Chapter 17 - Preoperative Care

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

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

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

Answer: a. "Tell me more about what happened to your mother." Rationale: The patient's statement may indicate an unusually high anxiety level or a family history of problems such as malignant hyperthermia, which will require precautions during surgery. The other statements may also address the patient's concerns, but further assessment is needed first.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

11. Five minutes after receiving the ordered preoperative midazolam by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate? a. Perform a straight catheterization. b. Assist the patient to the bathroom. c. Offer the patient a urinal or bedpan. d. Tell the patient that a catheter will be placed in the operating room.

Answer: c. Offer the patient a urinal or bedpan. Rationale: The patient will be at risk for a fall after receiving the sedative, so the best nursing action is to have the patient use a bedpan or urinal. Having the patient get up either with assistance or independently increases the risk for a fall. The patient will be uncomfortable and risk involuntary incontinence if the bladder is full during transport to the operating room. There is no need to perform a straight catheterization.

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

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

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

Answer: c. Serum potassium 3.2 mEq/L Rationale: The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of anxiety. The lower heart rate would be expected in a patient taking a -blocker. The hematocrit is in the low normal range but does not need any intervention before surgery.

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

Answer: c. Suggest that the patient give the ring to a family member to hold. Rationale: Jewelry is not allowed to be worn by the patient, especially if electrocautery will be used. Safety is the issue here. There is no need for a release form or to discuss liability with the patient.

18. The nurse interviews a patient scheduled to undergo general anesthesia for a bilateral hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery? a. The patient drinks 3 cups of coffee every day. b. The patient stopped taking aspirin 10 days ago. c. The patient's father died after general anesthesia for abdominal surgery. d. The patient drank 4 ounces of apple juice 6 hours before coming to the hospital

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

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

Answer: c. The patient's report that her last menstrual period was 8 weeks ago. Rationale: A last menstrual period 8 weeks ago in a woman of childbearing age suggests that the patient could be pregnant and pregnancy testing is needed before administration of anesthetic agents. Although the other data may also be communicated with the surgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery.