CH 17
The nurse is assigned a client scheduled for an outpatient colonoscopy in an ambulatory care setting. During which phase of perioperative care would the nurse document the admission vital signs in the recovery room?
During the postoperative phase Explanation: The nurse realizes that documentation of vital signs in the recovery room begins the postoperative phase of perioperative care. The preoperative phase occurs until the client reaches the operating area. The intra operative phase includes the entire surgical procedure until the transfer to the recovery area. There is no transfer phase of perioperative care.
The nurse discovers that the client did not sign the operative consent before receiving the preoperative medication. The appropriate nursing action is:
To notify the surgeon Explanation: Preoperative medication can impair the thinking ability of the client. For informed consent to be valid, the client must be competent to give consent. The surgery will be canceled.
A 17-year-old male client is having same-day surgery to remove a neuroma from his foot. Which of the following nursing interventions would occur during the intra operative phase of peri operative care?
The nurse continuously monitors the sedated client. Explanation: Intraoperative care includes the entire surgical procedure. During sedation, the nurse continuously evaluates the client. Monitoring during all phases includes assessment of heart rate, respiratory rate, BP, oxygen saturation, and level of consciousness. This would occur during the preoperative phase of perioperative care. During the postoperative phase of perioperative care, an important assessment is determining how the client is recovering from anesthesia.
The nurse is reviewing a preoperative informed consent when preparing the client for surgery. Which contents of the informed consent are required? Select all that apply.
• Explanation of procedure • Potential risks • Benefits of surgery • Description of alternatives Explanation: Informed consents should be in writing and contain an explanation of procedure and risks, description of benefits and alternative, an offer to answer questions about procedure, ability to withdraw consent, and statement informing the client if the protocol differs from customary procedure. An estimated time of procedure and personnel present are not required in the informed consent.
The nurse concludes that teaching about pain management was effective when the client states:
"I will support my incision with my hands when I do my coughing and deep breathing exercises." Explanation: Splinting of the incision provides support to the incision and helps to control pain.
The nurse is teaching leg exercises to the client preoperatively. The client asks why the exercises are important. The best response by the nurse is:
"Leg exercises help prevent blood clots in your legs." Explanation: Leg exercises improve circulation of the lower extremities by preventing venous stasis, which can lead to deep vein thrombosis in the postoperative client.
Which question is most important for the nurse to ask the client when obtaining the preoperative admission history?
"When is the last time you ate or drank?" Explanation: Consumption of food and fluids near to the time of surgery places the client at increased risk for aspiration.
For the patient who is taking aspirin, it is important to stop taking this medication at least how many day(s) prior to surgery?
7 Explanation: Aspirin should be stopped at least 7 to 10 days before surgery. The other timeframes are incorrect.
The surgical unit nurse is developing a postoperative plan of care. In which client's plan of care would the nurse document interventions of coughing and deep breathing, gastrointestinal assessment, and effective regulation of temperature?
A client with gastrointestinal surgery and general anesthesia Explanation: General anesthesia acts on the central nervous system to produce a loss of sensation, reflexes, and consciousness. The anesthesiologist monitors the vital functions of breathing, circulation, and temperature. Following general anesthesia, nurses must closely monitor for effective breathing and oxygenation, temperature regulation, and adequate fluid balance. Nursing interventions for those clients with regional anesthesia, spinal anesthesia, and regional nerve blockades focus on assessing for allergic reactions, neurovascular assessments to specific body regions, and side effects of the medication.
A physically fit 86-year-old is scheduled for right knee replacement. What factor in this client makes them at increased risk for surgery?
Age Explanation: On admission, the nurse reviews preoperative instructions, such as diet restrictions and skin preparations, to ensure the client has followed them. If the client has not carried out a specific portion of the instructions, such as withholding foods and fluids, the nurse immediately notifies the surgeon. He or she identifies the client's needs to determine if the client is at risk for complications during or after the surgery. General risk factors are related to age; nutritional status; use of alcohol, tobacco, and other substances; and physical condition. In this scenario the risk to the client is age, the other options are incorrect according to the scenario described.
The nurse is caring for a female postoperative client who is having difficulty voiding. Which nursing action is most helpful to promote normal voiding?
Assist to the bathroom. Explanation: The nurse encourages the client to void within 4 hours of surgery to minimize the risk of a urinary tract infection. Ambulating the client to the bathroom promotes normal body positioning for urination. Running water is a common psychological strategy to cause urination, but positioning is a better option. Encouraging water will help fill the bladder but not urination. Offering to catheterize is a last option.
During the preoperative assessment, the nurse learns that the client has been taking prednisone. The nurse realizes that the client is at risk for:
Cardiovascular collapse. Explanation: Prednisone, a corticosteroid, can result in cardiovascular collapse if suddenly discontinued. A bolus of corticosteroid may be given intravenously immediately before and after surgery. Hydrochlorothiazide and anesthetics may interact, resulting in respiratory depression. Phenothiazines may potentiate the hypotensive action of anesthetics. Anticoagulants can increase the risk of bleeding.
The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was INEFFECTIVE if the client selects which of the following?
Cheeseburger, french fries, coleslaw, and ice cream Explanation: Important nutrients for wound healing include protein; vitamins A, B-complex, C, and K; arginine, magnesium, copper, and zinc; and water. The diet should be sufficient in carbohydrates and low to moderate in fats. The cheeseburger option is high in fat and low in vitamin C
Which of the following medications may increases the hypotensive action of anesthesia?
Chlorpromazine (Thorazine) Explanation: Thorazine may increase the hypotensive action of anesthetics. Deltasone may cause cardiovascular collapse and should be discontinued immediately. Coumadin can increase the risk of bleeding during the intraoperative and postoperative periods. HydroDIURIL may cause respiratory depression resulting from an associated electrolyte imbalance during anesthesia.
