NCLEX FUNDAMENTALS OF NURSING: Preoperative Nursing Care PART 1

Which drainage is drained with a Hemovac? a. bile b. urine c. gastric contents d. wound drainage

d. wound drainage Bile is drained by a T-tube, urine is drained by an indwelling urinary catheter, and gastric contents are drained by a nasogastric tube or a gastrointestinal tube.

For which of the following types of anesthesia will the patient lose consciousness? A.) general B.) regional C.) epidural D.) spinal

A

The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit after abdominal surgery. The client has an indwelling urinary catheter in place. The vital signs are temperature 99.6° F (37.6° C), pulse 104 beats per minute, respirations 16 breaths per minute, and blood pressure (BP) 100/70 mm Hg. Urinary output is 20 mL for the past hour. Based on this data, which actions should the nurse take before notifying the registered nurse? Select all that apply. 1.Auscultate breath sounds. 2.Review vital signs from previous hour. 3.Observe the urinary catheter for patency and flow. 4.Observe the IV site for patency and correct flow rate. 5.Review when the client last received pain medication

2.Review vital signs from previous hour. 3.Observe the urinary catheter for patency and flow. 4.Observe the IV site for patency and correct flow rate. 5.Review when the client last received pain medication Postoperative vital signs and urinary output are important parameters to determine how the client is recovering from the surgical procedure. The nurse needs to consider if this data is an early sign of a complication. The nurse should review the previous vital signs to determine whether this is a change from how the vital signs have been trending since the BP is slightly low and the pulse rate is slightly fast. Noting when the last pain medication was administered will help the nurse determine whether the vital signs may be affected from the medication since opioids lower blood pressure. The nurse should determine whether the IV fluid is infusing correctly and whether the catheter is patent. Urine output should be maintained at a minimum of 30 mL/hr for an adult. An output of less than 30 mL for each of 2 consecutive hours should be reported. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Auscultation of breath sounds is not part of determining the significance of the vital signs and urinary output. Focus on the subject, assessment of a postoperative client. To answer this question correctly, you must know the normal ranges for temperature, blood pressure, and urinary output. The BP must be compared to trends for this particular client. You also need to consider whether fluid is being administered correctly and output is being measured correctly. By checking the situation thoroughly, the nurse can determine whether to report the findings to the registered nurse.

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply. 1.Slight redness along the incision 2.The presence of purulent drainage 3.A temperature of 98.8° F (37.1° C) 4.The client states that he feels cold. 5.The client states that the incision itches. 6.Tender firmness palpable around the incision

2.The presence of purulent drainage 6.Tender firmness palpable around the incision 1. Rationale:A wound infection occurs when healing is delayed and pathogens such as bacteria grow in the wound. Signs and symptoms of a wound infection include warmth, redness, swelling, and tenderness of skin around the incision. The client may have fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a wound that was contaminated before surgical exploration; it appears 3 to 6 days after surgery. Slight redness along an incision is a sign of inflammation and should be monitored to determine whether it progresses. A temperature of 98.8° F (37.1° C) is not an abnormal finding in a postoperative client. Itching around a wound may be from irritation or dryness and is not associated with infection. The fact that a client feels cold is not indicative of an infection, although chills and fever are signs of infection. The room temperature may be too cold for client comfort. Test-Taking Strategy(ies):Focus on the subject, wound infection. Noting the words purulent, tender, and hardness will direct you to the correct options.Review:The signs of a wound infection.Color Key:Cyan = StrategyMagenta = Content Review

The nurse is completing the preoperative checklist for an adult patient who is scheduled for an operative procedure later in the morning. Which of the following preoperative assessment findings for this patient indicates a need to contact the anesthesiologist? A.) temperature- 101 F B.) pulse - 84 C.) respirations - 20 D.) blood pressure- 130/74

A

The patient will have an incision in the lower left abdomen. Which of the following measures by the nurse sill help decrease discomfort in the incisional area when the patient coughs postoperatively? A.) applying a splint directly over the lower abdomen B.) keeping the patient flat with her feet flexed C.) Turing the patient onto the right side D.) applying pressure above and below the incision

A

Following a surgical procedure, the nurse applies sequential compression devices to both lower extremities and turns the machine on. The nurse implements this intervention for which purpose? 1.To promote arterial circulation 2.To prevent muscle cramps in the legs 3.To prevent thrombosis formation in the veins 4.To maintain muscle strength despite inactivity

3.To prevent thrombosis formation in the veins Compression devices, whether sequential, pneumatic, or intermittent, are external devices applied to the lower extremities to compress the calves of the legs and return blood to the heart similar to the way walking promotes venous return. These compression devices are used for clients who are in bed, especially during surgery and postoperatively, to prevent the complication of venous thrombotic embolism. This embolism can become a pulmonary embolism and cause death during the postoperative recovery period. Heart function determines arterial circulation. The compression devices are not significant in preventing muscle cramps or maintaining muscle strength. Focus on the subject, purpose of sequential compression devices. Recall they are applied when the client is not walking and that with walking, the calf muscles contract and return blood through the veins to the heart. Note that venous thrombotic embolism disease is a major cause of postoperative deaths.

Which of the following events in the surgical suite represents a violation of aseptic technique? A. A drape contacts the leg of the table that supports the sterile field. B. The cuff of the scrub nurse's sterile gown contacts the sterile field. C. The sterile field was established at 0650 and the current time is 0900. D. Bacteria are present in the nares and upper respiratory passages of the nurse.

