Perioperative Nursing Care Questions

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?

"Can you share with me what you've been told about your surgery?" rationale: 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.

The nurse assesses 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.

Serous drainage

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?

Pneumonia rationale: 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 retained pulmonary secretions

The nurse has conducted preoperative teaching for a client schedule for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse determines that the client needs additional teaching if the client makes which statement?

"I need to continue to take the aspirin until the day of surgery." rationale: Anticoagulants alter 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.

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?

- contact the surgeon - instruct the client to remain quiet -prepare the client for wound closure -document the findings and actions taken

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?

The best results are achieved when sitting up or with the head of he bed elevated 45 to 90 degrees rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler's or high Fowler's position.

The nurse is developing a plan of care for a client schedule for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?

Have a client void immediately before going into surgery rationale: The nurse would assist the client to void immediately before surgery so that the bladder will be empty.

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which lab result should be reported to the surgeon's office by the nurse, knowing it could cause the surgery to be postponed?

Hemoglobin 8.0 g/dL

The nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which sign that could indicate an evolving complication?

Increasing restlessness rationale: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock or pulmonary embolism.

A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?

Obtain a telephone consent from a family member, following agency policy. rationale: 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 can then sign the consent with the name of the family member, noting than an oral consent was obtained.

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

Urinary output of 20 mL/hr rationale: Urine output should be maintained at minimum of 30mL/hr for an adult. Output less than 30 mL for each of 2 consecutive hours should be reported to HCP.