What action by the nurse best encompasses the preoperative phase?
Educating the patients on signs and symptoms of infection Explanation: Educating the patient on prevention or recognition of complications begins in the preoperative phase. Applying SCD and frequent vital sign monitoring happens after the preoperative phase. Only electric clippers should be used to remove hair.
The client is scheduled for a biopsy for suspected cancer of the prostate. The nurse recognizes the purpose of this surgical procedure is:
Diagnostic Explanation: A biopsy is a type of diagnostic surgery.
You are caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?
Encourage the client to move legs frequently and do leg exercises. Explanation: The nurse should encourage the client to move legs frequently and do leg exercises to prevent venous stasis and other circulatory complications. The nurse should not place pillows under the client's knees or calves unless ordered and should avoid placing pressure on the client's lower extremities. Placing the client in a side-lying position will not help prevent venous stasis and other circulatory complications in a client who has undergone surgery.
The nurse concludes that further teaching about diaphragmatic breathing is needed when the client:
Exhales forcefully with a short expiration Explanation: Diaphragmatic breathing should be performed gently and fully.
A nurse is developing a teaching plan for a patient with urinary incontinence who will be performing intermittent self-catheterization. Which of the following would be most important for the nurse to emphasize?
Following a regular emptying schedule Explanation: When intermittent self-catheterization is used, the nurse would emphasize regular emptying of the bladder rather than sterility. The catheter is inserted for the length of time it would take to empty the bladder. A regular schedule, not evidence of bladder distention, is used to guide the frequency of the procedure.
A client taking chlorpromazine (Thorazine) is preparing to undergo surgery. Which of the following complications does the surgical team need to prepare to deal with before anesthetics are administered?
Hypotension Explanation: Chlorpromazine (Thorazine) may increase the hypotensive action of anesthetics. Seizures are a potential interaction if diazepam (Valium) is withdrawn suddenly before surgery. The client who takes prednisone (Deltasone) is at risk for cardiovascular collapse if the medication is discontinued suddenly. The combination of erythromycin (Ery-Tab) and a curariform muscle relaxant can lead to apnea from muscle paralysis.
A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?
Moisten sterile gauze with normal saline and place on any organ. Explanation: A wound evisceration occurs when the wound completely separates, and the internal organs protrude. The first action by the nurse would be to cover the protruding organs with sterile dressings moistened with normal saline. Once the client is safe, the nurse can notify the physician. The client is positioned in a manner that places the least stress on the organs. Dry or pressure dressings are placed over the protruding organ.
A patient is scheduled to have a cholecystectomy. Which of the nurse's finding is least likely to contribute to surgical complications?
Osteoporosis Explanation: Osteoporosis is most likely not going to contribute to complications related to a cholecystectomy. Pregnancy decreases maternal reserves. Diabetes increases wound-healing problems and risks for infection. Urinary tract infection decreases the immune system, increasing the chance for infections.
The nurse recognizes that written informed consent is required for insertion of a(n):
Peripherally-inserted central catheter. Explanation: Nonsurgical invasive procedures, such as insertion of a peripherally-inserted central catheter, that carry more than a slight risk to the client require written informed consent.
Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery?
Physician Explanation: It is the physician's responsibility to provide appropriate information. It is not the responsibility of the nurse, case manager, or certified nurse's aide to gain informed consent.
You are physically preparing a client for surgery and instruct the person to remove any jewelry. The client refuses to remove a wedding band. What should you do in this situation with approval from your facility?
Place gauze under and over the ring and apply adhesive tape over it. Explanation: If the client is reluctant to remove a wedding band, the nurse may slip gauze under the ring, then loop the gauze around the finger and wrist or apply adhesive tape over a plain wedding band. You would not tell the client that he or she cannot go to the operating room wearing the ring. You would never medicate the client and then remove the ring against his or her will. It is not necessary to tell the physician and the anesthesiologist that the client does not want to remove the wedding band.
A patient has a nursing diagnosis of risk for impaired skin integrity related to immobility and diabetes. As part of the plan of care, the nurse plans to reposition the patient frequently. Based on an understanding of positioning and its effects, the nurse identifies which position as preferred to the semi-Fowler's position?
Recumbent Explanation: Although a patient should be repositioned laterally, prone, and dorsally in sequence, the recumbent position is preferred to the semi-Fowler's position because this position provides an increased body surface area of support.
A nurse is witnessing a patient sign the consent form for surgery. After the patient signs the consent form, the patient starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?
Request that the surgeon come and answer the questions. Explanation: It is the physician's responsibility to provide information pertaining to risks and benefits of surgery. It is not the responsibility of the nurse or nurse manager to discuss risks and benefits. The consent form should not be placed in the medical record until all questions are answered fully for the patient.
The nurse recognizes that the client who takes hydrochlorothiazide (HydroDIURIL) to manage hypertension is predisposed for which interaction with anesthesia?
Respiratory depression Explanation: Common interaction effects of hydrochlorothiazide (HydroDIURIL) and anesthesia include respiration depression.
A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants?
Scrub nurse Explanation: The scrub nurse is sterile and assists the surgical team by handing instruments to the surgeon, preparing sutures, receiving specimens to be sent to the lab, and counting sponges and needles. The circulating nurse is not sterile and obtains and opens sterile equipment, adjusts lights, and keeps records. The first assistant is involved with the client's preoperative care. The certified registered nurse anesthetist assists in the client's anesthesia.
The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?
