Evolve perioperative quiz
To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care?
Encourage early mobility.
Which preoperative and postoperative care points should be included when providing education and intervention to a client scheduled for a septoplasty? Select all that apply.
Encourage the client to quit smoking before surgery. Observe the surgical site for edema. Teach the client about post-surgery activities that are restricted. Assess the client's respiratory status.
A healthcare provider informs a client that midazolam will be administered preoperatively. Later, the client asks the nurse why this medication is given. What primary reason should the nurse consider when formulating a response?
Induces sedation
A client who has had a continent urostomy created reports postoperative pain. What should the nurse do first?
Interview the client to gather more information.
In caring for the client with burr holes for a subdural hematoma postoperatively on day 2, the nurse notes the client has an increased temperature to 101.3 F° (38.5° C). What does the nurse understand about this reaction?
The client is exhibiting signs of an infection, and the healthcare provider needs to be notified.
A client who is scheduled for a bowel resection is to receive antibiotics preoperatively. What does the nurse include when teaching the client about the purpose of the antibiotics?
They are given to eliminate bacteria from the gastrointestinal (GI) tract.
After undergoing minor surgery, a postoperative child has recovered from anesthesia. Which observations may indicate that the child is fit to be discharged? Select all that apply.
Vital signs are stable. The child is alert and oriented. Pain rate is at baseline level.
The nurse is preparing an intraoperative care plan for a client. Which intervention should be excluded from the care plan?
Administering general anesthetic to the client
The nurse is providing preoperative teaching for a client who is to have cataract surgery. Which is appropriate for the nurse to include concerning what the client should do after surgery? Select all that apply.
Do not blow your nose. Avoid bending from the waist.
The registered nurse (RN) is caring for a client who underwent knee surgery. Which activity delegated to the novice unlicensed assistive personnel (UAP) in the immediate postoperative period would be most appropriate to achieve an effective care outcome?
Feeding the client with fluids
The nurse is caring for an older client during the intraoperative stage. The anesthesia process has already begun and the nurse has already removed the dentures, eyeglasses, and hearing aids. After the nurse performs these actions, what would be the order the intraoperative nursing interventions should take place?
First, the nurse uses a small pillow under the client's head if his or her head and neck are normally bent slightly forward. Next, the nurse lifts the client into position. Third, the nurse should position arthritic and artificial joints carefully to prevent postoperative pain and discomfort from strain on those joints. Fourth, the nurse should pad the bony prominences to prevent pressure sores. 5th It is essential that the nurse should use warming devices to prevent hypothermia. 6th would involve the nurse covering the client's head and feet for the prevention of hypothermia. Seventh, the nurse should warm intravenous fluid and irrigation fluid as indicated by the agency policy and the recommendation of the manufacturers. 8th, The nurse should follow strict aseptic technique throughout the procedure. 9th would involve the nurse monitoring the intake and output of fluid, including blood.
A female client is scheduled for a hysterectomy. While discussing the preoperative preparations, the nurse determines that the client's understanding of the surgery is inadequate. What is the next nursing intervention?
Notifying the surgeon that the client needs more information
Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client?
Removing the catheter within 24 hours
What should the nurse monitor for when caring for a postoperative client who presents with 180 mL of urine in the urinary drainage bag from the past 8 hours?
Renal failure
The client receives dosages of sedative and opioid drugs during the postoperative period following surgical correction of a small bowel obstruction. What is the most critical assessment to be performed as a nursing safety priority?
Respiratory assessment
A client is receiving oxycodone postoperatively for pain. The healthcare provider's prescription indicates that the dose should be administered every 3 hours for eight doses. What should the nurse assess before administering each dose of oxycodone?
Respiratory rate and level of consciousness
A client who is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to do what?
Decrease bacteria in the intestines
When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia?
Decreased blood pressure
The RN caring for a postoperative hysterectomy client is delegating tasks to the licensed practical nurse (LPN). Which statement made by the RN indicates the principle of right communication of delegation?
"Does the LPN understand when to report the vital signs?"
A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions?
"Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale."
The registered nurse is teaching a student nurse about the physical examination of the integumentary system for a preoperative client. Which statement made by the student nurse indicates a need for further teaching?
"I should assess the neck for distended veins."
Neomycin 1 gram is prescribed preoperatively for a client with cancer of the colon. The client asks why this is necessary. How should the nurse respond?
"It will kill the bacteria in your bowel and decrease the risk for infection after surgery."
While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response?
"You seem upset."
A nurse is planning to provide preoperative teaching to a 12-year-old child who is to undergo ostomy surgery. What should the nurse do before formulating a teaching plan?
Assess the child's developmental level.
A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's best intervention?
Attempt to identify the client's concerns.
A nurse is changing the dressing of a postoperative client. The nursing assistant informs the nurse that another client has fallen down near the nursing station after losing consciousness. What is the best nursing action in this situation?
Attend to the client who lost consciousness.
A nurse performs preoperative teaching for a client who is to have cataract surgery. Which is most important for the nurse to include concerning what the client should do after surgery?
Avoid bending from the waist
An 8-year-old child is being prepared for surgery the next day. How should the nurse present preoperative instructions to this child?
By focusing on simple anatomic diagrams
A nurse is providing immediate postoperative care to a client who had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse?
Constant bubbling in the water seal chamber
A nurse is caring for a postoperative client who has a nasogastric (NG) tube set to low intermittent suction. The nurse recalls that the primary reason that an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium has been prescribed is to prevent which complication?
Electrolyte imbalance
The registered nurse delegates the care of a client in the immediate postoperative period to the patient care associate (PCA). Which tasks performed are in the scope of practice of the PCA? Select all that apply.
Feeding the client Assisting the client with bathing
A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present?
Paresthesias
A nurse working in a postoperative ward assists an older client in getting to the washroom in order to prevent the client from falling. Which level of need did the nurse prioritize in the client according to Maslow's hierarchy of needs?
Level 2
In the postanesthesia care unit a client received intrathecal morphine intraoperatively to control pain. Considering the administration of this medication, what should the nurse include as part of the client's initial 24-hour postoperative care?
Monitoring of respiratory rate hourly
A client who is postoperative hip replacement is receiving morphine by patient-controlled analgesia and has a respiratory rate of 6 breaths/min. What intervention should the nurse anticipate?
Naloxone administration
The nurse suspects that an intraoperative client has a distended bladder. Which method is correct to assess for this condition?
Percuss and palpate in the hypogastric region.
A 10-year-old child is admitted to the hospital for surgery. The parents state that the child is mentally challenged and functions on the level of a 3-year-old. What should the nurse include in the child's preoperative teaching plan?
Providing explanations at a preschooler's level of understanding
When providing preoperative teaching, what should the nurse focus primarily on?
Providing general information to reduce client and family anxiety
While caring for a postoperative client, the nurse observed a pulse deficit during physical assessment. Which pulses are used to assess the pulse deficit?
Radial and apical pulse
The client is experiencing postoperative pain and requests a pain shot. Which of the following healthcare providers are legally permitted to administer an intramuscular (IM) injection to the client? Select all that apply.
Registered nurse (RN) Licensed practical nurse (LPN) Licensed vocational nurse (LVN)
A 15-year-old adolescent with Down syndrome is scheduled for surgery. The parents inform the nurse that their child has a mental age of 8 years. At what age level should the nurse prepare the child's preoperative teaching plan?
School-age, because this is the child's developmental age
