Quiz 1 Chapter 50: Care of Surgical Patients

16. Why is "huff "coughing recommended for postsurgical patients using positive expiratory pressure therapy? a. Promotes lung expansion b. Enhances thorax expansion c. Promotes bronchial hygiene d. Facilitates diaphragm excursion

Rationale "Huff" coughing promotes bronchial hygiene by increasing the expectoration of secretions. Slow, deep breathing promotes lung expansion before coughing. Maintaining an upright semi-Fowler's position enhances thorax expansion. Maintaining an upright semi-Fowler's position facilitates diaphragm excursion. p. 1300

23. You are caring for a patient after surgery for a liver resection. His prothrombin time (PT) or an activated partial thromboplastin time (aPTT) is greater than normal. He has low blood pressure; tachycardia; a thready pulse; and cool, clammy, pale skin; and he is restless. You assess his surgical wound, and the dressing is saturated with blood. Which immediate interventions should you perform? Select all that apply. a. Notify the surgeon. b. Maintain intravenous (IV) fluid infusion and prepare to give volume replacement. c. Monitor the patient's vital signs every 15 minutes or more frequently until his condition stabilizes. d. Wean oxygen therapy. e. Provide comfort through bathing.

Rationale A common early complication of surgery is bleeding. It is important to continue oxygen therapy and notify the surgeon. Signs of bleeding include hypotension; tachycardia; and cool, clammy, pale skin. Signs of bleeding may be visible, or the bleeding may be internal. Be prepared to administer fluid or blood as needed and frequently monitor vital signs to assess the patient's status. p. 1287

10. The nurse is assessing a patient who underwent a surgical procedure. The nurse notices a decrease in blood pressure; rapid, thready pulse; cool, clammy, pale skin; tachypnea; and restlessness. Which complication does the nurse suspect? a. Depression b. Hemorrhage c. Electrolyte imbalance d. Obstructive sleep apnea

Rationale A drop in blood pressure; rapid, thready pulse; cool, clammy, pale skin; tachypnea; and restlessness aresymptoms of hemorrhage[1][2]. Postoperative hemorrhage may lead to a loss of intravascular volume leading to a drop in blood pressure and a weak, thready pulse. The heart rate and respiratory rate increase to compensate for the low intravascular volume to maintain tissue perfusion. Depression is not an immediate postoperative complication unless the patient has a history of depression. Electrolyte imbalances may occur in the immediate postoperative period but would not display these symptoms. The symptoms of obstructive sleep apnea would be drowsiness, apneic periods, and somnolence. pp. 1287, 1291

24. Conscious sedation is being considered for a patient undergoing a cervical dilation and endometrial biopsy in the health care provider's office. The patient asks the nurse, "What is this conscious sedation?" How should the nurse respond? a. "It can be administered only by anesthesiologists or nurse anesthetists." b. "It enables the patient to respond to commands and tolerate painful procedures." c. "It is so safe that it can be administered by nurses with direction from health care providers." d. "It should never be used outside of the operating room because of the risk of serious complications."

Rationale Conscious sedation is a moderate sedation that allows the patient to manage his or her own airway and respond to commands; yet, the patient can emotionally and physically accept painful procedures. Drugs are used to provide analgesia, relieve anxiety, and/or provide amnesia. It can be administered by personnel other than anesthesiologists. Nurses should be specially trained in the techniques of conscious sedation to carry out this procedure due to the high risk of complications resulting in clinical emergencies. p. 1284

8. A patient with a history of hemophilia underwent surgery. For which complication does the nurse monitor the patient? a. Signs of infection b. Bleeding c. Severe hypoventilation d. Delayed wound healing

Rationale Hemophilia is a bleeding disorder that may increase the risk of hemorrhage during and after surgery. Therefore, the nurse should monitor for signs of bleeding in the patient. A history of hemophilia does not increase the risk of infection, severe hypoventilation, or delayed wound healing. An immunocompromised patient would be at risk of infection. Patients with an underlying respiratory condition such as chronic obstructive pulmonary disease may experience breathing problems after anesthesia. Patients with diabetes mellitus who take corticosteroids and those who have a weakened immune system may have delayed wound healing. p. 1268

12. The nurse instructs a patient to breathe normally between each set of 10 breaths with the incentive spirometer. What is the rationale behind this instruction? a. To prevent fatigue b. To promote lung expansion c. To reduce the risk of progressive collapse d. To reduce transmission of microorganisms

Rationale Instructing the patient to breathe normally for short periods between each set of 10 breaths with the incentive spirometer can prevent fatigue. Instructing the patient to sit in a semi-Fowler's or high-Fowler's position can promote optimal lung expansion. Instructing the patient to inhale slowly while maintaining a constant flow through the incentive spirometer can help reduce the risk of progressive collapse of the alveoli. Instructing the patient to perform hand hygiene before and after using the incentive spirometer can help in reduction of transmission of microorganisms. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question. p. 1299

