Perioperative + Oxygenation

A client is to have a transfusion of packed red blood cells from a designated donor. The client asks if any diseases can be transmitted by this donor. The nurse should inform the client that which of the fol- lowing diseases can be transmitted by a designated donor? Select all that apply. 1. Epstein-Barr virus. 2. Human immunodeficiency virus (HIV). 3. Cytomegalovirus (CMV). 4. Hepatitis A. 5. Malaria.

1, 2, 3. Using designated donors does not decrease the risk of contracting infectious diseases, such as the Epstein-Barr virus, HIV, or CMV. Hepa- titis A is transmitted by the oral-fecal route, not the blood route; however, hepatitis B and C can be con- tracted from a designated donor. Malaria is transmit- ted by mosquitoes.

A patient is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications? A) Folic acid B) Vitamin B12 C) Lactulose D) Magnesium sulfate

ANS: B Feedback: Pernicious anemia is characterized by vitamin B12 deficiency. Magnesium sulfate, lactulose, and folic acid do not address the pathology of this type of anemia.

Prior to a patients scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the patients care. What is the main rationale for organizing perioperative care in this collaborative manner? A) Historical precedence B) Patient requests C) Physicians needs D) Evidence-based practice

ANS: D Collaboration of the surgical team using evidence-based practice tailored to a specific case results in optimal patient care and improved outcomes. None of the other listed factors is the basis for the collaboration of the surgical team.

The nurse is performing a preoperative assessment on a patient going to surgery. The patient informs the nurse that he drinks approximately two bottles of wine each day and has for the last several years. What postoperative difficulties can the nurse anticipate for this patient? A) Alcohol withdrawal syndrome immediately following surgery B) Alcohol withdrawal syndrome 2 to 4 days after his last alcohol drink C) Alcohol withdrawal syndrome upon administration of general anesthesia D) Alcohol withdrawal syndrome 1 week after his last alcohol drink

Ans: B Feedback: Alcohol withdrawal syndrome may be anticipated between 48 and 96 hours after alcohol withdrawal and is associated with a significant mortality rate when it occurs postoperatively.

The nurse is describing normal RBC physiology to a patient who has a diagnosis of anemia. The nurse should explain that the RBCs consist primarily of which of the following? A) Plasminogen B) Hemoglobin C) Hematocrit D) Fibrin

Ans: B Feedback: Mature erythrocytes consist primarily of hemoglobin, which contains iron and makes up 95% of the cell mass. RBCs are not made of fibrin or plasminogen. Hematocrit is a measure of RBC volume in whole blood.

The nurse is monitoring the status of a postopera- tive client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving compli- cation? 1. Increasing restlessness 2. A pulse of 86 beats per minute 3. Blood pressure of 110/70 mm Hg 4. Hypoactive bowel sounds in all four quadrants

Answer: 1 Rationale: Increasing restlessness is a sign that requires contin- uous and close monitoring because it could indicate a poten- tial complication such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats per minute is within normal limits. Hypoactive bowel sounds heard in all four quadrants are a normal occur- rence in the immediate postoperative period.

The nurse is planning care for a client who has a platelet count of 30,000/mm3. Which intervention does the nurse include in this client's plan of care? a. Bleeding Precautions b. Vital signs every 4 hours c. Isolation Precautions d. Oxygen by nasal cannula

ANS: A The normal platelet count ranges between 150,000 and 400,000/mm3. This client is at extreme risk for bleeding. Although it is necessary to notify the provider, the nurse would first protect the client by instituting Bleeding Precautions. The other interventions are not related to the low platelet count.

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this patient? Select all that apply. A) Establishing an IV line B) Verifying the surgical site with the patient C) Taking measures to ensure the patients comfort D) Applying a grounding device to the patient E) Preparing the medications to be administered in the OR

Ans: A, B, C

An OR nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the OR? A) Reusable shoe covers B) Mask covering the nose and mouth C) Goggles D) Gloves

Ans: B Feedback: Masks are worn at all times in the restricted zone of the OR. Shoe covers are worn one time only; goggles and gloves are worn as required, but not necessarily at all times.

The nurses review of a patients most recent blood work reveals a significant increase in the number of band cells. The nurses subsequent assessment should focus on which of the following? Respiratory function Evidence of decreased tissue perfusion Signs and symptoms of infection Recent changes in activity tolerance

Ans:C Ordinarily, band cells account for only a small percentage of circulating granulocytes, although their percentage can increase greatly under conditions in which neutrophil production increases, such as infection. This finding is not suggestive of problems with oxygenation and subsequent activity intolerance.

A client has a platelet count of 31,000/μL. The nurse should instruct the client to: 1.Pad sharp surfaces to avoid minor trauma when walking. 2.Assess for spontaneous petechiae in the extremities. 3.Keep the room darkened. 4.Check for blood in the urine.

. 1. A client with a platelet count of 30,000to 50,000/μL is susceptible to bruising with minor trauma. Padding areas that the client might bump, scratch, or hit may help prevent minor trauma. A platelet count of 15,000 to 30,000/μL may resultin spontaneous petechiae and bruising, especially on the extremities. Safety measures to pad surfaces would still be used, but the focus would be on assessing for new spontaneous petechiae. Keep- ing the room dark does not help the client with a low platelet count. When the count is lower than 20,000/μL, the client is at risk for spontaneous bleeding from the mucous membranes (oral, nasal, urinary, and rectal) and intracranial bleeding.

A client with iron deficiency anemia is refusing to take the prescribed oral iron medication because the medication is causing nausea. The nurse should do which of the following? Select all that apply. 1.Suggest that the client use ginger when taking the medication. 2.Ask the client what she thinks is causing the nausea. 3.Tell the client to use stool softeners to mini mize constipation. 4.Offer to administer the medication by an intramuscular injection. 5.Suggest that the client take the iron with orange juice.

1, 2, 5. Nausea and vomiting are common adverse effects of oral iron preparations. The nurse should first ask the client why she does not wantto take the oral medication, and then suggest ways to decrease the nausea and vomiting. Ginger may help minimize the nausea and the client can try this remedy and evaluate its effectiveness. Iron should be taken on an empty stomach but can be taken with orange juice. The client can evaluate if this helps the nausea. Stool softeners should not be used in clients with iron deficiency anemia. Instead, constipation can be prevented by following a high-fiber diet. Administering iron intramuscularly is done only if other approaches are not effective.

The nurse writes a diagnosis of altered tissue perfusion for a client diagnosed with anemia. Which interventions should be included in the plan of care? Select all that apply. 1. Monitor the client's hemoglobin and hematocrit. 2.Move the client to a room near the nurse's desk. 3.Limit the client's dietary intake of green vegetables. 4.Assess the client for numbness and tingling. 5.Allow for rest periods during the day for the client.

1,2,4,5 The nurse should monitor the hemoglo- bin and hematocrit in all clients diagnosed with anemia. Because decreased oxygenation levels to the brain can cause the client to become confused, a room where the client can be observed frequently—near the nurse's desk—is a safety issue. Numbness and tingling may occur in anemia as a result of neurological involvement. Fatigue is the number-one presenting symptom of anemia.

