NUR 108 Ch 30 Perioperative Nursing
Which client most likely requires special preoperative assessment and treatment as a result of the existing medication regimen? a woman who takes daily anticoagulants to treat atrial fibrillation a woman who takes daily thyroid supplements to treat her longstanding hypothyroidism a man who takes an angiotensin-converting enzyme (ACE) inhibitor because he has hypertension a man who regularly treats his rheumatoid arthritis with over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs)
a woman who takes daily anticoagulants to treat atrial fibrillation Explanation: Anticoagulants present a risk of hemorrhage. This risk supersedes that posed by thyroid supplements, ACE inhibitors, or most NSAIDs. Thyroid supplements assist with thyroid function. Angiotensin-converting enzyme (ACE) inhibitors help relax blood vessels and lower blood pressure. Nonsteroidal anti-inflammatory drugs (NSAIDs) are a drug class that reduce pain, decrease fever, prevent blood clots, and, in higher doses, decrease inflammation.
A pediatric nurse is preparing a child for cleft palate repair surgery. The nurse identifies that this procedure will be documented as: constructive surgery. reconstructive surgery. transplantation surgery. palliative surgery.
constructive surgery. Explanation: Cleft palate repair is considered constructive surgery because the goal is to restore function in congenital anomalies. Reconstructive surgery serves to restore function to traumatized or malfunctioning tissues and includes plastic surgery or skin grafting. Transplant surgery replaces organs or structures that are diseased or malfunctioning, such as a liver or kidney transplant. Palliative surgery is not curative and seeks to relieve or reduce the intensity of an illness, such as debridement of necrotic tissue.
A nurse preparing an older adult client for hip replacement surgery is aware of the surgical risks related to the client's age. Which of the following accurately describes these risks? Select all that apply. increased cardiac output decreased peripheral circulation increased vascular rigidity increased oxygenation of blood decreased thermoregulation ability
decreased peripheral circulation increased vascular rigidity decreased thermoregulation ability Explanation: Older adults have decreased cardiac output, decreased peripheral circulation, decreased oxygenation of blood, decreased thermoregulation ability, and decreased skin moisture and elasticity. Older adults have increased vascular rigidity.
The nurse is assessing an obese client scheduled for heart surgery. Which priority surgical risk related to obesity should the nurse monitor? delayed wound healing and wound infection alterations in fluid and electrolyte balance nutritional maintenance hemorrhage
delayed wound healing and wound infection Explanation: Fatty tissue has a poor blood supply and, therefore, has less resistance to infection. As a result, postoperative complications of delayed wound healing, wound infection, and disruption in the integrity of the wound are more common. Alterations in fluid and electrolyte balance are more likely to occur with the malnourished client. Respiratory distress is a high risk for clients with preexisting respiratory conditions. Clients with cardiovascular disease are at an increased risk for hemorrhage.
A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice? Select all that apply. administering inhalation anesthetics positioning the client on the operating table administering regional nerve blocks counting sponges before and after surgery monitoring the client's vital signs
positioning the client on the operating table counting sponges before and after surgery monitoring the client's vital signs Explanation: The RN's role is a supportive one for the client, monitoring vital signs and positioning the client on the operating room table. The RN also helps maintain safety by counting sponges and instruments that may have been used during the surgery. The RN is unable to administer anesthetics, such as inhalation agents or regional nerve blocks, without an advanced practice degree.
A nurse teaches deep breathing exercises to a client scheduled for surgery. In which perioperative phase would this action occur? preoperative intraoperative postoperative postanesthesia care unit (PACU)
preoperative Explanation: Exercises and physical activities occurring in the preoperative phase include deep breathing exercises, coughing, incentive spirometry, turning, leg exercises, and pneumatic compression stockings. The intraoperative phase is when the client is in the operating room. In the postoperative area and postanesthesia care unit areas, clients are monitored and deep breathing exercises begin.
The nurse is caring for a client who is preparing to have a hip replacement. How will the nurse document the type of education provided prior to surgery? preoperative intraoperative outpatient surgery postoperative
preoperative Explanation: The care and education a client is provided before surgery are classified as preoperative. The other choices are incorrect.
The nurse has been waiting until after the administration of a toddler's anesthesia before removing the child's clothing and applying monitoring equipment. Doing these actions after the administration of anesthesia will: minimize blood loss. enhance thermoregulation. provide more accurate baseline vital signs. prevent anxiety.
prevent anxiety. Explanation: Relaxation can be enhanced by removing the child's clothing, applying the grounding pad, and applying monitoring devices after the child is anesthetized. This action has no effect on vital signs, thermoregulation, or blood loss.
As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site? operative site marking preoperative checklist procedural pause (time-out) informed consent
procedural pause (time-out) Explanation: The procedural pause (time-out) must be done prior to any procedure to ensure client safety and to verify the client identity, staff roles, and procedure being performed.
