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A nurse is educating a preoperative client on how to cough effectively. What can the nurse tell the client to do to facilitate coughing? "Hold a pillow or folded bath blanket over the incision." "Get up and walk before you try to cough." "It would be best if you do not cough until you feel better." "When you cough, cover your nose and mouth with a tissue."

"Hold a pillow or folded bath blanket over the incision." (Because postoperative coughing is often painful, the client should be taught how to splint the incision by supporting it with a pillow or folded bath blanket.)

Which of the following statements, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? "I can have a hamburger and French fries as soon as I wake up." "The better I eat before surgery, the more likely I will heal." "I might be sick to my stomach and throw up after surgery." "When I can eat again, the best meal would be steak and orange juice."

"I can have a hamburger and French fries as soon as I wake up." (Oral fluid and food may be withheld until intestinal motility resumes.)

In order to prevent the possibility of venous stasis, a nurse is teaching a surgical client how to perform leg exercises. Which of the client's following statements indicates a sound understanding of leg exercises? "I'll practice these now and try to start them as soon as I can after my surgery." "I'll try to do these lying on my stomach so that I can bend my knees more fully." "I'll make sure to do these, as long as my doctor doesn't tell me to stay on bed rest after my operation." "I'm pretty sure my stomach muscles are strong enough to lift both of my legs off the bed at the same time."

"I'll practice these now and try to start them as soon as I can after my surgery." (Leg exercises should be begun as soon as possible after surgery, unless contraindications exist. Bed rest does not preclude the performance of leg exercises and the legs should be lifted individually, not simultaneously. The client should perform leg exercises in a semi-Fowler's, not prone, position.)

A client has arrived in the same-day surgery suite. He states to the nurse, "I am so worried about being put to sleep and having the surgery." What would be the nurse's best response? "You don't have to worry. It will be fine." "Tell me what you are most worried about." "I will have the anesthesiologist talk to you." "Have you ever had surgery before?"

"Tell me what you are most worried about." (The nurse should first assess what the client is most worried about or fearful of and then provide emotional support.)

The adult male patient with significant body hair is being prepared for abdominal surgery. The patient states his dad had the same surgery many years ago and was shaved prior to the procedure. The nurse would explain to the patient: "That practice is no longer standard as shaving may cause breaks in the skin." "We no longer shave skin before procedures but we will apply a lotion that will remove the hair." "Your abdomen will be shaved in the operating room." "You will be shaved as well."

"That practice is no longer standard as shaving may cause breaks in the skin." (A surgical "prep," or shaving of the hair in the affected area, was a common preoperative procedure a decade ago. Current research indicates that preoperative shaving increases the risk for surgical site infection by causing tiny breaks in skin integrity.)

The nurse is caring for the postoperative patient in the PACU. The patient is concerned about the abdominal staples closing her wound for fear they will open and her "insides will fall out." Which of the following is the best response by the nurse? "Don't worry, the staples are properly placed and will not come out until they are removed by the physician." "If you are very careful and follow your postoperative instructions, there is no need to worry." "There are sutures in various levels below the staples that assist in keeping your wound intact." "Would you tell me why you are worried about that?" "That is possible, but we will keep a close eye on the staples."

"There are sutures in various levels below the staples that assist in keeping your wound intact." (A patient may have absorbable sutures closing the viscera and staples approximating the wound edges.)

A nurse is educating a surgical client on postoperative p.r.n. pain control. Which of the following should be included? "We will bring you pain medications; you don't need to ask." "Even if you have pain, you may get addicted to the drugs." "You won't have much pain so just tough it out." "You need to ask for the medication before the pain becomes severe."

"You need to ask for the medication before the pain becomes severe." (If medication for pain is ordered p.r.n., there is a time restriction between doses. The client needs to ask for the medication and should do so before the pain becomes severe.)

A nurse is educating a client about regional anesthesia. Which of the following statements is accurate about this type of anesthesia? "You will be asleep and won't be aware of the procedure." "You will be asleep but may feel some pain during the procedure." "You will be awake but will not be aware of the procedure." "You will be awake and will not have sensation of the procedure."

"You will be awake and will not have sensation of the procedure." (Regional anesthesia occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. The client remains awake but loses sensation in a specific area or region of the body.)

The nurse is preparing to start an IV in the preoperative adult patient. The nurse would likely choose which gauge of IV catheter? 22 gauge 25 gauge 18 gauge 14 gauge

18 gauge (For any surgical patient, a large-gauge (e.g., 18-gauge) IV device should be used in case a blood transfusion is necessary during the surgical or postoperative period.)

A patient has chronic confusion secondary to dementia. As a result, he is unable to sign an informed consent for surgery. In this situation: An informed consent is not needed. Two nurses may sign the informed consent for the patient. The surgeon must sign the informed consent. A family member will be asked to sign the informed consent.

A family member will be asked to sign the informed consent. (In most states, a family member, conservator, or legal guardian may give consent for a procedure if a patient is not capable of giving an informed consent or if the patient is a minor.)

A diabetic client is undergoing surgery to amputate a gangrenous foot. This procedure would be considered which of the following categories of surgery based on purpose? Diagnostic Ablative Palliative Reconstructive

Ablative (Ablative surgery is performed to remove a diseased body part. Diagnostic surgery is performed to make or confirm a diagnosis. Palliative surgery involves relieving or reducing intensity of an illness. Reconstructive surgery restores function to traumatized or malfunctioning tissue.)

Surgeries are commonly classified by which of the following? Choose all that apply. Acuity Level of urgency Length of surgery Organ involved

Acuity Level of urgency (Surgeries can be classified by body systems, purpose, level of urgency, and degree of seriousness. The length of surgery and organ involved are not used for classifying surgeries.)

A client with abdominal incisions experiences excruciating pain when he tries to cough. What should the nurse do to reduce the client's discomfort when coughing? Administer prescribed pain medication just before coughing. Ask the client to drink plenty of water before coughing. Ask the client to lie in a lateral position when coughing. Administer prescribed pain medication 30 minutes before deliberately attempting to cough.

Administer prescribed pain medication 30 minutes before deliberately attempting to cough. (Coughing is painful for clients with abdominal or chest incisions. Administering pain medication approximately 30 minutes before coughing, or splinting the incision when coughing, can reduce discomfort. Making the client lie in a lateral position or asking the client to drink plenty of water is not helpful because it will make breathing and coughing even more difficult for the client.)

Which of the following nursing interventions occurs in the postoperative phase of the surgical experience? Airway/oxygen therapy/pulse oximetry Teaching deep breathing exercises Reviewing the meaning of p.r.n. orders for pain medications Putting in IV lines and administering fluids

Airway/oxygen therapy/pulse oximetry (Airway/oxygen therapy/pulse oximetry occur in the postanesthesia unit in the postoperative phase. Teaching deep-breathing exercises and reviewing the meaning of p.r.n. orders for medications occur in the preoperative phase. Putting in IV lines and administering fluids occurs in the intraoperative phase.)

