Chapter 14: Perioperative Care

In which instance may a surgeon operate without informed consent? a. Invasive procedures b. Emergency situations c. Procedures requiring sedation d. Radiologic procedures

B In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the client's informed consent.

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? a. <30 mL b. Between 75 and 100 mL c. Between 100 and 200 mL d. >200 mL

a 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.

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. a. nutritional status b. age c. physical condition d. gender e. health status f. Ethnicity

a,b,c,e General surgical risk factors are related to age; nutritional status; use of alcohol, tobacco, and other substances; and physical condition.

The anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered? a. Unresponsive to verbal or tactile stimuli b. Denies sensation to perineum and lower abdomen c. Yelling and pulling at equipment d. No movement in right lower leg

b A transsacral block anesthetizes the perineum and occasionally the lower abdomen. Yelling and pulling at equipment can be related to the excitement phase of general anesthesia. Lack of response to verbal or tactile stimuli and no movement in the right lower leg are not consistent with a transsacral conduction block.

Which is the most common cause of anaphylaxis? a. Latex b. Medications c. Fibrin sealants d. Plastic

b Because medications are the most common cause of anaphylaxis, intraoperative nurses must be aware of the type and method of anesthesia used as well as the specific agents. Latex, fibrin sealants, and plastic are not the most common causes of anaphylaxis.

Corticosteroids have which effect on wound healing? a. Reduce blood supply b. Mask the presence of infection c. Cause hemorrhage d. May cause protein-calorie depletion

b Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. Edema may reduce blood supply. Corticosteroids do not cause hemorrhage or protein-calorie depletion.

A patient is scheduled for a reduction mammoplasty. What classification of surgery does the nurse understand that this is? a. Urgent b. Optional c. Required d. Reconstructive

b Cosmetic surgery, including reduction mammoplasties, is optional, as the decision to have the surgery rests with the patient.

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing? a. Hyperthermia b. Atelectasis c. Wound infection d. Uncontrolled pain

c Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.

What is an example of an intravenous anesthetic that is a hypnotic and produces excellent amnesia? a. Etomidate b. Ketamine c. Midazolam d. Propofol

c Midazolam (Versed), an excellent hypnotic, is often used as an adjunct to induction.

What complication is the nurse aware of that is associated with deep venous thrombosis? a. Pulmonary embolism b. Immobility because of calf pain c. Marked tenderness over the anteromedial surface of the thigh d. Swelling of the entire leg owing to edema

a Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010).

Which clinical manifestation is often the earliest sign of malignant hyperthermia? a. Tachycardia (heart rate >150 beats per minute) b. Hypotension c. Elevated temperature d. Oliguria

a Tachycardia is often the earliest sign of malignant hyperthermia. Hypotension is a later sign of malignant hyperthermia. The rise in temperature is actually a late sign that develops quickly. Scant urinary output is a later sign of malignant hyperthermia.

A client who had a colonoscopy is recovering from the effects of sedation. Which nursing interventions would the nurse use to care for this client? Select all that apply. a. Position the client in a semi-Fowler's position. b. Encourage the client to take deep breaths. c. Allow the client to drive home alone. d. Instruct the client to ambulate. e. Monitor the client for a return to presedation consciousness.

a, b, e Clients who are recovering from the effects of sedative medications are at risk for ineffective breathing patterns and injury until the full effects of the medication wear off. Nursing interventions during this time include keeping the client safe and free of injury and maintaining effective breathing patterns. Clients should not ambulate or drive during this period.

The client vomits during the surgical procedure. The best action by the nurse is: a. Increase the IV infusion rate to compensate for lost fluids. b. Suction the client to remove saliva and gastric secretions. c. Lower the head of the operating table to promote circulation to the brain. d. Administer an anti-emetic to alleviate nausea.

b The nurse immediately suctions the client to prevent aspiration of vomitus.

Informed consent from the surgical client is essential in all of the following categories of surgery except: a. Elective surgery b. Emergent surgery c. Required surgery d. Urgent surgery

b In an emergency, a physician may perform surgery without a client's informed consent in order to save the client's life.

A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take? a. Discuss the risk for infection caused by wearing the ring. b. Allow the client to wear the ring and cover it with tape. c. Notify the surgeon to cancel surgery. d. Remove the ring once the client is sedated.

b Most facilities will allow a client to wear a wedding band during a surgical procedure. The nurse must secure the ring with tape. Although it is appropriate to discuss the risk for infection, the client has already refused to remove the ring. The surgery should not be canceled and the ring should not be removed without permission.

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? a. Re-attempt to auscultate bowel sounds. b. Prepare to insert a nasogastric tube. c. Call the health care provider. d. Prepare to administer a stool softener.

c The client presents with a possible paralytic ileus, a serious condition where the intestines are paralyzed and peristalsis is absent. This may occur as a result of surgery, especially abdominal surgery. If the nurse is unable to auscultate bowel sounds and the client has pain and a rigid abdomen, the nurse will suspect an ileus and immediately call the health care provider. Re-attempting auscultation may occur, but only after the health care provider has been notified. The health care provider may order the placement of an NG tube, however, the nurse cannot do this without the provider's order. Administering a stool softener will not help the client and may make the condition worse.

The home health nurse is caring for a postoperative client who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the client's postoperative day 2. During the visit, the nurse will assess for wound infection. For most clients, what is the earliest postoperative day that a wound infection becomes evident? a. Day 9 b. Day 7 c. Day 5 d. Day 3

c Wound infection may not be evident until at least postoperative day 5.

A client is preparing for a surgical procedure is taking corticosteroids for Crohn's disease. What is most important for the nurse to monitor during the operative experience with the client? a. obstruction b. surgical site infection c. hypoglycemia d. adrenal insufficiency

d Clients who have received corticosteroids are at risk for adrenal insufficiency. They are not at greater risk for obstruction, infection, or hypoglycemia during the operative experience.

Which nursing diagnosis should the nurse plan to address first in the client upon arrival in the intraoperative setting? a. Risk for perioperative positioning injury related to positioning in the OR b. Risk of latex allergy response related to possible exposure in the OR environment c. Disturbed sensory perception related to the effects of general anesthesia d. Anxiety related to ineffective coping with surgical concerns

d Putting the client at ease helps the client prepare for the surgical experience by promoting psychological comfort of the client and giving the client a sense of control.

The nurse is caring for a 78-year-old female client who is scheduled for surgery to remove her brain tumor. The client is very apprehensive and keeps asking when she will get her preoperative medicine. The medicine is ordered to be given "on call to OR." When would be the best time to give this medication? a. As soon as possible, in order to alleviate the client's anxiety b. As the client is transferred to the OR bed c. When the porter arrives on the floor to take the client to surgery d. After being notified by the OR and before other preoperative preparations

d The nurse can have the medication ready to administer as soon as a call is received from the OR staff. It usually takes 15 to 20 minutes to prepare the client for the OR. If the nurse gives the medication before attending to the other details of preoperative preparation, the client will have at least partial benefit from the preoperative medication and will have a smoother anesthetic and operative course.

The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client? a. Heart rate and rhythm b. Skin integrity c. Core body temperature d. Airway patency

d The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).

The nurse is doing preoperative client education with a 61-year-old male client who has a 40 pack-year history of cigarette smoking. The client will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this client? a. Reduce smoking by 50% to prevent the development of pneumonia. b. Stop smoking at least 4 months before the scheduled surgery to enhance pulmonary function and decrease infection. c. Aim to quit smoking in the postoperative period to reduce the chance of surgical complications d. Stop smoking at least a month before the scheduled surgery to enhance pulmonary function and decrease infection.

d The reduction of smoking will enhance pulmonary function; in the preoperative period, clients who smoke should be urged to stop 30 days before surgery.

A 21-year-old client is positioned on the OR bed prior to knee surgery to correct a sports-related injury. The anesthesiologist administers the appropriate anesthetic. The OR nurse should anticipate which of the following events as the team's next step in the care of this client? a. Grounding b. Making the first incision c. Giving blood d. Intubating

d When the client arrives in the OR, the anesthesiologist or anesthetist reassesses the client's physical condition immediately prior to initiating anesthesia. The anesthetic is given, and the client's airway is maintained through an intranasal intubation, oral intubation, or a laryngeal mask airway. Grounding or blood administration does not normally follow anesthetic administration immediately. An incision would not be made prior to intubation.

There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements. a. Stage I: beginning anesthesia b. Stage II: excitement c. Stage III: surgical anesthesia d. Stage IV: medullary depression

b The excitement stage, characterized variously by struggling, shouting, talking, singing, laughing, or crying, is often avoided if the anesthetic is administered smoothly and quickly. Because of the possibility of uncontrolled movements, the patient should not be touched except for purposes of restraint.

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: a. Assisting with incentive spirometry every 6 hours b. Ambulating the client as soon as possible c. Positioning the client in a supine position d. Assessing breath sounds at least every 2 hours

b The nurse should assist the client to ambulate as soon as the client is able. Incentive spirometry should be performed every 1 to 2 hours. The client should be positioned from side to side and in semi-Fowler's position. While assessing breath sounds is essential, it does not help to prevent pneumonia.

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? a. Elevating the head of the bed b. Reinforcing dressings or applying pressure if bleeding is frank c. Rubbing the back d. Encouraging the client to breathe deeply

b The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply and rubbing the back will not help manage and minimize hemorrhage and shock.

The intraoperative nurse advocates for each client who receives care in the surgical setting. How can the nurse best exemplify the principles of client advocacy? a. By encouraging the client to perform deep breathing preoperatively b. By limiting the client's contact with family members preoperatively c. By maintaining the privacy of each client d. By eliciting informed consent from clients

c Patient advocacy in the OR entails maintaining the client's physical and emotional comfort, privacy, rights, and dignity. Deep breathing is not necessary before surgery and obtaining informed consent is the purview of the physician. Family contact should not be limited.

What measurement should the nurse report to the physician in the immediate postoperative period? a. A systolic blood pressure lower than 90 mm Hg b. A temperature reading between 97°F and 98°F c. Respirations between 20 and 25 breaths/min d. A hemoglobin of 13.6

a A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal.

What is the highest priority nursing intervention for a client in the immediate postoperative phase? a. Maintaining a patent airway b. Monitoring vital signs at least every 15 minutes c. Assessing urinary output every hour d. Assessing for hemorrhage

a All interventions listed are correct. The highest priority intervention, however, is maintaining a patent airway. Without a patent airway, the other interventions—monitoring vital signs, assessing urinary output, and assessing for hemorrhage—become secondary to the possibility of a lack of oxygen.