The client reports a small bowel movement. Explanation: A bowel movement demonstrates that the nursing outcome of the return to function of the gastrointestinal track has been met. All of the other options are components of meeting the outcome of functioning.
The nurse is educating patients requiring surgery for various ailments on the perioperative experience. What education provided by the nurse is most appropriate?
Three phases of surgery and safety measures for each phase Explanation: The perioperative period includes the preoperative, intraoperative, and postoperative phases. Specific safety guidelines are followed for all surgical patients. The information provided should be general enough to be informative about surgery and should not focus on individual surgeries, as all the patients are having different surgeries. Intraoperative techniques, expected pain levels, and pain medication are specific to the patient and type of surgery. The risks and benefits of the surgical procedure should be discussed by the physician.
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?
Use diaphragmatic breathing Explanation: In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.
You are caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock?
Weak and rapid pulse rate Explanation: Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock.
Which of the following activities are nursing activities in the preoperative phase of care? Select all that apply.
• Discussing and reviewing the advanced directive document • Establishing an intravenous line • Beginning discharge planning Explanation: Of the activities listed, discussing and reviewing the advanced directive document, establishing an intravenous line, and beginning discharge planning are preoperative nursing activities.
When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as
emergency Explanation: Emergency surgery means that the patient requires immediate attention and the disorder may be life threatening. Urgent surgery means that the patient requires prompt attention within 24 to 30 hours. Required surgery means that the patient needs to have surgery, and it should be planned within a few weeks or months. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.
When the patient is encouraged to concentrate on a pleasant experience or restful scene, the cognitive coping strategy being employed by the nurse is
imagery Explanation: Imagery has proven effective for oncology patients. Optimistic self-recitation is practiced when the patient is encouraged to recite optimistic thoughts such as, "I know all will go well." Distraction is employed when the patient is encouraged to think of an enjoyable story or recite a favorite poem. Progressive muscular relaxation requires contracting and relaxing muscle groups and is a physical coping strategy as opposed to a cognitive strategy.
An example of a curative surgical procedure is
the excision of a tumor Explanation: An example of a curative surgical procedure is the excision of a tumor. A biopsy, face-lift, and the placement of a gastrostomy tube are not examples of curative surgical procedures.
Completing your preoperative assessment, you mentally rehearse your client's needs to determine if there is increased risk for complications intra operatively or postoperatively. Which of the following are general risk factors? Select all that apply.
• Nutritional status • Age • Physical condition • Health status Explanation: General surgical risk factors are related to age; nutritional status; use of alcohol, tobacco, and other substances; and physical condition.
The nurse is assisting the client with imagery as a relaxation strategy. Which statement by the client describes imagery?
"I am lying on the beach in Florida." Explanation: Imagery requires the client to think of a pleasant or restful experience.
Which nursing statement would best decrease a client's anxiety before an emergency operative procedure?
"Let me explain to you what will happen next." Explanation: Many clients feel fearful of knowing little about the operative procedure and what to expect. This fear causes anxiety and can lead to a poorer response to surgery and surgical complications. Explanations of what the client is to expect can help to decrease anxiety. False reassurance of being fine does not diminish anxiety. Deep breathing and relaxation techniques can be helpful to the client, but addressing the source of the anxiety is more beneficial. Keeping the family informed helps the family and is not client focused.
The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed?
"The nurse will explain the details of the surgery before I sign a consent." Explanation: Further instruction would be needed to clarify that the physician, not the nurse, explains the details of the surgery and obtains voluntary consent for the procedure. It is correct that preoperative instructions must be followed prior to surgery for the safety of the client, medical records are present for review prior to surgery, and the physician speaks with the family following the procedure and provides instructions for discharge.
Which domain of perioperative nursing practice focuses on clinical processes and outcomes?
Health care systems Explanation: The health care system consists of structural data elements and focuses on clinical processes and outcomes. Safety, behavioral responses, and physiological responses reflect phenomena of concern to perioperative nurses and are composed of nursing diagnoses, interventions, and outcomes.
A patient with fractured skull after falling from a ladder requires surgery. The nurse should anticipate transporting the patient to surgery during what time frame?
Immediately Explanation: Emergent surgery occurs when the patient requires immediate attention. A fractured skull is an indication for emergent surgery. An urgent surgery occurs when the patient requires prompt attention, usually within 24-30 hours. Any surgery scheduled beyond 30 hours is classified as required or elective and a fractured skull does not meet the requirements for elective or required surgery.
A client will be undergoing an appendectomy tomorrow morning. The nurse spends significant time explaining to the client what will happen, including before and after the procedure is complete. What is the primary reason the nurse puts so much effort into preoperative teaching?
It increases the likelihood of a successful recovery. Explanation: Teaching clients about their surgical procedure and expectations before and after surgery is best done during the preoperative period. Clients and family members can better participate in recovery if they know what to expect. Although preoperative teaching may minimize the time spent postoperatively on questions and help nurses improve their teaching skills, these are not the primary reasons for spending significant preoperative time on teaching. Clients must participate in their recovery process. Education encourages clients to participate in their own care in addition to giving important information to family. This would not be a primary nursing goal.
A patient asks about the purpose of withholding food and fluid before surgery. Which response by the nurse is appropriate?
It prevents aspiration and respiratory complications. Explanation: The major purpose of withholding food and fluid before surgery is to prevent aspiration, which can lead to respiratory complications. Preventing overhydration, decreasing urine output, and decreasing blood sugar levels are not major purposes of withholding food and fluid before surgery.
During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which of the following complications?