A client is undergoing surgery for an appendectomy. This would be considered what type of surgery? emergency surgery elective surgery palliative surgery diagnostic surgery
emergency surgery Explanation: An appendectomy is considered emergency or urgent surgery. Elective surgery can be scheduled in advance, and a delay has no ill effects. Palliative surgery is done to relieve or reduce the intensity of an illness. Diagnostic surgery is done to make or confirm a diagnosis.
A client scheduled for surgery has been taking aspirin since his heart attack in 1997. The client is at risk for: infection. thrombophlebitis. hemorrhage. blood clots.
hemorrhage. Explanation: Current medication use, especially use of medications that can affect coagulation status (warfarin, nonsteroidal anti-inflammatory drugs, aspirin), is important and should be reported to the surgeon.
Which client will see the greatest permanent changes in lifestyle following surgery? right total knee replacement left mastectomy ileostomy appendectomy
ileostomy Explanation: Permanent changes in the client's activity level may occur as a result of surgery. The client with an ileostomy will encounter the greatest changes in lifestyle.
Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? "I can have a hamburger and French fries as soon as I wake up." "The better I eat before surgery, the more likely I will heal." "I might be sick to my stomach and throw up after surgery." "When I can eat again, the best meal would be steak and orange juice."
"I can have a hamburger and French fries as soon as I wake up." Explanation: Oral fluid and food may be withheld until intestinal motility resumes.
A client who is scheduled to undergo coronary bypass surgery in a week asks the nurse whether he should discontinue taking his cholesterol medicine ahead of the surgery. Which should be the nurse's response? "I will need to check with your health care provider about that." "Yes—you should be off all of your medications for 24 hours before surgery." "No—you should stay on your normal medication schedule before the surgery." "You should stay on your cholesterol medicine but stop taking all other medications 12 hours before surgery."
"I will need to check with your health care provider about that." Explanation: The client may be permitted to take certain medications before surgery. The health care provider, not the nurse, should provide guidance about which medications should be taken and which ones should be held.
The nurse is educating a client who is preparing for abdominal surgery tomorrow. A teaching demonstration has just been completed by the nurse related to splinting the incision site with a pillow. Which statement by the client best indicates the instructions provided by the nurse were effective? "I should hold my breath and place the pillow over the incision when coughing." "I will place the pillow on the incision after I cough." "I have to move the pillow from one side of the incision to the other when coughing." "I will put the pillow on the incision then cough."
"I will put the pillow on the incision then cough." Explanation: Splinting the incision site when moving helps to minimize pain or discomfort postoperatively when coughing or moving. Clients should not hold their breath when trying to cough or move to prevent the Valsalva maneuver, which can change the heart rate and blood pressure of a client. Placing the pillow on the incision site after coughing is ineffective at reducing pain. The pillow should remain over the incision until the coughing exercises are completed.
A postoperative client states "I don't understand why you are checking my skin on my back. My surgery was on my stomach." What is the nurse's best response? "We wanted to be sure we didn't leave any sponges or syringes underneath you." "The operating table is a firm surface; we need to be sure your skin looks okay." "The covers underneath you need to be straightened out. They look messy." "We needed to be sure you didn't have any skin breakdown before surgery."
"The operating table is a firm surface; we need to be sure your skin looks okay." Explanation: The client who has been on the operating table should be examined to ensure skin breakdown hasn't occurred. The client would not be told that his covers looked messy, or that the nurse was concerned about sponges or syringes underneath. The client's skin should be assessed on admission; after surgery would not be the time to do this initial assessment to document skin breakdown.
The procedural physician has initiated performance of a time-out in the operating room before surgery. The student nurse asks the operating room nurse why this is important. What is the operating room nurse's best response? "The time-out allows us to make sure that the client has had adequate anesthesia." "We need to be sure the client has had the preoperative antibiotic." "The time-out checks to be sure that we have the right client and procedure." "We are checking the client's baseline vital signs during the time-out."
"The time-out checks to be sure that we have the right client and procedure." Explanation: The time-out is a safety measure performed before any surgical procedure and allows the operating room staff to determine they have the right client, procedure, and side (if appropriate). The client's baseline vital signs should have already been performed. The anesthesia is managed by the anesthetist or anesthesiologist when the procedural physician is prepared for the beginning of the operation; however, this is not part of the time-out. The preoperative antibiotic should be administered within 60 minutes of the surgery but is also not part of the time-out.
The nurse is providing education about deep-breathing exercises to a postoperative client whose surgery took place earlier today. Which instruction should the nurse provide? "Take off your oxygen nasal prongs during your exercises and replace them as soon as you're done." "Try to do your exercises every 1 to 2 hours." "It's best to do your exercises before a meal rather than after eating and drinking." "If possible, lie flat on your back while you're doing your breathing exercises."
