Unit 3: Perioperative Concepts and Nursing Management

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required?

"I can resume my usual activities as soon as I get home." By time of discharge, clients should be able to verbalize clinical manifestations of complications, activity and diet restrictions, and specifics regarding follow-up appointments. The client with abdominal incision will need to avoid lifting and driving in the initial discharge period.

A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective?

"I will support my incision with my hands when I cough and do my deep breathing exercises." Splinting of the incision provides support to the incision and helps to control pain, so this client statement is correct. Clients should take pain medication routinely and frequently after surgery. Pain medications for postoperative clients are given orally at home. Pain is a subjective feeling, so comparison is difficult.

The nurse is providing teaching about tissue repair and wound healing to a client who has a leg ulcer. Which of the following statements by the client indicates that teaching has been effective?

"I'll eat plenty of fruits and vegetables." Optimal nutritional status is important for wound healing; the client 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 client's foot feels cold, circulation is impaired, which inhibits wound healing.

Which of the following activities are nursing activities in the preoperative phase of care? Select all that apply. -discussing and reviewing the advanced directive doc -establishing an intravenous line -ensuring that the sponge, needle, and instrument counts are correct -administering medications, fluid, and blood component therapy, if prescribed -beginning discharge planning

-discussing and reviewing the advanced directive doc -establishing an intravenous line -beginning discharge planning Of the activities listed, discussing and reviewing the advanced directive document, establishing an intravenous line, and beginning discharge planning are preoperative nursing activities.

The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply. -listen to music -an on-q pump -watching tv -an epidural infusion -changing position

-listen to music -watching tv -changing position Nonpharmacological management of pain includes listening to music, watching television, and changing position. Pharmacological pain management strategies include epidural infusions and On-Q pumps. An epidural infusion delivers a local opioid with or without a local anesthetic agent directly into the epidural space of the spine. An On-Q pump delivers a local anesthetic agent subcutaneously to the incisional area.

For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery?

7 Aspirin should be stopped at least 7 to 10 days before surgery. The other time frames are incorrect.

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?

<30 mL If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL per hour are reported; if the patient is voiding, an output of less than 240 mL per 8-hour shift is reported.

The nurse recognizes that which of the following clients is at the lowest risk for perioperative complications? a. a client who has a history of arthritis b. a client recently diagnosed with type 2 diabetes

A client who has a history of arthritis A history of arthritis does not increase the risk for complications during the perioperative period.

The nurse expects informed consent to be obtained for insertion of:

A gastrostomy tube Informed consent is required for invasive procedures that require sedation and are associated with more than usual risk to the client.

A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate?

Apply a warm air blanket, gradually increasing body temperature. A warm air blanket can be used to treat hypothermia. The body temperature should be increased gradually. A sudden increase in body temperature could cause complications. The OR temperature should not exceed 26.6°C to prevent pathogen growth. Only dry materials should be placed on the client because wet materials promote heat loss. IV fluids should be warmed to body temperature, not room temperature.

A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?

Assessing WBC count, temperature, and wound appearance The client has an increased risk for infection related to the surgical wound, which is classified as dirty. Assessing the WBC count, temperature, and wound appearance allows the nurse to intervene at the earliest sign of infection. The client will have special nutritional needs during wound healing and needs education on safe transfer procedures, but the need to monitor for infection is a higher priority. The client should receive pain medication as soon as possible after asking, but the latest literature suggests that pain medication should be given on a schedule versus "as needed."

A client is transferred from the postanesthesia care unit (PACU) to an inpatient care unit. What will the nurse assess first?

Breathing The nurse will assess the client being transferred from the PACU to an inpatient care unit. The priority is to assess breathing and administer oxygen if prescribed because this provides a baseline and helps identify for the development of respiratory distress. Pain level is assessed after the surgical site and level of consciousness are assessed.

The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system? a. Cardiovascular system b. Gastrointestinal system c. Endocrine system

Cardiovascular system Depolarizing muscle relaxants can cause cardiac dysrhythmias.

