PeriOp

Which client is at greatest risk for slow wound healing? A. 12-year-old healthy girl B. 47-year-old obese man with diabetes C. 48-year-old woman who smokes D. 98-year-old healthy man

B. Diabetes and obesity significantly contribute to slow wound healing.

The nurse assesses the client's wound 24 hours postoperatively. Which finding causes the nurse the greatest concern? A. Crusting along the incision line B. Redness and swelling around the incision C. Sanguineous drainage at the suture site D. Serosanguineous drainage on the dressing

B. Redness and swelling around the incision indicate an infection.

As the nurse obtains the informed consent, the client asks, "Now what exactly are they going to do to me?" What is the nurse's response? A. Contacts the anesthesiologist B. Contacts the surgeon C. Explains the procedure D. Has the client sign the form

B. The nurse is not responsible for providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the physician and to dispel myths that the client or family may have about the surgical experience.

What pain management does the client who has been admitted to the postanesthesia care unit typically receive? A. Intramuscular non-opioid analgesics B. Intramuscular opioid analgesics C. Intravenous non-opioid analgesics D. Intravenous opioid analgesics

D. IV opioids are given in small doses to provide pain relief but not to mask an anesthetic reaction.

The older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? A. Calls the legal department to draft the paperwork B. Documents this in the chart C. Thanks the person and does nothing D. Talks to the client

D. The nurse should determine the client's wishes and state of mind.

The client who is preparing to undergo a vaginal hysterectomy is concerned about being exposed. How does the nurse ensure that this client's privacy will be maintained? A. Tells the client that she will be asleep B. Ensures that drapes will minimize perianal exposure C. Explains postoperative expectations D. Restricts the number of technicians in the procedure

B. Using drapes is the best action to take.

When changing the client's abdominal dressing on the second postoperative day, the nurse observes crusting on about half of the suture line and oozing of a small amount of serosanguineous drainage. What is the nurse's best action? A. Loosen the sutures or staples in the area where crusts have formed. B. Clean the suture line with sterile saline and apply new dressings. C. Gently remove the crusts and culture the material beneath. D. Apply pressure over the incision and notify the surgeon.

B. Serosanguineous drainage and a small amount of crusting are normal incision findings on the second postoperative day. The suture line needs to be cleaned and a new dressing applied. The other actions are inappropriate.

The Joint Commission standards regarding Universal Protocols for preventing wrong site, wrong procedure, and wrong person surgery includes: Select all that apply. A. Marking the surgical site by the preoperative nurse. B. Validating the correct surgical site by the surgeon before beginning the procedure. C. Writing the word "yes" on the surgical check list line indicating the correct incision site. D. Completing a final verification of the site in the location where the procedure takes place.

C,D: The surgical site is marked by the person performing the procedure (1). All members of the surgical team verify the site (2).

The surgical client has signed do-not-resuscitate (DNR) orders before going to the operating room (OR). A complication requiring resuscitation happens during surgery. What is the nurse's proper action? A. Call the legal department. B. Call the client's medical physician. C. Honor the DNR order. D. Resuscitate per OR procedure.

C. According to the Association of Perioperative Registered Nurses, suspending a DNR order during surgery violates a client's right to self-determination.

The client is having an arthroscopy of the left knee and has just been moved to the surgical holding area. Which statement by the nurse properly identifies the client while the nurse checks the identification label? A. "Are you Mr. Smith?" B. "Good morning, Mr. Smith." C. "What is your name, and where were you born?" D. "What surgery are you having today?"

C. The nurse must verify the client's identity with two types of identifiers. This practice prevents errors by drowsy or confused clients. Asking the client about his or her surgery does help with identification. However, it is really done to ascertain that the client's perception of the procedure, the operative permit, and the operative schedule are the same.

The postanesthesia recovery unit nurse is receiving a hand-off report from the nurse anesthetist and the circulating nurse for an 82-year-old client who had a 2-hour open reduction of a fractured elbow. For which reported information about the client or surgery does the receiving nurse ask the reporting team for more details? A. The client is Jewish. B. The estimated blood loss is 150 mL. C. The client reported an allergy to codeine. D. The total intraoperative urine output is 25 mL.

D. The total intraoperative urine output is very low. Information regarding the client's total intake, kidney function, and fluid status is needed.

