medsurg2 chapter 17
The nurse expects informed consent to be obtained for insertion of: a) An intravenous catheter b) An indwelling urinary catheter c) A nasogastric tube d) A gastrostomy tube
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.
Patients who have received corticosteroids preoperatively are at risk for which type of insufficiency? a) Parathyroid b) Thyroid c) Pituitary d) Adrenal
Adrenal Correct Explanation: Patients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids does not occur to the pituitary, thyroid, or parathyroid glands.
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? a) Grilled salmon, rice pilaf, green beans, and cantaloupe b) Turkey breast, baked sweet potato, asparagus, and an orange c) Baked chicken, mashed potatoes, broccoli, and strawberries d) Cheeseburger, french fries, coleslaw, and ice cream
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. (less)
The nurse has just admitted a 12-year-old client who is going to have an above-the-knee amputation of their left leg due to osteosarcoma. The nurse knows that adequate preoperative teaching and learning is important for what reason? a) Client will have a shorter recovery period. b) Client will understand after surgery they will not have a left leg. c) Client will understand they have cancer. d) Client's family will understand their child will lose their leg in the surgery.
Client will have a shorter recovery period. Explanation: The purpose of adequate preoperative teaching/learning is for the client to have an uncomplicated and shorter recovery period. He or she will be more likely to deep breathe and cough, move as directed, and require less pain medication. Options B, C, and D are incorrect because preoperative teaching does not ensure that a 12-year-old client understands they are losing their leg or understand that they will have cancer. Preoperative teaching also does not ensure the client's family understands the child will lose their leg. This is the responsibility of the physicians who are treating the child and their family
At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period? a) During the preoperative period b) At the time of discharge instructions c) Upon arrival to the surgical unit d) Following the surgical procedure
During the preoperative period Correct 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.
You are caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery? a) Place pillows under the client's knees or calves. b) Encourage the client to move legs frequently and do leg exercises. c) Maintain the client in a side-lying position. d) Apply pressure on the client's lower extremities.
Encourage the client to move legs frequently and do leg exercises. Explanation: The nurse should encourage the client to move legs frequently and do leg exercises to prevent venous stasis and other circulatory complications. The nurse should not place pillows under the client's knees or calves unless ordered and should avoid placing pressure on the client's lower extremities. Placing the client in a side-lying position will not help prevent venous stasis and other circulatory complications in a client who has undergone surgery.
The nurse concludes that further teaching about diaphragmatic breathing is needed when the client: a) Performs diaphragmatic breathing in a semi-Fowler's position b) Breathes in deeply through the nose and mouth c) Places the hands on the lower chest to feel the rise and fall with breathing d) Exhales forcefully with a short expiration
Exhales forcefully with a short expiration Explanation: Diaphragmatic breathing should be performed gently and fully. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 17: Preoperative Nursing Management, p. 414. Chapter 17: Preoperative Nursing Management - Page 414
When a patient recites, "I know all will go well," what is the cognitive coping strategy he or she is using? a) Music therapy b) Distraction c) Imagery d) Optimistic self-recitation
Optimistic self-recitation Correct Explanation: When that patient verbalizes this statement, is an optimistic response. Imagery occurs when the patient concentrates on a pleasant experience or restful scene. Distraction occurs when the patient thinks of an enjoyable story or recites a favorite poem or song. Music therapy would be an incorrect answer.
A patient is scheduled to have a cholecystectomy. Which of the nurse's finding is least likely to contribute to surgical complications? a) Pregnancy b) Urinary tract infection c) Diabetes d) Osteoporosis
Osteoporosis Explanation: Osteoporosis is most 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, increasing the chance for infections.
Regarding the surgical patient, which one of the following phases refers to the period of time that constitutes the surgical experience? a) Postoperative b) Intraoperative c) Perioperative d) Preoperative
Perioperative Explanation: Perioperative period includes the preoperative, intraoperative, and postoperative phases. Preoperative phase is the period of time from when the decision for surgical intervention is made to when the patient is transferred to the operating room table. Intraoperative phase is the period of time from when the patient is transferred to the operating room table to when he or she is admitted to the postanesthesia care unit. Postoperative phase is the period of time that begins with the admission of the patient to the postanesthesia care unit and ends after a follow-up evaluation in the clinical setting or home.
