes sure the informed consent is signed and, ensures that the history/ final has been completed

specific changes to report

unresponsiveness, changes in LOC, o2 under 93%, resp rate under 10, tachycardia, hyper and hypotension, weak or absent peripheral pulses, urine output under 30 ml, more bleeding than expected