The client is being admitted with folic acid deficiency anemia. Which would be the most appropriate referral? 1. Alcoholics Anonymous. 2. Leukemia Society of America. 3. A hematologist. 4. A social worker.

1.Most clients diagnosed with folic acid deficiency anemia have developed the anemia from chronic alcohol abuse. Alcohol consumption increases the useof folates, and the alcoholic diet is usually deficient in folic acid. A referral to Alco- holics Anonymous would be appropriate

The nurse is admitting a 24-year-old African American female client with a diagnosis of rule- out anemia. The client has a history of gastric bypass surgery for obesity four (4) years ago. Current assessment findings include height 5′5′′; weight 75 kg; P 110, R 27, and BP 104/66; pale mucous membranes and dyspnea on exertion. Which type of anemia would the nurse suspect the client has developed? 1. Vitamin B12 deficiency. 2. Folic acid deficiency. 3. Iron deficiency. 4. Sickle cell anemia.

1.The rugae in the stomach produce intrinsic factor, which allows the body to use vitamin B from the foods eaten. Gastric bypass 12 surgery reduces the amount of rugae dras- tically. Clients develop pernicious anemia (vitamin B12 deficiency). Other symptoms of anemia include dizziness and the tachy- cardia and dyspnea listed in the stem.

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropri- ate for the nurse to make to the client at this time as it relates to these techniques? "Use of an incentive spirometer will help prevent pneumonia." "Close monitoring of your oxygen saturation will detect hypoxemia." "Administration of intravenous uids will pre- vent or treat uid imbalance." "Early ambulation and administration of blood thinners will prevent pulmonary embolism."

2. Answer: 1 Rationale: Postoperative respiratory problems are atelecta- sis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dys- pnea, and lung crackles and can be caused by retained pulmo- nary secretions. Use of an incentive spirometer helps prevent pneumonia and atelectasis. Hypoxemia is an inadequate con- centration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help detect hypoxemia, moni- toring is not directly related to coughing and deep-breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to one or more lobes of the lung; this is usually due to clot formation. Early ambulation and admin- istration of blood thinners help prevent this complication; however, it is not related to coughing and deep-breathing techniques.

A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. Which is the nurse's best response? 1"The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid." 2 "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor." 3"The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction." 4"The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production."

2. Most clients with pernicious anemiahave deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of red blood cells in this condi- tion.

When the nurse is conducting a preoperative interview with a client who is having a vaginal hys- terectomy, the client states that she forgot to tell her doctor that she had a total hip replacement 3 years ago. The nurse communicates this information to the perioperative nurse because: 1.The prosthesis may cause a problem with the electrosurgical unit used to control bleeding. 2.The client should not have her hip externally rotated when she is positioned for the procedure. 3.The perioperative nurse can inform the rest of the team about the total hip replacement. 4.There is not enough time to notify the sur- geon and note this finding on the history and physical information before the procedure.

2. The nurse should notify the surgery department and document the past surgery in the chart in the preoperative notes so that the client's hip is not externally rotated and the hip dislocated while she is in the lithotomy position. The prosthe- sis should not be a problem as long as the periop- erative nurse places the grounding pad away from the prosthesis site. The perioperative nurse will inform the rest of the team, but the primary reason to inform the perioperative nurse is related to safe positioning of the client. The surgeon can hand- write an addendum to the history and initial and date the entry. The history and physical information can then be retyped at a later date.

When a client with thrombocytopenia has of a severe headache, the nurse interprets that this may indicate which of the following? 1. Stress of the disease. 2. Cerebral bleeding. 3. Migraine headache. 4. Sinus congestion.

2. When the platelet count is very low, RBCs leak out of the blood vessels and into the tissue. If the blood pressure is elevated and the platelet count falls to less than 15,000/μL, internal bleeding in the brain can occur. A severe headache occurs from meningeal irritation when blood leaks out of the cerebral vascu- lature. When a client has thrombocytopenia, the nurse should always assess for cerebral bleeding by check- ing vital signs and performing neurologic checks. Headaches can be caused by stress, migraines, and sinus congestion. However, the concer

The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical unit. Which task should the nurse delegate to the UAP? 1. Check on the bowel movements of a client diagnosed with melena. 2.Take the vital signs of a client who received blood the day before. 3.Evaluate the dietary intake of a client who has been noncompliant with eating. 4.Shave the client diagnosed with severe hemolytic anemia.

2.The UAP can take the vital signs of a client who is stable; this client received the blood the day before.

The client diagnosed with anemia has an Hb of 6.1 g/dL. Which complication should the nurse assess for? 1. Decreased pulmonary functioning. 2. Impaired muscle functioning. 3. Congestive heart failure. 4. Altered gastric secretions.

2.The client with activity intolerance will need assistance to perform activities of daily living.

A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: 1. Adds dried fruit to cereal and baked goods. 2. Cooks tomato-based foods in iron pots. 3. Drinks coffee or tea with meals. 4. Adds vitamin C to all meals.

3. Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishesat every meal because dried fruits are a nonhemeor nonanimal iron source. Cooking in iron cook- ware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to adda rich supply of vitamin C to every meal becausethe absorption of iron is increased when food with vitamin C or ascorbic acid is consumed.

The nurse should instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? 1. Whole grains. 2. Green leafy vegetables. 3. Meats and dairy products. 4. Broccoli and brussels sprouts

3. Good sources of vitamin B12 include meats and dairy products. Whole grains are a good source of thiamine. Green, leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Broccoli and brussels sprouts are good sources of ascorbic acid (vitamin C).

The client diagnosed with iron-deficiency anemia is prescribed ferrous gluconate orally. Which should the nurse teach the client?1. 1.Take Imodium, an antidiarrheal, over-the- counter (OTC) for diarrhea. 2.Limit exercise for several weeks until a tolerance is achieved. 3.The stools may be very dark, and this can mask blood. 4.Eat only red meats and organ meats for protein.

3.The stool will be a dark green-black, which can mask the appearance of blood in the stool.

A client has been admitted with active rectal bleeding. He has been typed and cross-matched for 2 units of packed red blood cells (RBCs). Within 10 minutes of admission the client faints when getting up to go to the bedside commode. The nurse noti- fies the health care provider, who orders a unit of blood immediately. The nurse should expect which type of packed RBCs will be used for immediate transfusion? 1. A negative. 2. B negative. 3. AB negative. 4. O negative.

4. A routine serology study to confirm com- patibility between a blood donor and recipient takes about 1 hour. In an emergency, O negative RBCs can be safely administered to most clients, which is why a person with O-negative blood is called a univer- sal donor. The other types of RBCs may cause an adverse reaction.

The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first: 1. Discontinue the I.V. catheter if a blood trans- fusion reaction occurs. 2. Administer the PRBCs through a percutane- ously inserted central catheter line with a 20-gauge needle. 3. Flush PRBCs with 5% dextrose and 0.45% normal saline solution. 4. Stay with the client during the first 15 min- utes of infusion.