A

The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all that apply. 1.Wound care 2.Personal hygiene 3.Activity restrictions 4.Frequent assessment of vital signs 5.Coughing and deep breathing exercises 6.Pain monitoring and medications to relieve pain

4.Frequent assessment of vital signs 5.Coughing and deep breathing exercises 6.Pain monitoring and medications to relieve pain Rationale:The type of planning and instruction required varies with each individual and type of surgery. Preoperative education, including rationales related to a client's expected postoperative behavior, has a positive outcome on recovery and prevention of postoperative complications. Postoperatively, the client will be monitored closely with vital signs and the client should understand this is routine. General anesthesia predisposes clients to respiratory problems that can lead to atelectasis and pneumonia in the postoperative period. Therefore, coughing and deep breathing are important exercises to be taught in the preoperative period. Addressing that pain will be monitored and controlled with prescribed analgesia should allay client fears regarding pain. Specific instructions that the client needs to receive before discharge should include wound care, activity restrictions, dietary instructions, postoperative medication instructions, personal hygiene, and follow-up appointments. Test-Taking Strategy(ies):Focus on the subject, preoperative instructions. Options 1, 2, and 3 refer to information that needs to be taught postoperatively. Options 4, 5, and 6 refer to information that should be taught preoperatively. Review:Preoperative and postoperative care.Color Key:Cyan = StrategyMagenta = Content Review

The nurse is preparing a client for surgery. Which should be components of the plan of care? Select all that apply. 1.Verify the preoperative laboratory studies were drawn. 2.Report any increases in blood pressure (BP) on the day of surgery. 3.Verify that the client has received nothing by mouth (NPO) for 24 hours before surgery. 4.Instruct the client not to swallow water with oral hygiene on the morning of surgery. 5.Document that any medications the client was instructed to take before surgery are given.

4.Instruct the client not to swallow water with oral hygiene on the morning of surgery. 5.Document that any medications the client was instructed to take before surgery are given. The preoperative preparation is important to ensure that the surgery gets done with everything ready to ensure a successful outcome. The client may brush teeth and rinse with mouthwash but must not swallow any water. Any specific medications that the client was instructed to take on the day of surgery need to be administered and documented. This may include insulin or a blood pressure medication. The nurse cannot just verify the preoperative testing was done. The nurse needs to review the results of the preoperative laboratory studies and notify the primary health care provider of any abnormal results. Some increase in both blood pressure and pulse is common because of client anxiety regarding surgery. The client usually has a restriction of food and fluids for 8 hours before surgery instead of 24 hours. Note the subject, preparing a client for surgery. Read each option carefully and decide whether it promotes client safety when answering the question. Preoperative testing results, NPO status, and medications ordered need to be documented as done. Any concerns regarding laboratory results or the medications should be discussed with the primary health care provider. Recall that surgery can produce anxiety and elevate BP slightly.

A nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to do which of the following first on arrival of the client? a. assess the patency of the airway b. check tubes or drains for patency c. check the dressing to assess for bleeding d. assess the vital signs to compare with preoperative measurements

A

A patient in the PACU who has received general anesthesia in an ambulatory surgery center: A.) has to meet identified criteria in order to be discharged home B.) will remain in the recovery area longer than a hospitalized patient C.) is allowed to ambulate as soon as being admitted to the recovery area D.) is immediately given liberal amounts of fluid to promote the excretion of the anesthesia

A

A patient is just admitted to the PACU recovering from a vagotomy and pyloroplasty. Which of the following is a normal expectation of the patient in this stage of recovery? A.) a subdued level of consciousness and neurological function B.) pain that is relieved with nonpharmacological measures C.) normal bowel sounds on auscultation D.) voluntary bladder control and function

A

A patient who is scheduled for surgery is found to have thrombocytopenia. A specific postoperative concern for the nurse for this patient is: A.) hemorrhage B.) wound infection C.) fluid imbalance D.) respiratory depression

A

A surgical patient's premedication regimen includes midazolam (Versed). The most likely desired effects of this medication are A. Monitored anesthesia care and amnesia. B. Induction and maintenance of anesthesia. C. Analgesia and prevention of intraoperative vomiting. D. Relaxation of skeletal muscles and facilitation of endotracheal intubation.

A

After abdominal surgery, the nurse suspects that the patient may be having internal bleeding. Which of the following finding is indicative of this complication? A.) restlessness B.) increased blood pressure C.) slow, shallow respirations D.) increased urinary output

A

Procedural information that should be given to a patient in preparation for ambulatory surgery includes (select all that apply) a. how pain will be controlled b. any fluid and food restrictions c. characteristics of monitoring equipment d. what odors and sensations may be experienced e. the technique and practice of coughing and deep breathing, if appropriate

A, B, E- Procedural information includes what will or should be done for surgical preparation, including what to bring and what to wear to the surgery center, food and fluid restrictions for how long, physical preparation required, pain control, need for coughing and deep breathing, and procedures done before and during surgery (vital signs, IV lines, and how anesthesia is administered). Other options include sensory an process information.

