Ch14-16 Operative Nursing

C.) RN w/ 5 yrs of experience in the delivery room (The RN w/ delivery room experience wld have experience w/ abdominal sutures & w/ postop care of diabetics, & would be aware of possible postop complications for this client) - The pediatric RN would not be aware of potential complications & rountine assessment for this pt - The diabetic educator RN wld be able to provide care req for the pt's diabetes but not postop aspect of care - The scrub nurse wouldn't have knowledge & understanding of routine postop care that is needed for this client

**5 RNs from other units have been assigned to the PACU. A 16yr pt w/diabetes has also just arrived after having laparoscopic abdominal surgery. The charge nurse assigns which RN to care for this new client? A.) RN usually on the inpatient pediatric unit B.) RN who provides education to diabetic clients in a clinic C.) RN w/ 5 yrs of experience in the delivery room D.) RN who usually works as a OR scrub nurse

A.) 43yr pt w/ bowel resection 7 days ago & has new serosanguineous drainage on the dressing (Nurse would 1st care for 7 day postop pt who has new serosanguineous drainage. New drainage on the 7th postop day is unusual & suggests a complication that reqs further assessment & possible stat action.) - The pt awaiting DC is not a priority - A temp of 100.4 F & pain upon coughing following bladder surgery are norm on the 1st postsurgical day

**A RN has just received reports on all pts of the inpatient surgical unit. Which pt does the nurse care for first? A.) 43yr pt w/ bowel resection 7 days ago & has new serosanguineous drainage on the dressing B.) 46 yr pt who had a thoracotomy 5 days ago & needs DC teaching C.) 48yr pt who had bladder surgery earlier in the day & is reporting pain when coughing D.) 49 yr pt who underwent morning repair of a disloc shoulder & temp 100.4°F

A.) Supplemental pain reduction is needed. (pts will have breakthrough pain after an antagonist is given, so other comfort interventions are needed.) - Several doses of naloxone may be needed bc drug has a short half-life - Opioid depression is a manageable situation, not an acute emergency - The pt w/ opioid depression is not fully conscious

**A pt has an acute case of opioid depression & receives a dose of naloxone (Narcan). Which pt statement is true? A.) Supplemental pain reduction is needed. B.) One dose is needed. C.) This is an acute emergency. D.) The client will be hostile.

A.) Breathing pattern (Respiratory assessment is the 1st & most important, ABCs: Airway, Breathing, Circulation) - Assessing LOC, oxy sat, & the surgical site are important but not the priority

**In conducting a postop assessment of a pt, what is important for the nurse to examine first? A.) Breathing pattern B.) LOC (Level of consciousness) C.) Oxygen saturation D.) Surgical site

C.) Immediately stop all inhalation anesthetic agents and succinylcholine. (The nurse anesthetisti's initial action is to stop all inhalation anesthetic agents & succinylcholine. This client is exhibiting early sx of malignant hyperthermia (MH). The most sensitive indication of MH is an unexpected rise in the end-tidal carbon dioxide level, along w/ a decrease in oxygen saturation. Another early indication is sinus tachycardia. - Survival depends on early diagnosis & the actions of the entire surgical team. Time is crucial when MH is diagnosed, & MH requires immediate intervention - This client doesn't req resuscitation -Continuing as normal is inappropriate & informing the surgeon is not the priority

**The nurse anesthetist notices that a surgical client has an unexpected rise in the end-tidal carbon dioxide level, with a decrease in oxygen saturation and sinus tachycardia. What is the nurse anesthetist's initial action? A.) Administer cardiopulmonary resuscitation. B.) Continue as normal. C.) Immediately stop all inhalation anesthetic agents and succinylcholine. D.) Inform the surgeon.

D.) IV opioid analgesics (IV opioid analgesics are given in small doses to provide pain relief to mask an anesthetic rxn.) - IM nonopioid analgesics & opioid analgesics are too long acting - IV nonopioids usually are not given within the 1st 48hrs after surgery

**What pain management does a pt who has been admitted to the PACU typically receive? A.) IM nonopioid analgesics B.) IM opioid analgesics C.) IV nonopioid analgesics D.) IV opioid analgesics

D.) "My scrubs will be sterile." (Scrub attire is provided by the hospital & is clean, not sterile.) -All members of the surgical team must cover their hair, including any facial hair. - Team members who aren not scrubbed (ex; anesthesia provider, student nurse) are not required to be sterile & may wear cover scrub jackets that are snapped or buttoned closed to prevent shedding of organisms from bare arms - Everyone who enters an OR in which a sterile field is present must wear a mask

**Which statement by a nursing student indicates a need for further teaching about operating room (OR) surgical attire? A.) "I must cover my facial hair." B.) "I don't need a sterile gown to be in the OR." C.) "If I go into the OR, I must wear a protective mask." D.) "My scrubs will be sterile."