9. Which action helps prevent postoperative atelectasis? a. Pursed-lip exhalation b. Using the chest and shoulders while inhaling c. Repeating breathing exercises three to five times d. Ten deep-breathing exercises every hour

Rationale Instructing the patient to do deep breathing 10 times every hour while awake can prevent postoperative atelectasis. Pursed-lip exhalation facilitates the gradual expulsion of all air. The use of the chest and shoulders while inhaling can waste energy without promoting full expansion of the lungs. Repeating breathing exercises three to five times facilitates a slow and rhythmic breathing pattern. p. 1298

6. After a surgical patient has been given preoperative sedatives, which safety precaution should the nurse take? a. Reinforce to the patient that he or she should remain in bed or on the stretcher. b. Raise the side rails and keep the bed or stretcher in the high position. c. Determine if the patient has any allergies to latex. d. Obtain informed consent immediately after sedative administration.

Rationale It is important for patients' safety to inform them of the importance of remaining in bed after preoperative sedatives have been administered. It is inappropriate to have a bed or stretcher in the high position because of the increased risk of falling and potential for injury. Informed consent should be obtained and an allergy assessment done before sedative administration. p. 1280

5. You are a nurse in the post anesthesia care unit (PACU), and you note that your patient has a heart rate of 130 beats/minute and a respiratory rate of 32 breaths/minute; you also assess jaw muscle rigidity and rigidity of limbs, abdomen, and chest. What do you suspect, and which intervention is indicated? a. Infection: Notify surgeon and anticipate administration of antibiotics. b. Pneumonia: Listen to breath sounds, notify surgeon, and anticipate order for chest radiography. c. Hypertension: Check blood pressure, notify surgeon, and anticipate administration of antihypertensives. d. Malignant hyperthermia: Notify surgeon/anesthesia provider immediately; prepare to administer dantrolene sodium, and monitor vital signs frequently

Rationale Malignant hyperthermia[1][2] is a life-threatening complication of general anesthesia. It is a severe hypermetabolic condition that causes rigidity of skeletal muscles caused by an increase in intracellular calcium ion concentration; it leads to hypercarbia, tachypnea, and tachycardia. Despite the name, an elevated temperature is a late sign, and an increase in the respiratory rate to eliminate carbon dioxide is one of the first signs. Dantrolene sodium is a skeletal muscle relaxant that is used to treat this complication. p. 1288

11. The registered nurse is discussing the care of a postsurgical older adult with a group of nursing students. Which of a nursing student's statements indicates a need for further discussion? a. "Older adults are at risk for postoperative delirium." b. "Medical complications are more common in older adults." c. "Unexpected drug responses are often observed in older adults." d. "Older adults can tolerate long surgeries due to their increased physiological reserves."

Rationale Older adults cannot as easily tolerate long complicated surgeries because their physiological reserves are decreased. The remaining statements are correct. Older adults are at risk for postoperative delirium due to changes in the neurological system with age. Postoperative medical complications are more common in older adults. The older adult's body is more prone to unexpected drug responses. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. p. 1291

4. A patient is scheduled for surgery. The patient has been fasting the whole night. The surgery was postponed for 3 hours, and the patient feels hungry. What is the mostappropriate nursing action? a. Give solid food to the patient. b. Give fried food to the patient. c. Give fatty food to the patient. d. Give clear liquids to the patient.

Rationale Patients usually have a fasting period before surgery. However, if the surgery is postponed, the patient may be allowed clear liquids. Clear liquids can be metabolized within 2 hours and may not interfere with the gastrointestinal function or the anesthesia process. Solid food, fried food, and fatty food should not be given to the patient. Solid food requires 6 hours to metabolize. Fried food and fatty food require hours to metabolize. Test-Taking Tip: Don't be afraid to make educated guesses on the test. Even if you did not know that clear liquids are usually metabolized within 2 hours, you could still make an educated guess and answer this question correctly. Notice that three of the choices involve different types of foods, which you know take longer to digest than liquids. When you read the choice for clear liquids, it is definitely the most likely answer. You check again to make sure only one correct answer is expected (The question does not state, "Select all that apply."), so, you did it! p. 1279

20. Why should dorsiflexion and plantar flexion of the feet be parts of leg exercises? a. To maintain joint mobility b. To maintain knee mobility c. To facilitate contraction and relaxation of the quadriceps muscles d. To facilitate stretching and contraction of the gastrocnemius muscles

