Chapter 12

The nurse is caring for a client with an incision in the second phase of wound healing. Which statement by the nurse indicates an appropriate knowledge of wound healing?

"Granulation tissue forms during this phase." RATIONALE: Phase II is characterized as 3 to 14 days postoperative and the formation of granulation tissue in the wound bed.

The nurse is assisting with the care of a malnourished client being prepared for surgery. Which statement by the client regarding nutrition would indicate adequate teaching?

"I should take a vitamin with zinc and vitamin C in it after surgery." RATIONALE: Zinc has been shown to increase tissue growth, skin integrity, and cell-mediated immunity. Vitamin C has been shown to help with collagen formation for wounds. Both are good recommendations for clients who are potentially deficient in them.

The nurse is assisting a coworker in preparing a client for surgery. Which statement by the coworker would warrant intervention by the nurse?

"I will let the client keep her nail polish on." RATIONALE: Nail polish, makeup, and artificial nails should be removed before surgery so natural skin tone can be seen.

The nurse is reviewing informed consent with a coworker. Which statement by the coworker would concern the nurse?

"This protects the hospital from all lawsuits." RATIONALE: Consent does not protect the hospital from claims of malpractice or harm to the client. Informed consent only protects against claims of unauthorized procedures.

The nurse is assisting a registered nurse (RN) in discharging a client after procedural sedation. Which statement by the RN would warrant intervention by the nurse?

"You can drive yourself home." RATIONALE: Client cannot operate heavy machinery for 24 hours after sedation

The nurse is assisting a coworker in the preoperative health history for a client scheduled for surgery. Which statement by the coworker would concern the nurse?

"You can stop your steroids now." RATIONALE: Stopping of oral steroids abruptly can cause circulatory collapse. The surgeon should order a parenteral route for the steroids until after surgery.

The nurse is discharging a client after surgery. Which recommendation by the nurse to the caregiver is appropriate for this client? Select all that apply.

- "A shower stool can help the client bathe themselves easier." - "Always wash your hands before and after wound care." - "Place extra pillows and blankets on the bed." - "Try to place the client on the first floor." RATIONALE: - Shower grab bars and stools can allow the client more independence when bathing and reduce caregiver strain. - Strict hand washing before and after wound care will help prevent infections. - Placing extra blankets and pillows on the bed will assist in positioning and the comfort of the client. - Having the client in a bedroom on the first floor can be helpful when trying to get the client to the bathroom and kitchen during the day.

The nurse is assisting in the discharge of ambulatory postoperative clients. The nurse determines which client is ready for discharge? Select all that apply.

- 24-year-old client complaining of no nausea after PO (oral) hydrocodone given 30 minutes prior - 14-year-old client with his mom present RATIONALE: - PO pain medications can be given prior to discharge for pain relief during travel if a responsible adult is available to drive the client home. - A client can be discharged home to a responsible adult or caretaker.

The nurse is caring for a sedated client undergoing surgery. The nurse understands that what needs to be assessed during perianesthesia? Select all that apply.

- Airway maintenance - Intake and output - Exhaled end-tidal carbon dioxide (EtCO2) - Hand-off report to receiving nurse RATIONALE: - The nurse should monitor that the endotracheal tube is not dislodged and that no airway problem occurs. - The nurse should keep track of the amount of fluid given and lost during surgery. - EtCO2 monitoring during sedation is critical for monitoring oxygenation status and should be documented with every check of vital signs. - The nurse should always document who received the report and what time it was given when hand-off occurs.

The nurse is caring for a client undergoing surgery with the nursing diagnosis of deficient knowledge related to lack of previous surgical experience. Which nursing intervention is appropriate? Select all that apply.

- Assess client's anxiety levels - Provide client with written and verbal materials - Document client understanding and teaching provided - Include family members in teaching - Identify knowledge deficiencies

The practical nurse (PN) is assisting a client in the operating room. Which actions can the PN assist with? Select all that apply.

- Assist client onto operating table - Apply monitoring equipment to client - Remove body hair Any administration of paralytics and anesthesia or insertion of catheters or tubes must be completed by either the anesthesiologist or registered nurse

The nurse is assisting in the surgery of a client experiencing malignant hyperthermia. Which intervention should the nurse anticipate? Select all that apply.

