Perioperative Care Full Set

The perioperative nurse is constantly assessing the surgical patient for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the patient is developing malignant hyperthermia? A) Increased temperature B) Oliguria C) Tachycardia D) Hypotension

Ans: C Feedback: The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. Tachycardia (heart rate greater than 150 beats per minute) is often the earliest sign. Oliguria, hypotension, and increased temperature are later signs of malignant hyperthermia.

A 68-year-old patient is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding area to meet the patient and quickly realizes that the patient is profoundly anxious. What is the most appropriate intervention for the nurse to apply? A) Reassure the patient that modern surgery is free of significant risks. B) Describe the surgery to the patient in as much detail as possible. C) Clearly explain any information that the patient seeks. D) Remind the patient that the anesthetic will render her unconscious.

Ans: C Feedback: The nurse can alleviate anxiety by supplying information as the patient requests it. The nurse should not assume that every patient wants as much detail as possible and false reassurance must be avoided. Reminding the patient that she will be unconscious is unlikely to reduce anxiety.

An adult patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the patient may be at risk for what? A) Hemorrhage and shock B) Aspiration C) Postoperative infection D) Hypertension and dysrhythmias

Hemorrhage and shock The patient with a hemorrhage presents with hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin. Aspiration would manifest in airway disturbance. Hypertension or dysrhythmias would be less likely to cause pallor and cool skin. An infection would not be present at this early postoperative stage.

An OR nurse will be participating in the intraoperative phase of a patient's kidney transplant. What action will the nurse prioritize in this aspect of nursing care? A) Monitoring the patient's physiologic status B) Providing emotional support to family C) Maintaining the patient's cognitive status D) Maintaining a clean environment

A Feedback: During the intraoperative phase, the nurse is responsible for physiologic monitoring. The intraoperative nurse cannot support the family at this time and the nurse is not responsible for maintaining the patient's cognitive status. The intraoperative nurse maintains an aseptic, not clean, environment.

A clinic nurse is conducting a preoperative interview with an adult patient who will soon be scheduled to undergo cardiac surgery. What interview question most directly addresses the patient's safety? A) "What prescription and nonprescription medications do you currently take?" B) "Have you previously been admitted to the hospital, either for surgery or for medical treatment?" C) "How long do you expect to be at home recovering after your surgery?" D) "Would you say that you tend to eat a fairly healthy diet?"

A Feedback: It is imperative to know a preoperative patient's current medication regimen, including OTC medications and supplements. None of the other listed questions directly addresses an issue with major safety implications.

The admitting nurse in a short-stay surgical unit is responsible for numerous aspects of care. What must the nurse verify before the patient is taken to the preoperative holding area? A) That preoperative teaching was performed B) That the family is aware of the length of the surgery C) That follow-up home care is not necessary D) That the family understands the patient will be discharged immediately after surgery.

A Feedback: The nurse needs to be sure that the patient and family understand that the patient will first go to the preoperative holding area before going to the OR for the surgical procedure and then will spend some time in the PACU before being discharged home with the family later that day. Other preoperative teaching content should also be verified and reinforced, as needed. The nurse should ensure that any plans for follow-up home care are in place.

You are providing preoperative teaching to a patient scheduled for hip replacement surgery in 1 month. During the preoperative teaching, the patient gives you a list of medications she takes, the dosage, and frequency. Which of the following interventions provides the patient with the most accurate information? A) Instruct the patient to stop taking St. John's wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents. B) Instruct the patient to continue taking ephedrine prior to surgery due to its beneficial effect on blood pressure. C) Instruct the patient to discontinue Synthroid due to its effect on blood coagulation and the potential for heart dysrhythmias. D) Instruct the patient to continue any herbal supplements unless otherwise instructed, and inform the patient that these supplements have minimal effect on the surgical procedure.

A Feedback: Because of the potential effects of herbal medications on coagulation and potential lethal interactions with other medications, the nurse must ask surgical patients specifically about the use of these agents, document their use, and inform the surgical team and anesthesiologist, anesthetist, or nurse anesthetist. Currently, it is recommended that the use of herbal products be discontinued at least 2 weeks before surgery. Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis and respiratory failure. The administration of Synthroid is imperative in the preoperative period. The use of ephedrine in the preoperative phase can cause hypertension and should be avoided.

The nurse is performing a preadmission assessment of a patient scheduled for a bilateral mastectomy. Of what purpose of the preadmission assessment should the nurse be aware? A) Verifies completion of preoperative diagnostic testing B) Discusses and reviews patient's health insurance coverage C) Determines the patient's suitability as a surgical candidate D) Informs the patient of need for postoperative transportation

A Feedback: Purposes of preadmission testing (PAT) include verifying completion of preoperative diagnostic testing. The nurse's role in PAT does not normally involve financial considerations or addressing transportation. The physician determines the patient's suitability for surgery.

One of the things a nurse has taught to a patient during preoperative teaching is to have nothing by mouth for the specified time before surgery. The patient asks the nurse why this is important. What is the most appropriate response for the patient? A) "You will need to have food and fluid restricted before surgery so you are not at risk for choking." B) "The restriction of food or fluid will prevent the development of pneumonia related to decreased lung capacity." C) "The presence of food in the stomach interferes with the absorption of anesthetic agents." D) "By withholding food for 8 hours before surgery, you will not develop constipation in the postoperative period."

A Feedback: The major purpose of withholding food and fluid before surgery is to prevent aspiration. There is no scientific basis for withholding food and the development of pneumonia or interference with absorption of anesthetic agents. Constipation in patients in the postoperative period is related to the anesthesia, not from withholding food or fluid in the hours before surgery.

A surgical patient has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). The nurse should know that the requirements for safe and effective use of PCA include what? A) A clear understanding of the need to self-dose B) An understanding of how to adjust the medication dosage C) A caregiver who can administer the medication as ordered D) An expectation of infrequent need for analgesia

A clear understanding of the need to self-dose The two requirements for PCA are an understanding of the need to self-dose and the physical ability to self-dose. The patient does not adjust the dose and only the patient himself or herself should administer a dose. PCAs are normally used for patients who are expected to have moderate to severe pain with a regular need for analgesia

The surgical nurse is preparing to send a patient from the presurgical area to the OR and is reviewing the patient's informed consent form. What are the criteria for legally valid informed consent? Select all that apply. A) Consent must be freely given. B) Consent must be notarized. C) Consent must be signed on the day of surgery. D) Consent must be obtained by a physician. E) Signature must be witnessed by a professional staff member.

A, D, E Feedback: Valid consent must be freely given, without coercion. Consent must be obtained by a physician and the patient's signature must be witnessed by a professional staff member. It does not need to be signed on the same day as the surgery and it does not need to be notarized.

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this patient? Select all that apply. A) Establishing an IV line B) Verifying the surgical site with the patient C) Taking measures to ensure the patient's comfort D) Applying a grounding device to the patient E) Preparing the medications to be administered in the OR

A, B, C Feedback: In the holding area, the nurse reviews charts, identifies patients, verifies surgical site and marks site per institutional policy, establishes IV lines, administers medications, if prescribed, and takes measures to ensure each patient's comfort. A nurse in the preoperative holding area does not prepare medications to be administered by anyone else. A grounding device is applied in the OR.

The nurse is preparing to send a patient to the OR for a scheduled surgery. What should the nurse ensure is on the chart when it accompanies the patient to surgery? Select all that apply. A) Laboratory reports B) Nurses' notes C) Verification form D) Social work assessment E) Dietician's assessment

A, B, C Feedback: The completed chart (with the preoperative checklist and verification form) accompanies the patient to the OR with the surgical consent form attached, along with all laboratory reports and nurses' records. Any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted prominently at the front of the chart. The social work and dietician's assessments are not normally necessary when the patient goes to surgery.

The nurse is planning the care of a patient who has type 1 diabetes and who will be undergoing knee replacement surgery. This patient's care plan should reflect an increased risk of what postsurgical complications? Select all that apply. A) Hypoglycemia B) Delirium C) Acidosis D) Glucosuria E) Fluid overload

A, C, D Feedback: Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin. Hyperglycemia, which can increase the risk for surgical wound infection, may result from the stress of surgery, which can trigger increased levels of catecholamine. Other risks are acidosis and glucosuria. Risks of fluid overload and delirium are not normally increased.

The nurse is creating the plan of care for a patient who is status postsurgery for reduction of a femur fracture. What is the most important short-term goal for this patient? A) Relief of pain B) Adequate respiratory function C) Resumption of activities of daily living (ADLs) D) Unimpaired wound healing

Adequate respiratory function Maintenance of the patients airway and breathing are imperative. Respiratory status is important because pulmonary complications are among the most frequent and serious problems encountered by the surgical patient. Wound healing and eventual resumption of ADLs would be later concerns. Pain management is a high priority, but respiratory function is a more acute physiological need.