B.) Diminished peripheral pulses in the lower extremities (The nurse is most concerned w/ diminished peripheral pulses in the lower extremities. This could indicate diminished blood flow.) -decreased sensation, pale/cool extremities, & reddened areas over bony prominences can be normal occurrences in clients who have undergone a long surgical procedure

*A client has undergone an 8hr surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which finding? A.) Decreased sensation in the lower extremities B.) Diminished peripheral pulses in the lower extremities C.) Pale, cool extremities D.) Reddened areas over bony prominences

C.) Teach the importance of incentive spirometry (the nurse would 1st teach the importance of incentive spirometry. Incentive spirometry is good for lung hygiene and it encourages deep breathing.) - The nurse can suggest quitting or advice abt the dangers of tobacco, but it is not therapeutic to instruct it at this time

*A preop client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the physical outcomes? A.) Instruct the client to quit smoking B.) Teach about the dangers of tobacco C.) Teach the importance of incentive spirometry D.) Tell the client that smoking increases postoperative complications

A.) Ensure written consultation of 2 noninvolved physicians. (In a life-threatening situation in which every effort has been made to contact the person w/ medical power of attorney, consent is desired but not essential. In place of written or oral consent, written consultation by at least 2 physicians who are not associated with the cause may be requested by the health care provider.) - It is not within the nurse's role to make a judgement about the client's life-threatening status based on the surgeon's consult. - Signing documents on the client's behalf is not legal - Withholding surgery is not in this client's best interests

*An unidentified client from the ER requires immediate surgery, but he is not conscious and no one is with him. What must the nurse, who is verifying the informed consent, do? A.) Ensure written consultation of 2 noninvolved physicians. B.) Read the surgeon's consult to determine whether the client's condition is life-threatening. C.) Sign the operative permit. D.) Withhold surgery until the next of kin is notified.

A.) Circulating nurse (All OR team members are responsible, but the circulating nurse moves around the room & can see more of what is happening.) - the holding nurse is not in the OR -the anesthesiologist is focused on providing sedation to the client - the surgeon is concentration on surgery & usually cannot monitor all staff

*During surgery, who is most responsible for monitoring for possible breaks in sterile technique? A.) Circulating nurse B.) Holding nurse C.) Anesthesiologist D.) Surgeon

D.) 52yr client with stage I breast cancer who is having a tunneled central venous catheter placed (The client w/ stage I breast cancer who is having a tunneled CVC placed is the most stable client among all scheduled procedures. This assignment would be appropriate for the beginning nurse or one w/ less experience.) - The client who has a ruptured appendix is less stable & at high risk for infection/sepsis; a more experienced nurse is req - The client w/ a fractured femur is at high risk for clotting, infection, & aspiration owing to the surgery; a more experienced nurse would be better - The client w/ CAD is having high-risk surgery w/ risk for multiple complications and reqs an experienced OR nurse

*The charge nurse for a hospital operating room is making client assignments for the day. Which client is most appropriate to assign to the least-experienced circulating nurse? A.) 20yr client who has a ruptured appendix & is having an emergency appendectomy B.) 28yr client w/ a fractured femur who is having an open reduction & internal fixation C.) 45yr client w/ coronary artery disease who is having coronary artery bypass grafting D.) 52yr client with stage I breast cancer who is having a tunneled central venous catheter placed

C.) Diet-controlled diabetes mellitus (the greatest risk factor is DM. Diabetes contributes an increased risk for surgery or post-surgical complications) - > 65 yrs adts are at greater risk for surgical procedures - fam medical Hx & problems w/ anesthetics may indicate possible rxns to anesthesia, but this is not the best answer - Obesity increases the risk for poor wound healing, but being 10 lbs overweight does not categorize this person as obese

*The nurse completes the preop checklist on a client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure? A.) Age 59 years B.) General anesthesia complications experienced by the client's brother C.) Diet-controlled diabetes mellitus 10.) Ten pounds (4.5 kg) over the client's ideal body weight

D.) "Pain medication will take away my pain." (Pain meds will reduce the pain, but will not take it away completely) - The client statement about waking up w/ a tube in the throat is accurate bc the client will be intubated. - Following <3 surgery, a dressing is placed on the chest - The client will not be able to see family immediately bc he/she will go to recovery 1st

*The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction? A.) "I will wake up with a tube in my throat." B.) "I will have a bandage on my chest." C.) "My family will not be able to see me right away."

