Ch. 17 - Preoperative Care

*19. Which information in the preoperative patient's medication history is most important to communicate to the health care provider?* a. The patient takes garlic capsules every day. b. The patient quit using cocaine 10 years ago. c. The patient took a prescribed sedative the previous night. d. The patient uses acetaminophen (Tylenol) for aches and pains.

ANS: A Chronic use of garlic may predispose to intraoperative and postoperative bleeding. The use of a sedative the previous night, occasional acetaminophen use, and a distant history of cocaine use will not usually affect the surgical outcome.

*18. The nurse interviews a patient scheduled to undergo general anesthesia for a bilateral hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery?* a. The patient's father died after general anesthesia for abdominal surgery. b. The patient drinks 3 cups of coffee every morning before going to work. c. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. d. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital.

ANS: A The information about the patient's father suggests that there may be a family history of malignant hyperthermia and that precautions may need to be taken to prevent this complication. Current research indicates that having clear liquids 3 hours before surgery does not increase the risk for aspiration in most patients. Patients are instructed to discontinue aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative implications.

7. The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time? a. Auscultate for adventitious breath sounds. b. Obtain the blood pressure and temperature. c. Remind the patient about harmful effects of smoking. d. Ask the health care provider to prescribe a nicotine patch.

ANS: A The nurse should first ensure a patent airway and check for breathing and circulation (airway, breathing, and circulation [ABCs]) in a responsive patient. Circulation and temperature can be assessed after a patent airway and breathing have been established. The immediate postoperative period is not the optimal time for patient teaching about the harmful effects of smoking. Requesting a nicotine patch may be appropriate but is not a priority at this time.

5. A patient who is scheduled for a therapeutic abortion tells the nurse, "Having an abortion is wrong." Which functional health pattern should the nurse further assess? a. Value-belief b. Cognitive-perceptual c. Sexuality-reproductive d. Coping-stress tolerance

ANS: A The value-belief pattern includes information about conflicts between a patient's values and proposed medical care. In the cognitive-perceptual pattern, the nurse will ask questions about pain and sensory intactness. The sexuality-reproductive pattern includes data about the impact of the surgery on the patient's sexuality. The coping-stress tolerance pattern assessment will elicit information about how the patient feels about the surgery.

*17. Which statement by a patient scheduled for surgery is most important to report to the health care provider?* a. "I have a strong family history of cancer." b. "I had a heart valve replacement last year." c. "I had bacterial pneumonia 3 months ago." d. "I have knee pain whenever I walk or jog."

ANS: B A patient with a history of valve replacement is at risk for endocarditis associated with invasive procedures and may need antibiotic prophylaxis. A current respiratory infection may affect whether the patient should have surgery, but a history of pneumonia is not a reason to postpone surgery. The patient's knee pain is the likely reason for the surgery. A family history of cancer does not have implications for the current surgery.

*2. A patient arrives at the outpatient surgical center for a scheduled laparoscopy under general anesthesia. Which information requires the nurse's preoperative intervention to maintain patient safety?* a. The patient has never had general anesthesia. b. The patient is planning to drive home after surgery. c. The patient had a sip of water 4 hours before arriving. d. The patient's insurance does not cover outpatient surgery.

ANS: B After outpatient surgery, the patient should not drive that day and will need assistance with transportation and home care. Clear liquids only require a minimum preoperative fasting period of 2 hours. The patient's experience with anesthesia and the patient's insurance coverage are important to establish, but these are not safety issues.

*4. A patient who has not had any prior surgeries tells the nurse doing the preoperative assessment about allergies to avocados and bananas. Which action is most important for the nurse to take?* a. Notify the dietitian about the specific food allergies. b. Alert the surgery center about a possible latex allergy. c. Reassure the patient that all allergies are noted on the health record. d. Ask whether the patient uses antihistamines to reduce allergic reactions.

ANS: B Certain food allergies (e.g., eggs, avocados, bananas, chestnuts, potatoes, peaches) are related to latex allergies. When a patient is allergic to latex, special nonlatex materials are used during surgical procedures. The staff will need to know about the allergy in advance to obtain appropriate nonlatex materials and have them available during surgery. The other actions also may be appropriate, but prevention of allergic reaction during surgery is the most important action.

13. A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take? a. Withhold the usual scheduled insulin dose because the patient is NPO. b. Obtain a blood glucose measurement before any insulin administration. c. Give the patient the usual insulin dose because stress will increase the blood glucose. d. Give half the usual dose of insulin because there will be no oral intake before surgery.

ANS: B Preoperative insulin administration is individualized to the patient, and the current blood glucose will provide the most reliable information about insulin needs. It is not possible to predict whether the patient will require no insulin, a lower dose, or a higher dose without blood glucose monitoring.

10. Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for an open cholecystectomy? a. Care for the surgical incision b. Deep breathing and coughing c. Oral antibiotic therapy after discharge d. Medications to be used during surgery

ANS: B Preoperative teaching, demonstration, and re-demonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. The patient does not usually need information about medications that are used intraoperatively.

*11. Five minutes after receiving the ordered preoperative midazolam by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate?* a. Assist the patient to the bathroom. b. Offer the patient a urinal or bedpan. c. Ask the patient to wait until the drug has been fully metabolized. d. Tell the patient that a bladder catheter will be placed in the operating room.

ANS: B The patient will be at risk for a fall after receiving the sedative, so the best nursing action is to have the patient use a bedpan or urinal. Having the patient get up either with assistance or independently increases the risk for a fall. The drug is timed to be in effect during transportation to the operating room. The patient will be uncomfortable and risk involuntary incontinence if the bladder is full during transport to the operating room.