What is the blood glucose level goal for a diabetic client who will be having a surgical procedure? a. 80 to 110 mg/dL b. 150 to 240 mg/dL c. 250 to 300 mg/dL d. 300 to 350 mg/dL

a Although the surgical risk in the client with controlled diabetes is no greater than in the client without diabetes, strict glycemic control (80 to 110 mg/dL) leads to better outcomes. Frequent monitoring of blood glucose levels is important before, during, and after surgery.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: a. auscultate bowel sounds. b. palpate the abdomen. c. change the client's position. d. insert a rectal tube.

a If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.

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. a. The client will leave the hospital sooner than in the past. b. Need for teaching is increased. c. The client must be prepared to take on more self-care than he or she may have done in the past. d. Discharge planning is minimal because the stay is so short. e. Home care and other referrals are unlikely because same-day surgeries are usually minor.

a, b, c 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.

The nurse assesses an older adult patient who complains of dimmed vision. What does this alert the nurse to plan for? a. A safe environment b. Restrictions of the patient's unassisted mobility activities c. Probable cataract extractions d. Referral to an ophthalmologist

a Sensory limitations, such as impaired vision or hearing and reduced tactile sensitivity, frequently interact with the postoperative environment, so falls are more likely to occur (Meiner, 2011). Maintaining a safe environment for older adults requires alertness and planning.

What is the priority action by the scrub nurse when the surgeon begins to close the surgical wound? a. Count the sponges. b. Label the tissue specimen. c. Prepare the necessary sutures. d. Hand equipment to the surgeon as needed.

a Standards call for the scrub nurse and the circulating nurse to count the sponges at the beginning of the surgery, when the surgical wound is being sutured, and when the skin is being sutured. Tissue specimens should be labeled when obtained. The sutures should be ready before the surgeon needs them. Although the scrub nurse does hand equipment to the surgeon, the sponge count is a higher priority action.

As an OR nurse, you are required to assess the client continuously and protect them from developing potential complications, as much as humanly possible. To protect a client from malignant hyperthermia, you need to know the symptoms—what are the symptoms of malignant hyperthermia? a. All of the options are correct b. Cyanosis c. Hypotension d. Decreased urine output

a Symptoms of malignant hyperthermia include tachycardia, tachypnea, cyanosis, fever, muscle rigidity, diaphoresis, mottled skin, hypotension, irregular heart rate, decreased urine output, and cardiac arrest.

A client is administered succinylcholine and propofol for induction of anesthesia. One hour after administration, the client demonstrates muscle rigidity with a heart rate of 180. What should the nurse do first? a. Notify the surgical team. b. Document the assessment findings. c. Administer dantrolene sodium. d. Obtain cooling blankets.

a Tachycardia and muscle rigidity are often the earliest signs of malignant hyperthermia. Early recognition of malignant hyperthermia increases survival. The nurse would document the findings, and administer dantrolene sodium, obtain cooling blankets as part of the treatment for malignant hyperthermia, but the nurse would need to ensure the surgical team is aware of the findings first.

During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take? a. Assist the client to the bathroom. b. Offer the client a bedpan or urinal. c. Wait until the client gets to the operating room and is catheterized. d. Have the client go to the bathroom.

b If a preanesthetic medication is given, the client is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness. If a client needs to void following administration of a sedative, the nurse should offer the client a urinal. The client should not get out of bed because of the potential for lightheadedness.

An intraoperative nurse is applying interventions that will address surgical clients' risks for perioperative positioning injury. What factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply. a. Absence of reflexes b. Diminished ability to communicate c. Loss of pain sensation d. Nausea resulting from anesthetic e. Reduced blood pressure

a, b, c Loss of pain sense, reflexes, and ability to communicate subjects the intraoperative client to possible injury. Nausea and low blood pressure are not central factors that contribute to this risk, though they are adverse outcomes.

The intraoperative nurse is implementing a care plan that addresses the surgical client's risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication? a. Impaired skin integrity b. Hypoxia c. Malignant hyperthermia d. Hypothermia

b If the client aspirates vomitus, an asthma-like attack with severe bronchial spasms and wheezing is triggered. Pneumonitis and pulmonary edema can subsequently develop, leading to extreme hypoxia. Vomiting can cause choking, but the question asks about aspirated vomitus. Malignant hyperthermia is an adverse reaction to anesthesia. Aspirated vomitus does not cause hypothermia. Vomiting does not result in impaired skin integrity.

A written informed consent is necessary for which of the following? Select all that apply. a. Invasive procedures b. Procedures requiring sedation c. Procedures requiring radiation d. IV insertion

a, b, c Informed consent is necessary in the following circumstances: invasive procedures, procedures requiring sedation and/or anesthesia, a nonsurgical procedure that carries more than slight risk to the patient, and procedures involving radiation. No written consent is needed for IV insertion.

While meeting with the anesthesiologist prior to surgery, what statement from the client would indicate that the anesthesiologist needs to clarify points? a. "I'll receive procedural sedation." b. "I'll receive general anesthesia." c. "I'll receive regional anesthesia." d. "I'll receive local anesthesia."

a Surgical procedures are performed with general, regional, or local anesthesia.

Which of the following is a classic sign of hypovolemic shock? a. Pallor b. Dilute urine c. High blood pressure d. Bradypnea

a The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing.

A 79-year-old man is scheduled for surgical repair of an inguinal hernia. In light of this patient's age, the nurse will prioritize nursing interventions aimed at preventing: a. Overstimulation b. Skin breakdown c. Hyperglycemia or hypoglycemia d. Early ambulation

b Skin breakdown is an important nursing consideration when providing care for all surgical patients. However, older adults face an increased risk of this problem due to age-related changes to the integumentary system. Age alone does not create a heightened risk of hyperglycemia or hypoglycemia. Overstimulation should generally be avoided but this is not directly related to age. Early ambulation is beneficial for patients of all ages.

The nurse admits a client to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. Of what is the client showing signs? a. Hypothermia b. Hypovolemic shock c. Neurogenic shock d. Malignant hyperthermia

b The client is exhibiting symptoms of hypovolemic shock; therefore, the nurse should notify the client's physician and anticipate orders for fluid and/or blood product replacement. Neurogenic shock does not normally result in tachycardia and malignant hyperthermia would not present at this stage in the operative experience. Hypothermia does not cause hypotension and tachycardia.

The client received ketamine during a surgical procedure. What intervention by the nurse will assist with an optimal recovery period? a. Make sure that the client is stimulated frequently. b. Place the client in a darkened, quiet part of the recovery area. c. The client does not require a recovery period and may go back to the hospital room. d. Speak to the client in a loud, clear voice.

b Clients receiving ketamine (Ketalar) need a darkened, quiet room for recovery.

A client will be undergoing a total hip arthroplasty later in the day and it is anticipated that the client may require blood transfusion during surgery. How can the nurse best ensure the client's safety if a blood transfusion is required? a. Prime IV tubing with a unit of blood and keep it on hold. b. Check that the client's electrolyte levels have been assessed preoperatively. c. Ensure that the client has had a current cross-match. d. Keep the blood on standby and warmed to body temperature.

c Few clients undergoing an elective procedure require blood transfusion, but those undergoing high-risk procedures may require an intraoperative transfusion. The circulating nurse anticipates this need, checks that blood has been cross-matched and held in reserve, and is prepared to administer blood. Storing the blood at body temperature or in IV tubing would result in spoilage and potential infection.

The nurse cares for a client who is three hours post op abdominal hysterectomy and begins to develop hiccups. What nursing assessment will the nurse monitor more closely with the client's new symptoms? a. Temperature b. Respiratory rate c. Wound approximation d. Wound drainage

c Hiccups are produced by intermittent spasms of the diaphragm, secondary to irritation of the phrenic nerve. Hiccups may be caused by surgery and are usually not problematic. However, persistent or forceful spasms may lead to wound dehiscence, or wound separation at the surgical incision. The other answer choices are things the nurse will monitor; however, the approximation of wound edges will be monitored more closely.

What complication in the immediate postoperative period should the nurse understand requires early intervention to prevent? a. Laryngospasm b. Hyperventilation c. Hypoxemia and hypercapnia d. Pulmonary edema and embolism

c The primary objective in the immediate postoperative period is to maintain ventilation and thus prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Both can occur if the airway is obstructed and ventilation is reduced (hypoventilation). Besides administering supplemental oxygen (as prescribed), the nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds.

The physician schedules an elective surgical procedure for a patient who smokes cigarettes. When should the nurse recommend that the patient cease smoking before the surgical procedure to minimize risks associate with cigarette smoking? a. 1 to 2 months b. 3 to 4 months c. 2 weeks d. 3 weeks

a Patients who smoke are urged to stop 4 to 8 weeks before surgery to significantly reduce pulmonary and wound healing complications.

The nurse is caring for a client on the medical-surgical unit postoperative day 5. During each client assessment, the nurse evaluates the client for infection. Which of the following would be most indicative of infection? a. Presence of an indwelling urinary catheter b. Rectal temperature of 99.5ºF (37.5ºC) c. Red, warm, tender incision d. White blood cell (WBC) count of 8,000/mL

c Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a client to infection, but by itself does not indicate infection. An oral temperature of 99.5ºF may not signal infection in a postoperative client because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/mL.

The intraoperative nurse is transferring a client from the OR to the PACU after replacement of the right knee. The client is an older adult. The nurse should prioritize which of the following actions? a. Keeping the client sterile b. Keeping the client restrained c. Keeping the client warm d. Keeping the client hydrated

c Special attention is given to keeping the client warm because elderly clients are more susceptible to hypothermia. It is all important for the nurse to pay attention to hydration, but hypovolemia does not occur as quickly as hypothermia. The client is never sterile and restraints are very rarely necessary.

During a client's preoperative assessment, which of the following would the nurse identify as risk factors for intra- or postoperative complications? Select all that apply. a. Impaired nutritional status b. Advanced age c. Family support d. Physical deconditioning e. Solid financial resources f. Current tobacco use

a, b, d, f General risk factors are related to age; nutritional status; use of alcohol, tobacco, and other substances; and physical condition.

A client is undergoing a surgical procedure to repair an ulcerated colon. Which client education topics will be discussed preoperatively? Select all that apply. a. postoperative pain control b. cough and deep-breathing exercises c. the client's spouse's thoughts about the upcoming surgery d. the surgeon's fee and other hospital charges e. intravenous fluids and other lines and tubes

a, b, e 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.

The physician requests lidocaine 2% with epinephrine for use in local infiltration anesthesia. What does the nurse understand is the purpose of adding epinephrine to the lidocaine? (Select all that apply.) a. The epinephrine causes vasoconstriction. b. The epinephrine prevents rapid absorption of the anesthetic drug. c. The epinephrine prolongs the local action of the anesthetic agent. d. The lidocaine will not anesthetize the area locally without the epinephrine. e. The epinephrine will prevent the patient from having an allergic reaction to the lidocaine.

a, c, e Local anesthesia is often administered in combination with epinephrine. Epinephrine constricts blood vessels, which prevents rapid absorption of the anesthetic agent and thus prolongs its local action and prevents seizures.