The nurse is caring for a patient admitted for an outpatient surgical procedure. Which of the following will the nurse include in the care? Select all that apply. Begin discharge teaching as soon as the procedure is completed. Allow family members to be present during discharge teaching. Begin discharge teaching in the preoperative period. Investigate the patient's home care and discharge transportation following the procedure. Discuss discharge transportation during the preoperative period.

Allow family members to be present during discharge teaching. Begin discharge teaching in the preoperative period. Discuss discharge transportation (Patient teaching begins during the preoperative period and continues throughout all perioperative phases of care. In the preoperative phase, assess the patient's and family's readiness to learn and their knowledge base so that teaching can be individualized. If the patient will be discharged on the day of surgery, be sure to identify someone who can take the patient home and assist during the postoperative recovery period.)

The removal of a toddler's clothing and application of monitoring equipment after anesthesia is administered will Minimize blood loss Ensure temperature control Provide baseline vital signs Allow sufficient relaxation

Allow sufficient relaxation (Relaxation can be enhanced by removing the child's clothing, applying the grounding pad, and applying monitoring devices after the child is anesthetized.)

Surgery can lead to hypothermia. Of the following clients, who is at greatest risk for hypothermia? A woman delivering by C-section An adolescent for arthroscopic surgery A young adult with a fractured leg An elderly man with a fractured hip

An elderly man with a fractured hip (The risk of hypothermia increases in the very young and the very old.)

Identify the desired effects of general anesthesia. Choose all that apply. Reduction of risk Analgesia Amnesia Muscle relaxation

Analgesia Amnesia Muscle relaxation (General anesthesia is used to control pain (analgesia), relax muscles, and promote amnesia. Anesthesia is not used for the purpose of obtaining a reduction in risk potential; however, surgical risk is influenced by the type of anesthesia used.)

A postoperative home care client has developed thrombophlebitis in her right leg. What category of medications will probably be prescribed for this cardiovascular complication? Anticoagulants Antibiotics Antihistamines Antigens

Anticoagulants (Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative clients. Nursing interventions include administering ordered medications, most often anticoagulants.)

A nurse is providing ongoing postoperative care to a client who has had knee surgery. The nurse assesses the dressing and finds it saturated with blood. The client is restless and has a rapid pulse. What should the nurse do next? Document the data and apply a new dressing. Apply a pressure dressing and report findings. Reassure the family that this is a common problem. Make assessments every 15 minutes for four hours.

Apply a pressure dressing and report findings. (Hemorrhage is an excessive internal or external loss of blood. Common indications of hemorrhage include a rapid, thready pulse. If bleeding occurs, the nurse should apply a pressure dressing to the site, report findings to the physician, and be prepared to return the client to the operating room if bleeding cannot be stopped or is massive.)

A patient is to have a sequential compression device (SCD) applied on the postoperative unit. The patient is wearing knee-high elastic (antiembolism) stockings. When applying the SCD, what should the nurse do? Remove the antiembolism stockings and not replace them. Replace the knee-high stockings with thigh-high stockings. Notify the surgeon that the patient is wearing antiembolism stockings. Apply the SCD over the knee-high antiembolism stockings.

Apply the SCD over the knee-high antiembolism stockings. (If elastic stockings have been ordered with the sequential compression device, leave them in place; if the patient is not yet wearing them, obtain them and put them on the patient. Knee-high stockings do not need to be replaced with thigh-high stockings. Some research has shown knee-high stockings to be equally effective. There is no need to notify the surgeon, as patients commonly return from surgery wearing antiembolism stockings, as prescribed.)

A nurse is assisting a postoperative client with deep-breathing exercises. Which of the following is an accurate step for this procedure? Place the client in prone position, with the neck and shoulders supported. Ask the client to place the hands over the stomach, so he or she can feel the chest rise as the lungs expand. Ask the client to exhale rapidly and completely, and inhale through the nose rapidly and completely. Ask the client to hold his or her breath for three to five seconds and mentally count "one, one thousand, two, one thousand" and so forth.

Ask the client to hold his or her breath for three to five seconds and mentally count "one, one thousand, two, one thousand" and so forth. (The nurse should place the client in semi-Fowler's position, with the neck and shoulders supported, and ask the client to place the hands over the rib cage, so he or she can feel the chest rise as the lungs expand. Then, ask the patient to exhale gently and completely, inhale through the nose gently and completely, hold his or her breath for three to five seconds, and mentally count "one, one thousand, two, one thousand" etc., then exhale as completely as possible through the mouth with lips pursed (as if whistling).)

Which of the following interventions are recommended guidelines for meeting client postoperative elimination needs? Assess abdominal distention, especially if bowel sounds are audible or are low pitched. Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake. Encourage food and fluid intake when ordered, especially dairy products and low-fiber foods. Assess for bladder distention by Palpating below the symphysis pubis if the client has not voided within eight hours after surgery.

Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake. (Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake. Assess abdominal distention, especially if bowel sounds are inaudible or are high pitched. Encourage food and fluid intake when ordered, especially fruit juices and high-fiber foods. Assess for bladder distention by palpating above the symphysis pubis if the client has not voided within eight hours after surgery.)

A patient had a colon resection for removal of a cancerous tumor. Postoperatively, on the surgical floor which of the following activities would the nurse perform for the purpose of decreasing the risk of postoperative complications? Choose all that apply. Assist the patient to turn, breathe deeply, and cough every 2 hours. Teach the patient about the type of tumor removed. Assess the drainage from the surgical site. Monitor vital signs on a regular basis.

Assist the patient to turn, breathe deeply, and cough every 2 hours. Assess the drainage from the surgical site. Monitor vital signs on a regular basis. (The nurse assists the patient to turn, breathe deeply, and cough every 2 hours in order to decrease the risk of postoperative atelectasis or pneumonia. The nurse assesses the wound drainage to monitor for signs of bleeding, infection, or wound complications. Vital signs are monitored to detect the potential for infection or hemorrhage, not to prevent them. The nurse may teach the patient about cancerous tumors; however, this intervention will not decrease the risk of postoperative complications.)

A client returning to the floor after orthopedic surgery is complaining of nausea. The nurse is aware that an appropriate intervention is to do which of the following? Avoid strong smelling foods. Provide clear liquids with a straw. Avoid oral hygiene until the nausea subsides. Hold all medications.

Avoid strong smelling foods. (Nursing care for a client with nausea includes avoiding strong smelling foods, providing oral hygiene, administering prescribed medications (especially medications ordered for nausea and vomiting), and avoiding use of a straw.)

What instruction might the nurse give to nursing assistive personnel (NAP) regarding postoperative exercises? A. "Find out if the patient has any language barriers." B. "Let me know when the patient actually begins exercising." C. "Please review a copy of the preoperative literature with the patient." D. "Assess the method of learning the patient would prefer."

B. "Let me know when the patient actually begins exercising." (Rationale: NAP may let the nurse know if the patient is exercising. No aspect of patient assessment may be delegated to NAP. Patient education may not be delegated to NAP. Because assessment of learning preferences is part of patient education, NAP may not carry out this responsibility.)

Before teaching a patient postsurgical exercises, the nurse premedicates the patient for pain. What benefit does this have specific to the patient's learning? A. Reduced pain B. Improved focus C. Decreased relaxation D. Decreased irritability

B. Improved focus (Rationale: When pain is controlled, the patient is better able to concentrate. Although reduced pain is a desired outcome, this answer fails to address a specific effect on patient learning. To decrease relaxation would mean that the patient would be less relaxed and, with pain relief, the patient would be more relaxed. This option is also unrelated to a patient's learning. Although reduced pain may make the patient less irritable, this outcome is not directly related to learning.)

Why might a nurse teach a patient scheduled for surgery how to do postoperative exercises? A. To maximize a sense of well-being B. To minimize postoperative complications C. To identify cultural factors that reflect the patient's perception of pain D. To evaluate the patient's ability to participate in postoperative activities

B. To minimize postoperative complications (Rationale: Teaching postoperative exercises can minimize the patient's risk for injury. Promoting a sense of well-being is not why patients are taught postoperative exercises, although doing so may have that effect. Cultural factors are unrelated to postoperative exercise teaching. There is no link between teaching postoperative exercises and evaluating the patient's ability to participate in postoperative activities.)

Why does the nurse place a patient on bed rest after administering preoperative medication? A. To ensure that the surgical site is not injured B. To protect the patient from injury C. To maintain a calm environment D. To maintain the intravenous infusion

B. To protect the patient from injury (Rationale: A patient is placed on bed rest after receiving preoperative medication to ensure that he or she is not injured in a fall. Bed rest is not specifically required to prevent injury to the surgical site. A patient is not placed on bed rest after receiving preoperative medication in order to maintain a calm environment, although doing so might have that effect. Bed rest is not required in order to maintain an intravenous infusion.)

Which instruction might a nurse give a patient in order to protect a surgical incision when turning in bed? A. Hold your breath when turning. B. Use a pillow to splint the incision. C. Take pain medication 30 minutes before turning. D. Keep both legs straight when turning.

B. Use a pillow to splint the incision. (Rationale: Using a pillow to splint the incision will protect the incision when turning in bed. Holding one's breath when turning in bed is not appropriate technique and will not protect the incision. Taking pain medication before turning in bed will not protect the incision. Keeping both legs straight when turning in bed is not appropriate technique and will not protect the incision.)

The nurse is providing education to a client regarding pain control after surgery. What time does the nurse inform the client is the best time to request pain medication? Before the pain becomes severe When the client experiences a pain rating of "10" on a 1-to-10 pain scale When there is no pain, but it is time for the medication to be administered After the pain becomes severe and relaxation techniques have failed

Before the pain becomes severe (If a pain medication is ordered p.r.n., the client should be instructed to ask for the medication before the pain becomes severe.)

The nurse knows the term perioperative phase refers to care given to the client Before, during, and after the operative phase From the start of surgery until its conclusion Immediately before an operative procedure Immediately after the operative phase

Before, during, and after the operative phase (Perioperative nursing includes three distinct phases: preoperative, intraoperative, and postoperative.)

The nurse is concerned that a patient will not be able to turn independently in bed after having surgery. What must the nurse do to help this patient? A. Reinstruct the patient in proper turning techniques. B. Document that the patient refuses to turn independently. C. Communicate that the staff must turn the patient after surgery. D. Restrict turning unless absolutely necessary.

C. Communicate that the staff must turn the patient after surgery. (Rationale: The nurse must let the staff know to turn the patient after surgery. Reinstructing the patient will not improve the patient's ability to turn in bed. Documenting that the patient refuses to turn independently is not accurate. The patient is unable, but not necessarily unwilling, to turn without assistance. Restricting the patient from turning can lead to preventable postoperative complications. This should not be done.)

The telemetry unit nurse is reviewing laboratory results for a client who is scheduled for an operative procedure later in the day. The nurse notes on the laboratory report that the client has a serum potassium level of 6.5 mEq/L, indicative of hyperkalemia. The nurse informs the physician of this laboratory result because the nurse recognizes hyperkalemia increases the client's operative risk for which of the following? Cardiac problems Infection Bleeding and anemia Fluid imbalances

Cardiac problems (Hyperkalemia or hypokalemia increases the client's risk for cardiac problems. A decrease in the hematocrit and hemoglobin level may indicate the presence of anemia or bleeding. An elevated white blood cell count occurs in the presence of infection. Abnormal urine constituents may indicate infection or fluid imbalances.)

A physician has ordered a nurse to administer conscious sedation to a client. Which of the following is possible after administering conscious sedation to a client? Client can respond verbally despite physical immobility. Client can tolerate long therapeutic surgical procedures. Client is relaxed, emotionally comfortable, and conscious. Client's consciousness level can be monitored by equipment.

Client is relaxed, emotionally comfortable, and conscious. (Conscious sedation refers to a state in which the client is sedated in a state of relaxation and emotional comfort, but is not unconscious. The client is free of pain, fear, and anxiety and can tolerate unpleasant diagnostic and short therapeutic surgical procedures, such as an endoscopy or bone marrow aspiration. The client can respond verbally and physically. However, no equipment can replace a nurse's careful observations for monitoring clients.)

A nurse is caring for a client who is scheduled to undergo a breast biopsy. Which of the following major tasks does the nurse perform immediately during the pre-operative period? Obtain a signature on the consent form. Review the surgical checklist. Conduct a nursing assessment. Reduce the dosage of toxic drugs.

Conduct a nursing assessment. (During the immediate pre-operative period, the nurse conducts a nursing assessment. Nurses obtain the signature of the client, nearest blood relative, or someone with durable power of attorney before the administration of any pre-operative sedatives. They also administer medications as ordered by the physician regardless of their toxicity. They assist the client with psychosocial preparation and complete the surgical checklist, which is reviewed by the operating room personnel.)

The nurse is caring for a patient who had abdominal surgery 3 days ago and will be discharged home later today. The nurse will know that teaching is effective if the patient does which of the following? Choose all that apply. Describes clinical findings associated with infection Performs the dressing change as prescribed Demonstrates freedom from surgical incision pain Completes the regimen of prescribed antibiotics

Describes clinical findings associated with infection Performs the dressing change as prescribed Completes the regimen of prescribed antibiotics (The nurse would know that patient teaching was effective if the patient verbalizes signs and symptoms of infection, can perform the ordered dressing change, and completes the regimen of ordered antibiotics. Nurses cannot teach a patient to be free of pain. Pain is subjective. The nurse can teach the patient strategies to assist with pain, but they may not remove the pain completely.)