C.) "It's better if they are too tight rather than too loose." Antiembolism stockings should fit properly to achieve the desired result. - Stockings that are too tight will impede blood flow. - Frequent removal of the stockings is appropriate to allow for hygiene & a break from their wear - Stockings that are too loose are ineffective - Antiembolism stockings may be used during and after surgery to promote venous return

*The nurse is instructing a client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? A.) "I will take off my stockings one to three times a day for 30 minutes." B.) "My stockings are too loose." C.) "It's better if they are too tight rather than too loose." D.) "These stockings help promote blood flow."

C.) Notify the surgeon about possible wound dehiscence. (Serosanguineous discharge persisting past the 5th postop day may indicate dehiscence & would be reported.) - the nurse would not just reinforce the dressing but would notify the surgeon - Serosanguineous discharge does not indicate infection - Persistent serosanguineous discharge is an abnorm finding & to be reported

*The nurse is performing a dressing change on a pt who underwent abdominal surgery 6 days prior. There's a mod amt of serosanguineous drainage on the old dressing. What will the nurse do? A.) Apply extra gauze to the new dressing. B.) Contact surgeon to discuss the need for abx. C.) Notify the surgeon about possible wound dehiscence. D.) Perform the dressing change according to unit protocol.

D.) Mark the left knee site with the client awake and the surgeon present (The JC NSPG reqs surgical sites be marked by an independent licensed professional and should, when possible, involve the client. The surgeon is accountable & should be present.) - the EMR should identify the correct procedure, but is not a specific JCAHO requirement.

*The nurse is providing preop care to a client who will have an arthroscopy of the left knee. As part of the Joint Commission National Patient Safety Goals (NPSG), what will the nurse be required to do? A.) Ensure the correct procedure is noted in the client's history B.) Remind the surgeon that the client will have a left knee arthroscopy C.) Verify with the client that a left knee arthroscopy will be performed D.) Mark the left knee site with the client awake and the surgeon present

B.) Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. (Insertion of a catheter is the best task within the scope of skills approved for the LPN/LVN. Preop teaching & physical assessment of a preop client are under the scope of the RN. History info would be completed by the RN on the unit)

*Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area? A.) Provide preop teaching to a client who needs insertion of a tunneled central venous catheter. B.) Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. C.) Obtain the medical Hx from a client who is scheduled for a total hip replacement. D.) Assess the client who is being admitted for an elective laparoscopic cholecystectomy.

A.) Circulating Nurse (the circulating nurse is the most likely person to administer blood products to a client in the OR suite. Circulating nurses are RNs who coordinate, oversee, & are involved in the client's nursing care in the OR.) -Holding area nurses manage the client's care before surgery; blood wouldn't be needed at this point - Scrub nurses set up the sterile field, drape the client, & hand sterile supplies, sterile equipment, & instruments to the surgeon & the assistant. - Specialty nurses may be in charge of a particular type of surgical specialty. They are responsible for nursing care specific to clients who need that type of surgery, such as assessing, maintaining, and recommending equipment, instruments, & supplies.

*Who is the most likely person to administer blood products in an operating suite? A.) Circulating Nurse B.) Holding area nurse C.) Scrub Nurse D.) Specialty Nurse

A.) Determining the pt's LOC (After general anesthesia, the priority assessment is to determine that the pt's LOC has returned, all other assessments can be performed subsequently)

1. Which assessment is most important for the nurse to perform for the pt admitted to the post-anesthesia care unit (PACU) after surgery under general anesthesia? A.) Determining the pt's LOC B.) Checking for pain on dorsi & plantar ft. flexion C.) Assessing response to pin prick stimulation from feet to mid chest level D.) Comparing BP taken in the right arm to BP taken in the left arm

D.) reduce the number of intestinal bacteria. (Bowel/intestinal preparations are performed to empty the bowel to minimize the leaking of bowel contents, prevent injury to the colon, & reduce the number of intestinal bacteria) - decreasing expected blood loss & sterilizing the bowel are not the goals of a bowel preparation -While the bowel prep may reduce the number of intestinal bacteria it will not completely eliminate the risk of infection

A client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. This preoperative procedure is done to A.) decrease expected blood loss during surgery. B.) eliminate any risk of infection. C.) ensure that the bowel is sterile. D.) reduce the number of intestinal bacteria.

