Perioperative

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply: a. Contact the surgeon b. Instruct the client to remain quiet c. Prepare the client for wound closured. d. Document the findings and actions taken e. Place a sterile saline dressing and icepacks over the wound f. Place the client in a prone position without a pillow

Answer: A, B, C, D. Wound dehiscence is the separation of the wound edges. Wound evisceration is a protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low fowlers position and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

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. A responsible adult is taking the patient home e. Comfortable after IV opioid 15 minutes ago

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

The nurse is reviewing a prescription sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the physician to clarify which medication should be given to the client and not withheld? a. Prednisone b. Ferrous sulfate c. Cyclobenzaprine (Flexeril) d. Conjugated estrogen (Premarin)

Answer: A. Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. These last few medications may be withheld before surgery without undue effects on the client.

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on the 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

Answer: A. The first action of the nurse is to assess the patency of the airway snd 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 tubes or drains.

The nurse is providing discharge teaching to a 51-year-old female patient who has had a laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the patient, indicates an understanding of the discharge instructions? a. "I will have someone stay with me for 24 hours in case I feel dizzy." b. "I should wait for the pain to be severe before taking the medication." c. "Because I did not have general anesthesia, I will be able to drive home." d. "It is expected after this surgery to have a temperature up to 102.4 F."

Answer: A. The nurse must assess understanding of discharge instructions and the ability of the patient and caregiver to provide for home care needs. The patient must be accompanied by a responsible adult caregiver. The patient may not drive after receiving anesthetics or sedatives. The patient should understand how to manage pain, and pain medication should be taken before the pain becomes severe. The patient should understand the symptoms to be reported, such as a fever.

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.

Answer: B. 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 has conducted preoperative teaching for a patient scheduled for surgery in 1 week. The patient has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the patient needs additional teaching if the patient makes which statement? a. "Aspirin can cause 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 health care provider about the need to stop the aspirin before the scheduled surgery."

Answer: C Rationale: Antiplatelets alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter platelet aggregation and should be discontinued for 48 hours before surgery. However, the patient should always check with their health care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled. The other options are accurate patient statements.

A preoperative patient expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the patient and the nurse? a. "If it's any help, everyone is nervous before surgery." b. "I will be happy to explain the entire surgical procedure to you." c. "Can you share with me what you've been told about your surgery?" d. "Let me tell you about the care you will receive after surgery and the amount of pain you can anticipate."

Answer: C Rationale: Explanations should begin with the information that the patient knows. By providing the patient with individualized explanations of care and procedures, the nurse can assist the patient in handling anxiety and fear for a smooth preoperative experience. Patients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the patient's anxiety. Explaining the entire procedure may increase the patient's anxiety. Option 4 avoids the patient's anxiety and is focused on postoperative care.

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the patient on the day of surgery? a. Avoid oral hygiene and rinsing with mouthwash. b. Verify that the patient has not eaten for the last 24 hours. c. Have the patient void immediately before going into surgery. d. Report immediately any slight increase in blood pressure or pulse.

Answer: C Rationale: The nurse would assist the patient to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the patient should not swallow any water. The patient usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually a result of anxiety.

A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? a. "If it's any help, everyone is nervous before surgery." b. "I will be happy to explain the entire surgical procedure with you." c. "Can you share with me what you've been told about your surgery?" d. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

Answer: C. Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications.

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 BP 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, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A slight increase in BP and pulse is common during the preoperative period due to anxiety.

A patient with a gastric ulcer is scheduled for surgery. The patient 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 patient? a. Obtain 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 being signed. d. Obtain telephone consent from a family member, following agency policy.

Answer: D Rationale: Every effort should be made to obtain permission from a responsible family member to perform surgery if the patient is unable to sign the consent form. A telephone consent must be witnessed by 2 persons who hear the family members' verbal consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a patient who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a patient may not be able to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform the surgery without consent.

The nurse is conducting preoperative teaching with a patient about the use of an incentive spirometer. The nurse should include which piece of information in discussion with the client? a. Inhale as rapidly as possible. b. Keep a loose seal between the lips and the mouthpiece. c. After maximum inspiration, hold the breath for 15 seconds and exhale. d. The best results are achieved when sitting up with the head of the bed elevated 45 to 90 degrees.