The nurse is observing the patient who is receiving an inhaled general anesthetic for malignant hyperthermia. Which of the following are signs of this serious disorder? Select all that apply A). High fever B). Muscle relaxation C). Hypotension D). Tachycardia E). Erythema F). Bradypnea

A, D

*********The new graduate nurse is observed doing the following on the surgical unit. Which of the following actions require correction by the nurse manager? Select all that apply A.) leaving the side rails down after administrating preoperative medications B.) assisting the patient to shower with an anti microbial soap on the day of the surgery C.) removing hair from the surgical site with a razor D.) notifying the surgeon of an increase in the patients blood pressure before surgery E.) signing the consent form for the patient who is lethargic

A, E

Which of the following are accurate statements about the surgical scrub? Select all that apply A.) remove all rings B.) hand are held below the elbows C.) for the prescrub, fingertips are cleaned first D.) nails should receive 15 strokes each with a brush E.) each third of the arm receives 10 strokes with a brush F.) rinsing is done from fingertips to elbows G.) faucets are turned off with the hands

A, c, d, e, f

The nurse is preparing a patient for transport to the operating room. THe patient is scheduled for a right knee arthroscopy. What actions should the nurse take at this time? (select all that apply) a. Ensure that the patient has voided b. Verify that the informed consent is signed c. Complete the preoperative nursing documentation d. Verify that the right knee is marked with indelible marker e. Ensure that the H&P, diagnostic reports, and vital signs are on the chart

A,B,C,D,E- All are actions that are needed to ensure the patient is ready for surgery. In addition, the nurse should verify that the ID band and allergy band are on, that the patient is not wearing any cosmetics, that nail polish bas been removed, that valuables have been removed and secured, and that prosthetics, such as glasses, have been removed and secured.

The primary advantage of the use of midazolam (Versed) as an adjunct to general anesthesia is its a. amnestic effect b. analgesic effect c. antiemetic effect d. prolonged action

A- Amnestic effect Midazolam (Versed) is a rapid, short acting, sedative-hypnotic benzodiazepine that is used to prevent recall of events under anesthesia because of its amnestic properties.

A patient is scheduled for a hemorrhoidectomy at an ambulatory day surgery-center. An advantage of performing surgery at an ambulatory center is a decreased need for a. laboratory tests and perioperative medications b. preoperative and postoperative teaching by the nurse c. psychologic support to alleviate fears of pain and discomfort d. preoperative nursing assessment related to possible risks and complications

A- Laboratory tests and perioperative medications Ambulatory surgery is usually less expensive and more convenient, generally involving fewer laboratory tests, fewer preoperative and postoperative medications, less psychologic stress, and less susceptibility to hospital-acquired infections. However, the nurse is still responsible for assessing, supporting, and teaching the patient undergoing surgery, regardless of where the surgery is performed.

During preoperative physical examination, the nurse is alerted to the possibility of compromised respiratory function during or after surgery in the patient with a. obesity b. dehydration c. an enlarged liver d. decreased peripheral pulse volume

A- Obesity, as well as spinal, chest, and airway deformities, may compromise respiratory function during and after surgery. Dehydration may require preoperative fluid therapy, and an enlarged liver may indicate hepatic dysfunction that will increase perioperative risk related to glucose control, coagulation, and drug interactions. Weak peripheral pulses may reflect circulatory problems that could affect healing.

A break in sterile technique during surgery would occur when the scrub nurse touches a. the mask with gloved hands b. gloves hands to the gown at chest level c. the drape at the incision site with gloved hands d. the lower arms to the instruments on the instrument tray

A- The mask covering the face is not considered sterile, and if in contact with sterile gloved hands, contaminates the gloves. The gown at chest level and to 2 inches above elbows is considered sterile, as is the drape placed at the surgical area.

The nurse asks a preoperative patient to sign a surgical consent form as specified by the surgeon and signs the form after patient. By this action, the nurse is a. witnessing the patient's signature b. obtaining informed consent from the patient for the surgery c. verifying that the consent for surgery is truly voluntary and informed d. ensuring that te patient is mentally competent to sign the consent form

A- Witnessing the patient's signature The nurse may be responsible for obtaining and witnessing that patient's signature on the consent form, but the health care provider is ultimately responsible for obtaining informed consent. The nurse may be a patient advocate during the signature of the consent form, verifying that consent is voluntary and that the patient understands the implications of consent, but the primary legal action by the nurse is witnessing the patient's signature.

A patient who is being admitted for a hysterectomy to the surgical unit paces the floor, repeatedly saying, "I just want this over." To promote a positive surgical outcome for the patient, the nurse should a. ask the patient what her specific concerns are about the surgery. b. redirect the patient's attention to the necessary preoperative preparations c. reassure the patient that the surgery will be over soon and she will be fine. d. tell the patient she has no reason to be so anxious because she is having a common, safe surgery.

A- ask the patient what her specific concerns are about the surgery Excessive anxiety and stress can affect surgical recovery, and the nurse's role in psychologically preparing the patient for surgery is to assess for potential stressors that could be identified and addressed by the nurse by listening and by explaining planned postoperative care. Falsely reassuring the patient, ignoring her behavior, and telling her not to be anxious are not therapeutic.

