Preoperative Nursing Management
Completing your preoperative assessment, you mentally rehearse your client's needs to determine if there is increased risk for complications intra operatively or postoperatively. Which of the following are general risk factors? Select all that apply.
Nutritional status Age Physical condition Health status Explanation: General surgical risk factors are related to age; nutritional status; use of alcohol, tobacco, and other substances; and physical condition.
A patient is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?
Splint the incision site using a pillow during deep breathing and coughing exercises. Explanation: Splinting the incision site will help decrease pain and support the incision. This will increase compliance with the deep breathing and coughing exercises that assist with the prevention of respiratory complications. Pain medication should be taken regularly and not only before deep breathing and coughing exercises. Deep breathing and coughing exercises should be done at least every 2 hours, more frequently if possible. While some patients will find the exercises relaxing, most patients find it painful to complete the exercises.
An obese patient is scheduled for open abdominal surgery. What priority education should the nurse provide this patient?
prevention of respiratory complications Explanation: All answers are correct but the obese patient has an increased susceptibility to respiratory complications, and maintaining a patent airway would be the priority.
Patients who have received corticosteroids preoperatively are at risk for which type of insufficiency?
Adrenal Explanation: Patients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids does not occur to the pituitary, thyroid, or parathyroid glands.
The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following?
Cheeseburger, french fries, coleslaw, and ice cream Explanation: Important nutrients for wound healing include protein; vitamins A, B-complex, C, and K; arginine, magnesium, copper, and zinc; and water. The diet should be sufficient in carbohydrates and low to moderate in fats. The cheeseburger option is high in fat and low in vitamin C.
The nurse recognizes that the client most at risk for mortality associated with surgery is the:
Client with chronic alcoholism Explanation: The client with chronic alcoholism who experiences alcohol withdrawal symptoms is at significant risk for mortality, which can be attributed to cardiac dysrthymias, cardiomyopathy, and bleeding tendencies.
Which of the following nursing activities would not be part of the preoperative phase of care? Select all that apply.
Ensuring that the sponge, needle, and instrument counts are correct Administering medications, fluid, and blood component therapy, if prescribed Explanation: Of the activities listed, discussing and reviewing the advanced directive document, establishing an intravenous line, and beginning discharge planning are preoperative nursing activities.
The nurse concludes that further teaching about diaphragmatic breathing is needed when the client:
Exhales forcefully with a short expiration Explanation: Diaphragmatic breathing should be performed gently and fully.
A patient is scheduled to have a cholecystectomy. Which of the nurse's finding is least likely to contribute to surgical complications?
Osteoporosis Explanation: Osteoporosis is most likely not going to contribute to complications related to a cholecystectomy. Pregnancy decreases maternal reserves. Diabetes increases wound-healing problems and risks for infection. Urinary tract infection decreases the immune system, increasing the chance for infections.
Nursing assessment findings reveal that the client is afraid of dying during the surgical procedure. Which surgical team member would be most helpful in addressing the client's concern?
Surgeon Explanation: It is the surgeon's responsibility to explain the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts in obtaining informed consent from the client.
The nurse discovers that the client did not sign the operative consent before receiving the preoperative medication. The appropriate nursing action is:
To notify the surgeon Explanation: Preoperative medication can impair the thinking ability of the client. FFor informed consent to be valid, the client must be competent to give consent. The surgery will be canceled.
A perioperative nurse is assigned to complete a preoperative assessment on a patient who is scheduled for surgery for kidney stones. The nurse knows that the surgery is scheduled the following day and would therefore be classified as:
Urgent Explanation: Surgery for kidney or urethral stones requires prompt attention and is considered urgent. Refer to Table 5-1 in the text.
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?
Use diaphragmatic breathing. Explanation: In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.
When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as
emergency. Explanation: Emergency surgery means that the patient requires immediate attention and the disorder may be life threatening. Urgent surgery means that the patient requires prompt attention within 24 to 30 hours. Required surgery means that the patient needs to have surgery, and it should be planned within a few weeks or months. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.
A patient with a history of alcoholism and scheduled for an urgent surgery asks the nurse, "Why is everyone so concerned about how much I drink?" What is the best response by the nurse?
