Ch 9, 14, 15, 16 PrepU
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 chronic low back pain A history of diabetes A history of osteoarthritis A history of sensitivity to aspirin
A history of diabetes
The client reports chest pain. The nurse uses which of the following questions to assess the pain further. Select all answers that apply. "What aggravates your chest pain?" "Please point to where you are experiencing pain." "You've never had this pain before, have you?" "How long have you experienced this pain?" "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain."
"How long have you experienced this pain?" "Please point to where you are experiencing pain." "Rate the pain on a scale of 0 to 10, with 10 being the worst possible pain." "What aggravates your chest pain?"
The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required? "I need to keep my follow-up appointment with the physician." "I should call my physician if I develop a fever." "I can resume my usual activities as soon as I get home." "My incision should become less red and tender."
"I can resume my usual activities as soon as I get home."
After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements? "Only the surgical area will be numb." "I'll be sleepy but able to respond to your questions." "I won't feel it, but I'll have a tube to help me breathe." "I'm so glad that I will be unconscious during the surgery."
"I'll be sleepy but able to respond to your questions."
A client scheduled for surgery asks why blood tests are being done to evaluate liver function. Which response will the nurse make? "It is to make sure that you haven't had any alcohol before the surgery." "It is just a routine test done before every surgery." "It is because the anesthesia you will receive is cleared through the liver." "It is done to determine if you need antibiotics prior to surgery."
"It is because the anesthesia you will receive is cleared through the liver."
The client asks the nurse how the spinal anesthesia will be administered. What is the best response by the nurse? "The anesthesiologist will inject the anesthetic through your IV." "The anesthesiologist will inject the anesthetic into the space around your lower spinal cord." "The medication will be injected into the muscles near you back by the anesthesiologist." "You will inhale the medication through a mask the anesthesiologist will place over your face and receive medication through your spinal vein."
"The anesthesiologist will inject the anesthetic into the space around your lower spinal cord."
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? "If I do not follow the instructions, my surgery could be cancelled." "My medical records will be sent to the ambulatory care center prior to my surgery." "The nurse will explain the details of the surgery before I sign a consent." "The physician will update my family after the procedure and provide specific discharge instructions."
"The nurse will explain the details of the surgery before I sign a consent." 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.
The client is taking continuous-release oxycodone for chronic pain and now reports constipation. What should be the first question the nurse asks the client? "Are you able to increase fluids and fiber in your diet?" "What do you usually take for constipation?" "When was your last bowel movement?" "Can you take bisacodyl?"
"When was your last bowel movement?" Constipation is a common side effect of opioids. The nurse needs to assess the situation first before intervening. Asking about date of last bowel movement is most important. Once the history of constipation is completed, it would then be appropriate for the nurse to ask about effectiveness of past interventions and begin teaching about interventions, such as increasing fluids and fiber.
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. Home care and other referrals are unlikely because same-day surgeries are usually minor. The client must be prepared to take on more self-care than he or she may have done in the past. Discharge planning is minimal because the stay is so short. Need for teaching is increased. The client will leave the hospital sooner than in the past.
-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. 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.
For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery? 1 7 3 5
7
A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery? 2 to 3 days 7 to 10 days 4 weeks 2 weeks
7 to 10 days
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? <30 mL Between 75 and 100 mL >200 mL Between 100 and 200 mL
<30 mL If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL per hour are reported; if the patient is voiding, an output of less than 240 mL per 8-hour shift is reported.