C.) Adjust the administration time to be given within one hour prior to surgery. (The Joint Commission + other agencies' Surgical Care Improvement Project (SCIP) states prophylactic Abx should be received within 1 hr prior to surgical incision)

A client is scheduled for surgery at noon. The surgeon is delayed and the surgery is now scheduled for 3:00 PM. How will the nurse plan to administer the preoperative prophylactic antibiotic? A.) a. Give at noon as originally prescribed. B.) Cancel orders; preoperative prophylactic antibiotics are given optionally. C.) Adjust the administration time to be given within one hour prior to surgery. D.) Hold the preoperative antibiotic so it can be administered immediately following surgery.

B.) Ensure that drapes will minimize perianal exposure.

A client who is preparing to undergo a vaginal hysterectomy is concerned about being exposed. How does the nurse ensure that this client's privacy will be maintained? A.) Remind the client that she will be asleep. B.) Ensure that drapes will minimize perianal exposure. C.) Explain postop expectations. D.) Restrict the number of technicians in the procedure.

D.) Draw blood for glucose, electrolyte, and complete blood count values. (The blood sample needs to be drawn & sent to the lab 1st to confirm that results are within normal limits. If blood work is abnormal, the surgery may be rescheduled.) - Removal of hair can be accomplished in the OR directly before the start of the surgery - The IV infusion can be accomplished after the lab orders have been completed - The nurse should check blood glucose with the lab orders before administration of lispro

A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order does the nurse accomplish first? A.) Use electric clippers to cut hair at the surgical site. B.) Start an infusion of lactated Ringer's solution at 75 mL/hr. C.) Administer one-half of the client's usual lispro insulin dose. D.) Draw blood for glucose, electrolyte, and complete blood count values.

C.) Ask if the client may wear the hearing aid until anesthesia is given.

A preop client wears a hearing aid and is extremely hard of hearing without it. What does the nurse do to help reduce this client's anxiety? A.) Actively listen to this client's concerns. B.) Allow the client to wear the hearing aid to surgery. C.) Ask if the client may wear the hearing aid until anesthesia is given. D.) Explain that it is hospital policy to remove a hearing aid before surgery.

C.) Snoring sounds when inhaling (Snoring sounds when inhaling may indicate resp depression.) - Postsurgical pain at the surgical site is normal - Requiring verbal stimuli to awaken & a sore throat on swallowing are normal post-sedation

A pt has just undergone a surgical procedure w/ general anesthesia. Which finding indicates that the pt needs further assessment in the PACU? A.) Pain at surgical site B.) Req of verbal stimuli to awaken C.) Snoring sounds when inhaling D.) Sore throat on swallowing

1.) A pt's stomach needs to be empty prior to receiving anesthesia & undergoing surgery to decrease the chance of aspiration. 2.) Gently remind the pt that intake of food/drink is not permitted after midnight, due to aspiration risk. 3.) Assure the husband & pt, that efforts will be given to accommodate their schedule w/pt safety in mind. 4.) Tell the surgeon so a decision can be made regarding the time of soda consumption to the time of surgery. Although the surgery may be rescheduled, the surgeon may provide orders to evacuate the stomach via a NG tube and/or administer a dopamine D2 receptor antagonist like metoclopramide (Reglan). 5.) Teaching is based on if surgery continues. Continue pre-op education if the surgery will take place; teach about appropriate food/drink restrictions if the surgery is rescheduled.

A pt is scheduled for surgery req general anesthesia. During the preop assessment you ask the pt if she has had anything to eat or drink since midnight. The pt states, "I have not eaten anything since midnight. I only drank a can of soda this morning before I came in". The pt's husband responds, "This won't keep her from having surgery, will it?" 1.) What are the implications of the soda consumption before surgery? 2.) How would you respond to the pt about the soda? 3.) How would you respond to the husband? 4.) Should you tell the surgeon about the soda? 5.) What teaching should you provide at this time?

D.) "Gel polish is a type of artificial nail which alters skin flora and impedes hand hygiene."

A scrub person is discussing artificial nail use with the nurse. The scrub person states, "I do not use artificial nails; I am wearing gel polish to strengthen my nails." What is the appropriate nursing response? A.) "I understand. That is my nail treatment of choice, also." B.) "Hand hygiene is enhanced by covering natural nails." C.) "Wear double gloves to prevent puncture or contamination." D.) "Gel polish is a type of artificial nail which alters skin flora and impedes hand hygiene."

