Chapter 17: Preoperative Nursing Management
You are the nurse working in an ambulatory surgery center. A teenage son of your clients ask you why so many people have surgery. What would be your best reply?
"Many people have diagnostic or short therapeutic surgical procedures." Explanation: Many diagnostic or short therapeutic surgical procedures—such as bone marrow biopsy, endoscopy, or cardiac catheterization—are now performed in outpatient settings and ambulatory surgical centers. Options B, C, and D seem to minimize the teenager's question.
A client is scheduled for a surgical procedure. When planning the client's care, the nurse should consider that which of the following conditions will increase the client's risk of complications after surgery?
A history of diabetes Explanation: As a chronic condition that affects many body systems, diabetes is a risk factor for surgical complications. The client's blood glucose level and insulin requirements need to be closely monitored before and after surgery. Being sensitive to aspirin does not pose a risk for the client in surgery. Osteoarthritis is not a systemic condition and does not place the client at risk during surgery. Chronic low back pain is not a systemic condition that places the client at risk during surgery; however, it can be exacerbated by positioning on the operating room table.
The nurse expects informed consent to be obtained for insertion of:
A gastrostomy tube Explanation: Informed consent is required for invasive procedures that require sedation and are associated with more than usual risk to the client.
Which question is most important for the nurse to ask the client when obtaining the preoperative admission history?
"When is the last time you ate or drank?" Explanation: Consumption of food and fluids near to the time of surgery places the client at increased risk for aspiration.
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?
7 to 10 days Explanation: 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 fractured skull would be classified under which category of surgery based on urgency?
Emergent Explanation: 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.
Which of the following nursing activities would not be part of the preoperative phase of care? Select all that apply.
Ensuring that the sponge, needle, and instrument counts are correct Administering medications, fluid, and blood component therapy, if prescribed Explanation: Of the activities listed, discussing and reviewing the advanced directive document, establishing an intravenous line, and beginning discharge planning are preoperative nursing activities.
A client is scheduled for a cholecystectomy. Which finding by the nurse is least likely to contribute to surgical complications?
Osteoporosis Explanation: Osteoporosis is likely not going to contribute to complications related to a cholecystectomy. Pregnancy decreases maternal reserves. Diabetes increases wound-healing problems and risks for infection. Urinary tract infection decreases the immune system's effectiveness, increasing the chance for infections.
The nurse recognizes that written informed consent is required for insertion of a(n):
Peripherally-inserted central catheter. Explanation: Nonsurgical invasive procedures, such as insertion of a peripherally-inserted central catheter, that carry more than a slight risk to the client require written informed consent.
The nurse is caring for a client needing emergency surgery. Which preoperative teaching is least important to prepare the client for surgery?
Post-discharge diet Explanation: The least helpful postoperative teaching that could be omitted due to the need to obtain emergency surgery is explaining the post-discharge diet. This is not essential information to improve client participation in their postoperative recovery. Coughing and deep breathing is essential in the immediate postoperative period. Clients are often concerned about postoperative pain so instruction on pain medication can decrease anxiety. Knowledge of the surgical procedure must be explained by a physician when signing a surgical consent.
The nurse would identify which vitamin deficiency to prevent hemorrhaging during surgery?
Vitamin K Explanation: Vitamin K is important for normal blood clotting. Vitamin A and zinc deficiencies would affect the immune system, whereas a magnesium deficiency would delay wound healing.
In preparing the client for transfer to the operating room, which of the following actions by the nurse is inappropriate?
Allow the client to wear dentures. Explanation: Dentures, jewelry, glasses, and prosthetic devices are removed prior to surgery.
A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?
Allow the client to wear the ring and cover it with tape. Explanation: 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.
You are caring for a client preoperatively who is very anxious and fearful about their surgery. You know that this client's anxiety can cause problems with the surgical experience. What type of problems can this client have because of their anxiety and fear?
Anxious clients have a poor response to surgery and are prone to complications. Explanation: Anxiety and fear, if extreme, can affect a client's condition during and after surgery. Anxious clients have a poor response to surgery and are prone to complications. The scenario does not indicate an increased need for anesthesia or postoperative medications in the anxious and fearful client. Anxious clients do not generally need psychological counseling after surgery. Anxiety and fear do not affect a client positively during and after surgery.
The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following?
Cheeseburger, french fries, coleslaw, and ice cream Explanation: Important nutrients for wound healing include protein; vitamins A, B-complex, C, and K; arginine, magnesium, copper, and zinc; and water. The diet should be sufficient in carbohydrates and low to moderate in fats. The cheeseburger option is high in fat and low in vitamin C.