The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists?

Dehiscence Dehiscence is a disruption of the incision.

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?

Have the client lay on the back with the head elevated A wound evisceration occurs when the wound completely separates, and the internal organs protrude. If disruption of a wound occurs, the patient is placed in the low Fowler's position and instructed to lie quietly. These actions minimize the protrusion of body tissues. The protruding coils of the intestine are covered with sterile dressings moistened with sterile saline solution, and the surgeon is notified at once.

A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for?

Hypoglycemia The patient with diabetes who is undergoing surgery is at risk for both hypoglycemia and hyperglycemia. Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin. Hyperglycemia, which can increase the risk of surgical wound infection, may result from the stress of surgery, which can trigger increased levels of catecholamine. Other risks are acidosis and glucosuria, but hypoglycemia is a bigger risk. Dehydration is a lesser risk for a patient with diabetes than is hypoglycemia.

An anxious client being prepared for surgery is encouraged to concentrate on a pleasant experience or restful scene. What cognitive coping strategy would the nurse document as being used?

Imagery Imagery has proven effective for anxiety in surgical clients. Optimistic self-recitation is practiced when the client recites optimistic thoughts such as, "I know all will go well." Distraction is used when the client is encouraged to think of an enjoyable story or recite a favorite poem. Progressive muscular relaxation requires contracting and relaxing muscle groups and is a physical coping strategy as opposed to a cognitive strategy.

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?

Ineffective thermoregulation Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.

The nurse is aware that a religious group that refuses blood transfusions for religious reasons is:

Jehovah's Witnesses Jehovah's Witnesses decline blood transfusions for religious reasons.

As a circulating nurse, what task are you solely responsible for?

Keeping records. The circulating nurse wears OR attire but not a sterile gown. Responsibilities include obtaining and opening wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, receiving specimens for laboratory examination, and coordinating activities of other personnel, such as the pathologist and radiology technician. It is the responsibility of the scrub nurse to hand instruments to the surgeon and count sponges and needles. It is the responsibility of the surgeon to estimate blood loss.

A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention?

Mask is placed over nose and extends to bottom lip. The mask should fit tightly, covering the nose and mouth. The mask should extend down past the chin. The mask may not effectively cover the mouth if extended only to the bottom lip. The hair, scrub top, drawstring, and shoe covering are all appropriate and do not require intervention.

The nurse notes that the consent form for surgery needs to be signed; however, the client just received preoperative medication. Which action will the nurse take?

Notify the health care provider that the consent form has not been signed. Informed consent is the client's autonomous decision about whether to undergo a surgical procedure. Voluntary and written informed consent from the client is necessary before nonemergent surgery can be performed to protect the client from unsanctioned surgery and protect the health care provider from claims of an unauthorized operation or battery. Because of this, the health care provider should be notified that the consent form has not been signed. The consent form needs to be signed before administering psychoactive premedication because consent is not valid if it is obtained while the client is under the influence of medications that can affect judgment and decision-making capacity. A family member is not responsible for approving the client's surgery. Verbal agreement to a surgical procedure is not legal or appropriate.

The nurse is caring for a client 24 hours post surgery who is having persistent hiccups. What action is most appropriate for the nurse to take?

Notify the physician. Prolonged hiccups may cause pain or discomfort. Prolonged hiccups may also result in wound dehiscence or evisceration, inability to eat, nausea and vomiting, exhaustion, and fluid, electrolyte, and acid-base imbalances. If hiccups continue, the nurse needs to notify the physician. Deep breathing helps minimize pain and will not help in this condition. Positioning the client and ample water intake will not help stop the hiccups.

A significant mortality rate exists for patients with alcoholism who experience delirium tremens postoperatively. When caring for the patient with alcoholism, the nurse should assess for symptoms of alcoholic withdrawal:

On the second or third day. The person with a history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase surgical risk. Alcohol withdrawal syndrome or delirium tremens may be anticipated between 48 and 72 hours after alcohol withdrawal and is associated with a significant mortality rate when it occurs postoperatively.