The recovery room nurse is admitting a patient from the OR following the patients successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted patient? A) Heart rate and rhythm B) Skin integrity C) Core body temperature D) Airway patency

Airway patency The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).

The OR nurse acts in the circulating role during a patient's scheduled cesarean section. For what task is this nurse solely responsible? A) Performing documentation B) Estimating the patient's blood loss C) Setting up the sterile tables D) Keeping track of drains and sponges

Ans: A Feedback: Main responsibilities of the circulating nurse include verifying consent; coordinating the team; and ensuring cleanliness, proper temperature and humidity, lighting, safe function of equipment, and the availability of supplies and materials. The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel as well as implementing fire safety precautions. The circulating nurse also monitors the patient and documents specific activities throughout the operation to ensure the patient's safety and well-being. Estimating the patient's blood loss is the surgeon's responsibility; setting up the sterile tables is the responsibility of the first scrub; and keeping track of the drains and sponges is the joint responsibility of the circulating nurse and the scrub nurse.

A patient who underwent a bowel resection to correct diverticula suffered irreparable nerve damage. During the case review, the team is determining if incorrect positioning may have contributed to the patient's nerve damage. What surgical position places the patient at highest risk for nerve damage? A) Trendelenburg B) Prone C) Dorsal recumbent D) Lithotomy

Ans: A Feedback: Shoulder braces must be well padded to prevent irreparable nerve injury, especially when the Trendelenburg position is necessary. The other listed positions are less likely to cause nerve injury.

An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what? A) Sterile surfaces or articles may touch other sterile surfaces. B) Sterile supplies can be used on another patient if the packages are intact. C) The outer lip of a sterile solution is considered sterile. D) The scrub nurse may pour a sterile solution from a nonsterile bottle.

Ans: A Feedback: Basic guidelines for maintaining sterile technique include that sterile surfaces or articles may touch other sterile surfaces only. The other options each constitute a break in sterile technique.

. A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which patient most closely during the intraoperative period because of the increased risk for hypothermia? A) A 74-year-old woman with a low body mass index B) A 17-year-old boy with traumatic injuries C) A 45-year-old woman having an abdominal hysterectomy D) A 13-year-old girl undergoing craniofacial surgery

Ans: A Feedback: Elderly patients are at greatest risk during surgical procedures because they have an impaired ability to increase their metabolic rate and impaired thermoregulatory mechanisms, which increase susceptibility to hypothermia. The other patients are likely at a lower risk.

The nurse is preparing an elderly patient for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the patient? A) Hypothermia B) Pulmonary edema C) Cerebral ischemia D) Arthritis

Ans: A Feedback: Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open body wounds or cavities, decreased muscle activity, advanced age, or the pharmaceutical agents used (e.g., vasodilators, phenothiazines, general anesthetics). The anesthetist monitors for pulmonary edema and cerebral ischemia. Arthritis is not an adverse effect of surgical anesthesia.

The perioperative nurse has completed the presurgical assessment of an 82-year-old female patient who is scheduled for a left total knee replacement. When planning this patient's care, the nurse should address the consequences of the patient's aging cardiovascular system. These include an increased risk of which of the following? A) Hypervolemia B) Hyponatremia C) Hyperkalemia D) Hyperphosphatemia

Ans: A Feedback: The aging heart and blood vessels have decreased ability to respond to stress. Reduced cardiac output and limited cardiac reserve make the elderly patient vulnerable to changes in circulating volume and blood oxygen levels. There is not an increased risk for hypopnea, hyperkalemia, or hyperphosphatemia because of an aging cardiovascular system.

A patient waiting in the presurgical holding area asks the nurse, "Why exactly do they have to put a breathing tube into me? My surgery is on my knee." What is the best rationale for intubation during a surgical procedure that the nurse should describe? A) The tube provides an airway for ventilation. B) The tube protects the patients esophagus from trauma. C) The patient may receive an antiemetic through the tube. D) The patients vital signs can be monitored with the tube.

Ans: A Feedback: The anesthetic is administered and the patient's airway is maintained through an intranasal intubation, oral intubation, or a laryngeal mask airway. The tube also helps protect aspiration of stomach contents. The tube does not protect the esophagus. Because the tube goes into the lungs, no medications are given through the tube. The patient's vital signs are not monitored through the tube.

The circulating nurse in an outpatient surgery center is assessing a patient who is scheduled to receive moderate sedation. What principle should guide the care of a patient receiving this form of anesthesia? A) The patient must never be left unattended by the nurse. B) The patient should begin a course of antiemetics the day before surgery. C) The patient should be informed that he or she will remember most of the procedure. D) The patient must be able to maintain his or her own airway.

Ans: A Feedback: The patient receiving moderate sedation should never be left unattended. The patient's ability to maintain his or her airway depends on the level of sedation. The administration of moderate sedation is not a counter indication for giving an antiemetic. The patient receiving moderate sedation does not remember most of the procedure.

The OR nurse is participating in the appendectomy of a 20 year-old female patient who has a dangerously low body mass index. The nurse recognizes the patient's consequent risk for hypothermia. What action should the nurse implement to prevent the development of hypothermia? A) Ensure that IV fluids are warmed to the patients body temperature. B) Transfuse packed red blood cells to increase oxygen carrying capacity. C) Place warmed bags of normal saline at strategic points around the patients body. D) Monitor the patients blood pressure and heart rate vigilantly.

Ans: A Feedback: Warmed IV fluids can prevent the development of hypothermia. Applying warmed bags of saline around the patient is not common practice. The patient is not transfused to prevent hypothermia. Blood pressure and heart rate monitoring are important, but do not relate directly to the risk for hypothermia.

An intraoperative nurse is applying interventions that will address surgical patients' risks for perioperative positioning injury. Which of the following factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply. A) Absence of reflexes B) Diminished ability to communicate C) Loss of pain sensation D) Nausea resulting from anesthetic E) Reduced blood pressure

Ans: A, B, C Feedback: Loss of pain sense, reflexes, and ability to communicate subjects the intraoperative patient to possible injury. Nausea and low blood pressure are not central factors that contribute to this risk, though they are adverse outcomes.

When creating plans of nursing care for patients who are undergoing surgery using general anesthetic, what nursing diagnoses should the nurse identify? Select all that apply. A) Disturbed sensory perception related to anesthetic B) Risk for impaired nutrition: less than body requirements related to anesthesia C) Risk of latex allergy response related to surgical exposure D) Disturbed body image related to anesthesia E) Anxiety related to surgical concerns

Ans: A, C, E Feedback: Based on the assessment data, some major nursing diagnoses may include the following: anxiety related to surgical or environmental concerns, risk of latex allergy response due to possible exposure to latex in the OR environment, risk for perioperative positioning injury related to positioning in the OR, risk for injury related to anesthesia and surgical procedure, or disturbed sensory perception (global) related to general anesthesia or sedation. Malnutrition and disturbed body image are much less likely.

The patient's surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the surgical wound. This requires the nurse to prioritize assessments related to what complication? A) Hypothermia B) Anaphylaxis C) Infection D) Malignant hyperthermia

Ans: B Feedback: Fibrin sealants are used in a variety of surgical procedures, and cyanoacrylate tissue adhesives are used to close wounds without the use of sutures. These sealants have been implicated in allergic reactions and anaphylaxis. There is not an increased risk of malignant hyperthermia, hypothermia, or infection because of the use of tissue adhesives.

The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104°F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient? A) The patient may be experiencing presurgical anxiety. B) The patient may be at risk for malignant hyperthermia. C) The grandmothers surgery has minimal relevance to the patients surgery. D) The patient may be at risk for a sudden onset of postsurgical infection.

Ans: B Feedback: Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying patients at risk is imperative because the mortality rate is 50%. The patient's anxiety is not relevant, the grandmother's surgery is very relevant, and all patients are at risk for hypothermia.

An OR nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the OR? A) Reusable shoe covers B) Mask covering the nose and mouth C) Goggles D) Gloves

Ans: B Feedback: Masks are worn at all times in the restricted zone of the OR. Shoe covers are worn one time only; goggles and gloves are worn as required, but not necessarily at all times

The OR will be caring for a patient who will receive a transsacral block. For what patient would the use of a transsacral block be appropriate for pain control? A) A middle-aged man who is scheduled for a thoracotomy B) An older adult man who will undergo an inguinal hernia repair C) A 50-year-old woman who will be having a reduction mammoplasty D) A child who requires closed reduction of a right humerus fracture

Ans: B Feedback: A transsacral block produces anesthesia for the perineum and lower abdomen. Both a thoracotomy and breast reduction are in the chest region, and a transsacral block would not provide pain control for these procedures. A closed reduction of a right humerus is a procedure on the right arm, and a transsacral block would not provide pain control.

