AH Exam 1: Chapter 17

The patient asks the nurse why food is withheld before surgery. What is the best response by the nurse?

"Aspiration is a concern and can be a complication if food or fluid is taken close to the surgery time."

The nurse is preparing a client for surgery. The nurse would notify the surgeon if the client made which of the following statements?

"I took my Coumadin as usual last evening." "I took two aspirins for joint pain this morning."

Which nursing statement would best decrease a client's anxiety before an emergency operative procedure?

"Let me explain to you what will happen next."

You are the nurse working in an ambulatory surgery center. A teenage son of your clients ask you why so many people have surgery. What would be your best reply?

"Many people have diagnostic or short therapeutic surgical procedures."

A patient has been transported to the operating room for emergent surgery. Which statement by the nurse best supports the need for emergent surgery?

"The patient was unresponsive, had a distended abdomen, and unstable vital signs following a motor vehicle accident."

You are working in the preoperative area with a client going to surgery for a cholecystectomy. The client has histamine2-receptor antagonists ordered preoperatively. The client asks you why these medications are needed. What would be your best answer?

"These medications decrease gastric acidity and volume."

For the patient who is taking aspirin, it is important to stop taking this medication at least how many day(s) prior to surgery?

7

A patient having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the patient stop taking the aspirin before the surgery?

7 to 10 days

What is the blood glucose level goal for a diabetic patient who will be having a surgical procedure?

80 to 110 mg/dL

The nurse expects informed consent to be obtained for insertion of:

A gastrostomy tube

Patients who have received corticosteroids preoperatively are at risk for which type of insufficiency?

Adrenal

A physically fit 86-year-old is scheduled for right knee replacement. What factor in this client makes him at increased risk for surgery?

Age

The nurse is caring for a patient who is obese prior to a surgical procedure. What surgical complications positively correlated with obesity should the nurse monitor for? (Select all that apply.)

Cardiovascular system Gastrointestinal system Pulmonary system

The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following?

Cheeseburger, french fries, coleslaw and ice cream

Which of the following medications may increases the hypotensive action of anesthesia?

Chlorpromazine (Thorazine)

The nurse is monitoring a presurgical patient for electrolyte imbalance. Which classification of medication may cause electrolyte imbalance?

Diuretics

At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period?

During preoperative period

The nurse is assigned a client scheduled for an outpatient colonoscopy in an ambulatory care setting. During which phase of perioperative care would the nurse document the admission vital signs in the recovery room?

During the postoperative phase

What action by the nurse best encompasses the preoperative phase?

Educating the patients on signs and symptoms of infection

The nurse concludes that further teaching about diaphragmatic breathing is needed when the client:

Exhales forcefully with a short expiration

The nurse is reviewing a preoperative informed consent when preparing the client for surgery. Which contents of the informed consent are required? Select all that apply.

Explanation of procedure Potential risks Benefits of surgery Description of alternatives

The nurse is caring for a client needing emergency surgery. Which preoperative teaching should be omitted to prepare the client for surgery?

Frequency of postoperative vital signs

Which domain of perioperative nursing practice focuses on clinical processes and outcomes?

Health care systems

A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for?

Hypoglycemia

A client develops a hemorrhage an hour post surgery while in your care. Which of the following characteristics indicate this is most likely an intermediary hemorrhage from a vein?

It occurred within the first few hours and has darkly colored blood that bubbles out slowly.

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which of the following complications?

Malignant hyperthermia

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?

Moisten sterile gauze with normal saline and place on any organ.

An inappropriate nursing action implemented to keep the client safe includes:

Moving the client swiftly

The nurse is conducting a preoperative assessment on a patient scheduled for gallbladder surgery. The patient reports having a frequent cough producing green sputum for 3 days and denies fever. Upon auscultation, the nurse notes rhonchi throughout the right lung with an occasional expiratory wheeze. Respiratory rate is 20, temperature is 99.8 taken orally, heart rate is 87, and blood pressure is 124/70. What is the nurse's best action?