*9. The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I don't understand what the doctor said about the surgery." Which action should the nurse take next?* a. Provide a thorough explanation of the planned surgical procedure. b. Notify the surgeon that the informed consent process is not complete. c. Give the prescribed preoperative antibiotics and withhold sedative medications. d. Notify the operating room nurse to give a more complete explanation of the procedure.

ANS: B The surgeon is responsible for explaining the surgery to the patient. The nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurse's legal scope of practice to explain the surgical procedure. No preoperative medications should be given until the patient understands the surgical procedure and signs the consent form.

*8. The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. The patient reports use of garlic and ginkgo biloba. Which action by the nurse is most appropriate?* a. Teach the patient that these products may be continued preoperatively. b. Advise the patient to stop the use of herbs and supplements at this time. c. Discuss the herb and supplement use with the patient's health care provider. d. Reassure the patient that there will be no interactions with anesthetic agents.

ANS: C Both garlic and ginkgo biloba increase the risk for bleeding. The nurse should discuss the herb and supplement use with the patient's health care provider. The nurse should not advise the patient to stop the supplements or to continue them without consulting with the health care provider and the anesthesia care provider.

15. The nurse is preparing a patient on the morning of surgery. The patient refuses to remove a wedding ring, saying, "I've never taken it off since the day I was married." Which response by the nurse is best? a. Have the patient sign a release form and leave the ring on. b. Tell the patient that the hospital is not liable for loss of the ring. c. Suggest that the patient give the ring to a family member to keep. d. Inform the operating room personnel that the patient is wearing a ring.

ANS: C Jewelry is not allowed to be worn by the patient, especially if electrocautery will be used. Safety is the issue here. There is no need for a release form or to discuss liability with the patient.

*6. A patient undergoing an emergency appendectomy has been using St. John's wort to prevent depression. Which complication would the nurse expect in the postanesthesia care unit?* a. Increased discomfort b. Increased blood pressure c. Increased anesthesia recovery time d. Increased postoperative wound bleeding

ANS: C St. John's wort may prolong the effects of anesthetic agents and increase the time to waken completely after surgery. It is not associated with increased bleeding risk, hypertension, or increased pain.

14. The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery. The results are white blood cell (WBC) count 10.2 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 103/µL. Which action should the nurse take? a. Notify the surgeon and anesthesiologist immediately. b. Ask the patient about any symptoms of a recent infection. c. Continue to prepare the patient for the surgical procedure. d. Discuss the possibility of blood transfusion with the patient.

ANS: C The CBC count results are normal. With normal results, the patient can go to the holding area when the operating room is ready for the patient. There is no need to notify the surgeon or anesthesiologist, discuss blood transfusion, or ask about recent infection.

*20. A patient who takes a diuretic and a -blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery?* a. Hematocrit 36% b. Blood pressure 144/82 c. Serum potassium 3.2 mEq/L d. Pulse rate 54-58 beats/minute

ANS: C The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of anxiety. The lower heart rate would be expected in a patient taking a -blocker. The hematocrit is in the low normal range but does not require any intervention before surgery.

12. The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching? a. Use printed materials for instruction so that the patient will have more time to review the material. b. Direct all the teaching toward the wife because she is the obvious support and caregiver for the patient. c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. d. Ask the patient's wife to wait in the hall in order to focus preoperative teaching with the patient himself.

ANS: C The nurse should allow more time when doing preoperative teaching and preparation for older patients with sensory deficits. Because the patient has visual deficits, he will not be able to use written material for learning. The teaching should be directed toward both the patient and wife because both will need to understand preoperative procedures and teaching.

*3. A 38-yr-old woman is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to communicate to the anesthesiologist and surgeon before surgery?* a. The patient's lack of knowledge about postoperative pain control b. The patient's history of an infection following a cholecystectomy c. The patient's report that her last menstrual period was 8 weeks ago d. The patient's concern about being able to resume lifting heavy items

ANS: C This statement suggests that the patient may be pregnant and pregnancy testing is needed before administration of anesthetic agents. Although the other data may also be communicated with the surgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery.

1. When caring for a preoperative patient on the day of surgery, which actions included in the plan of care can the nurse delegate to unlicensed assistive personnel (UAP) (select all that apply)? a. Teach incentive spirometer use. b. Explain routine preoperative care. c. Obtain and document baseline vital signs. d. Remove nail polish and apply pulse oximeter. e. Transport the patient by stretcher to the operating room.

ANS: C, D, E Obtaining vital signs, removing nail polish, pulse oximeter placement, and transport of the patient are routine skills that are appropriate to delegate. Teaching patients about the preoperative routine and incentive spirometer use require critical thinking and should be done by the registered nurse.

16. A patient has received atropine before surgery and complains of dry mouth. Which action by the nurse is most appropriate? a. Check for skin tenting. b. Notify the health care provider. c. Ask the patient about any weakness or dizziness. d. Explain that dry mouth is an expected side effect.

ANS: D Anticholinergic medications decrease oral secretions, so the patient is taught that a dry mouth is an expected side effect. The dry mouth is not a symptom of dehydration in this case. Therefore there is no immediate need to check for skin tenting. The health care provider does not need to be notified about an expected side effect. Weakness, forgetfulness, and dizziness are side effects associated with other preoperative medications such as opioids and benzodiazepines.

A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which initial response by the nurse is appropriate? a. "Surgical techniques have improved in recent years." b. "Tell me more about what happened to your mother." c. "You will receive medication to reduce your anxiety." d. "You should talk to the doctor again about the surgery."

b. "Tell me more about what happened to your mother."