4. The most likely time for a blood transfu- sion reaction to occur is during the first 15 minutes or first 50 mL of the infusion. If a blood transfu- sion reaction does occur, it is imperative to keepan established I.V. line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle;a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solu- tion and should be infused with only normal saline solution.

8 The nurse has just admitted a 35-year-old female client who has a serum vitamin B12 concen- tration of 800 pg/mL. Which of the following labora- tory findings should cue the nurse to focus the client history assessment on specific drug or alcohol use? 1. Total bilirubin, 0.3 mg/dL. 2. Serum creatinine, 0.5 mg/dL. 3. Hemoglobin, 16 g/dL. 4. Folate, 1.5 ng/mL.

4. The normal range of folic acid is 1.8to 9 ng/mL, and the normal range of vitamin B12 (cyanocobalamin) is 200 to 900 pg/mL. A low folic acid level in the presence of a normal vitamin B12 level is indicative of a primary folic acid deficiency anemia. Factors that affect the absorption of folic acid are drugs such as methotrexate, oral contra- ceptives, antiseizure drugs, and alcohol. The total bilirubin, serum creatinine, and hemoglobin values are within normal limits.

A patient with a documented history of glucose-6-phosphate dehydrogenase deficiency has presented to the emergency department with signs and symptoms including pallor, jaundice, and malaise. Which of the nurses assessment questions relates most directly to this patients hematologic disorder? When did you last have a blood transfusion? What medications have taken recently?Have you been under significant stress lately? Have you suffered any recent injuries?

ANS B Feedback: Exacerbations of glucose-6-phosphate dehydrogenase deficiency are nearly always precipitated by medications. Blood transfusions, stress, and injury are less common triggers.

A patient is being treated for the effects of a longstanding vitamin B12 deficiency. What aspect of the patients health history would most likely predispose her to this deficiency? A) The patient has irregular menstrual periods. B) The patient is a vegan. C) The patient donated blood 60 days ago. D) The patient frequently smokes marijuana.

ANS B: Because vitamin B12 is found only in foods of animal origin, strict vegetarians may ingest little vitamin B12. Irregular menstrual periods, marijuana use, and blood donation would not precipitate a vitamin B12 deficiency.

A patient has been living with a diagnosis of anemia for several years and has experienced recent declines in her hemoglobin levels despite active treatment. What assessment finding would signal complications of anemia? A) Venous ulcers and visual disturbances B) Fever and signs of hyperkalemia C) Epistaxis and gastroesophageal reflux D) Ascites and peripheral edema

ANS D A significant complication of anemia is heart failure from chronic diminished blood volume and the hearts compensatory effort to increase cardiac output. Patients with anemia should be assessed for signs and symptoms of heart failure, including ascites and peripheral edema. None of the other listed signs and symptoms is characteristic of heart failure.

The nurse is performing a preadmission assessment of a patient scheduled for a bilateral mastectomy. Of what. purpose of the preadmission assessment should the nurse be aware? A.Verifies completion of preoperative diagnostic testing B.Discusses and reviews patients health insurance coverage C. Determines the patients suitability as a surgical candidate D.Informs the patient of need for postoperative transportation

ANS: A Purposes of preadmission testing (PAT) include verifying completion of preoperative diagnostic testing. The nurses role in PAT does not normally involve financial considerations or addressing transportation. The physician determines the patients suitability for surgery.

The nurse is caring for a client who is receiving chemotherapy for cancer. Which intervention does the nurse implement for this client? a. Maintain strict Standard Precautions. b. Monitor the client's pulse oximetry. c. Administer the prescribed iron. d. Assess the client's fibrinogen level.

ANS: A The client who is receiving chemotherapy drugs that suppress the bone marrow will be at risk for a decreased white blood cell (WBC) count and infection. The nurse will be most therapeutic by adhering to Standard Precautions to prevent infection, such as handwashing. The nurse will not expect the fibrinogen level to be affected by this therapy. Iron is not typically administered with chemotherapy because this is bone marrow suppression, so the administration of epoetin (Epogen) or filgrastim (Neupogen) is most effective. Monitoring the pulse oximetry is part of routine care and probably would not need to be done continuously.

One of the things a nurse has taught to a patient during preoperative teaching is to have nothing by mouth for the specified time before surgery. The patient asks the nurse why this is important. What is the most appropriate response for the patient? A)You will need to have food and fluid restricted before surgery so you are not at risk for choking. B)The restriction of food or fluid will prevent the development of pneumonia related to decreased lung capacity. C)The presence of food in the stomach interferes with the absorption of anesthetic agents. D)By withholding food for 8 hours before surgery, you will not develop constipation in the postoperative period.

ANS: A The major purpose of withholding food and fluid before surgery is to prevent aspiration. There is no scientific basis for withholding food and the development of pneumonia or interference with absorption of anesthetic agents. Constipation in patients in the postoperative period is related to the anesthesia, not from withholding food or fluid in the hours before surgery.

The surgical nurse is preparing to send a patient from the presurgical area to the OR and is reviewing the patients informed consent form. What are the criteria for legally valid informed consent? Select all that apply. A)Consent must be freely given. b)Consent must be notarized. C)Consent must be signed on the day of surgery. D)Consent must be obtained by a physician. E)Signature must be witnessed by a professional staff member.

ANS: A,D,E valid consent must be freely given, without coercion. Consent must be obtained by a physician and the patients signature must be witnessed by a professional staff member. It does not need to be signed on the same day as the surgery and it does not need to be notarized.

You are the nurse caring for an unconscious trauma victim who needs emergency surgery. The patient is a 55-year-old man with an adult son. He is legally divorced and is planning to be remarried in a few weeks. His parents are at the hospital with the other family members. The physician has explained the need for surgery, the procedure to be done, and the risks to the children, the parents, and the fianc. Who should be asked to sign the surgery consent form? A.The fiance B. The son C.The physician, acting as a surrogate D.The patients father

ANS: B B Feedback: The patient personally signs the consent if of legal age and mentally capable. Permission is otherwise obtained from a surrogate, who most often is a responsible family member (preferably next of kin) or legal guardian. In this instance, the child would be the appropriate person to ask to sign the consent form as he is the closest relative at the hospital. The fianc is not legally related to him as the marriage has not yet taken place. The father would only be asked to sign the consent if no children were present to sign. The physician would not sign if family members were available.

The nurse is providing preoperative teaching to a patient scheduled for surgery. The nurse is instructing the patient on the use of deep breathing, coughing, and the use of incentive spirometry when the patient states, I dont know why youre focusing on my breathing. My surgery is on my hip, not my chest. What rationale for these instructions should the nurse provide? A) To prevent chronic obstructive pulmonary disease (COPD) B)To promote optimal lung expansion C)To enhance peripheral circulation D)To prevent pneumothorax

ANS: B Feedback: One goal of preoperative nursing care is to teach the patient how to promote optimal lung expansion and consequent blood oxygenation after anesthesia. COPD is not a realistic risk and pneumothorax is also unlikely. Breathing exercises do not primarily affect peripheral circulation.