A patient scheduled for hip replacement surgery in the early afternoon receives and ingests a breakfast tray with clear liquids on the morning of surgery. The nurse notifies the ACP with the expectation that the patient a. will be able to undergo surgery as scheduled. b. will have to have surgery rescheduled for the following day c. should be rescheduled for surgery 8 hours after the fluid intake d. should have a nasogastric tube inserted to remove the fluids from the stomach

A. Will be able to undergo surgery as scheduled The preoperative fasting recommendations of the American Society of Anesthesiology indicate that clear liquids may be taken for up to 2 hours before surgery for healthy patients undergoing elective procedures. There is evidence that no longer fasting is necessary.

The nurse is working in an postoperative care unit in an ambulatory surgery center. Of the following patients that have come to have surgery is at greater risk during surgery ? A.) 44 year old taking an anti hypertensive agent B.) 27 year old taking an anticoagulant agent C.) 78 year old taking an analgesic agent D.) 10 year old taking an antibiotic agent

B

The patient is transferred to the PACU at 10 a.m. it is now 11:30 a.m., and the patient is not experiencing any complications or difficulties. The nurse will plan to measure the patients vital signs every: A.) 15 minutes B.) 30 minutes C.) 1 hour D.) 4 hours

B

The perioperative nurse would recognize the need to monitor the patient for hallucinations and agitation when which of the following anesthetic agents is administered? A. Nitrous oxide B. Ketamine (Ketalar) C. Thiopental (Pentathal) D. Halothane (Fluothane)

B

Which of the following intraoperative nursing responsibilities would be performed by the scrub nurse (select all that apply)? A. Documenting intraoperative care B. Keeping track of irrigation solutions for monitoring of blood loss C. Passing instruments and supplies to the surgeon by anticipating his or her needs D. Coordinating the flow and activities of members of the surgical team in the surgical suite E. Performing the count of sponges, needles, and instruments used during the surgical procedure

B, C, E

Before admitting a patient to the operating room, the nurse recognizes that which of the following must be in the chart of all patients (select all that apply)? A. Electrocardiogram B. Signed consent form C. Functional status evaluation D. Renal and liver function tests E. A physical examination report

B, E

A preoperative patient reveals that an uncle died during surgery because of a fever and cardiac arrest. The perioperative nurse alerts the surgical team, knowing that if the patient is at risk for malignant hyperthermia, a. the surgery will have to be cancelled b. specific precautions can be taken to safely anesthetize the patient c. dantrolene (Dantrium) must be given to prevent hyperthermia during surgery d. the patient should be placed on a cooling blanket during the surgical procedure

B- Although malignant hyperthermia can result in cardiac arrest and death, if the patient is known or suspected to be at risk for the disorder, appropriate precautions taken by the ACP can provide for safe anesthesia for the patient. Because preventive measures are possible if the risk is known, it is critical that the preoperative assessment include a careful family history of surgical events

Monitored anesthesia care (MAC) is being considered for a patient undergoing a cervical dilation and endometrial biopsy in health care provider's office. The patient asks the nurse, "What is the MAC?" The nurse's response is based on the knowledge that MAC a. can be administered only by anesthesiologists or nurse anesthetists b. enables the patient to respond to commands and accept painful procedures c. should never be used outside of the OR because of the risk of serious complications d. is so safe that it can be administered by nurses with direction from health care providers

B- MAC refers to sedation that allows the patient to manage his or her own airway and respond to commands, and yet the patient can emotionally and physically accept painful procedures. Drugs are used to provide analgesia, relieve anxiety, and/or provide amnesia. It can be administered by personnel other than anesthesiologists, but nurses should be specially trained in the techniques of MAC to carry out this procedure because of the high risk of complications resulting in clinical emergencies

The physical environment of a surgery suite is designed primarily to promote a. electrical safety b. medical and surgical asepsis c. comfort and privacy of the patient d. communication among the surgical team

B- Medical and surgical asepsis Although all the factors are important to the safety and well being of the patient, the first consideration in the physical environment of the surgical suite is prevention of transmission of infection to the patient

When transporting an inpatient to the surgical department, the nurse from another area of the hospital has access to a. the clean core b. the holding area c. corridors of the surgical suite d. an unprepared operating room

B- The holding area Persons in street clothes or attire other than surgical scrub clothing can interact with personnel of the surgical suite in unrestricted areas, such as the holding area, nursing station, control desk, or lockers rooms. Only authorized personnel wearing surgical attire and hair covering are allowed in semirestricted areas, such as corridors, and masks must be worn in restricted areas, such as operating rooms, clean core, and scrub sink areas.

Because of the rapid elimination of volatile liquids used for general anesthesia, the nurse should anticipate that early in the anesthesia recovery period, the patient will need a. warm blankets b. analgesic medication c. observation for respiratory depression d. airway protection in anticipation of vomiting

B- The volatile liquid inhalation agents have very little residual analgesia, and patients experience early onset of pain when the agents are discontinued. They are associated with a low incidence of nausea and vomiting. Prolonged respiratory depression is not common because of their rapid elimination. Hypothermia is not related to use of these agents, but they may precipitate malignant hyperthermia in conjunction with neuromuscular blocking agents.

Preoperative checklists are used on the day of surgery to ensure that a. the patient is correctly identified b. all preoperative order and procedures have been carried out and records are complete c. patient's families have been informed as to where they can accompany and wait for patients. d. preoperative medications are the last procedure carried out before the patient is transported to the operating room

B. All preoperative orders and procedures have been carried out and records are complete Preoperative checklists are a tool to ensure that the many preparations and precautions performed before the surgery have been completed and documented. Patient identification, instructions to the family, and administration of preoperative medications are often documented on the checklist that ensures that no details are omitted.