The nurse recognizes that written informed consent is required for insertion of a(n):

Peripherally-inserted central catheter. Nonsurgical invasive procedures, such as insertion of a peripherally-inserted central catheter, that carry more than a slight risk to the client require written informed consent.

Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery?

Physician It is the physician's responsibility to provide appropriate information. It is not the responsibility of the nurse, case manager, or certified nurse's aide to gain informed consent.

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?

Pink to red and soft, bleeding easily In second-intention healing, necrotic material gradually disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue.

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?

Position the client to maintain a patent airway. Maintaining a patent airway is the immediate priority in the PACU.

The nurse is preparing an older adult for a surgical procedure. Which action will the nurse take to protect the client from injury during the operative period?

Protect bony prominences with extra padding. Older adult clients are at higher risk for complications from anesthesia and surgery compared with younger adult clients due to several factors. One factor is age-related decline in physiological reserve that weakens the normal response to stressors, acute illness, anesthesia, and surgery. Nursing management for the older surgical client in the intraoperative period includes careful transferring and positioning in the OR bed by protecting pressure points and bony prominences with extra padding. Intraoperative warming techniques should be used to reduce unintentional hypothermia during the case. Blood loss is to be accurately measured and not estimated. Antiembolic stockings are to be used during the case to prevent the development of venous thromboemboli.

What complication is the nurse aware of that is associated with deep venous thrombosis? a. Marked tenderness over the anteromedial surface of the thigh b. Pulmonary embolism c. The whole leg is swollen

Pulmonary embolism Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010).

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing the dressing or applying pressure if bleeding is frank The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply will not help manage and minimize hemorrhage and shock. Monitoring vital signs every 15 minutes is an appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to determine the extent and progression of the problem.

The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to:

Respond verbally during the procedure Clients can respond to verbal and physical stimuli and maintain an oral airway and protective reflexes during moderate sedation.

Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out?

Review the scheduled procedure, site, and client. According to the 2016 National Patient Safety Goals, accurate identification of the client, procedure, and operative site is essential.

The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure?

Risk for perioperative positioning injury related to positioning in the OR Pressure ulcers, nerve and blood vessel damage, impeded respiration, hyperextended joints, and discomfort are risks associated with the prolonged, awkward positioning required for some surgical procedures. The other choices are also potential nursing diagnoses or concerns related to surgery, but they are not related to the duration of the surgery.

A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role?

Scrub role The scrub role includes performing a surgical hand scrub, setting up the sterile tables, and preparing sutures, ligatures, and special equipment. The circulating nurse manages the operating room and protects patient safety. The registered nurse first assistant functions under the direct supervision of the surgeon. Responsibilities may include handling tissue, providing exposure of the operative field, suturing, and maintaining hemostasis. The anesthetist administers the anesthetic medications.

A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?

Splint the incision site using a pillow during deep breathing and coughing exercises. Splinting the incision site will help decrease pain and support the incision. This will increase compliance with the deep breathing and coughing exercises that assist in preventing respiratory complications. Pain medication should be taken regularly, not only before deep breathing and coughing exercises. Deep breathing and coughing exercises should be done at least every 2 hours, more frequently if possible. While some clients will find the exercises relaxing, most clients find it painful to complete them.

The client vomits during the surgical procedure. The best action by the nurse is:

Suction the client to remove saliva and gastric secretions. The nurse immediately suctions the client to prevent aspiration of vomitus.

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage?

The Hemovac drain isn't compressed; instead it's fully expanded. The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.

When does the nurse understand the patient is knowledgeable about the impending surgical procedure?

The patient participates willingly in the preoperative preparation. The nurse knows that the patient understands the surgical intervention when the patient participates in preoperative preparation. The other answers pertain to the patient experiencing decreased fear or anxiety, not knowledge about the procedure.

The nurse discovers that the client did not sign the operative consent before receiving the preoperative medication. The appropriate nursing action is:

To notify the surgeon Preoperative medication can impair the thinking ability of the client. For informed consent to be valid, the client must be competent to give consent. The surgery will be canceled.

