Caring for the surgical client

A nurse is reinforcing teaching provided to a client on how to perform deep breathing exercises postoperatively. Which of the following instructions should the nurse ensure is included in their demonstration?

-Breathe in through your nose for four seconds. After sitting up in a chair or leaning back in the bed, you breathe in through your nose for four seconds.

A nurse is using the SBAR communication tool when handing the client off to the PACU nurse. Which of the following sections of the tool is the nurse using when describing the client's comorbidities?

-Background The background section of the SBAR communication tool addresses what brought the client to a specific point. This includes the client's surgical and medical history, allergies, and comorbidities.

A nurse is preparing a client for a surgical procedure. During which of the following timeframes should the nurse initiate the prescribed antibiotic to help decrease surgical site infections?

-60 minutes before performing the surgical incision The Surgical Care Improvement Project identified that administering antibiotics 60 min before performing the surgical incision can help decrease the risk of surgical site infections.

A transplant nurse is identifying client risk factors during the preoperative phase. Which of the following potential complications should the nurse know puts the client at a higher risk level due to the medications and procedures for organ transplants?

-Acquiring a secondary infection Because medications and procedures for organ transplant immunocompromised the client, the client will have a higher risk of developing secondary infections.

A nurse is providing information to a client being admitted to the surgical clinic for a right knee arthroscopy. The nurse explains to the client that they will be receiving perioperative care. The client asks, "When does that care occur?" Which of the following statements made by the nurse is correct?

-"Perioperative care occurs before, during, and after surgery." Perioperative care occurs in all three phases of the perioperative period, which includes before surgery, during surgery, and after surgery.

A nurse is preparing a client for surgery when the client expresses how nervous and anxious they are about the surgery. Which of the following responses by the nurse would help initiate collection of data on the client's need for further preoperative instruction?

-"Tell me what you have already been told about the surgery." It is important to evaluate what the client knows so that they can express their concerns while allowing for assessment for any further preoperative education that might be needed.

An experienced transplant nurse is describing the transplant nursing process to a student nurse. Which statement should the experienced nurse make?

-"Transplant nursing is similar to other types of perioperative nursing." The transplant nursing process follows the same pattern as the process for traditional perioperative nursing.

A transplant nurse is part of a multidisciplinary care team creating a documented plan of care for a client in need of a heart transplant. Which of the following standards of professional performance for transplant nursing is the nurse demonstrating by being part of the team?

-Collaboration Collaboration includes working with other health care providers and members of the care team to develop and implement the client's plan of care.

A nurse observes a client signing their informed consent for surgery. The client says to the nurse, "I am not sure why I have to have this surgery." Which of the following actions should the nurse take first?

-Contact the provider and notify them that the informed consent process is not complete, then notify the perioperative staff that the surgery is on hold. Perioperative standards require that the surgeon has discussed the reasons for surgery and any risks of complications with the client.

A nurse is caring for a client who is scheduled for a laparotomy. The client states that they are concerned about the possibility of postoperative infection. Which of the following actions should the nurse take to address the client's concern and decrease the risk of infection?

-Educate the client about wound care during the preoperative phase. Educating the client about wound care will address the client's worry, as well as help prevent wound infections by increasing the likelihood of proper client wound care.

A transplant nurse is providing care related to a client's kidney transplant. Which priority nursing action would be most likely to take place during the preoperative phase?

-Educating the client's caregivers about the transplant process While educating the client and their caregivers about the transplant process is an ongoing process that will likely continue across multiple phases, it begins in the preoperative phase.

A nurse is preparing a client scheduled for right knee arthroplasty surgery. Which of the following interventions should be the priority for the nurse to address to ensure client safety?

-Have the surgeon mark the surgical site. When using the greatest risk priority framework, the nurse should identify that the greatest risk relates to the completion of a surgical procedure on the wrong site. A National Patient Safety Goal is to prevent mistakes in surgery, which includes preventing surgery on the wrong site. To help prevent this, the surgical site is marked preoperatively by the surgeon.

A nurse is preparing a client for a surgical procedure, explaining that perioperative nursing care is primarily focused on the client to provide high quality care. The nurse is demonstrating knowledge of the Perioperative Patient Focused Model. Which of the following domains of this model has more emphasis on structural standardized data elements and analytical reporting?

-Health System The fourth domain comprises health care economics and outcomes, as well as analytical reporting and standardized elements.

A nurse documents how much solution is administered to a postoperative client intravenously, as well as how much output is collected in the client's catheter bag. Which of the following elements of postoperative care is the nurse directly performing?

-Maintain adequate fluid balance. The amount of IV fluid received and the catheter bag level are most closely associated with maintaining adequate fluid balance.

A nurse is collecting data for a surgical client. The nurse asks the client whether they or anyone in their family has a history of complications from anesthesia. Which of the following data findings is most concerning?

-Malignant hyperthermia Because malignant hyperthermia is genetic and can be triggered by anesthesia, it would be appropriate for the nurse to ask whether the client or anyone in their family has experienced complications from anesthesia.

A nurse administers IV medication and reviews breathing and relaxation techniques with a client recovering from a mastectomy. Which element of postoperative care is the nurse performing?

-Managing postoperative pain The latest approaches to pain management usually include more than one way to manage pain. Medication may be used along with non-pharmacological interventions such as breathing and relaxation exercises.

A nurse is caring for a client in the PACU following a surgical procedure during which they received moderate sedation. Which of the following interventions should the nurse implement?