The anesthetist is coming to the surgical admissions unit to see a patient prior to surgery scheduled for tomorrow morning. Which of the following is the priority information that the nurse should provide to the anesthetist during the visit? A) Last bowel movement B) Latex allergy C) Number of pregnancies D) Difficulty falling asleep

Ans: B Feedback: Due to the increased number of patients with latex allergies, it is essential to identify this allergy early on so precautions can be taken in the OR. The anesthetist should be informed of any allergies. This is a priority over pregnancy history, insomnia, or recent bowel function, though some of these may be relevant.

The nurse knows that elderly patients are at higher risk for complications and adverse outcomes during the intraoperative period. What is the best rationale for this phenomenon? A) The elderly patient has a more angular bone structure than a younger person. B) The elderly patient has reduced ability to adjust rapidly to emotional and physical stress. C) The elderly patient has impaired thermoregulatory mechanisms, which increase susceptibility to hyperthermia. D) The elderly patient has an impaired ability to decrease his or her metabolic rate.

Ans: B Feedback: Factors that affect the elderly surgical patient in the intraoperative period include the following: impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms increase susceptibility to hypothermia. Bone loss (25% in women, 12% in men) necessitates careful manipulation and positioning during surgery. Reduced ability to adjust rapidly to emotional and physical stress influences surgical outcomes and requires meticulous observation of vital functions. Older adults do not have more angular bones than younger people.

The intraoperative nurse is implementing a care plan that addresses the surgical patient's risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication? A) Impaired skin integrity B) Hypoxia C) Malignant hyperthermia D) Hypothermia

Ans: B Feedback: If the patient aspirates vomitus, an asthma-like attack with severe bronchial spasms and wheezing is triggered. Pneumonitis and pulmonary edema can subsequently develop, leading to extreme hypoxia. Vomiting can cause choking, but the question asks about aspirated vomitus. Malignant hyperthermia is an adverse reaction to anesthesia. Aspirated vomitus does not cause hypothermia. Vomiting does not result in impaired skin integrity.

The surgical patient is a 35-year-old woman who has been administered general anesthesia. The nurse recognizes that the patient is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage? A)Rub the patients back. B) Restrain the patient. C) Encourage the patient to express feelings. D) Stroke the patients hand.

Ans: B Feedback: In stage II, the patient may struggle, shout, or laugh. The movements of the patient may be uncontrolled, so it is essential the nurse help to restrain the patient for safety. None of the other listed actions protects the patient's safety.

Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the patient's accompanying documentation includes which of the following? A) Discharge planning B) Informed consent C) Analgesia prescription D) Educational resources

Ans: B Feedback: It is important to review the patient's record for the following: correct informed surgical consent, with patient's signature; completed records for health history and physical examination; results of diagnostic studies; and allergies (including latex). Discharge planning records and prescriptions are not normally necessary. Educational resources would not be included at this stage of the surgical process.

While the surgical patient is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the patient's weight. How should the nurse best respond? A) Ignore the comment because the patient is unconscious. B) Discourage the colleague from making such comments. C) Report the comment immediately to a supervisor. D) Realize that humor is needed in the workplace.

Ans: B Feedback: Patients, whether conscious or unconscious, should not be subjected to excess noise, inappropriate conversation, or, most of all, derogatory comments. The nurse must act as an advocate on behalf of the patient and discourage any such remarks. Reporting to a supervisor, however, is not likely necessary.

As an intraoperative nurse, you know that the patient's emotional state can influence the outcome of his or her surgical procedure. How would you best reinforce the patient's ability to influence outcome? A) Teach the patient strategies for distraction. B) Pair the patient with another patient who has better coping strategies. C) Incorporate cultural and religious considerations, as appropriate. D) Give the patient antianxiety medication.

Ans: C Feedback: Because the patient's emotional state remains a concern, the care initiated by preoperative nurses is continued by the intraoperative nursing staff that provides the patient with information and reassurance. The nurse supports coping strategies and reinforces the patient's ability to influence outcomes by encouraging active participation in the plan of care incorporating cultural, ethnic, and religious considerations, as appropriate. "Buddying" a patient is normally inappropriate and distraction may or may not be effective. Nonpharmacologic measures should be prioritized.

You are caring for a male patient who has had spinal anesthesia. The patient is under a physician's order to lie flat postoperatively. When the patient asks to go to the bathroom, you encourage him to adhere to the physician's order. What rationale for complying with this order should the nurse explain to the patient? A) Preventing the risk of hypotension B) Preventing respiratory depression C) Preventing the onset of a headache D) Preventing pain at the lumbar injection site

Ans: C Feedback: Lying flat reduces the risk of headache after spinal anesthesia. Hypotension and respiratory depression may be adverse effects of spinal anesthesia associated with the spread of the anesthetic, but lying flat does not help reduce these effects. Pain at the lumbar injection site typically is not a problem.

Maintaining an aseptic environment in the OR is essential to patient safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field? A) 2 feet B) 18 inches C) 1 foot D) 6 inches

Ans: C Feedback: Sterile areas must be kept in view during movement around the area. At least a 1-foot distance from the sterile field must be maintained to prevent inadvertent contamination.

A patient is scheduled for surgery the next day and the different phases of the patient's surgical experience will require input from members of numerous health disciplines. How should the patient's care best be coordinated? A) By planning care using a surgical approach B) By identifying the professional with the most knowledge of the patient C) By implementing an interdisciplinary approach to care D) By using the nursing process to guide all aspects of care and treatment

Ans: C Feedback: An interdisciplinary approach involving the surgeon, anesthesiologist or anesthetist, and nurse is best. This is superior to each of the other listed options

A patient will be undergoing a total hip arthroplasty later in the day and it is anticipated that the patient may require blood transfusion during surgery. How can the nurse best ensure the patient's safety if a blood transfusion is required? A) Discharge planning B) Informed consent C) Analgesia prescription D) Educational resources

Ans: C Feedback: Few patients undergoing an elective procedure require blood transfusion, but those undergoing high-risk procedures may require an intraoperative transfusion. The circulating nurse anticipates this need, checks that blood has been cross-matched and held in reserve, and is prepared to administer blood. Storing the blood at body temperature or in IV tubing would result in spoilage and potential infection.

As an intraoperative nurse, you are the advocate for each of the patients who receives care in the surgical setting. How can you best exemplify the principles of patient advocacy? A) By encouraging the patient to perform deep breathing preoperatively B) By limiting the patients contact with family members preoperatively C) By maintaining each of your patients privacy D) By eliciting informed consent from patients

Ans: C Feedback: Patient advocacy in the OR entails maintaining the patient's physical and emotional comfort, privacy, rights, and dignity. Deep breathing is not necessary before surgery and obtaining informed consent is the purview of the physician. Family contact should not be limited.

The OR nurse is providing care for a 25-year-old major trauma patient who has been involved in a motorcycle accident. The nurse should know that the patient is at increased risk for what complication of surgery? A) Respiratory depression B) Hypothermia C) Anesthesia awareness D) Moderate sedation

Ans: C Feedback: The Joint Commission has issued an alert regarding the phenomenon of patients being partially awake while under general anesthesia (referred to as anesthesia awareness). Patients at greatest risk of anesthesia awareness are cardiac, obstetric, and major trauma patients. This patient does not likely face a heightened risk of respiratory depression or hypothermia. Moderate sedation is not a complication.

The circulating nurse will be participating in a 78-year-old patient's total hip replacement. Which of the following considerations should the nurse prioritize during the preparation of the patient in the OR? A) The patient should be placed in Trendelenburg position. B) The patient must be firmly restrained at all times. C) Pressure points should be assessed and well padded. D) The preoperative shave should be done by the circulating nurse.

Ans: C Feedback: The vascular supply should not be obstructed by an awkward position or undue pressure on a body part. During surgical procedures, the patient is at risk for impairment of skin integrity due to a stationary position and immobility. An elderly patient is at an increased risk of injury and impaired skin integrity. A Trendelenburg position is not indicated for this patient. Once anesthetized for a total hip replacement, the patient cannot move; restraints are not necessary. A preoperative shave is not performed; excess hair is removed by means of a clipper.

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

Ans: C Feedback: Whenever a sterile barrier is breached, the area must be considered contaminated. Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. The other options are practices that help ensure surgical asepsis.

The nurse is caring for a patient who is scheduled to have a needle biopsy of the pleura. The patient has had a consultation with the anesthesiologist and a conduction block will be used. Which local conduction block can be used to block the nerves leading to the chest? A) Transsacral block B) Brachial plexus block C) Peudental block D) Paravertebral block

Ans: D Feedback: Examples of common local conduction blocks include paravertebral anesthesia, which produces anesthesia of the nerves supplying the chest, abdominal wall, and extremities; brachial plexus block, which produces anesthesia of the arm; and transsacral (caudal) block, which produces anesthesia of the perineum and, occasionally, the lower abdomen. A peudental block was used in obstetrics before the almost-routine use of epidural anesthesia.