During epidural and spinal anesthesia, the nurse should monitor the patient for a. spinal headache b. hypotension and bradycardia c. loss of consciousness d. downward extension of nerve block

B. During epidural and spinal anesthesia, a sympathetic nervous system blockade may occur that results in hypotension, bradycardia, and nausea and vomiting. A spinal headache may occur after, not during, spinal anesthesia, and unconsciousness and seizures are indicative of IV absorption overdose. Upward extension of the effect of the anesthesia results in inadequate respiratory excursion and apnea

Which of the following are commonly used antibiotics to prevent surgical site infection? Select all that apply A). Lidocaine B.) vancomycin C.) tamsulosin D.) cefazolin E.) clindamycin F.) captopril G.) lansoprazole

B.) vancomycin D.) cefazolin E.) clindamycin

A 43 year old patient is scheduled to have a gastrectomy. Which Of the following is a major preoperative concern? A.) an IV infusion is present B.) the patients brother has a tonsillectomy at age 11 C.) the patient smokes a pack of cigarettes a day D.) the patient has worked as a computer programmer

C

On admission to the PACU, the patient who has no orthopedic or neurological restrictions is positioned with the: A.) bed flat and the patients arms to the sides B.) patients neck flexed and body positioned laterally C.) head of the bed slightly elevated with the patients head to the side D.) patients arms crossed over the chest and the bed in high Fowler's position

C

Patient assessment reveals restlessness, chest pain, dyspnea, cyanosis, leg pain, and a dysrhythmia. The nurse suspects that the patient may have a(n): A.) airway obstruction B.) anxiety reaction C.) pulmonary embolism D.) hypovolemic Shock

C

The nurse is completing the preoperative checklist for an adult female patient who is scheduled for an operative procedure later in the morning. To evaluate renal function, the nurse reviews the results of the: A.) fasting blood sugar B.) serum glutamate pyruvic transaminase C.) blood urea nitrogen (BUN) D.) human chorionic gonadotropin

C

The patient tells the nurse that "blowing into this tube thing (incentive spirometer) is a ridiculous waste of time." The nurse explains that the specific purpose of the therapy is: A.) directly remove excess secretions from the lungs B.) increase pulmonary circulation C.) promote lung expansion D.) stimulate the cough reflex

C

Indicate the order in which surgical attire is removed. A.) eyewear B.) mask C.) gloves D.) gown

C, a, d, b

When teaching a patient deep breathing technique, what is the order for instruction? A.) inhale as deeply as possible B.) take slow deep breaths, inhaling through the nose, and feeling the abdomen push against the hands C.) exhale slowly through purses lips, stopping when the hands touch D.) hold the Breath for 3 to 5 seconds E.) rest the plams of the hands on the rib cage, with middle fingers touching F.) assume an upright position

F, E, B, A, D, C

When the nurse asks a preoperative patient about allergies, the patients reports a history of seasonal environmental allergies and allergies to a variety of fruits. The nurse should a. note this information in the patient's record as hay fever and food allergies. b. place an allergy alert wristband on the patient identifying the specific allergies c. ask the patient to describe the nature and severity of any allergic responses experienced to these agents. d. notify the anesthetic care provider (ACP) because the patient may have an increased risk for allergies to anesthetics

C- Ask the patient to describe the nature and severity of any allergic responses experienced to these agents Risk factors for latex allergies include a history of hay fever and allergies to foods such as avocados, kiwi, bananas, potatoes, peaches, and apricots. When a patient should be further questioned about exposure to altex and specific reactions to allergens. A history of any allergic responsiveness increases the risk for hypersensitivity reactions to drugs used during anesthesia, but the hay fever and fruit allergies are specifically related to latex allergy.

The nurse recognizes that extra time may be necessary when preparing an elderly adult for surgery because of a. ineffective coping b. limited adaptation to stress c. diminished vision and hearing d. the need to include caregivers in preoperative activities

C- Diminished vision and hearing One of the major reasons the elderly need increased time preoperatively is the presence of impaired vision and hearing that slows understanding of preoperative instructions and preparation for surgery. Thought processes and cognitive abilities may also be impaired in some older adults. The older adults decreased adaptation to stress because of physiologic changes may increase surgical risks, and overwhelming sugery-related losses may result in ineffective coping that is not directly related to time needed for preoperative preparation. The involvement of caregivers in preoperative activities may be appropriate for patients of all ages.

During surgery, a patient has a nursing diagnosis of risk for perioperative positioning injury. A common risk factor for this nursing diagnosis is a. skin lesions b. break in sterile technique c. musculoskeletal deformities d. electrical or mechanical equipment failure

C- Musculoskeletal deformities can be a risk factor for positioning injuries and require special padding and support on the operating table. Skin lesions and break in sterile technique are risk factors for infection, and electrical equipment failure may lead to other types of injuries.