The charge nurse for a hospital operating room is making client assignments for the day. Which client is most appropriate to assign to the least-experienced circulating nurse? A. A 20-year-old client who has a ruptured appendix and is having an emergency appendectomy B. A 28-year-old client with a fractured femur who is having an open reduction and internal fixation C. A 45-year-old client with coronary artery disease who is having coronary artery bypass grafting D. A 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed

D. This is the most stable client among all scheduled procedures. This assignment would be appropriate for the beginning nurse or one with less experience. Option A is at high risk for infection/sepsis. Option B is at high risk for clotting, infection, and aspiration owing to the surgery. Option C is having high-risk surgery with risk for multiple complications.

For which client preadmission testing laboratory result does the nurse take immediate action? A. International normalized ratio 0.9 B. White blood cell count 8500/mm3 C. Serum potassium level 2.8 mEq/L D. Serum sodium level 132 mEq/L

C. The serum potassium level is significantly low (hypokalemia) and must be corrected before surgery. This level increases the risk for toxicity if the client is taking digoxin, slows recovery from anesthesia, and increases cardiac irritability. Although the serum sodium and INR are also low, they are not low enough to cause any problems. The white blood cell count is normal.

The student's client assignment includes a preoperative client scheduled for surgery in 3 hours. The initial intervention is to reduce anxiety and stress for this client. This can best be accomplished by: Select all that apply. A. Discussing realistic outcomes with the client. B. Avoiding promoting false reassurances. C. Using touch to communicate caring. D. Encouraging range of motion and walking activities.

A-D. All distractors are correct. All of these interventions can and should be used to reduce anxiety in a preoperative client.

During surgery, who is most responsible for monitoring for possible breaks in sterile technique? A. Circulating nurse B. Holding nurse C. Anesthesiologist D. Surgeon

A. All are responsible, but the circulating nurse moves around the room and can see more of what is happening.

Who is the most likely person to administer blood products in an operating suite? A. Circulating nurse B. Holding area nurse C. Scrub nurse D. Specialty nurse

A. Circulating nurses or "circulators" are registered nurses who coordinate, oversee, and are involved in the client's nursing care in the operating room. Holding area nurses manage the client's care before surgery. Blood would not yet be needed at this point. Scrub nurses set up the sterile field, drape the client, and hand sterile supplies, sterile equipment, and instruments to the surgeon and the assistant.Specialty nurses may be in charge of a particular type of surgical specialty. They are responsible for nursing care specific to clients who need that type of surgery, such as assessing, maintaining, and recommending equipment, instruments, and supplies.

In conducting a postoperative assessment of the client, what is most important for the nurse to examine first? A. Breathing pattern B. Level of consciousness C. Oxygen saturation D. Surgical site

A. Respiratory assessment is the most important.

As a student nurse working in the outpatient setting, you are asked to provide postoperative instructions to a client after a laparoscopy. The most appropriate instructions should be to A. Instruct the client that he/she may experience a sharp pain under the scapula up to 24-48 hr after surgery. B. Inform the client he/she will be hospitalized for a minimum of 24 hr to monitor for pain. C. Inform the client that this type of surgery usually requires very little pain medication; Tylenol is sufficient to control the pain. D. Explain that the client can return to work the next day, as long as they do not lift anything over 50 pounds.

A. Sharp pain under the scapula post-operatively is indicative of carbon dioxide irritation of the phrenic nerve in the diaphragm, causing the referred pain. Very infrequently is a client with a laparoscopy hospitalized to monitor pain, unless there is some extenuating circumstance. Usually a stronger acting pain medication is administered for pain following any surgical procedure. Most clients do not return to work the next day; the recovery time for anesthesia is longer than 24 hours.

An RN and an LPN/LVN are working together in caring for a client who needs all of the following actions after orthopedic surgery. Which actions would be best for the RN to accomplish? A. Reinforce the need to cough and deep breathe every 2 to 4 hours. B. Develop the discharge teaching plan in conjunction with the client. C. Administer narcotic pain medications before assisting the client with ambulation. D. Listen for bowel sounds, and monitor the abdomen for distention and pain.