A 21-year-old patient is positioned on the OR bed prior to knee surgery to correct a sports-related injury. The anesthesiologist administers the appropriate anesthetic. The OR nurse should anticipate which of the following events as the teams next step in the care of this patient? A) Grounding B) Making the first incision C) Giving blood D) Intubating

Ans: D Feedback: When the patient arrives in the OR, the anesthesiologist or anesthetist reassesses the patient's physical condition immediately prior to initiating anesthesia. The anesthetic is administered, and the patient's airway is maintained through an intranasal intubation, oral intubation, or a laryngeal mask airway. Grounding or blood administration does not normally follow anesthetic administration immediately. An incision would not be made prior to intubation.

Prior to a patient's scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the patient's care. What is the main rationale for organizing perioperative care in this collaborative manner? A) Historical precedence B) Patient requests C) Physicians needs D) Evidence-based practice

Ans: D Feedback: Collaboration of the surgical team using evidence-based practice tailored to a specific case results in optimal patient care and improved outcomes. None of the other listed factors is the basis for the collaboration of the surgical team.

A nurse is caring for a patient following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache? A) Have the patient sit in a chair and perform deep breathing exercises. B) Ambulate the patient as early as possible. C) Limit the patients fluid intake for the first 24 hours postoperatively. D) Keep the patient positioned supine.

Ans: D Feedback: Measures that increase cerebrospinal pressure are helpful in relieving headache. These include maintaining a quiet environment, keeping the patient lying flat, and keeping the patient well hydrated. Having the patient sit or stand up decreases cerebrospinal pressure and would not relieve a spinal headache. Limiting fluids is incorrect because it also decreases cerebrospinal pressure and would not relieve a spinal headache.

The nurse is packing a patient's abdominal wound with sterile, half-inch Iodoform gauze. During the procedure, the nurse drops some of the gauze onto the patient's abdomen 2 inches (5 cm) away from the wound. What should the nurse do? A) Apply povidone-iodine (Betadine) to that section of the gauze and continue packing the wound. B) Pick up the gauze and continue packing the wound after irrigating the abdominal wound with Betadine solution. C) Continue packing the wound and inform the physician that an antibiotic is needed. D) Discard the gauze packing and repack the wound with new Iodoform gauze.

Ans: D Feedback: Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile; contact with unsterile objects at any point renders a sterile area contaminated. The sterile gauze became contaminated when it was dropped on the patient's abdomen. It should be discarded and new Iodoform gauze should be used to pack the wound. Betadine should not be used in the wound unless ordered.

As a perioperative nurse, you know that the National Patient Safety Goals have the potential to improve patient outcomes in a wide variety of health care settings. Which of these Goals has the most direct relevance to the OR? A) Improve safety related to medication use B) Reduce the risk of patient harm resulting from falls C) Reduce the incidence of health care-associated infections D) Reduce the risk of fires

Ans: D Feedback: The National Patient Safety Goals all pertain to the perioperative areas, but the one with the most direct relevance to the OR is the reduction of the risk of surgical fires.

A 59-year-old male patient is scheduled for a hemorrhoidectomy. The OR nurse should anticipate assisting the other team members with positioning the patient in what manner? A) Dorsal recumbent position B) Trendelenburg position C) Sims position D) Lithotomy position

Ans: D Feedback: The lithotomy position is used for nearly all perineal, rectal, and vaginal surgical procedures. The Sims or lateral position is used for renal surgery and the Trendelenburg position usually is used for surgery on the lower abdomen and pelvis. The usual position for surgery, called the dorsal recumbent position, is flat on the back, but this would be impracticable for rectal surgery.

The circulating nurse is admitting a patient prior to surgery and proceeds to greet the patient and discuss what the patient can expect in surgery. What aspect of therapeutic communication should the nurse implement? A) Wait for the patient to initiate dialogue. B) Use medically acceptable terms. C) Give preoperative medications prior to discussion. D) Use a tone that decreases the patients anxiety.

Ans: D Feedback: When discussing what the patient can expect in surgery, the nurse uses basic communication skills, such as touch and eye contact, to reduce anxiety. The nurse should use language the patient can understand. The nurse should not withhold communication until the patient initiates dialogue; the nurse most often needs to initiate and guide dialogue, while still responding to patient leading. Giving medication is not a communication skill.

The nurse is performing the shift assessment of a postsurgical patient. The nurse finds his mental status, level of consciousness, speech, and orientation are intact and at baseline, but the patient tells you he is very anxious. What should the nurse do next? A) Assess the patients oxygen levels. B) Administer antianxiety medications. C) Page the patients the physician. D) Initiate a social work referral.

Assess the patients oxygen levels. The nurse assesses the patients mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage. Antianxiety medications are not given until the cause of the anxiety is known. The physician is notified only if the reason for the anxiety is serious or if an order for medication is needed. A social work consult is inappropriate at this time.

The perioperative nurse is providing care for a patient who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The patient is reluctant to ambulate, citing the need to recover in bed. For what complication is the patient most at risk? A) Atelectasis B) Anemia C) Dehydration D) Peripheral edema

Atelectasis Atelectasis occurs when the postoperative patient fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia occurs rarely and usually in situations where the patient loses a significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the patient is most at risk for atelectasis.

You are caring for an 88-year-old woman who is scheduled for a right mastectomy. You know that elderly patients are frequently more anxious prior to surgery than younger patients. What would you increase with this patient to decrease her anxiety? A) Analgesia B) Therapeutic touch C) Preoperative medication D) Sleeping medication the night before surgery

B Feedback: Older patients report higher levels of preoperative anxiety; therefore, the nurse should be prepared to spend additional time, increase the amount of therapeutic touch utilized, and encourage family members to be present to decrease anxiety. For most patients, nonpharmacologic interventions should be attempted before administering medications.

The policies and procedures on a preoperative unit are being amended to bring them closer into alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most directly addresses the priorities of the SCIP? A) Actions aimed at increasing participation of families in planning care B) Actions aimed at preventing surgical site infections C) Actions aimed at increasing interdisciplinary collaboration D) Actions aimed at promoting the use of complementary and alternative medicine (CAM)

B Feedback: SCIP identifies performance measures aimed at preventing surgical complications, including venous thromboembolism (VTE) and surgical site infections (SSI). It does not explicitly address family participation, interdisciplinary collaboration, or CAM.

You are the nurse caring for an unconscious trauma victim who needs emergency surgery. The patient is a 55-year-old man with an adult son. He is legally divorced and is planning to be remarried in a few weeks. His parents are at the hospital with the other family members. The physician has explained the need for surgery, the procedure to be done, and the risks to the children, the parents, and the fiancé. Who should be asked to sign the surgery consent form? A) The fiancé B) The son C) The physician, acting as a surrogate D) The patient's father

B Feedback: The patient personally signs the consent if of legal age and mentally capable. Permission is otherwise obtained from a surrogate, who most often is a responsible family member (preferably next of kin) or legal guardian. In this instance, the child would be the appropriate person to ask to sign the consent form as he is the closest relative at the hospital. The fiancé is not legally related to him as the marriage has not yet taken place. The father would only be asked to sign the consent if no children were present to sign. The physician would not sign if family members were available.

A 77-year-old man's coronary artery bypass graft has been successful and discharge planning is underway. When planning the patient's subsequent care, the nurse should know that the postoperative phase of perioperative nursing ends at what time? A) When the patient is returned to his room after surgery B) When a follow-up evaluation in the clinical or home setting is done C) When the patient is fully recovered from all effects of the surgery D) When the family becomes partly responsible for the patient's care

B Feedback: The postoperative phase begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home.

The nurse is performing a preoperative assessment on a patient going to surgery. The patient informs the nurse that he drinks approximately two bottles of wine each day and has for the last several years. What postoperative difficulties can the nurse anticipate for this patient? A) Alcohol withdrawal syndrome immediately following surgery B) Alcohol withdrawal syndrome 2 to 4 days after his last alcohol drink C) Alcohol withdrawal syndrome upon administration of general anesthesia D) Alcohol withdrawal syndrome 1 week after his last alcohol drink

B Feedback: Alcohol withdrawal syndrome may be anticipated between 48 and 96 hours after alcohol withdrawal and is associated with a significant mortality rate when it occurs postoperatively.

A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery? A) Leg exercises increase the patient's muscle mass postoperatively. B) Leg exercises improve circulation and prevent venous thrombosis. C) Leg exercises help to prevent pressure sores to the sacrum and heels. D) Leg exercise help increase the patient's level of consciousness after surgery.

B Feedback: Exercise of the extremities includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side) unless contraindicated by type of surgical procedure (e.g., hip replacement). When the patient does leg exercises postoperatively, circulation is increased, which helps to prevent blood clots from forming. Leg exercises do not prevent pressure sores to the sacrum, or increase the patient's level of consciousness. Leg exercises have the potential to increase strength and mobility, but are unlikely to make a change to muscle mass in the short term.

