Managing Care: Perioperative Nursing

What are your priority considerations for a patient in the immediate recovery period after anesthesia?

- Assess pt. - Maintain a patent airway - Maintain cardiovascular stability - Relieve pain and anxiety - Control nausea/vomiting - Determine readiness for discharge of PACU

What are symptoms of malignant hyperthermia?

- Increase in body temperature - Tachycardia - Ventricular arrhythmia - Hypotension - Decreased cardiac output - Oliguria (no/little urine) - Cardiac arrest - Hypercapnia (high carbon) - Muscle rigidity

What are some responsibilities of the nurse in preparing the pt. for surgery?

- Informed consent signed - Surgical site labeled - Pre-op checklist filled out - Placing a bracelet on pt. with allergies on it - Ensuring pt. has all jewelry and ANYTHING in mouth removed - Ensure pt. voids immediately before surgery - Know the last times (ate, meds) - Pre-warming the pt. - Assess medical record and labs

What measurement should the nurse report to the physician in the immediate postoperative period? 1) A systolic blood pressure lower than 90 mm Hg 2) A temperature reading between 97°F and 98°F 3) Respirations between 20 and 25 breaths/min 4) A hemoglobin of 13.6

1) A systolic blood pressure lower than 90 mm Hg

The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply. 1) nutritional status 2) age 3) physical condition 4) gender 5) health status 6) ethnicity

1) nutritional status 2) age 3) physical condition 5) health status

A presurgical client asks, "Why will I go to the PACU instead of just going straight up to the postsurgical unit?" What is the nurse's best response? 1) "The PACU allows you to recover from anesthesia in a stimulating environment to facilitate awakening and reorientation." 2) "The PACU allows you to recover from the effects of anesthesia, and you'll stay in the PACU until you're oriented, have stable vital signs, and are without complications." 3) "Frequently, clients are placed in the medical-surgical unit to recover, but hospitals are usually short of beds, and the PACU is an excellent place to triage clients." 4) "You'll remain in the PACU for a predetermined time because the surgeon will often need to reinforce or alter the patient's incision in the hours following surgery."

2) "The PACU allows you to recover from the effects of anesthesia, and you'll stay in the PACU until you're oriented, have stable vital signs, and are without complications."

A 79-year-old man is scheduled for surgical repair of an inguinal hernia. In light of this patient's age, the nurse will prioritize nursing interventions aimed at preventing: 1) Overstimulation 2) Skin breakdown 3) Hyperglycemia or hypoglycemia 4) Early ambulation

2) Skin breakdown

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse? 1) Obtain an emesis basin. 2) Ask the client for more clarification. 3) Position the client in the side-lying position. 4) Administer an anti-emetic.

3) Position the client in the side-lying position.

When integrating the principles for maintaining surgical asepsis during surgery, which of the following would be most appropriate? 1) Considering the gown sterile from mid-thigh to neck 2) Positioning the sterile drape on a table from back to front 3) Allowing circulating nurses to contact sterile equipment 4) Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff

4) Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff

The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the postsurgical unit following a colon resection. This client's age and increased body mass index mean that she is at increased risk for what complication in the postoperative period? 1) Hyperglycemia 2) Azotemia 3) Falls 4) Infection

4) Infection

The nurse is admitting a client to the postanesthesia care unit (PACU) who received general anesthesia for the removal of a bunion. The nurse should prioritize what assessments? 1) lung auscultation and apical heart rate 2) pain and temperature 3) skin integrity and peripheral perfusion 4) respirations and airway

4) respirations and airway

List the correct order for the nurse to take in the pre-op area 1. Assess pt.'s physical, emotional, nutritional status, baseline pain 2. Administer medications if prescribed 3. Communicate pt. and family's needs to other HCPs 4. Establish IV line 5. Identify pt. 6. Provide psychological support 7. Review medical record 8. Take measures to ensure pt. comfort 9. Verify surgical site has been marked

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What is malignant hyperthermia?