The nurse is performing a preoperative assessment on a client going to surgery. The client informs the nurse that he drinks approximately two bottles of wine each day and has for the last several years. What postoperative difficulties should the nurse anticipate for this client? a. Nonadherence to prescribed treatment after surgery following surgery b. Increased risk for postoperative complications c. Alcohol withdrawal syndrome upon administration of general anesthesia d. Increased risk for allergic reactions

b Alcohol use increases the risk of complications. Withdrawal does not occur immediately upon administration of anesthesia. Alcohol does not increase the risk of allergies and is not necessarily a risk factor for nonadherence.

What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site? a. Ask the surgeon whether the marked surgical site is correct. b. Obtain the attention of all members of the surgical team. c. Discuss the surgical procedure and surgical site with the client. d. Review complications and allergies with the anesthesiologist.

b The second verification of the surgical procedure and surgical site should be done at one time and include all members of the surgical team. The marked surgical site is confirmed with all members of the surgical team, not just the surgeon or client. Complications, allergies, and anticipated problems are also discussed among the entire surgical team.

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? a. Pleurisy b. Pneumonia c. Hypoxemia d. Pulmonary edema

b Older clients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Delirium, pneumonia, decline in functional ability, exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and falls are all threats to recovery in the older adult.

The nurse is caring for a preoperative older adult client who is exceptionally anxious prior to surgery. What should the nurse increase with this client to decrease her anxiety? a. Analgesia b. Therapeutic touch c. Preoperative medication d. Sleeping medication the night before surgery

b Older clients report higher levels of preoperative anxiety; therefore, the nurse should be prepared to spend additional time, increase the amount of therapeutic touch utilized, and encourage family members to be present to decrease anxiety. For most clients, nonpharmacologic interventions should be attempted before administering medications.

A nurse is working in the postanesthesia unit (PACU). What evidence indicates that a client is ready for discharge from the PACU? Select all that apply. a. The client has been extubated, but still has an oropharyngeal airway in. b. The client is arousable, but falls back to sleep rapidly. c. The client has a blood pressure within 10 mm Hg of the baseline. d. The client has sonorous respirations and occasionally requires chin lift. e. The client rates pain a 9 out of 10 on a 0-10 scale after receiving morphine sulfate.

b, c A client remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function (no artificial airways or need of a chin tilt lift), and adequate oxygen saturation level compared with baseline. Pain levels are not considered when transferring clients out of PACU.

The dressing surrounding a mastectomy client's Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion? a. Describe the appearance of the dressing in the electronic health record. b. Photograph the client's abdomen for later comparison using a smartphone. c. Trace the outline of the drainage on the dressing for future comparison. d. Remove and weigh the dressing, reapply it, and then repeat in 8 hours.

c Spots of drainage on a dressing are outlined with a pen, and the date and time of the outline are recorded on the dressing so that increased drainage can be easily seen. A dressing is never removed and then reapplied. Photographs normally require informed consent, so they would not be used for this purpose. Documentation is necessary, but does not confirm or rule out an increase in drainage.

Which stage of anesthesia is referred to as surgical anesthesia? a. II b. I c. III d. IV

c Stage III may be maintained for hours with proper administration of the anesthetic. Stage I is beginning anesthesia, where the client breathes in the anesthetic mixture and experiences warmth, dizziness, and a feeling of detachment. Stage II is the excitement stage, which may be characterized by struggling, singing, laughing, or crying. Stage IV is a state of medullary depression and is reached when too much anesthesia has been administered.

Maintaining an aseptic environment in the OR is essential to client safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field? a. 2 feet (60 cm) b. 18 inches (45 cm) c. 1 foot (30 cm) d. 6 inches (15 cm)

c Sterile areas must be kept in view during movement around the area. At least a 1-foot distance from the sterile field must be maintained to prevent inadvertent contamination.

A client is scheduled for a bowel resection in the morning and the client's orders include a cleansing enema tonight. The client wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect? a. Preventing aspiration of gastric contents b. Preventing the accumulation of abdominal gas postoperatively c. Preventing potential contamination of the peritoneum d. Facilitating better absorption of medications

c The administration of a cleansing enema will allow for satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the peritoneum by feces. It will have no effect on aspiration of gastric contents or the absorption of medications. The client should expect to develop gas in the postoperative period.

The perioperative nurse is constantly assessing the surgical client for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the client is developing malignant hyperthermia? a. Increased temperature b. Oliguria c. Tachycardia d. Hypotension

c The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. Tachycardia (heart rate greater than 150 beats per minute) is often the earliest sign. Oliguria, hypotension, and increased temperature are later signs of malignant hyperthermia.

An older adult client is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding area to meet the client and quickly realizes that the client is profoundly anxious. What is the most appropriate intervention for the nurse to apply? a. Reassure the client that modern surgery is free of significant risks. b. Describe the surgery to the client in as much detail as possible. c. Clearly explain any information that the client seeks. d. Remind the client that the anesthetic will render her unconscious.

c The nurse can alleviate anxiety by supplying information as the client requests it. The nurse should not assume that every client wants as much detail as possible and false reassurance must be avoided. Reminding the client that she will be unconscious is unlikely to reduce anxiety.

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding? a. Hernia b. Dehiscence c. Erythema d. Evisceration

d 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's aide notifies the nurse that a client has decreased oxygen saturation levels. The nurse assesses the client and finds that he is tachypneic, has crackles on auscultation, and his sputum is frothy and pink. The nurse should suspect what complication? a. Pulmonary embolism b. Atelectasis c. Laryngospasm d. Flash pulmonary edema

d Flash pulmonary edema 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. Laryngospasm does not cause crackles or frothy, pink sputum. The client with atelectasis has decreased breath sounds over the affected area; the scenario does not indicate this. A pulmonary embolism does not cause this symptomatology.

The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system? a. Cardiovascular system b. Endocrine system c. Gastrointestinal system d. Genitourinary system

a Depolarizing muscle relaxants can cause cardiac dysrhythmias.

The nurse is conducting a preoperative assessment on a client scheduled for gallbladder surgery. The client reports 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 best action by the nurse? a. Notify the surgeon to possibly delay the surgery. b. Notify the primary physician about the assessment findings. c. Document the findings and continue moving the client through the preoperative phase. d. Wait 1 hour and complete the assessment again.

a 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 provide care based on 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 then repeating the assessment are not appropriate.

Which would be considered to require an urgent surgical procedure? a. Loose facial skin b. Cataract c. Acute gallbladder infection d. Severe bleeding

c An acute gallbladder infection is considered to require an urgent surgical procedure. Cosmetic surgery and cataract surgery are not considered urgent surgical procedures. Severe bleeding could be considered an emergent surgical procedure.

A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate? a. Continue with frequent client assessments. b. Remove the oral airway. c. Notify the physician of impaired neurological status. d. Obtain vital signs, including pulse oximetry, every 5 minutes.

a An immediate postoperative client may be transferred to the PACU with a hard, plastic oral airway in place. The airway should not be removed until the client shows signs of gagging or choking. The neurological status is appropriate for a client who received general anesthesia, and the nurse should continue with frequent client assessments. . None of the information provided requires the client to have vital signs measured more frequently than the standard 15 minutes.

A client develops a hemorrhage one hour post surgery. The nurse knows this is most likely an intermediary hemorrhage from a vein because it occurred: a. within the first few hours, and has darkly colored blood that flows quickly. b. during surgery, and has bright red blood that flows freely. c. at a suture site, and the blood appears intermittently in spurts. d. a few hours after surgery, and the bright red blood appears with each heartbeat.

a An intermediary hemorrhage appears within the first few hours following surgery. Darkly colored blood that flows out quickly indicates a venous hemorrhage. A hemorrhage that occurs during surgery is classified as a primary hemorrhage. A bright red color indicates that a hemorrhage's source is an artery. Secondary hemorrhages occur when sutures slip or drainage tubes dislodge insecure vessels.

What medication should the nurse prepare to administer in the event the client has malignant hyperthermia? a. Dantrolene sodium b. Fentanyl citrate c. Naloxone d. Thiopental sodium

a 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.

Preoperative medications are administered for very specific reasons with very specific outcomes expected. When an anticholinergic medication is administered, what is its expected effect? a. decreased respiratory secretions b. reduced preoperative anxiety c. decreased gastric acidity and volume d. enhanced proper sedation

a Anticholinergics decrease respiratory tract secretions, dry mucous membranes, and interrupt vagal stimulation. Both sedatives and opioids decrease anxiety. Decreased gastric acidity and volume are the expected effect of histamine 2-receptor antagonists. Enhanced proper sedation is the expected effect of sedatives.

The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk? a. Atelectasis b. Anemia c. Dehydration d. Peripheral edema

a Atelectasis occurs when the postoperative client fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia occurs rarely and usually in situations where the client loses a significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the client is most at risk for atelectasis

A nurse is preparing a client for surgery. The assessment is complete, all consents have been signed, and the client's family is present. Before administering preoperative medications, what is the nurse's first step? a. Check the client's ID bracelet. b. Ask about the client's drug allergies. c. Measure the client's vital signs. d. Ask the client to void.

a Before administering any medication, including preoperative medications, always confirm administration of the meds to the right client.

In preparing the client for transfer to the operating room, which of the following actions by the nurse is inappropriate? a. Allow the client to wear dentures. b. Remove all jewelry. c. Have the client void. d. Have client wear hospital gown.

a Dentures, jewelry, glasses, and prosthetic devices are removed prior to surgery.

An OR nurse will be participating in the intraoperative phase of a client's kidney transplant. What action will the nurse prioritize in this aspect of nursing care? a. Monitoring the client's physiologic status b. Providing emotional support to family c. Maintaining the client's cognitive status d. Maintaining a clean environment

a During the intraoperative phase, the nurse is responsible for physiologic monitoring. The intraoperative nurse cannot support the family at this time and the nurse is not responsible for maintaining the client's cognitive status. The intraoperative nurse maintains an aseptic, not clean, environment.

A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which client most closely during the intraoperative period because of the increased risk for hypothermia? a. A 74-year-old woman with a low body mass index b. A 17-year-old boy with traumatic injuries c. A 45-year-old woman having an abdominal hysterectomy d. A 13-year-old girl undergoing craniofacial surgery

a Elderly clients are at greatest risk during surgical procedures because they have an impaired ability to increase their metabolic rate and impaired thermoregulatory mechanisms, which increase susceptibility to hypothermia. The other clients are likely at a lower risk.

A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority? a. Applying a sterile, moist dressing b. Monitoring vital signs c. Inserting a nasogastric (NG) tube d. Putting the client on nothing-by-mouth (NPO) status

a Evisceration involves separation of all layers of the abdominal wall, resulting in protrusion of abdominal contents. The nurse's first priority should be to protect the client's abdominal contents. She should apply warm, sterile saline dressings over the protruding viscera. Next, the nurse should institute NPO status because the client will ultimately need surgery. The client is at risk for shock, so the nurse should monitor vital signs frequently after applying the sterile, moist dressing. The nurse doesn't need to make inserting an NG tube an immediate priority, especially because the physician may not order one.