C.) Honor the DNR order.

A surgical client has signed do-not-resuscitate (DNR) orders before going to the operating room (OR). A complication requiring resuscitation occurs during surgery. What is the nurse's proper action? A.) Call the legal department. B.) Call the client's primary health care provider. C.) Honor the DNR order. D.) Resuscitate per OR procedure.

C.) Position pt on L side. (Positioning the pt on their left side wld most likely be delegated to an experienced CNA.) - airway patency reqs the care of a nurse in case of emergency - Irrigating the NG tube w/ saline is a nursing skill & care by a nurse is req - Pain assessment is also within the scope of a nurse

After gastric surgery, a pt arrives in the PACU. Which nursing action is most appropriate for the RN to delegate to an experienced CNA? A.) Monitor RR & airway patency. B.) Irrigate the NG tube with saline. C.) Position pt on L side. D.) Assess pt's pain level.

B.) Develop the DC teaching plan in conjunction w/the pt. (the best axn for the nurse to take is to develop the discharge teaching plan w/ the patient. Education & preparation for DC are within the scope of practice of the RN, but not within that of the LPN/LVN) - Reinforcing the cough & deep breathing as well as monitoring the client are within the scope of the LPN/LVN nurse. - LPN/LVNs can also administer pain meds

An RN & an LPN/LVN are working together in caring for a pt who needs all of these interventions after orthopedic surgery. Which action(s) would be best for the RN to accomplish? A.) Reinforce the need to cough & deep-breathe every 2-4 hours. B.) Develop the DC teaching plan in conjunction w/the pt. C.) Admin narcotic pain meds before assisting the client w/ ambulation. D.) Listen for bowel sounds & monitor abdom. for distention & pain.

D.) Talk to the client. (The nurse would 1st talk to the client in order to determine the client's wishes & state of mind)

An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? A.) Call the legal department to draft the paperwork. B.) Document this in the chart. C.) Thank the person and do nothing else. D.) Talk to the client.

B.) Contact the surgeon. (the nurse is not responsible for explaining or providing detailed info about the surgical procedure) - rather the nurse's role is to clarify facts that have been presented by the health care provider & dispel myths that the client or family may have heard about the surgical experience - Although the nurse is only witnessing the signature, it is the nurse's role to ensure that the facts are clarified before the consent form is signed

As the nurse obtains informed consent, the client asks, "Now what exactly are they going to do to me?" What is the nurse's response? A.) Contact the anesthesiologist. B.) Contact the surgeon. C.) Explain the procedure. D.) Have the client sign the form.

D.) Asks the client to sign the consent form

As the unit nurse is about to give a preop med to a client going into surgery, it is discovered that the surgical consent form is not signed. What does the nurse do after verifying the procedure with the client? A.) Calls the surgeon B.) Calls the anesthesiologist C.) Gives the medication as ordered D.) Asks the client to sign the consent form

C.) Having a small glass of juice at 7:00 a.m. (Clients need to be NPO for a sufficient length of time before surgery to prevent aspiration of fluid into the lungs. Intake of food/fluids may delay the start time of the surgery, so the nurse must notify the surgeon & anesthesiologist for possible rescheduling) - the nurse would confirm that all allergies are charted & that the client has the correct allergy band identification. - Many clients experience nausea after surgery; the nurse would doc this in the client's info as well - The nurse would talk w/ the client & explore the anxiety; this is a norm feeling before surgery

At 8:00 a.m., the RN is admitting a client scheduled for sinus surgery to the outpatient surgery department. Which information given by the client is of most immediate concern to the nurse? A.) An allergy to iodine and shellfish B.) Being nauseated after a previous surgery C.) Having a small glass of juice at 7:00 a.m. D.) Expressing anxiety about the surgery

D.) Palliative (Colostomy surgery is categorized as palliative. Palliative surgery is performed to relieve Sx of a disease process, but doesn't cure the disease) - Curative surgery is performed to resolve a health problem by repairing or removing the cause - Diagnostic surgery is performed to determine the origin & cause of a disorder or the cell type for cancer

Colostomy surgery is categorized as what type of surgery? A.) Cosmetic B.) Curative C.) Diagnostic D.) Palliative

C.) Picks the gauze up without touching the surgeon

If sterile gauze falls to the ground and hits the front of the surgeon's gown on the way down, what does the nurse do to ensure proper infection control? A.) Helps the surgeon change the gown B.) Picks the gauze up with a pair of sterile gloves C.) Picks the gauze up without touching the surgeon D.) Sprays an antimicrobial on the surgeon's gown

C.) "I had a heart attack 4 months ago." (The heart attack statement reqs further investigation. Cardiac problems increase surgical risks, and the risk for a MI during surgery is higher in clients who have heart problems) - The type of vitamins the client takes should be assessed, but this is not the highest risk - Moderate alcohol consumption is not considered high-risk behavior - A past Hx of smoking should be notes, but current or more recent smoking is of greater concern.

