Perioperative Care

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway 2. Check tubes or drains for patency 3. Check the dressing to assess for bleeding 4. Assess the vital signs to compare with preoperative measurements

1. The first action of the nurse is to assess the patency of the airway snd respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking of the dressing and tubes or drains.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. Inhale as rapidly as possible 2. Keep a loose seal between the lips and the mouthpiece 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees

4 For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowlers or high fowlers position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again.

ANS: A Anxiety can interfere with learning and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious.

A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.) a. Metformin (Glucophage) b. Omega-3 fatty acids (Sea Omega 30) c. Phenytoin (Dilantin) d. Pilocarpine hydrochloride (Isopto Carpine) e. Warfarin (Coumadin)

ANS: A, C, D, E Although the client will be on NPO status before surgery, the nurse should check with the provider about allowing the client to take medications prescribed for diabetes, hypertension, cardiac disease, seizure disorders, depression, glaucoma, anticoagulation, or depression. Metformin is used to treat diabetes; phenytoin is for seizures; pilocarpine is for glaucoma, and warfarin is an anticoagulant. The omega-3 fatty acids can be held the day of surgery.

A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.) a. "A malnourished client will have fragile skin." b. "Malnourished clients always have other problems." c. "Many drugs are bound to protein in the body." d. "Protein stores are needed for wound healing." e. "Weakness and fatigue are common in malnutrition."

ANS: A, C, D, E Malnutrition can lead to poorer surgical outcomes for several reasons, including fragile skin that might break down, altered pharmacokinetics, poorer wound healing, and weakness or fatigue that can interfere with recovery. Malnutrition can exist without other comorbidities.

A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to "break scrub" when going to the console and sitting down. What action by the nurse is best? a. Call a "time-out" to discuss sterile procedure and scrub technique. b. Document the time the robotic portion of the procedure begins. c. Inform the surgeon that the scrub preparation has been compromised. d. Report the surgeon's actions to the charge nurse and unit manager.

ANS: B During a robotic operative procedure, the surgeon inserts the articulating arms into the client, then "breaks scrub" to sit at the viewing console to perform the operation. The nurse should document the time the robotic portion of the procedure began. There is no need for the other interventions.

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the surgeon. c. Have the client sign the consent, then call the surgeon. d. Remind the client of what teaching the surgeon has done.

ANS: B In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the surgeon. The nurse should notify the surgeon to come back and answer the client's questions before the client signs the consent form. The other actions are not appropriate.

A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important? a. Assist with administering muscle relaxants to the client. b. Place the client on a cardiac monitor and pulse oximeter. c. Prepare to administer intravenous antiemetics to the client. d. Prevent the client from experiencing postoperative shivering.

ANS: B Intravenous anesthetic agents have the potential to cause respiratory and circulatory depression. The nurse should ensure the client is on a cardiac monitor and pulse oximeter. Muscle relaxants are not indicated for this client at this time. Intravenous anesthetics have a lower rate of postoperative nausea and vomiting than other types. Shivering can occur in any client, but is more common after inhalation agents.

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. Call the provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallower breaths. d. Tell the client a little pain is expected.

ANS: B Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should know some pain is normal and expected after surgery, but that answer alone does not provide any interventions to help the client.

A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate? a. "After you wash the surgical site, shave that area with your own razor." b. "Be sure to wash the area where you will have surgery very thoroughly." c. "Use a washcloth to wash the surgical site; do not take a full shower or bath." d. "Wash the surgical site first, then shampoo and wash the rest of your body."

ANS: B The entire proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap. Shaving, if absolutely necessary, should be done in the operative suite immediately before the operation begins, using sterile equipment. The client needs a full shower or bath (shower preferred). The client should wash the surgical site last; dirty water from shampooing will run over the cleansed site if the site is washed first.

ANS: B The entire proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap. Shaving, if absolutely necessary, should be done in the operative suite immediately before the operation begins, using sterile equipment. The client needs a full shower or bath (shower preferred). The client should wash the surgical site last; dirty water from shampooing will run over the cleansed site if the site is washed first.

ANS: B The priority client problem related to a surgical drain is the potential for infection. An insertion site that is free of redness, warmth, and drainage indicates that goals for this client problem are being met. The other assessments are normal, but not related to the drain.

A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best? a. "All preoperative clients get this medication." b. "It helps prevent ulcers from the stress of the surgery." c. "Since you don't have ulcers, I will have to ask." d. "The physician prescribed this medication for you."

ANS: B Ulcer prophylaxis is common for clients undergoing long procedures or for whom high stress is likely. The nurse is not being truthful by saying all clients get this medication. If the nurse does not know the information, it is appropriate to find out, but this is a common medication for which the nurse should know the rationale prior to administering it. Simply stating that the physician prescribed the medication does not give the client any useful information.

Which is an inherited complication associated with general anesthesia?

Malignant hyperthermia is an inherited condition that involves drastic elevation of body temperature due to contraction of skeletal muscles. It is a life-threatening condition and associated with general anesthesia only

The most appropriate resources to include when planning to provide patient education related to a goal in the psychomotor domain would be a.diagnosis-related support groups. b.Internet resources. c.manikin practice sessions. d.self-directed learning modules.

ANS: C A teaching goal in the psychomotor domain should be matched with teaching strategies in the psychomotor domain, such as demonstration, practice sessions with a manikin, and return demonstrations. Diagnosis-related support groups would be most effective with goals in the affective domain. Internet resources would be most effective for goals in the cognitive domain. Self-directed learning modules would be most effective for goals in the cognitive domain.

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for abdominal surgery for an open cholecystectomy? a. Care for the surgical incision b. Medications used during surgery c. Deep breathing and coughing techniques d. Oral antibiotic therapy after discharge home

ANS: C Preoperative teaching, demonstration, and redemonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. The patient does not usually need information about medications that are used intraoperatively.

Two hours after abdominal surgery, the nurse auscultates the client's abdomen. No bowel sounds are present. What is the nurse's best first action? A. Position the client on the right side with the bed flat. B. Check the dressing and apply an abdominal binder. C. Palpate the bladder and measure abdominal girth. D. Document the finding as the only action.