"Try to do your exercises every 1 to 2 hours." Explanation: Instruct the client that deep-breathing exercises should be performed every 1 to 2 hours for the first 24 hours after surgery.
The nurse assists a client to turn in the bed. The client has just returned from abdominal surgery. How does the nurse instruct the client? "Use a pillow to splint the incision." "Change your position frequently." "Raise the head of the bed before turning." "Wait for assistance before moving in bed."
"Use a pillow to splint the incision." Explanation: The client needs to use a pillow to splint the incision during movement to reduce pain. The client needs to change position every 2 hours or less; "frequently" could be misinterpreted by the client. It is easier to turn laterally when the head of the bed is flat. Independence is encouraged, so if the client feels capable, he or she may move in the bed on his or her own.
The nurse needs to evaluate the effectiveness of a preoperative teaching session with a client scheduled for abdominal surgery. Which client statement indicates the need for further clarification? "I will splint my incision while I cough." "While my pneumatic compression device is on, I don't need to do leg exercises." "Every 2 hours while I am awake, I will take deep breaths and cough." "I will sit up in bed before using my incentive spirometer."
"While my pneumatic compression device is on, I don't need to do leg exercises." Explanation: Compression stockings and pneumatic compression devices help to decrease the formation of thrombus by helping to promote venous return to the heart. The nurse needs to clarify that the pneumatic compression device does not replace leg exercises because the exercises help keep the joints flexible and help strengthen muscles while the client is in bed. The client is correct that splinting the incision when coughing is important. The client should sit up in bed when using the incentive spirometer, taking deep breaths and coughing. The client should take deep breaths and cough at least every 2 hours while awake to help expand lungs, loosen secretions, and help prevent atelectasis and pneumonia.
The nurse has delegated to the unlicensed assistive personnel (UAP) the application of antiembolism stockings to a client who had an endarterectomy earlier in the day. Which UAP action requires the nurse to immediately intervene? cleanses hands with alcohol-based hand rub measures calf circumference massages legs prior to application elevates the legs 15 minutes after applying stockings
massages legs prior to application Explanation: Massaging the legs can dislodge clots. Other actions are appropriate and do not require intervention.
The licensed practical nurse (LPN) is observed by the registered nurse (RN) engaging in the re-inforcement of teaching related to therapeutic deep breathing and coughing with a client who is recovering from abdominal surgery. Which statement by the RN best supports the LPN's role in the implementation of this intervention? "You served as a good role model while showing the client the proper technigue for this intervention." "Advocating for the client's recovery is an important role LPNs engage in when providing client care." "Let me know whether the client reported any pain during the implementation of this respiratory intervention." "Be sure to chart your evaluation of the effectiveness of this postoperative intervention on the client's respiratory status."
"You served as a good role model while showing the client the proper technigue for this intervention." Explanation: Appropriately demonstrating a technique is an example of role modeling. When demonstratng effective posturing, abdominal splinting, and breathing, the LPN is acting as a role role and is re-inforcing the implementaion of the intervention. This is a component of the nurse's role to teach/educate the client. While advocacy and reporting client needs are both nursing responsibilites, neither are focused directly on client teaching as is role modeling. Evaluation is a RN responsiblity and not delegated to the LPN.
An operating room nurse is bringing a client to the nurse in the postanesthesia care unit (PACU). Which information would the operating room nurse provide during a hand-off report? Select all that apply. medications given in operating room length of surgery drains inserted in surgery all personnel present in operating room performance of time-out before surgery
medications given in operating room length of surgery drains inserted in surgery Explanation: The operating room nurse should give a hand-off report when bringing the client from the operating room and must include several critical pieces of information: medications given, the length of surgery, and any drains inserted. Other data that would be important include presenting condition of the client and any events that occurred during surgery. All personnel present in the operating room would not be an important detail to share; however, this is documented on the operating room record, as well as the time-out that was performed.
A 2-year-old toddler just underwent a tonsillectomy and adenoidectomy surgery. The postanesthesia care unit (PACU) nurse is checking on him. What is the best course of action regarding the developmental care of this child? Give the child a new teddy bear. Extubate the child as soon as possible. Administer acetaminophen before the child wakes. Allow the parents into the PACU before the child wakes.
Allow the parents into the PACU before the child wakes. Explanation: Toddlers are prone to separation anxiety. Allowing the child to be with the parents will lower anxiety levels for all members of the family. This will subsequently ease the care for the bedside nurse.
The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. What would be the nurse's most appropriate initial response? Determine the possible cause of the client's bleeding. Apply pressure to the surgical site to decrease bleeding. Assess the client's vital signs. Notify the health care provider.