Malignant hyperthermia Explanation: This inherited disorder occurs when body temperature, muscle metabolism, and heat production increase rapidly, progressively, and uncontrollably in response to stress and some anesthetic agents. If the client's temperature begins to rise rapidly, anesthesia is discontinued, and the OR team implements measures to correct physiologic problems, such as fever or dysrhythmias. Hypothermia is a lower than expected body temperature. Signs of infection would not present during the procedure. Increased body temperature would not indicate fluid volume excess.
A 57-year-old client is undergoing preoperative assessment before surgical repair of a fractured ulna. During admission paperwork, the client reveals that she enjoyed a hearty breakfast this morning to be ready for her procedure. What is the nurse's next action?
Notify the surgeon Explanation: If the client has not carried out a specific portion of preoperative instructions, such as withholding foods and fluids, the nurse immediately notifies the surgeon. Do the preoperative instructions allow food intake before this procedure? This scenario does not include information to support this nursing action. It is not the nurse's responsibility to cancel the surgery.
The nurse is conducting a preoperative assessment on a patient scheduled for gallbladder surgery. The patient reports having a frequent cough producing green sputum for 3 days and denies fever. Upon auscultation, the nurse notes rhonchi throughout the right lung with an occasional expiratory wheeze. Respiratory rate is 20, temperature is 99.8 taken orally, heart rate is 87, and blood pressure is 124/70. What is the nurse's best action?
Notify the surgeon to possibly delay the surgery. Explanation: A respiratory infection can delay a nonemergent surgical procedure because the infection can increase the risk for respiratory complications. Therefore, the nurse should notify the surgeon about delaying the surgery. The primary physician may be called to care for the assessment findings but that should be done only after the surgeon has been notified. Continuing through the preoperative phase without notifying the surgeon and waiting 1 hour is not appropriate.
Which nutrient plays an important role in normal blood clotting?
Vitamin K Explanation: Vitamin K is important for normal blood clotting.
The nurse is preparing a client for surgery. The nurse would notify the surgeon if the client made which of the following statements?
• "I took my Coumadin as usual last evening." • "I took two aspirins for joint pain this morning." Explanation: The nurse needs to alert the surgeon to any medications the client has taken that increase the client's risk for bleeding. Aspirin inhibits platelet aggregation and should be stopped at least 7 to 10 days prior to surgery. Coumadin (warfarin) interferes with the synthesis of vitamin K-dependent clotting factors. The type of surgical procedure and the medical condition of the client determine when the Coumadin should be stopped prior to surgery.
The nurse is physically preparing a client for surgery. What area does the nurse know needs to be addressed before the client is taken to the operating room?
Elimination Explanation: When physically preparing a client for surgery these areas need to be addressed: skin preparation; elimination; attire/grooming; prosthesis; foods and fluids; and care of valuables. The physical preparation of a client for surgery does not include the areas of medication, activity, or the client's support system.
A gunshot wound would be classified under which category of surgery based on urgency?
Emergent Explanation: Emergent surgery occurs when the patient requires immediate attention. An elective surgery is classified as a surgery that the patient should have. A required surgery means that the patient needs to have surgery. An urgent surgery is one which the patient required prompt attention.
Informed consent from the surgical client is essential in all of the following categories of surgery except:
Emergent surgery Explanation: In an emergency, a physician may perform surgery without a client's informed consent in order to save the client's life.
A patient refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?
Allow the ring to stay on the patient and cover it with tape. Explanation: Most facilities will allow a wedding band to remain on the patient during the surgical procedure. The nurse must secure the ring with tape. Although it is appropriate to discuss the risk for infection, the patient has already refused removal of the ring. The surgery should not be canceled and the ring should not be removed without permission.
You are working in the preoperative area with a client going to surgery for a cholecystectomy. The client has histamine2-receptor antagonists ordered preoperatively. The client asks you why these medications are needed. What would be your best answer?
"These medications decrease gastric acidity and volume." Explanation: The anesthesiologist frequently orders preoperative medications. Common preoperative medications include the following: anticholinergics, which decrease respiratory tract secretions, dry mucous membranes, and interrupt vagal stimulation; anti anxiety drugs, which reduce preoperative anxiety, slow motor activity, and promote induction of anesthesia; histamine2-receptor antagonists, which decrease gastric acidity and volume; narcotics, which decrease the amount of anesthesia needed, help reduce anxiety and pain, and promote sleep; sedatives, which promote sleep, decrease anxiety, and reduce the amount of anesthesia needed; and tranquilizers, which reduce nausea, prevent emesis, and enhance preoperative sedation.
A parent of a 16-year-old patient asks the nurse, "How could the surgeon operate without my consent?" What is the best response given by the nurse?
"Your child had life-threatening injuries that required immediate surgery." Explanation: In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the patient's or parent's informed consent. Informed consent must be obtained before any invasive procedure. A minor cannot consent for a surgical procedure. Two doctors' opinions do not overrule the need to obtain informed consent.
When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority?
1. Impaired Gas Exchange 2. Fluid Volume Deficit 3. Altered Comfort 4. Anxiety 5. Risk for Infection Explanation: According to the Maslow's hierarchy of deeds, airway and gas exchange is of the highest priority. Next would be the deficiency in fluid volume. Altered comfort would be higher than anxiety because decreasing pain may alleviate/reduce anxiety. Lastly, a risk for diagnosis is not a current problem but an important teaching point to reduce the risk.
The nurse recognizes that which of the following clients is at least risk for perioperative complications?
A 65-year-old Caucasian man who has a history of arthritis Explanation: A history of arthritis does not increase the risk for complications during the perioperative period.
The nurse expects informed consent to be obtained for insertion of:
A gastrostomy tube Explanation: Informed consent is required for invasive procedures that require sedation and are associated with more than usual risk to the client.