ANS: D Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that should be documented. No intervention specific to this finding is needed at this time.

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements

ANS: D Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered. Lack of experience with surgery may increase anxiety and may require higher teaching needs, but is not the priority over client safety.

A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best? a. Administer anxiolytics. b. Give the client warm blankets. c. Introduce the surgical staff. d. Remain with the client.

ANS: D The nurse can provide emotional support by remaining with the client until anesthesia has been provided. An extremely anxious client may need anxiolytics, but not all clients require this for emotional support. Physical comfort and introductions can also help decrease anxiety.

Which assessment finding in a postoperative client after general anesthesia requires immediate intervention? A. HR of 58 beats/min B. Pale, cool extremities C. Respiratory rate of 6 breaths/minute D. Suppressed gag reflex

C. Respiratory rate of 6 breaths/minute

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further assessment in the post-anesthesia 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

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. They protect both the client and the nurse from infection.

A patient undergoing hip replacement surgery suddenly develops unexplained bradycardia. The anesthetist administers epinephrine to the patient. Which complication is the anesthetist trying to prevent?

Cardiac arrest is a common complication of spinal anesthesia, which is manifested as unexplained bradycardia and can be managed by administering epinephrine.

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. The 20-year-old client who has a ruptured appendix and is having an emergency appendectomy B. The 28-year-old client with a fractured femur who is having an open reduction and internal fixation C. The 45-year-old client with coronary artery disease who is having coronary artery bypass grafting D. The 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed

D. The 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed

The most dangerous metabolic side effect of general anesthesia that can occur during surgery is: Hyperglycemia Hyperthermia Hypoglycemia Hypothermia Explanation: Malignant hyperthermia is the most dangerous metabolic side effect of general anesthesia.

Hyperthermia Explanation: Malignant hyperthermia is the most dangerous metabolic side effect of general anesthesia.

The nurse receives the client in the postanesthesia care unit (PACU) following a procedure requiring general anesthesia. The most important assessment made by the nurse relates to the client's: Level of consciousness. Pain. Vital signs. Respiratory status.

Respiratory status. Explanation: General anesthesia causes relaxation of all muscles, including respiratory muscles, requiring mechanical ventilation. The client's respiratory status must be monitored closely following general anesthesia.

What is the priority nursing diagnosis for the client under general anesthesia during surgery? A. Acute Pain related to surgical procedure B. Risk for Infection related to surgical wound C. Risk for Impaired Skin Integrity related to prolonged static position D. Disturbed Body Image related to presence of surgical wound or scar

Risk for Impaired Skin Integrity related to prolonged static position ANS: C (KEY WORD-during SURGERY) The problem that nursing is most responsible for with this client is ensuring maintenance of skin integrity.

Which of the following statements about shivering is correct? Shivering is a response controlled by the brainstem. Shivering can occur in the absence of hypothermia. Shivering is effectively treated with small doses of naloxone. Shivering is an uncomfortable, though harmless, effect of anesthesia.

Shivering can occur in the absence of hypothermia Explanation: Shivering can also appear after surgery. This is known as postanesthetic shivering.

Which teaching by the nurse during the preoperative period best informs the patient regarding the primary purpose of an incentive spirometer?

The PURPOSE (key word!) of the incentive spirometer is that it will encourage lung expansion, thus decreasing atelectasis. Proper use entails holding the breath 3 to 5 seconds at a time, setting daily goals, and sealing the lips tightly around the mouth piece are all directions on how to use the device, but do not describe its function. (be careful of key words in question!)

A client who has undergone preadmission testing, has had blood drawn for serum lab studies, including a complete blood count, coagulation studies and electrolytes and creatine levels. Which lab result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Sodium, 141mEq/L 2. Hemoglobin, 8.0 g/dL 3. Platelets, 210,000/mm3 4. Serum creatine, 0.8 mg/dL

The complete blood count includes the hemoglobin analysis. All these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon

A patient who takes a diuretic and a beta-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery? a. Hematocrit 36% b. Blood pressure 144/82 c. Pulse rate 58 beats/minute d. Serum potassium 3.2 mEq/L

d. Serum potassium 3.2 mEq/L ANS: D The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of anxiety. The lower heart rate would be expected in a patient taking a -blocker. The hematocrit is in the low normal range but does not require any intervention before surgery.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply 1. Contact the surgeon 2. Instruct the client to remain quiet 3. Prepare the client for wound closure 4. Document the findings and actions taken 5. Place a sterile saline dressing and icepacks over the wound 6. Place the client in a prone position without a pillow under the head.

1, 2, 3 ,4 Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low fowlers position and the client is kept quite and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

Which vital sign is most important for the nurse to monitor in a patient receiving general anesthesia in the postanesthesia care unit?

A patient receiving general anesthesia must be regularly monitored for respiratory rate because the medication may lead to respiratory depression. Pulse, blood pressure, and body temperature are evaluated and recorded in the patient's medical record but are not the most important vital sign to monitor. (MOST IMPORTANT=key word)

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

A. Breathing pattern

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. Circulating nurse

A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client? a. Document giving the drug. b. Raise the siderails on the bed. c. Record the client's vital signs. d. Teach relaxation techniques.

ANS: B All actions are appropriate for a preoperative client. However, for client safety, the nurse should raise the siderails on the bed because hydroxyzine can make the client sleepy.

. The nurse is completing a medication history for the surgical patient in preadmission testing. Which of the following medications should the nurse instruct the patient to hold in preparation for surgery? a.Ibuprofen b.Acetaminophen c. Vitamin C d. Miconazole

ANS: A Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen inhibit platelet aggregation and prolong bleeding time, increasing susceptibility to postoperative bleeding. Acetaminophen is a pain reliever that has no special implications for surgery. Vitamin C actually assists in wound healing and has no special implications for surgery. Miconazole is an antifungal and has no special implications for surgery.

The nurse assesses a 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

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider? a. The right calf is swollen, warm, and painful. b. The patient's temperature is 100.3° F (37.9° C). c. The 24-hour oral intake is 600 mL greater than the total output. d. The patient complains of abdominal pain at level 6 (0 to 10 scale) when ambulating.

ANS: A The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require the health care provider to order diagnostic tests and/or anticoagulants. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3° F on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities.

The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time? a. Auscultate for adventitious breath sounds. b. Obtain the patient's blood pressure and temperature. c. Remind the patient about harmful effects of smoking. d. Ask the health care provider about prescribing a nicotine patch.

ANS: A The nurse should first ensure a patent airway and check for breathing and circulation (airway, breathing, and circulation [ABCs]). Circulation and temperature can be assessed after a patent airway and breathing have been established. The immediate postoperative period is not the optimal time for patient teaching about the harmful effects of surgery. Requesting a nicotine patch may be appropriate, but is not a priority at this time.

The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take? a. Cover the patient with a warm blanket and put on socks. b. Notify the anesthesia care provider about the temperature. c. Avoid the use of opioid analgesics until the patient is warmer. d. Administer acetaminophen (Tylenol) 650 mg suppository rectally.

ANS: A The patient assessment indicates the need for active rewarming. There is no indication of a need for acetaminophen. Opioid analgesics may help reduce shivering. Because hypothermia is common in the immediate postoperative period, there is no need to notify the anesthesia care provider, unless the patient continues to be hypothermic after active rewarming.

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery c. Patient who has bibasilar crackles and a temperature of 100°F (37.8°C) on the first postoperative day after chest surgery d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) administration

ANS: A The patient's history and assessment suggests possible wound dehiscence, which should be reported immediately to the surgeon. Although the information about the other patients indicates a need for ongoing assessment and/or possible intervention, the data do not suggest any acute complications. Small amounts of red drainage are common in the first postoperative hours. Bibasilar crackles and a slightly elevated temperature are common after surgery, although the nurse will need to have the patient cough and deep breathe. Oral medications typically take more than 15 minutes for effective pain relief.

A 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. "What is your name, and where were you born?"

A client in the operating room has developed malignant hyperthermia. The client's potassium is 6.5 mEq/L. What action by the nurse takes priority? a. Administer 10 units of regular insulin. b. Administer nifedipine (Procardia). c. Assess urine for myoglobin or blood. d. Monitor the client for dysrhythmias.

ANS: A For hyperkalemia in a client with malignant hyperthermia, the nurse administers 10 units of regular insulin in 50 mL of 50% dextrose. This will force potassium back into the cells rapidly. Nifedipine is a calcium channel blocker used to treat hypertension and dysrhythmias, and should not be used in a client with malignant hyperthermia. Assessing the urine for blood or myoglobin is important, but does not take priority. Monitoring the client for dysrhythmias is also important due to the potassium imbalance, but again does not take priority over treating the potassium imbalance.

A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client? a. Allow the client to keep hearing aids in until anesthesia begins. b. Pad the table as appropriate for the surgical procedure. c. Position the client for maximum visualization of the site. d. Stay with the client, providing emotional comfort and support.

ANS: A Many older clients have sensory loss. To help prevent disorientation, facilities often allow older clients to keep their eyeglasses on and hearing aids in until the start of anesthesia. The other actions are appropriate for all operative clients.

An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment? a. Change in behavior b. Daily white blood cell count c. Presence of fever and chills d. Tolerance of increasing activity

ANS: A Older people have an age-related decrease in immune system functioning and may not show classic signs of infection such as increased white blood cell count, fever and chills, or obvious localized signs of infection. A change in behavior often signals an infection or onset of other illness in the older client.

A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best? a. "A rapid heart rate requires more effort by the heart." b. "Anesthesia has bad effects if the client is tachycardic." c. "The client may have an undiagnosed heart condition." d. "When the heart rate goes up, the blood pressure does too."

ANS: A Tachycardia increases the workload of the heart and requires more oxygen delivery to the myocardial tissues. This added strain is not needed on top of the physical and emotional stress of surgery. The other statements are not accurate.

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices.

ANS: A The SCIP project contains core measures that are mandatory for all surgical clients and focuses on preventing infection, serious cardiac events, and venous thromboembolism. The managers should start by reviewing charts to see if the guidelines of this project were implemented. The other actions may be necessary too, but first the managers need to assess the situation.

A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best? a. Ask the client to describe current feelings. b. Determine if the client wants a chaplain. c. Reassure the client this surgery is common. d. Tell the client there is no need to be anxious.

ANS: A The nurse needs to conduct further assessment of the client's anxiety. Asking open-ended questions about current feelings is an appropriate way to begin. The client may want a chaplain, but the nurse needs to do more for the client. Reassurance can be good, but false hope is not, and simply reassuring the client may not be helpful. Telling the client not to be anxious belittles the client's feelings.

A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate? a. Explain the rationale for giving the medicine now. b. Leave the room and come back in 15 minutes. c. Provide holistic client care and come back later. d. Tell the client you must start the medication now.

ANS: A The preoperative antibiotic must be given within 60 minutes of the surgical start time to ensure the proper amount is in the tissues when the incision is made. The nurse should explain the rationale to the client for this timing. The other options do not take this timing into consideration and do not give the client the information needed to be cooperative.

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best? a. Consult the surgeon about a postoperative dietitian referral. b. Document the findings thoroughly in the client's chart. c. Encourage the client to eat more after recovering from surgery. d. Refer the client to Meals on Wheels after discharge.

ANS: A This client has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the surgeon about prescribing a consultation with a dietitian in the postoperative period. The nurse should document the findings but needs to do more. Encouraging the client to eat more may be helpful, but the client needs a professional nutritional assessment so that the appropriate diet and supplements can be ordered. The client may or may not need Meals on Wheels after discharge.

A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.) a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations e. Inability to adapt to changes

ANS: A, B, C, D Older adults have many age-related physiologic changes that put them at higher risk of falling and other complications after surgery. Some of these include decreased cardiac output, decreased oxygenation of tissues, nocturia, and mobility alterations. They also have a decreased ability to adapt to new surroundings, but that is not the same as being unable to adapt.

