Fundamentals Chapter 30: Perioperative Nursing 1-4

Impaired thermoregulation

A 9-month-old baby is scheduled for heart surgery. When preparing this client for surgery, the nurse should consider which surgical risk associated with infants? Impaired thermoregulation Prolonged wound healing Surgical site infections Shock

Obtain vital signs, especially heart rate and blood pressure Give sublingual nitroglycerin as prescribed Ask the client to rate pain on a scale from zero to ten

A client comes to the postoperative area and reports chest pain and palpitations. What priority intervention(s) will the nurse perform? Select all that apply. Give pain medication as prescribed Obtain vital signs, especially heart rate and blood pressure Review prior medical history Give sublingual nitroglycerin as prescribed Ask the client to rate pain on a scale from zero to ten

Monitor the client closely and promote fluid intake.

A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding? Contact the physician to come assess the client. Immediately administer a cleansing enema. Monitor the client closely and promote fluid intake. Increase the rate of the client's intravenous infusion.

emergency surgery

A client is undergoing surgery for an appendectomy. This would be considered what type of surgery? emergency surgery elective surgery palliative surgery diagnostic surgery

hemorrhage.

A client scheduled for surgery has been taking aspirin since his heart attack in 1997. The client is at risk for: infection. thrombophlebitis. hemorrhage. blood clots.

Note the allergy on the client's record.

A client states having a latex allergy. Which action does the nurse take to communicate this allergy to hospital staff caring for the client? Obtain latex-free gloves for the client's room. Note the allergy on the client's record. Place a sign on the client's bed. Inform the client to tell the anesthesiologist.

Anticipating the needs of other members of the surgical team

A nurse is assigned to be the circulating nurse during a surgical procedure. The nurse would be responsible for which activity? Providing sponges and drains to the surgical team in the operating room Coordinating care activity Preparing the sterile tables in the operating room before surgery Anticipating the needs of other members of the surgical team

Client safety

A nurse is interacting with a client in the outpatient surgical unit intraoperatively. What is the nurse's priority responsibility? Educating the client about postoperative protocols Establishing a nurse-client rapport Client safety Providing emotional support for the client and family

The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed.

A nurse is reviewing postoperative protocols with the client, including an explanation and a demonstration of how to use an incentive spirometer. How does the nurse know that the teaching on the use of the incentive spirometer was effective? The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed. After taking a deep breath, the client demonstrates how to exhale into the mouthpiece while in the semi-Fowler position. The client explains the procedure should be completed first thing in the morning before rising from the bed. The client repeats the explanation and instructions in one's own words to demonstrate understanding.

Aspiration

A nurse is teaching a client about the rationale for fasting from food and fluids prior to surgery. What condition does this measure attempt to avoid? Infection Respiratory distress Aspiration Bowel alterations

Monitor the client closely for signs of hemorrhage

A perioperative nurse is assessing a client scheduled for surgery. The client mentions that he takes aspirin on a daily basis since having a heart attack several years ago. In addition to ensuring the surgeon is aware, what is the nurse's most appropriate action? Monitor for signs of deep vein thrombosis Monitor the client closely for signs of hemorrhage Ensure the client receives the medicaiton up to the day of surgery Assess the client's understanding of aspirin and heart attacks

Measure respiratory rate.

After a client receives morphine sulfate for pain in the postanesthesia care unit (PACU), which assessment finding would the nurse obtain as a priority? Auscultate bowel sounds. Obtain temperature. Measure respiratory rate. Check the neurologic status.

procedural pause (time-out)

As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site? operative site marking preoperative checklist procedural pause (time-out) informed consent

paralytic ileus

In the postoperative phase of abdominal surgery, the client reports severe abdominal pain. In the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect? normal response abdominal infection hernia development paralytic ileus

an older adult man with a fractured hip

Surgery can lead to hypothermia. Which client is at greatest risk for hypothermia? a woman experiencing a cesarean birth an older adult man with a fractured hip an adolescent having arthroscopic surgery a young adult with a fractured leg

"We all have the same goal and that is the safety of the client, so let's do the time-out."

The circulating nurse calls for a time-out prior to the surgical procedure and the surgeon states, "I don't have time for this. I have another case to follow and need to get busy." What is the best response by the circulator? "Whether you have time to do it or not, we will do it without you." "I understand you are very busy, so we can move on without the time-out." "These time-outs are ridiculous anyway; we all know what the client is having done." "We all have the same goal and that is the safety of the client, so let's do the time-out."

"I will be responsible for assisting the surgeon with instruments and exposure during the procedure" "I will be responsible for preparing the sterile surgical table for the procedure."

The graduate nurse will be orienting to the role of circulator in perioperative services. What statements made by the nurse requires further education regarding the role of the circulator? Select all that apply. "I will be responsible for ensuring that the "time out" is performed prior to the procedure" "I will be responsible for accounting for all sponges and instruments following the surgical procedure" "I will be responsible for assisting the surgeon with instruments and exposure during the procedure" "I will be responsible for maintaining the client's rights during the surgical procedure." "I will be responsible for preparing the sterile surgical table for the procedure."