B. Education and preparation for discharge are within the scope of practice of the RN. The other options are within the scope of the LPN

What information about the postoperative client does the nurse include in the report to the postanesthesia care unit (PACU) nurse? A. Confirmation of informed consent B. Estimated blood loss C. Type of surgical instruments used D. Type of suture material used

B. Estimated blood loss is important to know, so that the client can be properly monitored.

Which action does the nurse implement for the client with wound evisceration? A. Applies direct pressure to the wound B. Covers the wound with a sterile, warm, moist dressing C. Irrigates the wound with warm, sterile saline D. Replaces tissue protruding into the opening

B. Covering the wound with a sterile, warm, moist dressing protects the organs until the surgeon can repair the wound.Applying direct pressure to a wound traumatizes the organs.Replacing protruding tissue could induce infection.

Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area? A. Provide preoperative teaching to a client who needs insertion of a tunneled central venous catheter. B. Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. C. Obtain the medical history from a client who is scheduled for a total hip replacement. D. Assess the client who is being admitted for an elective laparoscopic cholecystectomy.

B. Insertion of a catheter is within the scope of skills approved for the LPN/LVN.

On admission to the preoperative area, the client scheduled for a hip replacement tells the nurse that three autologous blood donations for this surgery have been made in the past 3 weeks. What is the nurse's best action? A. Check the client's international normalized ratio (INR). B. Call the laboratory to ensure that the blood is physically at the operating facility. C. Ensure that the client has given consent to receive blood if a transfusion is necessary. D. Inform the client that an autologous transfusion does not eliminate the risk for development of bloodborne diseases.

B. Many hospitals or surgical centers do not initially process autologous blood collections. Any donated blood must be in the facility where the surgery will take place before the client undergoes the planned surgical procedure.

The preoperative client wears a hearing aid and is extremely hard of hearing without it. What does the nurse do to help reduce this client's anxiety? A. Actively listens to this client's concerns B. Allows the client to wear the hearing aid to surgery C. Checks to see whether the operating room (OR) staff minds if the client wears the hearing aid until anesthesia is given D. Apologizes to the client and explains that it is hospital policy to remove a hearing aid before surgery

C. In some facilities, clients may wear eyeglasses and hearing aids until after anesthesia induction.

How does the nurse position the client with postoperative respiratory depression? A. Flat in bed, with the head in alignment with the body B. Prone, with the head of the bed flat C. Side-lying, with the head in a neutral position D. Supine in bed, with the neck flexed

C. The side-lying position is the most natural and effective.

The client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. Why is this preoperative procedure done? A. Decreases expected blood loss during surgery B. Eliminates any risk of infection C. Ensures that the bowel is sterile D. Reduces the number of intestinal bacteria

D. Bowel or intestinal preparations are performed to empty the bowel to minimize the leaking of bowel contents, prevent injury to the colon, and reduce the number of intestinal bacteria.

While you are working on a surgical unit, you are preparing the client for a surgical procedure. Your responsibilities in this preparation include: A. Asking the client if he/she has made arrangements for home care after discharge. B. Instructing the client to sign the surgical consent form at the time the OR transporter arrives in the room. C. Administering the preoperative medication at least 2 hr before the surgery is scheduled. D. Checking for allergies to latex, food, and medications.

D. Check for allergies to latex, food, and medications. All latex articles must be removed from the OR, and this client should be scheduled as the first OR case for the day. (2) and (3): The surgical consent form must be signed before the preoperative medication is given. The medication is usually given at least 45 minutes before the OR transporter arrives to take the client to the OR.

The client undergoing induction of anesthesia with succinylcholine, a depolarizing blocker agent, begins to experience generalized muscle twitching. What the circulating nurse's best response? A. Call the anesthesia provider's attention to this response. B. Ensure the client is secured to the table. C. Cover the client with a warm blanket. D. Document this expected response.

D. Depolarizing blocker agents depolarize the motor end plates of nerves innervating skeletal muscles, causing a brief period of fasciculations or muscle twitching. This response is considered normal.

A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which orders should the registered nurse accomplish first? A. Use electrical clippers to cut hair at the surgical site. B. Start an infusion of LR solution at 75 mL/hr. C. Administer 1/2 of the client's usual lispro insulin dose. D. Draw blood for glucose, electrolyte, and CBCs

D. If blood work is abnormal, the surgery may be rescheduled. The blood work needs to be drawn and sent to the laboratory first to confirm that results are within normal limits.