What actions by the circulating nurse are important to promote client comfort? (Select all that apply.) a. Correct positioning b. Introducing one's self c. Providing warmth d. Remaining present e. Removing hearing aids

ANS: A, B, C, D The circulating nurse can do many things to promote client comfort, including positioning the client correctly and comfortably, introducing herself or himself to the client, keeping the client warm, and remaining present with the client. Removing hearing aids does not promote comfort and, if the client is still awake when they are removed, may contribute to disorientation and anxiety.

The circulating nurse reviews the day's schedule and notes clients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which clients does this include? (Select all that apply.) a. A 75-year-old client scheduled for an elective procedure b. Client who drinks a 6-pack of beer each day c. Client with a serum creatinine of 3.8 mg/dL d. Client who is taking birth control pills e. Young male client with a RYR1 gene mutation

ANS: A, B, C, E People at higher risk for anesthetic overdose or other anesthesia-related complications include people with a slowed metabolism (older adults generally have slower metabolism than younger adults), those with kidney or liver impairments, and those with mutations of the RYR1 gene. Drinking a 6-pack of beer per day possibly indicates some liver disease; a creatinine of 3.8 is high, indicating renal disease; and the genetic mutation increases the chance of malignant hyperthermia. Taking birth control pills is not a risk factor.

A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.) a. Allow the client to assume a position of comfort. b. Allow the client's family to remain at the bedside. c. Give the client a warm, non-caffeinated drink. d. Provide warm blankets or cool washcloths as desired. e. Pull the curtains around the bed to provide privacy.

ANS: A, B, D, E There are many nonpharmacologic comfort measures the nurse can employ, such as allowing the client to remain in the position that is most comfortable, letting the family stay with the client, providing warmth or cooling measures as requested by the client, and providing privacy. The client in the preoperative holding area is NPO, so drinks should not be provided.

A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.) a. Assessing distal circulation to the operative arm after positioning b. Keeping the client warm during the operative procedure c. Padding the client's shoulder and arm on the operating table d. Preparing to suction the client's airway if the client vomits e. Speaking in a low, quiet voice as anesthesia is administered

ANS: A, C After regional anesthesia is administered, the client loses all sensation distally. The nurse ensures client safety by assessing distal circulation and padding the shoulder and arm appropriately. Although awake, the client will not be able to report potential injury. Keeping the client warm is not related to this anesthesia, nor is suctioning or speaking quietly.

A 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 listen to this client's concerns. B. Allow the client to wear the hearing aid to surgery. C. Check to see whether the OR staff minds if the client wears the hearing aid until anesthesia is given. D. Apologize to the client and explain that it is hospital policy to remove a hearing aid before surgery.

C. Check to see whether the OR staff minds if the client wears the hearing aid until anesthesia is given.

A student nurse observing in the operating room notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? (Select all that apply.) a. Dressing the surgical wound b. Grafting new or synthetic skin c. Reattaching severed nerves d. Suctioning the surgical site e. Suturing the surgical wound

ANS: A, D, E The CRNFA can perform tasks under the direction of the surgeon such as suturing and dressing surgical wounds, cutting away tissue, suctioning the wound to improve visibility, and holding retractors. Reattaching severed nerves and performing grafts would be the responsibility of the surgeon.

The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.) a. Ensuring the client's safety b. Accounting for all sharps c. Documenting all care given d. Maintaining the sterile field e. Monitoring traffic in the room

ANS: A, E The circulating nurse has several functions, including maintaining client safety and privacy, monitoring traffic in and out of the operating room, assessing fluid losses, reporting findings to the surgeon and anesthesia provider, anticipating needs of the team, and communicating to the family. The circulating nurse and scrub person work together to ensure accurate counts of sharps, sponges, and instruments. The circulating nurse also documents care, but in the perioperative area, the preoperative or holding room nurse would also document care received there. Maintaining the sterile field is a joint responsibility among all members of the surgical team.

The nurse reviews the laboratory results for a patient on the first postoperative day after a hiatal hernia repair. Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing? a. Potassium 3.5 mEq/L b. Albumin level 2.2 g/dL c. Hemoglobin 11.2 g/dL d. White blood cells 11,900/µL

ANS: B Because proteins are needed for an appropriate inflammatory response and wound healing, the low serum albumin level (normal level 3.5 to 5.0 g/dL) indicates a risk for poor wound healing. The potassium level is normal. Because a small amount of blood loss is expected with surgery, the hemoglobin level is not indicative of an increased risk for wound healing. WBC count is expected to increase after surgery as a part of the normal inflammatory response. ***SIDE NOTE: K+ and Albumin have the same range 3.5-5)***

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? a. Administer the ordered opioid. b. Check the oxygen (O2) saturation. c. Take the blood pressure and pulse. d. Apply wrist restraints to secure IV lines.

ANS: B Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action.

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient? a. Potential complication: hypovolemic shock b. Potential complication: venous thromboembolism c. Potential complication: fluid and electrolyte imbalance d. Potential complication: impaired surgical wound healing

ANS: B The patient is older and relatively immobile, which are two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient.

The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority? a. Allergies noted and allergy band on b. Consent for MIS procedure only c. No prior anesthesia exposure d. NPO status for the last 8 hours

ANS: B All MIS procedures have the potential for becoming open procedures depending on findings and complications. The client's consent should include this possibility. The nurse should report this finding to the surgeon prior to surgery taking place. Having allergies noted and an allergy band applied is standard procedure. Not having any prior surgical or anesthesia exposure is not the priority. Maintaining NPO status as prescribed is standard procedure.

A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client's anxiety. b. Give the client a back rub. c. Remind the client to turn. d. Teach about postoperative care.

ANS: B A back rub reduces anxiety and can be delegated to the UAP. Once teaching has been done, the UAP can remind the client to turn, but this is not related to relieving anxiety. Assessing anxiety and teaching are not within the scope of practice for the UAP.

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.) a. Client with a humerus fracture b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client

ANS: B, C, D, E All surgical clients should be assessed for VTE risk. Those considered at higher risk include those who are obese; are over 40; have cancer; have decreased mobility, immobility, or a spinal cord injury; have a history of any thrombotic event, varicose veins, or edema; take oral contraceptives or smoke; have decreased cardiac output; have a hip fracture; or are having total hip or knee surgery. Prolonged surgical time increases risk due to mobility and positioning needs.