During a preop assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? A.) "I am taking vitamins." B.) "I drink a glass of wine a night." C.) "I had a heart attack 4 months ago." D.) "I quit smoking 10 years ago."

C.) Side-lying, w/ the head in a neutral position (side-lying w/ head in neutral position helps reduce postop nausea/vomiting) - the flat in-bed position w/ head aligned is not a neutral position - the prone position w/ HOB flat is unnatural as is the supine position w/ the neck flexed.

How does the nurse position a client with postoperative nausea and vomiting? A.) Flat in bed, w/ head aligned w/ the body B.) Prone, w/HOB flat C.) Side-lying, w/ the head in a neutral position D.) Supine in bed, with the neck flexed

D.) Call the pt's surgeon to report the drainage. (The presence of bright red blood reflects active bleeding & must be reported to the surgeon immediately)

The PACU nurse caring for a pt. w/ a nasogastric (NG) tube notes 300 mL of bright red blood has collected. What is the appropriate nursing action? A.) Doc as a norm finding. B.) Immediately remove the NG tube. C.) Place the client in Trendelenburg position. D.) Call the pt's surgeon to report the drainage.

B.) Redness + swelling around incision (redness & swelling is the greatest concern bc it could indicate an infection & should be reported) - Crusting along the incision line, sanguineous drainage, & sero-sanguineous drainage are normal

The nurse assesses a pt's wound 24hrs postop. Which finding causes great concern & should be reported to the surgeon? A.) Crusting along the incision line B.) Redness + swelling around incision C.) Sanguineous drainage at the suture site D.) Serosanguineous drainage on the dressing

C.) "Have you had concerns w/ drug dependence in the past?" D.) "Tell me what makes you most fearful about taking opioid meds" (Asking abt possible prior drug abuse allows the pt to identify tot he nurse whether they've had a past problem. Providing an open-ended ? abt what makes the pt fearful abt opioids allows the pt to express feelings, which guides the nurse abt the underlying reason for the pt's concerns)

The nurse is caring for an older adult client who reports being "afraid to get hooked" on opioid pain meds after surgery. What is the appropriate nursing response? Select all that apply. A.) "No one ever gets hooked on these drugs." B.) "Don't worry, I won't give you opioid meds." C.) "Have you had concerns w/ drug dependence in the past?" D.) "Tell me what makes you most fearful about taking opioid meds" E.) "There are ways we can keep you from becoming dependent." F.) "Older adults are less likely to rely on pain meds than young ppl."

A.) 52yr pt who takes aspirin daily (Aspirin & NSAIDs taken before surgery may increase clotting time & risk for hemorrhage)

The nurse is caring for four clients who will undergo surgery today. Which client does the nurse recognize as at highest risk for surgical complication? A.) 52yr pt who takes aspirin daily B.) 58yr pt who has well-controlled Type II diabetes C.) 64yr pt who has just received pre-surgical prophylactic abx D.) 69yr pt who will be DC after surgery to an extended care facility

B.) "When I eat shrimp, my tongue swells up & I have difficulty breathing." (An allergy to iodine or shellfish indicates a risk for rxn to the agents used in the surgical area. The nurse intervene immediately)

The nurse is performing an assessment on a client who has arrived in the preoperative holding area. Which client statement requires immediate nursing intervention? A.) "I am a little bit anxious about my surgery." B.) "When I eat shrimp, my tongue swells up & I have difficulty breathing." C.) "This left knee replacement will help me to walk much more comfortably again." D.) "Before I get discharged home, I want to have my eyeglasses & hearing aids returned."

A.) "I may need to restrict activities for a few mnths." (To protect the integrity of the wound, activities may need to be restricted.) - wounds are usually open to air for healing but draining wounds need to be covered - Bleeding & serosanguineous drainage is not normal after 5 days - The length of time it takes for a wound to heal varies, & it can take up to 2 years to heal

The nurse reviews a routine DC teaching plan concerning postop care with a client. Which pt. statement indicates that the wound care teaching was effective? A.) "I may need to restrict activities for a few mnths." B.) "I should remove dressing if wound drains." C.) "Some incision bleeding is norm for several weeks." D.) "Wound will heal fully in about 2 months."