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? a. Remove the item from the sterile field. b. Mark the client's chart for future review of infections. c. Remove the entire sterile field from use. d. Ask another nurse to review the technique used.

a 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.

The nurse is preparing an elderly client for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the client? a. Hypothermia b. Pulmonary edema c. Cerebral ischemia d. Arthritis

a Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open body wounds or cavities, decreased muscle activity, advanced age, or the pharmaceutical agents used (e.g., vasodilators, phenothiazines, general anesthetics). Older adults are particularly susceptible to this. The anesthetist monitors for pulmonary edema and cerebral ischemia. Arthritis is not an adverse effect of surgical anesthesia.

A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse a. continuously monitors the sedated client. b. performs a complete assessment of the client. c. obtains a surgical consent from the client's mother. d. assesses how well the client is recovering from anesthesia.

a Intraoperative care includes the entire surgical procedure. During sedation, the nurse continuously evaluates the client. Assessment of heart rate, respiratory rate, BP, oxygen saturation, and level of consciousness occurs during all phases of perioperative care. Obtaining consent would occur during the preoperative phase of perioperative care. During the postoperative phase the nurse would assess how the client is recovering from anesthesia.

A medical student scheduled to observe surgery enters the restricted surgical zone wearing jeans, a t-shirt, and tennis shoes. What is the best action by the nurse? a. Immediately escort the medical student out of the area. b. No action is needed. c. Provide the medical student a cap and mask. d. Educate the medical student on required attire for each surgical zone.

a It would be best to remove the student from the surgical zone before educating on the required attire for each surgical zone. Because the student will be observing a surgery, he or she will need to dress appropriately in each zone to decrease the risk of introducing pathogens. The student should not enter the semi-restricted or restricted zone without appropriate attire. Providing a cap and mask does not address the need to change out of the street clothes to observe the surgery.

The OR nurse acts in the circulating role during a client's scheduled cesarean section. For what task is this nurse solely responsible? a. Performing documentation b. Estimating the client's blood loss c. Setting up the sterile tables d. Keeping track of drains and sponges

a Main responsibilities of the circulating nurse include verifying consent; coordinating the team; and ensuring cleanliness, proper temperature and humidity, lighting, safe function of equipment, and the availability of supplies and materials. The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel as well as implementing fire safety precautions. The circulating nurse also monitors the client and documents specific activities throughout the operation to ensure the client's safety and well-being. Estimating the client's blood loss is the surgeon's responsibility; setting up the sterile tables is the responsibility of the first scrub; and keeping track of the drains and sponges is the joint responsibility of the circulating nurse and the scrub nurse.

The OR nurse acts in the circulating role during a client's scheduled cesarean section. For what task is this nurse solely responsible? a. Performing documentation b. Estimating the client's blood loss c. Setting up the sterile tables d. Keeping track of drains and sponges

a Main responsibilities of the circulating nurse include verifying consent; coordinating the team; and ensuring cleanliness, proper temperature and humidity, lighting, safe function of equipment, and the availability of supplies and materials. The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel as well as implementing fire safety precautions. The circulating nurse also monitors the client and documents specific activities throughout the operation to ensure the client's safety and well-being. Estimating the client's blood loss is the surgeon's responsibility; setting up the sterile tables is the responsibility of the first scrub; and keeping track of the drains and sponges is the joint responsibility of the circulating nurse and the scrub nurse.

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication? a. malignant hyperthermia b. hypothermia c. infection d. fluid volume excess

a Malignant hyperthermia is an inherited disorder that 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.

The nurse is performing a preadmission assessment of a client scheduled for a bilateral mastectomy. The nurse should be aware of what purpose of the preadmission assessment? a. Verifies completion of preoperative diagnostic testing b. Discusses and reviews client's financial status c. Determines the client's suitability as a surgical candidate d. Informs the client of need for postoperative transportation

a Purposes of preadmission testing (PAT) include verifying completion of preoperative diagnostic testing. The nurse's role in PAT does not normally involve financial considerations or addressing transportation. The physician determines the client's suitability for surgery.

In advance of a client's scheduled appendectomy, the nurse spends significant time explaining to the client what will happen, both before the procedure and after the procedure is complete. The primary reason the nurse puts so much effort into preoperative teaching is to: a. increase the likelihood of a successful recovery. b. minimize the time that will need to be spent on postoperative questions. c. decrease the client's participation and allow the family to take on the caregiver role. d. absolve the hospital of legal responsibility should complications arise.

a 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. Absolving the hospital of legal responsibility would not be a primary nursing goal.

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? a. The client can be discharged from the PACU. b. The client must remain in the PACU. c. The client should be transferred to an intensive care area. d. The client must be put on immediate life support.

a The Aldrete score is usually 8 to 10 before discharge from the PACU. Clients with a score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area, depending on their preoperative baseline score.

The perioperative nurse has completed the presurgical assessment of an 82-year-old female client who is scheduled for a left total knee replacement. When planning this client's care, the nurse should address the consequences of the client's aging cardiovascular system. These include an increased risk of which of the following? a. Hypervolemia b. Hyponatremia c. Hyperkalemia d. Hyperphosphatemia

a The aging heart and blood vessels have decreased ability to respond to stress. Reduced cardiac output and limited cardiac reserve make the elderly client vulnerable to changes in circulating volume and blood oxygen levels. There is not an increased risk for hypopnea, hyperkalemia, or hyperphosphatemia because of an aging cardiovascular system.

Which statement by the client indicates further teaching about epidural anesthesia is necessary? a. "I will become unconscious." b. "I will lose the ability to move my legs." c. "I will be able to hear the surgeon during the surgery." d. "A needle will deliver the anesthetic into the area around my spinal cord."

a The client receiving epidural anesthesia will remain conscious during the procedure.

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition? a. The client is displaying early signs of shock. b. The client is showing signs of a medication reaction. c. The client is displaying late signs of shock. d. The client is showing signs of an anesthesia reaction.

a The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated. Medication or anesthesia reactions may cause client symptoms similar to these; however, these causes are not as likely as early shock.

A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? a. Report the infection to an immediate supervisor. b. Ensure the infection is covered with a dressing. c. Return to work after taking antibiotics for 24 hours. d. Request a role change to circulating nurse.

a 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.

A patient with renal failure is scheduled for a surgical procedure. When would surgery be contraindicated for this patient due to laboratory results? a. A blood urea nitrogen level of 42 mg/dL b. A creatine kinase level of 120 U/L c. A serum creatinine level of 0.9 mg/dL d. A urine creatinine level of 1.2 mg/dL

a The kidneys are involved in excreting anesthetic medications and their metabolites; therefore, surgery is contraindicated if a patient has acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems (see Chapter 54). A blood urea nitrogen level of 42 mg/dL (significantly elevated) is an indicator of renal failure. The other levels are normal.

The nurse is caring for a patient with liver disease who had a surgical procedure. When should the nurse alert the physician? a. When the patient's blood ammonia concentration reaches 180 mg/dL b. When a lactate dehydrogenase concentration is 300 units c. When a serum albumin concentration is 5.0 g/dL d. a serum globulin concentration reaches 2.8 g/dL

a The liver is important in the biotransformation of anesthetic compounds. Disorders of the liver may substantially affect how anesthetic agents are metabolized. Acute liver disease is associated with high surgical mortality; preoperative improvement in liver function is a goal. Careful assessment may include various liver function tests (see Chapter 49).

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this client? Select all that apply. a. Establishing an IV line b. Verifying the surgical site with the client c. Taking measures to ensure the client's comfort d. Applying a grounding device to the client e. Preparing the medications to be given in the OR

a, b, c In the holding area, the nurse reviews charts, identifies clients, verifies surgical site and marks site per institutional policy, establishes IV lines, administers medications, if prescribed, and takes measures to ensure each client's comfort. A nurse in the preoperative holding area does not prepare medications to be given by anyone else. A grounding device is applied in the OR.

One of the things a nurse has taught to a client during preoperative teaching is to have nothing by mouth for the specified time before surgery. The client asks the nurse why this is important. What is the most appropriate response for the client? a. "You will need to have food and fluid restricted before surgery so you are not at risk for choking." b. "The restriction of food or fluid will prevent the development of pneumonia related to decreased lung capacity." c. "The presence of food in the stomach interferes with the absorption of anesthetic agents." d. "By withholding food for 8 hours before surgery, you will not develop constipation in the postoperative period."

a The major purpose of withholding food and fluid before surgery is to prevent aspiration. There is no scientific basis for withholding food and the development of pneumonia or interference with absorption of anesthetic agents. Constipation in clients in the postoperative period is related to the anesthesia, not from withholding food or fluid in the hours before surgery.

The nurse is performing the shift assessment of a postsurgical client. The nurse finds the client's mental status, level of consciousness, speech, and orientation are intact and at baseline, but the client appears unusually restless. What should the nurse do next? a. Assess the client's oxygen levels. b. Administer antianxiety medications. c. Page the client's the physician. d. Initiate a social work referral.

a The nurse assesses the client's mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage. Antianxiety medications are not given until the cause of the anxiety is known. The physician is notified only if the reason for the anxiety is serious or if a prescription for medication is needed. A social work consult is inappropriate for addressing restlessness.

The nurse is educating clients who require surgery for various ailments about the perioperative experience. What education provided by the nurse is most appropriate? a. Three phases of surgery and safety measures for each phase b. Intraoperative techniques used to perform the surgery c. Expected pain levels and narcotic medications used to treat the pain d. Risks and benefits of the surgical procedures

a The perioperative period includes the preoperative, intraoperative, and postoperative phases. Specific safety guidelines are followed for all surgical clients. The information provided should be general enough to be informative about surgery and should not focus on individual surgeries, as all the clients 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 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? a. Position the client in the side-lying position. b. Administer an anti-emetic. c. Obtain an emesis basin. d. Ask the client for more clarification.

a The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits. The nurse may also obtain an emesis basin and administered an anti-emetic if one is ordered; however, these will be done after the client is repositioned. There is no need for the nurse to ask the client for more clarification.

A surgical client has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). What must the client require for safe and effective use of PCA? a. A clear understanding of the need to self-dose b. An understanding of how to adjust the medication dosage c. A caregiver who can administer the medication as prescribed d. An expectation of infrequent need for analgesia

a The two requirements for PCA are an understanding of the need to self-dose and the physical ability to self-dose. The client does not adjust the dose and only the client himself or herself should administer a dose. PCAs are normally used for clients who are expected to have moderate to severe pain with a regular need for analgesia.