A severe reaction to anesthetic agents

What is the nurse's role with informed consent?

Ascertain consent form has been signed before administering psychoactive medication

This procedure removes atherosclerotic plaque or thrombus from the carotid artery

CEA - Carotid Endarterectomy

Although some neck edema is expected after this procedure, the nurse must monitor for extensive edema or hematoma formation

CEA - Carotid endarterectomy

This procedure may be paired with or without an angioplasty

Carotid stenting

After a CEA (Carotid endarterectomy), a nurse must assess these nerves for injury

Cranial nerves

Increased ICP (intracranial pressure) or signs of brain stem compression may prompt this procedure

Craniotomy

Who is the next to sign the informed consent form if the pt. is unable?

The next of kin or legal guardian

This may be inserted by a neurosurgeon to control ICP (intracranial presure)

Ventricular catheter (CSF drainage device) cerebral spinal fluid

There is an emergency situation. The pt. is incapacitated and family cannot be gotten ahold of. Can the pt. undergo surgery without the informed consent form being signed?

Yes, this is the surgeons call

Which assessment findings require a follow-up by the nurse? · Has no history of chronic health problems except osteoarthritis (OA) · Small amount of serosanguineous drainage present on surgical dressing · Reports left knee pain of 6/10 on a 0 to 10 pain intensity scale · Drowsy but arouses easily · Reports that her legs and feet feel "heavy and numb" · Reports "frequent waves of nausea"

· Reports left knee pain of 6/10 on a 0 to 10 pain intensity scale · Drowsy but arouses easily · Reports that her legs and feet feel "heavy and numb" · Reports "frequent waves of nausea"

What are complications of anesthesia/surgery and what should you do about it?

- Respiratory distress: Assess breathing and administer O2 - Shock: Monitor VS, skin warmth, moisture and color - Hemorrhage: Assess surgical site, wound drainage systems - Neuro: Assess LOC, orientation, extremity movement - Urinary retention: Monitor output, can use bladder scanner - Atelectasis: Have pt. use incentive spirometer - Blood clot: Encourage mobility, compression boots - Pain: Administer pain meds, calm environment, repo - Nausea/vomiting: Administer antiemetics, keep basin close

The nurse should monitor postoperative clients who have a total knee arthroplasty under epidural anesthesia for common complications that can occur during their hospital stay, including ____1____ and ____2____. Nursing interventions that can help prevent these complications are to _____3____, _____4_____, and _____5______. Options for 1 and 2 Respiratory infection Venous thromboembolism Intestinal obstruction Surgical knee dislocation Urinary retention Anemia Options for 3, 4, and 5 Encourage fluids Administer stool softener Maintain abduction pillow or device Ambulate the client early Administer an anticoagulant Refer to respiratory therapy

1 and/or 2: Venous thromboembolism, urinary retention 3,4, and/or 5: Encourage fluids, ambulate the client early, administer an anticoagulant

In order to prevent the possibility of venous stasis, a nurse is teaching a surgical patient how to perform leg exercises. Which of the patient's following statements indicates a sound understanding of leg exercises? 1) "I'll practice these now and try to start them as soon as I can after my surgery." 2) "I'll try to do these lying on my stomach so that I can bend my knees more fully." 3) "I'll make sure to do these, as long as my doctor doesn't tell me to stay on bedrest after my operation." 4) "I'm pretty sure my stomach muscles are strong enough to lift both of my legs off the bed at the same time."

1) "I'll practice these now and try to start them as soon as I can after my surgery."

What action by the nurse best encompasses the preoperative phase? 1) Educating clients on signs and symptoms of infection 2) Documenting the application of sequential compression devices (SCDs) 3) Monitoring vital signs every 15 minutes 4) Shaving the client using a straight razor

1) Educating clients on signs and symptoms of infection

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition? 1) The client is displaying early signs of hypovolemic shock. 2) The client is showing signs of a medication reaction. 3) The client is displaying late signs of hypovolemic shock. 4) The client is showing signs of an anesthesia reaction.