C.) Point toes of one foot toward bottom of bed, then point toes of same leg toward their face. Repeat several times, then switch legs. (Exercises should be repeated several times for each leg) - Clients should begin by lying in bed w/ HOB at 45 degree angle - Clients should push the ball of the foot into the bed until the calf & thigh muscles contract

What client teaching will the nurse provide regarding postoperative leg exercises, to minimize the risk for development of deep vein thrombosis after surgery? A.)Only perform each exercise one time to prevent overuse. B.) Begin exercises by sitting at a 90-degree angle on the side of the bed. C.) Point toes of one foot toward bottom of bed, then point toes of same leg toward their face. Repeat several times, then switch legs. D.) Bend knee, and push heel of foot into the bed until the calf and thigh muscles contract. Repeat several times, then switch legs.

B.) Cover wound w/ sterile/warm/moist dressing. (Covering the wound w/ a sterile, warm, & moist dressing protects the organs until a surgeon can repair the wound.) -Evisceration occurs when a wound opens up & organs are exposed - Applying direct pressure to a wound traumatizes the organs - Irrigating the wound is not necessary -Replacing protruding tissue could induce infection

Which action does the nurse implement for a pt w/wound evisceration? A.) Apply direct pressure to wound. B.) Cover wound w/ sterile/warm/moist dressing. C.) Irrigate wound w/warm, sterile saline. D.) Replace tissue protruding into opening.

B.) Serum potassium level is 3.0 mEq/L (3.0 mmol/L). C.) Client took a total of 1300 mg aspirin yesterday. F.) Client tells the nurse he lied on the assessment form & he's a current smoker. (Potassium K+ should be 3.5-5.0 mEq/L, so 3.0 is low & should be communicated to the surgeon & anesthesia provider prior to surgery, taking aspirin prior to surgery can increase the risk of bleeding, the client's smoking status can change important assessment information collected) - it's acceptable that the regularly scheduled anti-HTN was taken w/ a sip of water 2 hours ago

Which assessment data finding for a client scheduled for total knee replacement surgery is most important for the nurse to communicate to the surgeon and the anesthesia provider before the procedure? Select all that apply. A.) The oxygen saturation is 97%. B.) Serum potassium level is 3.0 mEq/L (3.0 mmol/L). C.) The client took a total of 1300 mg of aspirin yesterday. D.) The client requests to talk with a registered dietitian about weight loss. E.) The client took a regularly scheduled antihypertensive drug with a sip of water 2 hours ago. F.) After receiving the preop meds, the client tells the nurse that he lied on the assessment form & he's a current smoker.

C.) RR of 6 breaths/min

Which assessment finding in a postop client after general anesthesia requires immediate intervention? A.) Heart rate of 58 bpm B.) Pale, cool extremities C.) RR of 6 breaths/min D.) Suppressed gag reflex

A.) Creatinine, 1.9 mg/dL (168 mcmol/L) (The nurse will immediately report a creatinine of 1.9 mg/dL to the anesthesiologist. A creatinine of 1.9 mg/dL is higher than normal & may indicate renal problems) - All other lab values were within normal ranges

Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? A.) Creatinine, 1.9 mg/dL (168 mcmol/L) B.) Fasting glucose, 80 mg/dL (4.4 mmol/L) C.) Potassium, 3.9 mEq/L (3.9 mmol/L) D.) Sodium, 140 mEq/L (140 mmol/L)

B.) Cessation (stopping) of surgery, when possible C.) Inserting Foley catheter to monitor urine output D.) Transfer of client to ICU when stabilized F.) Use active cooling techniques, such as a cooling blanket, and ice packs around the axillae & groin (The surgery should be D/C if possible, foley catheter should be inserted to monitor urine output, pt should be transferred to ICU after stabilization, cooling techniques should be applied to axillae & groin and may also be applied to the head & neck) - The endotracheal tube (ET tube) should stay in place -ABGs will be monitored but for metabolic acidosis not respiratory alkalosis

Which emergency care does the nurse recognize that will be implemented for a client with malignant hyperthermia? Select all that apply. A.) Removal of endotracheal tube B.) Cessation (stopping) of surgery, when possible C.) Insertion of Foley catheter to monitor urine output D.) Transfer of client to intensive care unit when stabilized E.) Assess arterial blood gases (ABGs) for respiratory alkalosis F.) Use active cooling techniques, such as a cooling blanket, and ice packs around the axillae and groin

C.) Pad bony prominences.