The OR nurse is participating in the appendectomy of a 20 year-old female client who has a dangerously low body mass index. The nurse recognizes the patient's consequent risk for hypothermia. What action should the nurse implement to prevent the development of hypothermia? a. Ensure that IV fluids are warmed to the client's body temperature. b. Transfuse packed red blood cells to increase oxygen carrying capacity. c. Place warmed bags of normal saline at strategic points around the client's body. d. Monitor the client's blood pressure and heart rate vigilantly.

a Warmed IV fluids can prevent the development of hypothermia. Applying warmed bags of saline around the client is not common practice. The client is not transfused to prevent hypothermia. Blood pressure and heart rate monitoring are important, but do not relate directly to the risk for hypothermia.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? a. First intention b. Second intention c. Third intention d. Fourth intention

a When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing.

The nurse is discharging a client home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the client and her caregiver. What else should the nurse do before discharging the client from the facility? Select all that apply. a. Provide all discharge instructions in writing. b. Provide the nurse's or surgeon's contact information. c. Give prescriptions to the client. d. Irrigate the client's incision and perform a sterile dressing change. e. Administer a bolus dose of an opioid analgesic.

a, b, c Before discharging the client, the nurse provides written instructions, prescriptions and the nurse's or surgeon's telephone number. Administration of an opioid would necessitate further monitoring to ensure safety. A dressing change would not normally be ordered on the day of surgery.

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? a. 2 weeks b. 4 weeks c. 7 to 10 days d. 2 to 3 days

c Aspirin, a common OTC medication that inhibits platelet aggregation, should be prudently discontinued 7 to 10 days before surgery; otherwise, the client may be at increased risk for bleeding.

A 76-year-old client had surgery for an abdominal hernia. The PACU nurse observes that the client is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply. a. Reorient the client. b. Assess for hypoxia. c. Assess urine output. d. Administer opioid pain medication per orders. e. Ambulate the client. f. Apply wrist restraints.

a, b, c The nurse should provide reassurance and reorient the client as needed. Hypoxia and urinary retention may cause acute confusion in the older adults postoperatively, so it would be appropriate for the nurse to assess for hypoxia and urine output. Opioid pain medications may cause further confusion; the physician should be consulted about the type and dosage of the pain medication. Ambulating the client may present safety concerns, especially if the client is bleeding or hypoxic.

The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply.) a. Assisting the patient with leg exercises b. Encouraging early ambulation c. Massaging the legs every 4 hours d. Avoiding placement of pillows or blanket rolls under the patient's knees e. Applying compression stockings only at night

a, b, d The benefits of early ambulation and leg exercises in preventing deep vein thrombosis cannot be overemphasized, and these activities are recommended for all patients, regardless of their risk. It is important to avoid the use of blanket rolls, pillow rolls, or any form of elevation that can constrict vessels under the knees. Compression stockings should be worn all the time, not just at night. Massage would be contraindicated due to the risk of dislodging a clot.

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 is the nurse's best response? Select all that apply. a. "The client can be involved in marking the knee, the site for the surgery." b. "The surgical team performs a 'time-out' prior to surgery to conduct a final verification." c. "The surgeon on the team has never been involved in such a mix-up." d. "The client will be involved in the verification process prior to surgery." e. "Our surgical team would never make that mistake."

a, b, d 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 (2019) 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." Telling the client that the surgeon has not been involved in such a mix-up or would never make that mistake is false reassurance.

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. a. Removal of a tumor b. Skin biopsy c. Mammoplasty d. Removal of a diseased appendix e. Insertion of a gastrostomy tube

a, d A surgical procedure may be diagnostic (e.g., biopsy, exploratory laparotomy), curative (e.g., excision of a tumor or an inflamed appendix), or reparative (e.g., 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 OR will be caring for a client who will receive a transsacral block. For what client would the use of a transsacral block be appropriate for pain control? a. A middle-aged man who is scheduled for a thoracotomy b. An older adult man who will undergo an inguinal hernia repair c. A 50-year-old woman who will be having a reduction mammoplasty d. A child who requires closed reduction of a right humerus fracture

b A transsacral block produces anesthesia for the perineum and lower abdomen. Both a thoracotomy and breast reduction are in the chest region, and a transsacral block would not provide pain control for these procedures. A closed reduction of a right humerus is a procedure on the right arm, and a transsacral block would not provide pain control.

While the surgical client is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the client's weight. How should the nurse best respond? a. Ignore the comment because the patient is unconscious. b. Discourage the colleague from making such comments. c. Report the comment immediately to a supervisor. d. Realize that humor is needed in the workplace.

b Clients, whether conscious or unconscious, should not be subjected to excess noise, inappropriate conversation, or, most of all, derogatory comments. The nurse must act as an advocate on behalf of the client and discourage any such remarks. Reporting to a supervisor, however, is not likely necessary.

A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery? a. Leg exercises increase the client's muscle mass postoperatively. b. Leg exercises improve circulation and prevent venous thrombosis. c. Leg exercises help to prevent pressure sores to the sacrum and heels. d. Leg exercise help increase the client's level of consciousness after surgery.

b Exercise of the extremities includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side) unless contraindicated by type of surgical procedure (e.g., hip replacement). When the client does leg exercises postoperatively, circulation is increased, which helps to prevent blood clots from forming. Leg exercises do not prevent pressure sores to the sacrum, or increase the client's level of consciousness. Leg exercises have the potential to increase strength and mobility, but are unlikely to make a change to muscle mass in the short term.

Fentanyl is categorized as which type of intravenous anesthetic agent? a. Tranquilizer b. Opioid c. Dissociative agent d. Neuroleptanalgesic

b Fentanyl is 75 to 100 times more potent than morphine and has about 25% of the duration of morphine (IV). Examples of tranquilizers include midazolam and diazepam. Ketamine is a dissociative agent.

The nurse is checking the informed consent for an older adult client who requires surgery and who has recently been diagnosed with Alzheimer disease. When obtaining informed consent, who is legally responsible for signing? a. The client's next of kin b. The client's spouse c. The client d. The surgeon

c A client with a new diagnosis of Alzheimer disease would be unlikely to have been declared incompetent; the client would consequently be required to personally provide informed consent.

A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first? a. Explain to the client what is happening and provide support. b. Cover the protruding internal organs with sterile gauze moistened with sterile saline solution. c. Push the protruding organs back into the abdominal cavity. d. Ask the client to drink as much fluid as possible.

b Immediately covering the wound with moistened gauze prevents the organs from drying. The gauze and the saline solution must be sterile to reduce the risk of infection. Although providing support to reduce the client's anxiety is important, it isn't the priority nursing action. The organs shouldn't be pushed back into the abdomen; doing so may tear or damage them. Evisceration requires emergency surgery; therefore, the nurse should put the client on nothing-by-mouth status immediately.

The OR nurse is taking the client into the OR when the client informs the operating nurse that his grandmother spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client? a. The client may be experiencing presurgical anxiety. b. The client may be at risk for malignant hyperthermia. c. The grandmother's surgery has minimal relevance to the client's surgery. d. The client may be at risk for a sudden onset of postsurgical infection.

b Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying clients at risk is imperative because the mortality rate is 50%. The client's anxiety is not relevant, the grandmother's surgery is very relevant, and all clients are at risk for hypothermia.

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? a. Heart rate of 84 beats/minute b. Oxygen saturation (SaO2) of 85% c. Decreased cough and gag reflexes d. Blood-tinged stools

b Normal SaO2 is 95% to 100%. Oxygen saturation of 85% indicates inadequate oxygenation, which may be a consequence of the moderate sedation. Appropriate nursing actions include rousing the client, if necessary, assisting the client with coughing and deep breathing, and evaluating the need for additional oxygen. A heart rate of 84 beats/minute is within normal limits. Colonoscopy doesn't affect cough and gag reflexes, although these reflexes may be slightly decreased from the administration of sedation. These findings don't require immediate intervention. Blood-tinged stools are a normal finding after colonoscopy, especially if the client had a biopsy.

The nurse is providing preoperative teaching to a client scheduled for surgery. The nurse is instructing the client on the use of deep breathing, coughing, and the use of incentive spirometry when the client states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide? a. To prevent chronic obstructive pulmonary disease (COPD) b. To promote optimal lung expansion c. To enhance peripheral circulation d. To prevent pneumothorax

b One goal of preoperative nursing care is to teach the client how to promote optimal lung expansion and consequent blood oxygenation after anesthesia. COPD is not a realistic risk and pneumothorax is also unlikely. Breathing exercises do not primarily affect peripheral circulation.

A client is receiving general anesthesia. The nurse anesthetist starts to administer the anesthesia. The client begins giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings? a. I b. II c. III d. IV

b Stage II is the excitement stage, which is characterized by struggling, shouting, and laughing. Stage I is the beginning of anesthesia, during which the client breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia characterized by unconsciousness and quietness. Surgical anesthesia is achieved by continued administration of anesthetic vapor and gas. Stage IV is medullary depression.

A perioperative nurse is assigned to complete a preoperative assessment on a client who is scheduled for surgery for kidney stones the next day. What category of surgery does this procedure fall into? a. emergent b. urgent c. required d. elective

b Surgery for kidney or urethral stones is considered urgent; it is usually performed the next day. Emergent surgery is performed without delay. Required surgery is performed within a few weeks or months. Elective surgery refers to procedures that the client plans in advance.

The nurse is caring for an unconscious trauma victim who needs emergency surgery. The client is a 55-year-old man with an adult son. He is legally divorced and is planning to be remarried in a few weeks. His parents are at the hospital with the other family members. The physician has explained the need for surgery, the procedure to be done, and the risks to the children, the parents, and the fiancé. Who should be asked to sign the surgery consent form? a. The fiancé b. The son c. The physician, acting as a surrogate d. The client's father

b The client personally signs the consent if of legal age and mentally capable. Permission is otherwise obtained from a surrogate, who most often is a responsible family member (preferably next of kin) or legal guardian. In this instance, the child would be the appropriate person to ask to sign the consent form as he is the closest relative at the hospital. The fiancé is not legally related to him as the marriage has not yet taken place. The father would only be asked to sign the consent if no children were present to sign. The physician would not sign if family members were available.

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate? a. Document the findings and reassess in 24 hours. b. Assess for signs and symptoms of fluid volume deficit. c. Assess for edema. d. Discontinue the nasogastric tube suctioning.

b The client's 24-hour intake is 1800 mL (75 x 24). The client's 24-hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Because the output is significantly higher than the intake, the client is at risk for fluid volume deficit. The nurse should not discontinue the nasogastric suctioning without a physician's order. The findings should be documented and reassessed, but the nurse needs to take more action to prevent complication. Edema is usually associated with fluid volume excess.