The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient? A) How to milk the chest tubing B) How to splint the incision when coughing C)How to take prophylactic antibiotics correctly D)How to manage the need for fluid restriction

ANS: B Feedback: Prior to thoracotomy, the nurse educates the patient about how to splint the incision with the hands, a pillow, or a folded towel. The patient is not taught how to milk the chest tubing because this is performed by the nurse. Prophylactic antibiotics are not normally used and fluid restriction is not indicated following thoracotomy.

The nurse is preparing a patient for surgery. The patient states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take? A) Have the patient sign the informed consent and place it in the chart. B) Call the physician to review the procedure with the patient. C) Explain the procedure clearly to the patient and her family. D)Provide the patient with a pamphlet explaining the procedure.

ANS: B While the nurse may ask the patient to sign the consent form and witness the signature, it is the surgeons responsibility to provide a clear and simple explanation of what the surgery will entail prior to the patient giving consent. The surgeon must also inform the patient of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods.

A patient is on call to the OR for an aortobifemoral bypass and the nurse administers the ordered preoperative medication. After administering a preoperative medication to the patient, what should the nurse do? A) Encourage light ambulation. B) Place the bed in a low position with the side rails up. C) Tell the patient that he will be asleep before he leaves for surgery. D) Take the patients vital signs every 15 minutes.

ANS: B Feedback: When the preoperative medication is given, the bed should be placed in low position with the side rails raised. The patient should not get up without assistance. The patient may not be asleep, but he may be drowsy. Vital signs should be taken before the preoperative medication is given; vital signs are not normally required every 15 minutes after administration.

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The childs parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed? A.A social worker should temporarily sign the informed consent. B.Consent should be obtained from the hospitals ethics committee. C.Surgery should be done without informed consent. D.Surgery should be delayed until the parents arrive.

ANS: C Feedback: In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the patients informed consent. However, every effort must be made to contact the patients family. In such a situation, contact can be made by electronic means. In this scenario, the surgery is considered lifesaving, and the parents are on their way to the hospital and not available. A delay would be unacceptable. Neither a social worker nor a member of the ethics committee may sign.

The nurse is caring for a patient who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the patients ribs and xiphoid process are prominent. The patient states she exercises two to three times daily and her mother indicates that she is being treated for anorexia nervosa. How should the nurse best follow up these assessment data? A).Inform the postoperative team about the patients risk for wound dehiscence. B).Evaluate the patients ability to manage her pain level. C)Facilitate a detailed analysis of the patients electrolyte levels. D)Instruct the patient on the need for a high-sodium diet to promote healing.

ANS: C The surgical team should be informed about the patients medical history regarding anorexia nervosa. Any nutritional deficiency, such as malnutrition, should be corrected before surgery to provide adequate protein for tissue repair. The electrolyte levels should be evaluated and corrected to prevent metabolic abnormalities in the operative and postoperative phase.

The medical nurse is aware that patients with sickle cell anemia benefit from understanding what situations can precipitate a sickle cell crisis. When teaching a patient with sickle cell anemia about strategies to prevent crises, what measures should the nurse recommend? A) Using prophylactic antibiotics and performing meticulous hygiene B)Maximizing physical activity and taking OTC iron supplements C)Limiting psychosocial stress and eating a high-protein diet D) Avoiding cold temperatures and ensuring sufficient hydration

ANS: D Feedback: Keeping warm and providing adequate hydration can be effective in diminishing the occurrence and severity of attacks. Hygiene, antibiotics, and high protein intake do not prevent crises. Maximizing activity may exacerbate pain and be unrealistic.

The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? A.Notify the patients physician. B.Stop the transfusion immediately. C.Remove the patients IV access. D.Assess the patients chest sounds and vital signs.

ANS:B Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the patients vital signs, and notify the physician. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The patients IV access should not be removed.

A patient comes to the clinic complaining of fatigue and the health interview is suggestive of pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that the patient will be diagnosed? A) Iron deficiency anemia B) Pernicious anemia C) Sickle cell anemia D) Hemolytic anemia

Ans: A Feedback: A low serum iron level, a low ferritin level, and symptoms of pica are associated with iron deficiency anemia. TIBC may also be elevated. None of the other anemias are associated with pica.

The perioperative nurse is preparing to discharge a female patient home from day surgery performed under general anesthetic. What instruction should the nurse give the patient prior to the patient leaving the hospital? A) The patient should not drive herself home. B) The patient should take an OTC sleeping pill for 2 nights. C) The patient should attempt to eat a large meal at home to aid wound healing. D) The patient should remain in bed for the first 48 hours postoperative.

Ans: A Feedback: Although recovery time varies, depending on the type and extent of surgery and the patients overall condition, instructions usually advise limited activity for 24 to 48 hours. Complete bedrest is contraindicated in most cases, however. During this time, the patient should not drive a vehicle and should eat only as tolerated. The nurse does not normally make OTC recommendations for hypnotics.

You are providing preoperative teaching to a patient scheduled for hip replacement surgery in 1 month. During the preoperative teaching, the patient gives you a list of medications she takes, the dosage, and frequency. Which of the following interventions provides the patient with the most accurate information? A) Instruct the patient to stop taking St. Johns wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents. B) Instruct the patient to continue taking ephedrine prior to surgery due to its beneficial effect on blood pressure. C) Instruct the patient to discontinue Synthroid due to its effect on blood coagulation and the potential for heart dysrhythmias. D) Instruct the patient to continue any herbal supplements unless otherwise instructed, and inform the patient that these supplements have minimal effect on the surgical procedure.

Ans: A Feedback: Because of the potential effects of herbal medications on coagulation and potential lethal interactions with other medications, the nurse must ask surgical patients specifically about the use of these agents, document their use, and inform the surgical team and anesthesiologist, anesthetist, or nurse anesthetist. Currently, it is recommended that the use of herbal products be discontinued at least 2 weeks before surgery. Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis and respiratory failure. The administration of Synthroid is imperative in the preoperative period. The use of ephedrine in the preoperative phase can cause hypertension and should be avoided.

n OR nurse will be participating in the intraoperative phase of a patients kidney transplant. What action will the nurse prioritize in this aspect of nursing care? A) Monitoring the patients physiologic status B) Providing emotional support to family C) Maintaining the patients cognitive status D) Maintaining a clean environment

Ans: A Feedback: During the intraoperative phase, the nurse is responsible for physiologic monitoring. The intraoperative nurse cannot support the family at this time and the nurse is not responsible for maintaining the patients cognitive status. The intraoperative nurse maintains an aseptic, not clean, environment.

A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which patient most closely during the intraoperative period because of the increased risk for hypothermia? A) A 74-year-old woman with a low body mass index B) A 17-year-old boy with traumatic injuries C) A 45-year-old woman having an abdominal hysterectomy D) A 13-year-old girl undergoing craniofacial surgery

Ans: A Feedback: Elderly patients are at greatest risk during surgical procedures because they have an impaired ability to increase their metabolic rate and impaired thermoregulatory mechanisms, which increase susceptibility to hypothermia. The other patients are likely at a lower risk.