A client, scheduled for open-heart surgery, tells the nurse he does not want to be "saved" if he dies during surgery. What should the nurse do next? Discuss with and document the wishes of the client and family Administer the ordered oral and intravenous preoperative medications Notify the physician after completion of the surgical procedure Verbally report the client's wishes to the operating room supervisor

Discuss with and document the wishes of the client and family (Advance directives allow the client to specify instructions for health care treatment if unable to communicate these wishes during or after surgery. It is important for the nurse to discuss and document exact do not resuscitate (DNR) wishes of the client and family before surgery.)

A nurse is reviewing results of preoperative screening tests and notes the client's potassium level is dangerously low. What should the nurse do next? Nothing; potassium levels have no influence on surgical outcome. Include the information in the postoperative end of shift report. Document the data and notify the physician who will do the surgery. Ask the client and family members why the potassium is low.

Document the data and notify the physician who will do the surgery. (Either high or low levels of potassium put the surgical client at increased risk for cardiac problems during and after surgery. The nurse's role includes recording the data in the client's record and reporting abnormal findings.)

A female client is scheduled for liposuction surgery to reduce her weight. Based on urgency, how is this surgery classified? Urgent Elective Emergency Emergent

Elective (A liposuction procedure is classified as elective surgery, in which the procedure is preplanned and based on the client's choice. Other classifications are urgent (surgery is necessary for the client's health but not an emergency) and emergency (the surgery must be done immediately to preserve life, body part, or body function).)

Which of the following interventions is of major importance during preoperative education? Performing skills necessary for gastrointestinal preparation Encouraging the client to identify and verbalize fears Discussing the site and extent of the surgical incision Telling the client not to worry or be afraid of surgery

Encouraging the client to identify and verbalize fears (A surgical procedure causes anxiety and fear. The nurse should encourage the client to identify and verbalize fears; often simply talking about fears helps to diminish their magnitude.)

The focus of nursing care in the intraoperative phase is to: Prepare the patient for surgery. Maintain the sterile field. Ensure patient safety during the surgery. Obtain a signed informed consent.

Ensure patient safety during the surgery. (The intraoperative phase begins when the patient enters the operating suite and ends when the patient is admitted to the postanesthesia care unit. The nursing focus is to ensure patient safety during the surgical procedure by functioning as an advocate when clients cannot advocate for themselves and by monitoring the client and surgical environment throughout the procedure. Although the sterile field must be maintained in this phase, the focus of care is broader than the maintenance of sterility. Obtaining informed consent and preparing the patient for surgery are activities associated with the preoperative phase.)

The preoperative patient has called the nurse about his upcoming surgical procedure, which will be six weeks from now. He is concerned about receiving blood after surgery for fear of acquiring a bloodborne disease. Which of the following might the nurse do? Instruct the patient to notify the physician. Remind the patient that blood is tested prior to administration, making it safe and free of disease. Ask the patient if he has ever had any blood products. Explain to the patient the use of autologous blood donation. Instruct patient to refuse transfusion.

Explain to the patient the use of autologous blood donation. (Because of the fears of hepatitis B and human immunodeficiency virus infection associated with blood transfusion, donation of autologous blood (one's own blood) for surgery is becoming a common practice. If the patient wishes, provide the necessary information about blood donation if the patient is seen a number of weeks before surgery.)

The patient tells the nurse, "I'm so nervous. I want to be knocked out for the surgery so that I don't know what is going on." When the nurse communicates with the surgeon and anesthetist, she tells them that the patient desires which type of anesthesia? Conscious sedation General anesthesia Local anesthesia Regional anesthesia

General anesthesia (General anesthesia produces rapid unconsciousness and loss of sensation. During conscious sedation, the client feels sleepy but is easily aroused by touch or speech. Regional anesthesia interrupts nerve impulses to and from the affected area, but the patient remains alert. Local anesthesia produces loss of pain sensation at the desired site and is typically used for minor procedures. The client remains alert during local anesthesia.)

A client has been taking aspirin since his heart attack in 1997. The client is at risk for Infection Thrombophlebitis Hemorrhage Blood clots

Hemorrhage (Current medication use, especially use of medications that can affect coagulation status (warfarin, nonsteroidal anti-inflammatory drugs, aspirin) is important and should be reported to the surgeon.)

Which statement accurately represents a recommended guideline when providing postoperative care for the following clients? Force fluids for an adult client who has a urine output of less that 30 mL per hour. If client is febrile within 12 hours of surgery, notify the physician immediately. If the dressing was clean but now has a large amount of fresh blood, remove the dressing and reapply it. If vital signs are progressively increasing or decreasing from baseline, notify the physician of possible internal bleeding.

If vital signs are progressively increasing or decreasing from baseline, notify the physician of possible internal bleeding. (A continued decrease in blood pressure or an increase in heart rate could indicate internal bleeding, and the physician should be notified. If an adult client has a urine output of less than 30 mL per hour, the physician should be notified, unless this is expected. If the client is febrile within 12 hours of surgery, the nurse should assist the client with coughing and deep-breathing exercises. When large amounts of fresh blood are present, the dressing should be reinforced with more bandages and the physician notified.)

Which of the following clients will see the greatest permanent changes in lifestyle following surgery? Right total knee replacement Left mastectomy Ileostomy Appendectomy

Ileostomy (Permanent changes in the client's activity level may occur as a result of surgery. The client with an ileostomy will encounter the greatest changes in lifestyle.)

A 2-year-old child is scheduled for a tonsillectomy. When determining the plan of care, the nurse should: Include the parents or caregivers in the plan of care. Explain to the child that she will have a sore throat after surgery. Tell the child that she can have her favorite foods for the first 24 hours after surgery. Prepare the child for discharge from the hospital as soon as she is alert.

Include the parents or caregivers in the plan of care. (It is developmentally normal for toddlers to experience anxiety with separation from parents or caregivers. Be sure to include these people in the plan of care. Developmentally, a 2-year-old lives in the "here and now" and wouldn't grasp an intangible concept, such as pain in the future. The toddler would take liquids and soft foods within the first 24 hours when her throat is sore during swallowing. She should not eat foods that are rough and crunchy because they may scratch her throat and cause bleeding. After a tonsillectomy, the child will need to be monitored for bleeding and stable vital signs; therefore, she will not be discharged as soon as she is alert.)

The preoperative nurse is preparing a patient for surgery. Identify the interventions the nurse will perform. Choose all that apply. Inform the family to wait in the surgical waiting room. Prepare the surgical suite for the operation. Remove the patient's dentures and contact lenses. Assist the patient to complete a living will.