"It is important for us to know how much and how often you drink to help prevent surgical complications." Explanation: Alcohol use and alcoholism can contribute to serious postoperative complications. If the medical and nursing staff is aware of the use or abuse, measures can be implemented proactively to prevent complications. Although alcohol may interfere with a medication's effectiveness, it does not determine the amount of pain medications that are prescribed following surgery. Even though this is a required screening question and counselors can be made available for those who want help, those are not the best responses to answer the patient's question.
The nurse is teaching leg exercises to the client preoperatively. The client asks why the exercises are important. The best response by the nurse is:
"Leg exercises help prevent blood clots in your legs." Explanation: Leg exercises improve circulation of the lower extremities by preventing venous stasis, which can lead to deep vein thrombosis in the postoperative client.
You are the nurse working in an ambulatory surgery center. A teenage son of your clients ask you why so many people have surgery. What would be your best reply?
"Many people have diagnostic or short therapeutic surgical procedures." Explanation: Many diagnostic or short therapeutic surgical procedures—such as bone marrow biopsy, endoscopy, or cardiac catheterization—are now performed in outpatient settings and ambulatory surgical centers. Options B, C, and D seem to minimize the teenager's question.
A patient has been transported to the operating room for emergent surgery. Which statement by the nurse best supports the need for emergent surgery?
"The patient was unresponsive, had a distended abdomen, and unstable vital signs following a motor vehicle accident." Explanation: Emergency surgery means that the patient requires immediate attention and the disorder may be life threatening. The patient with unstable vital signs and a distended abdomen following a motor vehicle accident requires immediate attention. The patient with left sided abdominal pain may not need surgery. Epigastric pain with vomiting for 1 day is usually not an indication for emergent surgery. Lacerations to the face require sutures, not emergent surgery. A thyroidectomy to treat hyperthyroidism is a required surgery, not an emergent one.
The on-call perioperative team is called for an urgent surgery to be performed as soon as they arrive. What surgical procedure is considered emergent?
A repair of multiple stab wounds Explanation: Repair of multiple stab wounds is emergent. Removal of kidney stones is urgent. An exploratory laparotomy is required. A face lift is optional.
The nurse is monitoring a presurgical patient for electrolyte imbalance. Which classification of medication may cause electrolyte imbalance?
Diuretics Explanation: During anesthesia, diuretics may cause excessive respiratory depression resulting from an associated electrolyte imbalance. The other drugs listed do not cause an electrolyte imbalance.
A gunshot wound would be classified under which category of surgery based on urgency?
Emergent Explanation: Emergent surgery occurs when the patient requires immediate attention. An elective surgery is classified as a surgery that the patient should have. A required surgery means that the patient needs to have surgery. An urgent surgery is one which the patient required prompt attention.
A client taking chlorpromazine (Thorazine) is preparing to undergo surgery. Which of the following complications does the surgical team need to prepare to deal with before anesthetics are administered?
Hypotension Explanation: Chlorpromazine (Thorazine) may increase the hypotensive action of anesthetics. Seizures are a potential interaction if diazepam (Valium) is withdrawn suddenly before surgery. The client who takes prednisone (Deltasone) is at risk for cardiovascular collapse if the medication is discontinued suddenly. The combination of erythromycin (Ery-Tab) and a curariform muscle relaxant can lead to apnea from muscle paralysis.
The nurse is aware that a religious group that refuses blood transfusions for religious reasons is:
Jehovah's Witnesses Explanation: Jehovah's Witnesses decline blood transfusions for religious reasons.
A 57-year-old client is undergoing preoperative assessment before surgical repair of a fractured ulna. During admission paperwork, the client reveals that she enjoyed a hearty breakfast this morning to be ready for her procedure. What is the nurse's next action?
Notify the surgeon. Explanation: If the client has not carried out a specific portion of preoperative instructions, such as withholding foods and fluids, the nurse immediately notifies the surgeon. Do the preoperative instructions allow food intake before this procedure? This scenario does not include information to support this nursing action. It is not the nurse's responsibility to cancel the surgery.
Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery?
Physician Explanation: It is the physician's responsibility to provide appropriate information. It is not the responsibility of the nurse, case manager, or certified nurse's aide to gain informed consent.
The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which of the following values would be of greatest concern to the nurse?
Potassium 6.2 mEq/L Explanation: Hyperkalemia places the client at risk for surgical complications.