An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate? A) Stool for occult blood B) Bone marrow biopsy C) Lumbar puncture D) Urinalysis

Ans: A Feedback: Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow). Bleeding in the GI tract can be preliminarily identified by testing stool for the presence of blood. A bone marrow biopsy would not be undertaken for the sole purpose of investigating an iron deficiency. Lumbar puncture and urinalysis would not be clinically relevant.

A clinic nurse is conducting a preoperative interview with an adult patient who will soon be scheduled to undergo cardiac surgery. What interview question most directly addresses the patients safety? A) What prescription and nonprescription medications do you currently take? B) Have you previously been admitted to the hospital, either for surgery or for medical treatment? C) How long do you expect to be at home recovering after your surgery? D) Would you say that you tend to eat a fairly healthy diet?

Ans: A Feedback: It is imperative to know a preoperative patients current medication regimen, including OTC medications and supplements. None of the other listed questions directly addresses an issue with major safety implications.

The OR nurse acts in the circulating role during a patients scheduled cesarean section. For what task is this nurse solely responsible? A) Performing documentation B) Estimating the patients blood loss C) Setting up the sterile tables D) Keeping track of drains and sponges

Ans: A Feedback: Main responsibilities of the circulating nurse include verifying consent; coordinating the team; and ensuring cleanliness, proper temperature and humidity, lighting, safe function of equipment, and the availability of supplies and materials. The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel as well as implementing fire safety precautions. The circulating nurse also monitors the patient and documents specific activities throughout the operation to ensure the patients safety and well-being. Estimating the patients blood loss is the surgeons responsibility; setting up the sterile tables is the responsibility of the first scrub; and keeping track of the drains and sponges is the joint responsibility of the circulating nurse and the scrub nurse.

The admitting nurse in a short-stay surgical unit is responsible for numerous aspects of care. What must the nurse verify before the patient is taken to the preoperative holding area? A) That preoperative teaching was performed B) That the family is aware of the length of the surgery C) That follow-up home care is not necessary D) That the family understands the patient will be discharged immediately after surgery.

Ans: A Feedback: The nurse needs to be sure that the patient and family understand that the patient will first go to the preoperative holding area before going to the OR for the surgical procedure and then will spend some time in the PACU before being discharged home with the family later that day. Other preoperative teaching content should also be verified and reinforced, as needed. The nurse should ensure that any plans for follow-up home care are in place.

The nurse is preparing to send a patient to the OR for a scheduled surgery. What should the nurse ensure is on the chart when it accompanies the patient to surgery? Select all that apply. A)Laboratory reports B)Nurses notes C)Verification form D)Social work assessment E) Dieticians assessment

Ans: A, B, C Feedback: The completed chart (with the preoperative checklist and verification form) accompanies the patient to the OR with the surgical consent form attached, along with all laboratory reports and nurses records. Any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted prominently at the front of the chart. The social work and dieticians assessments are not normally necessary when the patient goes to surgery.

A nurse is providing discharge education to a patient who has recently been diagnosed with a bleeding disorder. What topic should the nurse prioritize when teaching this patient? A) Avoiding buses, subways, and other crowded, public sites B) Avoiding activities that carry a risk for injury C) Keeping immunizations current D) Avoiding foods high in vitamin K

Ans: B Feedback: A patients absolute neutrophil count (ANC) is 440/mm3. But the nurses assessment reveals no apparent signs or symptoms of infection. What action should the nurse prioritize when providing care for this patient? Patients with bleeding disorders need to understand the importance of avoiding activities that increase the risk of bleeding, such as contact sports. Immunizations involve injections and may be contraindicated for some patients. Patients with bleeding disorders do not need to normally avoid crowds. Foods high in vitamin K may beneficial, not detrimental.

A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The nurses teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery? A) Leg exercises increase the patients muscle mass postoperatively. B) Leg exercises improve circulation and prevent venous thrombosis. C) Leg exercises help to prevent pressure sores to the sacrum and heels. D) Leg exercise help increase the patients level of consciousness after surgery.

Ans: B Feedback: Exercise of the extremities includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side) unless contraindicated by type of surgical procedure (e.g., hip replacement). When the patient does leg exercises postoperatively, circulation is increased, which helps to prevent blood clots from forming. Leg exercises do not prevent pressure sores to the sacrum, or increase the patients level of consciousness. Leg exercises have the potential to increase strength and mobility, but are unlikely to make a change to muscle mass in the short term.

The nurse knows that elderly patients are at higher risk for complications and adverse outcomes during the intraoperative period. What is the best rationale for this phenomenon? A) The elderly patient has a more angular bone structure than a younger person. B) The elderly patient has reduced ability to adjust rapidly to emotional and physical stress. C) The elderly patient has impaired thermoregulatory mechanisms, which increase susceptibility to hyperthermia. D) The elderly patient has an impaired ability to decrease his or her metabolic rate.

Ans: B Feedback: Factors that affect the elderly surgical patient in the intraoperative period include the following: impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms increase susceptibility to hypothermia. Bone loss (25% in women, 12% in men) necessitates careful manipulation and positioning during surgery. Reduced ability to adjust rapidly to emotional and physical stress influences surgical outcomes and requires meticulous observation of vital functions. Older adults do not have more angular bones than younger people.

During the care of a preoperative patient, the nurse has given the patient a preoperative benzodiazepine. The patient is now requesting to void. What action should the nurse take? A) Assist the patient to the bathroom. B) Offer the patient a bedpan or urinal. C) Wait until the patient gets to the operating room and is catheterized. D) Have the patient go to the bathroom.

Ans: B Feedback: If a preanesthetic medication is administered, the patient is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness. If a patient needs to void following administration of a sedative, the nurse should offer the patient a urinal. The patient should not get out of bed because of the potential for lightheadedness.

You are caring for an 88-year-old woman who is scheduled for a right mastectomy. You know that elderly patients are frequently more anxious prior to surgery than younger patients. What would you increase with this patient to decrease her anxiety? A) Analgesia B) Therapeutic touch C) Preoperative medication D) Sleeping medication the night before surgery

Ans: B Feedback: Older patients report higher levels of preoperative anxiety; therefore, the nurse should be prepared to spend additional time, increase the amount of therapeutic touch utilized, and encourage family members to be present to decrease anxiety. For most patients, nonpharmacologic interventions should be attempted before administering medications.

A patient with poorly controlled diabetes has developed end-stage renal failure and consequent anemia. When reviewing this patients treatment plan, the nurse should anticipate the use of what drug? A) Magnesium sulfate B) Epoetin alfa C) Low-molecular weight heparin D) Vitamin K

Ans: B Feedback: The availability of recombinant erythropoietin (epoetin alfa [Epogen, Procrit], darbepoetin alfa [Aranesp]) has dramatically altered the management of anemia in end-stage renal disease. Heparin, vitamin K, and magnesium are not indicated in the treatment of renal failure or the consequent anemia.