During the care of a preoperative patient, the nurse has given the patient a preoperative benzodiazepine. The patient is now requesting to void. What action should the nurse take? A) Assist the patient to the bathroom. B) Offer the patient a bedpan or urinal. C) Wait until the patient gets to the operating room and is catheterized. D) Have the patient go to the bathroom.

B Feedback: If a preanesthetic medication is administered, the patient is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness. If a patient needs to void following administration of a sedative, the nurse should offer the patient a urinal. The patient should not get out of bed because of the potential for lightheadedness.

The nurse is providing preoperative teaching to a patient scheduled for surgery. The nurse is instructing the patient on the use of deep breathing, coughing, and the use of incentive spirometry when the patient states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide? A) To prevent chronic obstructive pulmonary disease (COPD) B) To promote optimal lung expansion C) To enhance peripheral circulation D) To prevent pneumothorax

B Feedback: One goal of preoperative nursing care is to teach the patient how to promote optimal lung expansion and consequent blood oxygenation after anesthesia. COPD is not a realistic risk and pneumothorax is also unlikely. Breathing exercises do not primarily affect peripheral circulation.

A patient is on call to the OR for an aortobifemoral bypass and the nurse administers the ordered preoperative medication. After administering a preoperative medication to the patient, what should the nurse do? A) Encourage light ambulation. B) Place the bed in a low position with the side rails up. C) Tell the patient that he will be asleep before he leaves for surgery. D) Take the patient's vital signs every 15 minutes.

B Feedback: When the preoperative medication is given, the bed should be placed in low position with the side rails raised. The patient should not get up without assistance. The patient may not be asleep, but he may be drowsy. Vital signs should be taken before the preoperative medication is given; vital signs are not normally required every 15 minutes after administration.

The nurse is preparing a patient for surgery. The patient states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take? A) Have the patient sign the informed consent and place it in the chart. B) Call the physician to review the procedure with the patient. C) Explain the procedure clearly to the patient and her family. D) Provide the patient with a pamphlet explaining the procedure.

B Feedback: While the nurse may ask the patient to sign the consent form and witness the signature, it is the surgeon's responsibility to provide a clear and simple explanation of what the surgery will entail prior to the patient giving consent. The surgeon must also inform the patient of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the patient requests additional information, the nurse notifies the physician. The consent formed should not be signed until the patient understands the procedure that has been explained by the surgeon. The provision of a pamphlet will benefit teaching the patient about the surgical procedure, but will not substitute for the information provided by the physician.

The clinic nurse is doing a preoperative assessment of a patient who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the patient's medical history, the nurse notes that this patient had a kidney transplant 8 years ago and that the patient is taking immunosuppressive drugs. For what is this patient at increased risk when having surgery? A) Rejection of the kidney B) Rejection of the implanted lens C) Infection D) Adrenal storm

C Feedback: Because patients who are immunosuppressed are highly susceptible to infection, great care is taken to ensure strict asepsis. The patient is unlikely to experience rejection or adrenal storm.

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? A) A social worker should temporarily sign the informed consent. B) Consent should be obtained from the hospital's ethics committee. C) Surgery should be done without informed consent. D) Surgery should be delayed until the parents arrive.

C Feedback: In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the patient's informed consent. However, every effort must be made to contact the patient's family. In such a situation, contact can be made by electronic means. In this scenario, the surgery is considered lifesaving, and the parents are on their way to the hospital and not available. A delay would be unacceptable. Neither a social worker nor a member of the ethics committee may sign.

The nurse is caring for a trauma victim in the ED who will require emergency surgery due to injuries. Before the patient leaves the ED for the OR, the patient goes into cardiac arrest. The nurse assists in the successful resuscitation and proceeds to release the patient to the OR staff. When can the ED nurse perform the preoperative assessment? A) When he or she has the opportunity to review the patient's electronic health record B) When the patient arrives in the OR C) When assisting with the resuscitation D) Preoperative assessment is not necessary in this case

C Feedback: The only opportunity for preoperative assessment may take place at the same time as resuscitation in the ED. Preoperative assessment is necessary, but the nurse could not normally enter the OR to perform this assessment. The health record is an inadequate data source.

The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurse's preoperative assessment of an elderly patient? A) Elderly patients have a smaller lung capacity than younger patients. B) Elderly patients require higher medication doses than younger patients. C) Elderly patients have less physiologic reserve than younger patients. D) Elderly patients have more sophisticated coping skills than younger patients.

C Feedback: The underlying principle that guides the preoperative assessment, surgical care, and postoperative care is that elderly patients have less physiologic reserve (the ability of an organ to return to normal after a disturbance in its equilibrium) than do younger patients. Elderly patients do not have larger lung capacities than younger patients. Elderly patients cannot necessarily cope better than younger patients and they often require lower doses of medications.

The nurse is checking the informed consent for a 17-year-old who has just been married and expecting her first child. She is scheduled for a cesarean section. She is still living with her parents and is on her parents' health insurance. When obtaining informed consent for the cesarean section, who is legally responsible for signing? A) Her parents B) Her husband C) The patient D) The obstetrician

C Feedback: An emancipated minor (married or independently earning his or her own living) may sign his or her own consent form. In this case, the patient is the only person who can provide consent unless she would be neurologically incapacitated or incompetent, in which case her husband would need to provide consent.

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

C Feedback: Emergency surgeries are unplanned and occur with little time for preparation for the patient or the perioperative team. An active bleed is considered an emergency, and the patient requires immediate attention because the disorder may be life threatening. The surgery would not likely be deferred until after elective surgeries have been completed.

A patient is scheduled for a bowel resection in the morning and the patient's orders include a cleansing enema tonight. The patient wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect? A) Preventing aspiration of gastric contents B) Preventing the accumulation of abdominal gas postoperatively C) Preventing potential contamination of the peritoneum D) Facilitating better absorption of medications

C Feedback: The administration of a cleansing enema will allow for satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the peritoneum by feces. It will have no effect on aspiration of gastric contents or the absorption of medications. The patient should expect to develop gas in the postoperative period.

In anticipation of a patient's scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the patient? A) The patient should take three deep breaths and cough hard three times, at least every 15 minutes for the immediately postoperative period. B) The patient should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs. C) The patient should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. D) The patient should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly.

C Feedback: The patient assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to take a deep, slow breath and how to exhale slowly. After practicing deep breathing several times, the patient is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs.

The nurse is preparing a patient for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the patient's signature on a consent form. Which comment by the patient would best indicate informed consent? A) "I know I'll be fine because the physician said he has done this procedure hundreds of times." B) "I know I'll have pain after the surgery but they'll do their best to keep it to a minimum." C) "The physician is going to remove my uterus and told me about the risk of bleeding." D) "Because the physician isn't taking my ovaries, I'll still be able to have children."

C Feedback: The surgeon must inform the patient of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the patient requests additional information, the nurse notifies the physician. In the correct response, the patient is able to tell the nurse what will occur during the procedure and the associated risks. This indicates the patient has a sufficient understanding of the procedure to provide informed consent. Clarification of information given may be necessary, but no additional information should be given. The other listed statements do not reflect an understanding of the surgery to be performed.

The nurse is caring for a patient who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the patient's ribs and xiphoid process are prominent. The patient states she exercises two to three times daily and her mother indicates that she is being treated for anorexia nervosa. How should the nurse best follow up these assessment data? A) Inform the postoperative team about the patient's risk for wound dehiscence. B) Evaluate the patient's ability to manage her pain level. C) Facilitate a detailed analysis of the patient's electrolyte levels. D) Instruct the patient on the need for a high-sodium diet to promote healing.

C Feedback: The surgical team should be informed about the patient's medical history regarding anorexia nervosa. Any nutritional deficiency, such as malnutrition, should be corrected before surgery to provide adequate protein for tissue repair. The electrolyte levels should be evaluated and corrected to prevent metabolic abnormalities in the operative and postoperative phase. The risk of wound dehiscence is more likely associated with obesity. Instruction on proper nutrition should take place in the postoperative period, and a consultation should be made with her psychiatric specialist. Evaluation of pain management is always important, but not particularly significant in this scenario.

The nurse is caring for a patient who is experiencing pain and anxiety following his prostatectomy. Which intervention will likely best assist in decreasing the patient's pain and anxiety? A) Administration of NSAIDs rather than opioids B) Allowing the patient to increase activity C) Use of guided imagery along with pain medication D) Use of deep breathing and coughing exercises

C Feedback: The use of guided imagery will enhance pain relief and assist in reduction of anxiety. It may be combined with analgesics. Deep breathing and the increase in activity may produce increased pain. Replacing opioids with NSAIDs may cause an increase in pain.