A client vomits postoperatively. What is the most important nursing intervention?

Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs. When a client vomits, the nurse should turn the client's head to the side to prevent aspiration; the vomitus is collected in the emesis basin. Measuring the vomitus is not helpful to the client. Offering fluids is not advised with vomiting. Supporting the wound is important, but not a priority with vomiting.

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing?

Wound infection Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

auscultate bowel sounds. If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.

A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client?

experiences pain within tolerable limits. Because pain can contribute to postoperative delirium, adequate pain control without oversedation is essential. Nursing assessment of mental status and of all physiologic factors influencing mental status helps the nurse plan for care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult client.

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation. The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and monitoring for hypotension are important, but they are not primary objectives in the immediate postoperative period.

The client complains of weakness and dizziness as the nurse assists the client to sit on the side of the bed. The nurse recognizes the client is experiencing:

orthostatic hypotension Clinical manifestations of orthostatic hypotension include weakness, dizziness, fainting, and a 20 mm Hg decrease in systolic blood pressure or a 10 mm Hg decrease in diastolic blood pressure.

A client is to receive general anesthesia with sevoflurane. What does the nurse anticipate would be given with the inhaled anesthesia?

oxygen Sevoflurane is an inhalation anesthetic always combined with oxygen to decrease the risk of coughing and laryngospasm. It would not be combined with alfentanil, rocuronium, or lidocaine. Alfentanil and rocuronium are intravenous anesthetics. Lidocaine is a local anesthetic.

A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to:

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 client's vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.

A gunshot wound would be classified under which category of surgery based on urgency? a. urgent b. emergent c. elective d. required

Emergent Emergent surgery occurs when the patient requires immediate attention. An elective surgery is classified as a surgery that the patient should have. A required surgery means that the patient needs to have surgery. An urgent surgery is one which the patient required prompt attention.

A patient with renal failure is scheduled for a surgical procedure. When would surgery be contraindicated for this patient due to laboratory results?

A blood urea nitrogen level of 42 mg/dL The kidneys are involved in excreting anesthetic medications and their metabolites; therefore, surgery is contraindicated if a patient has acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems (see Chapter 54). A blood urea nitrogen level of 42 mg/dL (significantly elevated) is an indicator of renal failure. The other levels are normal.

A client is scheduled for a surgical procedure. When planning the client's care, the nurse should consider that which of the following conditions will increase the client's risk of complications after surgery?

A history of diabetes As a chronic condition that affects many body systems, diabetes is a risk factor for surgical complications. The client's blood glucose level and insulin requirements need to be closely monitored before and after surgery. Being sensitive to aspirin does not pose a risk for the client in surgery. Osteoarthritis is not a systemic condition and does not place the client at risk during surgery. Chronic low back pain is not a systemic condition that places the client at risk during surgery; however, it can be exacerbated by positioning on the operating room table.

What measurement should the nurse report to the physician in the immediate postoperative period?

A systolic blood pressure lower than 90 mm Hg A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal.

Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency? a. pituitary b. adrenal c. thyroid d. parathyroid glands

Adrenal Clients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids does not occur in the pituitary, thyroid, or parathyroid glands.

The nurse is caring for a client who has just arrived for surgery. Which assessment finding indicates to the nurse that the client may be experiencing dehydration because of taking nothing by mouth after midnight for the surgery?

Blood pressure 80/50 mm Hg Assessment of a client's hydration status is essential preoperatively. The client's NPO (nothing by mouth or nil per os) status should be confirmed preoperatively. Preoperative fasting helps prevent the risk of aspiration but it also induces stress on the body, including the loss of glycogen stores, and the body sacrifices lean muscle to meet the energy needs of the surgery. This may lead to dehydration, which may be exhibited day of surgery by low blood pressure. A urine output of 60 mL/hr is within normal limits. A pulse of 88 beats per minute is within normal limits. A respiratory rate of 20 breaths per minute is within normal limits.