A group of nurses are learning about the high incidence and prevalence of anemia among different populations. Which of the following individuals is most likely to have anemia? A) A 50-year-old African-American woman who is going through menopause B) An 81-year-old woman who has chronic heart failure C) A 48-year-old man who travels extensively and has a high-stress job D) A 13-year-old girl who has just experienced menarche

Ans: B Feedback: The incidence and prevalence of anemia are exceptionally high among older adults, and the risk of anemia is compounded by the presence of heart disease. None of the other listed individuals exhibits high-risk factors for anemia, though exceptionally heavy menstrual flow can result in anemia.

A 77-year-old mans coronary artery bypass graft has been successful and discharge planning is underway. When planning the patients subsequent care, the nurse should know that the postoperative phase of perioperative nursing ends at what time? A) When the patient is returned to his room after surgery B) When a follow-up evaluation in the clinical or home setting is done C) When the patient is fully recovered from all effects of the surgery D) When the family becomes partly responsible for the patients care

Ans: B Feedback: The postoperative phase begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home.

A patient undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions? A) Safe transfusion for patients with a history of transfusion reactions B) Prevention of viral infections from another persons blood C) Avoidance of complications in patients with alloantibodies D) Prevention of alloimmunization

Ans: B Feedback: The primary advantage of autologous transfusions is the prevention of viral infections from another persons blood. Other secondary advantages include safe transfusion for patients with a history of transfusion reactions, prevention of alloimmunization, and avoidance of complications in patients with alloantibodies.

The nurse is assessing a new patient with complaints of overwhelming fatigue and a sore tongue that is visibly smooth and beefy red. This patient is demonstrating signs and symptoms associated with what form of what hematologic disorder? A) Sickle cell anemia B) Hemophilia C) Megaloblastic anemia D) Thrombocytopenia

Ans: C Feedback: A red, smooth, sore tongue is a symptom associated with megaloblastic anemia. Sickle cell disease, hemophilia, and thrombocytopenia do not have symptoms involving the tongue.

A client with several chronic health problems has been newly diagnosed with a qualitative platelet defect. What component of the patients previous medication regimen may have contributed to the development of this disorder? A) Calcium carbonate B) Vitamin B12 C) Aspirin D) Vitamin D

Ans: C Feedback: Aspirin may induce a platelet disorder. Even small amounts of aspirin reduce normal platelet aggregation, and the prolonged bleeding time lasts for several days after aspirin ingestion. Calcium, vitamin D, and vitamin B12 do not have the potential to induce a platelet defect.

A patient is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting coffee-ground like emesis. The patient is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the patient most likely anticipate that the surgery will be scheduled? A) Within 24 hours B) Within the next week C) Without delay because the bleed is emergent D) As soon as all the days elective surgeries have been completed

Ans: C Feedback: Emergency surgeries are unplanned and occur with little time for preparation for the patient or the perioperative team. An active bleed is considered an emergency, and the patient requires immediate attention because the disorder may be life threatening. The surgery would not likely be deferred until after elective surgeries have been completed.

A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron- deficiency anemia in recent weeks. When providing the patient with nutritional guidelines and meal suggestions, what foods would be most likely to increase the womans iron stores? A) Salmon accompanied by whole milk B) Mixed vegetables and brown rice C) Beef liver accompanied by orange juice D) Yogurt, almonds, and whole grain oats

Ans: C Feedback: Food sources high in iron include organ meats, other meats, beans (e.g., black, pinto, and garbanzo), leafy green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron. All of the listed foods are nutritious, but liver and orange juice are most likely to be of benefit.

The perioperative nurse is constantly assessing the surgical patient for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the patient is developing malignant hyperthermia? A.Increased temperature B.Oliguria C.Tachycardia D.Hypotension

Ans: C Feedback: The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. Tachycardia (heart rate greater than 150 beats per minute) is often the earliest sign. Oliguria, hypotension, and increased temperature are later signs of malignant hyperthermia.

A nurse is providing education to a patient with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education? A) Take the iron with dairy products to enhance absorption. B) Increase the intake of vitamin E to enhance absorption. C) Iron will cause the stools to darken in color. D) Limit foods high in fiber due to the risk for diarrhea.

Ans: C Feedback: The nurse will inform the patient that iron will cause the stools to become dark in color. Iron should be taken on an empty stomach, as its absorption is affected by food, especially dairy products. Patients should be instructed to increase their intake of vitamin C to enhance iron absorption. Foods high in fiber should be consumed to minimize problems with constipation, a common side effect associated with iron therapy.

The nurse is caring for a trauma victim in the ED who will require emergency surgery due to injuries. Before the patient leaves the ED for the OR, the patient goes into cardiac arrest. The nurse assists in the successful resuscitation and proceeds to release the patient to the OR staff. When can the ED nurse perform the preoperative assessment?When he or she has the opportunity to review the patients electronic health record A) B) When the patient arrives in the OR C) When assisting with the resuscitation D) Preoperative assessment is not necessary in this case

Ans: C Feedback: The only opportunity for preoperative assessment may take place at the same time as resuscitation in the ED. Preoperative assessment is necessary, but the nurse could not normally enter the OR to perform this assessment. The health record is an inadequate data source.

In anticipation of a patients scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the patient? A) The patient should take three deep breaths and cough hard three times, at least every 15 minutes for the immediately postoperative period. B) The patient should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs. C) The patient should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. D) The patient should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly.

Ans: C Feedback: The patient assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to take a deep, slow breath and how to exhale slowly. After practicing deep breathing several times, the patient is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs.

The nurse is preparing a patient for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the patients signature on a consent form. Which comment by the patient would best indicate informed consent? A) I know Ill be fine because the physician said he has done this procedure hundreds of times. B) I know Ill have pain after the surgery but theyll do their best to keep it to a minimum. C) The physician is going to remove my uterus and told me about the risk of bleeding. D) Because the physician isnt taking my ovaries, Ill still be able to have children.

Ans: C Feedback: The surgeon must inform the patient of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the patient requests additional information, the nurse notifies the physician. In the correct response, the patient is able to tell the nurse what will occur during the procedure and the associated risks. This indicates the patient has a sufficient understanding of the procedure to provide informed consent. Clarification of information given may be necessary, but no additional information should be given. The other listed statements do not reflect an understanding of the surgery to be performed.

The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurses preoperative assessment of an elderly patient? A) Elderly patients have a smaller lung capacity than younger patients. B) Elderly patients require higher medication doses than younger patients. C) Elderly patients have less physiologic reserve than younger patients. D) Elderly patients have more sophisticated coping skills than younger patients.

Ans: C Feedback: The underlying principle that guides the preoperative assessment, surgical care, and postoperative care is that elderly patients have less physiologic reserve (the ability of an organ to return to normal after a disturbance in its equilibrium) than do younger patients. Elderly patients do not have larger lung capacities than younger patients. Elderly patients cannot necessarily cope better than younger patients and they often require lower doses of medications.