The PACU nurse is caring for a patient who has been deemed ready to go to the postsurgical floor after her surgery. What would the PACU nurse be responsible for reporting to the nurse on the floor? Select all that apply. A) The names of the anesthetics that were used B) The identities of the staff in the OR C) The patient's preoperative level of consciousness D) The presence of family and/or significant others E) The patient's full name

C, D, E Feedback: The PACU nurse is responsible for informing the floor nurse of the patient's intraoperative factors (e.g., insertion of drains or catheters, administration of blood or medications during surgery, or occurrence of unexpected events), preoperative level of consciousness, presence of family and/or significant others, and identification of the patient by name. The PACU nurse does not tell which anesthetic was used, only the type and amount used. The PACU nurse does not identify the staff that was in the OR with the patient.

The nurse just received a postoperative patient from the PACU to the medicalsurgical unit. The patient is an 84-year-old woman who had surgery for a left hip replacement. Which of the following concerns should the nurse prioritize for this patient in the first few hours on the unit? A) Beginning early ambulation B) Maintaining clean dressings on the surgical site C) Close monitoring of neurologic status D) Resumption of normal oral intake

Close monitoring of neurologic status In the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding are primary concerns. A patient who has had total hip replacement does not ambulate during the first few hours on the unit. Dressings are assessed, but may have some drainage on them. Oral intake will take more time to resume

A 90-year-old female patient is scheduled to undergo a partial mastectomy for the treatment of breast cancer. What nursing diagnosis should the nurse prioritize when planning this patient's postoperative care? A) Risk for Delayed Growth and Development related to prolonged hospitalization B) Risk for Decisional Conflict related to discharge planning C) Risk for Impaired Memory related to old age D) Risk for Infection related to reduced immune function

D Feedback: The lessened physiological reserve of older adults results in an increased risk for infection postoperatively. This physiological consideration is a priority over psychosocial considerations, which may or may not be applicable. Impaired memory is always attributed to a pathophysiological etiology, not advanced age.

The nurse is caring for a hospice patient who is scheduled for a surgical procedure to reduce the size of his spinal tumor in an effort to relieve his pain. The nurse should plan this patient care with the knowledge that his surgical procedure is classified as which of the following? A) Diagnostic B) Laparoscopic C) Curative D) Palliative

D Feedback: A patient on hospice will undergo a surgical procedure only for palliative care to reduce pain, but it is not curative. The reduction of tumor size to relieve pain is considered a palliative procedure. A laparoscopic procedure is a type of surgery that is utilized for diagnostic purposes or for repair. The excision of a tumor is classified as curative. This patient is not having the tumor removed, only the size reduced.

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

D Feedback: Like age, obesity increases the risk and severity of complications associated with surgery. During surgery, fatty tissues are especially susceptible to infection. In addition, obesity increases technical and mechanical problems related to surgery. Therefore, dehiscence (wound separation) and wound infections are more common. A postoperative patient who is obese will not likely be at greater risk for hyperglycemia, azotemia, or falls.

The nurse is caring for a patient in the postoperative period following an abdominal hysterectomy. The patient states, "I don't want to use my pain meds because they'll make me dependent and I won't get better as fast." Which response is most important when explaining the use of pain medication? A) "You will need the pain medication for at least 1 week to help in your recovery. What do you mean you feel you won't get better faster?" B) "Pain medication will help to decrease your pain and increase your ability to breath. Dependency is a risk with pain medication, but you are young and won't have any problems." C) "Pain medication can be given by mouth to prevent the risk of dependency that you are worried about. The pain medication has not been shown to affect your risk of a slowed recovery." D) "You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is administered for an extended period of time."

D Feedback: Postoperatively, medications are administered to relieve pain and maintain comfort without increasing the risk of inadequate air exchange. In the responses by the nurse, (response D) addresses the patient's concerns about drug dependency and the nurse's need to increase the patient's ability to move and recover from surgery. The other responses offer incorrect information, such as increasing the patient's ability to breathe or specifying the time needed to take the medication. Opioids will cause respiratory depression.

The nurse is planning patient teaching for a patient who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching? A) Upon the patient's admission to the postanesthesia care unit (PACU) B) When the patient returns from the PACU C) During the intraoperative period D) As soon as possible before the surgical procedure

D Feedback: Teaching is most effective when provided before surgery. Preoperative teaching is initiated as soon as possible, beginning in the physician's office, clinic, or at the time of preadmission testing when diagnostic tests are performed. Upon admission to the PACU, the patient is usually drowsy, making this an inopportune time for teaching. Upon the patient's return from the PACU, the patient may remain drowsy. During the intraoperative period, anesthesia alters the patient's mental status, rendering teaching ineffective.

The nurse is caring for a 78-year-old female patient who is scheduled for surgery to remove her brain tumor. The patient is very apprehensive and keeps asking when she will get her preoperative medicine. The medicine is ordered to be given "on call to OR." When would be the best time to give this medication? A) As soon as possible, in order to alleviate the patient's anxiety B) As the patient is transferred to the OR bed C) When the porter arrives on the floor to take the patient to surgery D) After being notified by the OR and before other preoperative preparations

D Feedback: The nurse can have the medication ready to administer as soon as a call is received from the OR staff. It usually takes 15 to 20 minutes to prepare the patient for the OR. If the nurse gives the medication before attending to the other details of preoperative preparation, the patient will have at least partial benefit from the preoperative medication and will have a smoother anesthetic and operative course.

The nurse admitting a patient who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this patient's diagnosis of type 1 diabetes affect the care that the nurse plans? A) The nurse should administer a bolus of dextrose IV solution preoperatively. B) The nurse should keep the patient NPO for at least 8 hours preoperatively. C) The nurse should initiate a subcutaneous infusion of long-acting insulin. D) The nurse should assess the patient's blood glucose levels vigilantly.

D Feedback: The patient with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia. Close glycemic monitoring is necessary. Dextrose infusion and prolonged NPO status are contraindicated. There is no specific need for an insulin infusion preoperatively.

The nurse is doing preoperative patient education with a 61-year-old male patient who has a 40-pack per year history of cigarette smoking. The patient will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this patient? A) Reduce smoking by 50% to prevent the development of pneumonia. B) Stop smoking at least 6 weeks before the scheduled surgery to enhance pulmonary function and decrease infection. C) Aim to quit smoking in the postoperative period to reduce the chance of surgical complications D) Stop smoking 4 to 8 weeks before the scheduled surgery to enhance pulmonary function and decrease infection.

D Feedback: The reduction of smoking will enhance pulmonary function; in the preoperative period, patients who smoke should be urged to stop 4 to 8 weeks before surgery.

The home health nurse is caring for a postoperative patient who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the patients postoperatative day 2. During the visit, the nurse will assess for wound infection. For most patients, what is the earliest postoperative day that a wound infection becomes evident? A) Day 9 B) Day 7 C) Day 5 D) Day 3

Day 5 Wound infection may not be evident until at least postoperative day 5. This makes the other options incorrect

The nursing instructor is talking with a group of medicalsurgical students about deep vein thrombosis (DVT). A student asks what factors contribute to the formation of a DVT. What would be the instructors best response? A) There is a genetic link in the formation of deep vein thrombi. B) Hypervolemia is often present in patients who go on to develop deep vein thrombi. C) No known factors contribute to the formation of deep vein thrombi; they just occur. D) Dehydration is a contributory factor to the formation of deep vein thrombi.

Dehydration is a contributory factor to the formation of deep vein thrombi. The stress response that is initiated by surgery inhibits the fibrinolytic system, resulting in blood hypercoagulability. Dehydration, low cardiac output, blood pooling in the extremities, and bedrest add to the risk of thrombosis formation. Hypervolemia is not a risk factor and there are no known genetic factors

The nurse is preparing to change a patients abdominal dressing. The nurse recognizes the first step is to provide the patient with information regarding the procedure. Which of the following explanations should the nurse provide to the patient? A) The dressing change is often painful, and we will be giving you pain medication prior to the procedure so you do not have to worry. B) During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to. C) The dressing change should not be painful, but you can never be sure, and infection is always a concern. D) The best time for doing a dressing change is during lunch so we are not interrupted. I will provide privacy, and it should not be painful.

During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to. When having dressings changed, the patient needs to be informed that the dressing change is a simple procedure with little discomfort; privacy will be provided; and the patient is free to look at the incision or even assist in the dressing change itself. If the patient decides to look at the incision, assurance is given that the incision will shrink as it heals and that the redness will likely fade. Dressing changes should not be painful, but giving pain medication prior to the procedure is always a good preventive measure. Telling the patient that the dressing change should not be painful, but you can never be sure, and infection is always a concern does not offer the patient any real information or options and serves only to create fear. The best time for dressing changes is when it is most convenient for the patient; nutrition is important so interrupting lunch is probably a poor choice.