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.) a. Allow small sips of plain water. b. Check that consent is on the chart. c. Ensure the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation.

ANS: B, C, D, E Providing for client safety is a priority function of the preoperative nurse. Checking for appropriately completed consent, verifying the client's identity, having the client assist in marking the surgical site if applicable, and allowing the client to use the toilet prior to sedating him or her are just some examples of important safety measures. The preoperative client should be NPO, so water should not be provided.

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.) a. Hemorrhage b. Infection c. Serious cardiac events d. Stroke e. Thromboembolism

ANS: B, C, E The SCIP project includes core measures to prevent infection, serious cardiac events, and thromboembolic events such as deep vein thrombosis.

A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.) a. Hemicolectomy: diagnostic b. Liver biopsy: diagnostic c. Mastectomy: restorative d. Spinal cord decompression: palliative e. Total shoulder replacement: restorative

ANS: B, E A diagnostic procedure is used to determine cell type of cancer and to determine the cause of a problem. An example is a liver biopsy. A restorative procedure aims to improve functional ability. An example would be a total shoulder replacement or a spinal cord decompression (not palliative). A curative procedure either removes or repairs the causative problem. An example would be a mastectomy (not restorative) or a hemicolectomy (not diagnostic). A palliative procedure relieves symptoms but will not cure the disease. An example is an ileostomy. A cosmetic procedure is done to improve appearance. An example is rhinoplasty (a "nose job").

The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which of the following actions would be most appropriate for this patient? a.Encourage copious amounts of water. b. Weigh the patient and compare with preoperative weight. c. Measure and record all intake and output. d. Start an additional intravenous (IV) line.

ANS: C Accurate recording of intake and output assesses renal and circulatory function. Measure and record all sources of intake and output. Encouraging copious amounts of water in a postoperative patient might encourage nausea and vomiting. In the PACU, it is impractical to weigh the patient while waking from surgery, but in the days afterward, it is a good assessment parameter for fluid imbalance. Starting an additional IV is not necessary and is not important at this juncture.

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first? a. Reinforce the dressing. b. Apply an abdominal binder. c. Take the patient's vital signs. d. Recheck the dressing in 1 hour for increased drainage.

ANS: C New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing.

A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed? a. Patient drinks 2 to 3 L of fluid in 24 hours. b. Patient uses the spirometer 10 times every hour. c. Patient's breath sounds are clear to auscultation. d. Patient's temperature is less than 100.4° F orally.

ANS: C One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or crackles, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems.

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

C. Honor the DNR order.

The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife usually answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching? a. Use printed materials for instruction so that the patient will have more time to review the material. b. Direct the teaching toward the wife because she is the obvious support and caregiver for the patient. c. Provide additional time for the patient to understand postoperative instructions and carry out procedures. d. Ask the patient's wife to wait in the hall in order to focus preoperative teaching with the patient himself.

ANS: C The nurse should allow more time when doing preoperative teaching and preparation for older patients with sensory deficits. Because the patient has visual deficits, he will not be able to use written material for learning. The teaching should be directed toward both the patient and the wife because both will need to understand preoperative procedures and teaching.

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL b. Hemoglobin: 14.8 mg/dL c. Potassium: 2.9 mEq/L d. Sodium: 134 mEq/L

ANS: C A potassium of 2.9 mEq/L is critically low and can affect cardiac and respiratory status. The nurse should communicate this laboratory value immediately. The creatinine is at the high end of normal, the hemoglobin is normal, and the sodium is only slightly low (normal low being 136 mEq/L), so these values do not need to be reported immediately.

A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best? a. Allow the client to walk to the bathroom. b. Delegate assisting the client to the nurse's aide. c. Give the client a bedpan or urinal to use. d. Insert a urinary catheter now instead of waiting.

ANS: C Although possibly uncomfortable or embarrassing for the client, the client should not be allowed out of bed after receiving sedation. The nurse should get the client a bedpan or urinal. The client may or may not need a urinary catheter.

A nurse is monitoring a client after moderate sedation. The nurse documents the client's Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best? a. Assess the client's gag reflex. b. Begin providing discharge instructions. c. Document findings and continue to monitor. d. Increase oxygen and notify the provider.

ANS: C An RSS score of 3 means the client is able to respond quickly, but only to commands. The client has not had enough time to fully arouse. The nurse should document the findings and continue to monitor per agency policy. If the client had an oral endoscopy or was intubated, checking the gag reflex would be appropriate prior to permitting eating or drinking. The client is not yet awake enough for teaching. There is no need to increase oxygen and notify the provider.

A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client? a. Hydroxyzine (Atarax) b. Lorazepam (Ativan) c. Metoclopramide (Reglan) d. Morphine sulfate

ANS: C Reglan increases gastric emptying, an important issue for this client who was eating just prior to the operation. The other drugs are appropriate for any surgical client.

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care? a. Married young adult who is the primary caregiver for children b. Middle-aged client who is post knee replacement, needs physical therapy c. Older adult who lives at home despite some memory loss d. Young client who lives alone, has family and friends nearby

ANS: C The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The client's physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed. The other clients all have evidence of a support system and no known potential for serious safety issues.

When caring for a patient who has received a general anesthetic, the circulating nurse notes red, raised wheals on the patient's arms. Which action should the nurse take immediately? a. Apply lotion to the affected areas. b. Cover the arms with sterile drapes. c. Recheck the patient's arms in 30 minutes. d. Notify the anesthesia care practitioner (ACP) immediately.

ANS: D The presence of wheals indicates a possible allergic or anaphylactic reaction, which may have been caused by latex or by medications administered as part of general anesthesia. Because general anesthesia may mask anaphylaxis, the nurse should report this to the ACP. The other actions are not appropriate at this time.

A 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.