Inform the family to wait in the surgical waiting room. Remove the patient's dentures and contact lenses. (Before being transported to the operating suite, the patient must remove all artificial body parts, such as dentures, artificial limbs, or contact lenses. Wigs, eyeglasses, makeup, and jewelry must also be removed. The nurse will also inform the patient's relatives where they may wait during the surgery. The surgical suite will be prepared by the surgical team. It is not necessary to have a living will prior to surgery. However, the nurse will ask the patient if there is one when obtaining the nursing history.)

The nurse is preparing to send a client to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the client's chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature from the client. What is the nurse's best action to the physician's request? Inform the physician that it is his or her responsibility to obtain the signature. Obtain the signature and ask another nurse to cosign the signature. Inform the physician that the nurse manager will need to obtain the signature. Call the house officer to obtain the signature.

Inform the physician that it is his or her responsibility to obtain the signature. (The responsibility for securing informed consent from the client lies with the person who will perform the procedure. The nurse's best action is to inform the physician that it is his or her responsibility to obtain the signature.)

A patient is admitted from a local skilled nursing facility to the outpatient surgery center for surgical débridement of a stage IV sacral pressure ulcer. The perioperative nurse discovers that the patient does not have a signed consent form for the surgery on the chart or in the surgery center. The patient says that she has not talked to the surgeon and that she has many questions regarding her surgery. When informed of this, the surgeon tells the nurse to have the patient sign the informed consent form, and he will review it prior to the surgery. What should the nurse do? Follow the surgeon's orders, and ask the patient to sign the surgical consent form. Inform the surgeon that she will have the patient sign after he discusses the surgery with the patient. Ensure that the signed surgical consent is witnessed by two nurses, because the surgeon is not available. Cancel the surgery and transfer the patient back t

Inform the surgeon that she will have the patient sign after he discusses the surgery with the patient. (Informed surgical consent requires that the surgeon present information about the surgery to the patient, that the patient understands the information and agrees to the surgery, and that the patient has not been coerced to give consent. As a patient advocate, the nurse should verify with the patient that the surgeon has explained the procedure and answered all her questions. The surgeon is responsible for giving the patient the necessary information and determining the patient's competence to make an informed decision about the surgery. If the patient has further questions, the nurse should notify the surgeon and delay sending the patient to surgery until an informed consent is obtained.)

A patient is scheduled for abdominal surgery tomorrow. While gathering preoperative data, the nurse learns that the patient takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E 1,500 IU. The patient reports that he stopped taking the anticoagulant 4 days ago as instructed by the surgeon. He has continued to take the multivitamin and vitamin E. Based on the information given, the nurse telephones the surgeon because she: Needs an order to restart the anticoagulant. Is concerned about continued use of the multivitamin. Is concerned about the vitamin E dosage. Thinks the surgery should be delayed until further notice.

Is concerned about the vitamin E dosage. (Both prescribed and over-the-counter medications may increase surgical risk. Many herbs can cause potassium loss and increase the risk for cardiac arrhythmias. High doses of vitamin E may increase the risk for bleeding. This patient's use of 1,500 IU of vitamin E daily exceeds the recommended dosage, so the nurse should inform the surgeon of the vitamin E intake. Generally, the surgeon or anesthesiologist instructs patients to continue or discontinue taking their prescribed medicines. However, it is important to assess use of supplements and over-the-counter medicines. The surgeon would determine if the surgery should be delayed.)

A nurse is assisting a physician during a cesarean section for a client. The client is administered epidural anesthesia. Which of the following is an advantage of epidural anesthesia? It counteracts the effects of conscious sedation. It decreases the risk of gastrointestinal complications. It prevents clients from remembering the initial recovery period. It acts on the central nervous system to produce loss of sensation.

It decreases the risk of gastrointestinal complications. (Epidural anesthesia is a regional anesthesia administered to a client before surgery; it decreases the risk of gastrointestinal complications in clients. Reversal drugs are medications that counteract the effects of those used for conscious sedation. General anesthesia acts on the central nervous system to produce loss of sensation; it prevents clients from remembering their initial recovery period.)

A student is assessing a postoperative client who has developed pneumonia. The plan of care includes positioning the client in the Fowler's or semi-Fowler's position. What is the rationale for this position? It increases blood flow to the heart. The client will be more comfortable and have less pain. It facilitates nursing assessments of skin color and temperature. It promotes full aeration of the lungs.

It promotes full aeration of the lungs. (Pneumonia may occur in the postoperative client from aspiration, immobilization, depressed cough reflex, infection, increased secretions from anesthesia, or dehydration. Nursing interventions include positioning the client in the Fowler or semi-Fowler position to promote full aeration of the lungs.)

Which of the following surgical clients will return to activities in their everyday lives more quickly? Vaginal hysterectomy Laparoscopic cholecystectomy Right nephrectomy Open-heart surgery

Laparoscopic cholecystectomy (Clients who have surgery using a laparoscope are able to return to previous activity levels much sooner.)

Upon assessment, a client reports that he drinks five to six bottles of beer every evening after work. Based upon this information, the nurse is aware that the client may require which of the following? Larger doses of anesthetic agents and larger doses of postoperative analgesics Larger doses of anesthetic agents and lower doses of postoperative analgesics Lower doses of anesthetic agents and lower doses of postoperative analgesics Lower doses of anesthetic agents and larger doses of postoperative analgesics

Larger doses of anesthetic agents and larger doses of postoperative analgesics (Clients with a large habitual intake of alcohol require larger doses of anesthetic agents and postoperative analgesics, increasing the risk for drug-related complications.)

An operating room nurse is preparing for a surgical procedure on an infant. The nurse's perioperative care is based on what physiologic factor that puts infants at greater risk from surgery than adults? Increased vascular rigidity Diminished chest expansion Lower total blood volume Decreased peripheral circulation

Lower total blood volume (Infants are at a greater risk from surgery as a result of various physiologic factors. A major factor is that the infant has a lower total blood volume, making even a small loss of blood a serious consideration because of the risk for dehydration and the inability to respond to the need for increased oxygen during surgery.)

Which of the following nursing actions provides the greatest assistance in healing? Maintaining a restful environment Providing solid food in the first day Allowing family members to visit often Keeping the client recumbent

Maintaining a restful environment (The nurse should plan for adequate periods of rest and sleep, maintaining a quiet, restful environment.)

The nurse-anesthetist is monitoring his client during surgery. He notices a ventricular dysrhythmia and unstable blood pressure. He notifies the surgeon. The operative team suspects Myocardial infarction Malignant hyperthermia Mitral valve prolapse Major blood loss

Malignant hyperthermia (The symptoms of malignant hyperthermia are masseter muscle rigidity, ventricular dysrhythmia, tachypnea, cyanosis, skin mottling, and unstable blood pressure.)

After conducting a preoperative health assessment, the nurse documents that the client has physical assessments supporting the medical diagnosis of emphysema. Based on this finding, what postoperative interventions would be included on the plan of care? Perform sterile dressing changes each morning. Administer pain medications as needed. Conduct a head-to-toe assessment each shift. Monitor respirations and breath sounds.