The nurse is caring for a patient who is experiencing pain and anxiety following his prostatectomy. Which intervention will likely best assist in decreasing the patients pain and anxiety? A) Administration of NSAIDs rather than opioids B) Allowing the patient to increase activity C) Use of guided imagery along with pain medication D) Use of deep breathing and coughing exercises

Ans: C Feedback: The use of guided imagery will enhance pain relief and assist in reduction of anxiety. It may be combined with analgesics. Deep breathing and the increase in activity may produce increased pain. Replacing opioids with NSAIDs may cause an increase in pain.

. A nurse is planning the care of a patient with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. What nursing diagnosis should the nurse prioritize in the patients plan of care? A) Risk for disuse syndrome related to ineffective peripheral circulation B) Functional urinary incontinence related to urethral occlusion C) Ineffective tissue perfusion related to thrombosis D) Ineffective thermoregulation related to hypothalamic dysfunction

Ans: C Feedback: There are multiple potential complications of sickle cell disease and sickle cell crises. Central among these, however, is the risk of thrombosis and consequent lack of tissue perfusion. Sickle cell crises are not normally accompanied by impaired thermoregulation or genitourinary complications. Risk for disuse syndrome is not associated with the effects of acute vaso-occlusive crisis.

A nurse is a long-term care facility is admitting a new resident who has a bleeding disorder. When planning this residents care, the nurse should include which of the following? A) Housing the resident in a private room B) Implementing a passive ROM program to compensate for activity limitation C) Implementing of a plan for fall prevention D) Providing the patient with a high-fiber diet

Ans: C Feedback: To prevent bleeding episodes, the nurse should ensure that an older adult with a bleeding disorder does not suffer a fall. Activity limitation is not necessarily required, however. A private room is not necessary and there is no reason to increase fiber intake.

An adult patient has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely to apply to this patients health status? A) Risk for deficient fluid volume related to impaired erythropoiesis B) Risk for infection related to tissue hypoxia C) Acute pain related to uncontrolled hemolysis D) Fatigue related to decreased oxygen-carrying capacity

Ans: D Feedback: Fatigue is the major assessment finding common to all forms of anemia. Anemia does not normally result in acute pain or fluid deficit. The patient may have an increased risk of infection due to impaired immune function, but fatigue is more likely.

A patient comes into the clinic complaining of fatigue. Blood work shows an increased bilirubin concentration and an increased reticulocyte count. What would the nurse suspect the patient has? A) A hypoproliferative anemia B) A leukemia C) Thrombocytopenia D) A hemolytic anemia

Ans: D Feedback: In hemolytic anemias, premature destruction of erythrocytes results in the liberation of hemoglobin from the erythrocytes into the plasma; the released hemoglobin is converted in large part to bilirubin, and therefore the bilirubin concentration rises. The increased erythrocyte destruction leads to tissue hypoxia, which in turn stimulates erythropoietin production. This increased production is reflected in an increased reticulocyte count as the bone marrow responds to the loss of erythrocytes. Hypoproliferative anemias, leukemia, and thrombocytopenia lack this pathology and presentation.

The nurse is creating the care plan for a 70-year-old obese patient who has been admitted to the postsurgical unit following a colon resection. This patients age and increased body mass index mean that she is at increased risk for what complication in the postoperative period? A) Hyperglycemia B) Azotemia C) Falls D) Infection

Ans: D Feedback: Like age, obesity increases the risk and severity of complications associated with surgery. During surgery, fatty tissues are especially susceptible to infection. In addition, obesity increases technical and mechanical problems related to surgery. Therefore, dehiscence (wound separation) and wound infections are more common. A postoperative patient who is obese will not likely be at greater risk for hyperglycemia, azotemia, or falls.

The nurse is caring for a patient in the postoperative period following an abdominal hysterectomy. The patient states, I dont want to use my pain meds because theyll make me dependent and I wont get better as fast. Which response is most important when explaining the use of pain medication? A) You will need the pain medication for at least 1 week to help in your recovery. What do you mean you feel you wont get better faster? B) Pain medication will help to decrease your pain and increase your ability to breath. Dependency is a risk with pain medication, but you are young and wont have any problems. C) Pain medication can be given by mouth to prevent the risk of dependency that you are worried about. The pain medication has not been shown to affect your risk of a slowed recovery. D) You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is administered for an extended period of time.

Ans: D Feedback: Postoperatively, medications are administered to relieve pain and maintain comfort without increasing the risk of inadequate air exchange. In the responses by the nurse, (response D) addresses the patients concerns about drug dependency and the nurses need to increase the patients ability to move and recover from surgery. The other responses offer incorrect information, such as increasing the patients ability to breathe or specifying the time needed to take the medication. Opioids will cause respiratory depression.

The nurse is planning patient teaching for a patient who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching? A) Upon the patients admission to the postanesthesia care unit (PACU) B) When the patient returns from the PACU C) During the intraoperative period D) As soon as possible before the surgical procedure

Ans: D Feedback: Teaching is most effective when provided before surgery. Preoperative teaching is initiated as soon as possible, beginning in the physicians office, clinic, or at the time of preadmission testing when diagnostic tests are performed. Upon admission to the PACU, the patient is usually drowsy, making this an inopportune time for teaching. Upon the patients return from the PACU, the patient may remain drowsy. During the intraoperative period, anesthesia alters the patients mental status, rendering teaching ineffective.

The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate? A) Keep the patient in a low Fowlers position. B) Perform tracheostomy care at least once per day. C) Maintain continuous bedrest. D) Monitor cuff pressure every 8 hours.

Ans: D Feedback: The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy care at least every 8 hours because of the risk of infection. The patient should be encouraged to ambulate, if possible, and a low Fowlers position is not indicated.

A 90-year-old female patient is scheduled to undergo a partial mastectomy for the treatment of breast cancer. What nursing diagnosis should the nurse prioritize when planning this patients postoperative care? A) Risk for Delayed Growth and Development related to prolonged hospitalization B) Risk for Decisional Conflict related to discharge planning C) Risk for Impaired Memory related to old age D) Risk for Infection related to reduced immune function

Ans: D Feedback: The lessened physiological reserve of older adults results in an increased risk for infection postoperatively. This physiological consideration is a priority over psychosocial considerations, which may or may not be applicable. Impaired memory is always attributed to a pathophysiological etiology, not advanced age.

The nurse admitting a patient who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this patients diagnosis of type 1 diabetes affect the care that the nurse plans? A) The nurse should administer a bolus of dextrose IV solution preoperatively. B) The nurse should keep the patient NPO for at least 8 hours preoperatively. C) The nurse should initiate a subcutaneous infusion of long-acting insulin. D) The nurse should assess the patients blood glucose levels vigilantly.

Ans: D Feedback: The patient with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia. Close glycemic monitoring is necessary. Dextrose infusion and prolonged NPO status are contraindicated. There is no specific need for an insulin infusion preoperatively.

The recovery room nurse is admitting a patient from the OR following the patients successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted patient? A) Heart rate and rhythm B) Skin integrity C) Core body temperature D) Airway patency

Ans: D Feedback: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).

