prepu chp 30, 32, 35

The preoperative nurse is teaching a client about deep-breathing exercises. The client asks, "Why do I need to learn about this?" Which response by the nurse is correct?

"After surgery, deep-breathing exercises help to remove anesthetic gases and mucus and improve oxygen supply to body tissues."

The nurse is preparing a client for surgery and asks if the client has an advance directive. The client asks "What is an advance directive?" What is the nurse's best response to this?

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

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?

"Dehiscence is when a wound has partial or total separation of the wound layers."

After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what?

"I could use the TENS unit if I feel pain somewhere else on my body."

A client who is scheduled to undergo coronary bypass surgery in a week asks the nurse whether he should discontinue taking his cholesterol medicine ahead of the surgery. Which should be the nurse's response?

"I will need to check with your health care provider about that."

The nurse is preparing a client for a total hip arthroplasty and is obtaining data preoperatively. Which statement made by the client is most important for the nurse to immediately report to the health care provider?

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

A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse?

"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression."

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?

"It provides a way to remove drainage and blood from the surgical wound."

Two hours after receiving a pain medication, the client reports still suffering from pain. Which question is most appropriate to ask the client?

"Tell me more about your pain."

A nurse is caring for a client in the same-day surgery unit. The client asks the nurse, "Do I really need to be put to sleep for this surgery?" Which would be the nurse's best response?

"Tell me what you are most worried about."

The nurse is talking with a client who wishes to have a tattoo removed. Which client statement indicates that the client understands how the procedure will be accomplished?

"The provider will perform this laser surgery in an ambulatory care setting."

The nurse is providing education about deep-breathing exercises to a postoperative client whose surgery took place earlier today. Which instruction should the nurse provide?

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

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?

"Very little scar tissue will form."

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound."

Which surgical client does the nurse in the preoperative setting anticipate having the greatest potential for surgical complications?

76-year-old client with a history of renal failure and chronic bronchitis

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

An obese woman with a history of type 1 diabetes

Which action by the nurse is most appropriate when attempting to remove surgical staples that have dried blood or drainage on them?

Apply moist saline compresses to loosen crusts before attempting to remove the staples.

A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first?

Apply warm blankets to the client.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding?

As a stage I pressure injury

The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate? Select all that apply.

Assess for pain control 30 minutes after administering an analgesic. Consider cultural implications of the perception of pain. Provide pain medication before activity that may increase pain.

A client has presented to the outpatient surgical center for a scheduled procedure. Which action should the nurse perform prior to the procedure?

Assess the client's allergy status.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

Clean the wound from the top to the bottom and from the center to outside.

A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure?

Cutaneous stimulation

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

Dehiscence of the wound

An elder adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client?

Delirium (common in the acute postoperative period)

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings?

Diffuse dermatitis accompanied by pruritus

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time?

Discontinue the therapy and assess the client.

While providing a back massage, the nurse observes a reddened area on the client's sacral area. Which action by the nurse is appropriate?

Document the finding.

When asking an older adult client about abdominal pain, the client reports, "I don't want to be a bother because nothing hurts too much." The nurse notes that the client grimaces and splints the abdomen when moving. What is the appropriate nursing action?

Gently mention that the client appears to be experiencing pain that can be treated.

Which surgical clients will return to activities in their everyday lives more quickly?

Laparoscopic cholecystectomy

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors?

Local capillary pressure must be lower than external pressure.

The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client?

Monitor intake and output.

A 9-month-old baby is scheduled for heart surgery. When preparing this client for surgery, the nurse should consider which surgical risk associated with infants?

Potential for hypothermia or hyperthermia

The nurse is teaching the client who recently experienced abdominal surgery to deep breathe and cough effectively. What observable action serves to best minimize pain that may result from the intervention?

Providing support to abdominal and accessory respiratory muscles

A PCA has been ordered for a client who is experiencing significant postoperative pain. To minimize the risk of adverse effects of this therapy, the nurse should perform what action?

Teach the client to perform deep-breathing and coughing exercises.

A client has been admitted to a post-surgical unit with a patient-controlled analgesia (PCA) system. Which statement is true of this medication delivery system?

The dose that is delivered when the client activates the machine is preset.

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

Which statement accurately describes a consideration when using a patient-controlled analgesia (PCA) pump to relieve client pain?

The pump mechanism can be programmed to deliver a specified amount of analgesic within a given time interval.

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?

The status of the client's tetanus immunization

A client has arrived to the postanesthesia care unit (PACU) and is drowsy with a respiratory rate of 12 breaths per minute. What would be an accurate interpretation by the nurse?

This is an expected finding in the immediate postoperative period.

Who is the authority on the presence and extent of pain experienced by a client?

client

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?

a client sitting in a chair who slides down

When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of:

a partial airway obstruction.