A patient is undergoing abdominal surgery and has been anesthetized for 3 hours. Which nursing diagnosis would be appropriate for this patient? a.Anxiety related to the use of an anesthetic b. Risk for injury related to increased sensorium from general anesthesia c.Decreased cardiac output related to systemic effects of local anesthesia d.Impaired gas exchange related to central nervous system depression produced by general anesthesia

ANS: D The nursing diagnosis of impaired gas exchange is appropriately worded for this patient. Anxiety would not be appropriate while the patient is in surgery. Sensorium would be decreased during surgery, not increased. Cardiac output is affected by general anesthesia, not local anesthesia.

What are the main domains of learning?

Affective (feelings/attitude), cognitive (knowledge), and psychomotor (skills/performance) .

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

B. A 47-year-old obese man with diabetes

Which action does the nurse implement for a client with wound evisceration? A. Apply direct pressure to the wound. B. Cover the wound with a sterile, warm, moist dressing. C. Irrigate the wound with warm, sterile saline. D. Replace tissue protruding into the opening.

B. Cover the wound with a sterile, warm, moist dressing.

What would the nurse expect to find when assessing a patient with a postoperative wound infection?

Purulent drainage is the collection of pus in the draining fluid, which is an indication of infection in a postoperative patient. (INFECTION was key word)

If your client smokes 3 packs of cigarettes a day for the part 10 years, you will anticipate increased risk for: perioperative anxiety and stress delayed coagulation time delayed wound healing postoperative respiratory dysfunction

postoperative respiratory dysfunction

A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition? 1. Pneumonia 2. Hypoxemia 3. Fluid imbalance 4. Pulmonary embolism

1. Postoperative respiratory problems are atelectasis, pneumonia and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by the retention of pulmonary secretions.

The nurse is reviewing a prescription sheet for preoperative client that states that he client must be NPO after midnight. The nurse would telephone the physician to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine (Flexeril) 4. Conjugated estrogen (Premarin)

1. Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. These last few medications may be withheld before surgery without undue effects on the client.

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urine output of 20ml/hour 2. Temperature of 37.6 C 3. Blood pressure of 114/70 4. Serous drainage on the surgical dressing

1. Urine output should be maintained at a minimum of 30mL/hour for an adult. An output of less than that for each of 2 consecutive hours should be reported to the health care provider.

The nurse assess a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm tender skin

2 Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Wound infection usually appears 3 to 6 days after surgery.

A patient is scheduled for surgery. What factor plays an important role in determining the dose and type of anesthesia to be given? 1 Patient gender 2 Duration of the procedure 3 Patient ethnicity 4 Number of hospital personnel present

2. The type and dosage of anesthesia to be given depend on multiple factors, one of which is the duration of the procedure. Anesthetic agents can be short-acting or long-acting; therefore, the anesthesiologist determines which drug to use based on the length of the procedure. The patient's sex or ethnicity and number of hospital personnel present do not play a major role in deciding which drug and dosage to use.

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? 1. "Aspirin can cause bleeding after surgery." 2. "Aspirin can cause my ability to clot blood to be abnormal." 3. "I need to continue to take the aspirin until the day of surgery." 4. "I need to check with my HCP about the need to stop the aspirin before the scheduled surgery."

3. Anticoagulants altered normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. However, the client should always check with his or her health care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled.

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure with you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate".

3. Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications.

The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash 2. Verify that the client has not eaten for the last 24 hours 3. Have the client void immediately before going into surgery 4. Report immediately any slight increase in BP or pulse

3. The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A slight increase in BP and pulse is common during the preoperative period due to anxiety.

A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? 1. Obtain a court order for the surgery. 2. Have the charge nurse sign the informed consent immediately 3. Send the client to surgery without the consent form being signed 4. Obtain a telephone consent from a family member, following agency policy

4. Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency the client may not be able to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but tin this case it is not an emergency. Agency policies regarding informed consent should always be followed.

Which actions will the nurse include in the surgical time-out procedure before surgery (select all that apply)? a. Check for placement of IV lines. b. Have the surgeon identify the patient. c. Have the patient state name and date of birth. d. Verify the patient identification band number. e. Ask the patient to state the surgical procedure. f. Confirm the hospital chart identification number.

ANS: C, D, E, F These actions are included in surgical time out. IV line placement and identification of the patient by the surgeon are not included in the surgical time-out procedure.

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

A. A 43-year-old who had a bowel resection 7 days ago and has new sero-sanguineous drainage on the dressing

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 nurse

A 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. Supplemental pain reduction is needed.

A client is having surgery. The circulating nurse notes the client's oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best? a. Assess the client's end-tidal carbon dioxide level. b. Document the findings in the client's chart. c. Inform the anesthesia provider of these values. d. Prepare to administer dantrolene sodium (Dantrium).

ANS: A Malignant hyperthermia is a rare but serious reaction to anesthesia. The triad of early signs include decreased oxygen saturation, tachycardia, and elevated end-tidal carbon dioxide (CO2) level. The nurse should quickly check the end-tidal CO2 and then report findings to the anesthesia provider and surgeon. Documentation is vital, but not the most important action at this stage. Dantrolene sodium is the drug of choice if the client does have malignant hyperthermia.

A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate? a. Facilitate marking the site with the client and surgeon. b. Have the client mark the operative site. c. Mark the operative site with a waterproof marker. d. Tell the surgeon it is time to mark the surgical site.

ANS: A The Joint Commission now recommends that both the client and the surgeon mark the operative site together in order to prevent wrong-site surgery. The nurse should facilitate this process.

On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse ismost appropriate? a. Increase the IV fluid rate. b. Continue to take vital signs every 15 minutes. c. Administer oxygen therapy at 100% per mask. d. Notify the anesthesia provider immediately.

ANS: B A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration.

An RN and an LPN/LVN are working together in caring for a client who needs all of these interventions 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. Develop the discharge teaching plan in conjunction with the client.

In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient to a clinical unit. d. Increase the rate of the postoperative IV fluids.

ANS: B The patient's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable blood pressure and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU to a clinical unit is not appropriate.

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I do not really understand what the doctor said." Which action is best for the nurse to take? a. Provide an explanation of the planned surgical procedure. b. Notify the surgeon that the informed consent process is not complete. c. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications. d. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure.