Apply pressure to the surgical site to decrease bleeding. Explanation: It is essential that the nurse be prepared to address life-threatening needs of the client. Excessive bleeding is a life-threatening issue. Determining the cause of the client's bleeding, assessing the vital signs, and notifying the health care provider are important, but the life-threatening issue must be addressed first.
A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first? Check the client's blood pressure. Apply an oxygen saturation monitor. Apply warm blankets to the client. Notify the health care provider.
Apply warm blankets to the client. Explanation: The nurse should apply warm blankets to the client because the client is hypothermic with a temperature of 96.2°F (35.7°C). The client can be assessed further by checking vital signs and using an oxygen saturation monitor. The health care provider should be notified about the client's temperature but an intervention should be done first to ensure the client begins warming immediately.
A nurse is teaching a client about the rationale for fasting from food and fluids prior to surgery. What condition does this measure attempt to avoid? Infection Respiratory distress Aspiration Bowel alterations
Aspiration Explanation: Food and fluid are restricted before surgery to ensure that the stomach contains a minimal amount of gastric secretions. This restriction is important to reduce the risk of aspiration.
A client has presented to the outpatient surgical center for a scheduled procedure. Which action should the nurse perform prior to the procedure? Assess the client's allergy status. Encourage the client to create an advance directive. Have the client perform leg exercises every 30 minutes. Administer analgesia (pain medications).
Assess the client's allergy status. Explanation: The nurse should assess or confirm the client's allergy status prior to surgery. An advance directive may be in place, but one would not be created on the day of surgery if it were not already established. Analgesia is not normally given preoperatively. Leg exercises should be taught and modeled preoperatively, but they do not need to be performed during this phase.
Which nursing action should the PACU nurse take to prevent postoperative complications in clients? Instruct the client to avoid coughing to prevent injury to the incision. Encourage the client to breathe shallowly to prevent collapse of the alveoli. Assist the client to do leg exercises to increase venous return. Avoid turning the client in bed until the incision is no longer painful.
Assist the client to do leg exercises to increase venous return. Explanation: Leg exercises increase venous return in order to prevent the postoperative complication of clot formation in the lower extremities. Coughing, while splinting the incision, and deep breathing is encouraged to prevent respiratory complications such as pneumonia and atelectasis. Turning the client stimulates the circulatory and respiratory system, and prevents skin breakdown.
Which preoperative task can the nurse delegate to the UAP (unlicensed assistive personnel)? Auscultating of the client's breath sounds Teaching about use of the incentive spirometer Checking to be sure all diagnostic tests are completed Assisting the client to the bathroom before surgery
Assisting the client to the bathroom before surgery Explanation: Preoperative tasks would include assessing the client, ensuring all diagnostic tests are complete, and teaching the client regarding the postoperative period. None of these tasks can be delegated to a UAP; however, the UAP can assist the client to the bathroom before transport to a preoperative area or the operating room.
The acute care nurse is preparing a client for surgery. Which action is essential to complete before transferring the client to surgery? Assure that diagnostic testing has been completed and results are available. Place the client in a side-lying position. Remove graduated compression stockings. Mark the client's skin to indicate the location of the surgery.
Assure that diagnostic testing has been completed and results are available. Explanation: All prescribed diagnostic tests should be performed, and results made available before the client goes to surgery. Unless otherwise indicated, no special positioning is required preoperatively. Graduated compression stockings, if prescribed, should remain in place. The surgeon, not the nurse, is responsible for marking the skin.
An elder adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client? Dementia Delirium Narcotic overuse Boredom
Delirium Explanation: Delirium refers to acute confusion that is reversible. It is common in the acute postoperative period.
The nurse is performing a preoperative assessment of a client who has been scheduled for a reduction mammoplasty (breast reduction). The client states, "I'm starting to wonder if I made the right decision in going ahead with this." What should the nurse do next? Explore the client's feelings and inform the surgeon. Assess the client's rationale and affirm that she has made a good decision. Remind the client that she has signed the informed consent documents. Ask the client about her understanding of the potential benefits of the surgery.
Explore the client's feelings and inform the surgeon. Explanation: The nurse should discuss this and notify the care provider. Clients should not undergo surgery until they are sure that surgery is what they want. Informed consent documents do not bind the client to an earlier decision. It would be inappropriate to try to convince the client to go through with the surgery if she is questioning her decision.
A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client? Position the client in bed with pillows placed under his knees to hasten venous return. Keep the client from ambulating until the day after surgery. Implement leg exercises and turn the client in bed every 2 hours. Keep the client cool and uncovered to prevent elevated temperature.
Implement leg exercises and turn the client in bed every 2 hours. Explanation: Ambulation and leg exercises increase circulation, which prevents cardiovascular complications. The nurse should provide covers, forced warm air, or other warming devices/techniques as necessary to prevent shivering and hypothermia caused by the surgical procedure, the procedure's length, anesthetic agents, a cool environment, the client's age, or the use of cool irrigating/infusion fluids. Pillows placed under the knees can cause venous pooling, leading to thrombophlebitis.