The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which of the following values would be of greatest concern to the nurse? a) Calcium 9.8 mg/dL b) Potassium 6.2 mEq/L c) Sodium 138 mEq/L d) White blood cell count 7.2 cells/mm
Potassium 6.2 mEq/L Explanation: Hyperkalemia places the client at risk for surgical complications. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 17: Preoperative Nursing Management, p. 408. Chapter 17: Preoperative Nursing Management - Page 408
When is the ideal time to discuss preoperative teaching a) Day of surgery b) Prior to entering the pre-op area c) When the patient is comfortable and sedated d) Preadmission visit
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 patient sign the consent form for surgery. After the patient signs the consent form, the patient starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate? a) Place the consent form in the patient's medical record. b) Answer the patient's questions. c) Notify the nurse manager of the patient's questions. d) Request that the surgeon come and answer the questions.
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 questions are answered fully for the patient.
Which of the following consequences may result if tranquilizers are withdrawn suddenly? a) Respiratory depression b) Cardiovascular collapse c) Hypotension d) Seizures
Seizures Explanation: Abrupt withdrawal of tranquilizers may result in anxiety, tension, and even seizures if withdrawn suddenly. Abrupt withdrawal of steroids may precipitate cardiovascular collapse. Monoamine oxidase inhibitors increase the hypotensive effects of anesthetics. Thiazide diuretics may cause excessive respiratory depression during anesthesia due to an associated electrolyte imbalance.
The nurse discovers that the client did not sign the operative consent before receiving the preoperative medication. The appropriate nursing action is: a) To notify the surgeon b) For the nurse to sign the consent with verbal permission of the client c) To have the client sign the consent immediately d) To have the client's next of kin sign the consent
To notify the surgeon Explanation: Preoperative medication can impair the thinking ability of the client. FFor informed consent to be valid, the client must be competent to give consent. The surgery will be canceled.
When a person with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the patient may show signs of alcohol withdrawal delirium during which time period? a) Up to 24 hours after alcohol withdrawal b) Up to 72 hours after alcohol withdrawal c) Immediately upon admission d) Upon awakening in the postanesthesia care unit
Up to 72 hours after alcohol withdrawal Explanation: Alcohol withdrawal delirium is associated with a significant mortality rate when it occurs postoperatively. Onset of symptoms depends upon time of last consumption of alcohol. Twenty-four hours is too short a time frame to consider alcohol withdrawal delirium as no longer a threat to a chronic alcoholic
When assessing a postoperative client, the nurse is correct to relate which surgical risk factor that would decrease if the surgical client maintained a blood glucose level under 150 mg/dL? a) Respiratory complications b) Wound healing c) Nutrient deficiencies d) Liver dysfunction
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. There is no direct correlation between blood glucose levels and nutrient deficiencies, respiratory complications, and liver dysfunction
When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) required. b) emergency. c) urgent. d) elective.
emergency. Explanation: Emergency surgery means that the patient requires immediate attention and the disorder may be life threatening. Urgent surgery means that the patient requires prompt attention within 24 to 30 hours. Required surgery means that the patient 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.
An example of a curative surgical procedure is a) a face-lift. b) a biopsy. c) the excision of a tumor. d) the placement of gastrostomy tube.
the excision of a tumor. Explanation: An example of a curative surgical procedure is the excision of a tumor. A biopsy, face-lift, and the placement of a gastrostomy tube are not examples of curative surgical procedures.
Choice Multiple question - Select all answer choices that apply. Which of the following nursing activities would not be part of the preoperative phase of care? Select all that apply. a) Beginning discharge planning b) Establishing an intravenous line c) Ensuring that the sponge, needle, and instrument counts are correct d) Administering medications, fluid, and blood component therapy, if prescribed e) Discussing and reviewing the advanced directive document
• 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.
The nurse is teaching leg exercises to the client preoperatively. The client asks why the exercises are important. The best response by the nurse is: a) "Clients are often on bed rest following surgery, and the exercises can help prevent pressure ulcers." b) "Leg exercises help prevent blood clots in your legs." c) "Your intestinal tract slows down following surgery, and the exercises will help restore normal intestinal activity." d) "Leg exercises help prevent pneumonia while you are on bed rest."
"Leg exercises help prevent blood clots in your legs." Explanation: Leg exercises improve circulation of the lower extremities by preventing venous stasis, which can lead to deep vein thrombosis in the postoperative client.
Which nursing statement would best decrease a client's anxiety before an emergency operative procedure? a) "Let me explain to you w8hat will happen next." b) "You will be just fine; the operating room nurses will take good care of you." c) "It is best to take deep breaths and relax before the procedure." d) "We will keep your family informed of your progress."
"Let me explain to you w8hat will happen next." Correct 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.
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? a) "The physician will update my family after the procedure and provide specific discharge instructions." b) "If I do not follow the instructions, my surgery could be cancelled." c) "The nurse will explain the details of the surgery before I sign a consent." d) "My medical records will be sent to the ambulatory care center prior to my surgery."