Which statement by a student nurse indicates a need for further teaching about operating room (OR) surgical attire? A. "I must cover my facial hair." B. "I don't need a sterile gown to be in the OR." C. "If I go into the OR, I must wear a protective mask." D. "My scrubs are sterile."

D. Scrub attire is provided by the hospital and is clean, not sterile. Team members who are not scrubbed (e.g., anesthesia provider, student nurse) are not required to be sterile. They may wear cover scrub jackets that are snapped or buttoned closed to prevent shedding of organisms from bare arms.

The client scheduled for knee replacement surgery today performed all of the following actions yesterday. Which action is most important for the nurse to report to the surgeon? A. Took 50 mg of diphenhydramine (Benadryl) at bedtime B. Smoked one pack of cigarettes instead of two C. Drank two 12-oz glasses of beer D. Took two aspirins three times

D. The aspirin taken yesterday will significantly reduce blood clotting for surgery. The surgeon may decide to delay the surgery for at least a week to ensure that adequate numbers of platelets capable of activation are present. The reduction of cigarettes smoked from two packs to one is not significant; the client is a smoker. The beer (in this volume) and the 50 mg of diphenhydramine are not critical information

A client is returning to the nursing unit after an abdominal surgical procedure. The priority nursing intervention is to A. Take and record vital signs. B. Assess type of IV solution and amount of IV solution remaining in bag. C. Check pulse oximeter reading. D. Assess for patent airway.

D. The initial assessment/intervention is to assess for patent airway. If the client is experiencing difficulty breathing, color is pale, skin is cool, oxygen must be administered and the head of the bed slightly elevated. The other interventions should immediately follow this initial assessment and intervention.

As the nurse is about to give the preoperative medication to the client going into surgery, it is discovered that the preoperative permit is not signed. What does the nurse do? A. Calls the surgeon B. Calls the anesthesiologist C. Gives the medication as ordered D. Has the client sign the permit

D. The nurse may ask the client to sign the permit, after which the medication can be administered.It is illegal for the client to sign the permit after being sedated.

In going through the preoperative checklist, the nurse notices that the client's armband does not match the handwritten name on the informed consent, but it matches the stamped name. What does the nurse do first? A. Calls admissions B. Cancels the surgery C. Contacts the surgeon D. Talks to the operating team

D. The operating team should be called to see if any clients with similar names are having surgery done. The client should confirm the spelling of his or her last name. Also, confirm the procedure that is expected to be done and compare it with the informed consent form.This is an administrative issue, not one for the surgeon.

During a preoperative assessment, which statement by the client requires further investigation by the nurse to assess risk? A. "I am taking vitamins." B. "I drink a glass of wine a night." C. "I had a heart attack 4 months ago." D. "I don't like latex balloons."

C. Cardiac problems increase surgical risks. The risk for a myocardial infarction (MI) during surgery is higher in clients who have heart problems.

Which intervention does the nurse implement for the older adult client to minimize skin breakdown related to surgical positioning? A. Applies elastic stocking to lower extremities B. Monitors for excessive blood loss C. Pads bony prominences D. Secures joints on a board in anatomic positions

C. Padding bony prominences best minimizes skin breakdown.

The client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further assessment in the postanesthesia care unit? A. Pain at the surgical site B. Requirement for verbal stimuli to awaken C. Snoring sounds when inhaling D. Sore throat on swallowing

C. Snoring sounds when inhaling may indicate respiratory depression.

Why is it important to wear sterile gloves during a dressing change? A. They protect the client from infection. B. They protect the nurse from infection. C. They protect both the client and the nurse from infection. D. Their use prevents lawsuits.

C. Standard Precautions and infection control protect both the nurse and the client from infection.

The nurse is educating the client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction? A. "I will wake up with a tube in my throat." B. "I will have a bandage on my chest." C. "My family will not be able to see me right away." D. "Pain medication will take away my pain."

D. Pain medication will minimize pain but will not take it away completely. the others are accurate statements.

The nurse is educating a preoperative client about colostomy surgery. The colostomy surgery is categorized as what type of surgery? A. Cosmetic B. Curative C. Diagnostic D. Palliative

D. Palliative surgery is performed to relieve symptoms of a disease process but does not cure the disease.

The role of the circulating nurse in the operating room is to A. Mark the operative site with a felt pen. B. Insert the IV and begin infusing fluids. C. Assist the physician during the operative procedure. D. Position the client on the operative table and attach grounding pad.