Nociception includes four specific processes: transduction, transmission, perception, and modulation. Which action illustrates the nociception process of pain transmission? A child quickly removing a hand when touching a hot object A mother in labor utilizing imagery to reduce pain A patient taking tramadol to enhance pain management A surgeon making an incision to perform surgery
A child quickly removing a hand when touching a hot object
The nurse expects informed consent to be obtained for insertion of: A nasogastric tube An intravenous catheter A gastrostomy tube An indwelling urinary catheter
A gastrostomy tube
How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client? Administering the analgesics on an as-needed per client request Administering analgesics with increased dosage Administering the analgesics intravenously Administering the analgesics on a regular basis
Administering the analgesics on a regular basis
A 75-year-old client had surgery for a hip fracture yesterday. The client is under stress because of the pain, the medications, sleep deprivation, and hospital surroundings. Which nursing intervention to treat the client's pain should the nurse question when ordered by the doctor? Morphine rather than Advil for pain management Advil for pain management Use of transcutaneous electrical nerve stimulator (TENS) Acetaminophen for pain management
Advil for pain management
Acute pain can be distinguished from chronic pain by assessing which characteristic? Chronic pain diminishes with healing. Acute pain responds poorly to drug therapy. Acute pain is specific and localized. Chronic pain is symptomatic of primary injury.
Acute pain is specific and localized. Acute pain is specific and localized. Acute pain responds well to drug therapy. Acute pain usually diminishes with healing. Acute pain is symptomatic of primary injury.
A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take? Allow the client to wear the ring and cover it with tape. Remove the ring once the client is sedated. Discuss the risk for infection caused by wearing the ring. Notify the surgeon to cancel surgery.
Allow the client to wear the ring and cover it with tape.
A patient is scheduled for a surgical procedure. For which surgical procedure should the nurse prepare an informed consent form for the surgeon to sign? Irrigation of the external ear canal An insertion of an intravenous catheter Urethral catheterization An open reduction of a fracture
An open reduction of a fracture
Prior to starting a peripheral intravenous line on a patient, what intervention can the nurse provide to decrease the pain from the needle puncture? Inject lidocaine 2% with epinephrine locally around the potential procedure site. Apply eutectic mixture of local anesthetic cream 30 minutes prior to the procedure. Give an oral opioid analgesic 30 minutes before the procedure. Apply diclofenac gel over the site 1 hour before the procedure.
Apply eutectic mixture of local anesthetic cream 30 minutes prior to the procedure. The topical route of administration is used for both acute and chronic pain. For example, the nonopioid diclofenac is available in patch and gel formulations for application directly over painful areas. Local anesthetic creams, such as EMLA (eutectic mixture or emulsion of local anesthetics) and L.M.X.4 (lidocaine cream 4%), can be applied directly over the injection site prior to painful needle stick procedures, and the lidocaine patch 5% is often used for well-localized types of neuropathic pain, such as postherpetic neuralgia.
A 78-year-old client is undergoing surgery to repair a right hip fracture. What nursing action is appropriate during the intraoperative phase? Discuss with the anesthesiologist the need for higher doses of anesthetic agents. Withhold pain medication due to decreased renal function. Maintain an operating room temperature of 18°C to prevent hypothermia. Appropriately position the client using adequate padding and support.
Appropriately position the client using adequate padding and support. Adequate padding and support should be used to prevent positioning injuries. Older adults have lower bone mass, which increases the risk of intraoperative positioning injuries. Pain medication can still be used, just in smaller doses, due to decreased liver and kidney function. For the same reason, lower doses of anesthetic agents are used with older adults. The operating room is usually maintained from 20°C to 24°C; 18°C is lower than the recommended temperature and can promote hypothermia in an older adult who already has impaired thermoregulation and is prone to hypothermia.
When should the nurse encourage the postoperative patient to get out of bed? Within 6 to 8 hours after surgery On the second postoperative day As soon as it is indicated Between 10 and 12 hours after surgery
As soon as it is indicated Postoperative activity orders are checked before the patient is assisted to get out of bed, in many instances, on the evening following surgery. Sitting up at the edge of the bed for a few minutes may be all that the patient who has undergone a major surgical procedure can tolerate at first.