The nurse is aware that which of the following helps to stimulate T-cell response:
Arginine Explanation: Arginine is necessary for collagen synthesis and deposition, increases wound strength, and stimulates T-cell response.
The nurse recognizes that the client most at risk for mortality associated with surgery is the:
Client with chronic alcoholism Explanation: The client with chronic alcoholism who experiences alcohol withdrawal symptoms is at significant risk for mortality, which can be attributed to cardiac dysrthymias, cardiomyopathy, and bleeding tendencies.
Which of the following would be the least important issue concerning safety for the perioperative team prior to proceeding to the operating room?
Patient ambulatory aids Explanation: It is imperative that the entire perioperative team participates in verifying the correct patient identity, surgical procedure, and surgical site before preceding to the OR. Patient ambulatory aids are not an important safety concern prior to proceeding to the OR.
Regarding the surgical patient, which one of the following phases refers to the period of time that constitutes the surgical experience?
Perioperative Explanation: Perioperative period includes the preoperative, intraoperative, and postoperative phases. Preoperative phase is the period of time from when the decision for surgical intervention is made to when the patient is transferred to the operating room table. Intraoperative phase is the period of time from when the patient is transferred to the operating room table to when he or she is admitted to the postanesthesia care unit. Postoperative phase is the period of time that begins with the admission of the patient to the postanesthesia care unit and ends after a follow-up evaluation in the clinical setting or home.
The nurse in the preoperative area has just medicated her client according to the anesthesiologist's orders. What is the nurse's priority action at this time?
Place the side rails in the up position and make sure the call button is in reach. Explanation: Immediately after giving the medications, the nurse instructs the client to remain in bed; he or she places side rails in the up position and ensures that the call button is within easy reach. Once the client has been preoperatively medicated you do not get them up to the bathroom. The nurses' immediate responsibility after preoperatively medicating the client is not to take the clients' vital signs or to send the family to the waiting room.
The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which of the following values would be of greatest concern to the nurse?
Potassium 6.2 mEq/L Explanation: Hyperkalemia places the client at risk for surgical complications.
A patient is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?
Splint the incision site using a pillow during deep breathing and coughing exercises Explanation: Splinting the incision site will help decrease pain and support the incision. This will increase compliance with the deep breathing and coughing exercises that assist with the prevention of respiratory complications. Pain medication should be taken regularly and not only before deep breathing and coughing exercises. Deep breathing and coughing exercises should be done at least every 2 hours, more frequently if possible. While some patients will find the exercises relaxing, most patients find it painful to complete the exercises.
The nurse is aware that the amino acid, arginine,
Stimulates T-cell response Correct Explanation: Arginine is necessary for collagen synthesis and deposition, increases wound strength, and stimulates T-cell response.
Following diagnostic testing, a patient requires a cholecystectomy. This surgical procedure would be categorized as which of the following?
Urgent Explanation: Acute gallbladder infection would be categorized as an urgent surgery. Emergent surgeries include severe bleeding, bladder or intestinal obstruction, and a fractured skull. Required surgeries include thyroid disorders and cataracts. Elective surgeries include repair of scars, simple hernia, and vaginal repair.
A client is preparing to undergo a curative surgical procedure. Which of the following is the type of surgery the client could be having? Select all that apply.
• Removal of a tumor • Removal of a diseased appendix Explanation: A surgical procedure may be diagnostic (e.g., biopsy, exploratory laparotomy), curative (e.g., excision of a tumor or an inflamed appendix), or reparative (eg, multiple wound repair). It may be reconstructive or cosmetic (e.g., mammoplasty or a facelift) or palliative (e.g., to relieve pain or correct a problem—for instance, a gastrostomy tube may be inserted to compensate for the inability to swallow food).
The nurse is completing a preoperative assessment. The nurse notices the patient is tearful and constantly wringing hands. The patient states, "I'm really nervous about this surgery. Do you think it will be ok?" What is the nurse's best response?
"What are your concerns?" Explanation: Asking the patient about their concerns is an open-ended therapeutic technique. It allows the patient to guide the conversation and address their emotional state. Asking about family support is changing the subject and is nontherapeutic. Discussing the surgical team and the low death rate associated with a procedure is minimizing the patient's feelings and is nontherapeutic.
A client develops a hemorrhage an hour post surgery while in your care. Which of the following characteristics indicate this is most likely an intermediary hemorrhage from a vein?
It occurred within the first few hours and has darkly colored blood that bubbles out slowly. Explanation: An intermediary hemorrhage appears within the first few hours following surgery. The darkly colored blood bubbles out quickly makes it a venous hemorrhage. A hemorrhage that occurs during surgery is classified as a primary hemorrhage. The blood's color indicates its source is an artery. Secondary hemorrhages occur when sutures slip or drainage tubes dislodge insecure vessels. These characteristics are for a secondary hemorrhage from an artery.
The nurse is conducting a health history of a preoperative client. The client shares that she experienced vaginal itching and burning and labial swelling after her partner tried a new brand of condoms. The nurse suspects that the client:
May have a latex allergy Explanation: Most condoms are made of latex. The client who experiences itching, swelling, hives, or other symptoms after contact with a condom may have a latex allergy.
A nurse is assisting an 80-year-old patient out of bed for the first time after being on strict bedrest for several days. Which of the following would lead the nurse to suspect that the patient is experiencing orthostatic hypotension?
Nausea Explanation: Orthostatic hypotension is manifested by a drop in blood pressure, pallor, diaphoresis, nausea, tachycardia, and dizziness.
A patient is scheduled for elective surgery. To prevent the complication of hypotension and cardiovascular collapse, the nurse should report the use of what medication?