The surgeons preoperative assessment of a patient has identified that the patient is at a high risk for venous thromboembolism. Once the patient is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the patients risk of developing this complication? A) Maintain the head of the bed at 45 degrees or higher. B) Encourage early ambulation. C) Encourage oral fluid intake. D) Perform passive range-of-motion exercises every 8 hours

Encourage early ambulation. The benefits of early ambulation and leg exercises in preventing DVT cannot be overemphasized, and these activities are recommended for all patients, regardless of their risk. Increasing the head of the bed is not effective. Ambulation is superior to passive range-of-motion exercises. Fluid intake is important, but is less protective than early ambulation

The nurse is admitting a patient to the medicalsurgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia? Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 392 A) Encourage the patient to eat a balanced diet that is high in protein. B) Encourage the patient to limit his activity for the first 72 hours. C) Encourage the patient to take his medications as ordered. D) Encourage the patient to use the incentive spirometer every 2 hours

Encourage the patient to use the incentive spirometer every 2 hours To clear secretions and prevent pneumonia, the nurse encourages the patient to turn frequently, take deep breaths, cough, and use the incentive spirometer at least every 2 hours. These pulmonary exercises should begin as soon as the patient arrives on the clinical unit and continue until the patient is discharged. A balanced, high protein diet; visiting family in the waiting room; or taking medications as ordered would not help to clear secretions or prevent pneumonia.

The nurses aide notifies the nurse that a patient has decreased oxygen saturation levels. The nurse assesses the patient and finds that he is tachypnic, has crackles on auscultation, and his sputum is frothy and pink. The nurse should suspect what complication? A) Pulmonary embolism B) Atelectasis C) Laryngospasm D) Flash pulmonary edema

Flash pulmonary edema Flash pulmonary edema occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation; tachypnea; tachycardia; decreased pulse oximetry readings; frothy, pink sputum; and crackles on auscultation. Laryngospasm does not cause crackles or frothy, pink sputum. The patient with atelectasis has decreased breath sounds over the affected area; the scenario does not indicate this. A pulmonary embolism does not cause this symptomatology.

You are caring for a 71-year-old patient who is 4 days postoperative for bilateral inguinal hernias. The patient has a history of congestive heart failure and peptic ulcer disease. The patient is highly reluctant to ambulate and will not drink fluids except for hot tea with her meals. The nurses aide reports to you that this patients vital signs are slightly elevated and that she has a nonproductive cough. When you assess the patient, you auscultate crackles at the base of the lungs. What would you suspect is wrong with your patient? A) Pulmonary embolism B) Hypervolemia C) Hypostatic pulmonary congestion D) Malignant hyperthermia

Hypostatic pulmonary congestion Hypostatic pulmonary congestion, caused by a weakened cardiovascular system that permits stagnation of secretions at lung bases, may develop; this condition occurs most frequently in elderly patients who are not mobilized effectively. The symptoms are often vague, with perhaps a slight elevation of temperature, pulse, and respiratory rate, as well as a cough. Physical examination reveals dullness and crackles at the base of the lungs. If the condition progresses, then the outcome may be fatal. A pulmonary embolism does not have this presentation and hypervolemia is unlikely due to the patients low fluid intake. Malignant hyperthermia occurs concurrent with the administration of anesthetic

The PACU nurse is caring for a 45-year-old male patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply. A) Hypotension B) Hypervolemia C) Heart murmurs D) Dysrhythmias E) Hypertension

Hypotension Dysrhythmias Hypertension The primary cardiovascular complications seen in the PACU include hypotension and shock, hemorrhage, hypertension, and dysrhythmias. Heart murmurs are not adverse reactions to surgery. Hypervolemia is not a common cardiovascular complication seen in the PACU, though fluid balance must be vigilantly monitored.

The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the patients blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the patients skin is cold, moist, and pale. Of what is the patient showing signs? A) Hypothermia B) Hypovolemic shock C) Neurogenic shock D) Malignant hyperthermia

Hypovolemic shock The patient is exhibiting symptoms of hypovolemic shock; therefore, the nurse should notify the patients physician and anticipate orders for fluid and/or blood product replacement. Neurogenic shock does not normally result in tachycardia and malignant hyperthermia would not present at this stage in the operative experience. Hypothermia does not cause hypotension and tachycardia.

The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer. Which of the following statements by the patient indicates that teaching has been effective? A) Ill make sure to limit my intake of protein. B) Ill make sure that the bandage is wrapped tightly. C) My foot should feel cool or cold while my legs healing. D) Ill eat plenty of fruits and vegetables.

Ill eat plenty of fruits and vegetables. Optimal nutritional status is important for wound healing; the patient should eat plenty of fruits and vegetables and not reduce protein intake. To avoid impeding circulation to the area, the bandage should be secure but not tight. If the patients foot feels cold, circulation is impaired, which inhibits wound healing.

The intraoperative nurse is transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year-old woman. The nurse should prioritize which of the following actions? A) Keeping the patient sterile B) Keeping the patient restrained C) Keeping the patient warm D) Keeping the patient hydrated

Keeping the patient warm Special attention is given to keeping the patient warm because elderly patients are more susceptible to hypothermia. It is all important for the nurse to pay attention to hydration, but hypovolemia does not occur as quickly as hypothermia. The patient is never sterile and restraints are very rarely necessary

The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority? A) Assessing for hemorrhage B) Maintaining a patent airway C) Managing the patients pain D) Assessing vital signs every 30 minutes

Maintaining a patent airway The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Assessing for hemorrhage and assessing vital sign are also important, but constitute second and third priorities. Pain management is important but only after the patient has been stabilized.

A patient is 2 hours postoperative with a Foley catheter in site. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do? A) Irrigate the Foley with 30 mL normal saline. B) Notify the physician and continue to monitor the hourly urine output closely. C) Decrease the IV fluid rate and massage the patients abdomen. D) Have the patient sit in high-Fowlers position.

Notify the physician and continue to monitor the hourly urine output closely. If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/hr are reported. The urine output should continue to be monitored hourly by the nurse. Irrigation would not be warranted.

The PACU nurse is caring for a male patient who had a hernia repair. The patients blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery? A) Dysrhythmias, blood loss, and hyperthermia B) Electrolyte imbalances and neurologic changes C) A parasympathetic reaction and low blood volumes D) Pain, hypoxia, or bladder distention

Pain, hypoxia, or bladder distention Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Dysrhythmias, blood loss, hyperthermia, electrolyte imbalances, and neurologic changes are not common postoperative reasons for hypertension. A parasympathetic reaction and low blood volumes would cause hypotension

The nursing instructor is discussing the difference between ambulatory surgical centers and hospital- based surgical units. A student asks why some patients have surgery in the hospital and others are sent to ambulatory surgery centers. What is the instructors best response? A) Patients who go to ambulatory surgery centers are more independent than patients admitted to the hospital. B) Patients admitted to the hospital for surgery usually have multiple health needs. C) In most cases, only emergency and trauma patients are admitted to the hospital. D) Patients who have surgery in the hospital are those who need to have anesthesia administered.

Patients admitted to the hospital for surgery usually have multiple health needs. Patients admitted to the clinical unit for postoperative care have multiple needs and stay for a short period of time. Patients who have surgery in ambulatory centers do not necessarily have greater independence. It is not true that only trauma and emergency surgeries are done in the hospital. Ambulatory centers can administer anesthesia.

The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurses first response? A) Return the patient to his previous position and call the physician. B) Place saline-soaked sterile dressings on the wound. C) Assess the patients blood pressure and pulse. D) Pull the dehiscence closed using gloved hands

Place saline-soaked sterile dressings on the wound. The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the patients vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.

The nurse is caring for an 82-year-old female patient in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurses subsequent assessment? A) Postoperative confusion in older adults is an indication of impaired oxygenation or possibly a stroke during surgery. B) Confusion, restlessness, and agitation are expected postoperative findings in older adults and they will diminish in time. C) Postoperative confusion is common in the older adult patent, but it could also indicate a significant blood loss. D) Confusion, restlessness, and agitation indicate an underlying cognitive deficit such as dementia.

Postoperative confusion is common in the older adult patent, but it could also indicate a significant blood loss. Postoperative confusion is common in the older adult patient, but it could also indicate blood loss and the potential for hypovolemic shock; it is a critical symptom for the nurse to identify. Despite being common, it is not considered to be an expected finding. Postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery, but blood loss is more likely. A new onset of confusion, restlessness, and agitation does not necessarily suggest an underlying cognitive disorder.

The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect is the problem with the patient? A) Postoperative delirium B) Postoperative dementia C) Senile dementia D) Senile confusion

Postoperative delirium Postoperative delirium, characterized by confusion, perceptual and cognitive deficits, altered attention levels, disturbed sleep patterns, and impaired psychomotor skills, is a significant problem for older adults. Dementia does not have a sudden onset. Senile confusion is not a recognized health problem

The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply. A) Provide all discharge instructions in writing. B) Provide the nurses or surgeons contact information. C) Give prescriptions to the patient. D) Irrigate the patients incision and perform a sterile dressing change. E) Administer a bolus dose of an opioid analgesic.