A home health nurse is visiting a client who has been taking the same dose of acetaminophen/hydrocodone for 2 months. To monitor for the presence of expected side effects of this medication, what should the nurse include in the assessment of the client? Take the client's blood pressure. Assess level of consciousness. Ask about the client's bowel pattern. Observe respiratory rate and depth.
Ask about the client's bowel pattern.
A client recovering from hip surgery is receiving morphine through a patient-controlled analgesia (PCA) infusion pump with a set basal rate. What action is most important for the nurse to implement? Ask the client about pain status Obtain consent for PCA by proxy Instruct the client about bolus doses Assess the client's respiratory status
Assess the client's respiratory status A basal rate is a continuous infusion of the medication. Assessment of the client's respiratory status is a major nursing responsibility and the most important one listed per Maslow's hierarchy of needs. The nurse will instruct the client about bolus doses for increased pain or painful activities and assess pain status. There is no information in the stem of the question to support the need for consent for PCA by proxy.
A client who fell at home is hospitalized for a hip fracture. The client is in Buck's traction, anticipating surgery, and reports pain as "2" on a pain intensity scale of 0 to 10. The client also exhibits moderate anxiety and moves restlessly in the bed. The best nursing intervention to address the client's anxiety is to Administer the prescribed alprazolam (Xanax). Administer the prescribed dose of morphine. Assess the reason for the client's anxiety. Assist the client out of bed and into a chair.
Assess the reason for the client's anxiety. Following the steps of the nursing process, the nurse needs to assess the reason for the client's anxiety. The client could be anxious about impending surgery, an unattended pet, a sick family member, etc. Then, the nurse intervenes appropriately by obtaining the assistance the client may need or administering anti-anxiety medication. The question is asking about treatment for anxiety. Pain medication should not be administered for anxiety. The nurse will not assist the client to a chair, because the client is on bedrest and in Buck's traction.
The nurse is assisting the anesthesiologist with the insertion of an epidural catheter and the administration of an epidural opioid for pain control. What adverse effect of epidural opioids should the nurse monitor for? Hypertension Bradypnea Asystole Tachycardia
Bradypnea Most patients experience sedation at the beginning of opioid therapy and whenever the opioid dose is increased significantly. If left untreated, excessive sedation can progress to clinically significant respiratory depression (bradypnea, or reduced breathing rate).
When a nurse asks a patient to describe the quality of the pain, what type of descriptive term does the nurse expect the patient to use? Intermittent Burning Chronic Severe
Burning
A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action? Prepare to administer a stool softener. Re-attempt to auscultate bowel sounds. Call the health care provider. Prepare to insert a nasogastric tube.
Call the health care provider.
The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply. Tachypnea Wheezes Crackles Chills Afebrile
Chills Crackles Tachypnea
The OR personnel responsible for maintaining the safety of the client and the surgical environment is the: Scrub nurse Anesthesiologist Surgeon Circulating nurse
Circulating nurse
Which of the following nursing interventions contributes to achieving a client's goal for pain relief? Use all forms of available pain management techniques. Collaborate with the client about his or her goal for a level of pain relief. Minimize the client's description of pain or need for pain relief. Prevent the client from self-administering analgesics.
Collaborate with the client about his or her goal for a level of pain relief.
A nursing measure for evisceration is to: Apply an abdominal binder snugly so that the intestines can be slowly pushed back into the abdominal cavity. Carefully push the exposed intestines back into the abdominal cavity. Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution. Approximate the wound edges with adhesive tape so that the intestines can be gently pushed back into the abdomen.
Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution. If evisceration occurs, the nurse aseptically covers the abdominal contents with moist saline dressings to prevent drying of the bowel, notifies the surgical team immediately, and assesses the patient's vital signs including oxygen saturation. The patient remains in bed with knees bent to reduce abdominal muscle tension.