Prednisone (Deltasone) Explanation: Patients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids can cause circulatory collapse and hypotension. Hydrochlorothiazide and erythromycin can cause respiratory complications. Warfarin will increase the risk of bleeding.
Your 72-year-old client is scheduled to have a mastectomy. You will prepare the client's skin, encourage the client to void, and remove the client's dentures during which phase of peri operative care?
Preoperative Explanation: Preoperative care begins with the decision to perform surgery and continues until the client reaches the operating area. During this time, the nurse will physically prepare the client for surgery, and nursing actions may include skin preparation, hair removal, and food and fluids management.
A nurse is performing range-of-motion exercises with a patient and preparing to hyperextend the hip. The nurse places the patient in which position?
Prone Explanation: When hyperextending the hip, the patient is placed in the prone position and the leg is moved backward from the body as far as possible. The supine position is used for all other range-of-motion exercises.
The nursing instructor is talking with her class about spinal anesthesia. What would be the nursing care intervention required when caring for a client recovering from spinal anesthesia?
• Instruct the client to stay in bed until sensation and movement returns. • Monitor respiratory rate and sensation every 2 hours or as per ordered. Explanation: The client who has received spinal anesthesia should remain in bed until sensation and movement returns. Also, the respiratory rate and sensation must be monitored every 2 hours. If permitted, the nurse should turn the client from side to side at least every 2 hours. The client who has received spinal anesthesia should be permitted to sit.
A client is undergoing a surgical procedure to repair his ulcerated colon. During your care, you discuss at length pertinent information for his condition peri operatively. Which of the following client education topics will be discussed preoperatively? Select all that apply.
• Postoperative pain control • Cough and deep-breathing exercises • Intravenous fluids and other lines and tubes Explanation: Preoperative teaching involves teaching clients about their upcoming surgical procedure and expectations. Topics include preoperative medications (when they are given and their effects); postoperative pain control; explanation and description of the post anesthesia recovery room or postsurgical area; and deep-breathing and coughing exercises.
A client is being prepared for a same-day surgical procedure and is discussing with the nurse what potential ramifications this type of surgery has. Which of the following would the nurse correctly identify? Select all that apply.
• The client will leave the hospital sooner than in the past. • Need for teaching is increased. • The client must be prepared to take on more self-care than he or she may have done in the past. Explanation: The increasing use of ambulatory, same-day, or short-stay surgery, means that clients leave the hospital sooner, which increases the need for teaching, discharge planning, preparation for self-care, and referral for home care and rehabilitation services.
You are the nurse working in an ambulatory surgery center. A teenage son of your clients ask you why so many people have surgery. What would be your best reply?
"Many people have diagnostic or short therapeutic surgical procedures." Explanation: Many diagnostic or short therapeutic surgical procedures—such as bone marrow biopsy, endoscopy, or cardiac catheterization—are now performed in outpatient settings and ambulatory surgical centers. Options B, C, and D seem to minimize the teenager's question.
Which of the following would be considered an urgent surgical procedure?
Acute gallbladder infection Explanation: An acute gallbladder infection is considered an urgent surgical procedure. Cosmetic surgery and cataract surgery are not considered urgent surgical procedures. Severe bleeding could be considered an emergent surgical procedure.
Patients who have received corticosteroids preoperatively are at risk for which type of insufficiency?
Adrenal Explanation: Patients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids does not occur to the pituitary, thyroid, or parathyroid glands.
The nurse is caring for a client needing emergency surgery. Which preoperative teaching should be omitted to prepare the client for surgery?
Frequency of postoperative vital signs Explanation: The least helpful postoperative teaching that could be omitted due to the need to obtain emergency surgery is explaining the frequency of postoperative vital signs. This is not essential information to improve client participation in their postoperative recovery. Coughing and deep breathing is essential in the immediate postoperative period. Clients are often concerned about postoperative pain so instruction on pain medication can decrease anxiety. Knowledge of the surgical procedure must be explained by a physician when signing a surgical consent.
What is the major purpose of withholding food and fluid before surgery?
Prevent aspiration Explanation: The major purpose of withholding food and fluid before surgery is to prevent aspiration. Decreasing overhydration, decreasing urine output, and decreasing constipation are not major purposes of withholding food and fluid before surgery. Until recently, fluid and food were restricted preoperatively overnight and often longer. Currently, specific recommendations depend on the age of the patient and the type of food eaten.
As a nurse working in an ambulatory surgery center, you are admitting a client who is going to have a biopsy of a skin lesion. What is an important part of the preoperative process?
Review preoperative instructions. Explanation: On admission, the nurse reviews preoperative instructions, such as diet restrictions and skin preparations, to ensure the client has followed them. The preoperative nurse does not give postoperative instructions; teach dressing changes or give instructions to caregivers.
Which of the following consequences may result if tranquilizers are withdrawn suddenly?
Seizures Explanation: Abrupt withdrawal of tranquilizers may result in anxiety, tension, and even seizures if withdrawn suddenly. Abrupt withdrawal of steroids may precipitate cardiovascular collapse. Monoamine oxidase inhibitors increase the hypotensive effects of anesthetics. Thiazide diuretics may cause excessive respiratory depression during anesthesia due to an associated electrolyte imbalance.
The nurse is assessing the postoperative client on the second postoperative day. Which assessment finding requires immediate physician notification?
The client has an absence of bowel sounds. Explanation: A nursing assessment finding of concern on the second postoperative day is the absence of bowel sounds, which may indicate a paralytic ileus. Other assessment findings may include abdominal pain and distention as fluids, solids, and gas do not move through the intestinal tract. Rales in the bases are a frequent finding postoperatively, especially if general anesthesia was administered. Encourage the client to cough and deep breathe. Pain is a common symptom following a surgical procedure. Serous drainage on the postoperative dressing needs to monitored and brought to the physician's attention when he or she assesses the client.