When is the ideal time to discuss preoperative teaching
Preadmission visit Explanation: The ideal timing for preoperative teaching is not on the day of surgery but during the preadmission visit, when diagnostic tests are performed. Teaching should be done long before the patient enters the preop area. Preoperative teaching should not be done when the patient is sedated.
A 17-year-old male client is having same-day surgery to remove a neuroma from his foot. Which of the following nursing interventions would occur during the intra operative phase of peri operative care?
The nurse continuously monitors the sedated client. Explanation: Intraoperative care includes the entire surgical procedure. During sedation, the nurse continuously evaluates the client. Monitoring during all phases includes assessment of heart rate, respiratory rate, BP, oxygen saturation, and level of consciousness. This would occur during the preoperative phase of perioperative care. During the postoperative phase of perioperative care, an important assessment is determining how the client is recovering from anesthesia.
When does the nurse understand the patient is knowledgeable about the impending surgical procedure?
The patient participates willingly in the preoperative preparation. Explanation: The nurse knows that the patient understands the surgical intervention when the patient participates in preoperative preparation. The other answers pertain to the patient experiencing decreased fear or anxiety, not knowledge about the procedure.
An example of a curative surgical procedure is
the excision of a tumor. Explanation: An example of a curative surgical procedure is the excision of a tumor. A biopsy, face-lift, and the placement of a gastrostomy tube are not examples of curative surgical procedures.
The nurse is preparing a client for surgery. The nurse would notify the surgeon if the client made which of the following statements?
"I took my Coumadin as usual last evening." "I took two aspirins for joint pain this morning." Explanation: The nurse needs to alert the surgeon to any medications the client has taken that increase the client's risk for bleeding. Aspirin inhibits platelet aggregation and should be stopped at least 7 to 10 days prior to surgery. Coumadin (warfarin) interferes with the synthesis of vitamin K-dependent clotting factors. The type of surgical procedure and the medical condition of the client determine when the Coumadin should be stopped prior to surgery.
The nurse concludes that teaching about pain management was effective when the client states:
"I will support my incision with my hands when I do my coughing and deep breathing exercises." Explanation: Splinting of the incision provides support to the incision and helps to control pain.
A patient is scheduled for a surgical procedure. For which surgical procedure should the nurse prepare an informed consent form for the surgeon to sign?
An open reduction of a fracture Explanation: Informed consent is necessary in the following circumstances: invasive procedures, such as a surgical incision (such as would be involved in an open reduction of a fracture), a biopsy, a cystoscopy, or paracentesis; procedures requiring sedation and/or anesthesia (see Chapter 18 for a discussion of anesthesia); a nonsurgical procedure, such as an arteriography, that carries more than a slight risk to the patient; and procedures involving radiation. Non-invasive procedures such as insertion of an intravenous or urethral catheter or irrigation of the external ear canal would not require informed consent.
The nurse is aware that which of the following helps to stimulate T-cell response:
Arginine Explanation: Arginine is necessary for collagen synthesis and deposition, increases wound strength, and stimulates T-cell response.
At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period?
During the preoperative period Explanation: The best time to begin teaching about care needed in the postoperative period is during the preoperative time. At this time, the client is more alert and focused on the information provided by the nurse. Clients and family members can better be prepared and participate in the recovery period if they know what to expect. Anxiety is a factor on arrival to the surgical unit that could interfere with learning. Pain could interfere with the learning process, following a surgical procedure. At the time of discharge, both pain and timeliness may be an issue in understanding and obtaining care needed during the postoperative time.
What action by the nurse best encompasses the preoperative phase?
Educating the patients on signs and symptoms of infection Explanation: Educating the patient on prevention or recognition of complications begins in the preoperative phase. Applying SCD and frequent vital sign monitoring happens after the preoperative phase. Only electric clippers should be used to remove hair.
A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for?
Hypoglycemia Explanation: The patient with diabetes who is undergoing surgery is at risk for both hypoglycemia and hyperglycemia. Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin. Hyperglycemia, which can increase the risk of surgical wound infection, may result from the stress of surgery, which can trigger increased levels of catecholamine. Other risks are acidosis and glucosuria, but hypoglycemia is a bigger risk. Dehydration is a lesser risk for a patient with diabetes than is hypoglycemia.
Which of the following would be the least important issue concerning safety for the perioperative team prior to proceeding to the operating room?
Patient ambulatory aids Explanation: It is imperative that the entire perioperative team participates in verifying the correct patient identity, surgical procedure, and surgical site before preceding to the OR. Patient ambulatory aids are not an important safety concern prior to proceeding to the OR.