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action?

Call the health care provider. The client presents with a possible paralytic ileus, a serious condition where the intestines are paralyzed and peristalsis is absent. This may occur as a result of surgery, especially abdominal surgery. If the nurse is unable to auscultate bowel sounds and the client has pain and a rigid abdomen, the nurse will suspect an ileus and immediately call the health care provider. Re-attempting auscultation may occur, but only after the health care provider has been notified. The health care provider may order the placement of an NG tube, however, the nurse cannot do this without the provider's order. Administering a stool softener will not help the client and may make the condition worse.

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?

Central venous pressure Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, level of consciousness, central venous pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output are monitored to provide information on the patient's respiratory and cardiovascular status.

The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following?

Cheeseburger, french fries, coleslaw, and ice cream Important nutrients for wound healing include protein; vitamins A, B-complex, C, and K; arginine, magnesium, copper, and zinc; and water. The diet should be sufficient in carbohydrates and low to moderate in fats. The cheeseburger option is high in fat and low in vitamin C.

A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented?

Circulating nurse The circulating nurse is responsible for ensuring that the second verification of the surgical procedure and site takes place and is documented. Each member of the surgical team verifies the patient's name, procedure, and surgical site using objective documentation and data before beginning the surgery.

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 client?

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

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding? a. hernia b. dehiscence c. evisceration d. erythema

Evisceration Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.

Which term refers to the protrusion of abdominal organs through the surgical incision?

Evisceration Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.

The circulating nurse is documenting all medications administered during a surgical procedure. The anesthesiologist administers an opioid analgesic. What medication would the nurse check as being administered?

Fentanyl Fentanyl is an opioid analgesic. Mivacurium and metocurine are muscle relaxants. Etomidate is an anesthetic agent.

The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by:

First intention First-intention healing is characterized by a closed incision with little tissue reaction and the absence of signs and symptoms of infection.

The nurse is caring for a client 24 hours post surgery who is having persistent hiccups. What action is most appropriate for the nurse to take? a. Instruct the client to take deep breaths. b. Notify the physician. c. Reposition the client d. Give the pt ample water

Notify the physician. Prolonged hiccups may cause pain or discomfort. Prolonged hiccups may also result in wound dehiscence or evisceration, inability to eat, nausea and vomiting, exhaustion, and fluid, electrolyte, and acid-base imbalances. If hiccups continue, the nurse needs to notify the physician. Deep breathing helps minimize pain and will not help in this condition. Positioning the client and ample water intake will not help stop the hiccups.

A client is at postoperative hour 8 after an appendectomy and is anxious, stating "Something is not right. My pain is worse than ever and my stomach is swollen." Blood pressure is 88/50, pulse is 115, and respirations are 24 and labored. The abdomen is soft and distended. No obvious bleeding is noted. What action by the nurse is most appropriate?

Notify the physician. The physician should be notified of the findings. The client may be hemorrhaging internally and may need to return to surgery. The client may be in need of pain medication, but morphine will lower the blood pressure further and may cause further complications. Ambulating the client increases the risk of injury because the client may experience orthostatic hypotension. What the client is experiencing is not the normal progression after abdominal surgery.

A client is undergoing preoperative assessment. During admission paperwork, the client reports having enjoyed a hearty breakfast this morning to be ready for the procedure. What is the nurse's next action?

Notify the surgeon. If the client has not carried out a specific portion of preoperative instructions, such as withholding foods and fluids, the nurse immediately notifies the surgeon. This scenario does not include information to support documentation of the client's food intake or giving the client water at this point. It is not the nurse's responsibility to cancel the surgery.

How would the operating room nurse place a patient in the Trendelenburg position?

On his back with his head lowered so that the plane of his body meets the horizontal on an angle The Trendelenburg position usually is used for surgery on the lower abdomen and pelvis to obtain good exposure by displacing the intestines into the upper abdomen. In this position, the head and body are lowered. The patient is supported in position by padded shoulder braces (see Fig. 18-5B), bean bags, and foam padding.