Rationale Performing dorsiflexion and plantar flexion of the feet facilitates stretching and contraction of the gastrocnemius muscles, improving venous return. Rotating the ankle in a complete circle helps maintain joint mobility. Performing quadriceps setting by tightening the thigh and bringing the knee toward the mattress then relaxing maintains knee mobility. Alternating raising each leg straight up from the bed while keeping the knees flexed facilitates contraction and relaxation of the quadriceps muscles. p. 1301

18. Which action during leg exercises helps to maintain joint mobility? a. Lifting the buttocks b. Dorsiflexion of the feet c. Plantar flexion of the feet d. Rotating the ankles in complete circles

Rationale Rotation of the ankles in complete circles helps maintain joint mobility. Lifting the buttocks can help prevent shearing with the mattress. Dorsiflexion and plantar flexion of the feet can help with stretching and contraction of the gastrocnemius muscles to promote venous return. p. 1301

15. In coaching a patient in diaphragmatic breathing, the nurse instructs the postoperative patient to take slow, deep breaths. What is the rationale for this nursing intervention? a. Allows gradual expulsion of air b. Decreases wasted energy c. Prevents panting and hyperventilation d. Allows the patient to feel the movement of the chest

Rationale The nurse should instruct the patient to take slow, deep breaths to prevent panting and hyperventilation. Pursed-lip breathing allows for gradual expulsion of air. The nurse should instruct the patient to avoid using the chest and shoulders while inhaling to avoid wasting energy. Positioning the hands on the lower border of the rib cage allows the patient to feel the movement of the chest. p. 1298

17. What should the nurse observe to assess a patient's maximum potential for chest expansion? a. Ability to maintain a sitting position b. Ability to cough and breathe deeply c. Ability to move independently in bed d. Calves for redness, warmth, and tenderness

Rationale The nurse should observe the patient's ability to cough and breathe deeply to assess the patient's maximum potential for chest expansion. The nurse should observe the patient's ability to maintain a sitting position and to move and turn independently in bed to identify any mobility restrictions. The nurse should observe the patient's calves for redness, warmth, and swelling to identify any signs of phlebitis and thrombus formation. p. 1297

21. How should the nurse position a severely obese post surgical patient during incentive spirometry? a. Supine b. Side-lying c. High-Fowler's d. Semi-Fowler's

Rationale The nurse should use a side-lying position for a severely obese patient during incentive spirometer exercises to facilitate better movement of the diaphragm. The supine position is not appropriate for incentive spirometer exercises. High-Fowler's and semi-Fowler's positions are appropriate for postsurgical patients of normal weight during incentive spirometer exercises. p. 1299

2. The nurse is working in the preoperative holding area and is assigned to care for a patient who is having a prosthetic aortic valve placed. The nurse inserts an intravenous (IV) line and obtains vital signs. The patient has a temperature of 39° C (102° F), heart rate of 120, blood pressure (BP) of 84/50, and an elevated white blood cell (WBC) count. Why does the nurse immediately notify the surgeon of the patient's vital signs? a. They need to get the patient into the operating room (OR) quickly to start the surgery because of the low blood pressure. b. The surgery may need to be delayed to check the patient's WBC count and investigate the source of fever before surgery. c. The nurse anticipates the need for a fluid bolus to increase the patient's BP. d. The nurse anticipates an order for a sedative to help calm the patient and decrease the heart rate.

Rationale The patient has a fever, elevated WBC count, tachycardia, and hypotension, which are all signs of a potential infection. The surgery may need to be delayed until the source of the fever is treated. Test-Taking Tip: The question asking why the nurse should immediately notify the surgeon should tell you that the situation might involve a safety issue. If you are unsure of an answer, reexamine it keeping safety first in mind. Look for clues that your awareness of safety is being tested. pp. 1271, 1274

7. The nurse observes that a patient is unable to sleep the night before surgery because of anxiety. Which nursing action is appropriate to relieve anxiety in the patient? a. Postpone the surgical procedure. b. Administer alprazolam to the patient. c. Give herbal medicine to the patient. d. Leave the patient alone to rest.

Rationale The patient may be anxious due to surgery and needs to be calmed down. Therefore, the nurse should administer alprazolam to the patient. Alprazolam acts on the cerebral cortex and limbic system to relieve anxiety. Postponing the surgery may worsen the patient's condition. Some herbal medicines increase the risk of postoperative complications and should be avoided. Leaving the patient alone is not likely to relieve anxiety. p. 1278

3. You have been given the following postoperative patients to care for on your shift. Based on the information provided, which patient should you see first? a. A 75-year-old following hip replacement surgery who is complaining of moderate pain in the surgical site, with a heart rate of 92 b. A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous patient-controlled analgesia (PCA) with a history of obstructive sleep apnea (OSA). The pulse oximeter has been going off and reads 85. c. A 36-year-old following bladder neck suspension who is 30 minutes late to receive her postoperative dose of antibiotic d. A 48-year-old following total knee replacement that needs help repositioning in bed