"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. (less)
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? a) "The nurse will explain the details of the surgery before I sign a consent." b) "If I do not follow the instructions, my surgery could be cancelled." c) "My medical records will be sent to the ambulatory care center prior to my surgery." d) "The physician will update my family after the procedure and provide specific discharge instructions."
"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. (less)
You are working in the preoperative area with a client going to surgery for a cholecystectomy. The client has histamine2-receptor antagonists ordered preoperatively. The client asks you why these medications are needed. What would be your best answer? a) "These medications slow motor activity." b) "These medications decrease anxiety before surgery." c) "These medications decrease the amount of anesthesia you will need." d) "These medications decrease gastric acidity and volume."
"These medications decrease gastric acidity and volume." Explanation: The anesthesiologist frequently orders preoperative medications. Common preoperative medications include the following: anticholinergics, which decrease respiratory tract secretions, dry mucous membranes, and interrupt vagal stimulation; anti anxiety drugs, which reduce preoperative anxiety, slow motor activity, and promote induction of anesthesia; histamine2-receptor antagonists, which decrease gastric acidity and volume; narcotics, which decrease the amount of anesthesia needed, help reduce anxiety and pain, and promote sleep; sedatives, which promote sleep, decrease anxiety, and reduce the amount of anesthesia needed; and tranquilizers, which reduce nausea, prevent emesis, and enhance preoperative sedation.
Which question is most important for the nurse to ask the client when obtaining the preoperative admission history? a) "Did you bring a copy of your health care power of attorney?" b) "Did you bring any valuables with you?" c) "Who is here with you?" d) "When is the last time you ate or drank?"
"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.
For the patient who is taking aspirin, it is important to stop taking this medication at least how many day(s) prior to surgery? a) 1 b) 5 c) 7 d) 3
7 Explanation: Aspirin should be stopped at least 7 to 10 days before surgery. The other timeframes are incorrect. Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 17: Preoperative Nursing Management, p. 411. Chapter 17: Preoperative Nursing Management - Page 411
The nurse recognizes that which of the following clients is at least risk for perioperative complications? a) A 32-year-old African-American woman who takes prednisone b) A 76-year-old Asian man who takes clopidogrel (Plavix) c) A 45-year-old African-American man recently diagnosed with type 2 diabetes d) A 65-year-old Caucasian man who has a history of arthritis
A 65-year-old Caucasian man who has a history of arthritis Explanation: A history of arthritis does not increase the risk for complications during the perioperative period.
The surgical unit nurse is developing a postoperative plan of care. In which client's plan of care would the nurse document interventions of coughing and deep breathing, gastrointestinal assessment, and effective regulation of temperature? a) A client having a knee replacement and regional anesthesia b) A client with gastrointestinal surgery and general anesthesia c) A client having lower extremity muscle repair and spinal anesthesia d) A client with spinal stenosis and a regional nerve blockade
A client with gastrointestinal surgery and general anesthesia Correct Explanation: General anesthesia acts on the central nervous system to produce a loss of sensation, reflexes, and consciousness. The anesthesiologist monitors the vital functions of breathing, circulation, and temperature. Following general anesthesia, nurses must closely monitor for effective breathing and oxygenation, temperature regulation, and adequate fluid balance. Nursing interventions for those clients with regional anesthesia, spinal anesthesia, and regional nerve blockades focus on assessing for allergic reactions, neurovascular assessments to specific body regions, and side effects of the medication
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) A history of chronic low back pain b) A history of sensitivity to aspirin c) A history of osteoarthritis d) A history of diabetes
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 is triaging the surgical patients. Which patient would the nurse document as urgent for surgical care? a) A patient needing cataract surgery b) A patient scheduled for cosmetic surgery c) A patient with severe bleeding d) A patient with an acute gallbladder infection
A patient with an acute gallbladder infection Explanation: An acute gallbladder infection is considered 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 physically fit 86-year-old is scheduled for right knee replacement. What factor in this client makes them at increased risk for surgery? a) Age b) Ability to metabolize medication c) Nutritional status d) Type of surgery
Age Explanation: On admission, the nurse reviews preoperative instructions, such as diet restrictions and skin preparations, to ensure the client has followed them. If the client has not carried out a specific portion of the instructions, such as withholding foods and fluids, the nurse immediately notifies the surgeon. He or she identifies the client's needs to determine if the client is at risk for complications during or after the surgery. General risk factors are related to age; nutritional status; use of alcohol, tobacco, and other substances; and physical condition. In this scenario the risk to the client is age, the other options are incorrect according to the scenario described.
