Perioperative EAQs

Which finding would the nurse expect when assessing a client who has lost a large amount of blood after an automobile collision?

Apical heart rate of 142 beats/minute

Which statement needs correction regarding obtaining informed consent from clients?

"Obtaining informed consent is an important part of the nurse-client relationship; it is a vital part of the nursing duty."

Which situation does the nurse consider to be the most appropriate method of obtaining informed consent?

A client signs a consent after the primary health care provider has given a detailed explanation of the risks, benefits, and alternatives to the procedure.

The nurse is preparing an intraoperative care plan for a client. Which intervention would be excluded from the care plan?

Administering a general anesthetic to the client

Which action would the nurse take to prevent postoperative respiratory complications after abdominal surgery?

Assist with incentive spirometry.

A client has an abdominal cholecystectomy for treatment of a gangrenous gallbladder. Considering the location of the surgical site, the nurse would assess the client for which postoperative complication?

Atelectasis

Nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complication?

Atelectasis

The postanesthesia care unit (PACU) receives a client postabdominal surgery with a nasogastric tube with low-intermittent wall suction in place. Which initial action would the nurse implement when the client vomits 90 mL of bile-colored fluid?

Check the patency of the tube.

Which finding will the nurse expect when caring for a client who is in hypovolemic shock?

Cool skin temperature

Which is the most important for the nurse to include in teaching for a client scheduled for a cholecystectomy regarding prevention of postoperative complications?

Coughing and deep breathing

A child's blood test after receiving a general anesthetic indicates increased intracellular calcium levels. Which medication would the nurse anticipate administering to this client?

Dantrolene

Which initial action would the nurse take when obtaining consent for surgery?

Determine whether the client's knowledge level is sufficient to give consent.

The nurse finds that the surgical mask being worn has become moist before going into surgery. Which would the nurse do?

Dispose of the mask and put on a new one.

A pregnant client with severe abdominal pain and heavy bleeding is being prepared for a cesarean birth. Which is the priority intervention?

Ensuring that an informed consent is obtained and that the client is assessed for medication allergies

Which action will the nurse take to avoid postural hypotension when getting a postoperative client out of the bed?

Have the client sit on the edge of the bed for a few minutes before standing up.

Which nursing intervention would be included in the plan of care of a client with liver cancer and ascites who is scheduled for a paracentesis?

Having the client void before the procedure

Which is the first sign that would assist the nurse in suspecting malignant hyperthermia in a client?

Increased expired carbon dioxide

Which action would the nurse take first after noticing stridor in a client who just arrived in the postanesthesia care unit (PACU) after receiving a general anesthetic?

Notify the health care provider.

Which finding would the nurse expect when assessing a client diagnosed with hypovolemic shock?

Oliguria

When monitoring a client 24 to 48 hours after abdominal surgery, the nurse would assess for which problem associated with anesthetic agents?

Paralytic ileus

Which action by a client who requires an above-the-knee amputation for peripheral arterial disease best indicates emotional readiness for the surgery?

Participates in learning perioperative care

D5W is infusing intravenously when a 7-year-old child is returned to the pediatric unit from surgery. The postoperative prescription does not indicate the desired rate of infusion. Which is the most appropriate action for the nurse to take?

Reduce the flow rate to keep the vein open and obtain a prescription.

Which action would the nurse take first after observing serosanguineous drainage on the abdominal dressing of a client in the postanesthesia care unit (PACU) who had an abdominal cholecystectomy?

Reinforce the dressing.

Which action needs correction regarding insertion of an intravenous cannula for administration of fluids?

Shaving the client's skin immediately around the insertion site

Which site would the nurse assess first for the amount of drainage from a client discharged from the postanesthesia care unit (PACU)?

Surgical incision

Which assessment finding would be important for the nurse to report to the health care provider when caring for a client who is in the postanesthesia care unit after receiving general anesthesia?

Systolic blood pressure decrease from 130 mm Hg to 90 mm Hg

Which action would be used to decrease risk for postoperative respiratory complications in an older client with decreased vital capacity?

Teach the client coughing and deep-breathing exercises.

Which explanation is the rationale for performing sponge, needle, and instrument counts in the operating room?

The nurse is responsible for performing sponge and instrument counts as a part of routine surgical standards.

A client who wakes up after surgery spits out the oral airway placed during the recovery from anesthesia. What would this behavior indicate to the nurse?

Their gag reflex has returned.