Rationale The patient with OSA has a risk of airway obstruction, which takes immediate precedence. She is symptomatic of oxygen desaturation. p. 1265

22. You are caring for a 65-year-old patient 2 days after surgery; you are helping him walk down the hallway. The surgeon has ordered exercise as tolerated. Your assessment indicates that the patient's heart rate at baseline is 88. After walking approximately 30 yards down the hallway, the heart rate is 110. What should be your next action? a. Stop the exercise immediately and have him sit in a nearby chair. b. Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue the exercise. c. Tell him that he needs to walk further to reach a heart rate of 120. d.Have him walk more slowly; he has reached his maximum.

Rationale The patient's maximum heart rate with exercise should be 155 (220 - 65 = 155). He is currently still in a safe range. An assessment of how the patient feels is good practice. The patient can safely continue to walk. Test-Taking Tip: To memorize the formula (220 minus the age) for maximum heart rate, remind yourself of this formula when you exercise to monitor your own heart rate. Then you will have rehearsed it enough to be able to apply it to questions like this one. As long as a patient's heart rate is well below the expected maximum, you can ask the patient how she or he feels before continuing the exercise. p. 1293

14. Which is the primary goal of including family members or significant others in postoperative teaching? a. They can coach and encourage the patient after surgery. b. They can teach the patient what to do after the surgery. c. It relieves anxiety over their family member. d. It frees up the recovery nurse for other tasks.

Rationale The primary goal in including the family members or significant others in postoperative teaching is that they can participate after the surgery by providing support and motivation in the form of teaching. The family can coach, but it is not their responsibility to provide teaching to the patient. That is part of the RN role. Participation in the care of a loved one may help to relieve anxiety, but that is a secondary gain, not the primary goal. The nurse cannot delegate patient teaching to family to save time. pp. 1270-1271

13. Which instruction is appropriate for a preoperational patient? a. "Take over-the-counter nonsteroidal antiinflammatory drugs the night before surgery." b. "Avoid fried food beginning 3 hours before surgery." c. "Begin fasting 2 hours before surgery." d. "Avoid any fluid intake for at least 2 hours before surgery."

Rationale The stress of surgery causes fluid and electrolyte imbalances, and sedation can cause complications, so the patient must refrain from drinking any liquids for two or more hours before the surgery. Nonsteroidal antiinflammatory drugs should be avoided in the weeks prior to surgery to reduce the risk for abnormal bleeding during surgery. The nurse should instruct the patient to avoid eating fried food 8, not 3, hours before surgery. The nurse should instruct the patient to begin fasting at least 6 hours prior to surgery. p. 1279

25. A patient is scheduled for a coronary artery bypass graft surgery. While going through the patient's medical records, the nurse finds that the patient has a medical condition that may affect the outcome of the surgery. Which condition is the patient likely suffering from? a. Cervical spondylosis b. Thrombocytopenia c. History of urinary tract infection in the last 6 months d. Hormone replacement therapy postmenopause 7 years ago

Rationale Thrombocytopenia refers to a relative decrease of platelets in the blood. It can cause serious complications during surgery. Cervical spondylosis, resolved urinary tract infections, and hormone replacement therapy do not interfere with surgery. p. 1264

1. An older adult is at increased risk for respiratory complications after surgery. What should the nurse do? a. Withhold pain medications and ambulate the patient every 2 hours. b. Monitor fluid and electrolyte status as ordered and vital signs with temperature every 4 hours. c. Frequently orient the patient to the surrounding environment, and ambulate the patient every 2 hours. d. Encourage the patient to turn, breathe deeply, cough frequently, and ensure adequate pain control.

Rationale To prevent respiratory complications, adequate pain control is important to allow participation in postoperative exercises such as turning, frequent coughing, and deep breathing. Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for keywords or phrases. This question specifies that that patient is at risk for respiratory complications. Only the correct answer addresses this risk. p. 1264

19. While working with a patient on positive expiratory pressure (PEP) therapy, the nurse instructs the patient to place his or her lips around the mouthpiece of the PEP device. What is the rationale behind this instruction? a. Facilitates diaphragm excursion b. Ensures the patient breathes through the mouth c. Enhances the expansion of the thorax d. Reduces the transmission of microorganisms

Rationale When working with a patient on positive expiratory pressure (PEP) therapy, the nurse should instruct the patient to place the lips around the mouthpiece to ensure proper use of the device, which means the patient will only breathe through the mouth. To facilitate diaphragm excursion, the nurse will help the patient into a semi-Fowler's position. This also enhances expansion of the thorax. Hand hygiene reduces the transmission of microorganisms. p. 1299