Monitor respirations and breath sounds. (Respiratory disorders, including emphysema, increase the risk for respiratory depression from anesthesia as well as postoperative pneumonia and atelectasis.)

A nurse is taking care of a client during the immediate post-operative period. Which of the following duties performed during the immediate post-operative period is most important? Ensure the safe recovery of surgical clients. Monitor the client for complications. Prepare a room for the client's return. Assess the client's health constantly.

Monitor the client for complications. (The immediate post-operative period refers to the first 24 hours after surgery. During this time, the nurse monitors the client for complications as he or she recovers from anesthesia. Once the client is stable, the nurse prepares a room for the client's return and assesses the client to prevent or minimize potential complications. The nurse ensures the safe recovery of the client after the client has stabilized.)

he healthy adult patient is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the patient. Which of the following should the nurse do first? Immediately have the patient sign the consent form. Have the patient's family member sign the consent form. Ask the patient if he still wants to proceed with the procedure. Notify the physician of the oversight.

Notify the physician of the oversight. (Do not administer any medications that might alter judgment or perception before the patient signs the consent form because many drugs commonly administered as preoperative medications, such as narcotics or barbiturates, can alter cognitive abilities and invalidate informed consent.)

Identify the type of surgery a terminally ill patient will undergo if the purpose is removal of tissue to relieve pain. Procurement Ablative Palliative Diagnostic

Palliative (Palliative surgery alleviates discomfort or other disease symptoms without producing a cure. Procurement surgery occurs when an organ or tissue is harvested for transplantation into another. Ablative surgery involves removal of a body part. Diagnostic surgery confirms or negates a diagnosis.)

In the postoperative phase of abdominal surgery, the client complains of severe abdominal pain, and in the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect? Normal response Abdominal infection Hernia development Paralytic ileus

Paralytic ileus (A potential complication after surgery is paralytic ileus, a condition in which there is decreased bowel functioning.)

When an elderly client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this most likely a result of Effects of anesthesia Normal return of reflexes Partial airway obstruction Type of surgery

Partial airway obstruction (Loud, irregular respirations may indicate obstruction of the airway, possibly from emesis, accumulated secretions, or client positioning that allows the tongue to fall to the back of the throat.)

A patient had a hiatal hernia repair earlier today and is now in the postanesthesia care unit (PACU). The family asks the nurse why the patient is in the PACU rather than back in his room on the postsurgical unit. The nurse should inform the family that: Patients who have had surgical complications are observed in the PACU until they are stable enough to return to the floor. Patients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care. The PACU is a holding area for patients awaiting a surgical unit bed or awaiting adequate staff to provide care on the postsurgical unit. The nurse will ask the surgeon explain to them why the patient is not on the postsurgical unit, as is the usual procedure.

Patients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care. (A client remains in the PACU until he has recovered from the effects of anesthesia. In the PACU, the client is assessed every 5 to 15 minutes in order to quickly identify surgical or anesthesia-related problems. Most surgical units routinely admit patients to the PACU for a period of observation. Admission to the PACU does not indicate surgical complications nor imply that a holding area is required. There is no reason the surgeon would need to explain this to the family, as the nurse could do it. It is not usual procedure for a patient to be transferred directly from surgery to the postsurgical unit.)

A cleansing enema is ordered for a client who is scheduled to have colon surgery. What is the rationale for this procedure? Surgical clients routinely are given a cleansing enema. Cleansing enemas are given before surgery at the client's request. There will be less flatus and discomfort postoperatively. Peristalsis does not return for 24 to 48 hours after surgery.

Peristalsis does not return for 24 to 48 hours after surgery. (If the client is scheduled for gastrointestinal tract surgery, a cleansing enema is usually ordered. Peristalsis does not return for 24 to 48 hours after the bowel is handled, so preoperative cleansing helps decrease postoperative constipation.)

A client states he has a latex allergy. What action should the nurse take? Inform the client to tell the anesthesiologist Have the client take a Benadryl before surgery Send the client to the OR with epinephrine Place an allergy identification band

Place an allergy identification band (Assist client with allergies to medications, food, and latex before the surgical procedure, and clearly mark them on the client record and on the client identification band.)

A patient is admitted for hip surgery. The patient usually takes the following medications daily: an anticoagulant, a multivitamin, and vitamin E 1,500 IU. He stopped taking his anticoagulant 4 days ago as instructed by his surgeon, but has continued to take the multivitamin and vitamin E. An important collaborative problem or nursing diagnosis for this patient is which of the following? Potential complication: anemia Risk for infection related to inadequate anticoagulant dosage Risk for noncompliance related to inability to follow instructions Potential complication: increased bleeding

Potential complication: increased bleeding (The patient is at an increased risk for bleeding due to his intake of vitamin E. He may be at risk for anemia if he experiences a large blood loss in surgery; however, this problem is not appropriate before he experiences the blood loss. This patient does not have a higher-than-average risk for infection because he is not having surgery involving a "contaminated" system (e.g., the gastrointestinal system). There is no evidence to suggest that this is noncompliant simply he because he stopped taking his anticoagulant as ordered.)

The focus of nursing activities in the preoperative phase is to: Admit the patient to the surgical suite. Prepare the patient mentally and physically for surgery. Set up the sterile field in the operating room. Perform the primary surgical scrub to the surgical site.

Prepare the patient mentally and physically for surgery. (The nursing focus in the preoperative phase is to prepare the patient mentally and physically for surgery. The patient is in the intraoperative phase when admitted to the surgical suite. The sterile field and the surgical scrub would be performed in the surgery suite during the intraoperative phase.)

When educating a client in the postoperative period, it is important to educate the client to consume a diet high in Protein Calcium Bicarbonate Potassium

Protein (After surgery, a diet with sufficient amounts of protein and vitamins A and C helps rebuild tissues and promotes wound healing.)

A client scheduled for major surgery will receive general anesthesia. Why is inhalation anesthesia often used to provide the desired actions? Rapid excretion and reversal of effects Safe administration in the client's own room Involves only the respiratory system and skin Slow onset of action and maintains reflexes

Rapid excretion and reversal of effects (General anesthesia involves the administration of drugs by inhalation and intravenous routes to produce central nervous system depression. Inhalation anesthesia is often used because it has the advantage of rapid excretion and reversal of effects.)

What nursing action will assist in pain management for a client in the postoperative phase? Client teaching Relaxation techniques Dim lighting Provide food and medication

Relaxation techniques (Nursing interventions vital in helping clients cope with pain include administering medications, positioning, relaxation techniques, psychological support, distraction techniques, and appropriate referrals to other health professionals.)

Which of the following are potential complications of anesthesia? Choose all that apply. Hypothermia Respiratory depression Cardiovascular compromise Aspiration

Respiratory depression Cardiovascular compromise Aspiration (Hypothermia is a potential complication of surgery. It is not induced by anesthesia.)