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?

a sterile, flexible applicator moistened with saline

Surgery can lead to hypothermia. Which client is at greatest risk for hypothermia?

an older adult man with a fractured hip (The risk of hypothermia increases in the very young and the very old)

A nurse consults with a nurse practitioner trained to perform acupressure to teach the method to a client being discharged. What process is involved in this pain relief measure?

cutaneous stimulation

A nurse is reinforcing wound edges and applying a blinder to the separated incisions of a client after a surgery. Which postoperative complication has the client developed?

dehiscence

The recovery nurse is caring for a surgical client in the PACU. The client's blood pressure is dropping and the heart rate is increasing. The nurse suspects the client is:

developing shock

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

emergency surgery

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?

fish

In the postoperative phase of abdominal surgery, the client reports severe abdominal pain. In the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect?

paralytic ileus

A nurse teaches deep breathing exercises to a client scheduled for surgery. In which perioperative phase would this action occur?

preoperative

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?

preventing the client from sliding in bed

A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain?

referred pain

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

removing dead or infected tissue to promote wound healing

Which of the following is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump?

respiratory

A nurse is caring for a client who was administered opioid narcotics. The client reports constipation. What is another potential side effect of opioid narcotics?

sedation

When preparing a client who has diabetes mellitus for surgery, the nurse should be aware of what surgical risk associated with this disease?

slow wound healing

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. T/F

true

A male college student age 20 years has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing?

visceral pain

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective?

"I will put a layer of cloth between my skin and the ice pack."

A client reports pain and requests the prescribed pain medication. When entering the client's room, the client is laughing with visitors and does not appear to be in pain. What is the appropriate action by the nurse?

Administer the pain medication.

A client reports after a back massage that his lower back pain has decreased from 8 to 3 on the pain scale. Which opioid neuromodulator does the nurse know is released with skin stimulation and is more than likely responsible for this increased level of comfort?

Endorphins

The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority?

Examine the effectiveness of the current pain regimen

The nurse is performing a preoperative assessment of a client who has been scheduled for a reduction mammoplasty (breast reduction). The client states, "I'm starting to wonder if I made the right decision in going ahead with this." What should the nurse do next?

Explore the client's feelings and inform the surgeon.

A 77-year-old woman is on the nurse's unit s/p left knee replacement. The client typically stools every morning but has not had a bowel movement in 3 days. The nurse knows that which medication places the client at increased risk for constipation?

Hydromorphone (Hydromorphone is a narcotic agent which is often constipating in older adults. Psyllium helps promote regular bowel elimination. Acetaminophen is not linked to constipation. Furosemide is used as a diuretic. It does not cause constipation)

The preoperative nurse has prepared a client for surgery and has been notified that the operating room staff is ready for the client. The client states, "My bladder feels full. I need to go to the bathroom!" Which action by the nurse is appropriate?

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

The nurse is teaching a novice nurse about the therapeutic effects of laughter. Which example correctly identifies one of these effects?

It activates the immune system.

The nurse recognizes which statement is true of chronic pain?

It may cause depression in clients.

The nurse cares for a client following surgery to repair an abdominal aortic aneurysm. Which nursing intervention assists with healing and maintaining client comfort?

Maintaining a calm environment

The nurse-anesthetist is monitoring the client during surgery. He notices a ventricular dysrhythmia and unstable blood pressure. He notifies the surgeon. The operative team suspects:

Malignant hyperthermia (The symptoms of malignant hyperthermia are masseter muscle rigidity, ventricular dysrhythmia, tachypnea, cyanosis, skin mottling, and unstable blood pressure)

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

Which principle should the nurse integrate into the pain assessment and pain management of pediatric clients?

Pain assessment may require multiple methods in order to ensure accurate pain data.

Which nursing action will best promote pain management for a client in the postoperative phase?

Performing relaxation techniques

Which measure would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client?

Place graduated compression stockings on the client.

A nurse is working with a 12-year-old boy who was involved in an MVA. He has several broken bones and contusions. He rates his pain as a 7/10. The nurse plans to administer intravenous hydromorphone to relieve the pain. What side effect is the nurse most worried about?

Respiratory depression

The nurse is caring for a client during the first 12 hours of receiving epidural analgesia and assesses the client every hour. Along with vital signs, which best describes the priority of the hourly assessment?

Respiratory status, oxygen saturation, pain, and sedation level

A client has required frequent scheduled and breakthrough doses of opioid analgesics in the 6 days since admission to the hospital. The client's medication regimen may necessitate which intervention?

Stool softeners and increased fluid intake

A client limps into the emergency department and states, "I stepped on a nail and did not have shoes on. Now I can barely walk." What types of concern does the nurse anticipate the client will have?

Tetanus, infection, wound care, and pain control

The nurse is caring for a client who has had back pain for 2 years, following a fall from a ladder. How does the nurse going off-shift report this kind of pain to the oncoming nurse? Select all that apply.

chronic, somatic

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

Transparent

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?

a transparent film

What is the nurse's role in the informed consent process for a surgical procedure?

witnessing the signed informed consent document