1) The client is displaying early signs of hypovolemic shock.

A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize? 1) The edges of a sterile package, once opened, are considered unsterile. 2) A distance of 3 feet must be maintained when moving around a sterile field. 3) If a tear occurs in a sterile drape, a new sterile drape is applied on top of it. 4) Circulating nurses may come in contact with the sterile field without contaminating it.

1) The edges of a sterile package, once opened, are considered unsterile.

A client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse? 1) Verify consent. 2) Document the start of surgery. 3) Acquire ordered blood products. 4) Count sponges and syringes.

1) Verify consent.

A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse: 1) continuously monitors the sedated client. 2) performs a complete assessment of the client. 3) obtains a surgical consent from the client's mother. 4) assesses how well the client is recovering from anesthesia.

1) continuously monitors the sedated client.

The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed? 1) "If I do not follow the instructions, my surgery could be cancelled." 2) "The nurse will explain the details of the surgery before I sign a consent." 3) "My medical records will be sent to the ambulatory care center prior to my surgery." 4) "The physician will update my family after the procedure and provide specific discharge instructions."

2) "The nurse will explain the details of the surgery before I sign a consent."

A nurse is assisting a postsurgical patient with effective coughing. How often should this exercise be performed? 1) Every hour 2) Every 2 hours 3) Every 4 hours 4) Every shift

2) Every 2 hours

A client has been administered ketamine for moderate sedation. What is the priority nursing intervention? 1) Assessing for hallucinations 2) Frequently monitoring vital signs 3) Administering oxygen 4) Providing a quiet dark room for recovery

2) Frequently monitoring vital signs

Which nursing action will best promote pain management for a client in the postoperative phase? 1) Breathing into a paper bag 2) Performing relaxation techniques 3) Dimming the lights 4) Providing food and medication

2) Performing relaxation techniques

What complication is the nurse aware of that is associated with deep venous thrombosis? 1) Immobility because of calf pain 2) Pulmonary embolism 3) Marked tenderness over the anteromedial surface of the thigh 4) Swelling of the entire leg owing to edema

2) Pulmonary embolism

The OR nurse is taking the client into the OR when the client informs the operating nurse that his grandmother spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client? 1) The client may be experiencing presurgical anxiety. 2) The client may be at risk for malignant hyperthermia. 3) The grandmother's surgery has minimal relevance to the client's surgery. 4) The client may be at risk for a sudden onset of postsurgical infection.

2) The client may be at risk for malignant hyperthermia.

List the correct order for the nurse to take during pre-admission testing 1. Confirm understanding of surgeon-specific pre-operative therapies 2. Involve family in interview 3. Initial pre-operative assessment 4. Begin discharge planning for post-op transportation and care 5. Verify completion of pre-op diagnostic testing 6. Discuss and review advanced directive 7. Education appropriate to patient's needs

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Which nursing statement would best decrease a client's anxiety before an emergency operative procedure? 1) "You will be just fine; the operating room nurses will take good care of you." 2) "It is best to take deep breaths and relax before the procedure." 3) "Let me explain to you what will happen next." 4) "We will keep your family informed of your progress."

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

Which intervention should the nurse plan to implement to decrease the client's risk for injury during the intraoperative period? 1) Allow the client to verbalize fears. 2) Verify the client's preoperative vital signs. 3) Assess the client for allergies. 4) Keep the family informed of the client's status.

3) Assess the client for allergies.

A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client? 1) Position the client in bed with pillows placed under his knees to hasten venous return. 2) Keep the client from ambulating until the day after surgery. 3) Implement leg exercises and turn the client in bed every 2 hours. 4) Keep the client cool and uncovered to prevent elevated temperature.

3) Implement leg exercises and turn the client in bed every 2 hours.