Answer: D Rationale: For optimal lung expansion with the incentive spirometer, the patient should assume the semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the patient inhales slowly, with a constant flow through the unit. He breath should be held for 5 seconds before exhaling slowly.

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.

Answer: D. 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.

Which patient would be at the highest risk for hypothermia after surgery? a. A 42-year-old patient who had a laparoscopic appendectomy b. A 38-year-old patient who had a lumpectomy for breast cancer c. A 20-year-old patient with an open reduction of a fractured radius d. A 75-year-old patient with the repair of a femoral neck fracture after a fall

Answer: D. Patients at highest risk for hypothermia are those who are older, debilitated, or intoxicated. Also, long surgical procedures and prolonged anesthetic administration place the patient at increased risk for hypothermia.

A 17 year old patient with a leg fracture who is scheduled for surgery is an emancipated minor. She has a statement from the court for verification. Which intervention is most appropriate? a.) Witness the permit after the surgeon obtains consent. b.) Call a parent or legal guardian to sign the permit since the patient is under 18 c.) Notify the hospital attorney that an emancipated minor is consenting for surgery. d.) Obtain verbal consent since written consent is not necessary for emancipated minors.

Answer: a Rationale: An emancipated minor may sign his or her own permit. The nurse should be available to witness the signature, but no further action is needed.

An 85 year old patient returns to the inpatient surgical unit after leaving the PACU. Which of the following places the patient at risk during surgery? a.) Stiffened lung tissue. b.) Reduced diaphragmatic excursion. c.) Increases laryngeal reflexes. d.) Reduced blood flow to the kidneys. e.) Increased cholinergic transmission.

Answer: a, b, d Rationale: Older adults have stiffened lung tissue, reduced diaphragmatic excursion, and reduced blood flow to kidneys. Laryngeal reflexes are reduced, increasing risk for aspiration, and reduced cholinergic transmission puts them at risk for cognitive changes

When using ice massage for pain relief, which of the following is correct? (select all that apply) a. Apply ice using firm pressure over the skin b. Apply ice for 5 minutes or until numbness occurs c. Apply ice no more than 3 times a day d. Limit application of ice to no longer than 10 minutes e. Use a slow, circular steady massage

Answer: a, b, e. Apply the ice with firm pressure to the skin, which is covered with a lightweight cloth. Then use a slow, steady circular massage over the area. Apply cold within a 6-inch circular area near the pain site or on the opposite side of the body corresponding to the pain site. Limit application to 5 minutes or when the patient feels numbness. Application near the actual site of pain tends to work best, and it can be applied several times each hour to help reduce pain.

A patient has been on bed rest for over 5 days. Which of these findings during the nurse's assessment may indicate a complication of immobility? a. Decreased peristalsis b. Decreased heart rate c. Increased blood pressure d. Increased urinary output

Answer: a. Immobility disrupts normal metabolic functioning: decreasing the metabolic rate; altering the metabolism of carbohydrates, fats, and proteins; causing fluid, electrolyte, and calcium imbalances; and causing gastrointestinal disturbances such as decreased appetite and slowing of peristalsis.

Which of the following signs or symptoms in a patient who is opioid naïve is of greatest concern to the nurse when assessing the patient 1 hour after administering an opioid? a. Oxygen saturation of 95% b. Difficulty arousing the patient c. Respiratory rate of 12 breaths/min d. Pain intensity rating of 5 on a scale of 0 to 10

Answer: b Sedation is a concern because it may indicate that the patient is experiencing opioid-related side effects. Advancing sedation may indicate that the patient may progress to respiratory depression.

When doing a pain assessment for a patient who has been admitted with metastatic breast cancer, which question asked by the nurse will give the most information about the patient's pain? a. "How long have you had this pain?" b. "How would you describe your pain?" c. "How much medication do you take for the pain?" d."How many times a day do you medicate for pain?"

Answer: b. Because pain is a multidimensional experience, asking a question that addresses the patient's experience with the pain is likely to elicit more information than the more specific information asked in the other three responses. All of these questions are appropriate, but the response beginning "How would you describe your pain?" is the best initial question.

