Week 1 Perioperative Study Guide

Voiding

MAKE SURE pt uses the restroom as the FIRST thing the patient does when entering preop

Benzodiazepines uses

Used for preop anxiety, promotes amnesia. Adverse effect: cardiac/resp arrest

Opioids

Used for sedation, to relieve preop and postop pain. Adverse effect: CNS depression

The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement? A. Notify the surgeon about the client's request to wear the medal. B. Tape the medal to the client and allow the client to wear the medal. C. Request the family member take the medal prior to surgery. D. Explain taking the medal to surgery is against the policy.

B.

The nurse is administering an opioid narcotic to the client. Which interventions should the nurse implement for client safety? Select all that apply. A. Compare the hospital number on the MAR to the client's bracelet. B. Have a witness verify the wasted portion of the narcotic. C. Assess the client's vital signs prior to administration. D. Determine if the client has any allergies to medications. E. Clarify all pain medication orders with the health-care provider.

A. C. D.

Which client statement indicates that a client who is scheduled for a 3-hour surgery under general anesthesia needs further teaching? A. A breathing tube will be placed when I am in the operating room B. I should shave the skin in the surgical area the evening prior to surgery C. I should splint my incision with a pillow when coughing and deep breathing after surgery D. I might need a urinary catheter inserted before surgery so my urine output can be monitored

B.

Which nursing intervention has the highest priority when preparing the client for a surgical procedure? A. Pad the client's elbows and knees. B. Apply soft restraint straps to the extremities. C. Prepare the client's incision site. D. Document the temperature of the room.

B.

IV access

18 gauge catheter (large-bore) incase of blood transfusion or need to push fluids

The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after three (3) tap water enemas. Which intervention should the nurse implement first? A. Notify the surgeon of the client's status. B. Continue giving enemas until clear. C. Increase the client's IV fluid rate. D. Obtain STAT serum electrolytes.

A.

The PACU nurse is receiving the client from the OR. Which intervention should the nurse implement first? A. Assess the client's breath sounds. B. Apply oxygen via nasal cannula. C. Take the client's blood pressure. D. Monitor the pulse oximeter reading.

A.

The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement? A. Prepare ice packs and mix dantrolene sodium. B. Request the defibrillator be brought into the OR. C. Draw a PTT and prepare a heparin drip. D. Obtain finger stick blood glucose immediately.

A.

The client is complaining of left shoulder pain. Which intervention should the nurse implement first? A. Assess the neurovascular status of the left hand. B. Check the medication administration record (MAR). C. Ask if the client wants pain medication. D. Administer the client's pain medication.

A.

The nurse and the unlicensed assistive personnel (UAP) are working on the surgical unit. Which task can the nurse delegate to the UAP? A. Take routine vital signs on clients. B. Check the Jackson Pratt insertion site. C. Hang the client's next IV bag. D. Ensure the client obtains pain relief.

A.

General anesthesia

3 phases: induction: initiation of IV access, administration of preop medications given and securing of airway patency maintenance: performance of surgery and airway maintenance emergence: completion of surgery and removal of assistive airway devices

The nurse clears the PCA pump and discovers the client has used only a small amount of medication during the shift. Which intervention should the nurse implement? A. Determine why the client is not using the PCA pump. B. Document the amount and take no action. C. Chart the client is not having pain. D. Contact the HCP and request oral medication.

A.

The nurse is conducting an interview with a 75-year-old client admitted with acute pain. Which question would have priority when assisting with pain management? A. "Have you ever had difficulty getting your pain controlled?" B. "What types of surgery have you had in the last 10 years?" C. "Have you ever been addicted to narcotics?" D. "Do you have a list of your prescription medications?"

A.

The nurse is planning the care of the surgical client having procedural sedation. Which intervention has highest priority? A. Assess the client's respiratory status. B. Monitor the client's urinary output. C. Take a 12-lead ECG prior to injection. D. Attempt to keep the client focused.

A.

The nurse requests the client to sign a surgical informed consent form for an emergency appendectomy. Which statement by the client indicates further teaching is needed? A. "I will be glad when this is over so I can go home today." B. "I will not be able to eat or drink anything prior to my surgery." C. "I can practice relaxing by listening to my favorite music." D. "I will need to get up and walk as soon as possible."

A.

Which activities are the circulating nurse's responsibilities in the operating room? A. Monitor the position of the client, prepare the surgical site, and ensure the client's safety. B. Give preoperative medication in the holding area and monitor the client's response to anesthesia. C. Prepare sutures; set up the sterile field; and count all needles, sponges, and instruments. D. Prepare the medications to be administered by the anesthesiologist and change the tubing for the anesthesia machine.

A.

Which problem should the nurse identify as priority for client who is one (1) day postoperative? A. Potential for hemorrhaging. B. Potential for injury. C. Potential for fluid volume excess. D. Potential for infection.