A preoperative assessment finds a client to be 75 pounds overweight. The client is to have abdominal surgery. What nursing diagnosis would be appropriate based on the client's weight? Risk for Aspiration Risk for Imbalanced Body Temperature Risk for Infection Risk for Falls

Risk for Infection (Fatty tissue in obese clients has a poor blood supply and, therefore, has less resistance to infections. Postoperative complications of delayed wound healing, wound infection, and disruption of the wound are more common in obese clients.)

A client is being discharged following surgery for cancer care. The client will require extensive dressing changes two times per day. The client is on a fixed income and cannot afford to purchase dressing supplies. The nurse contacts the local Peregrine Society to assist in the provision of dressings. This contribution in care will assist in improving the client's Family relationships Return to daily activities Decision making Self-concept

Self-concept (In addition to providing the client with the necessary technical care, teaching, extensive rehabilitation, and emotional support, nursing interventions may also include referral to agencies and support groups that can benefit the client after surgery and discharge from the acute care facility.)

Which of the following is the most appropriate nursing goal for a 2-year-old who is to have a tonsillectomy? Separation anxiety will be minimal. The child will verbalize understanding of expected pain. The child will tolerate a normal diet 24 hours after surgery. The parent will indicate readiness to assume the child's care.

Separation anxiety will be minimal. (The only concrete information in this question is that the child is 2 years old. Therefore, the only problem the nurse can reasonably predict from this would be developmental in nature. It is developmentally normal for toddlers to experience anxiety with separation from parents or caregivers. Minimizing anxiety by involving the parents or caregivers would be the appropriate goal for separation anxiety. A 2-year-old child would not be expected to verbalize understanding of expected pain. The toddler would take liquids and soft foods within the first 24 hours when her throat is sore during swallowing. She should not eat foods that are rough and crunchy because they may scratch her throat and cause bleeding. Nurses should encourage parental involvement, but parents should not be expected to assume the child's care.)

A nurse has been asked to ensure informed consent for a surgical procedure. What might be a role of the nurse? Securing informed consent from the client Signing the consent form as a witness Ensuring the client does not refuse treatment Refusing to participate based on legal guidelines

Signing the consent form as a witness (The responsibility for securing informed consent from the client lies with the person who will perform the procedure, usually the physician. The nurse may sign as a witness, signifying that the client signed the consent form without coercion, and was alert and aware of the act.)

Which of the following members of the operative team use sterile technique during the surgical procedure? Choose all that apply. Surgeon Anesthetist Scrub nurse Registered nurse first assistant

Surgeon Scrub nurse Registered nurse first assistant (The anesthetist is a member of the clean team and remains outside the sterile field. Members of the sterile team include the surgeon, the scrub nurse, and the registered first nurse assistant.)

Following a surgical procedure, which of the following are generally responsible for moving the patient to the recovery area? The surgeon The orderly The recovery nurses The anesthesiologist, circulating nurse, and surgeon

The anesthesiologist, circulating nurse, and surgeon (After the intraoperative phase of the surgical procedure has been completed, the circulating nurse, the anesthesia provider, and the surgeon safely transport the patient to the PACU, taking care to maintain the patient's airway during this critical time.)

The nursing instructor is discussing the role of the circulating nurse in the operative suite with the student nurses. Which of the following would the nursing instructor include as duties of the circulating nurse? Select all that apply. The circulating nurse is included in the responsibility of accounting for all sponges and instruments following the surgical procedure. The circulating nurse is responsible for preparing the surgical table for the procedure. The circulating nurse is responsible for assisting the surgeon with instruments during the procedure. The surgical nurse is responsible for maintaining the patient's rights during the surgical procedure.

The circulating nurse is included in the responsibility of accounting for all sponges and instruments following the surgical procedure. The surgical nurse is responsible for maintaining the patient's rights during the surgical procedure. (The circulating nurse ensures that the patient's rights are protected and coordinates patient care in the operating room. The circulating nurse and the scrub person are responsible for accounting for all sponges and instruments at the close of surgery.)

A nurse in an outpatient surgical center is teaching a client about what will be necessary for discharge to home. What information should the nurse include about transportation? The client is not allowed to drive a car home. If the client is not dizzy, driving a car is allowed. Only adults over the age of 25 may drive home. None; this is not necessary information.

The client is not allowed to drive a car home. (After outpatient surgery, clients may go home when they are no longer dizzy or drowsy, have stable vital signs, and have voided. Clients are not allowed to drive a car home.)

The preoperative phase encompasses which period of time? Entry to the operating suite until admission to postanesthesia care Entry into the operating suite until discharge from the hospital The decision to have surgery until admission to postanesthesia care The decision to have surgery until entry to the operating suite

The decision to have surgery until entry to the operating suite (The preoperative phase begins with the decision to have surgery and ends when the patient enters the operating room. The intraoperative phase begins when the patient enters the operating suite and ends when the patient is admitted to the postanesthesia care unit.)

Which of the following describes the Perioperative Nursing Data Set? Choose all that apply. A standardized tool for assessing high-risk surgical patients A standardized vocabulary encompassing all surgical patient outcomes The first specialized nursing language recognized by the ANA A standardized language designed to describe the care of perioperative patients

The first specialized nursing language recognized by the ANA A standardized language designed to describe the care of perioperative patients (The Perioperative Nursing Data Set (PNDS) is a standardized vocabulary specifically designed to describe the care of perioperative clients. It consists of 74 nursing diagnoses, 133 nursing interventions, and 28 nurse-sensitive patient outcomes appropriate for use in any surgical setting. It was the first specialty language recognized by the ANA.)

The patient has been transported to the operating suite and positioned on the operating table. Suddenly, the patient states, "I don't want to do this. Get me out of here now!" Which of the following actions should occur? The patient should be given the anesthesia. The surgeon should tell the patient to remain calm and the procedure will be over soon. The patient should be told it is too late to change his mind. The procedure should be stopped.

The procedure should be stopped. (The patient has the right to ask any questions and to withdraw consent at any point before the surgery begins.)

Which of the following personnel are legally responsible for obtaining the patient's informed consent for a surgical procedure? The surgeon The registered nurse The admissions clerk The licensed practical nurse Any licensed person

The surgeon (The surgeon is legally responsible for obtaining the patient's informed consent.)

A young woman has been in an automobile crash that resulted in an amputation of her left lower leg. She verbalizes grief and loss. What knowledge by the nurse is used to provide interventions to help the client cope? The client should be grateful to be alive. This is a normal, appropriate response. This is an abnormal, inappropriate response. Tissue healing will help the client adapt.

This is a normal, appropriate response. (Many surgical clients have the same reaction to loss of a body part as they would to a death. A surgical client's grief is a normal, appropriate response. The nurse must be aware of the client's needs and provide interventions to meet those needs in coping with change.)