The nurse is caring for a client after abdominal surgery in the PACU. The client's blood pressure has increased and the client is restless. The client's oxygen saturation is 97%. What cause for this change in status should the nurse first suspect? a. Hypothermia b. Shock c. Pain d. Hypoxia

c An increase in blood pressure and restlessness are symptoms of pain. The client's oxygen saturation is 97%, so hypothermia, hypoxia, and shock are not likely causes of the client's restlessness.

What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities? a. Assisting the surgeon b. Coordinating the surgical team c. Setting up the sterile tables d. Passing instruments

b The person in the scrub role, either a nurse or a surgical technician, provides sterile instruments and supplies to the surgeon during the procedure by anticipating the surgical needs as the surgical case progresses. The circulating nurse coordinates the care of the patient in the OR. Care provided by the circulating nurse includes planning for and assisting with patient positioning, preparing the patient's skin for surgery, managing surgical specimens, anticipating the needs of the surgical team, and documenting intraoperative events.

A responsibility of the scrub nurse is to: a. provide anesthesia to the client. b. prepare sutures. c. obtain and open wrapped sterile equipment. d. keep all records and adjust lights.

b The responsibilities of a scrub nurse are to assist the surgical team by preparing sutures, receiving specimens for laboratory examination, and counting sponges and needles.

Which zone of the surgical area only requires attire in the form of scrub clothes and caps? a. Unrestricted zone b. Semi-restricted zone c. Restricted zone d. Operative zone

b The semi-restricted zone is where attire consists of scrub clothes and caps. The unrestricted zone is where street clothes are allowed. The restricted zone is where scrub clothes, shoe covers, caps, and masks are worn. The surgeons and other surgical team members wear additional sterile clothing and protective devices during the operation.

A postoperative client rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the client is experiencing a hemorrhage. What should be the nurse's first action? a. Leave and promptly notify the physician. b. Quickly attempt to determine the cause of hemorrhage. c. Begin resuscitation. d. Put the client in the Trendelenburg position.

b Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures. Resuscitation is not necessarily required and the nurse must not leave the client. The Trendelenburg position would be contraindicated.

The PACU nurse is caring for a client who has arrived from the OR. During the initial assessment, the nurse observes that the client's skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the client is not breathing. What is the priority intervention? a. Check the client's oxygen saturation level, continue to monitor for apnea, and perform a focused assessment. b. Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw. c. Assess the arterial pulses, and place the client in the Trendelenburg position. d. Reintubate the client.

b When a nurse finds a client who is not breathing, the priority intervention is to open the airway and treat a possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the head back and then pushes forward on the angle of the lower jaw or performs the jaw thrust method to open the airway. This is an emergency and requires the basic life support intervention of airway, breathing, and circulation assessment. Arterial pulses should be checked only after airway and breathing have been established. Reintubation and resuscitation would begin after rapidly ruling out a hypopharyngeal obstruction.

The nurse is preparing to change a client's abdominal dressing. The nurse recognizes the first step is to provide the client with information regarding the procedure. Which of the following explanations should the nurse provide to the client? a. "The dressing change is often painful, and we will be giving you pain medication prior to the procedure so you do not have to worry." b. "During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to." c. "The dressing change should not be painful, but you can never be sure, and infection is always a concern." d. "The best time for doing a dressing change is during lunch so we are not interrupted. I will provide privacy, and it should not be painful."

b When having dressings changed, the client needs to be informed that the dressing change is a simple procedure with little discomfort; privacy will be provided; and the client is free to look at the incision or even assist in the dressing change itself. If the client decides to look at the incision, assurance is given that the incision will shrink as it heals and that the redness will likely fade. Dressing changes should not be painful, but giving pain medication prior to the procedure is always a good preventive measure. Telling the client that the dressing change "should not be painful, but you can never be sure, and infection is always a concern" does not offer the client any real information or options and serves only to create fear. The best time for dressing changes is when it is most convenient for the client; nutrition is important so interrupting lunch is probably a poor choice.

A client asks the nurse how an inhalant general anesthetic is expelled by the body. What is the best response by the nurse? a. "The kidneys will eliminate the inhalant with urination." b. "The lungs primarily eliminate the anesthesia." c. "The skin will eliminate the anesthesia through evaporation." d. "The liver will eliminate the inhalant anesthesia."

b When inhalant anesthetic administration is discontinued, the vapor or gas is eliminated through the lungs.

A client is on call to the OR for an aortobifemoral bypass and the nurse administers the prescribed preoperative medication. After administering a preoperative medication to the client, what should the nurse do? a. Encourage light ambulation. b. Place the bed in a low position with the side rails up. c. Tell the client that he will be asleep before he leaves for surgery. d. Take the client's vital signs every 15 minutes.

b When the preoperative medication is given, the bed should be placed in low position with the side rails raised. The client should not get up without assistance. The client may not be asleep, but he may be drowsy. Vital signs should be taken before the preoperative medication is given; vital signs are not normally required every 15 minutes after administration.

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? a. Ensure that sufficient surgical supplies are available. b. Check that all surgical personnel are properly attired. c. Review the scheduled procedure, site, and client. d. Confirm that informed consent has been obtained.

c According to the 2016 National Patient Safety Goals, accurate identification of the client, procedure, and operative site is essential.

A patient is complaining of a headache after receiving spinal anesthesia. What does the nurse understand may be the cause of the headache related to the spinal anesthesia? (Select all that apply.) a. The patient lying in the supine position b. Leakage of spinal fluid from the subarachnoid space c. Size of the spinal needle used d. Degree of patient hydration e. An allergic reaction to the medication used

b, c, d Headache may be an aftereffect of spinal anesthesia. Several factors are related to the incidence of headache: the size of the spinal needle used, the leakage of fluid from the subarachnoid space through the puncture site, and the patient's hydration status. Measures that increase cerebrospinal pressure are helpful in relieving headache. These include maintaining a quiet environment, keeping the patient lying flat, and keeping the patient well hydrated. A headache is not likely to occur as the result of the patient lying in the supine position or of an allergic reaction to the medication.

The nurse is caring for a postoperative client who needs daily dressing changes. The client is 3 days postoperative and is scheduled for discharge the next day. Until now, the client has refused to learn how to change her dressing. What would indicate to the nurse the client's possible readiness to learn how to change her dressing? Select all that apply. a. The client wants you to teach a family member to do dressing changes. b. The client expresses interest in the dressing change. c. The client is willing to look at the incision during a dressing change. d. The client expresses dislike of the surgical wound. e. The client assists in opening the packages of dressing material for the nurse.

b, c, e While changing the dressing, the nurse has an opportunity to teach the client how to care for the incision and change the dressings at home. The nurse observes for indicators of the client's readiness to learn, such as looking at the incision, expressing interest, or assisting in the dressing change. Expressing dislike and wanting to delegate to a family member do not suggest readiness to learn.

A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? Select all that apply. a. Absence of pain b. Stable blood pressure c. Ability to tolerate oral fluids d. Sufficient oxygen saturation e. Adequate respiratory function

b, d, e A client remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. Clients can be released from PACU before resuming oral intake. Pain is often present at discharge from the PACU and can be addressed in other inpatient settings.

The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurse's preoperative assessment of an elderly client? a. Elderly clients have a smaller lung capacity than younger clients. b. Elderly clients require higher medication doses than younger clients. c. Elderly clients have less physiologic reserve than younger clients. d. Elderly clients have more sophisticated coping skills than younger clients.

c The underlying principle that guides the 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 do younger clients. Elderly clients do not have larger lung capacities than younger clients. Elderly clients cannot necessarily cope better than younger clients and they often require lower doses of medications.

The nurse is caring for a client who anticipates pain and anxiety following his prostatectomy. Which intervention will likely best assist in decreasing the client's pain and anxiety? a. Administration of NSAIDs rather than opioids b. Allowing the client to increase activity c. Use of guided imagery along with pain medication d. Use of deep breathing and coughing exercises

c The use of guided imagery will enhance pain relief and assist in reduction of anxiety. It may be combined with analgesics. Deep breathing and the increase in activity may produce increased pain. Replacing opioids with NSAIDs may cause an increase in pain.

An unconscious patient with normal pulse and respirations would be considered to be in what stage of general anesthesia? a. Beginning anesthesia b. Excitement c. Surgical anesthesia d. Medullary depression

c Surgical anesthesia is reached by administration of anesthetic vapor or gas and supported by IV agents as necessary. The patient is unconscious and lies quietly on the table. The pupils are small but contract when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. In beginning anesthesia, as the patient breathes in the anesthetic mixture, warmth, dizziness, and a feeling of detachment may be experienced. The patient may have a ringing, roaring, or buzzing in the ears and, although still conscious, may sense an inability to move the extremities easily. The excitement stage, characterized variously by struggling, shouting, talking, singing, laughing, or crying, is often avoided if IV anesthetic agents are administered smoothly and quickly. The pupils dilate, but they contract if exposed to light; the pulse rate is rapid, and respirations may be irregular. Medullary depression is reached if too much anesthesia has been administered. Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer contract when exposed to light.

A nurse is teaching a client who is at risk for malignant hyperthermia subsequent to general anesthesia. What should the nurse include in the teaching? a. "The surgery can continue as long as your temperature is controlled." b. "There are reversal agents that will lessen the occurrence of the malignant hyperthermia." c. "The surgical team is aware of the risk, so the team is prepared." d. "Your vital signs will indicate if you need more inhalant medication."

c Recognizing symptoms early and discontinuing anesthesia promptly are imperative in countering malignant hyperthermia. The surgical team being aware of the possibility is crucial for safe management. The Malignant Hyperthermia Association of the United States (MHAUS) publishes a treatment protocol that should be posted in the OR and be readily available on a malignant hyperthermia cart. However, if end-tidal 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. 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. That the surgery can continue is true but does not provide client reassurance. The reversal agents are not true, but a different anesthetic agent will be used. Vital signs will not determine more medication but a change in anesthesia.

The intraoperative nurse knows that the client's emotional state can influence the outcome of the surgical procedure. How should the nurse best address this? a. Teach the client strategies for distraction b. Pair the client with another client who has better coping strategies. c. Incorporate cultural and religious considerations, as appropriate. d. Give the client antianxiety medication.

c Because the client's emotional state remains a concern, the care initiated by preoperative nurses is continued by the intraoperative nursing staff that provides the client with information and reassurance. The nurse supports coping strategies and reinforces the client's ability to influence outcomes by encouraging active participation in the plan of care incorporating cultural, ethnic, and religious considerations, as appropriate. "Buddying" a client is normally inappropriate and distraction may or may not be effective. Nonpharmacologic measures should be prioritized.

