VNSG 1400 Ch. 14 (Med-Surg) Prep U Questions

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

Age Health Status Physical Condition Nutritional Status Explanation:General surgical risk factors are related to age; nutritional status; use of alcohol, tobacco, and other substances; and physical condition.

The OR personnel responsible for maintaining the safety of the client and the surgical environment is the:

Circulating nurse Explanation: The circulating nurse is responsible for maintaining the safety of the client and the surgical environment.

While the surgical client is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the client's weight. How should the nurse best respond?

Discourage the colleague from making such comments. Explanation: Clients, whether conscious or unconscious, should not be subjected to excess noise, inappropriate conversation, or, most of all, derogatory comments. The nurse must act as an advocate on behalf of the client and discourage any such remarks. Reporting to a supervisor, however, is not likely necessary.

The perioperative nurse has a number of major responsibilities when a patient is admitted to a surgical unit or center. Which of the following is the most important function?

Verifies that operative consent is signed. Explanation:All choices listed are essential but, without a signed consent form, surgery cannot occur

The nurse is preparing to change a client's abdominal dressing. The nurse recognizes the first step is to provide the client with information regarding the procedure. Which of the following explanations should the nurse provide to the client?

"During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to." Explanation: When having dressings changed, the client needs to be informed that the dressing change is a simple procedure with little discomfort; privacy will be provided; and the client is free to look at the incision or even assist in the dressing change itself. If the client decides to look at the incision, assurance is given that the incision will shrink as it heals and that the redness will likely fade. Dressing changes should not be painful, but giving pain medication prior to the procedure is always a good preventive measure. Telling the client that the dressing change "should not be painful, but you can never be sure, and infection is always a concern" does not offer the client any real information or options and serves only to create fear. The best time for dressing changes is when it is most convenient for the client; nutrition is important so interrupting lunch is probably a poor choice.

The nurse cares for a client who is three hours post op abdominal hysterectomy and begins to develop hiccups. What nursing assessment will the nurse monitor more closely with the client's new symptoms?

Wound approximation Explanation:Hiccups are produced by intermittent spasms of the diaphragm, secondary to irritation of the phrenic nerve. Hiccups may be caused by surgery and are usually not problematic. However, persistent or forceful spasms may lead to wound dehiscence, or wound separation at the surgical incision. The other answer choices are things the nurse will monitor; however, the approximation of wound edges will be monitored more closely.

What measurement should the nurse report to the physician in the immediate postoperative period?

A systolic blood pressure lower than 90 mm Hg Explanation: A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal.

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

Assess for signs and symptoms of fluid volume deficit Explanation:The client's 24-hour intake is 1800 mL (75 x 24). The client's 24-hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Because the output is significantly higher than the intake, the client is at risk for fluid volume deficit. The nurse should not discontinue the nasogastric suctioning without a physician's order. The findings should be documented and reassessed, but the nurse needs to take more action to prevent complication. Edema is usually associated with fluid volume excess.

The intraoperative nurse advocates for each client who receives care in the surgical setting. How can the nurse best exemplify the principles of client advocacy?

By maintaining the privacy of each client Explanation: Patient advocacy in the OR entails maintaining the client's physical and emotional comfort, privacy, rights, and dignity. Deep breathing is not necessary before surgery and obtaining informed consent is the purview of the physician. Family contact should not be limited.

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?

Central venous pressure Explanation:Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, level of consciousness, central venous pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output are monitored to provide information on the patient's respiratory and cardiovascular status.

The home health nurse is caring for a postoperative client who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the client's postoperative day 2. During the visit, the nurse will assess for wound infection. For most clients, what is the earliest postoperative day that a wound infection becomes evident?

Day 5 Explanation:Wound infection may not be evident until at least postoperative day 5.

The intraoperative nurse knows that the client's emotional state can influence the outcome of the surgical procedure. How should the nurse best address this?

Incorporate cultural and religious considerations, as appropriate Explanation: Because the client's emotional state remains a concern, the care initiated by preoperative nurses is continued by the intraoperative nursing staff that provides the client with information and reassurance. The nurse supports coping strategies and reinforces the client's ability to influence outcomes by encouraging active participation in the plan of care incorporating cultural, ethnic, and religious considerations, as appropriate. "Buddying" a client is normally inappropriate and distraction may or may not be effective. Nonpharmacologic measures should be prioritized.

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?

Mask covering the nose and mouth Explanation: 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.

During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take?