You are physically preparing a client for surgery and instruct the person to remove any jewelry. The client refuses to remove a wedding band. What should you do in this situation with approval from your facility?
Place gauze under and over the ring and apply adhesive tape over it. Explanation: If the client is reluctant to remove a wedding band, the nurse may slip gauze under the ring, then loop the gauze around the finger and wrist or apply adhesive tape over a plain wedding band. You would not tell the client that he or she cannot go to the operating room wearing the ring. You would never medicate the client and then remove the ring against his or her will. It is not necessary to tell the physician and the anesthesiologist that the client does not want to remove the wedding band.
Following diagnostic testing, a patient requires a cholecystectomy. This surgical procedure would be categorized as which of the following?
Urgent Explanation: Acute gallbladder infection would be categorized as an urgent surgery. Emergent surgeries include severe bleeding, bladder or intestinal obstruction, and a fractured skull. Required surgeries include thyroid disorders and cataracts. Elective surgeries include repair of scars, simple hernia, and vaginal repair.
The nurse is caring for the client in the preoperative period and documenting rationale for a palliative surgical procedure. Which rationale is most appropriate?
he client and physician are focusing on symptom relief not a cure. Explanation: The nurse realizes a palliative surgical procedure is focused on the relief of symptoms or enhancement of function without a cure. Diagnostic surgical procedures provide additional information for medical diagnosis and treatment. Cosmetic surgery procedures are elective, with the purpose of improving body appearance. Reconstructive surgery corrects a deformity.
When assessing a postoperative client, the nurse is correct to relate which surgical risk factor that would decrease if the surgical client maintained a blood glucose level under 150 mg/dL?
w ound healing Explanation: In caring for a postoperative client, the nurse is correct to correlate hyperglycemia with an increased risk of surgical incision infections and delayed wound healing. There is no direct correlation between blood glucose levels and nutrient deficiencies, respiratory complications, and liver dysfunction.
For the patient who is taking aspirin, it is important to stop taking this medication at least how many day(s) prior to surgery?
7 Explanation: Aspirin should be stopped at least 7 to 10 days before surgery.
What is the blood glucose level goal for a diabetic patient who will be having a surgical procedure?
80 to 110 mg/dL Explanation: Although the surgical risk in the patient with controlled diabetes is no greater than in the patient without diabetes, strict glycemic control (80 to 110 mg/dL) leads to better outcomes (Alvarex et al., 2010). Frequent monitoring of blood glucose levels is important before, during, and after surgery.
The nurse expects informed consent to be obtained for insertion of:
A gastrostomy tube Explanation: Informed consent is required for invasive procedures that require sedation and are associated with more than usual risk to the client.
A client is scheduled for a surgical procedure. When planning the client's care, the nurse should consider that which of the following conditions will increase the client's risk of complications after surgery?
A history of diabetes Explanation: As a chronic condition that affects many body systems, diabetes is a risk factor for surgical complications. The client's blood glucose level and insulin requirements need to be closely monitored before and after surgery. Being sensitive to aspirin does not pose a risk for the client in surgery. Osteoarthritis is not a systemic condition and does not place the client at risk during surgery. Chronic low back pain is not a systemic condition that places the client at risk during surgery; however, it can be exacerbated by positioning on the operating room table.
A patient is scheduled for an invasive procedure. What is the priority documentation needed regarding the procedure?
A signed consent form from the patient Explanation: A signed consent is required and is important for initiating invasive procedures. The nurse should therefore check for the patient's signed consent form. A health history, medication reconciliation, and postoperative prescriptions are good items to have, but are not required documentation before performing an invasive procedure.
A fractured skull would be classified under which category of surgery based on urgency?
Emergent Explanation: Emergent surgery occurs when the patient requires immediate attention. An elective surgery is classified as a surgery that the patient should have. A required surgery means that the patient needs to have surgery. An urgent surgery occurs when the patient requires prompt attention.
The nurse is conducting a preoperative assessment on a patient scheduled for gallbladder surgery. The patient reports having a frequent cough producing green sputum for 3 days and denies fever. Upon auscultation, the nurse notes rhonchi throughout the right lung with an occasional expiratory wheeze. Respiratory rate is 20, temperature is 99.8 taken orally, heart rate is 87, and blood pressure is 124/70. What is the nurse's best action?