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? a) Anxious clients need psychological counseling after surgery. b) Anxiety and fear increases the need for anesthesia and postoperative medications. c) Anxious clients have a poor response to surgery and are prone to complications. d) Anxiety and fear can affect a client positively during and after surgery.
Anxious clients have a poor response to surgery and are prone to complications. Correct 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 caring for a female postoperative client who is having difficulty voiding. Which nursing action is most helpful to promote normal voiding? a) Run water to assist in the let-down reflex. b) Offer to catheterize. c) Assist to the bathroom. d) Encourage 8 oz of water.
Assist to the bathroom. Explanation: The nurse encourages the client to void within 4 hours of surgery to minimize the risk of a urinary tract infection. Ambulating the client to the bathroom promotes normal body positioning for urination. Running water is a common psychological strategy to cause urination, but positioning is a better option. Encouraging water will help fill the bladder but not urination. Offering to catheterize is a last option.
The nurse is assigned a client scheduled for an outpatient colonoscopy in an ambulatory care setting. During which phase of perioperative care would the nurse document the admission vital signs in the recovery room? a) During the postoperative phase b) During the transfer phase c) During the intraoperative phase d) During the preoperative phase
During the postoperative phase Explanation: The nurse realizes that documentation of vital signs in the recovery room begins the postoperative phase of perioperative care. The preoperative phase occurs until the client reaches the operating area. The intra operative phase includes the entire surgical procedure until the transfer to the recovery area. There is no transfer phase of perioperative care
What action by the nurse best encompasses the preoperative phase? a) Documenting the application of sequential compression devices (SCD) b) Monitoring vital signs every 15 minutes c) Educating the patients on signs and symptoms of infection d) Shaving the patient using a straight razor
Educating the patients on signs and symptoms of infection Correct Explanation: Educating the patient on prevention or recognition of complications begins in the preoperative phase. Applying SCD and frequent vital sign monitoring happens after the preoperative phase. Only electric clippers should be used to remove hair
The nurse is physically preparing a client for surgery. What area does the nurse know needs to be addressed before the client is taken to the operating room? a) Support system b) Activity c) Medication d) Elimination
Elimination Explanation: When physically preparing a client for surgery these areas need to be addressed: skin preparation; elimination; attire/grooming; prosthesis; foods and fluids; and care of valuables. The physical preparation of a client for surgery does not include the areas of medication, activity, or the client's support system
A gunshot wound would be classified under which category of surgery based on urgency? a) Urgent b) Required c) Elective d) Emergent
Emergent Explanation: Emergent surgery occurs when the patient requires immediate attention. An elective surgery is classified as a surgery that the patient should have. A required surgery means that the patient needs to have surgery. An urgent surgery is one which the patient required prompt attention.
A fractured skull would be classified under which category of surgery based on urgency? a) Urgent b) Elective c) Required d) Emergent
Emergent Explanation: Emergent surgery occurs when the patient requires immediate attention. An elective surgery is classified as a surgery that the patient should have. A required surgery means that the patient needs to have surgery. An urgent surgery occurs when the patient requires prompt attention.
Which domain of perioperative nursing practice focuses on clinical processes and outcomes? a) Health care systems b) Safety c) Physiological responses d) Behavioral responses
Health care systems Explanation: The health care system consists of structural data elements and focuses on clinical processes and outcomes. Safety, behavioral responses, and physiological responses reflect phenomena of concern to perioperative nurses and are composed of nursing diagnoses, interventions, and outcomes.
A client taking chlorpromazine (Thorazine) is preparing to undergo surgery. Which of the following complications does the surgical team need to prepare to deal with before anesthetics are administered? a) Hypotension b) Apnea from respiratory paralysis c) Seizures d) Cardiovascular collapse
Hypotension Explanation: Chlorpromazine (Thorazine) may increase the hypotensive action of anesthetics. Seizures are a potential interaction if diazepam (Valium) is withdrawn suddenly before surgery. The client who takes prednisone (Deltasone) is at risk for cardiovascular collapse if the medication is discontinued suddenly. The combination of erythromycin (Ery-Tab) and a curariform muscle relaxant can lead to apnea from muscle paralysis.
A client will be undergoing an appendectomy tomorrow morning. The nurse spends significant time explaining to the client what will happen, including before and after the procedure is complete. What is the primary reason the nurse puts so much effort into preoperative teaching? a) It absolves the hospital of legal responsibility should complications arise. b) It decreases the client's participation and allows the family to take on the caregiver role. c) It increases the likelihood of a successful recovery. d) It minimizes the time needed to be spent on postoperative questions.