Which intervention does the nurse implement for an older adult client to minimize skin breakdown related to surgical positioning? A.) Apply elastic stockings to lower extremities. B.) Monitor for excessive blood loss. C.) Pad bony prominences. D.) Secure joints on a board in anatomic positions.

B.) 47yr obese man w/ diabetes (Obesity/DM wld significantly put a pt at greater risk for slow wound healing) - healthy 12yr boy wld likely heal fast - 48yr smoker will experience delayed wound healing but not as high a risk as an obese pt w/ DM - healthy 98yr pt is not at risk for delayed wound healing

Which pt is at greatest risk for slow wound healing? A.) 12yr healthy girl B.) 47yr obese man w/ diabetes C.) 48yr woman who smokes D.) 98yr healthy man

C.) "If the prescribed dose of med doesn't help my pain, I'll take an extra dose."

Which pt statement regarding appropriate pain control requires nursing intervention? A.) "I will listen to music when I feel pain." B.) "Before exercise, I will be sure I have taken my med." C.) "If the prescribed dose of med doesn't help my pain, I'll take an extra dose." D.) "I plan to keep a pain diary so that I can see trends about when my pain worsens."

D.) Circulating RN who has been employed in the hospital OR for 7 yrs (the circulating RN is the best staff member to assign. This nurse has the experience/background to write OR policy, has been employed in the hospital for 7 yrs, & is aware of hospital policy & procedures) - A surgical technologist doens't have the background to write policy for nurses. - A CRNFA who has worked in multiple hospitals doesn't have a work Hx w/ this specific hospital to be aware of the unit policy - A holding room, preop, or postop care nurse would not be the choice to write OR policy

Which staff member will be best for the nurse manager to assign to update standard nursing care plans and policies for care of the client in the operating room (OR)? A.) Surgical technologist with 10 yrs of experience in the OR at this hospital B.) Certified registered nurse first assistant (CRNFA) who has worked for 5 yrs in the ORs of multiple hospitals C.) Holding room RN who has worked in the hospital holding room for longer than 15 yrs D.) Circulating RN who has been employed in the hospital OR for 7 yrs

1.) At this time, VS are stable. Placing the nasal cannula back on the pt has likely influenced the difference in VS from 15 min prior until now. 2.) Always assess for postsurgical bleeding for any postsurgical pt. Assess the surgical site & lab info. 3.) Oxygen should be continued until an order is received to D/C it. Check pulse ox to ensure that it remains at or above 95% oxygen sat (SpO2). 4.) At this time, there is no need to notify the surgeon or anesthesia provider. Continue monitoring.

You are caring for a 57yr pt who came from the OR to the PACU 30 min ago after surgery for a hernia repair. He responds when you say his name, but he is mildly confused about where he is & why. He continuously attempts to remove the oxygen cannula but allows you to gently replace the cannula several times. VS taken 15 min ago were BP 130/90, pulse 88, RR 20. VS now show BP 120/80, pulse 86, RR 18. 1. Are any of the changes in VS a cause for concern? If so, which? 2. Should you be assessing for postsurgical bleeding? Why/why not? If so, where would you assess for this bleeding? 3. Should you remove oxygen from the pt? Why/why not? 4. Should you notify the surgeon or anesthesia provider? Why/why not?

1.) Remind members of the IPE healthcare team that the patient has a current DNR in place. 2.) Confirm the DNR doc date & time of signature, & provide this info to team. 3.) AORN's position statement claims that automatically suspending a DNR or allow-natural-death order during surgery undermines a pt's right to self-determination (AORN, 2014). 4.) Continue acting as the pt's advocate, by explaining implications of the signed DNR as indicative of the pt's right to self-determination.

You are caring for a 70yr pt who was A&O x 3 to person, place, & time during the preop assessment. At that time, the pt confirmed that she has a current DNR order, & stated that she is "ready to die" if surgery to "does not go well." During the surgery, complications arise & members of the IPE healthcare team prepare to administer life-saving measures. 1. How do you serve as the pt's advocate at this time? 2. What info do you communicate to the IPE healthcare team? 3. Should the DNR be suspended during surgery, especially if it appears that the pt can be saved? 4. What info will you share with the fam, when they ask why you did not save their loved one?