D. The physician and the entire operative team identify the correct side and site. The anesthesiologist inserts the IV if it is not already in place. The scrub nurse assists the physician throughout the surgical procedure.

The unidentified client from the emergency department requires immediate surgery, but he is not conscious and no one is with him. What must the nurse who is verifying the informed consent do? A. Ensure written consultation of two noninvolved physicians. B. Read the surgeon's consult to determine whether the client's condition is life threatening. C. Sign the operative permit. D. Withhold surgery until the next of kin is notified.

A. In a life-threatening situation in which every effort has been made to contact the person with medical power of attorney, consent is desired but not essential. In place of written or oral consent, written consultation by at least two physicians who are not associated with the case may be requested by the physician.

The nurse reviews with the client a routine discharge teaching plan concerning postoperative care. Which statement by the client indicates that teaching was effective? A. "I may need to restrict my activities for several months." B. "The dressing should stay in place unless it gets wet." C. "The incision needs to be cleaned every 4 hours with hydrogen peroxide." D. "The wound will completely heal in about 2 months."

A. To protect the integrity of the wound, activities may need to be restricted.

If a sterile gauze falls to the ground and hits the front of the surgeon's gown on the way down, what does the nurse do for proper infection control? A. Helps the surgeon change the gown B. Picks the gauze up with a pair of sterile gloves C. Picks the gauze up without touching the surgeon D. Sprays an antimicrobial on the surgeon's gown

C. The surgeon is sterile, but the gauze is now nonsterile and must be removed and counted.

The circulating nurse sees that a sponge is dropped onto the floor from the instrument table after the first surgical incision is opened. What is this nurse's best action? A. Obtain an additional sterile sponge to replace the contaminated one and place it on the instrument table. B. Place the sponge in the circulating area to include in the final count before incision closure. C. Pick up the sponge and throw it out so no one slips on it. D. Hand the sponge back to the scrub nurse.

B. An accurate count of all sponges initially prepared on the instrument table is matched to the count of sponges present before the incision can be closed. This sponge was counted before surgery and needs to be included in the final count. It cannot be thrown away before the final count is performed. The sponge is now contaminated and cannot not given back to the scrub nurse or surgeon. A replacement sponge should not be needed. Additional sponges are added to the instrument table only if requested and must be added to the initial count.

The client has undergone an 8-hour surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which finding? A. Decreased sensation in the lower extremities B. Diminished peripheral pulses in the lower extremities C. Pale, cool extremities D. Reddened areas over bony prominences

B. Diminished peripheral pulses in the lower extremities indicate diminished blood flow. the other options can be normal occurrences in clients who have undergone a long surgical procedure.

Pneumonia is a major postoperative complication related to inactivity and decreased pulmonary ventilation. As you are assessing the client postoperatively, you recall the usual onset of signs and symptoms is: A. Within 24 hr. B. 24-36 hr. C. 36-48 hr. D. More than 72 hr.

B. Pulmonary complications are usually evident 24-36 hours after surgery. Signs and symptoms of an ileus occur between 24-36 hours postoperatively. Urinary tract infections occur from the third to the fifth post-operative day. Wound infections can occur from 24 hours to 5 days post operatively.

You are caring for a client after a procedure where moderate (conscious) sedation was used. You understand the client will not be discharged until the A. Ramsay Sedation Scale is normal. B. Riker Sedation-Agitation Scale is -1 to +1. C. Aldrete score is ±1 point of preprocedure score. D. Glasgow Coma scale is more than 9.

C. A score of ≤ 9 or ± 1 point of the pre-procedural score on the Aldrete Scale must be obtained before the discharge is completed. A&B are scales used for sedation assessment parameters during the use of moderate sedation. Glasgow is used for assessing clients who have head injuries or who are not alert.

A postoperative client's arterial blood gas (ABG) values are pH 7.36, HCO3 21 mEq/L, PaCO2 35 mm Hg, PaO2 98 mm Hg. What is the nurse's priority action? A. Compare these values with the client's preoperative ABG values. B. Assess the airway and notify the physician. C. Document the values as the only action. D. Increase the oxygen flow rate.

C. All of these ABG results are within the normal range and indicate adequacy of ventilation, gas exchange, and kidney function. Documentation is the only action that needs to be taken.