What is the rationale for the administration of IV cephalosporin antibiotic before surgery? To prevent the development of strep To prevent the development of pneumonia To allow for decreased level of white blood cells To allow the client high levels of medication

To allow the client high levels of medication (A cephalosporin antibiotic is administered just before the surgical procedure so that the level of medication circulating in the client's blood will be high during surgery.)

What is the rationale for having the client void before surgery? To assess for pregnancy in women To assess for urinary tract infection To prevent bladder distention To prevent electrolyte imbalance

To prevent bladder distention (Having the client void before surgery will assist in the prevention of bladder distention during or after the procedure.)

A nurse working in a PACU is responsible for conducting assessments on immediate postoperative clients. What is the purpose of these assessments? To determine the length of time to recover from anesthesia To use intraoperative data as a basis for comparison To focus on cardiovascular data and findings To prevent complications from anesthesia and surgery

To prevent complications from anesthesia and surgery (Immediate postoperative care in the PACU involves assessing the postoperative client with emphasis on preventing complications from the surgery.)

A young adult woman is scheduled for a bilateral breast reduction under general anesthesia. She is normally healthy and takes no daily medications. Identify the preoperative screening tests appropriate for this patient. Choose all that apply. Urinalysis EKG Creatinine clearance CBC

Urinalysis CBC (Preoperative screening tests are ordered to determine if the client has undetected underlying health concerns. Most institutions require a complete blood count (CBC) and urinalysis prior to all surgical procedures. Generally, an electrocardiograph (ECG) is ordered for clients over the age of 50 years or with known cardiac disease. A creatinine clearance is not a routine presurgical screening test.)

A patient returns from surgery with a nasogastric tube and intermittent gastric suction to provide abdominal decompression. Which of the following are correct nursing activities for managing the equipment and drainage? Choose all that apply. Wear nonsterile procedure gloves when emptying the drainage container. When irrigating the nasogastric tube, use sterile water. Wear sterile gloves when irrigating the nasogastric tube. Apply water-soluble lubricant if the patient's lips are dry.

Wear nonsterile procedure gloves when emptying the drainage container. Apply water-soluble lubricant if the patient's lips are dry. (Nonsterile procedure gloves are to protect the nurse and other patients against microorganisms that might be present in body fluids; wearing them is in observance of standard precautions. For patients with an NG tube, frequent oral care, including water-soluble lubricant for dry lips, is important. Sterile gloves are not needed for irrigating the NG tube because the nasal passages, esophagus, and stomach are not sterile. Sterile normal saline and a sterile syringe are used for irrigation, however. Sterile water is not used.)

The nurse has a prescription to give a series of medications on an "on call" basis. The nurse realizes that these medications will be given: In the postanesthesia recovery unit. At the time specified in the order. On the patient's arrival in the surgery suite. When the OR staff notify the nurse to do so.

When the OR staff notify the nurse to do so. (The anesthesia team may order medications to be given "on call" if the surgery time is likely to vary. The nurse will give "on call" medications when he is notified to do so by the OR staff.)

Maintaining a safe environment is a major responsibility of which surgical team member? a. Circulating nurse b. Scrub nurse c. Surgeon d. Certified registered nurse anesthetist

a. Circulating nurse (The circulating nurse observes the surgical procedure, coordinates the needs of the surgical team, and assists the team in maintaining a safe and comfortable environment. The scrub nurse is within the sterile field and passes instruments and other equipment needed to the surgeon during the surgical procedure. The surgeon performs the surgical procedure. The certified registered nurse anesthetist is a registered nurse who has been trained to deliver anesthesia.)

A patient scheduled for surgery takes several medications. Which medication indicates that the patient's surgical risk is increased? a. Tylenol b. Insulin c. Thyroid medication d. Vitamin C

b. Insulin (Insulin is taken for an elevated glucose level. This person has diabetes, which increases the surgical risk. Tylenol does not increase the risk. Aspirin, steroids, and herbal medications increase surgical risk. Thyroid medication does not increase surgical risk. Vitamin C is needed for normal growth and development. It is also required for the growth and repair of tissues in all parts of the body.)

The nurse is teaching a patient about regional anesthesia. Which statement is accurate about this type of anesthesia? a. Patients will be awake but disoriented during the surgery. b. Patients are awake with loss of sensation in an area of the body. c. Patients will be asleep but may feel some pressure during the surgery. d. Patients are asleep and won't be able to remember the surgery.

b. Patients are awake with loss of sensation in an area of the body. (Regional anesthesia allows for the patient to remain awake. The patient will not feel any sensations during the surgery. The patient will not be disoriented. Many patients may be asked to follow instructions during the surgery. The patient will remain awake and he or she should not feel any pressure. The patient should have full memory of the surgical experience.)

A patient is having a conversation with a surgeon. Which perioperative phase should the nurse anticipate will begin once the patient has agreed to have surgery? a. Postoperative b. Preoperative c. Intraoperative d. Interoperative

b. Preoperative (The preoperative phase begins when the patient agrees to have surgery. The postoperative phase begins when the patient is transferred from the operating room to the PACU. The intraoperative phase begins when the patient is transferred to the operating room. Interoperative is not a surgical phase.)

A patient is scheduled for surgery. Which should the nurse include in the preoperative teaching? a. Side effects of postoperative pain medication b. The importance of stopping smoking before the surgery c. The different types of wound drainage d. Advice to call the doctor if having severe pain while in the hospital

b. The importance of stopping smoking before the surgery (A patient should stop smoking once he or she has made the decision to have surgery. Smoking can increase the risk for respiratory complications. At this time the nurse may not know what will be ordered for postoperative pain management. The patient should be given information to help him or her understand signs of infection. Giving information on all the types of drainage is unnecessary. The patient would not be responsible for calling the doctor for inpatient pain management.)

The nurse is teaching a patient about being discharged after an elective surgery. The procedure is being performed at an ambulatory surgical center. What information should the nurse include about transportation? a. You will be able to drive home. b. You will need someone to drive you home. c. You can drive home if someone is in the car with you. d. If you are lightheaded or dizzy, you will not be able to drive home.

b. You will need someone to drive you home. (Patients undergoing surgery in an ambulatory center will need someone to drive them home because of the effects of anesthesia, pain medication, and the surgery itself. Patients are instructed not to drive home. A patient cannot drive home with or without feeling lightheaded or dizzy. Patients should not drive even if someone is in the car with them. Driving is not allowed because of the medications given during the surgical procedure.)

The recovery nurse is caring for a surgical patient in the PACU. The patient's blood pressure is dropping and their heart rate is increasing. The nurse suspects the patient is: overmedicated. experiencing normal adaptation to the postoperative period. allergic to the anesthesia. developing shock.

developing shock. (Decreasing blood pressure and an increased pulse rate in the postoperative patient are significant because they may signify hemorrhage or shock.)