What medication should the nurse prepare to administer in the event the client has malignant hyperthermia? Fentanyl citrate Dantrolene sodium Thiopental sodium Naloxone
Dantrolene sodium Anesthesia and surgery should be postponed. However, if end-tidal carbon dioxide (CO2) monitoring and dantrolene sodium (Dantrium) are available and the anesthesiologist is experienced in managing malignant hyperthermia, the surgery may continue using a different anesthetic agent.
The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists? Evisceration Dehiscence Hemorrhage Normal healing by primary intention.
Dehiscence
A client scheduled for surgery follows a vegan eating plan. For which potential postoperative complication will the nurse plan care for this client? Stasis pneumonia Delayed wound healing Hypoactive bowel sounds Blood clots
Delayed wound healing The client following a vegan eating plan is at risk for a low protein intake. The reduced protein can lead to impaired or delayed wound healing and cause decreased skin and wound strength. A low protein intake does not cause blood clots, stasis pneumonia, or hypoactive bowel sounds.
Which nursing intervention should a nurse perform when caring for a client who is prescribed opiate therapy for pain? Monitor blood counts and liver function tests Do not administer if respirations are less than 12 breaths per minute Avoid caffeine or other stimulants, such as decongestants Monitor weight, vital signs, and serum glucose concentration
Do not administer if respirations are less than 12 breaths per minute
A fractured skull would be classified under which category of surgery based on urgency? Elective Emergent Urgent Required
Emergent
A client being treated for rheumatoid arthritis has been prescribed a glucocorticosteroid. How should the nurse best ensure this client's safety during treatment?' Ensure the client knows to taper down the dose if it is discontinued by the care provider. Educate the client about the need to avoid grapefruit and grapefruit juice during treatment. Teach the client the signs and symptoms of gastrointestinal bleeding. Educate the client about the difference between tolerance and dependence.
Ensure the client knows to taper down the dose if it is discontinued by the care provider. Corticosteroids must be tapered slowly in order to prevent an adrenal crisis. These medications do not normally cause dependence and they do not pose a risk for GI bleeding. Grapefruit is not contraindicated.
Which term refers to the protrusion of abdominal organs through the surgical incision? Dehiscence Evisceration Hernia Erythema
Evisceration Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.
The nurse is administering a narcotic analgesic for the control of a newly postoperative client's pain. What medication will the nurse administer to this client? Fentanyl Midazolam Ibuprofen Acetaminophen
Fentanyl
The physician has ordered a mu opioid analgesic for a patient with pain. What drug does the nurse anticipate administering? Nubain Stadol Fentanyl Buprenex
Fentanyl
The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by: Third intention Granulation Second intention First intention
First intention
Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis? Ineffective thermoregulation Decreased cardiac output Ineffective airway clearance Acute incisional pain
Ineffective thermoregulation
An older adult is being treated with opioids for pain relief. Which of the following should the nurse strongly recommend to this client? Exercise regularly. Avoid harsh sunlight. Reduce fiber intake. Follow a bowel regimen.
Follow a bowel regimen. The nurse should ensure that a bowel regimen to prevent constipation is started when any older adult is treated with opioids. A high-fiber diet along with increased fluids should be encouraged. The client should not reduce fiber intake because this increases the risk for constipation. Exercising regularly or avoiding harsh sunlight have no effects on the drug therapy.
Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis? Fluid restriction Hourly leg exercises Prolonged dangling of the legs over the edge of the bed Use of blanket rolls to elevate the lower extremitiesF
Hourly leg exercises The benefits of early ambulation and hourly leg exercises in preventing deep vein thrombosis cannot be overemphasized. It is important to avoid the use of blanket rolls, pillow rolls, or any form of elevation that constricts vessels under the knees. Prolonged dangling can be dangerous and is not recommended in susceptible clients because the pressure under the knees can impede circulation. Dehydration adds to the risk of thrombosis formation.