The intraoperative nurse knows that the client's emotional state can influence the outcome of the surgical procedure. How should the nurse best address this? a. Teach the client strategies for distraction. b. Pair the client with another client who has better coping strategies. c. Incorporate cultural and religious considerations, as appropriate. d. Give the client antianxiety medication.

c Because the client's emotional state remains a concern, the care initiated by preoperative nurses is continued by the intraoperative nursing staff that provides the client with information and reassurance. The nurse supports coping strategies and reinforces the client's ability to influence outcomes by encouraging active participation in the plan of care incorporating cultural, ethnic, and religious considerations, as appropriate. "Buddying" a client is normally inappropriate and distraction may or may not be effective. Nonpharmacologic measures should be prioritized.

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required? a. "I should call my physician if I develop a fever." b. "My incision should become less red and tender." c. "I can resume my usual activities as soon as I get home." d. "I need to keep my follow-up appointment with the physician."

c By time of discharge, clients should be able to verbalize clinical manifestations of complications, activity and diet restrictions, and specifics regarding follow-up appointments. The client with abdominal incision will need to avoid lifting and driving in the initial discharge period.

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The child's parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed? a. A social worker should temporarily sign the informed consent. b. Consent should be obtained from the hospital's ethics committee. c. Surgery should be done without informed consent. d. Surgery should be delayed until the parents arrive.

c In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the client's informed consent. However, every effort must be made to contact the client's family. In such a situation, contact can be made by electronic means. In this scenario, the surgery is considered lifesaving, and the parents are on their way to the hospital and not available. A delay would be unacceptable. Neither a social worker nor a member of the ethics committee may sign.

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? a. Necrotic and hard b. Pale yet able to blanch with digital pressure c. Pink to red and soft, bleeding easily d. White with long, thin areas of scar tissue

c In second-intention healing, necrotic material gradually disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue.

The OR nurse is providing care for a 25-year-old major trauma client who has been involved in a motorcycle accident. What intraoperative change may suggest the presence of anesthesia awareness? a. Respiratory depression b. Sudden hypothermia and diaphoresis c. Vital sign changes and client movement d. Bleeding that is beyond what is anticipated

c Indications of the occurrence of anesthesia awareness include an increase in the blood pressure, rapid heart rate, and client movement. Respiratory depression, hypothermia and bleeding are not associated with this complication.

The nurse expects informed consent to be obtained for insertion of: a. An indwelling urinary catheter b. An intravenous catheter c. A gastrostomy tube d. A nasogastric tube

c Informed consent is required for invasive procedures that require sedation and are associated with more than usual risk to the client.

The nurse is caring for a male client who has had spinal anesthesia. The client is under a physician's order to lie flat postoperatively. When the client asks to go to the bathroom, you encourage him to adhere to the physician's order. What rationale for complying with this order should the nurse explain to the client? a. Preventing the risk of hypotension b. Preventing respiratory depression c. Preventing the onset of a headache d. Preventing pain at the lumbar injection site

c Lying flat reduces the risk of headache after spinal anesthesia. Hypotension and respiratory depression may be adverse effects of spinal anesthesia associated with the spread of the anesthetic, but lying flat does not help reduce these effects. Pain at the lumbar injection site typically is not a problem.

The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus? a. Abdominal tightness b. Abdominal distention c. Absence of peristalsis d. Increased abdominal girth

c Paralytic ileus and intestinal obstruction are potential postoperative complications that occur more frequently in patients undergoing intestinal or abdominal surgery. Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for 24 to 48 hours, depending on the type and extent of surgery.

The nurse is attempting to ambulate a client who underwent shoulder surgery earlier in the day, but the client is refusing to do so. What action by the nurse is most appropriate? a. Document the client's refusal. b. Delegate the task to the unlicensed assistive personnel. c. Reinforce the importance of early mobility in preventing complications. d. Use multiple staff members to remove the client from the bed.

c The client may be refusing to ambulate because of fear or pain. Educating the client on the importance of mobility in preventing complications may encourage the client to ambulate. The nurse should try all reasonable measures (e.g., pain control, education) before documenting the client's refusal to ambulate. If the client is already refusing to ambulate, delegating the task to the unlicensed assistive personnel is not an appropriate action. The client should not be forcefully removed from the bed.

A nurse on the surgical team has been assigned the role of scrub nurse. What action by the scrub nurse is appropriate? a. Leading the surgical team in a debriefing session b. Keeping all records and adjusting lights c. Handing instruments to the surgeon and assistants d. Coordinating activities of other personnel

c The responsibilities of a scrub nurse are to assist the surgical team by handing instruments to the surgeon and assistants, preparing sutures, receiving specimens for laboratory examination, and counting sponges and needles. Responsibilities of a circulating nurse include leading the surgical team in a debriefing session, keeping records, adjusting lights, and coordinating activities of other personnel.

Which would be included as a responsibility of the scrub nurse? a. Obtaining and opening wrapped sterile equipment b. Keeping all records and adjusting lights c. Handing instruments to the surgeon and assistants d. Coordinating activities of other personnel

c The responsibilities of a scrub nurse are to assist the surgical team by handing instruments to the surgeon and assistants, preparing sutures, receiving specimens for laboratory examination, and counting sponges and needles. Responsibilities of a circulating nurse include obtaining and opening wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, and coordinating activities of other personnel.

The nurse is caring for a client who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the client's ribs and xiphoid process are prominent. The client states she exercises two to three times daily and her mother indicates that she is being treated for anorexia nervosa. How should the nurse best follow up these assessment data? a. Inform the postoperative team about the client's risk for wound dehiscence. b. Evaluate the client's ability to manage her pain level. c. Facilitate a detailed analysis of the client's electrolyte levels. d. Instruct the client on the need for a high-sodium diet to promote healing.

c The surgical team should be informed about the client's medical history regarding anorexia nervosa. Any nutritional deficiency, such as malnutrition, should be corrected before surgery to provide adequate protein for tissue repair. The electrolyte levels should be evaluated and corrected to prevent metabolic abnormalities in the operative and postoperative phase. The risk of wound dehiscence is more likely associated with obesity. Instruction on proper nutrition should take place in the postoperative period, and a consultation should be made with her psychiatric specialist. Evaluation of pain management is always important, but not particularly significant in this scenario.

The circulating nurse will be participating in a 78-year-old client's total hip replacement. What consideration should the nurse prioritize during the preparation of the client in the OR? a. The client should be placed in Trendelenburg position. b. The client must be firmly restrained at all times. c. Pressure points should be assessed and well padded. d. The preoperative shave should be done by the circulating nurse.

c The vascular supply should not be obstructed by an awkward position or undue pressure on a body part. During surgical procedures, the client is at risk for impairment of skin integrity due to a stationary position and immobility. An elderly client is at an increased risk of injury and impaired skin integrity. A Trendelenburg position is not indicated for this client. Once anesthetized for a total hip replacement, the client cannot move; restraints are not necessary. A preoperative shave is not performed; excess hair is removed by means of a clipper.

What intravenous anesthetic administered by the anesthesiologist has a powerful respiratory depressant effect sufficient to cause apnea and cardiovascular depression? a. Etomidate b. Ketamine c. Thiopental sodium d. Midazolam

c Thiopental sodium (Pentothal) is an intravenous anesthetic agent that in large doses may cause apnea and cardiovascular depression. The other medications listed are also intravenous anesthetic agents, but none causes apnea and cardiovascular depression.

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? a. Primary-intention healing b. First-intention healing c. Second-intention healing d. Third-intention healing

c When wounds dehisce, they are allowed to heal by secondary intention. Primary or first-intention healing is the method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation. Third-intention healing is a method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by bringing apposing granulations together.

The nurse is performing wound care on a 68-year-old postsurgical client. Which of the following practices violates the principles of surgical asepsis? a. Holding sterile objects above the level of the nurse's waist b. Considering a 1 inch (2.5 cm) edge around the sterile field as being contaminated c. Pouring solution onto a sterile field cloth d. Opening the outermost flap of a sterile package away from the body

c Whenever a sterile barrier is breached, the area must be considered contaminated. Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.

The PACU nurse is caring for a client who has been deemed ready to go to the postsurgical floor after her surgery. What would the PACU nurse be responsible for reporting to the nurse on the floor? Select all that apply. a. The names of the anesthetics that were used b. The identities of the staff in the OR c. The client's preoperative level of consciousness d. The presence of family and/or significant others e. The client's full name

c, d, e The PACU nurse is responsible for informing the floor nurse of the client's intraoperative factors (e.g., insertion of drains or catheters, administration of blood or medications during surgery, or occurrence of unexpected events), preoperative level of consciousness, presence of family and/or significant others, and identification of the client by name. The PACU nurse does not tell which anesthetic was used, only the type and amount used. The PACU nurse does not identify the staff that was in the OR with the client.

The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the postsurgical unit following a colon resection. This client's age and increased body mass index mean that she is at increased risk for what complication in the postoperative period? a. Hyperglycemia b. Azotemia c. Falls d. Infection

d Like age, obesity increases the risk and severity of complications associated with surgery. During surgery, fatty tissues are especially susceptible to infection. In addition, obesity increases technical and mechanical problems related to surgery. Therefore, dehiscence (wound separation) and wound infections are more common. A postoperative client who is obese will not likely be at greater risk for hyperglycemia, azotemia, or falls.

The nurse is caring for a hospice client who is scheduled for a surgical procedure to reduce the size of his spinal tumor in an effort to relieve his pain. The nurse should plan this client care with the knowledge that his surgical procedure is classified as which of the following? a. Diagnostic b. Laparoscopic c. Curative d. Palliative

d A client on hospice will undergo a surgical procedure only for palliative care to reduce pain, but it is not curative. The reduction of tumor size to relieve pain is considered a palliative procedure. A laparoscopic procedure is a type of surgery that is utilized for diagnostic purposes or for repair. The excision of a tumor is classified as curative. This client is not having the tumor removed, only the size reduced.

A client is preparing for a surgical procedure is taking corticosteroids for Crohn's disease. What is most important for the nurse to monitor during the operative experience with the client? a. obstruction b. surgical site infection c. hypoglycemia d. adrenal insufficiency

d Clients who have received corticosteroids are at risk for adrenal insufficiency. They are not at greater risk for obstruction, infection, or hypoglycemia during the operative experience.

Prior to a client's scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the client's care. What is the main rationale for organizing perioperative care in this collaborative manner? a. Historical precedent b. Client requests c. Physicians' needs d. Evidence-based practice

d Collaboration of the surgical team using evidence-based practice tailored to a specific case results in optimal client care and improved outcomes. None of the other listed factors is the basis for the collaboration of the surgical team.

A fractured skull would be classified under which category of surgery based on urgency? a. Elective b. Required c. Urgent d. Emergent

d Emergent surgery occurs when the client requires immediate attention. An elective surgery is classified as a surgery that the client should have. A required surgery means that the client needs to have surgery. An urgent surgery occurs when the client requires prompt attention.