When a person with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the patient may show signs of alcohol withdrawal delirium during which time period?
Up to 72 hours after alcohol withdrawal Explanation: Alcohol withdrawal delirium is associated with a significant mortality rate when it occurs postoperatively. Onset of symptoms depends upon time of last consumption of alcohol. Twenty-four hours is too short a time frame to consider alcohol withdrawal delirium as no longer a threat to a chronic alcoholic.
The nurse would identify which of the following vitamin deficiencies to prevent the complication of hemorrhaging during surgery?
Vitamin K Explanation: Vitamin K is important for normal blood clotting. Vitamin A and zinc deficiencies would affect the immune system, whereas a magnesium deficiency would delay wound healing.
At what point does the preoperative period end?
When the client is transferred onto the operating table Explanation: The preoperative phase begins when the decision to proceed with surgical intervention is made and ends with the transfer of the client onto the OR table. The intraoperative phase begins when the client is transferred onto the operating table and ends with admission to the PACU.
A client who is scheduled for knee surgery is anxious about the procedure, saying, "You hear stories on the news all the time about doctors working on the wrong body part. What if that happens to me?" What can you tell this client to help alleviate his concerns?
• He can be involved in marking his knee, the site for the surgery. • The surgical team performs a "time-out" prior to surgery to conduct a final verification. • The client will be involved in the verification process prior to surgery. Explanation: There is an increased emphasis on making sure that the right client has the right procedure at the right site. To prevent "wrong site, wrong procedure, wrong person surgery," The Joint Commission (2012) established a universal protocol to achieve this goal. Included in this checklist are steps to verify the preoperative process, mark the operative site, and perform a "time-out."
A patient is scheduled for an invasive procedure. What is the priority documentation needed regarding the procedure?
A signed consent form from the patient Explanation: A signed consent is required and is important for initiating invasive procedures. The nurse should therefore check for the patient's signed consent form. A health history, medication reconciliation, and postoperative prescriptions are good items to have, but are not required documentation before performing an invasive procedure.
You are caring for a client preoperatively who is very anxious and fearful about their surgery. You know that this client's anxiety can cause problems with the surgical experience. What type of problems can this client have because of their anxiety and fear?
Anxious clients have a poor response to surgery and are prone to complications. Explanation: Anxiety and fear, if extreme, can affect a client's condition during and after surgery. Anxious clients have a poor response to surgery and are prone to complications. The scenario does not indicate an increased need for anesthesia or postoperative medications in the anxious and fearful client. Anxious clients do not generally need psychological counseling after surgery. Anxiety and fear do not affect a client positively during and after surgery.
The nurse has just admitted a 12-year-old client who is going to have an above-the-knee amputation of their left leg due to osteosarcoma. The nurse knows that adequate preoperative teaching and learning is important for what reason?
Client will have a shorter recovery period. Explanation: The purpose of adequate preoperative teaching/learning is for the client to have an uncomplicated and shorter recovery period. He or she will be more likely to deep breathe and cough, move as directed, and require less pain medication. Options B, C, and D are incorrect because preoperative teaching does not ensure that a 12-year-old client understands they are losing their leg or understand that they will have cancer. Preoperative teaching also does not ensure the client's family understands the child will lose their leg. This is the responsibility of the physicians who are treating the child and their family.
During the preoperative assessment, the patient states he is allergic to avocados, bananas, and hydrocodone (Vicodin). What is the priority action by the nurse?
Notify the surgical team to remove all latex-based items. Explanation: Allergies to avocados and bananas may indicate an allergy to latex. Although it is necessary to notify the dietary department and physician, it is not an immediate threat, as the patient is NPO (nothing by mouth) and pain medication will be ordered postoperatively. The nurse manager does not need to be notified of the patient's allergies.
An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults?
Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients. Explanation: The underlying principle that guides preoperative assessment, surgical care, and postoperative care is that elderly clients have less physiologic reserve (the ability of an organ to return to normal after a disturbance in its equilibrium) than younger clients. The hazards of surgery for the elderly are proportional to the number and severity of coexisting health problems and the nature and duration of the operative procedure. Respiratory and cardiac complications are the leading causes of postoperative morbidity and mortality in older adults.
When a patient recites, "I know all will go well," what is the cognitive coping strategy he or she is using?
Optimistic self-recitation Explanation: When that patient verbalizes this statement, is an optimistic response. Imagery occurs when the patient concentrates on a pleasant experience or restful scene. Distraction occurs when the patient thinks of an enjoyable story or recites a favorite poem or song. Music therapy would be an incorrect answer.
Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out?
Review the scheduled procedure, site, and client. Explanation: According to the 2009 National Patient Safety Goals, accurate identification of the client, procedure, and operative site is essential.
Several of the clients at the clinic are preparing to have surgery within the next 2 weeks. They are completing preoperative paperwork today with their visit. What are some of the reasons that people might need to have surgery? Select all that apply.
• Diagnostic • Cosmetic • Palliative Explanation: Reasons people have surgery include cosmetic reasons, diagnostic procedures, palliative surgeries, exploratory surgeries, and curative surgeries. Options D and E are distractors.
You are providing preoperative care to a 51-year-old male client who is anxious about his total hip replacement surgery. "What if I can never walk again? I don't want to end up like my father!" What are some ways you might help alleviate his anxiety? Select all that apply.