Offer the client a bedpan or urinal. Explanation: If a preanesthetic medication is given, the client is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness. If a client needs to void following administration of a sedative, the nurse should offer the client a urinal. The client should not get out of bed because of the potential for lightheadedness.

The nurse is caring for a client after abdominal surgery in the PACU. The client's blood pressure has increased and the client is restless. The client's oxygen saturation is 97%. What cause for this change in status should the nurse first suspect?

Pain Explanation: An increase in blood pressure and restlessness are symptoms of pain. The client's oxygen saturation is 97%, so hypothermia, hypoxia, and shock are not likely causes of the client's restlessness.

The OR nurse acts in the circulating role during a client's scheduled cesarean section. For what task is this nurse solely responsible?

Performing documentation Explanation: 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 client and documents specific activities throughout the operation to ensure the client's safety and well-being. Estimating the client's blood loss is the surgeon's 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.

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.

Position the client in Fowlers position. Don sterile gloves. Lubricate the sterile suction catheter. Insert suction catheter into the lumen of the tube. Apply intermittent suction while withdrawing the catheter. Explanation: Suctioning a tracheostomy is a sterile procedure. The nurse should first position the client in Fowler's position then don sterile gloves. Next, the nurse will lubricate the sterile suction catheter and insert the catheter into the lumen of the tube. Finally, the nurse will apply intermittent suction while withdrawing the catheter.

The nurse is caring for a male client who has had spinal anesthesia. The client is under a physician's order to lie flat postoperatively. When the client asks to go to the bathroom, you encourage him to adhere to the physician's order. What rationale for complying with this order should the nurse explain to the client?

Preventing the onset of a headache Explanation:Lying flat reduces the risk of headache after spinal anesthesia. Hypotension and respiratory depression may be adverse effects of spinal anesthesia associated with the spread of the anesthetic, but lying flat does not help reduce these effects. Pain at the lumbar injection site typically is not a problem.

Which clinical manifestation is often the earliest sign of malignant hyperthermia?

Tachycardia (heart rate >150 beats per minute) Explanation: Tachycardia is often the earliest sign of malignant hyperthermia. Hypotension is a later sign of malignant hyperthermia. The rise in temperature is actually a late sign that develops quickly. Scant urinary output is a later sign of malignant hyperthermia.

A nurse is providing preoperative care for a client who is scheduled for cholecystectomy under general anesthesia. When the nurse instructs that the client will need to remove face makeup before the surgery, the client complains by saying, "They're not operating on my face." What would the nurse tell this client?

The surgical team needs to observe the natural color of the client's face and lips while the client is under anesthesia. Explanation: Removal of cosmetics assists the surgical team to observe the client's lips, face, and nail beds for cyanosis, pallor, or other signs of decreased oxygenation. Declaring that makeup removal is mandatory hospital policy does promote client teaching and is especially not appropriate for a client who is already likely anxious about surgery. It is not appropriate to suggest that an exception could be made. Cosmetics would not cause an adverse reaction with anesthesia.

The PACU nurse is caring for a client who has arrived from the OR. During the initial assessment, the nurse observes that the client's skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the client is not breathing. What is the priority intervention?

Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw. Explanation: When a nurse finds a client who is not breathing, the priority intervention is to open the airway and treat a possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the head back and then pushes forward on the angle of the lower jaw or performs the jaw thrust method to open the airway. This is an emergency and requires the basic life support intervention of airway, breathing, and circulation assessment. Arterial pulses should be checked only after airway and breathing have been established. Reintubation and resuscitation would begin after rapidly ruling out a hypopharyngeal obstruction.

The nurse is educating a community group about types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true?

Tumor excision Explanation: An example of a curative surgical procedure is tumor excision. A biopsy, a face-lift, and the placement of a gastrostomy tube are not examples of curative surgical procedures.

An adult client is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The client's vital signs and level of consciousness have stabilized, but the client then reports severe nausea and begins to retch. What should the nurse do next?

Turn the client completely to one side Explanation: Turning the client completely to one side allows collected fluid to escape from the side of the mouth if the client vomits. After turning the client to the side, the nurse can offer a cool cloth to the client's forehead. Ice chips can increase feelings of nausea. An analgesic is not given for nausea and vomiting.

The nurse is performing a preadmission assessment of a client scheduled for a bilateral mastectomy. The nurse should be aware of what purpose of the preadmission assessment?

Verifies competition of preoperative diagnostic testing Explanation:Purposes of preadmission testing (PAT) include verifying completion of preoperative diagnostic testing. The nurse's role in PAT does not normally involve financial considerations or addressing transportation. The physician determines the client's suitability for surgery.