The preoperative nurse has prepared a client for surgery and has been notified that the operating room staff is ready for the client. The client states, "My bladder feels full. I need to go to the bathroom!" Which action by the nurse is appropriate? Inform the operating room staff and assist the client to the bathroom. Inform the client that anesthesia will prevent the bladder from emptying during surgery. Insert a catheter into the bladder. Remind the client that bladder fullness is a common preoperative sensation.
Inform the operating room staff and assist the client to the bathroom. Explanation: Clients should empty the bowel and bladder before surgery. A urinary catheter is not indicated. The remaining statements are untrue.
The nurse is preparing a client for coronary artery bypass graft cardiac surgery. Which interventions should the nurse provide during the preoperative phase? Select all that apply. Instruct the client how to use the incentive spirometer. Measure the legs for graduated compression stockings. Prep the skin of the chest and legs with surgical prep. Explain what to expect after the surgery. Assess the midsternal and leg dressings.
Instruct the client how to use the incentive spirometer. Measure the legs for graduated compression stockings. Explain what to expect after the surgery. Explanation: During the preoperative phase the nurse would instruct the client on what to expect after surgery, including lines, chest tubes, and mechanical ventilator. The nurse would instruct the client on how to use the incentive spirometer and mark on it the client's maximum volume, so the goal after surgery is that the client can reach that level. This ensures that the client is taking a sufficient deep breath. Measurements for graduated compression stockings are made before surgery since the client will wear them after surgery. Surgical skin prep is intraoperative. Midsternal and leg dressings are assessed during the postoperative phase.
A nurse teaches deep breathing exercises to a preoperative client. Which action should the nurse perform? Assist or place the client in a supine position for the exercises. Instruct the client to place the palms of both hands along the upper posterior rib cage. Instruct the client to exhale gently and completely before inhaling. Instruct the client to breathe in through the nose as deeply as possible and hold the breath for 10 seconds.
Instruct the client to exhale gently and completely before inhaling. Explanation: The nurse should assist the client to sit up and place the palms of both hands along the lower anterior rib cage. The client should then exhale gently and completely inhale through the nose as deeply as possible, holding the breath for 3 seconds.
The nurse is supervising a nursing student who is providing postoperative education to a client with an abdominal incision. The nurse sees the student coaching the client to perform coughing exercises, as pictured above. What is the nurse's best action? Instruct the student to provide the client with a pillow or folded blanket to hug. Help the student assist the client into a high Fowler's position. Help the client determine whether she is able to dangle at the side of the bed. Remind the student to support the client while she performs the exercises.
Instruct the student to provide the client with a pillow or folded blanket to hug. Explanation: Because coughing is often painful, the student should teach the client how to splint the incision (i.e., support the incision with a pillow or folded bath blanket). It is not normally necessary to physically support the client, and it may be unsafe for the client to dangle. The client should not be in a supine or in a low Fowler's position, but the client does not necessarily need to be fully upright.
A nurse is preparing a client for endotracheal intubation. The anesthesiologist has ordered an anticholinergic medication for this client. What is an action of this medication? It promotes induction of anesthesia. It decreases gastric acidity and volume. It promotes sleep or conscious sedation. It decreases respiratory secretions.
It decreases respiratory secretions. Explanation: An anticholinergic medication decreases respiratory secretions and prevents vagal nerve stimulation during endotracheal intubation. Antianxiety drugs slow motor activity and promote the induction of anesthesia. Histamine-2 receptor antagonists decrease gastric acidity and volume. Sedatives promote sleep or conscious sedation.
The preoperative nurse is reviewing the chart of a client whose surgery is scheduled to begin in the next 15 minutes and notices that the consent form is not signed. The nurse contacts the surgeon who states, "We have already reviewed this procedure extensively, so ask the client to sign the consent form and I will verify it in the operating room." Which action by the nurse is appropriate? Keep the client in the preoperative area and inform the surgeon that it is the health care provider's responsibility to obtain consent for surgery. Ask the client to sign the consent; witness the signature and inform the operating room staff of the modification in the procedure. Send the client to the operating room and inform the staff that the consent form needs to be signed. Ask the operating room staff to delay the procedure until the consent is signed.
Keep the client in the preoperative area and inform the surgeon that it is the health care provider's responsibility to obtain consent for surgery. Explanation: If a consent form is not signed, the nurse should notify the surgeon. It is the health care provider's responsibility to obtain consent for surgery and anesthesia. Preoperative medications cannot be given until the consent form is signed. The client should not proceed to surgery without a signed consent form (unless it is an emergency).