The nurse positions the client in the lithotomy position in preparation for

Perineal surgery The client undergoing perineal surgery will be placed in the lithotomy position.

A postoperative client begins coughing forcefully while eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first? a. notify the surgeon b. cover the intestines with sterile, moist dressings c. place the client in the low Fowler's position. d. document the event

Place the client in the low Fowler's position. Placing the client in the low Fowler's position decreases further protrusion of the intestines. The nurse should cover the intestines with a sterile, moist dressing; notify the surgeon and document the event; but first the nurse should minimize further protrusion of the intestines.

A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention?

Report early calf pain. The client needs to report calf pain or cramping for the nurse to investigate any swelling or potential DVT. Blanket rolls or prolonged dangling should be avoided to reduce impediment of circulation behind the knee. Prevention of DVT includes early ambulation, use of antiembolism or pneumatic compression devices, and low-molecular-weight or low-dose heparin and low-dose warfarin for clients postoperatively. Adequate fluids need to be offered to avoid dehydration.

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client?

The client can be discharged from the PACU. The Aldrete score is usually 8 to 10 before discharge from the PACU. Clients with a score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area, depending on their preoperative baseline score.

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition?

The client is displaying early signs of shock. The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated. Medication or anesthesia reactions may cause client symptoms similar to these; however, these causes are not as likely as early shock.

A nursing assessment's findings reveal a postoperative client has a temperature of 96.2 °F (35.7 °C), shivering, and reports feeling cold. What does the nurse conclude about the client?

The client is experiencing hypothermia. Clinical manifestations of hypothermia include a low body temperature, shivering, and feelings of coldness. These symptoms are not present with atelectasis, pneumonia, or pain.

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?

Urine retention Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus.

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

Use diaphragmatic breathing. In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.

A client is being prepared for a surgical procedure. The circulating nurse is specifically responsible for which piece of the surgical timeout? a. Verification of the timeout b. Verification of the procedure c. verification of the clients name d. verification of the surgical site

Verification of the timeout The circulating nurse is responsible for ensuring that the second verification of the surgical procedure and site takes place and is documented. In some institutions, this is referred to as a timeout, surgical pause, or universal protocol that takes place among the surgical team prior to induction of anesthesia with a briefing about anticipated problems, potential complications, allergies, and comorbidities. Every member of the surgical team verifies the client's name, procedure, and surgical site using objective documentation and data before beginning the surgery. The scrub nurse, first assistant, and nurse anesthetist participate in the timeout; however, they are not responsible for ensuring that the timeout occurs.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

first intention. Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.

A client is scheduled to have surgery to address a cleft palate. What type of surgery would the nurse be preparing this client for?

reconstructive Clients have surgery for many different reasons. Reconstructive surgery is intended to repair or reconstruct physical deformities and abnormalities caused by traumatic injuries, birth defects, developmental abnormalities, or disease. Corrective surgery usually involves fixing a problem. Diagnostic surgery is the removal and study of tissue to make a diagnosis. Prophylactic surgery is the removal of tissue that does not yet contain cancer cells but has a high probability of becoming cancerous in the future.

A perioperative nurse is assigned to complete a preoperative assessment on a client who is scheduled for surgery for kidney stones the next day. What category of surgery does this procedure fall into?

urgent Surgery for kidney or urethral stones is considered urgent; it is usually performed the next day. Emergent surgery is performed without delay. Required surgery is performed within a few weeks or months. Elective surgery refers to procedures that the client plans in advance.

A nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which post-surgical risk factor would decrease if the surgical client maintained strict blood glycemic control?

wound healing In caring for a postoperative client, the nurse is correct to correlate hyperglycemia with an increased risk of surgical incision infections and delayed wound healing. Strict control of glycemic blood levels at the therapeutic range of 80-110 mg/dL would reduce this risk factor. There is no direct correlation between blood glucose levels and nutrient deficiencies, respiratory complications, or liver dysfunction.