Notify the physician of the oversight.

The healthy adult client is given an opioid prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first? Immediately have the client sign the consent form. Have the client's family member sign the consent form. Ask the client if he still wants to proceed with the procedure. Notify the physician of the oversight.

Apply pressure to the surgical site to decrease bleeding.

The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. What would be the nurse's most appropriate initial response? Determine the possible cause of the client's bleeding. Apply pressure to the surgical site to decrease bleeding. Assess the client's vital signs. Notify the health care provider.

delayed wound healing and wound infection

The nurse is assessing an obese client scheduled for heart surgery. Which priority surgical risk related to obesity should the nurse monitor? hemorrhage nutritional maintenance delayed wound healing and wound infection alterations in fluid and electrolyte balance

Respiratory obstruction

The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency? Respiratory obstruction Wound infection Dehydration Cardiac distress

"You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By listening for bowel sounds, I can check for a return of peristalsis."

The nurse is caring for a client after breast augmentation. Before performing a bowel assessment, what education will the nurse provide the client? "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By lightly pressing on the abdomen, I can check for a return of peristalsis." "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By pressing on the symphysis pubis, I can check for a return of peristalsis." "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By listening for bowel sounds, I can check for a return of peristalsis." "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By giving you sips of water periodically, I can promote the return of peristalsis."

Cardiac - Use sidelying position for lethargic clients. Respiratory - Assess skin color. Neurologic - Gently touch the client.

The nurse is caring for a client in the postanesthesia care unit (PACU). The nurse uses specific interventions to avoid complications for each body system. Complete the table by selecting the intervention associated with each body system. Body System Intervention Cardiac Select...Use sidelying position for lethargic clients. Monitor urinary function. Note response to stimulation. Provide verbal stimulation. Respiratory Select... Auscultate bowel sounds. Check pupillary response. Assess skin color. Monitor muscle strength. Neurologic Select... Encourage leg exercises. Gently touch the client. Assess the dressing for drainage.

Teach the client how to splint the abdomen while coughing.

The nurse is caring for a client who had abdominal surgery yesterday and is reluctant to cough and perform deep breathing. Which strategy will most likely increase the client's willingness to cough and perform deep breathing? Teach the client how to splint the abdomen while coughing. Remind the client of the serious complications that can result from ineffective coughing and deep breathing. Administer respiratory treatments to encourage coughing. Assist the client to a side-lying position to cough.

Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact.

The nurse is caring for a confused older adult client who requires surgery for a broken hip. What steps does the nurse take to determine if the client has a durable power of attorney for health care and how to contact that person? Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact. Explain the client's need for hip surgery to visitors and ask them for information about a durable power of attorney for health care. Look on the chart for a living will if a durable power of attorney for health care cannot be located. Allow the surgeon to handle the issue as part of his or her legal responsibility for explaining the surgical procedure and obtaining the appropriate signature on the consent form.

Explore the client's feelings and inform the surgeon.

The nurse is performing a preoperative assessment of a client who has been scheduled for a reduction mammoplasty (breast reduction). The client states, "I'm starting to wonder if I made the right decision in going ahead with this." What should the nurse do next? Ask the client about her understanding of the potential benefits of the surgery. Assess the client's rationale and affirm that she has made a good decision. Explore the client's feelings and inform the surgeon. Remind the client that she has signed the informed consent documents.

"I've been taking ibuprofen for my hip pain twice a day."

The nurse is preparing a client for a total hip arthroplasty and is obtaining data preoperatively. Which statement made by the client is most important for the nurse to immediately report to the health care provider? "I've been taking ibuprofen for my hip pain twice a day." "I have not had anything to eat or drink for 8 hours." "My other hip will probably need to be done eventually." "My hip pain has prevented me from doing the things I enjoy."

"An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so."

The nurse is preparing a client for surgery and asks if the client has an advance directive. The client asks "What is an advance directive?" What is the nurse's best response to this? "An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so." "An advance directive is a living will. Some people already have one when they come to the hospital." "We are not sure if you will wake up after surgery so the advance directive will let us know your wishes just in case." "When you are going to have surgery, the hospital likes to have you fill out all paperwork needed beforehand."

Establish therapeutic rapport with the client and family.

The nurse is preparing a postoperative assessment of a client who has been admitted to the postsurgical unit from the recovery room. Which action should the nurse perform first? Ask the client to demonstrate deep-breathing and coughing exercises. Establish therapeutic rapport with the client and family. Assess the client's likelihood of adhering to prescribed treatment. Identify the client's specific learning needs.

"Try to do your exercises every 1 to 2 hours."

The nurse is providing education about deep-breathing exercises to a postoperative client whose surgery took place earlier today. Which instruction should the nurse provide? "Take off your oxygen nasal prongs during your exercises and replace them as soon as you're done." "Try to do your exercises every 1 to 2 hours." "It's best to do your exercises before a meal rather than after eating and drinking." "If possible, lie flat on your back while you're doing your breathing exercises."