Which surgical clients will return to activities in their everyday lives more quickly? Vaginal hysterectomy Laparoscopic cholecystectomy Right nephrectomy Open-heart surgery
Laparoscopic cholecystectomy Explanation: Clients who have surgery using a laparoscope are able to return to previous activity levels much sooner.
A nurse anesthetist administers regional anesthesia to a client being prepared for facial surgery. Which type of regional anesthesia would be the appropriate choice for this client? Nerve block Subdural block Surface anesthesia Local infiltration with lidocaine
Local infiltration with lidocaine Explanation: Local infiltration with lidocaine is a local anesthetic which numbs a specific, more superficial, area of the body. Nerve blocks are accomplished by injecting a local anesthetic around a nerve trunk supplying the area of surgery (such as the jaw, face, and extremities). Subdural block is an unintended subdural injection during epidural anesthesia. Surface anesthesia refers to total or partial loss of sensation with an anesthetic (such as chloroform or nitrous oxide).
After a client receives morphine sulfate for pain in the postanesthesia care unit (PACU), which assessment finding would the nurse obtain as a priority? Auscultate bowel sounds. Obtain temperature. Measure respiratory rate. Check the neurologic status.
Measure respiratory rate. Explanation: The client who is receiving morphine sulfate for pain has a potential for decreased respiratory effort because of the side effect of respiratory depression; the client may also have constipation as a side effect, but this would not be a priority over respiratory depression. The postoperative client needs to be monitored for changes in their neurologic status and temperature, but this would not be a priority over the respiratory status.
A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding? Monitor the client closely and promote fluid intake. Contact the physician to come assess the client. Immediately administer a cleansing enema. Increase the rate of the client's intravenous infusion.
Monitor the client closely and promote fluid intake. Explanation: Bowel function does not typically return immediately after surgery, but it can be promoted by encouraging fluid and fiber intake as appropriate to the client and his or her surgery. A medical assessment is likely unnecessary at this early postoperative stage, and an enema would likely be premature. The nurse may not independently increase the client's IV infusion, and doing so would not necessarily promote a bowel movement.
The healthy adult client is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first? Immediately have the client sign the consent form. Have the client's family member sign the consent form. Ask the client if he still wants to proceed with the procedure. Notify the physician of the oversight.
Notify the physician of the oversight. Explanation: Do not administer any medications that might alter judgment or perception before the client signs the consent form because many drugs commonly administered as preoperative medications, such as narcotics or barbiturates, can alter cognitive abilities and invalidate informed consent.
A nurse is giving preoperative information to a client scheduled for outpatient surgery. What are recommended education guidelines? Select all that apply. Continue with all medications routinely taken. Notify the surgeon's office if a cold or infection develops before surgery. List allergies and be sure the operating staff is aware of these. Wear clothing without buttons or zippers. Have someone available for transportation home after recovery from anesthesia.
Notify the surgeon's office if a cold or infection develops before surgery. List allergies and be sure the operating staff is aware of these. Have someone available for transportation home after recovery from anesthesia. Explanation: The nurse should list medications routinely taken and ask the physician which should be taken or omitted the morning of surgery. The nurse should also have the client notify the surgeon's office if a cold or infection develops before surgery. The nurse should list allergies and be sure the operating staff is aware of these. The nurse should tell the client to wear clothing that buttons in front. The nurse should tell the client to have someone available for transportation home after recovery from anesthesia. The nurse should also inform the client of limitations on eating or drinking before surgery, with a specific time to begin the limitations.
Which nursing action will best promote pain management for a client in the postoperative phase? Breathing into a paper bag Performing relaxation techniques Dimming the lights Providing food and medication
Performing relaxation techniques Explanation: Performing relaxation techniques is the best nursing action to promote pain management for a client in the postoperative phase.
Which measure would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client? Educate the client about the use of an incentive spirometer. Encourage the client to elevate the head of the bed. Elevate bilateral legs when the client is lying in bed. Place graduated compression stockings on the client.
Place graduated compression stockings on the client. Explanation: Use of graduated compression stockings and/or pneumatic compression devices on the client will help with prevention of DVT, which is a risk for clients after surgery. Elevating the client's legs will passively improve venous return but not prevent DVT if a client is not up and walking (to more actively promote the venous return). Elevating the head of the bed and using the incentive spirometer help prevent postoperative complications of atelectasis or pneumonia.
A nurse caring for clients in a PACU assesses a client who is displaying signs and symptoms of shock. What is the priority nursing intervention for this client? Remove extra coverings on the client to keep temperature down. Place the client in a flat position with legs elevated 45 degrees. Do not administer any further medication. Place the client in the prone position.
Place the client in a flat position with legs elevated 45 degrees. Explanation: Placing the client in a flat position with the legs elevated 45 degrees uses gravity to help direct blood to the vital organs. Removing extra coverings would cause the client's temperature to drop further during the blood loss occurring during shock. Medications will likely be ordered to help treat the shock. Prone position would be contraindicated.