A client arrives in the orthopedic clinic with complaints of twisting the right ankle while playing softball. The nurse collects data including complaints of pain and swelling in the right ankle. What intervention will the nurse provide that will decrease vasodilation and reduce localized swelling? Injection of a steroid into the joint space Ice bag Elevation of the extremity Warm compresses
Ice bag Pain associated with injury is best treated initially with cold applications such as an ice bag or chemical pack. The cold decreases vasodilation which reduces localized swelling, which may be useful for minor or moderate pain. Heat will increase vasodilation. Elevation of the extremity will not decrease vasodilation. It is beyond the scope of practice for the nurse to inject steroids into the joint space.
An anxious client being prepared for surgery is encouraged to concentrate on a pleasant experience or restful scene. What cognitive coping strategy would the nurse document as being used? Progressive muscular relaxation Distraction Imagery Optimistic self-recitation
Imagery Imagery has proven effective for anxiety in surgical clients. Optimistic self-recitation is practiced when the client recites optimistic thoughts such as, "I know all will go well." Distraction is used when the client 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.
About which issue should the nurse inform clients who use pain medications on a regular basis? Consume the medications just before or along with meals. Minimize fiber intake during the therapy. Inform the primary health care provider about the use of salicylates before any procedure, and avoid over-the-counter analgesics consistently without consulting a physician. Avoid harsh sunlight for 2 hours after administering analgesic agents or salicylates.
Inform the primary health care provider about the use of salicylates before any procedure, and avoid over-the-counter analgesics consistently without consulting a physician.
When drafting a nursing care plan for a patient in pain, it is important for the nurse to determine if the pain is acute or chronic. Choose the best example of chronic pain. Angina Intervertebral disk herniation Appendicitis A migraine headache
Intervertebral disk herniation
The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply. Listening to music An epidural infusion Watching television Changing position An On-Q pump
Listening to music Watching television Changing position
A nurse is receiving a client to the postanesthesia unit. What initial nursing activity is most important in the postoperative recovery area? Assess pain level. Administer medications and fluids. Inspect surgical site. Maintain patient safety.
Maintain patient safety.
A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention? Mask is placed over nose and extends to bottom lip. Scrub top and drawstring are tucked into pants. Hair is pulled back and covered by a cap. Shoe covers are used.
Mask is placed over nose and extends to bottom lip.
The nurse is educating new employees about wearing masks in the operating room. What information should the nurse provide? Select all that apply. Masks should cover the nose and mouth completely. Masks must be worn at all times in the semi-restricted zone. Masks should fit tightly. When not using the mask, you can wear it around your neck. Masks can be worn outside the surgical department if the surgery is less than 5 minutes away. You must change masks between treating clients.
Masks should cover the nose and mouth completely. You must change masks between treating clients. Masks should fit tightly.
The nurse notes that the consent form for surgery needs to be signed; however, the client just received preoperative medication. Which action will the nurse take? Ask the client to sign the consent form now. Ask a family member to sign the consent form. Notify the health care provider that the consent form has not been signed. Document that the client provided verbal consent to the surgery.
Notify the health care provider that the consent form has not been signed. Informed consent is the client's autonomous decision about whether to undergo a surgical procedure. Voluntary and written informed consent from the client is necessary before nonemergent surgery can be performed to protect the client from unsanctioned surgery and protect the health care provider from claims of an unauthorized operation or battery. Because of this, the health care provider should be notified that the consent form has not been signed. The consent form needs to be signed before administering psychoactive premedication because consent is not valid if it is obtained while the client is under the influence of medications that can affect judgment and decision-making capacity. A family member is not responsible for approving the client's surgery. Verbal agreement to a surgical procedure is not legal or appropriate.
A client is undergoing preoperative assessment. During admission paperwork, the client reports having enjoyed a hearty breakfast this morning to be ready for the procedure. What is the nurse's next action? Document what foods the client ate. Give the client plenty of water to aid digestion. Cancel the surgery. Notify the surgeon.