At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period?
During the preoperative period Explanation: The best time to begin teaching about care needed in the postoperative period is during the preoperative time. At this time, the client is more alert and focused on the information provided by the nurse. Clients and family members can better be prepared and participate in the recovery period if they know what to expect. Anxiety is a factor on arrival to the surgical unit that could interfere with learning. Pain could interfere with the learning process, following a surgical procedure. At the time of discharge, both pain and timeliness may be an issue in understanding and obtaining care needed during the postoperative time.
What action by the nurse best encompasses the preoperative phase?
Educating clients on signs and symptoms of infection Explanation: Educating clients on preventing or recognizing complications begins in the preoperative phase. Applying SCDs and frequently monitoring vital signs happen after the preoperative phase. Only electric clippers should be used to remove hair.
Informed consent from the surgical client is essential in all of the following categories of surgery except:
Emergent surgery Explanation: In an emergency, a physician may perform surgery without a client's informed consent in order to save the client's life.
An anxious client being prepared for surgery is encouraged to concentrate on a pleasant experience or restful scene. What cognitive coping strategy would the nurse document as being used?
Imagery Explanation: Imagery has proven effective for anxiety in surgical clients. Optimistic self-recitation is practiced when the client recites optimistic thoughts such as, "I know all will go well." Distraction is used when the client is encouraged to think of an enjoyable story or recite a favorite poem. Progressive muscular relaxation requires contracting and relaxing muscle groups and is a physical coping strategy as opposed to a cognitive strategy.
A nurse is planning preoperative teaching for an older client. Which structural or functional changes in the older adult impact the surgical experience? Select all that apply.
Increased fatty tissue prolongs elimination of anesthesia. Decreased ability to compensate for hypoxia increases the risk of an embolism. Loss of collagen increases the risk of skin complications. Reduced tactile sensitivity can lead to assessment and communication problems. Explanation: The older adult has increased fatty tissue which prolongs elimination of anesthesia, decreased ability to compensate for hypoxia increases the risk of an embolism, loss of collagen increases the risk of skin complications, and reduced tactile sensitivity can lead to assessment and communication problems. The older adult has decreased plasma proteins, and no enlarged liver unless there is an underlying disease.
A client is undergoing preoperative assessment. During admission paperwork, the client reports having enjoyed a hearty breakfast this morning to be ready for the procedure. What is the nurse's next action?
Notify the surgeon. Explanation: If the client has not carried out a specific portion of preoperative instructions, such as withholding foods and fluids, the nurse immediately notifies the surgeon. This scenario does not include information to support documentation of the client's food intake or giving the client water at this point. It is not the nurse's responsibility to cancel the surgery.
An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults?
Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients. Explanation: The underlying principle that guides preoperative assessment, surgical care, and postoperative care is that elderly clients have less physiologic reserve (the ability of an organ to return to normal after a disturbance in its equilibrium) than younger clients. The hazards of surgery for the elderly are proportional to the number and severity of coexisting health problems and the nature and duration of the operative procedure. Respiratory and cardiac complications are the leading causes of postoperative morbidity and mortality in older adults.
A patient is scheduled for a reduction mammoplasty. What classification of surgery does the nurse understand that this is?
Optional Explanation: Cosmetic surgery, including reduction mammoplasties, is optional, as the decision to have the surgery rests with the patient.
Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery?
Physician Explanation: It is the physician's responsibility to provide appropriate information. It is not the responsibility of the nurse, case manager, or certified nurse's aide to gain informed consent.
You are physically preparing a client for surgery and instruct the person to remove any jewelry. The client refuses to remove a wedding band. What should you do in this situation with approval from your facility?
Place gauze under and over the ring and apply adhesive tape over it. Explanation: If the client is reluctant to remove a wedding band, the nurse may slip gauze under the ring, then loop the gauze around the finger and wrist or apply adhesive tape over a plain wedding band. You would not tell the client that he or she cannot go to the operating room wearing the ring. You would never medicate the client and then remove the ring against his or her will. It is not necessary to tell the physician and the anesthesiologist that the client does not want to remove the wedding band.
When is the ideal time to discuss preoperative teaching
Preadmission visit Explanation: The ideal timing for preoperative teaching is not on the day of surgery but during the preadmission visit, when diagnostic tests are performed. Teaching should be done long before the patient enters the preop area. Preoperative teaching should not be done when the patient is sedated.
A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?
