PeriOperative Assignment Prep U

Reorient the client. Assess for hypoxia. Assess urine output.

A 76-year-old client had surgery for an abdominal hernia. The PACU nurse observes that the client is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply.

Heart rate over 150 beats per minute

A client develops malignant hyperthermia. What client symptom would the nurse most likely observe as the first indicator of the disorder?

Assess for signs and symptoms of fluid volume deficit.

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?

Cardiovascular complications Pulmonary complications

A nurse is caring for a bariatric client prior to a surgical procedure. What surgical complications would the nurse monitor the bariatric client for post operatively? Select all that apply.

Leakage of spinal fluid from the subarachnoid space Size of the spinal needle used Degree of patient hydration

A patient is complaining of a headache after receiving spinal anesthesia. What does the nurse understand may be the cause of the headache related to the spinal anesthesia? (Select all that apply.)

Absence of reflexes Diminished ability to communicate Loss of pain sensation

An intraoperative nurse is applying interventions that will address surgical clients' risks for perioperative positioning injury. What factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply.

Notify the surgical team to remove all latex-based items.

During the preoperative assessment, the client mentions allergies to avocados, bananas, and hydrocodone. What is the priority action by the nurse?

dantrolene sodium (Dantrium)

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

Assess for bleeding

The nurse is caring for a client in the postanesthesia care unit (PACU). The client has the following vital signs: pulse 115, respirations 20, oral temperature 97.2°F, blood pressure 84/50. What should the nurse do first?

Post-discharge diet

The nurse is caring for a client needing emergency surgery. Which preoperative teaching is least important to prepare the client for surgery?

Facilitate a detailed analysis of the client's electrolyte levels.

The nurse is caring for a client who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the client's ribs and xiphoid process are prominent. The client states she exercises two to three times daily and her mother indicates that she is being treated for anorexia nervosa. How should the nurse best follow up these assessment data?

The client expresses interest in the dressing change. The client is willing to look at the incision during a dressing change. The client assists in opening the packages of dressing material for the nurse.

The nurse is caring for a postoperative client who needs daily dressing changes. The client is 3 days postoperative and is scheduled for discharge the next day. Until now, the client has refused to learn how to change her dressing. What would indicate to the nurse the client's possible readiness to learn how to change her dressing? Select all that apply.

"Some possible negative effects include difficulty waking up and slow heart rate."

A client asks the nurse about possible ill effects from general anesthesia. What is the best response by the nurse?

The client has an absence of bowel sounds.

The nurse is assessing the postoperative client on the second postoperative day. Which assessment finding requires immediate physician notification?

Ambulating the client as soon as possible

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:

On the second or third day

When caring for a patient with alcoholism, when should the nurse assess for symptoms of alcoholic withdrawal?

Avoid touching sterile items unless necessary. Alert the surgical team of any breaches of sterile technique. Wear a long-sleeved, sterile gown and gloves.

The nurse is aware that infection is a potential complication of surgery. Which intervention should the nurse implement to prevent infection? Select all that apply.

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

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

Restrain the client.

The surgical client has been given general anesthesia. The nurse recognizes that the client is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage?

Assess the client's heart rhythm and nail beds.

When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O₂ saturation monitor despite the client's breathing appearing normal, what action should the nurse take first?

Valsalva maneuver

Which of the following clinical manifestations increase the risk for evisceration in the postoperative client?

postoperative pain control cough and deep-breathing exercises intravenous fluids and other lines and tubes

A client is undergoing a surgical procedure to repair an ulcerated colon. Which client education topics will be discussed preoperatively? Select all that apply.

Increased fatty tissue prolongs elimination of anesthesia. Decreased ability to compensate for hypoxia increases the risk of an embolism. Loss of collagen increases the risk of skin complications. Reduced tactile sensitivity can lead to assessment and communication problems.

A nurse is planning preopertive teaching for an older client. Which structural or functional changes in the older adult impact the surgical experience? Select all that apply.

Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients.

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?

nutritional status age physical condition health status

The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply.

Hypoxemia and hypercapnia.

The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of:

Consent must be freely given. Consent must normally be obtained by a physician. Signature must be witnessed by a professional staff member.

The surgical nurse is preparing to send a client from the presurgical area to the OR and is reviewing the client's informed consent form. What are the criteria for legally valid informed consent? Select all that apply.

Risk for perioperative positioning injury related to positioning in the OR

Which nursing diagnosis is most important for the client who is undergoing a surgical procedure expected to last several hours?

Ciliary action decreases, reducing the cough reflex. Fatty tissue increases, prolonging the effects of anesthesia. Liver size decreases, reducing the metabolism of anesthetics.

Why should the nurse be vigilant with assessment of perioperative risks on the older adult client? Select all that apply.

Quickly attempt to determine the cause of hemorrhage.

A postoperative client rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the client is experiencing a hemorrhage. What should be the nurse's first action?

Peripheral pulses palpable

The surgical client is at risk for injury related to positioning. Which of the following clinical manifestations exhibited by the client would indicate the goal was met of avoiding injury?

Performing guided imagery Putting on soothing music Changing the client's position

A client who is receiving the maximum levels of pain medication for postoperative recovery asks the nurse if there are other measures that the nurse can employ to ease pain. Which of the following strategies might the nurse employ? Select all that apply.

Educate on activity limitations. Discuss wound care. Have the spouse review when to notify the physician. Provide information on health promotion topics.

A postoperative client is being discharged home after minor surgery. The PACU nurse is reviewing discharge instructions with the client and the client's spouse. What actions by the nurse are appropriate? Select all that apply.