A.

NPO

6 hours for solid foods 2 hours for clear liquids MAKE SURE TO ASK WHEN PT LAST HAD SOMETHING TO DRINK

Urine output

>30 mL/hr

PRIORITIES during immediate postoperative stage

A airway patency B ventilation C circulatory status

The nurse identifies the nursing diagnosis "risk for injury related to positioning" for the client in the operating room. Which nursing intervention should the nurse implement? A. Avoid using the cautery unit which does not have a biomedical tag on it. B. Carefully pad the client's elbows before covering the client with a blanket. C. Apply a warming pad on the OR table before placing the client on the table. D. Check the chart for any prescription or over- the-counter medication use.

B.

Sedatives

Adverse effects: total flaccid paralysis. Pt must not be on an antidepressant

Post-op complications

Airway obstruction, hypoxemia, hypoventilation

Intraoperative

Airway patency is the MAIN priority in all situations but cardiovascular problems can also arise

Criteria indicating readiness for discharge from the PACU

Aldrete score of 8-10, stable vital signs, no evidence of bleeding, return of reflexes, minimal to absent N/V, wound drainage that is minimal to moderate, urine output of at least 30 mL/hr

R/F local anesthesia

Allergy to ester-type anesthetics, alterations in peripheral circulation

Who can transfer a client from OR to PACU?

Anesthesia provider or CRNA

Spinal block

Anesthetic injection into the CSF in the subarachnoid space to provide autonomic, sensory and motor blockade below the level or innervation

Epidural

Anesthetic injection into the epidural space in the thoracic or lumbar areas of the spine to block sensory pathways but leave motor function intact

Topical anesthetic

Apply directly to the skin or mucous membranes

Verify surgical site and mark it

Ask patient "what procedure are you here for today?"

Medications to hold

Aspirin (acetylsalicylic acid) 1 wk before surgery Herbal meds: 2-3 wks before surgery

Initial postoperative care

Assessments, administering medications, managing clients pain, preventing complications and determining when a client is ready to be discharge from the PACU

A nurse evaluates that a preoperative client can properly use a volume incentive spirometer when which client action is noted? A. Sits upright inserts the mouthpiece and blows until the lungs are emptied of air B. Sits upright, exhales, seals lips around the mouthpiece, inhales, and holds breath for 5 seconds C. Sits at the edge of the bed, coughs, inserts the mouthpiece and blows slowly for 10 seconds D. Sits at the end of the bed, breathes deeply five times, inserts the mouthpiece and inhales quickly

B.

The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication? A. Alteration in comfort. B. Risk for depressed respiratory pattern. C. Potential for infection. D. Fluid and electrolyte imbalance.

B.

The nurse is receiving a client from the postanesthesia care unit (PACU). Which interventions should the nurse implement? Select all that apply. A. Ambulate the client to the bathroom to void. B. Take the client's vital signs to compare with PACU data. C. Monitor all lines into and out of the client's body. D. Assess the client's surgical site. E. Push the client's PCA button to treat for pain during movement.

B. C. D.

The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature and complains of muscle stiffness. Which interventions should the nurse implement? Select all that apply. A. Give a back rub to the client to relieve stiffness. B. Apply ice packs to the axillary and groin areas. C. Prepare an ice slush for the client to drink. D. Prepare to administer dantrolene, a smooth- muscle relaxant. E. Reposition the client on a warming blanket.

B. D.

The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select all that apply. A. Perform passive range-of-motion exercises. B. Discuss how to cough and deep breathe effectively. C. Tell the client he can have a meal in the PACU. D. Teach ways to manage postoperative pain. E. Discuss events which occur in the post-anesthesia care unit.

B. D. E.

Preoperative nursing care

Begins when the decision is made or surgery is scheduled. Ends when the pt is transferred to the OR

Intraoperative nursing care

Begins when the pt is transferred from the OR. Ends when the pt is transferred to PACU

Postoperative nursing care

Begins when the pt leaves the OR for the PACU Ends when the pt is transferred to med-surg unit or sent home

General anesthesia anesthetics

Benzodiazepines, propofol DO NOT GIVE TO ALLERGIES WITH EGGS OR SOYBEAN Antidotes: naloxone-narcan (opioids), flumazenil-Romazicon (benzo)

Anesthetics

Betomidate, propofol

A physician writes an order to hold all the medications the morning surgery for a client with a history of type 1 diabetes mellitus and hypertension. A nurse should call the physician to clarify the hold order for what medication? A. Acetylsalicylic acid B. Docusate sodium C. Regular and NPH insulin D. Clonidine

C.