Notify the surgeon. 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. This scenario does not include information to support documentation of the client's food intake or giving the client water at this point. It is not the nurse's responsibility to cancel the surgery.
A high school football player hurts his foot while playing a game. The client complains of intense pain with muscle spasms and swelling of the toe. Which pain assessment tool will the nurse most likely use to assess the client's pain level? Numeric Rating Scale (NRS) Verbal Descriptor Scales (VDS) Visual Analog Scale (VAS) Wong-Baker FACES Pain Rating Scale
Numeric Rating Scale (NRS)
A postoperative client with an open abdominal wound is currently taking corticosteroids. The physician orders a culture of the abdominal wound even though no signs or symptoms of infection are seen. What action by the nurse is appropriate? Use an antibiotic cleaning agent before obtaining the specimen. Request the order be discontinued without obtaining the specimen. Obtain the wound culture specimen. Hold the order until purulent drainage is noted.
Obtain the wound culture specimen. Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. The culture should be obtained even though the client is not demonstrating traditional signs and symptoms of infection. The order should not be discontinued or held until purulent drainage is noted because the infection could worsen and the client could develop sepsis. An antibiotic cleaning agent should not be used before obtaining the specimen because it will alter the growth of the organisms.
How would the operating room nurse place a patient in the Trendelenburg position? On his side with his uppermost leg adducted and flexed at the knee On his back with his legs and thighs flexed at right angles On his back with his head lowered so that the plane of his body meets the horizontal on an angle Flat on his back with his arms next to his sides
On his back with his head lowered so that the plane of his body meets the horizontal on an angle
A client who is deaf without bilateral hearing aids has them removed in preparation for a surgical procedure. Which action(s) will the nurse take to communicate with this client? Select all that apply. Plan for a sign language interpreter. Provide written information. Use hand gestures to communicate. Speak slowly so the client can lip read. Talk loudly into one of the client's ears.
Provide written information. Use hand gestures to communicate. Speak slowly so the client can lip read. Plan for a sign language interpreter.
Which phase of pain transmission occurs when the one is made aware of pain? Modulation Transduction Transmission Perception
Perception
A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem? Pink color Pieces of vomitus Copious red blood in the sputum Foul smell
Pink color Flash pulmonary edema that occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation, tachypnea, tachycardia, decreased pulse oximetry readings, frothy, pink sputum, and crackles on auscultation.
The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? Pale yet able to blanch with digital pressure Pink to red and soft, bleeding easily White with long, thin areas of scar tissue Necrotic and hard
Pink to red and soft, bleeding easily
Which is a true statement regarding placebos? Placebos should never be used to test a client's truthfulness about pain. A placebo effect is an indication that the client does not have pain. A placebo should be used as the first line of treatment for a client. A positive response to a placebo indicates that the client's pain is not real.
Placebos should never be used to test a client's truthfulness about pain.
What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? Pneumonia Pulmonary edema Hypoxemia Pleurisy
Pneumonia
A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse? Administer an anti-emetic. Obtain an emesis basin. Ask the client for more clarification. Position the client in the side-lying position.
Position the client in the side-lying position.
When is the ideal time to discuss preoperative teaching Prior to entering the pre-op area Day of surgery Preadmission visit When the patient is comfortable and sedated
Preadmission visit
The circulating nurse is unsure whether proper technique was followed when an object was placed in the sterile field during a surgical procedure. What is the best action by the nurse? Ask another nurse to review the technique used. Remove the item from the sterile field. Remove the entire sterile field from use. Mark the client's chart for future review of infections.
Remove the entire sterile field from use. If any doubt exists about the maintenance of sterility, the field should be considered not sterile. Because the object in question was placed in the sterile field, the sterile field must be removed from use. Removing the individual item is not appropriate, as the entire field was potentially contaminated. Reviewing the client's chart at a later date does not decrease the chance of infection. Although another nurse could observe the technique used to put objects in a sterile field, it does not resolve the immediate concern.