Notify the surgeon to possibly delay the surgery. Explanation: A respiratory infection can delay a nonemergent surgical procedure because the infection can increase the risk for respiratory complications. Therefore, the nurse should notify the surgeon about delaying the surgery. The primary physician may be called to care for the assessment findings but that should be done only after the surgeon has been notified. Continuing through the preoperative phase without notifying the surgeon and waiting 1 hour is not appropriate.
Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out?
Review the scheduled procedure, site, and client. Explanation: According to the 2009 National Patient Safety Goals, accurate identification of the client, procedure, and operative site is essential.
The nurse is educating a community group regarding types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true?
The excision of a tumor Explanation: An example of a curative surgical procedure is the excision of a tumor. A biopsy, a face-lift, and the placement of a gastrostomy tube are not examples of curative surgical procedures.
When a person with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the patient may show signs of alcohol withdrawal delirium during which time period?
p to 72 hours after alcohol withdrawal Explanation: Alcohol withdrawal delirium is associated with a significant mortality rate when it occurs postoperatively. Onset of symptoms depends upon time of last consumption of alcohol. Twenty-four hours is too short a time frame to consider alcohol withdrawal delirium as no longer a threat to a chronic alcoholic.
At what point does the preoperative period end?
when the client is transferred onto the operating table Explanation: The preoperative phase begins when the decision to proceed with surgical intervention is made and ends with the transfer of the client onto the OR table. The intraoperative phase begins when the client is transferred onto the operating table and ends with admission to the PACU.
A patient refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?
Allow the ring to stay on the patient and cover it with tape. Explanation: Most facilities will allow a wedding band to remain on the patient during the surgical procedure. The nurse must secure the ring with tape. Although it is appropriate to discuss the risk for infection, the patient has already refused removal of the ring. The surgery should not be canceled and the ring should not be removed without permission.
Which nursing statement would best decrease a client's anxiety before an emergency operative procedure?
"Let me explain to you w8hat will happen next." Explanation: Many clients feel fearful of knowing little about the operative procedure and what to expect. This fear causes anxiety and can lead to a poorer response to surgery and surgical complications. Explanations of what the client is to expect can help to decrease anxiety. False reassurance of being fine does not diminish anxiety. Deep breathing and relaxation techniques can be helpful to the client, but addressing the source of the anxiety is more beneficial. Keeping the family informed helps the family and is not client focused.
A patient having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the patient stop taking the aspirin before the surgery?
7 to 10 days Explanation: Aspirin, a common OTC medication that inhibits platelet aggregation, should be prudently discontinued 7 to 10 days before surgery; otherwise, the patient may be at increased risk for bleeding (Rothrock, 2010).
The nurse is caring for a patient who is obese prior to a surgical procedure. What surgical complications positively correlated with obesity should the nurse monitor for? (Select all that apply.)
Cardiovascular system Gastrointestinal system Pulmonary system Explanation: Like age, obesity increases the risk and severity of complications associated with surgery. The estimation of about 25 additional miles of blood vessels needed for every 30 pounds of excess weight results in increased cardiac demand (Alvarex, Brodsky, Lemmens, et al., 2010). The patient tends to have shallow respirations when supine, increasing the risk of hypoventilation and postoperative pulmonary complications. The acquired physical characteristics of short thick necks, large tongues, recessed chins, and redundant pharyngeal tissue, associated with increased oxygen demand and decreased pulmonary reserves, impedes intubation (Haupt & Reed, 2010). Obesity also affects the gastrointestinal system.
Which of the following medications may increases the hypotensive action of anesthesia?
Chlorpromazine (Thorazine) Explanation: Thorazine may increase the hypotensive action of anesthetics. Deltasone may cause cardiovascular collapse and should be discontinued immediately. Coumadin can increase the risk of bleeding during the intraoperative and postoperative periods. HydroDIURIL may cause respiratory depression resulting from an associated electrolyte imbalance during anesthesia.
A nurse is witnessing a patient sign the consent form for surgery. After the patient signs the consent form, the patient starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?
Request that the surgeon come and answer the questions. Explanation: It is the physician's responsibility to provide information pertaining to risks and benefits of surgery. It is not the responsibility of the nurse or nurse manager to discuss risks and benefits. The consent form should not be placed in the medical record until all questions are answered fully for the patient.