The nurse is assessing a client in the day surgery unit who states, "I am really afraid of having this surgery. I'm afraid of what they will find." Which statement would be the most therapeutic response by the nurse? A. "Don't worry about your surgery. It is safe." B. "Tell me why you're worried about your surgery." C. "Tell me about your fears of having this surgery." D. "I understand how you feel. Surgery is frightening."

C.

The nurse is completing a preoperative assessment on a male client who states, "I am allergic to codeine." Which intervention should the nurse implement first? A. Apply an allergy bracelet on the client's wrist. B. Label the client's allergies on the front of the chart. C. Ask the client what happens when he takes the codeine. D. Document the allergy on the medication administration record.

C.

The nurse must obtain surgical consent forms for the scheduled surgery. Which client would not be able to consent legally to surgery? A. The 65-year-old client who cannot read or write. B. The 30-year-old client who does not understand English. C. The 16-year-old client who has a fractured ankle. D. The 80-year-old client who is not oriented to the day.

C.

The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first? A. Apply antiembolism hose to the client. B. Attach the drain to 20 cm suction. C. Assess the client's vital signs. D. Listen to the report from the anesthesiologist.

C.

The three (3)-day postoperative client is complaining of unrelieved pain at the incision site one (1) hour after the administration of narcotic pain medication. Which action should the nurse implement first? A. Check the MAR for another medication to administer. B. Teach the client to use guided imagery to relieve the pain. C. Assess the client for complications. D. Elevate the head of the client's bed.

C.

Which technique would be most appropriate for the nurse to implement when assessing a four (4)-year-old client in acute pain? A. Use words a four (4)-year-old child can remember. B. Explain the 0-to-10 pain scale to the child's parent. C. Have the child point to the face which describes the pain. D. Administer the medication every four (4) hours.

C.

You are assigned to care for a patient who underwent surgical cholecystectomy. Several potential complications or conditions may occur. Which of the following nursing diagnosis would have the highest priority in caring for this patient? A. Impaired skin integrity related to biliary drainage status post surgery B. Altered nutrition related to dietary modifications C. Impaired gas exchange related to surgical procedure D. Knowledge deficit regarding home care

C.

The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply. A. The client has loose, decayed teeth. B. The client is experiencing anxiety. C. The client smokes two (2) packs of cigarettes a day. D. The client has had a chest x-ray which does not show infiltrates. E. The client reports using herbs.

C. E.

Postoperative diet

Check for bowel sounds before giving any food or liquids

If hypotension occurs as an adverse effect of medication or dehydration

Lower the head of the bed, administer a prescribed IV fluid bolus and monitor and notify the surgeon and anesthesiologist

The circulating nurse and the scrub technician find a discrepancy in the sponge count. Which action should the circulating nurse take first? A. Notify the client's surgeon. B. Complete an occurrence report. C. Contact the surgical manager. D. Recount all sponges.

D.

The nurse is preparing a client for surgery. Which intervention should the nurse implement first? A. Check the permit for the spouse's signature. B. Take and document intake and output. C. Administer the "on call" sedative. D. Complete the preoperative checklist.

D.

Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery? A. Calcium 9.2 mg/dL. B. Bleeding time two (2) minutes. C. Hemoglobin 15 g/dL. D. Potassium 2.4 mEq/L.

D.

Which nursing intervention is the highest priority when administering pain medication to a client experiencing acute pain? A. Monitor the client's vital signs. B. Verify the time of the last dose. C. Check for the client's allergies. D. Discuss the pain with the client.

D.

Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? A. Complete the preoperative checklist. B. Assess the client's preoperative vital signs. C. Teach the client about coughing and deep breathing. D. Assist the client to remove clothing and jewelry.

D.

Which violation of surgical asepsis would require immediate intervention by the circulating nurse? A. Surgical supplies were cleaned and sterilized prior to the case. B. The circulating nurse is wearing a long- sleeved sterile gown. C. Masks covering the mouth and nose are being worn by the surgical team. D. The scrub nurse setting up the sterile field is wearing artificial nails.

D.

Anticholinergics

Decrease risk of bradycardia. Decrease salivation,decrease risk of aspiration

Health history

Diagnosed medical conditions, allergies, previous sx, medication use, substance use, lab results DVT or PE risk, head 2 toe assessment, pregnancy status and chronic diseases

Checklist

Ensure everything on checklist is complete prior to pt leaving preop

How often does PACU nurse check vitals?