A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? Report the infection to an immediate supervisor. Request a role change to circulating nurse. Ensure the infection is covered with a dressing. Return to work after taking antibiotics for 24 hours.
Report the infection to an immediate supervisor. The infection needs to be reported immediately because of the aseptic environment of the operating room. The usual barriers may not protect the client when an infection is present. The employee needs to follow the policy of the operating room regarding infections. Covering the infected area with a dressing may be necessary, but the infection must be reported first. The scrub nurse may still be able to work depending on the policy; therefore, returning to work after 24 hours is not the priority action. Even if the nurse requests a role change to circulating nurse, the policy for infections in the operating room must be followed; therefore, it must be reported first.
The nurse's major area of assessment for a patient receiving patient-controlled analgesia is assessment of what system? Integumentary Cardiovascular Neurologic Respiratory
Respiratory Essential to the safe use of a basal rate with PCA is close monitoring by nurses of sedation and respiratory status and prompt decreases in opioid dose (e.g., discontinue basal rate) if increased sedation is detected (Pasero, Quinn et al., 2011).
The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to: Be anxious throughout the procedure Respond verbally during the procedure Need an endotracheal tube Need pain control throughout the procedure
Respond verbally during the procedure
A nurse is working as part of the surgical team in the semi-restricted area. Which of the following would be appropriate to wear? Select all that apply. Caps Masks Scrub clothes Street clothes Shoe covers
Scrub clothes Caps
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? Circulating nurse Certified registered nurse anesthetist First assistant Scrub nurse
Scrub nurse
Which of the following is a disadvantage to using the IV route of administration for analgesics? Short duration No risk of respiratory depression Long duration Slower entry into bloodstream
Short duration Disadvantages of using the IV route for analgesic administration include short duration, the occurrence of possible respiratory depression, and that careful dosage calculations are needed. Intramuscular analgesics have a slower entry into the bloodstream.
The client vomits during the surgical procedure. The best action by the nurse is: Lower the head of the operating table to promote circulation to the brain. Administer an anti-emetic to alleviate nausea. Increase the IV infusion rate to compensate for lost fluids. Suction the client to remove saliva and gastric secretions.
Suction the client to remove saliva and gastric secretions.
A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member? Scrub nurse Anesthetist Circulating nurse Surgeon
Surgeon The registered nurse first assistant practices under the direct supervision of the surgeon. The circulating nurse works in collaboration with other members of the health care team to plan the best course of action for each patient. The scrub nurse assists the surgeon during the procedure as well as setting up sterile tables and preparing equipment. The anesthetist administers the anesthetic medications.
The nurse is caring for a client during an intraoperative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately? Temperature of 102.5°F (39°C) Respiratory rate of 18 breaths/min Pulse rate of 110 beats/min Blood pressure of 104/62 mm Hg
Temperature of 102.5°F (39°C) Intraoperative 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.
A client is scheduled for abdominal surgery and states that he is afraid of postoperative pain. The best nursing action is to inform the client That the nurse will notify the surgeon of his fear About activities that would distract him from pain How anxiety could increase his pain perception That medication will be prescribed for pain relief
That medication will be prescribed for pain relief
A client reports abdominal pain as "8" on a pain intensity scale of 0-10 thirty minutes after receiving an opioid intravenously. Her past medical history includes partial-thickness burns to approximately 60% of her body several years ago. The nurse assesses That the client has become dependent on drugs from her previous experience of burns That based on her past experiences the client's perception of pain should be less That the client's past experiences with pain may influence her perception of current pain That the client is experiencing pain relating to the burn injuries from several years ago
That the client's past experiences with pain may influence her perception of current pain
A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client? The client must be put on immediate life support. The client can be discharged from the PACU. The client must remain in the PACU. The client should be transferred to an intensive care area.
The client can be discharged from the PACU.