Provide all discharge instructions in writing. Provide the nurses or surgeons contact information. Give prescriptions to the patient. Before discharging the patient, the nurse provides written instructions, prescriptions and the nurses or surgeons telephone number. Administration of an opioid would necessitate further monitoring to ensure safety. A dressing change would not normally be ordered on the day of surgery

The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication? A) Sepsis B) Infection C) Pulmonary embolism D) Hematoma

Pulmonary embolism Patients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of an external pneumatic compression stocking significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection or sepsis would not be affected by an external pneumatic compression stocking. A hematoma or bruise would not be affected by the external pneumatic compression stocking unless the stockings were placed directly over the hematoma.

A postoperative patient rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be the nurses first action? A) Leave and promptly notify the physician. B) Quickly attempt to determine the cause of hemorrhage. C) Begin resuscitation. D) Put the patient in the Trendelenberg position.

Quickly attempt to determine the cause of hemorrhage. Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures. Resuscitation is not necessarily required and the nurse must not leave the patient. The Trendelenberg position would be contraindicated.

The nurse is caring for a patient on the medicalsurgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection? A) Presence of an indwelling urinary catheter B) Rectal temperature of 99.5F (37.5C) C) Red, warm, tender incision D) White blood cell (WBC) count of 8,000/mL

Red, warm, tender incision Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a patient to infection, but by itself does not indicate infection. An oral temperature of 99.5F may not signal infection in a postoperative patient because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/mL

A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? Select all that apply. A) Absence of pain B) Stable blood pressure C) Ability to tolerate oral fluids D) Sufficient oxygen saturation E) Adequate respiratory function

Stable blood pressure Sufficient oxygen saturation Adequate respiratory function A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. Patients can be released from PACU before resuming oral intake. Pain is often present at discharge from the PACU and can be addressed in other inpatient settings.

The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do? A) Sit in a chair for 10 minutes prior to ambulating. B) Drink plenty of fluids to increase circulating blood volume. C) Stand upright for 2 to 3 minutes prior to ambulating. D) Perform range-of-motion exercises for each joint.

Stand upright for 2 to 3 minutes prior to ambulating. Older adults are at an increased risk for orthostatic hypotension secondary to age-related changes in vascular tone. The patient should sit up and then stand for 2 to 3 minutes before ambulating to alleviate orthostatic hypotension. The nurse should assess the patients ability to mobilize safely, but full assessment of range of motion in all joints is not normally necessary. Sitting in a chair and increasing fluid intake are insufficient to prevent orthostatic hypotension and consequent falls.

The nursing instructor is discussing postoperative care with a group of nursing students. A student nurse asks, Why does the patient go to the PACU instead of just going straight up to the postsurgical unit? What is the nursing instructors best response? A) The PACU allows the patient to recover from anesthesia in a stimulating environment to facilitate awakening and reorientation. B) The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications. C) Frequently, patients are placed in the medicalsurgical unit to recover, but hospitals are usually short of beds, and the PACU is an excellent place to triage patients. D) Patients remain in the PACU for a predetermined time because the surgeon will often need to reinforce or alter the patients incision in the hours following surgery.

The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications. The PACU provides care for the patient while he or she recovers from the effects of anesthesia. The patient must be oriented, have stable vital signs, and show no evidence of hemorrhage or other complications. Patients will sometimes recover in the ICU, but this is considered an extension of the PACU. The PACU does allow the patient to recover from anesthesia, but the environment is calm and quiet as patients are initially disoriented and confused as they begin to awaken and reorient. Patients are not usually placed in the medicalsurgical unit for recovery and, although hospitals are occasionally short of beds, the PACU is not used for patient triage. Incisions are very rarely modified in the immediate postoperative period.

The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patients possible readiness to learn how to change her dressing? Select all that apply. A) The patient wants you to teach a family member to do dressing changes. B) The patient expresses interest in the dressing change. C) The patient is willing to look at the incision during a dressing change. D) The patient expresses dislike of the surgical wound. E) The patient assists in opening the packages of dressing material for the nurse.

The patient expresses interest in the dressing change. The patient is willing to look at the incision during a dressing change. The patient assists in opening the packages of dressing material for the nurse. While changing the dressing, the nurse has an opportunity to teach the patient how to care for the incision and change the dressings at home. The nurse observes for indicators of the patients readiness to learn, such as looking at the incision, expressing interest, or assisting in the dressing change. Expressing dislike and wanting to delegate to a family member do not suggest readiness to learn.

A patient underwent an open bowel resection 2 days ago and the nurses most recent assessment of the patients abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have caused the dehiscence? A) The patients surgical dressing was changed yesterday and today. B) The patient has vomited three times in the past 12 hours. C) The patient has begun voiding on the commode instead of a bedpan. D) The patient used PCA until this morning.

The patient has vomited three times in the past 12 hours. Vomiting can produce tension on wounds, particularly of the torso. Dressing changes and light mobilization are unlikely to cause dehiscence. The use of a PCA is not associated with wound dehiscence

The nurse is caring for a patient after abdominal surgery in the PACU. The patients blood pressure has increased and the patient is restless. The patients oxygen saturation is 97%. What cause for this change in status should the nurse first suspect? A) The patient is hypothermic. B) The patient is in shock. C) The patient is in pain. D) The patient is hypoxic.

The patient is in pain. An increase in blood pressure and restlessness are symptoms of pain. The patients oxygen saturation is 97%, so hypothermia, hypoxia, and shock are not likely causes of the patients restlessness.

The perioperative nurse is preparing to discharge a female patient home from day surgery performed under general anesthetic. What instruction should the nurse give the patient prior to the patient leaving the hospital? A) The patient should not drive herself home. B) The patient should take an OTC sleeping pill for 2 nights. C) The patient should attempt to eat a large meal at home to aid wound healing. D) The patient should remain in bed for the first 48 hours postoperative.

The patient should not drive herself home. Although recovery time varies, depending on the type and extent of surgery and the patients overall condition, instructions usually advise limited activity for 24 to 48 hours. Complete bedrest is contraindicated in most cases, however. During this time, the patient should not drive a vehicle and should eat only as tolerated. The nurse does not normally make OTC recommendations for hypnotics.

The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what means? A) Late intention B) Second intention C) Third intention D) First intention

Third intention Third-intention healing or secondary suture is used for deep wounds that either had not been sutured early or that had the suture break down and are resutured later, which is what has happened in this case. Secondary suture brings the two opposing granulation surfaces back together; however, this usually results in a deeper and wider scar. These wounds are also packed postoperatively with moist gauze and covered with a dry, sterile dressing. Late intention is a term that sounds plausible, but is not used in practice. Second intention is when the wound is left open and the wound is filled with granular tissue. First intention wounds are wounds made aseptically with a minimum of tissue destruction.

The dressing surrounding a mastectomy patients 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? A) Describe the appearance of the dressing in the electronic health record. B) Photograph the patients abdomen for later comparison using a smartphone. C) Trace the outline of the drainage on the dressing for future comparison. D) Remove and weigh the dressing, reapply it, and then repeat in 8 hours.

Trace the outline of the drainage on the dressing for future comparison. Spots of drainage on a dressing are outlined with a pen, and the date and time of the outline are recorded on the dressing so that increased drainage can be easily seen. A dressing is never removed and then reapplied. Photographs normally require informed consent, so they would not be used for this purpose. Documentation is necessary, but does not confirm or rule out an increase in drainage.

The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention? A) Check the patients oxygen saturation level, continue to monitor for apnea, and perform a focused assessment. B) Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw. C) Assess the arterial pulses, and place the patient in the Trendelenburg position. D) Reintubate the patient.

Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw. When a nurse finds a patient who is not breathing, the priority intervention is to open the airway and treat a possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the head back and then pushes forward on the angle of the lower jaw or performs the jaw thrust method to open the airway. This is an emergency and requires the basic life support intervention of airway, breathing, and circulation assessment. Arterial pulses should be checked only after airway and breathing have been established. Reintubation and resuscitation would begin after rapidly ruling out a hypopharyngeal obstruction.

An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patients vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next? A) Administer a dose of IV analgesic. B) Apply a cool cloth to the patients forehead. C) Offer the patient a small amount of ice chips. D) Turn the patient completely to one side.

Turn the patient completely to one side. Turning the patient completely to one side allows collected fluid to escape from the side of the mouth if the patient vomits. After turning the patient to the side, the nurse can offer a cool cloth to the patients forehead. Ice chips can increase feelings of nausea. An analgesic is not administered for nausea and vomiting.