• Make sure the client understands what will happen during surgery. • Listen empathetically to the client's concerns about the procedure. • Review the client's postoperative goals following the procedure. • Ask the client if he would like to speak with a clergyperson. Explanation: Preparing the client emotionally and spiritually is as important as doing so physically. Anxiety and fear, if extreme, can affect a client's condition during and after surgery. Careful preoperative teaching and listening by the nurse about what will happen and what to expect can help allay some of these fears and anxieties.
A client is scheduled for a surgical procedure. When planning the client's care, the nurse should consider that which of the following conditions will increase the client's risk of complications after surgery?
A history of diabetes Explanation: As a chronic condition that affects many body systems, diabetes is a risk factor for surgical complications. The client's blood glucose level and insulin requirements need to be closely monitored before and after surgery. Being sensitive to aspirin does not pose a risk for the client in surgery. Osteoarthritis is not a systemic condition and does not place the client at risk during surgery. Chronic low back pain is not a systemic condition that places the client at risk during surgery; however, it can be exacerbated by positioning on the operating room table.
A fractured skull would be classified under which category of surgery based on urgency?
Emergent Explanation: Emergent surgery occurs when the patient requires immediate attention. An elective surgery is classified as a surgery that the patient should have. A required surgery means that the patient needs to have surgery. An urgent surgery occurs when the patient requires prompt attention.
Nursing assessment findings reveal that the client is afraid of dying during the surgical procedure. Which surgical team member would be most helpful in addressing the client's concern?
Surgeon Explanation: It is the surgeon's responsibility to explain the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts in obtaining informed consent from the client.
The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?
Temperature of 102.5° F Explanation: Intra operative hyperthermia can indicate a life-threatening condition called malignant hyperthermia. The circulating nurse closely monitors the client for signs of hyperthermia. The pulse rate, respiratory rate, and blood pressure did not indicate a significant concern.
Which client would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period?
The 35-year-old client with non-insulin dependent diabetes. Explanation: The client with diabetes is at risk for complications during the intraoperative or postoperative period. Hypoglycemia can develop during anesthesia or from inadequate carbohydrate intake or excess insulin administration postoperatively. Hyperglycemia can increase the risk for wound infection and delay wound healing. Smokers are encouraged to stop 4 to 8 weeks before surgery. Recent ilicit drug use can increase the risk for adverse reactions to anesthesia. Healthy older adults are not at increased risk.
The nurse is educating a community group regarding types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true?
The excision of a tumor Explanation: An example of a curative surgical procedure is the excision of a tumor. A biopsy, a face-lift, and the placement of a gastrostomy tube are not examples of curative surgical procedures.
When assessing a postoperative client, the nurse is correct to relate which surgical risk factor that would decrease if the surgical client maintained a blood glucose level under 150 mg/dL?
Wound healing Explanation: In caring for a postoperative client, the nurse is correct to correlate hyperglycemia with an increased risk of surgical incision infections and delayed wound healing. There is no direct correlation between blood glucose levels and nutrient deficiencies, respiratory complications, and liver dysfunction.
At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period?
During the preoperative period Explanation: The best time to begin teaching about care needed in the postoperative period is during the preoperative time. At this time, the client is more alert and focused on the information provided by the nurse. Clients and family members can better be prepared and participate in the recovery period if they know what to expect. Anxiety is a factor on arrival to the surgical unit that could interfere with learning. Pain could interfere with the learning process, following a surgical procedure. At the time of discharge, both pain and timeliness may be an issue in understanding and obtaining care needed during the postoperative time.
The nurse is caring for the client in the preoperative period and documenting rationale for a palliative surgical procedure. Which rationale is most appropriate?
The client and physician are focusing on symptom relief not a cure. Explanation: The nurse realizes a palliative surgical procedure is focused on the relief of symptoms or enhancement of function without a cure. Diagnostic surgical procedures provide additional information for medical diagnosis and treatment. Cosmetic surgery procedures are elective, with the purpose of improving body appearance. Reconstructive surgery corrects a deformity.
The nurse should determine that a client is coughing effectively after surgery if the nurse observes which of the following activities?
The client takes a deep abdominal breath and then "huff" or "hack" coughs three or four times. Explanation: Taking a deep abdominal breath and then "huff" coughing is the most effective manner of coughing. This technique helps facilitate removal of secretions and conserves energy for the client. The client should breathe slowly but not hold her breath. Short, panting breaths and then coughing from the throat do not promote expectoration of sputum from the lungs. Coughing forcefully can cause alveoli to collapse; "huff" coughing prevents this.
Sudden withdrawal of which of the following may result in seizures?
Tranquilizers Explanation: Abrupt withdrawal of tranquilizers may result in anxiety, tension, and even seizures if withdrawn suddenly. Abrupt withdrawal of steroids may precipitate cardiovascular collapse. Monoamine oxidase inhibitors increase the hypotensive effects of anesthetics. Thiazide diuretics may cause excessive respiratory depression during anesthesia due to an associated electrolyte imbalance.
You are caring for a client 6 hours post surgery. You observe that the client voids urine frequently and in small amounts. You know that this most probably indicates what?
Urine retention Explanation: Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus.
A patient with a history of alcoholism and scheduled for an urgent surgery asks the nurse, "Why is everyone so concerned about how much I drink?" What is the best response by the nurse?
"It is important for us to know how much and how often you drink to help prevent surgical complications." Explanation: Alcohol use and alcoholism can contribute to serious postoperative complications. If the medical and nursing staff is aware of the use or abuse, measures can be implemented proactively to prevent complications. Although alcohol may interfere with a medication's effectiveness, it does not determine the amount of pain medications that are prescribed following surgery. Even though this is a required screening question and counselors can be made available for those who want help, those are not the best responses to answer the patient's question.