The nurse is doing preoperative patient education with a 61-year-old male patient who has a 40-pack per year history of cigarette smoking. The patient will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this patient? A) Reduce smoking by 50% to prevent the development of pneumonia. B) Stop smoking at least 6 weeks before the scheduled surgery to enhance pulmonary function and decrease infection. C) Aim to quit smoking in the postoperative period to reduce the chance of surgical complications D) Stop smoking 4 to 8 weeks before the scheduled surgery to enhance pulmonary function and decrease infection.

Ans: D Feedback: The reduction of smoking will enhance pulmonary function; in the preoperative period, patients who smoke should be urged to stop 4 to 8 weeks before surgery.

The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes? A) Cognition is decreased. B) Daily arterial blood gases (ABGs) are necessary. C) Slight tracheal bleeding is anticipated. D) The cough reflex is depressed.

Ans: D Feedback: There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the patients cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required.

The nurse is planning the care of a patient with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this patients health problem is due to what? A) Production of inadequate quantities of RBCs B) Premature release of immature RBCs C) Injury to the RBCs in circulation D) Abnormalities in the structure and function RBCs

Ans: D Feedback: Vitamin B12 and folic acid deficiencies are characterized by the production of abnormally large erythrocytes called megaloblasts. Because these cells are abnormal, many are sequestered (trapped) while still in the bone marrow, and their rate of release is decreased. Some of these cells actually die in the marrow before they can be released into the circulation. This results in megaloblastic anemia. This pathologic process does not involve inadequate production, premature release, or injury to existing RBCs.

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse needs to call the surgeon to clarify that which medication would be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine 4. Conjugated estrogen

Answer: 1 Rationale: Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the abil- ity of the body to withstand stress. When stress is severe, corti- costeroids are essential to life. Before and during surgery, dos- ages may be increased temporarily and may be given parenter- ally rather than orally. Ferrous sulfate is an oral iron prepara- tion used to treat iron-deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal individuals. These last three medications may be withheld before surgery without undue effects on the client.

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagula- tion studies, and electrolytes and creatinine levels. Which laboratory result would be reported to the surgeon's ofce by the nurse, knowing that it could cause surgery to be postponed? 1. Hemoglobin, 8.0 g/dL (80 mmol/L) 2. Sodium, 145 mEq/L (145 mmol/L) 3. Serum creatinine, 0.8 mg/dL (70.6 mcmol/L) 4. Platelets, 210,000 cells/mm3 (210 × 109/L)

Answer: 1 Rationale: Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and Serum creatinine test. The complete blood count includes the hemoglobin analysis. All of these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery is likely to be postponed by the surgeon.

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 rst 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 preopera- tive measurements.

Answer: 1 Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the sur- vival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions would be performed after a patent airway has been established.

The nurse has just reassessed the condition of a post- operative 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. Urinary output of 20 mL/hr2. Temperature of 37.6° C (99.6° F)3. Blood pressure of 100/70 mm Hg4. Serous drainage on the surgical dressingj9om=

Answer: 1 Rationale: Urine output would be maintained at a mini- mum of 30 mL/hr for an adult. An output of less than 30 mL for 2 consecutive hours needs to be reported to the surgeon. A temperature higher than 37.7° C (100° F) or lower than 36.1° C (97° F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable imme- diately. The client's preoperative or baseline blood pres- sure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

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 interventions would the nurse take? Select all that apply. Contact the surgeon. Instruct the client to remain quiet. Prepare the client for wound closure. Document the finndings and actions taken. Place a sterile saline dressing and ice packs over the wound. Place the client in a supine position without a pillow under the head.

Answer: 1, 2, 3, 4 Rationale: 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 would call for help, stay with the client, ask another nurse to contact the surgeon, and obtain needed sup- plies to care for the client. The nurse places the client in a low- Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstric- tive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

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? 1. Hard reddened skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin

Answer: 2 Rationale: Serous drainage is an expected finding at a surgi- cal site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and ten- der skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from sepa- rated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical explora- tion; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.

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? "Aspirin can cause bleeding after surgery." "Aspirin can cause my ability to clot blood to be abnormal." "I need to continue to take the aspirin until theday of surgery." "I need to check with my doctor about the need to stop the aspirin before the scheduled surgery."

Answer: 3 Rationale: Antiplatelets alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has proper- ties that can alter platelet aggregation and would be discontin- ued at least 48 hours before surgery. However, the client needs to check with the surgeon regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client statements.

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 sur- gery." 2. "I will be happy to explain the entire surgical procedure to 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 antici- pate."

Answer: 3 Rationale: Explanations would begin with the information that the client knows. By providing the client with individual- ized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preop- erative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the entire surgical proce- dure may increase the client's anxiety. Option 4 avoids the cli- ent's anxiety and is focused on postoperative care.

The nurse is creating a plan of care for a client sched uled for surgery. The nurse would 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 4. Report immediately any slight increase in blood pressure or pulse.

Answer: 3 Rationale: The nurse would assist the client to void immedi- ately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client would not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours (or longer as prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is com- mon during the preoperative period and is usually the result of anxiety.

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

Answer: 4 Rationale: For optimal lung expansion with the incentive spirometer, the client would assume the semi-Fowler's or high-Fowler's position. The mouthpiece needs to be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath would be held for 5 seconds before exhaling slowly.

A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to do which of the following to reduce the risk of possible transfusion complications? a. give an autologous blood donation before the surgery b. ask a friend or family member to donate blood ahead of time c. take iron supplements before surgery to boost hemoglobin levels d. request that any donated blood be screened twice by the blood bank.

a. give an autologous blood donation before the surgeryA donation of the client's own blood before a scheduled procedure is autologous. Donating autologous blood to be reinfused as needed during or after surgery reduces the risk of disease transmission and potential transfusion complications. The next most effective way is ask a family member to donate blood before surgery. Blood banks do not provide extra screening on request. Preoperative iron supplements are not helpful in replacing blood lost during the surgery

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6F orally. Which of the following is the appropriate nursing action? a. Begin the transfusion as prescribed b. Delay hanging the blood and notify the physician c. Administer an antihistamine and begin the transfusion d. Administer two tablets of acetaminophen (Tylenol) and begin the transfusion

b. Delay hanging the blood and notify the physicianIf the client's temperature is higher than 100F the unit of blood should not be hung until the physician is notified and has the opportunity to give further prescriptions. The physician will likely prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurse's scope of practice to make.

A client has experienced a rash with pruritus during previous blood transfusions. The client asks the nurse whether it is safe to receive another transfusion. In formulating a response, the nurse incorporates the understanding that which medication will most likely be prescribed before the transfusion is begun? a. Ibuprofen (Motrin) b. Acetaminophen (Tylenol) c. Diphenhydramine (Benadryl) d. Acetylsalicylic Acid (ASA Aspirin)

c. Diphenhydramine (Benadryl)An urticarial reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine such as diphenhydramine. Acetaminophen and ASA are analgesics and ibuprofen is a NSAID