ANS: B The surgeon is responsible for explaining the surgery to the patient, and the nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurse's legal scope of practice to explain the surgical procedure. No preoperative medications should be administered until the patient understands the surgical procedure and signs the consent form.

A client is in stage 2 of general anesthesia. What action by the nurse is most important? a. Keeping the room quiet and calm b. Being prepared to suction the airway c. Positioning the client correctly d. Warming the client with blankets

ANS: B During stage 2 of general anesthesia (excitement, delirium), the client can vomit and aspirate. The nurse must be ready to react to this potential occurrence by being prepared to suction the client's airway. Keeping the room quiet and calm does help the client enter the anesthetic state, but is not the priority. Positioning the client usually occurs during stage 3 (operative anesthesia). Keeping the client warm is important throughout to prevent hypothermia.

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the surgeon. c. Have the client sign the consent, then call the surgeon. d. Remind the client of what teaching the surgeon has done.

ANS: B Do not have the client sign the consent and call the surgeon. In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the surgeon. The nurse should notify the surgeon to come back and answer the client's questions before the client signs the consent form. The other actions are not appropriate.

Which nursing action or statement is most likely to reduce anxiety in a client being brought to the surgical suite? A. Asking the client if he or she has talked with the hospital chaplain B. Asking the client what specific surgery he or she is having done today C. Asking the client if he or she wants family members to be with them in the holding area D. Explaining to the client that the surgical area is the most technologically advanced in the city

ANS: C Most anxious clients would feel some relief by having one or more familiar persons waiting with them until surgery begins. In addition, asking the client what he or she wants allows the client to have more control over the situation. Asking the client if he or she has visited with the hospital chaplain and telling the client about the advanced technology can imply to the client that the procedure is dangerous. Although the client must be asked what procedure he or she is having (to ascertain that the client does know what is to be done), this question may make the client worry about the competency of the staff.

The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best? a. Call maintenance for repair. b. Check the machine before using. c. Get another piece of equipment. d. Notify the charge nurse.

ANS: C The circulating nurse is responsible for client safety. If an electrical cord is frayed, the risk of fire or sparking increases. The nurse should obtain a replacement. The nurse should also tag the original equipment for repair as per agency policy. Checking the equipment is not important as the nurse should not even attempt to use it. Calling maintenance or requesting maintenance per facility protocol is important, but first ensure client safety by having a properly working piece of equipment for the procedure about to take place. The charge nurse probably does need to know of the need for equipment repair, but ensuring client safety is the priority.

The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate? a. Ask the surgeon to change the sterile gown. b. Do nothing; this is acceptable sterile procedure. c. Inform the surgeon that the sterile field has been broken. d. Obtain a new pair of sterile gloves for the surgeon to put on.

ANS: C The surgical gown is considered sterile from the chest to the level of the surgical field. By placing the hands down by the hips, the surgeon has broken sterile field. The circulating nurse informs the surgeon of this breach. Changing only the gloves or only the gown does not "restore" the sterile sections of the gown. Doing nothing is unacceptable.

A 78-year-old patient is in the recovery room after having a lengthy surgery on his hip. As he is gradually awakening, he requests pain medication. Within 10 minutes after receiving a dose of morphine sulfate, he is very lethargic and his respirations are shallow, with a rate of 7 per minute. The nurse prepares for which priority action at this time? a. Assessment of the patient's pain level b. Immediate intubation and artificial ventilation c. Administration of naloxone (Narcan)

ANS: C Naloxone, an opioid-reversal agent, is used to reverse the effects of acute opioid overdose and is the drug of choice for reversal of opioid-induced respiratory depression. This situation is describing an opioid overdose, not opioid tolerance. Intubation and artificial ventilation are not appropriate because the patient is still breathing at 7 breaths per minute. It would be inappropriate to assess the patient's level of pain.

The anesthetized client with an open abdomen suddenly develops malignant hyperthermia. What intervention should the nurse be prepared to initiate or assist with? A. Discontinue mechanical ventilation. B. Administer intravenous potassium chloride. C. Administer intravenous calcium chloride. D. Administer intravenous dantrolene (Dantrium).

ANS: D Dantrolene is a skeletal muscle relaxant and can help lower body temperature by reducing metabolic heat production by the muscles. Clients become hyperkalemic and hypercalcemic; therefore, neither of these electrolytes should be administered. The client's gas exchange is severely compromised. If the client is not already receiving mechanical ventilation, it is initiated.

Who is responsible for accompanying the surgical client to the postanesthesia recovery area after surgery and for giving a report of the client's intraoperative experience to the PACU nurse? A. The surgeon and scrub nurse B. The surgeon and circulating nurse C. The anesthesiologist and scrub nurse D. The anesthesiologist and circulating nurse

ANS: D The anesthesiologist (or certified registered nurse anesthetist) and the circulating nurse are responsible for accompanying the client to the postoperative recovery area and giving a report of the client's intraoperative experience.

A 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. Tell the client that she will be asleep. B. Ensure that drapes will minimize perianal exposure. C. Explain post-operative expectations. D. Restrict the number of technicians in the procedure.

B. Ensure that drapes will minimize perianal exposure.

The nurse anesthetist notices that a 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. B. Continue as normal. C. Immediately stop all inhalation anesthetic agents and succinylcholine. D. Inform the surgeon.

C. Immediately stop all inhalation anesthetic agents and succinylcholine.

Which intervention does the nurse implement for an older adult client to minimize skin breakdown related to surgical positioning? A. Apply elastic stockings to lower extremities. B. Monitor for excessive blood loss. C. Pad bony prominences. D. Secure joints on a board in anatomic positions.

C. Pad bony prominences

If sterile gauze falls to the ground and hits the front of the surgeon's gown on the way down, what does the nurse do to ensure 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. Spays an antimicrobial on the surgeon's gown

C. Picks the gauze up without touching the surgeon

After gastric surgery, a client arrives in the post-anesthesia care unit. Which nursing action is most appropriate for the RN to delegate to an experienced nursing assistant? A. Monitor respiratory rate and airway patency. B. Irrigate the NG tube with saline. C. Position the client on the left side. D. Assess the client's pain level.