Every 15 minutes until the patient is stable

PACU nurse

Full head to toe assessment, keeping in mind ABC's

Client responsibilities for informed consent

Gives informed consent. Must give it voluntarily, be completed and of legal age or be emancipated minor. When the client is unable to provide consent, another authorized person must give consent and receive enough information to make a decision based on an understanding of what to expect

Malignant hyperthermia

Hypermetabolic condition causing an alteration in calcium activity in muscle cells. Muscle rigidity causes damage to CNS. Anesthetics is a trigger, s/s increased CO2, tachycardia, hypotension, cyanosis, EXTREMELY high temp 111 F

Positioning for PACU

If responding to verbal stimuli: semi-fowlers If unresponsive: right or left lateral position If hypotension or shock: elevate legs and lower head of the bed If recovering from spinal anesthesia: do not elevate legs higher than placement on a pillow

Regional nerve block

Injection into or around specific nerves

Nerve block

Injection of anesthetic around or into an area of nerves to block sensation often for surgery on an extremity or for chronic pain

Field block

Injection of anesthetic around the operative field for procedures of the chest, plastic surgery, dental and hernia repairs

Local infiltration

Injects directly into the tissues through which the surgeon will make an incision

R/F general anesthesia

Malignant hyperthermia, respiratory disease (smoking, asthma), cardiac disease, GI, alcohol or drug use

CSF leakage

Manifests with a severe headache when the ead of the bed is elevated. Keep the head of the bed flat to promote the dura tear to seal. Provide a quiet environment and keep the client well hydrated to help replace CSF loss

Benzodiazepines

Midazolam, diazepam

Opiods

Morphine, fentanyl and alfentanil

Local anesthesia

Movement returns first, then sense of touch, pain, warmth and sensation of cold

Invasive devices aka drains, catheters and IV lines

Must document INO and color

Skin preparation

NO SHAVING, trim with electric razor. Remove jewelry, dentures, prostheses, makeup, nail polish and glasses. Hearing aids remain in

Normal lab values

Na: 136-145 Mg: 1.3-2.1 Ca: 9-10.5 K: 3.5-5.0 BUN: 10-20 Creatinine: 0.6-1.2 WBC: 5,000-10,000 PTT: 0.7-1.8 Hgb: F: 12-16, M: 14-18 Hct: 37%-47%

Informed consent

Nurse is only able to witness and reinforce teaching, NO teaching (only surgeon)

Preprocedure

Obtain a full history including allergies, medication usage and pre-existing medical conditions. Note the last dose of each med especially if it could alter the clients response (diuretic, antihypertensive, opioid). Perform a full assessment, determine the last time the client ate or drank. Establish IV access and administer fluids. Verify that the client signed the informed consent. Attach monitoring equipment and remove dentures in case intubation becomes necessary

Provider responsibilities for informed consent

Obtains informed consent. Must give the purpose of the procedure, a complete description of the procedure, a description of the professionals who will perform and participate in the procedure, a description of the potential harm, pain or discomfort that might occur and the option to refuse treatment and the consequences doing so

Preop medication

Prophylactic antibiotics are administered within 1 hour of surgical incision, if the client previously took a beta blocker, administer prior to surgery

12 lead EKG

Receives baseline rhythm, dysrhythmias and cardiac diseases. ALL PTS OLDER THAN 40 YEARS OLD

Intraprocedure

Remain with the pt at all times, continually assess and monitor LOC, cardiac rhythm, RR and vital signs. Pay CAREFUL attention to cardiac and respiratory status for older clients as problems can arise faster. The following equipment must be present within immediate reach for routine monitoring and in case deep sedation with respiratory depression occurs: emergency cart, a 100% O2 source, ECG monitor and display, noninvasive BP monitor,pulse oximeter, thermometer and stethoscope

All pts should receive info about deep breathing, coughing and early ambulation

Show pt how to use incentive spirometer. to prevent atelectasis and pneumonia

wound dehiscence and evisceration

Stay with patient and call for help, low fowler's position with hips and knees bent, cover wound with sterile wet normal saline gauze, do not attempt to reinsert organs, notify physician

Nursing actions for malignant hyperthermia

Terminate surgery, administer dantroleve IV, O2 > 100%, ICED ns 0.9%, cooling blanket, monitor INO, BP, and ABG

Reposition every 2 hours

To prevent pressure injuries, DO NOT place pillows under the knees or elevate the knee gatch on the bed

If pt is only able to sign consent with an "x", blind, deaf or english is a second language

Two witnesses are required, BOTH nurses MUST be in the room

Incentive spirometer

Use every 1-2 hrs while awake

Flumazenil (Romazicon)

Used for benzodiazepine overdose

Antiemetics

Used for nausea and vomiting post-anesthesia. Use metoclopramide with caution if history of parkinsons disease and asthma

Naloxone (Narcan)

Used for opioid overdose

Nurse responsibilities for informed consent

Witnesses informed consent. must ensure that the provider gave the client the necessary information, ensure that the client understood the information and is competent to give informed consent, have the client sign the informed consent document, notify the provider if the client has more questions or appears not to understand any of the information and document questions the client has, notification of the provider, reinforcement of teaching and use of an interpreter.

Watch video on incentive spirometry

http://media.atitesting.com/RM/01_AMS/Media_02/RM_AMS_Ch108_Incen_Spiro_Media2/index.html