It increases 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. This would not be a primary nursing goal.
During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which of the following complications? a) Infection b) Malignant hyperthermia c) Fluid volume excess d) Hypothermia
Malignant hyperthermia Explanation: This inherited disorder 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.
A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first? a) Place a dry, sterile dressing over the protruding organs. b) Moisten sterile gauze with normal saline and place on any organ. c) Place a pressure dressing over the opening and secure. d) Have the client lay quietly on back and call the physician.
Moisten sterile gauze with normal saline and place on any organ. Explanation: A wound evisceration occurs when the wound completely separates, and the internal organs protrude. The first action by the nurse would be to cover the protruding organs with sterile dressings moistened with normal saline. Once the client is safe, the nurse can notify the physician. The client is positioned in a manner that places the least stress on the organs. Dry or pressure dressings are placed over the protruding organ.
The nurse is conducting a preoperative assessment on a patient scheduled for gallbladder surgery. The patient reports having 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 nurse's best action? a) Notify the primary physician about the assessment findings. b) Notify the surgeon to possibly delay the surgery. c) Document the findings and continue the patient through the preoperative phase. d) Wait 1 hour and complete the assessment again.
Notify the surgeon to possibly delay 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? a) Neurologic and musculoskeletal complications are the leading cause of postoperative morbidity and mortality for older adults. b) Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients. c) All older people face similar risks when undergoing surgeries. d) Aging processes reduce the chances that surgery will be successful for these clients.
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.
The nurse recognizes that written informed consent is required for insertion of a(n): a) Peripherally-inserted central catheter. b) Nasogastric tube. c) Oral airway. d) Urinary catheter.
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.
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? a) Place gauze under and over the ring and apply adhesive tape over it. b) Tell the physician and anesthesiologist. c) Medicate the client and then remove the ring. d) Explain that the client cannot go into the operating room with jewelry on.
Place gauze under and over the ring and apply adhesive tape over it. Correct 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.
The nurse in the preoperative area has just medicated her client according to the anesthesiologist's orders. What is the nurse's priority action at this time? a) Take the client's vital signs. b) Place the side rails in the up position and make sure the call button is in reach. c) Take the client to the bathroom. d) Have the family go to the waiting room.
Place the side rails in the up position and make sure the call button is in reach. Explanation: Immediately after giving the medications, the nurse instructs the client to remain in bed; he or she places side rails in the up position and ensures that the call button is within easy reach. Once the client has been preoperatively medicated you do not get them up to the bathroom. The nurses' immediate responsibility after preoperatively medicating the client is not to take the clients' vital signs or to send the family to the waiting room. (less)
A patient is scheduled for elective surgery. To prevent the complication of hypotension and cardiovascular collapse, the nurse should report the use of what medication? a) Erythromycin (Ery-Tab) b) Warfarin (Coumadin) c) Prednisone (Deltasone) d) Hydrochlorothiazide (HydroDIURIL)
Prednisone (Deltasone) Explanation: Patients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids can cause circulatory collapse and hypotension. Hydrochlorothiazide and erythromycin can cause respiratory complications. Warfarin will increase the risk of bleeding.
Your 72-year-old client is scheduled to have a mastectomy. You will prepare the client's skin, encourage the client to void, and remove the client's dentures during which phase of peri operative care? a) Transoperative b) Preoperative c) Postoperative d) Intraoperative
Preoperative Correct Explanation: Preoperative care begins with the decision to perform surgery and continues until the client reaches the operating area. During this time, the nurse will physically prepare the client for surgery, and nursing actions may include skin preparation, hair removal, and food and fluids management.
What is the major purpose of withholding food and fluid before surgery? a) Decrease urine output b) Prevent aspiration c) Decrease risk of constipation d) Prevent overhydration
Prevent aspiration Explanation: The major purpose of withholding food and fluid before surgery is to prevent aspiration. Decreasing overhydration, decreasing urine output, and decreasing constipation are not major purposes of withholding food and fluid before surgery. Until recently, fluid and food were restricted preoperatively overnight and often longer. Currently, specific recommendations depend on the age of the patient and the type of food eaten.
As a nurse working in an ambulatory surgery center, you are admitting a client who is going to have a biopsy of a skin lesion. What is an important part of the preoperative process? a) Review preoperative instructions. b) Give caregiver instructions. c) Teach dressing changes. d) Give postoperative instructions.
