Medsurg Chap 14,15,16

The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply.

Chills, crackles, tachypnea

What measurement should the nurse report to the physician in the immediate postoperative period?

Systolic BP lower than 90mm mg

A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse?

Report the infection to an immediate supervisor.

A client asks the nurse how an inhalant general anesthetic is expelled by the body. What is the best response by the nurse?

"The lungs primarily eliminate the anesthesia."

After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements?

"I'll be sleepy but able to respond to your questions."

A client scheduled for surgery asks why blood tests are being done to evaluate liver function. Which response will the nurse make?

"It is because the anesthesia you will receive is cleared through the liver."

A client is undergoing a lumbar puncture. The nurse educates the client about surgical positioning. Which statement by the nurse is appropriate?

"You will be lying on your side with your knees to your chest."

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

1st intention

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?

2

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?

7-10 days

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?

<30 ml

The nurse is triaging surgical clients. Which client would the nurse document as in need of urgent surgical care?

Acute gallbladder infection

A 78-year-old client is undergoing surgery to repair a right hip fracture. What nursing action is appropriate during the intraoperative phase?

Appropriately position the client using adequate padding and support.

A client is transferred from the postanesthesia care unit (PACU) to an inpatient care unit. What will the nurse assess first?

Breathing

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented?

Circulating nurse

What is the priority action by the scrub nurse when the surgeon begins to close the surgical wound?

Count the sponges

The anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered?

Denies sensation to perineum and lower abdomen

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?

Early signs of shock

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as

Emergency

A fractured skull would be classified under which category of surgery based on urgency?

Emergent

Nursing students are reviewing information about agents used for anesthesia. The students demonstrate understanding when they identify which of the following as an inhalation anesthetic?

Halothane

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?

Hypervolemia

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?

Inform the resident that all communication needs to remain professional.

Which position is used for perineal surgical procedures?

Lithotomy

A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention?

Mask is placed over nose and extends to bottom lip.

Unless contraindicated, how should the nurse position an unconscious client?

On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration

The nurse observes bloody drainage on the surgical dressing of the client who has just arrived on the nursing unit. Which intervention should the nurse plan to do next?

Outline the drainage with a pen and record the date and time next to the drainage.

The scrub nurse is responsible for:

Preparing the sterile instruments for the surgical procedure

What complication is the nurse aware of that is associated with deep venous thrombosis?

Pulmonary embolism

A 55-year-old patient arrives at the operating room. The nurse is reviewing the medical record and notes that the patient has a history of osteoporosis in her lower back and hips. The patient is scheduled to receive epidural anesthesia. Which of the following nursing diagnoses would be a priority for this patient?

Risk for perioperative positioning injury related to operative position

A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants?

Scrub Nurse

A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role?

Scrub role

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?

Stage 4

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.

Stage II: excitement

The nurse is caring for a client during an intraoperative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?

Temperature of 102.5°F (39°C)

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client?

The client can be discharged from the PACU

A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia?

To prevent cerebrospinal fluid (CSF) leakage

A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize?

The edges of a sterile package, once opened, are considered unsterile.

You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult?

Tolerance

A client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse?

Verify consent.

Which of the following is an inappropriate nursing action by the surgical nurse?

Wearing sterile gloves over artificial nails

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?

Wound infection

During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer:

dantrolene sodium (Dantrium)

The nurse recognizes that the older adult is at risk for surgical complications due to:

decreased renal function

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

A client with osteoarthritis receives a recommendation to have joint replacement surgery. For which type of surgery will the nurse plan teaching for this client?

elective

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

first intention

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?

ineffective thermoregulation

The nurse recognizes the client has reached stage III of general anesthesia when the client:

lies quietly on the table

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication?

malignant hyperthermia

Which is a classic sign of hypovolemic shock?

pallor

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?

pink/red - bleeds easily

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client reports feeling chilled. Which of the following actions by the nurse would be inappropriate?

restrict oral fluids

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?

urinary retention