Notify the surgeon to possibly delay the surgery.

During the preoperative assessment, the patient states he is allergic to avocados, bananas, and hydrocodone (Vicodin). What is the priority action by the nurse?

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

An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults?

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

An OR nurse needs to assist a patient to the Trendelenburg position. Which of the following is the correct position?

On his back, with his head lowered, so that the plane of his body meets the horizontal on an angle

When a patient recites, "I know all will go well," what is the cognitive coping strategy he or she is using?

Optimistic self-recitation

The nurse recognizes that written informed consent is required for insertion of a(n):

Peripherally-inserted central catheter.

Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery?

Physician

You are physically preparing a client for surgery and instruct the person to remove any jewelry. The client refuses to remove a wedding band. What should you do in this situation with approval from your facility?

Place gauze under and over the ring and apply adhesive tape over it.

The nurse in the preoperative area has just medicated her client according to the anesthesiologist's orders. What is the nurse's priority action at this time?

Place the side rails in the up position and make sure the call button is in reach.

The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which of the following values would be of greatest concern to the nurse?

Potassium 6.2 mEq/L

When is the ideal time to discuss preoperative teaching

Preadmission visit

An obese patient is scheduled for open abdominal surgery. What priority education should the nurse provide this patient?

Prevention of respiratory complications

A nurse is witnessing a patient sign the consent form for surgery. After the patient signs the consent form, the patient starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?

Request that the surgeon come and answer the questions.

Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out?

Review the scheduled procedure, site, and client.

Which nursing assessment finding indicates the preoperative client has not met expected outcomes?

Sobs uncontrollably about pending amputation of foot.

A patient is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?

Splint the incision site using a pillow during deep breathing and coughing exercises.

The nurse is caring for the client in the preoperative period and documenting rationale for a palliative surgical procedure. Which rationale is most appropriate?

The client and physician are focusing on symptom relief not a cure.

A client who is scheduled for knee surgery is anxious about the procedure, saying, "You hear stories on the news all the time about doctors working on the wrong body part. What if that happens to me?" What can you tell this client to help alleviate his concerns?

The client will be involved in the verification process prior to surgery. He can be involved in marking his knee, the site for the surgery. The surgical team performs a "time-out" prior to surgery to conduct a final verification

A client is being prepared for a same-day surgical procedure and is discussing with the nurse what potential ramifications this type of surgery has. Which of the following would the nurse correctly identify? Select all that apply.

The client will leave the hospital sooner than in the past. Need for teaching is increased. The client must be prepared to take on more self-care than he or she may have done in the past.

When does the nurse understand the patient is knowledgeable about the impending surgical procedure?

The patient participates willingly in the preoperative preparation.

Following diagnostic testing, a patient requires a cholecystectomy. This surgical procedure would be categorized as which of the following?

Urgent

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

Which question is most important for the nurse to ask the client when obtaining the preoperative admission history?

"When is the last time you ate or drank?"

Which of the following is the appropriate response to the statement, "I'm so nervous about my surgery"?

"You seem nervous about your surgery."

The surgical unit nurse is developing a postoperative plan of care. In which client's plan of care would the nurse document interventions of coughing and deep breathing, gastrointestinal assessment, and effective regulation of temperature?

A client with gastrointestinal surgery and general anesthesia

A patient refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?

Allow the ring to stay on the patient and cover it with tape.

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as

Emergency

In which instance may a surgeon operate without informed consent?

Emergency situations

A fractured skull would be classified under which category of surgery based on urgency?

Emergent

A gunshot wound would be classified under which category of surgery based on urgency?

Emergent

A client will be undergoing an appendectomy tomorrow morning. The nurse spends significant time explaining to the client what will happen, including before and after the procedure is complete. What is the primary reason the nurse puts so much effort into preoperative teaching?

It increases the likelihood of a successful recovery.

Regarding the surgical patient, which one of the following phases refers to the period of time that constitutes the surgical experience?

Perioperative

The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?