Request that the surgeon come and answer the questions. Explanation: It is the physician's responsibility to provide information pertaining to risks and benefits of surgery. It is not the responsibility of the nurse or nurse manager to discuss risks and benefits. The consent form should not be placed in the medical record until all of the client's questions are answered fully.
Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out?
Review the scheduled procedure, site, and client. Explanation: According to the 2016 National Patient Safety Goals, accurate identification of the client, procedure, and operative site is essential.
A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?
Splint the incision site using a pillow during deep breathing and coughing exercises. Explanation: Splinting the incision site will help decrease pain and support the incision. This will increase compliance with the deep breathing and coughing exercises that assist in preventing respiratory complications. Pain medication should be taken regularly, not only before deep breathing and coughing exercises. Deep breathing and coughing exercises should be done at least every 2 hours, more frequently if possible. While some clients will find the exercises relaxing, most clients find it painful to complete them.
The nurse is caring for the client in the preoperative period and documenting rationale for a palliative surgical procedure. Which rationale is most appropriate?
The client and physician are focusing on symptom relief not a cure. Explanation: The nurse realizes a palliative surgical procedure is focused on the relief of symptoms or enhancement of function without a cure. Diagnostic surgical procedures provide additional information for medical diagnosis and treatment. Cosmetic surgery procedures are elective, with the purpose of improving body appearance. Reconstructive surgery corrects a deformity.
A nurse is teaching a client about diaphragmatic breathing. What client action indicates that further teaching is needed?
The client exhales forcefully with a short expiration. Explanation: Diaphragmatic breathing should be performed gently and fully. Placing the hands on the lower chest to feel the rise and fall with breathing, performing diaphragmatic breathing in a semi-Fowler's position, and breathing deeply through the nose and mouth are all aspects of diaphragmatic breathing.
When does the nurse understand the patient is knowledgeable about the impending surgical procedure?
The patient participates willingly in the preoperative preparation. Explanation: The nurse knows that the patient understands the surgical intervention when the patient participates in preoperative preparation. The other answers pertain to the patient experiencing decreased fear or anxiety, not knowledge about the procedure.
The nurse is educating a community group about types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true?
Tumor excision Explanation: An example of a curative surgical procedure is tumor excision. A biopsy, a face-lift, and the placement of a gastrostomy tube are not examples of curative surgical procedures.
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?
Use diaphragmatic breathing. Explanation: In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.
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?
adrenal insufficiency Explanation: 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.
A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse:
continuously monitors the sedated client. Explanation: 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 physically fit older adult is scheduled for right knee replacement. What factor for the client would create an increased risk for postoperative complications?
current smoking history Explanation: The nurse identifies the client's current smoking status as a risk factor for surgical complications. General risk factors are related to age; nutritional status; use of alcohol, tobacco, and other substances; and physical condition. The type of surgery, the ability to metabolize medication, and surgical site are not risk factors.
A nurse evaluates the potential effects of a client's medication therapies before surgery. Which drug classification may cause respiratory depression from an associated electrolyte imbalance during anesthesia?
diuretics Explanation: Diuretics during anesthesia may cause excessive respiratory depression resulting from an associated electrolyte imbalance. Corticosteroids, insulin, and anticoagulants are not known to cause respiratory depression during anesthesia.
During the admission history the client reports to the nurse of taking the usual dose of warfarin the previous day. What is an appropriate nursing action?
Notify the surgeon that the client took warfarin the day before surgery. Explanation: Warfarin (Coumadin), an anticoagulant, places the client at risk for excessive bleeding during the intraoperative and postoperative periods.
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?
urgent Explanation: 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 has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed?
"The nurse will explain the details of the surgery before I sign a consent." Explanation: Further instruction would be needed to clarify that the physician, not the nurse, explains the details of the surgery and obtains voluntary consent for the procedure. It is correct that preoperative instructions must be followed prior to surgery for the safety of the client, medical records are present for review prior to surgery, and the physician speaks with the family following the procedure and provides instructions for discharge.
For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery?
7 Explanation: Aspirin should be stopped at least 7 to 10 days before surgery. The other time frames are incorrect.
What is the blood glucose level goal for a diabetic client who will be having a surgical procedure?
80 to 110 mg/dL Explanation: 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.
Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency?
Adrenal Explanation: Clients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids does not occur in the pituitary, thyroid, or parathyroid glands.
The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which laboratory value would be of greatest concern to the nurse?
potassium 6.2 mEq/L Explanation: Hyperkalemia places the client at risk for surgical complications. The sodium level, calcium level, and white blood cell count are within normal limits.
Which nursing statement would best decrease a client's anxiety before an emergency operative procedure?