The nurse is performing wound care on a 68-year-old postsurgical client. Which of the following practices violates the principles of surgical asepsis? 1) Holding sterile objects above the level of the nurse's waist 2) Considering a 1 inch (2.5 cm) edge around the sterile field as being contaminated 3) Pouring solution onto a sterile field cloth 4) Opening the outermost flap of a sterile package away from the body

3) Pouring solution onto a sterile field cloth

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The child's parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed? 1) A social worker should temporarily sign the informed consent. 2) Consent should be obtained from the hospital's ethics committee. 3) Surgery should be done without informed consent. 4) Surgery should be delayed until the parents arrive.

3) Surgery should be done without informed consent.

The dressing surrounding a mastectomy client's Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion? 1) Describe the appearance of the dressing in the electronic health record. 2) Photograph the client's abdomen for later comparison using a smartphone. 3) Trace the outline of the drainage on the dressing for future comparison. 4) Remove and weigh the dressing, reapply it, and then repeat in 8 hours.

3) Trace the outline of the drainage on the dressing for future comparison.

The nurse is caring for a client who anticipates pain and anxiety following his prostatectomy. Which intervention will likely best assist in decreasing the client's pain and anxiety? 1) Administration of NSAIDs rather than opioids 2) Allowing the client to increase activity 3) Use of guided imagery along with pain medication 4) Use of deep breathing and coughing exercises

3) Use of guided imagery along with pain medication

A client is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting "coffee-ground" like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the client most likely anticipate that the surgery will be scheduled? 1) Within 24 hours 2) Within the next week 3) Without delay because the bleed is emergent 4) As soon as all the day's elective surgeries have been completed

3) Without delay because the bleed is emergent

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: 1) the effects of anesthesia. 2) the normal return of reflexes. 3) a partial airway obstruction. 4) the type of surgery.

3) a partial airway obstruction.

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? 1) Pulse rate of 110 beats/min 2) Respiratory rate of 18 breaths/min 3) Blood pressure of 104/62 mm Hg 4) Temperature of 40° c 104 F

4) Temperature of 40° c (104 F)

List the correct order for the nurse to take during admission to the surgical center 1. Explain phases in perioperative period and expectations 2. Assess for risks for post-op complications 3. Coordinate pt. education and POC with nursing staff and other HCPs 4. Report unexpected findings 5. Pre-op assessment 6. Verify that informed consent has been signed 7. Reinforce previous education 8. Answer pt. and family questions

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A 55-year-old woman has a long history of osteoarthritis (OA) in both knees, ankles, and feet due to obesity and her job, which requires long periods of standing. She is scheduled for a left total knee arthroplasty next month. What preoperative health teaching by the nurse is appropriate for the client in preparation for this surgery? Select all that apply. _____ A. "You will need to shower with a special solution the night prior to your surgery." _____ B. "The physical therapist will teach you about postoperative leg exercises and how to ambulate with a walker." _____ C. "You will need an elevated toilet to prevent you from bending your knees." _____ D. "You will be on a blood thinner to prevent blood clots in your legs and lungs." _____ E. "After surgery you will be placed on pain medication and a cold application for your surgical knee." _____ F. "You should only be in the hospital after surgery for a few days." _____ G. "Although not as common today, you may have a surgical drain near your incision that will be removed before hospital discharge." _____ H. "When you progress to walking with a cane, use it on the affected surgical side."

A B D E F G

What is informed consent?

A patient's signed agreement about an autonomous decision about whether to undergo a surgical procedure

Why does malignant hyperthermia occur?

It is a rare genetic mutation. Anesthesia triggers it. Usually occurs within an hour of anesthetic administration.

Why can't a pt. under the influence of medications sign an informed consent form?

It is invalid. Medications can affect judgement and decision making capacity

The nurse is preparing to send a client to the OR for a scheduled surgery. What should the nurse ensure is on the chart when it accompanies the client to surgery? Select all that apply. 1) Laboratory reports 2) Nurses' notes 3) Verification form 4) Social work assessment 5) Dietitian's assessment

Lab notes Nurse's notes Verification form