The primary goal of the circulating nurse during preparation of the operating room, transferring and positioning the patient, and assisting the anesthesia team is a. avoiding any type of injury to the patient b. maintaining a clean environment for the patient c. providing for patient comfort and sense of well being d. preventing breaks in aseptic technique by the sterile members of the team

C- Providing for patient comfort and sense of well being The protection of the patient from injury in the operating room environment is maintained by the circulating nurse by ensuring functioning equipment, preventing falls and injury during transport and transfer, monitoring asepsis, and being with the patient during anesthesia induction

Goals for patient safety in the operating room (OR) include the Universal Protocol, in which a. all surgical centers of any type must submit reports on patient safety infractions to the accreditation agencies b. the members of the surgical team stop whatever they are doing to check that all sterile items have been properly prepared c. a surgical timeout is performed just before the procedure is started to verify patient identity, surgical procedure, and surgical site d. all members of the surgical team pause right before surgery to meditate for 1 minute to decrease stress and possible errors

C- The Universal Protocol supported by The Joint Commission is used to prevent wrong site, wrong procedure, and wrong surgery in view of a high rate of these problems nationally. It involves pausing just before the procedure starts to verify identity, site, and procedure.

A 71-year-old male patient who is currently undergoing coronary artery bypass graft (CABG) surgery has just experienced intraoperative vomiting. The nurse should consequently anticipate the use of which of the following drugs? A. Midazolam (Versed) B. Fentanyl (Sublimaze) C. Meperidine (Demerol) D. Ondansetron (Zofran)

D

A 92 year old patient is scheduled for a colectomy. Which normal physiological change that accompanies the aging process increases this patients risk for surgery? A.) an increased tactile sensation B.) an increased metabolic rate C.) a relaxation of arterial walls D.) reduced glomerular filtration

D

An obese patient is admitted for abdominal surgery. The nurse recognizes that this patient is more susceptible to the postoperative complication of: A.) anemia B.) seizures C.) protein loss D.) dehiscence

D

During stage 3 of general anesthesia, the nurse expects that the patient will: A.) become drowsy B.) lose respiratory function C.) experience muscle tension D.) have regular breathing

D

The nurse is assessing the patient in the postoperative period and finds that there is a possible pneumonia. This is based on the finding of which specific sign or symptom? A.) fever B.) chills C.) adventitious sounds D.) rust colored secretions

D

The patient asks the nurse the purpose of having medications (sedatives) given before surgery. The nurse should inform the patient that these particular medications: A.) decrease body secretions B.) reduce preoperative fear C.) promote emptying of the stomach D.) ease the introduction of the anesthesia

D

The patient had surgery in the morning that involved the right femoral artery. To assess the patients circulation status to the right leg, the nurse will make sure to check the pulse at which arterial site? A.) radial B.) ulnar C.) brachial D.) dorsalis pedis

D

The patient is scheduled for abdominal surgery and has just received the preoperative medications. The nurse should: A.) keep the patient quiet B.) obtain that consent C.) prepare the skin at the surgical site D.) place the side rails up on the bed or stretcher

D

During a preoperative systems review, the patient reveals a history of renal disease. This finding suggests the need for preoperative diagnostic tests of a. ECG and chest x-ray b. Serum glucose and CBC c. ABGs and coagulation tests d. BUN, serum creatinine, and electrolytes

D- BUN, serum creatinine, and electrolytes BUN, serum creatinine, and electrolytes are commonly abnormal in renal disease and should be evaluated before surgery. Other tests are often evaluated in the presence of diabetes, bleeding tendencies, and respiratory or heart disease.

At the end of the surgical procedure, the perioperative nurse evaluates the patient's response to the nursing care delivered during the perioperative period. Which of the following criteria reflects an outcome related to the patient's physical status? a. the patient's right to privacy is maintained b. the patient's care is consistent with the perioperative plan of care c. the patient receives consistent and comparable care regardless of the setting d. the patient's respiratory function is consistent with or improved from baseline levels established preoperatively.

D- The Perioperative Nursing Data Set includes outcome statements that reflect standards and recommended practices or perioperative nursing. Outcomes related to physiologic responses include those of physiologic function, such as respiratory function; perioperative safety includes the patient's freedom from any type of injury; and behavioral responses include knowledge and actions of the patient and family, including the consistency of the patient's care with the perioperative plan and the patient's right to privacy.

The nurse is reviewing the lab results for a preoperative patient. Which of these results should be brought to the attention of the surgeon? a. Hemoglobin of 15 g/dL b. Serum K+ of 3.8 mEq/L c. Blood glucose of 100 mg/dL d. White blood cell count of 18,500/microL

D- WBC of 18,500 This finding may indicate an infection. THe surgeon will probably postpone the surgery until the cause of the elevated WBC has been found.

What does progression of patients through various phases of care in a postanesthesia care unit (PACU) primarily depend on? a. condition of patient b. type of anesthesia used c. respiratory adequacy d. type of surgical procedure

a. condition of patient Although some surgical procedures and drug administration require more intensive postanesthesia care, how fast and through which levels of care patients are moved depend on the condition of the patient. A physiologically unstable outpatient may stay an extended time in Phase I, whereas a patient requiring hospitalization but who is stable and recovering may well be transferred quickly to an inpatient unit.