- Discontinuation of anesthesia - 100% oxygen given - Change to cooled fluids - Administration of dantrolene sodium (Dantrium) RATIONALE: - Anesthesia is a suspected trigger for malignant hyperthermia and will be discontinued immediately by the anesthesiologist. - 100% oxygen is given via mask or ET tube to support the increased metabolic processes occurring in the muscles of the client. - Ice packs and cooled fluids are given to help lower core body temperature. - Dantrolene sodium is a potent muscle relaxer and is the most effective medication for malignant hyperthermia.

The nurse is educating a client about the use of incentive spirometry after surgery. Which statement by the nurse is correct? Choose all that apply.

- Elevate the head of the bed to at least 45 degrees - Exhale completely - Hold breath for 3 to 5 seconds - Perform hourly while awake RATIONALE: hourly performance prevents buildup of fluid in the lungs

The nurse is obtaining vital signs on a client after surgery. The nurse understands which vital sign should be continuously monitored? Select all that apply.

- End-tidal carbon dioxide (EtCO2) - Blood Pressure - Pulse Oximetry - Electrocardiogram RATIONALE: EtCO2 monitors the amount of carbon dioxide exhaled by the client and can be an indicator of respirator status in sedated clients. Blood pressure should be monitored until the patient is awake. Pulse oximetry should be monitored to ensure the patient is oxygenating appropriately. Heart rhythm and rate should be monitored until the patient is stable.

The nurse is reviewing the laboratory test results for a client experiencing malignant hyperthermia. Which laboratory finding would the nurse expect? Select all that apply.

- Hyperkalemia - Respiratory acidosis - Metabolic acidosis RATIONALE: - Hyperkalemia is an expected abnormal value due to cell destruction occurring. - The high rate of metabolism occurring can lead to anaerobic metabolism and lactic acid formation, causing metabolic acidosis.

The nurse is caring for a client with the nursing diagnosis of pain related to tissue damage from surgery. Which intervention by the nurse is appropriate? Select all that apply.

- Monitor client pain using the appropriate pain rating scale. - Monitor cognitively impaired clients at the beginning of the shift and frequently. - Position the client comfortably. RATIONALE: - Self-reported pain is the most reliable indicator of pain in a client, and the use of an appropriate pain scale is critical for accurate reporting. - Clients who are cognitively impaired are vulnerable to undertreatment of pain. - Repositioning of tubes, drains, and equipment can help alleviate pain caused from pulling or tugging on wound sites.

The nurse is caring for a client with the nursing diagnosis of impaired physical mobility related to surgery and decreased strength. Which nursing intervention is appropriate for this client? Select all that apply.

- Perform active and passive range-of-motion exercises. - Slowly elevate the head of the bed. - Sit client on side of bed prior to standing. - RATIONALE: Range-of-motion exercises should be done to prevent complications from surgery such as muscle wasting and blood clots. - The head of the bed should slowly be elevated so the client's circulatory system can adjust without dizziness or lightheadedness. - Starting the client on the side of the bed with their feet "dangling" can improve arterial circulation and blood flow to the extremities prior to standing.

The nurse is caring for a client with urinary retention after a hysterectomy. Which nursing intervention is appropriate when assisting this client? Select all that apply.

- Place bedpan in warmer before use - Record oral intake. - Assist client to bedside toilet. - Inform the surgeon if client has not voided in 4 to 6 hours. - Pour warm water over the perineum. RATIONALE: - Cold bedpans can cause reflexive sphincter tightening and inhibit emptying. - Recording oral intake and any output will assist the nurse in detecting urinary retention problems. - Assisting a client to the bedside toilet or men to a standing position can ease voiding rather than using a bedpan. - The typical time frame for clients undergoing gynecological surgeries is 4 to 6 hours. If the client has still not voided within the time frame then the surgeon should be informed. - Pouring warm water over a female's perineum, turning on running water, or drinking hot beverages are ways to stimulate voiding in clients.

The nurse is caring for a client during the intraoperative phase of surgery. Which nursing diagnoses are appropriate for this client? Select all that apply.