Providing support to abdominal and accessory respiratory muscles

The nurse is teaching the client who recently experienced abdominal surgery to deep breathe and cough effectively. What observable action serves to best minimize pain that may result from the intervention? Supporting the head and shoulders effectively to prevent muscle strain Exhaling through the mouth with lips pursed to slowly empty the lungs Offering emotional support to help minimize concern of abdominal pain Providing support to abdominal and accessory respiratory muscles

before, during, and after the operative phase.

The nurse knows the term perioperative phase refers to care given to the client: before, during, and after the operative phase. from the start of surgery until its conclusion. immediately before an operative procedure. immediately after the operative phase.

"While my pneumatic compression device is on, I don't need to do leg exercises."

The nurse needs to evaluate the effectiveness of a preoperative teaching session with a client scheduled for abdominal surgery. Which client statement indicates the need for further clarification? "Every 2 hours while I am awake, I will take deep breaths and cough." "While my pneumatic compression device is on, I don't need to do leg exercises." "I will sit up in bed before using my incentive spirometer." "I will splint my incision while I cough."

"While my pneumatic compression device is on, I don't need to do leg exercises."

The nurse needs to evaluate the effectiveness of a preoperative teaching session with a client scheduled for abdominal surgery. Which client statement indicates the need for further clarification? "I will splint my incision while I cough." "While my pneumatic compression device is on, I don't need to do leg exercises." "Every 2 hours while I am awake, I will take deep breaths and cough." "I will sit up in bed before using my incentive spirometer."

to lessen the intensity of an illness

The nurse recognizes that palliative surgery is performed for what purpose? to remove a part of the body that is diseased to lessen the intensity of an illness to make or confirm a diagnosis to restore function to tissue that is traumatized

prior to surgery

The nurse recognizes the value of leg exercises in the prevention of postoperative thrombophlebitis. When should the nurse teach the correct technique for leg exercises to a client? prior to surgery in postanesthesia recovery upon transfer from the postanesthesia care unit (PACU) to the postoperative unit when early signs of venous stasis are evident

Inform the operating room staff and assist the client to the bathroom.

The preoperative nurse has prepared a client for surgery and has been notified that the operating room staff is ready for the client. The client states, "My bladder feels full. I need to go to the bathroom!" Which action by the nurse is appropriate? Inform the operating room staff and assist the client to the bathroom. Inform the client that anesthesia will prevent the bladder from emptying during surgery. Insert a catheter into the bladder. Remind the client that bladder fullness is a common preoperative sensation.

Contact lenses Body piercings Fingernail polish Cosmetics False eyelashes

The preoperative nurse is admitting a client who is scheduled for surgery later in the day. The client is wearing contact lenses, has several body piercings, has fingernails covered with nail polish, and is wearing cosmetics, false eyelashes, and a wedding band. Which should the nurse instruct the client to remove before the surgery? Select all that apply. Contact lenses Body piercings Fingernail polish Cosmetics False eyelashes Wedding band

"The time-out checks to be sure that we have the right client and procedure."

The procedural physician has initiated performance of a time-out in the operating room before surgery. The student nurse asks the operating room nurse why this is important. What is the operating room nurse's best response? "The time-out allows us to make sure that the client has had adequate anesthesia." "We need to be sure the client has had the preoperative antibiotic." "The time-out checks to be sure that we have the right client and procedure." "We are checking the client's baseline vital signs during the time-out."

Prepare interventions aimed at resolving shock

The recovery nurse is caring for a surgical client who entered the PACU 30 minutes ago. The client's blood pressure is dropping steadily while the client's heart rate has doubled since admission. What is the nurse's best action? Document this expected post-operative transition Monitor the client closely during the post-operative phase Prepare interventions aimed at resolving shock Administer naloxone as per orders

a partial airway obstruction.

When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of: the effects of anesthesia. the normal return of reflexes. a partial airway obstruction. the type of surgery.

In emergency situations, the doctor may obtain consent over the telephone. The responsibility for securing a consent form lies with the physician; the nurse may witness the client signing a consent form.

Which fact should the nurse keep in mind when obtaining consent forms from clients scheduled to undergo surgery? A consent form is legal, even if the client is confused or sedated. The form that is signed is not a legal document and would not hold up in court. In emergency situations, the doctor may obtain consent over the telephone. The responsibility for securing informed consent from the client lies with the nurse.

Assist the client to do leg exercises to increase venous return.

Which nursing action should the PACU nurse take to prevent postoperative complications in clients? Instruct the client to avoid coughing to prevent injury to the incision. Encourage the client to breathe shallowly to prevent collapse of the alveoli. Assist the client to do leg exercises to increase venous return. Avoid turning the client in bed until the incision is no longer painful.

Performing relaxation techniques

Which nursing action will best promote pain management for a client in the postoperative phase? Breathing into a paper bag Performing relaxation techniques Dimming the lights Providing food and medication