The nurse is instructing the client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? A. "I will take off my stockings one to three times a day for 30 minutes." B. "My stockings are too loose." C. "These stockings will prevent blood clots." D. "These stockings help promote blood flow."

C. Antiembolism stockings alone will not prevent deep venous thrombosis (DVT). However, along with exercise, they will help promote venous return, which aids in preventing DVT.

The preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best physical outcomes? A. Instructs the client to quit smoking B. Teaches about the dangers of tobacco C. Teaches the importance of incentive spirometry D. Tells the client where the smoking lounge is

C. Incentive spirometry is good for lung hygiene. It encourages deep breathing.

Which of these staff members will be best for the nurse manager to assign to update standard nursing care plans and policies for care of the client in the OR? A. A surgical technologist with 10 years of experience in the OR at this hospital B. A certified registered nurse first assistant (CRNFA) who has worked for 5 years in the ORs of multiple hospitals C. A holding room RN who has worked in the hospital holding room for longer than 15 years D. A circulating RN who has been employed in the hospital OR for 7 years

D. This nurse has the experience and background to write OR policy and has been employed in this hospital and is aware of hospital policy and procedures.

The most common malpractice action against operating room nurses is A. Sponges and instruments left in the surgical site accidentally. B. Surgical procedure performed on wrong site or side. C. Burns from electrical grounding pad not placed correctly on client. D. Infection at surgical site after surgical procedure.

A. Nurses, both scrub and circulating, monitor sponge and instrument counts before, during and after the procedure. The entire OR staff participate in checking the side and site of the procedure, not just the nurses.

The client who had neck surgery to remove the entire thyroid gland is transferred to the medical-surgical unit after 4 hours in the PACU. The client reports difficulty swallowing. What is the nurse's priority action? A. Assess the client's respiratory status. B. Inspect the client's throat with a penlight. C. Adjust the position of the drain in the incision. D. Reassure the client that this is a normal and common problem after anesthesia.

A. Most clients have a sore throat for the first 12 to 24 hours after intubation during surgery, and this is made worse when the client tries to swallow. However, it is important for the nurse to differentiate soreness from true difficulty swallowing. Surgery in the neck area can cause swelling that reduces the lumen of the throat. This can cause respiratory impairment and swallowing difficulties. The most important action is to assess the airway and respiratory response to ensure that breathing impairment is not accompanying a swallowing problem.

The RN has just received reports about all of these clients on the inpatient surgical unit. Which client would the nurse care for first? A. A 43-year-old client who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing B. A 46-year-old client who had a thoracotomy 5 days ago and needs discharge teaching before going home C. A 48-year-old client who had bladder surgery earlier in the day and is complaining of pain when coughing D. A 49-year-old client who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4° F (38° C)

A. New drainage on the fifth postoperative day is unusual and suggests a complication that would require further assessment and possible immediate action.

The client is NPO for surgery scheduled to occur in 4 hours. It is now 9 AM, and the client's regularly prescribed oral drugs (digoxin 0.125 mg, docusate [Colace] 300 mg, and ferrous fumarate [Feostat] 325 mg) are due to be administered. The physician will not be available until the time of surgery. What is the nurse's best action? A. Administer digoxin with minimal water and hold the other drugs. B. Administer all medications parenterally. C. Administer all medications orally. D. Hold all medications.

A. Regularly scheduled cardiac medications should be administered on schedule. If taken with only a few small sips of water at least 2 hours before surgery, the amount of water should not increase the risk of intraoperative or postoperative aspiration. However, not administering this drug could result in cardiac complications during surgery.

The client has an acute case of opioid depression and receives a dose of naloxone (Narcan). Which statement is true about this client? A. Supplemental pain reduction is needed. B. One dose is needed. C. This is an acute emergency. D. The client will be hostile.

A. The client has breakthrough pain after the opioid antagonist is given, so other interventions to promote comfort are needed. Several doses may be needed because naloxone has a shorter half-life.

Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? A. Creatinine, 1.9 mg/dL B. Fasting glucose, 80 mg/dL C. Potassium, 3.9 mEq/L D. Sodium, 140 mEq/L

A. This result is outside the normal range.

The client scheduled to have surgery today cannot read or write. The surgeon obtaining the consent wants to have the client's spouse sign the consent instead. What is the nurse's best action? A. Nothing; a signed informed consent statement does not need to be obtained from this client. B. Locate the spouse because the informed consent statement must be signed by the client's closest relative. C. Remind the surgeon that the client may sign the informed consent statement with an X in front of two witnesses. D. Notify the administration because the court must appoint a legal guardian to represent the client's best interests and give consent for all surgical procedures.