- Risk for injury - Risk for impaired skin integrity RATIONALE: - Clients in surgery are at an increased risk for injury related to positioning, injuries, or medications given. - Clients in surgery, especially longer surgeries, are at an increased risk for developing skin integrity issues due to their immobility and inability to reposition themselves.

The nurse is reviewing the care of surgical wounds with a coworker. Which wounds should the nurse categorize as dirty? Select all that apply.

- Second-degree burn on left hand - Abdominal incision after ruptured gallbladder - Reduction after an open fracture RATIONALE: - Accidental wounds are considered dirty and contain bacteria. - Surgical wounds that were contaminated with ruptured organs are considered dirty. - Wounds sustained due to trauma are considered dirty.

The nurse is assisting in the discharge of an elderly client after surgery. Which intervention best facilitates teaching in elderly clients?

- Speak slowly in a low tone RATIONALE: Elderly clients can hear lower tones easier than higher tones. Speaking slowly allows the client time to process and ask questions.

The nurse is assisting another nurse in the care of a postoperative client. Which intervention by the nurse will prevent deep vein thrombosis formation? Select all that apply.

- Use elastic stockings - Encourage early ambulation - Assist the client in foot circles hourly RATIONALE: - Elastic stockings or intermittent pneumatic compression devices will reduce the risk of thrombophlebitis. -Early ambulation will prevent blood stasis and prevent thromboembolism. - Early ambulation will improve blood flow and reduce venous stasis.

The nurse is assisting with a client just arriving to the surgical department. Place in order the priority of actions starting with highest priority first.

1) Verify client name, age, allergies, and consent. 2) Alleviate anxiety 3) Confirm surgical site 4) Begin prophylactic antibiotics

The nurse is caring for a client with an incision closed using staples. How long should the nurse expect the staples to remain in the client?

10 days

The nurse is calculating total intake for a client after a 12-hour shift. The client reports drinking 2 cups of orange juice for breakfast, one 12-ounce can of soda for lunch, and 2 cups of coffee for dinner. What is the total intake for this client?

1320mL RATIONALE: 1 cup = 8 ounces1 ounce = 30 mL4 cups = 8 ounces x 4 = 32 ounces x 30 mL = 960 mL12 ounces x 30 mL = 360 mL960 mL + 360 mL = 1320 mL

The nurse is caring for a client preparing for surgery. Which finding would concern the nurse?

Positive pregnancy test - Pregnant clients are not put under general anesthesia due to the potential harm in fetal exposure.

The nurse is calculating the intake and output of a client receiving nothing by mouth and receiving intravenous fluids at 75 ml/hr for 8 hours and has voided 250 mL. How many milliliters would the nurse expect for total intake for this client?

600ml RATIONALE: The output of the client does not matter when calculating total intake

The nurse is receiving a report on a team of four clients. Which client should the nurse see first?

A client complaining of left leg pain and swelling RATIONALE: This client should be seen first due to suspected deep vein thrombosis (DVT). DVTs present as swelling, warmth, redness, and pain in an extremity.

The nurse is recovering a client after receiving epidural anesthesia. The client is reporting pressure and pain in the abdomen. Which action by the nurse is appropriate?

Assess for urinary retention RATIONALE: Clients who received spinal epidurals can have urinary retention until the epidural has completely worn off.

The nurse is assisting in the care of a preoperative client. The client states, "I'm really afraid I won't make it through this surgery." Which action by the nurse is appropriate?

Call the surgeon to talk to the client. RATIONALE: The surgeon is the only one who can explain the complications and questions the client has about the surgery.

The nurse is caring for a drowsy client after surgery. Vital signs are pulse 112 beats/min, 16 breaths/min, SpO2 88% on room air, and blood pressure 145/88 mm Hg. Which nursing intervention is the priority for this client?

Ineffective airway clearance related to ineffective cough RATIONALE: The client was just taken out of surgery and is still drowsy from the sedation. Clients who are still lethargic from sedation do not cough or deep breathe appropriately and can have mucus build up in the lungs, inhibiting gas exchange.

The nurse is caring for a client in the postanesthesia care unit after an abdominal surgery. Which nursing action is appropriate?

Document the surgical site incision. RATIONALE: Documentation of surgical incision sites is critical to the prevention of complications. Hematoma formation and dressing status should be monitored.

The nurse is preparing a client for a knee replacement surgery. The nurse understands that this surgery is which level of urgency?