A 76-year old client is to undergo a hernia repair. The nurse knows that in order to aid in the healing process, the perioperative nurse must assist the client with which concept during what surgical phase? a.) Perfusion therapy during the intraoperative phase. b.) Wound healing during the postoperative phase. c.) Wound healing during the preoperative and intraoperative phase. d.) Infection during the postoperative phase

Answer: c Rationale: Inadequate control of stress and coping mechanisms can prolong the perioperative healing process and a client's prognosis. Perioperative care includes assessing client stress and coping mechanisms during the preoperative phase and reassessing following the procedure. Postoperative infections may occur as a result of improper wound care or hospital acquired infections may occur as a result of infection control protocols not being followed. Adequate perfusion enhances wound healing and perioperative recovery. Nurses providing intraoperative and postoperative care must follow infection protocols.

A patient recovering from open heart surgery is taught how to cough and deep breathe using a pillow to support or splint the chest incision. Following the teaching session, which of the following is the best way for the nurse to evaluate if learning has taken place? a.) Verbalization of the steps to use in splinting. b.) Selecting from a series of flash cards the images the images showing the correct technique. c.) Return demonstration. d.) Cloze test.

Answer: c Rationale: Return demonstration permits a patient to perform a skill as the nurse observes. It provides excellent feedback and reinforcement.

Preoperative considerations for older adults include (Select all that apply) a.) Using only large print educational materials. b.) Speaking louder for patients with hearing aids. c.) Recognizing that sensory deficits may be present. d.) Providing warm blankets to prevent hypothermia. e.) Teaching important information early in the morning.

Answer: c, d Rationale: Many older adults have sensory deficits. Preoperative and operating rooms are cool; provide warm blankets as needed.

The physical environment of a surgery suite is designed primarily to promote a. electrical safety b. medical and surgical asepsis c. comfort and privacy of the patient d. communication among the surgical team

B. Rationale: Medical and surgical asepsis, Although all the factors are important to the safety and well being of the patient, the first consideration in the physical environment of the surgical suite is prevention of transmission of infection to the patient

A break in sterile technique during surgery would occur when the scrub nurse touches a. the mask with gloved hands b. gloves hands to the gown at chest level c. the drape at the incision site with gloved hands d. the lower arms to the instruments on the instrument tray

Rationale: A The mask covering the face is not considered sterile, and if in contact with sterile gloved hands, contaminates the gloves. The gown at chest level and to 2 inches above elbows is considered sterile, as is the drape placed at the surgical area.

A preoperative patient reveals that an uncle died during surgery because of a fever and cardiac arrest. The perioperative nurse alerts the surgical team, knowing that if the patient is at risk for malignant hyperthermia, a. the surgery will have to be canceled b. specific precautions can be taken to safely anesthetize the patient c. dantrolene (Dantrium) must be given to prevent hyperthermia during surgery d. the patient should be placed on a cooling blanket during the surgical procedure

Rationale: B Although malignant hyperthermia can result in cardiac arrest and death, if the patient is known or suspected to be at risk for the disorder, appropriate precautions taken by the ACP can provide for safe anesthesia for the patient. Because preventive measures are possible if the risk is known, it is critical that the preoperative assessment include a careful family history of surgical events

When transporting an inpatient to the surgical department, the nurse from another area of the hospital has access to a. the clean core b. the holding area c. corridors of the surgical suite d. an unprepared operating room

Rationale: B The holding area. Persons in street clothes or attire other than surgical scrub clothing can interact with personnel of the surgical suite in unrestricted areas, such as the holding area, nursing station, control desk, or lockers rooms. Only authorized personnel wearing surgical attire and hair covering are allowed in semi restricted areas, such as corridors, and masks must be worn in restricted areas, such as operating rooms, clean core, and scrub sink areas.

The primary goal of the circulating nurse during preparation of the operating room, transferring and positioning the patient, and assisting the anesthesia team is a. avoiding any type of injury to the patient b. maintaining a clean environment for the patient c. providing for patient comfort and sense of well being d. preventing breaks in aseptic technique by the sterile members of the team

Rationale: C- Providing for patient comfort and sense of well being The protection of the patient from injury in the operating room environment is maintained by the circulating nurse by ensuring functioning equipment, preventing falls and injury during transport and transfer, monitoring asepsis, and being with the patient during anesthesia induction