A client at risk for malignant hyperthermia returns to the surgical unit. For what time period will the nurse monitor the client for development of malignant hyperthermia? Malignant hyperthermia occurs in the operating room only. The client can develop malignant hyperthermia up to 24 hours after surgery. A client can develop malignant hyperthermia only with intravenous anesthesia after surgery. The client will need to be discharged with special instructions.
The client can develop malignant hyperthermia up to 24 hours after surgery. Although malignant hyperthermia usually manifests about 10 to 20 minutes after induction of anesthesia, it can also occur during the first 24 hours after surgery. Malignant hyperthermia can be triggered by inhalant anesthesia with muscle relaxants.
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? Use chest breathing. Use diaphragmatic breathing. Exhale through an open mouth. Make inhalation longer than exhalation.
Use diaphragmatic breathing.
Which type of pain arises from an internal organ, such as the kidneys? Visceral Neuropathic Somatic Nociceptive
Visceral
A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for? Wound dehiscence Phlebitis Hypotension Contractures
Wound dehiscence Risk factors for wound dehiscence include advanced age over 65 years, chronic disease such as diabetes, hypertension, obesity, history of radiation or chemotherapy, malnutrition, particularly insufficient protein and vitamin C, and hypoalbuminemia. This client is not at increased risk for hypotension, contractures, or phlebitis.
A nurse is caring for a bariatric client prior to a surgical procedure. What surgical complications would the nurse monitor the bariatric client for postoperatively? Select all that apply. pulmonary complications cardiovascular complications nervous system complications gastrointestinal complications renal complications
cardiovascular complications pulmonary complications
A client reports having joint pain that has gotten worse over the last year despite gradually increasing doses of an OTC pain reliever. Which type of pain will the nurse document as the chief complaint? chronic pain referred pain breakthrough pain acute pain
chronic pain This client is experiencing chronic pain, which is pain or discomfort that lasts for a period longer than 6 months. Pain or discomfort with a short duration is acute pain. It is associated with trauma, injury, or surgery. Referred pain is pain felt in the body in a location that is different from the actual source of the pain. Breakthrough pain is a period of acute pain experienced by those suffering from chronic pain.
The nurse recognizes older adults require lower doses of anesthetic agents due to: increased liver mass. increased tissue elasticity. decreased lean tissue mass. decreased bone mass.
decreased lean tissue mass. Lower doses of anesthetic agents are required in older adults, as they have decreased lean tissue mass, decreased tissue elasticity, and decreased liver mass. Bone mass is unrelated to doses of anesthesia.
A nurse evaluates the potential effects of a client's medication therapies before surgery. Which drug classification may cause respiratory depression from an associated electrolyte imbalance during anesthesia? anticoagulants corticosteroids diuretics insulin
diuretics Diuretics during anesthesia may cause excessive respiratory depression resulting from an associated electrolyte imbalance. Corticosteroids, insulin, and anticoagulants are not known to cause respiratory depression during anesthesia.
A client with osteoarthritis receives a recommendation to have joint replacement surgery. For which type of surgery will the nurse plan teaching for this client? Emergent Elective Urgent Required
elective
When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as urgent. elective. emergency. required.
emergency
A client has a long history of diabetes mellitus and developed diabetic neuropathy more than 25 years ago. The client is without breakthrough pain at this point in time. How would this client's pain be classified? neuropathic and chronic nociceptive and chronic nociceptive and acute neuropathic and acute
neuropathic and chronic
The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply. Ethnicity gender health status age nutritional status physical condition
nutritional status age physical condition health status
Hypothermia may occur as a result of increased muscle activity. open body wounds. the infusion of warm fluids. being young.
open body wounds.
A client is admitted with generalized abdominal pain, nausea, vomiting, and hypotension. The client has not passed stool in over 1 week and has been in pain for the past 4 days. Which type of pain would you expect the client to be experiencing? deeper somatic neuropathic chronic visceral
visceral