Temperature of 102.5° F

A 17-year-old male client is having same-day surgery to remove a neuroma from his foot. Which of the following nursing interventions would occur during the intra operative phase of peri operative care?

The nurse continuously monitors the sedated client.

The nurse discovers that the client did not sign the operative consent before receiving the preoperative medication. The appropriate nursing action is:

To notify the surgeon

Sudden withdrawal of which of the following may result in seizures?

Tranquilizers

At what point does the preoperative period end?

When the client is transferred onto the operating table

Completing your preoperative assessment, you mentally rehearse your client's needs to determine if there is increased risk for complications intra operatively or postoperatively. Which of the following are general risk factors? Select all that apply.

Age Physical condition Nutritional status Health status

You are providing preoperative care to a 51-year-old male client who is anxious about his total hip replacement surgery. "What if I can never walk again? I don't want to end up like my father!" What are some ways you might help alleviate his anxiety? Select all that apply.

Ask the client if he would like to speak with a clergyperson. Review the client's postoperative goals following the procedure. Listen empathetically to the client's concerns about the procedure. Make sure the client understands what will happen during surgery.

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

Client has an absence of bowel sounds

The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?

Client reports a small bowel movement

The nurse has just admitted a 12-year-old client who is going to have an above-the-knee amputation of their left leg due to osteosarcoma. The nurse knows that adequate preoperative teaching and learning is important for what reason?

Client will have a shorter recovery period.

A patient with fractured skull after falling from a ladder requires surgery. The nurse should anticipate transporting the patient to surgery during what time frame?

Immediately

When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority?

Impaired Gas Exchange Risk for Infection Altered Comfort Fluid Volume Deficit Anxiety

A 57-year-old client is undergoing preoperative assessment before surgical repair of a fractured ulna. During admission paperwork, the client reveals that she enjoyed a hearty breakfast this morning to be ready for her procedure. What is the nurse's next action?

Notify the surgeon

A patient is scheduled to have a cholecystectomy. Which of the nurse's finding is least likely to contribute to surgical complications?

Osteoporosis

A patient is scheduled for elective surgery. To prevent the complication of hypotension and cardiovascular collapse, the nurse should report the use of what medication?

Prednisone

A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants?

Scrub nurse

The nurse is aware that the amino acid, arginine,

Stimulates T-cell response

Nursing assessment findings reveal that the client is afraid of dying during the surgical procedure. Which surgical team member would be most helpful in addressing the client's concern?

Surgeon

When a person with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the patient may show signs of alcohol withdrawal delirium during which time period?

Up to 72 hours after alcohol withdrawal

When assessing a postoperative client, the nurse is correct to relate which surgical risk factor that would decrease if the surgical client maintained a blood glucose level under 150 mg/dL?

Wound healing

The nurse concludes that teaching about pain management was effective when the client states:

"I will support my incision with my hands when I do my coughing and deep breathing exercises."

A patient with a history of alcoholism and scheduled for an urgent surgery asks the nurse, "Why is everyone so concerned about how much I drink?" What is the best response by the nurse?

"It is important for us to know how much and how often you drink to help prevent surgical complications."

A patient is scheduled for an invasive procedure. Which of the following should the nurse document in the chart regarding the procedure?

A signed consent form from the patient

The nurse assesses an older adult patient who complains of dimmed vision. What does this alert the nurse to plan for?

A safe environment

You are caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?

Encourage the client to move legs frequently and do leg exercises.

Which of the following nursing activities would not be part of the preoperative phase of care? Select all that apply.

Ensuring that the sponge, needle, and instrument counts are correct Administering medications, fluid, and blood component therapy, if prescribed

A client taking chlorpromazine (Thorazine) is preparing to undergo surgery. Which of the following complications does the surgical team need to prepare to deal with before anesthetics are administered?

Hypotension

You are caring for a client 6 hours post surgery. You observe that the client voids urine frequently and in small amounts. You know that this most probably indicates what?

Urine retention

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

Use diaphragmatic breathing