"Let me explain to you what will happen next." Explanation: Many clients feel fearful of knowing little about the operative procedure and what to expect. This fear causes anxiety and can lead to a poorer response to surgery and surgical complications. Explanations of what the client is to expect can help to decrease anxiety. False reassurance of being fine does not diminish anxiety. Deep breathing and relaxation techniques can be helpful to the client, but addressing the source of the anxiety is more beneficial. Keeping the family informed helps the family and is not client focused.
A patient with renal failure is scheduled for a surgical procedure. When would surgery be contraindicated for this patient due to laboratory results?
A blood urea nitrogen level of 42 mg/dL Explanation: 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.
In which instance may a surgeon operate without informed consent?
Emergency situations Explanation: In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the client's informed consent.
Nursing assessment findings reveal that the client is afraid of dying during the surgical procedure. Which surgical team member would be most helpful in addressing the client's concern?
Surgeon Explanation: It is the surgeon's responsibility to explain the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts in obtaining informed consent from the client.
A nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which post-surgical risk factor would decrease if the surgical client maintained strict blood glycemic control?
wound healing Explanation: In caring for a postoperative client, the nurse is correct to correlate hyperglycemia with an increased risk of surgical incision infections and delayed wound healing. Strict control of glycemic blood levels at the therapeutic range of 80-110 mg/dL would reduce this risk factor. There is no direct correlation between blood glucose levels and nutrient deficiencies, respiratory complications, or liver dysfunction.
A client with a skull fracture after falling from a ladder requires surgery. The nurse should anticipate transporting the client to surgery during what time frame?
Immediately Explanation: Emergent surgery occurs when the client requires immediate attention. A fractured skull is an indication for emergent surgery. An urgent surgery occurs when the client requires prompt attention, usually within 24-30 hours. Any surgery scheduled beyond 30 hours is classified as required or elective; a fractured skull does not meet the requirements for elective or required surgery.
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.
nutritional status age physical condition health status Explanation: General surgical risk factors are related to age; nutritional status; use of alcohol, tobacco, and other substances; and physical condition.
A client is undergoing a surgical procedure to repair an ulcerated colon. Which client education topics will be discussed preoperatively? Select all that apply.
postoperative pain control cough and deep-breathing exercises intravenous fluids and other lines and tubes Explanation: Preoperative teaching involves teaching clients about their upcoming surgical procedure and expectations. Topics include preoperative medications (when they are given and their effects); postoperative pain control; explanation and description of the post anesthesia recovery room or postsurgical area; and deep-breathing and coughing exercises.
A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective?
"I will support my incision with my hands when I cough and do my deep breathing exercises." Explanation: Splinting of the incision provides support to the incision and helps to control pain, so this client statement is correct. Clients should take pain medication routinely and frequently after surgery. Pain medications for postoperative clients are given orally at home. Pain is a subjective feeling, so comparison is difficult.
A patient is scheduled for a surgical procedure. For which surgical procedure should the nurse prepare an informed consent form for the surgeon to sign?
An open reduction of a fracture Explanation: Informed consent is necessary in the following circumstances: invasive procedures, such as a surgical incision (such as would be involved in an open reduction of a fracture), a biopsy, a cystoscopy, or paracentesis; procedures requiring sedation and/or anesthesia (see Chapter 18 for a discussion of anesthesia); a nonsurgical procedure, such as an arteriography, that carries more than a slight risk to the patient; and procedures involving radiation. Non-invasive procedures such as insertion of an intravenous or urethral catheter or irrigation of the external ear canal would not require informed consent.
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?
Notify the surgeon to possibly delay the surgery. Explanation: A respiratory infection can delay a nonemergent surgical procedure because the infection can increase the risk for respiratory complications. Therefore, the nurse should notify the surgeon about delaying the surgery. The primary physician may be called to 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.
When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as
emergency. Explanation: Emergency surgery means that the client requires immediate attention and the disorder may be life threatening. Urgent surgery means that the client requires prompt attention within 24 to 30 hours. Required surgery means that the client needs to have surgery, and it should be planned within a few weeks or months. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.
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:
increase the likelihood of a successful recovery. Explanation: Teaching clients about their surgical procedure and expectations before and after surgery is best done during the preoperative period. Clients and family members can better participate in recovery if they know what to expect. Although preoperative teaching may minimize the time spent postoperatively on questions and help nurses improve their teaching skills, these are not the primary reasons for spending significant preoperative time on teaching. Clients must participate in their recovery process. Education encourages clients to participate in their own care in addition to giving important information to family. Absolving the hospital of legal responsibility would not be a primary nursing goal.