The outpatient surgery nurse is preparing to discharge a client who has recovered from surgery. Which actions should the nurse plan to carry out before the client is discharged? Select all that apply. Provide verbal postoperative instructions. Provide written postoperative instructions. Provide contact information to schedule a postoperative appointment with the surgeon. Provide instructions about caring for the intravenous (IV) catheter that will remain in place until the postoperative appointment. Ask the client to list home medications and allergies. Provide a sterile specimen cup and instructions about collecting a routine postoperative urine sample.
Provide verbal postoperative instructions. Provide written postoperative instructions. Provide contact information to schedule a postoperative appointment with the surgeon. Explanation: The nurse should provide verbal and written discharge instructions and information about a follow-up appointment. Questions about home medications and allergies should be asked preoperatively. IV catheters are typically removed before discharge. Collecting a postoperative urine sample is not routine.
The nurse is teaching the client who recently experienced abdominal surgery to deep breathe and cough effectively. What observable action serves to best minimize pain that may result from the intervention? Supporting the head and shoulders effectively to prevent muscle strain Exhaling through the mouth with lips pursed to slowly empty the lungs Offering emotional support to help minimize concern of abdominal pain Providing support to abdominal and accessory respiratory muscles
Providing support to abdominal and accessory respiratory muscles Explanation: Coughing and deep breathing uses abdominal and accessory respiratory muscles, which may have been cut during surgery. Splinting, in this case with a pillow, supports the incision and surrounding tissues and reduces pain during coughing and deep breathing exercises. While providing emotional support is appropriate, doing so will not affect physiological pain resulting from the intervention. Exhaling with lips pursed increases resistance in the airways, which helps them stay open during exhalation. Supporting the head and shoulders adds to the client's comfort, but doing so does not address the primary source of pain produced by therapuetic coughing and deep breathing.
The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency? Respiratory obstruction Cardiac distress Wound infection Dehydration
Respiratory obstruction Explanation: Respiratory obstruction may occur as a result of secretion accumulation, obstruction by the tongue, laryngospasm (a sudden, violent contraction of the vocal cords), or laryngeal edema. Cardiac distress, wound infection, and dehydration are all possible postoperative complications, but respiratory obstruction is most common.
The nurse is caring for a client who had abdominal surgery yesterday and is reluctant to cough and perform deep breathing. Which strategy will most likely increase the client's willingness to cough and perform deep breathing? Teach the client how to splint the abdomen while coughing. Remind the client of the serious complications that can result from ineffective coughing and deep breathing. Administer respiratory treatments to encourage coughing. Assist the client to a side-lying position to cough.
Teach the client how to splint the abdomen while coughing. Explanation: Splinting the abdomen decreases discomfort while coughing. Telling the client about complications will be less effective than teaching splinting techniques. Respiratory treatments are not indicated for cough production. Side-lying position is less effective than upright positioning to clear secretions and expand the lungs.
A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which characteristic applies to this type of surgery? The client will be admitted the day of surgery and return home the same day. The surgery will be conducted using moderate sedation rather than general anesthesia. The surgery is classified as urgent rather than elective. The client must be previously healthy with low surgical risks.
The client will be admitted the day of surgery and return home the same day. Explanation: Outpatient surgeries, also known as ambulatory surgeries, are conducted with admission and discharge on the same day. Such surgeries have become increasingly common in recent years, and some surgeries of increasing complexity and risk are conducted on an outpatient basis. General anesthesia is possible and common. This approach is more common for elective surgeries than urgent surgeries.
In the postoperative phase of abdominal surgery, the client reports severe abdominal pain. In the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect? normal response abdominal infection hernia development paralytic ileus
paralytic ileus Explanation: A potential complication after surgery is paralytic ileus, a condition in which there is decreased bowel functioning.
The nurse is teaching a client about postoperative pain management. The client states, "I would like to use as little medication as possible after surgery. Will anything else help to relieve my pain?" Which response is appropriate? There are several nonpharmacologic methods to reduce pain and anxiety. Let me teach you about some of them." Are you afraid of becoming addicted to pain medications?" "Your pain needs to be managed with medication for the first 24 hours, then you can try nonpharmacologic methods." "There are nonpharmacologic methods, but they only work when clients have practiced them extensively beforehand."
There are several nonpharmacologic methods to reduce pain and anxiety. Let me teach you about some of them." Explanation: Nonpharmacologic measures may reduce anxiety and reduce the need for pain medication at any time during the postoperative period. Asking about fear of addiction does not address the client's question. Nonpharmacologic methods can be implemented postoperatively regardless of prior client experience.