The nurse is caring for a client who is scheduled to have a needle biopsy of the pleura. The client has had a consultation with the anesthesiologist and a conduction block will be used. Which local conduction block can be used to block the nerves leading to the chest? a. Transsacral block b. Brachial plexus block c. Peudental block d. Paravertebral block

d Examples of common local conduction blocks include paravertebral anesthesia, which produces anesthesia of the nerves supplying the chest, abdominal wall, and extremities; brachial plexus block, which produces anesthesia of the arm; and transsacral (caudal) block, which produces anesthesia of the perineum and, occasionally, the lower abdomen. A pudental block was used in obstetrics before the almost-routine use of epidural anesthesia.

The PACU nurse is caring for a male client who had a hernia repair. The client's blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery? a. Dysrhythmias, blood loss, and hyperthermia b. Electrolyte imbalances and neurologic changes c. A parasympathetic reaction and low blood volumes d. Pain, hypoxia, or bladder distention

d Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Dysrhythmias, blood loss, hyperthermia, electrolyte imbalances, and neurologic changes are not common postoperative reasons for hypertension. A parasympathetic reaction and low blood volumes would cause hypotension.

The nurse is caring for a postoperative client with an indwelling urinary catheter. The hourly urinary output is 80 mL at 9 am. At 10 am, the nurse assesses the hourly urinary output as 20 mL. What is the priority action by the nurse? a. Irrigate the catheter with sterile normal saline. b. Document the findings. c. Reassess the output at 11 am. d. Notify the primary care provider immediately.

d If the client has an indwelling urinary catheter, hourly outputs are monitored and rates <30 mL/h are reported. Any urinary output <30 mL/h should be reported to the primary care provider immediately. Though urinary output will be reassessed at 11 am, but waiting to notify the primary care provider puts the patient at risk. The findings should be documented, but this is not the highest priority. A urinary catheter may need to be irrigated, but a postoperative client with a low urinary output is demonstrating a complication of inadequate fluid imbalance that needs to be reported immediately.

A patient has a wound that has hemorrhaged. What does the nurse understand is the cause of the patient's increased risk of infection? a. Reduced amounts of oxygen and nutrients are available b. The tissue becomes less resilient c. Retrograde bacterial contamination may occur d. Dead space and dead cells provide a culture medium

d In hemorrhage, accumulation of blood creates dead spaces as well as dead cells that must be removed. The area becomes a growth medium for organisms.

A nurse is caring for a client following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache? a. Have the client sit in a chair and perform deep breathing exercises. b. Ambulate the client as early as possible. c. Limit the client's fluid intake for the first 24 hours postoperatively. d. Keep the client positioned supine.

d Measures that increase cerebrospinal pressure are helpful in relieving headache. These include maintaining a quiet environment, keeping the client lying flat, and keeping the client well hydrated. Having the client sit or stand up decreases cerebrospinal pressure and would not relieve a spinal headache. Limiting fluids is incorrect because it also decreases cerebrospinal pressure and would not relieve a spinal headache.

The surgical client has been intubated and general anesthesia has been administered. The client exhibits cyanosis, shallow respirations, and a weak, thready pulse. The nurse recognizes that the client is in which stage of general anesthesia? a. Stage I b. Stage II c. Stage III d. Stage IV

d Stage IV: medullary depression is characterized by shallow respirations, a weak, thready pulse, dilated pupils that do not react to light, and cyanosis.

A postanesthesia care unit (PACU) nurse is preparing to discharge a client home following ankle surgery. The client keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate? a. Ask the client, "Do you understand?" b. Continuously repeat the instructions until the client restates them. c. Give the written instructions to the client's 16-year-old child. d. Review the instructions with the client and an accompanying adult.

d The effects of anesthesia may impair a client's memory or concentration. It is important that the discharge instructions are covered with the client and an accompanying adult. Giving the instructions to a 16-year-old is not appropriate. Repeating the instructions until the client restates them does not ensure that the client will remember them, because anesthesia can impair memory. Asking whether the client understands the instructions only elicits an yes or no answer; it does not give insight into whether the client comprehends the instructions.

Unless contraindicated, how should the nurse position an unconscious client? a. Flat on the back, without elevation of the head, to facilitate frequent turning and minimize pulmonary complications b. In semi-Fowler's position, to promote respiratory function and reduce the incidence of orthostatic hypotension when the patient can eventually stand c. In Fowler's position, which most closely simulates a sitting position, thus facilitating respiratory as well as gastrointestinal functioning d. On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration

d The head of the bed is elevated 15 to 30 degrees unless contraindicated, and the patient is closely monitored to maintain the airway as well as to minimize the risk of aspiration. If vomiting occurs, the patient is turned to the side to prevent aspiration and the vomitus is collected in the emesis basin.

The nurse is caring for a patient who is at risk for malignant hyperthermia subsequent to general anesthesia. What is the most common early sign that the nurse should assess for? a. Hypertension b. Muscle rigidity ("tetanylike" movements) c. Oliguria d. Tachycardia

d The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. Tachycardia (an abnormally high heart rate) is often the earliest sign. Sympathetic nervous stimulation also leads to ventricular dysrhythmia, hypotension, decreased cardiac output, oliguria, and, later, cardiac arrest. With the abnormal transport of calcium, rigidity or tetanuslike movements occur, often in the jaw. Generalized muscle rigidity is one of the earliest signs.

A 90-year-old female client is scheduled to undergo a partial mastectomy for the treatment of breast cancer. What nursing diagnosis should the nurse prioritize when planning this client's postoperative care? a. Risk for Delayed Growth and Development related to prolonged hospitalization b. Risk for Decisional Conflict related to discharge planning c. Risk for Impaired Memory related to old age d. Risk for Infection related to reduced immune function

d The lessened physiologic reserve of older adults results in an increased risk for infection postoperatively. This physiologic consideration is a priority over psychosocial considerations, which may or may not be applicable. Impaired memory is always attributed to a pathophysiologic etiology, not advanced age.

An adult client is scheduled for a hemorrhoidectomy. The OR nurse should anticipate assisting the other team members with positioning the client in what manner? a. Dorsal recumbent position b. Trendelenburg position c. Sims position d. Lithotomy position

d The lithotomy position is used for nearly all perineal, rectal, and vaginal surgical procedures. The Sims or lateral position is used for renal surgery and the Trendelenburg position usually is used for surgery on the lower abdomen and pelvis. The usual position for surgery, called the dorsal recumbent position, is flat on the back, but this would be impracticable for rectal surgery.

The patient is NPO prior to having a colonoscopy. The patient is to take a daily blood pressure pill prior to the procedure. Until when may water be given prior to the procedure? a. Up to 8 hours before surgery b. Up to 6 hours before surgery c. Up to 4 hours before surgery d. Up to 2 hours before surgery

d The major purpose of withholding food and fluid before surgery is to prevent aspiration. Until recently, fluid and food were restricted preoperatively overnight and often longer. The American Society of Anesthesiologists reviewed this practice and made new recommendations for people undergoing elective surgery who are otherwise healthy. Specific recommendations depend on the age of the patient and the type of food eaten. For example, adults may be advised to fast for 8 hours after eating fatty food and 4 hours after ingesting milk products. Healthy patients are allowed clear liquids up to 2 hours before an elective procedure (Crenshaw, 2011).

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? a. Hair is pulled back and covered by a cap. b. Scrub top and drawstring are tucked into pants. c. Shoe covers are used. d. Mask is placed over nose and extends to bottom lip.

d The mask should fit tightly, covering the nose and mouth. The mask should extend down past the chin. The mask may not effectively cover the mouth if extended only to the bottom lip. The hair, scrub top, drawstring, and shoe covering are all appropriate and do not require intervention.

An obese client is undergoing abdominal surgery. During the procedure a surgical resident states, "The amount of fat we have to cut through is disgusting." What is the best response by the nurse? a. Ignore the comment. b. Report the resident to the attending surgeon. c. Discuss concerns regarding the comments with the charge nurse. d. Inform the resident that all communication needs to remain professional.

d The nurse must advocate for the client, especially when the client cannot speak for themselves. By informing the resident that all communication needs to be professional, the nurse is addressing the comment at that moment in time, advocating for the client. Ignoring the comment is not appropriate. The nurse may need to address the concerns of unprofessional communication with the attending surgeon or the charge nurse if the behavior continues. The best action is to address the behavior when it happens.

You are admitting an insulin-dependent patient to the same-day surgical suite for carpal tunnel surgery. You know that this patient may be at risk for which metabolic disorder? a. Adrenal insufficiency b. Thyrotoxicosis c. Impaired acid base balance d. Hyperglycemia

d The patient with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia. Hyperglycemia during the surgical procedure is a risk based on the body's defense mechanism to raise the blood sugar in the event of stress. Patients who have received corticosteroids are at risk of adrenal insufficiency. Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis. Because the kidneys are involved in excreting anesthetic medications and their metabolites and because acid-base status and metabolism are also important considerations in anesthesia administration, surgery is contraindicated when a patient has acute nephritis, acute renal insufficiency with oliguria or anuria, or other renal problems.

The scrub nurse is responsible for: a. Calling the "time-out" to verify the surgical site and procedure b. Monitoring the administration of the anesthesia c. Monitoring the operating-room personnel for breaks in sterile technique d. Preparing the sterile instruments for the surgical procedure

d The scrub nurse is responsible for preparing the sterile instruments for the surgical procedure.

The nurse is admitting a client to the medical-surgical unit from the PACU. In order to help the client clear secretions and help prevent pneumonia, the nurse should encourage the client to: a. eat a balanced diet that is high in protein. b. limit activity for the first 72 hours. c. take medications as prescribed. d. use the incentive spirometer every 2 hours.

d To clear secretions and prevent pneumonia, the nurse encourages the client to turn frequently, take deep breaths, cough, and use the incentive spirometer at least every 2 hours. These pulmonary exercises should begin as soon as the client arrives on the clinical unit and continue until the client is discharged. A balanced, high protein diet; visiting family in the waiting room; or taking medications as prescribed would not help to clear secretions or prevent pneumonia.

An adult client is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The client's vital signs and level of consciousness have stabilized, but the client then reports severe nausea and begins to retch. What should the nurse do next? a. Administer a dose of IV analgesic. b. Apply a cool cloth to the client's forehead. c. Offer the client a small amount of ice chips. d. Turn the client completely to one side.

d Turning the client completely to one side allows collected fluid to escape from the side of the mouth if the client vomits. After turning the client to the side, the nurse can offer a cool cloth to the client's forehead. Ice chips can increase feelings of nausea. An analgesic is not given for nausea and vomiting.

A novice nurse provides aftercare instructions to a client who has just had sutures removed. Which statement by the novice nurse requires the nurse preceptor to clarify? a. "If the wound site gets wet, pat the wound dry." b. "The wound will continue to heal for several weeks." c. "The wound should not be rubbed or scrubbed." d. "If the wound edges are red or raised, you should call your doctor."

d Wound edges that are slightly red or raised are normal and do not require the client to report these findings to the health care provider. All other statements are true.