C. Position the client on the left side.

Five RNs have been floated to the postanesthesia care unit for the day. A 16-year-old diabetic client has also just arrived from the operating room (OR) after having laparoscopic abdominal surgery. The charge nurse assigns the floating RN with which kind of experience to care for this new client? A. RN who usually works on the inpatient pediatric unit B. RN who provides education to diabetic clients in a clinic C. RN who has 5 years of experience in the delivery room D. RN who ordinarily works as a scrub nurse in the OR

C. RN who has 5 years of experience in the delivery room

How does the nurse position a client with postoperative nausea and vomiting? 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. Side-lying, with the head in a neutral position

Vicodin (acetaminophen/hydrocodone) is prescribed for a patient who has had surgery. The nurse informs the patient that which common adverse effects can occur with this medication?

Constipation , lightheadedness, urinary retention, and itching are some of the common adverse effects that the patient may experience while taking Vicodin.

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. "My scrubs are sterile."

The nurse reviews with a 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."

D. "The wound will completely heal in about 2 months."

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

D. Asks the client to sign the consent form

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

D. Circulating RN who has been employed in the hospital OR for 7 years

What pain management does a client who has been admitted to the post-anesthesia care unit typically receive? A. IM non-opioid analgesics B. IM opioid analgesics C. IV non-opioid analgesics D. IV opioid analgesics

D. IV opioid analgesics

The nurse interviews a patient scheduled to undergo general anesthesia for a hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery? a. The patient drinks 3 or 4 cups of coffee every morning before going to work. b. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. c. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital. d. The patient's father died after receiving general anesthesia for abdominal surgery.

D. The patient's father died after receiving general anesthesia for abdominal surgery. The information about the patient's father suggests that there may be a family history of malignant hyperthermia and that precautions may need to be taken to prevent this complication. Current research indicates that having clear liquids 3 hours before surgery does not increase the risk for aspiration in most patients. Patients are instructed to discontinue aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative implications.

What are the stages of general anesthesia?

During stage I of general anesthesia, the nurse positions the patient securely with safety belts to prevent falls because the patient is drowsy and amnesic. Stage 2-The nurse assists the anesthesiologist with suctioning as needed with general anesthesia to prevent aspiration of vomitus. In stage III, the patient experiences general muscle relaxation, with loss of reflexes and depression of vital function. In this stage, the nurse assists the anesthesiologist with smooth intubation to prevent injury. In stage III, the operative site is scrubbed in preparation for surgery.

Mr. Baltazar will be undergoing surgery with general anesthesia. The client should be given which of the following instructions preoperatively? Eat big breakfast Expect to be incontinent of urine postoperatively Double your medication doses Eat big breakfast Expect to be incontinent of urine postoperatively Expect nausea, vomiting, shivering, and pain postoperatively.

Expect nausea, vomiting, shivering, and pain postoperatively. Explanation: These responses should be expected, and the client should be prepared for them. Food is contraindicated before surgery. Urinary retention, not incontinence is likely. Medication is more likely to be held on the day of surgery.

All narcotics, regardless of their origin, reduce pain by: Stimulating opiate receptors Promoting the release of excitatory transmitters Releasing large quantities of endorphin Blocking the mu receptors

Stimulating opiate receptors Explanation: It is the stimulation of cerebral opiate receptors that reduces pain. Excitatory transmitters are not released during administration of morphine. Endorphin release is not associated with narcotic pain relief. The mu receptors mediate analgesia and are not blocked during narcotic administration.

The primary health care provider asks a nurse to assess the emotional status of a patient with depression before a surgery. Which nurse is responsible for assessing the patient's emotional status?

The holding area nurse is responsible for assessing the patient's physical and emotional status before going into surgery. The scrub nurse is responsible for setting up the surgical table. The specialty nurse is in charge during specialty surgeries such as cardiac, ophthalmologic, and orthopedic surgeries. The circulating nurse is the registered nurse who manages patient care in the operating room (OR).

The nurse is attending to an older patient scheduled for heart surgery. What intervention by the nurse is most appropriate to ensure skin integrity?

The older patient is likely to have reduced hydration and risk for skin damage, which can be reduced by padding bony prominences. Assisting the patient with ambulation, allowing extra time to teach the patient, and preventing the risk for falls indirectly help to maintain skin integrity (note:keyword was skin integrity, not safety or teaching!)

A patient in a medical-surgical unit reports that something popped out from his surgical wound while coughing. Which nursing intervention may benefit the patient?

The patient could have an evisceration, or protrusion of the internal organs, so the nurse should apply a sterile nonadherent dressing or a saline dressing to the wound and notify the primary health care provider or surgeon immediately.

The nurse should be well versed with all these to safeguard the safety and quality to patient delivery outcome. Which of the following should be given highest priority when receiving patient in the OPERATING ROOM? Assess level of consciousness Verify patient identification and informed consent Assess vital signs

Verify patient identification and informed consent

Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best? a. "Let me call the surgeon to see if you really need them." b. "No, you have to use those for 24 hours after surgery." c. "OK, we can remove them since you are stable now." d. "To prevent blood clots you need them a few more hours."

d. "To prevent blood clots you need them a few more hours." According to the Surgical Care Improvement Project (SCIP), any prophylactic measures to prevent thromboembolic events during surgery are continued for 24 hours afterward. The nurse should explain this to the client. Calling the surgeon is not warranted. Simply telling the client he or she has to wear the hose and compression devices does not educate the client. The nurse should not remove the devices.

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements

d. Use of multiple herbs and supplements Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered. Lack of experience with surgery may increase anxiety and may require higher teaching needs, but is not the priority over client safety. ***side note:pt taking St. John's wort may prolong the effects of anesthetic agents and increase the time to waken completely after surgery.**

Minimally invasive surgery is surgery that can be performed in a body cavity or body area through one or more endoscopes, such as arthroscopy. Partial mastectomy is a simple surgery. Radical prostatectomy is a radical surgery. Mitral valve replacement is major surgery.

know the different types of surgeries