With what are the post-op respiratory complications of atelectasis and aspiration of gastric contents associated? a. hypoxemia b. hypercapnia c. hypoventilation d. airway obstruction

a. hypoxemia Hypoxemia occurs with atelectasis and aspiration as well as pulmonary edema, pulmonary embolism, and bronchospasm. Hypercapnia is caused by decreased removal of CO2 from the respiratory system that could occur with airway obstruction or hypoventilation. Hyperventilation may occur with depression of central respiratory drive, poor respiratory muscle tone due to disease or anesthesia, mechanical restriction, or pain. Airway obstruction could occur with the tongue blocking the airway, restrained thick secretions, laryngospasm, or laryngeal edema.

A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess for first in the patient? a. hypoxemia b. neurologic injury c. distended bladder d. cardiac dysrhythmias

a. hypoxemia The most common cause of emergence delirium is hypoxemia and initial assessment should evaluate respiratory function. When hypoxemia is ruled out, other causes, such as distended bladder, pain, and fluid and electrolyte disturbances, should be considered. Delayed awakening may result from neurologic injury and cardiac dysrhythmias most often result from specific respiratory, electrolyte, or cardiac problems.

The PACU nurse applies warm blankets to a post-op patient who is shivering and has a body temperature of 96 degrees Fahrenheit. What treatment also may be used to treat the patient? a. oxygen b. vasodilating drugs c. antidysrhythmic drugs d. analgesics or sedatives

a. oxygen The most common cause of emergence delirium is hypoxemia and initial assessment should evaluate respiratory function. When hypoxemia is ruled out, other causes, such as distended bladder, pain, and fluid and electrolyte disturbances, should be considered. Delayed awakening may result from neurologic injury and cardiac dysrhythmias most often result from specific respiratory, electrolyte, or cardiac problems.

What is included in the routine assessment of the patient's cardiovascular function on admission to the PACU? a.monitoring arterial blood gases b. ECG monitoring c. determining fluid and electrolyte status d. direct arterial blood pressure monitoring

b. ECG monitoring ECG monitoring is performed on patients to assess initial cardiovascular problems during anesthesia recovery. Fluid and electrolyte status is an indication of renal function and determinations of arterial blood gases and direct arterial blood pressure monitoring are used only in special cardiovascular or respiratory problems.

For which nursing diagnoses or collaborative problems common in post-op patients has ambulation been found to be an appropriate intervention (SELECT ALL THAT APPLY) a. impaired skin integrity r/t incision b. impaired mobility r/t decreased muscle strength c. risk for aspiration r/t decreased muscle strength d. ineffective airway clearance r/t decreased respiratory excursion e. constipation r/t decreased physical activity and impaired GI motility f. venous thromboembolism r/t dehydration, immobility, vascular manipulation, or injury

b. impaired mobility r/t decreased muscle strengthd. ineffective airway clearance r/t decreased respiratory excursion e. constipation r/t decreased physical activity and impaired GI motility f. venous thromboembolism r/t dehydration, immobility, vascular manipulation, or injury These problems are improved with ambulation. Other collaborative problems could be potential complications: urinary retention, atelectasis, and pneumonia.

To prevent agitation during the patient's recovery from anesthesia, when should the nurse begin orientation explanations? a. when the patient is awake b. when the patient first arrives in the PACU c. when the patient becomes frightened or agitated d. when the patient can be aroused and recognizes where he or she is

b. when the patient first arrives in the PACU Even before patients awaken from anesthesia, their sense of hearing returns and all activities should be explained by the nurse from the time of admission to the PACU to assist in orientation and decrease confusion.

What should be included in the instructions given to the post-op patient before discharge? a. need for follow-up care with home care nurses b. directions for maintaining routine post-op diet c. written information about self-care during recuperation d. need to restrict all activity until surgical healing is complete

c. All postoperative patients need discharge instructions regarding what to expect and what self-care can be assumed during recovery. Diet, activities, follow-up care, symptoms to report, and instructions about medications are individualized to the patient.

While assessing a patient in the PACU, the nurse finds that the patient's blood pressure is below the pre-op baseline. The nurse determines that the patient has residual vasodilating effects of anesthesia when what is assessed? a. a urinary output >30 mL/hr b. an oxygen saturation of 88% c. a normal pulse with warm, dry, pink skin d. a narrowing pulse pressure with normal pulse

c. a normal pulse with warm, dry, pink skin Hypotension with normal pulse and skin assessment is typical of residual vasodilating effects of anesthesia and requires continued observation. An oxygen saturation of 88% indicates hypoxemia, whereas a narrowing pulse pressure accompanies hypoperfusion. A urinary output >30 mL/hr is desirable and indicates normal renal function.

How is the initial information given to the PACU nurses about the surgical patient? a. a copy of the written operative report b. a verbal report from the circulating nurse c. a verbal report from the ACP d. an explanation of the surgical procedure from the surgeon

c. a verbal report from the ACP The admission of the patient to the PACU is a joint effort between the ACP, who is responsible for supervising the postanesthesia recovery of the patient, and the PACU nurse, who provides care during anesthesia recovery. The ACP gives a verbal report that presents the details of the surgical and anesthetic course, preoperative conditions influencing the surgical and anesthetic outcome, and PACU treatment plans to ensure patient safety and continuity of care.