Review preoperative instructions. Explanation: On admission, the nurse reviews preoperative instructions, such as diet restrictions and skin preparations, to ensure the client has followed them. The preoperative nurse does not give postoperative instructions; teach dressing changes or give instructions to caregivers
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) Confirm that informed consent has been obtained. b) Ensure that sufficient surgical supplies are available. c) Review the scheduled procedure, site, and client. d) Check that all surgical personnel are properly attired.
Review the scheduled procedure, site, and client. Explanation: According to the 2009 National Patient Safety Goals, accurate identification of the client, procedure, and operative site is essential.
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? a) Circulating nurse b) First assistant c) Certified registered nurse anesthetist d) Scrub nurse
Scrub nurse Explanation: The scrub nurse is sterile and assists the surgical team by handing instruments to the surgeon, preparing sutures, receiving specimens to be sent to the lab, and counting sponges and needles. The circulating nurse is not sterile and obtains and opens sterile equipment, adjusts lights, and keeps records. The first assistant is involved with the client's preoperative care. The certified registered nurse anesthetist assists in the client's anesthesia.
A patient is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications? a) Pain medication should be taken before completing deep breathing and coughing exercises. b) Deep breathing and coughing exercises should be completed every 8 hours. c) Splint the incision site using a pillow during deep breathing and coughing exercises. d) Deep breathing and coughing exercises may be used as relaxation techniques.
Splint the incision site using a pillow during deep breathing and coughing exercises. Correct 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 with the prevention of respiratory complications. Pain medication should be taken regularly and 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 patients will find the exercises relaxing, most patients find it painful to complete the exercises.
The nurse is aware that the amino acid, arginine, a) Is essential for antibody formation b) Is involved in capillary formation c) Stimulates T-cell response d) Is important for normal blood clotting
Stimulates T-cell response Explanation: Arginine is necessary for collagen synthesis and deposition, increases wound strength, and stimulates T-cell response.
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? a) Registered nurse first assistant b) Circulating nurse c) Surgeon d) Anesthesiologist
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.
The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately? a) Pulse rate of 110 beats/min b) Blood pressure of 104/62 mm Hg c) Respiratory rate of 18 breaths/min d) Temperature of 102.5° F
Temperature of 102.5° F Explanation: Intra operative hyperthermia can indicate a life-threatening condition called malignant hyperthermia. The circulating nurse closely monitors the client for signs of hyperthermia. The pulse rate, respiratory rate, and blood pressure did not indicate a significant concern.
Which client would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period? a) The 35-year-old client with non-insulin dependent diabetes. b) The 72-year-old client who takes no routine medications. c) The 47-year-old client who stopped smoking 2 years ago. d) The 28-year-old client who occasionally smoked marijuana in high school.
The 35-year-old client with non-insulin dependent diabetes. Explanation: The client with diabetes is at risk for complications during the intraoperative or postoperative period. Hypoglycemia can develop during anesthesia or from inadequate carbohydrate intake or excess insulin administration postoperatively. Hyperglycemia can increase the risk for wound infection and delay wound healing. Smokers are encouraged to stop 4 to 8 weeks before surgery. Recent ilicit drug use can increase the risk for adverse reactions to anesthesia. Healthy older adults are not at increased risk.
The nurse is caring for the client in the preoperative period and documenting rationale for a palliative surgical procedure. Which rationale is most appropriate? a) The physician is repairing a deformity from birth or disease process. b) The client wishes to improve body structures and elects a procedure. c) The physician needs additional information to plan medical treatment. d) The client and physician are focusing on symptom relief not a cure.
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
The nurse is assessing the postoperative client on the second postoperative day. Which assessment finding requires immediate physician notification? a) The client states a moderate amount of pain at the incisional site. b) A moderate amount of serous drainage is noted on the operative dressing. c) The client's lungs reveal rales in the bases. d) The client has an absence of bowel sounds.
The client has an absence of bowel sounds. Explanation: A nursing assessment finding of concern on the second postoperative day is the absence of bowel sounds, which may indicate a paralytic ileus. Other assessment findings may include abdominal pain and distention as fluids, solids, and gas do not move through the intestinal tract. Rales in the bases are a frequent finding postoperatively, especially if general anesthesia was administered. Encourage the client to cough and deep breathe. Pain is a common symptom following a surgical procedure. Serous drainage on the postoperative dressing needs to monitored and brought to the physician's attention when he or she assesses the client.
The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract? a) The client states being hungry. b) The client is tolerating sips of water. c) The client is passing flatus. d) The client reports a small bowel movement.
The client reports a small bowel movement. Explanation: A bowel movement demonstrates that the nursing outcome of the return to function of the gastrointestinal track has been met. All of the other options are components of meeting the outcome of functioning.