C. : The lack of ability to read or write does not constitute incapacity to give legal consent. If the client meets all other legal and clinical aspects of competence for self-determination, he or she has the right to consent directly by using either his or her own signature or an X to demonstrate consent if the act is witnessed by two people.

During the preoperative stage, the client activity not completed is A. Obtaining a health history. B. Identifying a client's allergies. C. Beginning the infusion of a moderate sedative drug. D. Identifying the side and site of the surgical procedure.

C. A moderate sedation would not be provided in the preoperative stage. This drug is usually administered during the intraoperative stage. The other three distractors are all activities that will be performed during the preoperative stage.

At 8 AM, the registered nurse is admitting to the outpatient surgery department a client who is scheduled for sinus surgery. Which information given by the client would be of most immediate concern to the nurse? A. The client has an allergy to iodine and shellfish. B. The client was nauseated after a previous surgery. C. The client had a small glass of juice at 7 AM. D. The client expresses anxiety about the surgery.

C. Clients need to be NPO for a sufficient length of time before surgery. Intake of food or fluids may delay the start time of the surgery; the nurse needs to notify the surgeon and anesthesia for possible rescheduling.

The nurse completes the preoperative checklist on the client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure? A. Age of 59 years B. General anesthesia complications experienced by the client's brother C. Diet-controlled diabetes mellitus D. Ten pounds over the client's ideal body weight

C. Diabetes contributes an increased risk for surgery. Older adults are at greater risk for surgical procedures. This client is not classified as an older adult. Family medical history and problems with anesthetics may indicate possible reactions to anesthesia, but this is not the best answer.

The client brought to the holding area before surgery tells the nurse he has never had surgery before and is afraid of anything "medical." Which nursing action is most likely to reduce this client's anxiety? A. Administering the preoperative medication as soon as possible. B. Assuring the client that his scheduled surgery is routine and that nothing will go wrong. C. Determining whether the client wants family members to be with him in the holding area. D. Explaining to the client that this hospital's surgical area is the most technologically advanced in the city.

C. Most anxious clients would feel some anxiety relief by having one or more familiar people waiting with them until the time of surgery. In addition, asking the client what he or she wants allows him to have more control over the situation. Telling the client about the advanced technology can imply to him that the procedure is dangerous. Stating that the procedure is routine and that nothing will go wrong does not address the client's fears about his surgery and his lack of familiarity with "medical" routines.

The nurse anesthetist notices that the surgical client has an unexpected rise in the end-tidal carbon dioxide level, with a decrease in oxygen saturation and sinus tachycardia. What is the nurse's first action? A. Administer cardiopulmonary resuscitation (CPR). B. Continue as normal. C. Immediately stop all inhalation anesthetic agents and succinylcholine. D. Inform the surgeon.

C. The most sensitive indication of malignant hypothermia (MH) is an unexpected rise in the end-tidal carbon dioxide level, along with a decrease in oxygen saturation. Another early indication is sinus tachycardia. Survival depends on early diagnosis and the actions of the entire surgical team. Time is crucial when MH is diagnosed.

Which of these RNs who have been floated to the postanesthesia care unit (PACU) for the day should the charge nurse assign to care for an 18-year-old diabetic client who has just arrived from the operating room (OR) after having laparoscopic abdominal surgery? A. An RN who usually works on the inpatient pediatric unit B. An RN who provides education to diabetic clients in a clinic C. An RN who has 5 years of experience in the delivery room D. An RN who ordinarily works as a scrub nurse in the OR

C. This RN would have experience with abdominal surgery and with postoperative care of clients with diabetes and would be aware of possible postoperative complications for this client.

After gastric surgery, a client arrives in the postanesthesia care unit (PACU). Which of these nursing actions is most appropriate for the RN to delegate to an experienced nursing assistant? A. Monitor respiratory rate and airway patency. B. Irrigate the nasogastric tube with saline. C. Position the client on the left side. D. Assess the client's pain level.

C. This action can be delegated to a unlicensed care provider.