Which patient is ready for discharge from Phase 1 PACU care to the clinical unit? a. arouses easily, pulse is 112 bpm, respiratory rate is 24, dressing is saturated, SaO2 is 88% b. difficult to arouse, pulse is 52, respiratory rate is 22, dressing is dry and intact, SaO2 is 91% c. awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92% d. arouses, blood pressure higher than pre-op and respiratory rate is 10 no excess bleeding, SaO2 is 90%

c. awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92% On initial assessment in PACU the airway, breathing, and circulation (ABC) status is assessed using a standardized tool that usually includes consciousness, respiration, oxygen saturation, circulation, and activity. Increased or decreased respiratory rate, hypertension, and a SaO2 below 90% indicate inadequate oxygenation that will be treated or managed in the PACU before discharging the patient to the next phase.

A patient who had major surgery is experiencing emotional stress as well as physiologic stress from the effects of surgery. What can this stress cause? a. diuresis b. hyperkalemia c. fluid retention d. impaired blood coagulation

c. fluid retention The stress response causes fluid retention during the first 1 to 3 days postoperatively and fluid overload is possible during this time. Fluid retention results from secretion and release of antidiuretic hormone (ADH) and adrenocorticotropic hormone (ACTH) by the pituitary and activation of the renin-angiotensin-aldosterone system (RAAS). ACTH stimulates that adrenal cortex to secrete cortisol and aldosterone. The RAAS increases aldosterone release, which also increases fluid retention. Aldosterone causes renal potassium loss with possible hypokalemia and blood coagulation is enhanced by cortisol.

Which tubes drain gastric contents (SELECT ALL THAT APPLY)? a. T-tube b. hemovac c. nasogastric tube d. indwelling catheter e. gastrointestinal tube

c. nasogastric tube e. gastrointestinal tube The nasogastric tube and gastrointestinal tube drain gastric contents. The T-tube drains bile, the Hemovac drains blood from the surgical site, and the indwelling catheter drains urine form the bladder.

To promote effective coughing, deep breathing, and ambulation in the post-op patient, what is most important for the nurse to do? a. teach the patient controlled breathing b. explain the rationale for these activities c. provide adequate and regular pain meds d. use an incentive spirometer to motivate the patient

c. provide adequate and regular pain meds Incisional pain is often the greatest deterrent to patient participation in effective ventilation and ambulation and adequate and regular analgesic medications should be provided to encourage these activities. Controlled breathing may help the patient to manage pain but does not promote coughing and deep breathing. Explanations and use of an incentive spirometer help to gain patient participation but are more effective if pain is controlled.

Upon admission of a patient to the PACU, the nurse's priority nursing assessment is a. vital signs b. surgical site c. respiratory adequacy d. level of consciousness

c. respiratory adequacy Physiologic status of the patient is always prioritized with regard to airway; breathing, and circulation, and respiratory adequacy is the first assessment priority of the patient on admission to the PACU from the operating room. Following assessment of respiratory function, cardiovascular, neurologic and renal function should be assessed as well as the surgical site.

In addition to ambulation, which nursing intervention could be implemented to prevent or treat the post-op complication of syncope? a. monitor vital signs after ambulation b. do not allow the patient to eat before ambulation c. slowly progress to ambulation with slow changes in position d. have the patient deep breathe and cough before getting out of bed

c. slowly progress to ambulation with slow changes in position Slow progression to ambulation by slowly changing the patient's position will help to prevent syncope. Monitoring vital signs after walking will not prevent or treat syncope. Monitor the patient's pulse and blood pressure (BP) before, during, and after position changes. Elevate the patient's head, then slowly have the patient dangle, then stand by the bed to help determine if the patient is safe for walking. Eating will not have an effect on syncope. Deep breathing and coughing will not decrease syncope, although it will prevent respiratory complications.

The health care provider has ordered IV morphine q2-4hr PRN for a patient following major abdominal surgery. When should the nurse plan to administer the morphine? a. before all planned painful activities b. every 2 to 4 hours during the first 48 hours c. every 4 hours as the patient requests the medication d. after assessing the nature and intensity of the patient's pain

d. after assessing the nature and intensity of the patient's pain Before administering all analgesic medication, the nurse should first assess the nature and intensity of the patient's pain to determine if the pain is expected, prior doses of the medication have been effective, and any undesirable side effects are occurring. The administration of PRN analgesic medication is based on the nursing assessment. If possible, pain medication should be in effect during painful activities but activities may be scheduled around medication administration.

Thirty-six hours post-op a patient has a temperature of 100 degrees Fahrenheit. What is the most likely cause of this temperature elevation? a. dehydration b. wound infection c. lung congestion and atelectasis d. normal surgical stress response

d. normal surgical stress response The nurse must be aware of drains, if used, and the type of surgery to help predict the expected drainage. Dressings over surgical sites are initially removed by the surgeon unless otherwise specified and should not be changed, although reinforcing the dressing is appropriate. Some drainage is expected for most surgical wounds and the drainage should be evaluated and recorded to establish a baseline for continuing assessment. The surgeon should be notified of excessive drainage. Dressings will then be changed as ordered with assessment for infection being done as well.

To prevent airway obstruction in the post-op patient who is unconscious or semiconscious, what will the nurse do? a. encourage deep breathing b. elevate the head of the bed c.administer oxygen per mask d. position the patient in a side-lying position

d. position the patient in a side-lying position An unconscious or semiconscious patient should be placed in a lateral position to protect the airway from obstruction by the tongue. Deep breathing and elevation of the head of the bed are implemented to facilitate gas exchange when the patient is responsive. Oxygen administration is often used but the patient must first have a patent airway.