A 17-year-old male client is having same-day surgery to remove a neuroma from his foot. Which of the following nursing interventions would occur during the intra operative phase of peri operative care? a) The nurse continuously monitors the sedated client. b) The nurse obtains a surgical consent from the client's mother. c) The nurse assesses how well the client is recovering from anesthesia. d) The nurse performs a complete assessment of the client.
The nurse continuously monitors the sedated client. Explanation: Intraoperative care includes the entire surgical procedure. During sedation, the nurse continuously evaluates the client. Monitoring during all phases includes assessment of heart rate, respiratory rate, BP, oxygen saturation, and level of consciousness. This would occur during the preoperative phase of perioperative care. During the postoperative phase of perioperative care, an important assessment is determining how the client is recovering from anesthesia.
The nurse is educating patients requiring surgery for various ailments on the perioperative experience. What education provided by the nurse is most appropriate? a) Risks and benefits of the surgical procedures b) Intraoperative techniques used to perform the surgery c) Three phases of surgery and safety measures for each phase d) Expected pain levels and narcotic pain medication used to treat the pain
Three phases of surgery and safety measures for each phase Correct Explanation: The perioperative period includes the preoperative, intraoperative, and postoperative phases. Specific safety guidelines are followed for all surgical patients. The information provided should be general enough to be informative about surgery and should not focus on individual surgeries, as all the patients 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.
Sudden withdrawal of which of the following may result in seizures? a) Monoamine-oxidase inhibitors b) Tranquilizers c) Thiazide diuretics d) Steroids
Tranquilizers Explanation: Abrupt withdrawal of tranquilizers may result in anxiety, tension, and even seizures if withdrawn suddenly. Abrupt withdrawal of steroids may precipitate cardiovascular collapse. Monoamine oxidase inhibitors increase the hypotensive effects of anesthetics. Thiazide diuretics may cause excessive respiratory depression during anesthesia due to an associated electrolyte imbalance
Following diagnostic testing, a patient requires a cholecystectomy. This surgical procedure would be categorized as which of the following? a) Required b) Urgent c) Elective d) Emergent
Urgent Explanation: Acute gallbladder infection would be categorized as an urgent surgery. Emergent surgeries include severe bleeding, bladder or intestinal obstruction, and a fractured skull. Required surgeries include thyroid disorders and cataracts. Elective surgeries include repair of scars, simple hernia, and vaginal repair.
You are caring for a client 6 hours post surgery. You observe that the client voids urine frequently and in small amounts. You know that this most probably indicates what? a) Requirement of intermittent catheterization b) Calculus formation c) Urinary infection d) Urine retention
Urine retention Explanation: Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus.
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? a) Make inhalation longer than exhalation. b) Use diaphragmatic breathing. c) Exhale through an open mouth. d) Use chest breathing.
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.
At what point does the preoperative period end? a) When the client is transferred onto the operating table b) When the decision is made to proceed with surgery c) When the client signs the consent form d) When the client is admitted to the PACU
When the client is transferred onto the operating table Explanation: The preoperative phase begins when the decision to proceed with surgical intervention is made and ends with the transfer of the client onto the OR table. The intraoperative phase begins when the client is transferred onto the operating table and ends with admission to the PACU.
When the patient is encouraged to concentrate on a pleasant experience or restful scene, the cognitive coping strategy being employed by the nurse is a) distraction. b) progressive muscular relaxation. c) imagery. d) optimistic self-recitation.
imagery Correct Explanation: Imagery has proven effective for oncology patients. Optimistic self-recitation is practiced when the patient is encouraged to recite optimistic thoughts such as, "I know all will go well." Distraction is employed when the patient 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
When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority? a) Altered Comfort b) Impaired Gas Exchange c) Risk for Infection d) Anxiety e) Fluid Volume Deficit
just click them all because you can't put them in order... :/
Choice Multiple question - Select all answer choices that apply. Which of the following activities are nursing activities in the preoperative phase of care? Select all that apply. a) Beginning discharge planning b) Discussing and reviewing the advanced directive document c) Establishing an intravenous line d) Administering medications, fluid, and blood component therapy, if prescribed e) Ensuring that the sponge, needle, and instrument counts are correct
• Beginning discharge planning • Discussing and reviewing the advanced directive document • Establishing an intravenous line Correct Explanation: Of the activities listed, discussing and reviewing the advanced directive document, establishing an intravenous line, and beginning discharge planning are preoperative nursing activities
The nursing instructor is talking with her class about spinal anesthesia. What would be the nursing care intervention required when caring for a client recovering from spinal anesthesia? a) Assist the client to a sitting position at the side of the bed. b) Turn the client from side to side at least every 2 hours. c) Instruct the client to stay in bed until sensation and movement returns. d) Monitor respiratory rate and sensation every 2 hours or as per ordered.