-Monitor level of consciousness. The nurse will need to generate solutions when caring for this client, which includes identifying actions that improve client outcomes. A client who received moderate sedation during a surgical procedure will be in a medication-induced state that impairs cognitive function and coordination but does not affect the airway. Therefore, the PACU nurse needs to monitor the client's level of level of consciousness.

A surgical nurse receives additional training to become a transplant nurse. When the nurse administers postoperative care to a transplant client for the first time, which element of care will be new for that nurse?

-Monitoring for signs of organ rejection Monitoring the client for signs of organ rejection is an element of postoperative care unique to transplant nursing.

A nurse is reinforcing teaching with a client about breathing and relaxation exercises during the preoperative phase. Which postoperative complication would breathing and relaxation exercises assist with?

-Pain Pain management includes breathing and relaxation methods in addition to medication. Because pain is a common and often immediate complication of surgery, pain management should begin during the preoperative phase.

A nurse is preparing to admit a client to an outpatient surgical center. Which of the following will assist the nurse in collecting data that can be used to assist with planning of care during the preoperative phase?

-Physical assessment The nurse needs to collect data by performing a physical assessment. Data collected is used to plan care for a client in the preoperative phase.

A nurse is admitting a client to the surgical clinic for elective surgery. Which of the following is the priority focus during the preoperative phase?

-Prepare the client mentally and physically for surgery. The focus of care in the preoperative phase is to prepare the client mentally and physically for surgery

A nurse is preparing a client for total hip surgery. The client has been on anticoagulant therapy for the last few months. During which of the following periods in the surgical checklist is the risk of greater than 500 mL blood loss assessed and recorded?

-SIGN-IN The SIGN-IN column on the surgical checklist has the check-off box to ensure the risk assessment for blood loss is performed and units of blood are on hand.

A nurse is using the "I Pass the Baton" hand-off tool when transferring a client to the operating room. Which of the following steps of the tool should the nurse use when reporting the client has allergies to latex and penicillin?

-Safety The safety step of the "I Pass the Baton" hand-off communication tool addresses allergies, critical lab values, and safety alerts, such as falls and isolation.

A nurse transfers a client to the PACU postoperatively. During the hand-off report, the nurse states that, "Dr. Jones performed a bowel resection." Which of the following sections of the SBAR communication tool does this statement address?

-Situation The situation section of the SBAR communication tool includes why the client is in the hospital. Information may encompass introductions and which surgical procedure will be performed.

A nurse is caring for a client who is having a total abdominal hysterectomy. The nurse reinforces teaching to the surgical client about minimizing the pain and discomfort postoperatively. Which priority instruction should the nurse give the client?

-Splinting the incision and deep breathing exercises Postoperative splinting around the incision while performing deep breathing exercises helps to relax the client and minimizes the pain at the incision site.

A nurse is providing preoperative education to a client scheduled for elective surgery. Which of the following is the best time for the nurse to provide preoperative teaching?

-The afternoon or evening prior to surgery This is the best time to provide preoperative instructions because it is not too far in advance. The client has probably finished lab work at this time, there is less anxiety, and the client can retain and understand the instructions provided.

History and Physical ​ Client has a history of a cut on left knee after falling outside 2 weeks ago. Saw health care provider yesterday in clinic. Knee swollen, red, warm to the touch, and painful. Reports having fever and chills for the last 24 hr. The client comes in today for an incision and drainage of a left knee abscess caused by cellulitis.

-The client's elevated white blood cell count (WBC), pain level, extremity data, and temperature are associated with the inflammatory process (cellulitis), with an abscess present that requires the incision and drainage in the first place. Therefore, these are expected findings, even though they are outside defined limits, so the surgeon would not need to be notified. The client's positive human chorionic gonadotropin (HCG) result (possible pregnancy) is an unexpected abnormal for a client about to have surgery, where the risk to the pregnancy is higher. Therefore, this needs to be reported to the surgeon in case the surgery needs to be delayed while further labs are obtained, and risk/benefits are determined. The client's platelet count is normal.

A nurse is preparing a client for a surgical appendectomy. The nurse identifies an appendectomy as which of the following types of surgical classification?

-Urgent Because the client has an inflamed appendix, the surgery needs to be performed within hours to ensure the safety of the client. Emergent (within minutes to save life} =eminutes Elective (no urgency, can be planned)=elplanned Expedited (not emergency, can perform within days, needed)=exdayneeded

History and Physical ​ 1000: ​ The client presented to the Emergency Department via ambulance following a motor vehicle accident (MVA) where they sustained a compound femur fracture. The stretcher blanket was blood-soaked, and their clothing was dripping with blood. The client is scheduled for emergency surgery to repair the fracture.

-When analyzing cues, the nurse should determine that the client is at risk for hypoxemia, as evidenced by their low hematocrit and hemoglobin values, excessive blood loss prior to and during surgery, and current oxygen saturation levels.

Vital Signs ​ Preoperative 0600: ​ Temperature 36.7° C (98° F)Blood pressure 118/86 mm HgHeart rate 76/minRespiratory rate 16/minOxygen saturation 96% on room airPain level 2 on a scale from 0 to 10

-When prioritizing hypotheses, the nurse should identify that the client's platelet count and positive hCG result should be reported immediately to the provider. This client is at a higher risk for bleeding related to the low platelet count. The client may likely be pregnant as they have a positive hCG. Therefore, elective surgery should be postponed until a negative pregnancy test is confirmed or after the pregnancy has been completed.