Which client in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse? a 30-year-old client who is drowsy and reporting pain a 6-year-old client who is crying for a parent to visit an 80-year-old client who is disoriented to place and time a 26-year-old client who is exhibiting a crowing sound
a 26-year-old client who is exhibiting a crowing sound Explanation: A client with a crowing sound is exhibiting stridor, which is an indication of an airway obstruction and can be a respiratory emergency. This client needs immediate attention. The client with disorientation needs to be frequently reoriented and observed for safety reasons but is not a priority over respiratory distress. The client who needs pain medication or the pediatric client requesting a parent are also not priority over a client in respiratory distress.
When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of: the effects of anesthesia. the normal return of reflexes. a partial airway obstruction. the type of surgery.
a partial airway obstruction. Explanation: Loud, irregular respirations may indicate obstruction of the airway, possibly from emesis, accumulated secretions, or client positioning that allows the tongue to fall to the back of the throat.
A nurse is working with a group of clients in the preoperative area. Which client task would be the highest priority? inserting a Foley catheter in a client before major surgery raising the stretcher side rails when administering a sedative obtaining a list of home medications from a client measuring a diabetic client's blood glucose
raising the stretcher side rails when administering a sedative Explanation: Although all of these are important to do, making sure of client safety with raising the side rails of the client's bed when administering a sedative is most important. Inserting the Foley catheter before surgery, obtaining a list of home medications, and measuring a blood glucose on a client could potentially prevent safety issues as well but are not as direct an intervention as raising the side rails of the bed to prevent a client fall.
A client is scheduled for cardiac surgery in an acute care facility. What intervention would occur in the intraoperative phase of this client's perioperative care? airway/oxygen therapy/pulse oximetry skin preparation frequent vital signs/assessments visit by the anesthesiologist
skin preparation Explanation: The intraoperative phase begins when the client is transferred to the operating room bed until transfer to the postsurgical recovery area. One of the interventions performed in this phase is skin preparation. The preoperative phase provides client teaching regarding the surgical experience, including a visit by the anesthesiologist. The postoperative phase begins immediately after the surgical procedure is completed when assessments and therapies are performed, such as taking vital signs frequently and monitoring airway/oxygen therapy/pulse oximetry.
When preparing a client who has diabetes mellitus for surgery, the nurse should be aware of what surgical risk associated with this disease? fluid and electrolyte imbalance slow wound healing respiratory depression from anesthesia altered metabolism and excretion of drugs
slow wound healing Explanation: Due to impaired circulation and high glucose levels, the client with diabetes is at an increased risk for slow wound healing. The surgical risk of fluid and electrolyte imbalances is often associated with clients who have kidney and liver disease. The risk of respiratory depression from surgery increases for clients with existing respiratory disorders. Altered metabolism may occur as a result of surgery for clients with kidney and liver diseases.
Who is legally responsible for obtaining the client's informed consent for a surgical procedure? the surgeon the registered nurse the admissions clerk any licensed person
the surgeon Explanation: The surgeon is legally responsible for obtaining the client's informed consent.
The nurse recognizes that palliative surgery is performed for what purpose? to remove a part of the body that is diseased to lessen the intensity of an illness to make or confirm a diagnosis to restore function to tissue that is traumatized
to lessen the intensity of an illness Explanation: Palliative surgery is performed to help lessen the intensity of an illness; it is not meant to be curative but will help improve the client's quality of life. A diagnostic surgery makes or confirms a diagnosis such as with a biopsy to check for cancer. A removal of a body part that is diseased is ablative surgery, such as an appendectomy. Restoring function to traumatized tissue is reconstructive surgery, such as with plastic surgery.
Which nursing intervention is most likely to prevent respiratory complications such as pneumonia and atelectasis in a postoperative client? use of incentive spirometry adequate pain control control of anxiety and agitation adequate nutrition and fluids
use of incentive spirometry Explanation: Incentive spirometry improves lung expansion, helps expel anesthetic gases and mucus from the airway, and facilitates oxygenation of body tissues. Pain control and hydration may facilitate lung expansion and mobilization of secretions, but incentive spirometry directly increases lung volume and alveolar expansion. Control of anxiety and agitation are not affected by the respiratory system.
A nurse from the ambulatory surgical center is preparing discharge instructions for a client who has had pelvic surgery. Which criterion would the client need to demonstrate to ensure that she is ready for discharge? verbalize absence of pain void normally eat without nausea exhibit no bleeding
void normally Explanation: Before discharge from an ambulatory surgical unit, the client should be able to void normally after a pelvic surgery. It is natural for the client to experience pain after surgery; however, the client should also have the comfort level to control it. The client may not be in a position to eliminate nausea and vomiting completely before discharge, but should suffer minimally from them. The client may have some bleeding or drainage, which should not be excessive at the time of discharge from an ambulatory surgical unit.