• Instruct the client to stay in bed until sensation and movement returns. • Monitor respiratory rate and sensation every 2 hours or as per ordered. Explanation: The client who has received spinal anesthesia should remain in bed until sensation and movement returns. Also, the respiratory rate and sensation must be monitored every 2 hours. If permitted, the nurse should turn the client from side to side at least every 2 hours. The client who has received spinal anesthesia should be permitted to sit.
Choice Multiple question - Select all answer choices that apply. A client is undergoing a surgical procedure to repair his ulcerated colon. During your care, you discuss at length pertinent information for his condition peri operatively. Which of the following client education topics will be discussed preoperatively? Select all that apply. a) The surgeon's fee and other hospital charges b) Intravenous fluids and other lines and tubes c) Postoperative pain control d) His wife's thoughts about the upcoming surgery e) Cough and deep-breathing exercises
• Intravenous fluids and other lines and tubes • Postoperative pain control • Cough and deep-breathing exercises Correct 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.
Choice Multiple question - Select all answer choices that apply. You are providing preoperative care to a 51-year-old male client who is anxious about his total hip replacement surgery. "What if I can never walk again? I don't want to end up like my father!" What are some ways you might help alleviate his anxiety? Select all that apply. a) Make sure the client understands what will happen during surgery. b) Review the client's postoperative goals following the procedure. c) Listen empathetically to the client's concerns about the procedure. d) Ask the client if he would like to speak with a clergyperson. e) Offer the client a sedative to help him relax and feel more comfortable. f) Remind the client that the chances of something going wrong are statistically low.
• Make sure the client understands what will happen during surgery. • Listen empathetically to the client's concerns about the procedure. • Review the client's postoperative goals following the procedure. • Ask the client if he would like to speak with a clergyperson. Explanation: Preparing the client emotionally and spiritually is as important as doing so physically. Anxiety and fear, if extreme, can affect a client's condition during and after surgery. Careful preoperative teaching and listening by the nurse about what will happen and what to expect can help allay some of these fears and anxieties.
Several of the clients at the clinic are preparing to have surgery within the next 2 weeks. They are completing preoperative paperwork today with their visit. What are some of the reasons that people might need to have surgery? Select all that apply. a) Palliative b) Normative c) Cosmetic d) Diagnostic e) Causative
• Palliative • Cosmetic • Diagnostic Correct Explanation: Reasons people have surgery include cosmetic reasons, diagnostic procedures, palliative surgeries, exploratory surgeries, and curative surgeries. Options D and E are distractors.
Completing your preoperative assessment, you mentally rehearse your client's needs to determine if there is increased risk for complications intra operatively or postoperatively. Which of the following are general risk factors? Select all that apply. a) Physical condition b) Gender c) Age d) Nutritional status e) Health status f) Ethnicity
• Physical condition • Age • Nutritional status • Health status Correct Explanation: General surgical risk factors are related to age; nutritional status; use of alcohol, tobacco, and other substances; and physical condition.
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) Skin biopsy b) Removal of a tumor c) Removal of a diseased appendix d) Mammoplasty e) Insertion of a gastrostomy tube
• Removal of a tumor • Removal of a diseased appendix Correct Explanation: A surgical procedure may be diagnostic (e.g., biopsy, exploratory laparotomy), curative (e.g., excision of a tumor or an inflamed appendix), or reparative (eg, 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).
Choice Multiple question - Select all answer choices that apply. 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) Need for teaching is increased. b) The client must be prepared to take on more self-care than he or she may have done in the past. c) The client will leave the hospital sooner than 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.
• The client will leave the hospital sooner than in the past. • Need for teaching is increased. • The client must be prepared to take on more self-care than he or she may have done in the past. Explanation: 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.
Choice Multiple question - Select all answer choices that apply. 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 can you tell this client to help alleviate his concerns? a) The surgical team performs a "time-out" prior to surgery to conduct a final verification. b) The surgeon on his team has never been involved in such a mix-up. c) He can be involved in marking his knee, the site for the surgery. d) The client will be involved in the verification process prior to surgery.
• The surgical team performs a "time-out" prior to surgery to conduct a final verification. • He can be involved in marking his knee, the site for the surgery. • The client will be involved in the verification process prior to surgery. Correct Explanation: 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 (2012) 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."