Elective RATIONALE: Elective surgeries are planned/scheduled in advance with no time requirements. Joint replacements and hernia repairs are examples.

The nurse is caring for a client after a mammoplasty. The nurse understands that the client had which procedure done?

Formation or repair of the breast

The nurse is caring for a client receiving a spinal block. Which symptom would most concern the nurse?

Hypotension RATIONALE: Hypotension after a spinal block is very concerning for decreased cardiac output and vasodilation. This is the highest concern for the nurse.

The nurse is assisting in the care of a client after open heart surgery. Which action by the other nurse would warrant intervention?

Instructing client to perform deep coughing every 30 minutes RATIONALE: Deep breathing and coughing should be performed in small sets every 1 to 2 hours. *Many complications of surgery are complications of decreased mobility, such as fluid in the lungs and deep vein thrombosis.*

The nurse is assisting during general surgery for a client. The nurse notes tachycardia, muscle rigidity, respiratory acidosis, and hyperthermia. The nurse suspects which complication of surgery?

Malignant hyperthermia RATIONALE: Malignant hyperthermia can occur to clients under general anesthesia and presents as tachycardia, muscle rigidity, respiratory or metabolic acidosis, and cyanosis. This is a medical emergency and must be addressed immediately.

The nurse is assisting in the care of a client undergoing anesthesia. Which medication would the nurse expect to be ordered by the health-care provider?

Midazolam RATIONALE: Midazolam is a sedative hypnotic commonly used for anesthesia induction.

The nurse is caring for a client in the postanesthesia care unit. Vital signs are pulse 88 beats/min, respirations 16 breaths/min, temperature 95.0°F (35°C), blood pressure 117/68 mm Hg. Which action is the priority for the nurse?

Obtain a forced-air warming system. RATIONALE: Active warming is indicated for hypothermic clients, and body temperature should be monitored every 15 minutes until return to normal temperature.

The nurse is caring for a client with a patient-controlled analgesia pump. The nurse finds the client lethargic and pale upon entering the room. Which intervention is priority?

Obtain a set of vital signs. RATIONALE: Obtaining vital signs can assist the nurse in assessing the problem. A low SpO2 and decreased respirations can indicate opioid overdose, whereas tachycardia and hypotension can indicate hemorrhage.

The practical nurse (PN) is assisting in the care of an elderly client preoperatively. Which action by the PN is appropriate?

Pad bony prominences RATIONALE: Elderly clients have an increased risk of pressure-related injuries during and after surgery.

The nurse is drawing general preoperative blood work on a client. Which laboratory test would the nurse expect to be ordered?

Partial thromboplastin time (PTT) RATIONALE: PTT levels are used to detect clotting problems and are drawn before surgery.

The nurse is caring for a client with a surgical incision that is 18 days old. The nurse understands that the wound is in which phase of wound healing?

Phase III RATIONALE: Phase III occurs from week 3 to week 6 postoperative. During this phase collagen is forming

The nurse is assisting in the recovery of a client in the postoperative unit after the removal of cerebrospinal fluid. The client is reporting a headache. Which intervention should the nurse anticipate?

Prepare for blood patch procedure RATIONALE: A leak of cerebrospinal fluid after a spinal tap is the cause of the headache. A blood patch performed by the anesthesiologist.

The nurse is assisting in the care of a client undergoing a closed fracture reduction. Which type of sedation would the nurse expect to be given to the client?

Procedural RATIONALE: Procedural sedation is used in clients not needing to undergo general anesthesia but local anesthesia is inappropriate. Common procedures include dental surgeries, endoscopy, cardioversion, and closed fracture reduction.

The nurse is assisting an unlicensed assistive personnel (UAP) in preparing a hospital room for the arrival of a postoperative client. Which action by the UAP would warrant intervention by the nurse?

Removal of IV pump from the room RATIONALE: Surgical clients will arrive to the room with IV fluids running. A pump should be there to transfer over to.

The nurse is caring for a client with the nursing diagnosis of deficient fluid volume related to hemorrhage after surgery. Which outcome would show improvement in fluid volume?

Return of urinary output to normal RATIONALE: Decreased urinary output is an indicator of decreased tissue perfusion.