Chapter 14 & 16

Which nonpharmacological interventions may help reduce pain and promote comfort in a patient being treated with analgesics who asks the nurse about alternative therapies for pain management? Select all that apply.

Answer: "Elevate and cushion the painful areas." "Apply some ice to reduce and prevent swelling." "Stimulate the area that is contralateral to the painful area." Alternative therapies include nonpharmacological comfort measures that may lower the amount of drugs needed to control pain. Elevating and cushioning painful areas prevents pressure or tension on those areas. Application of ice helps in reducing swelling and pain through reactive vasodilation mechanisms. Contralateral stimulation of the painful area is an alternative therapy to alleviate the pain. The calves should not be massaged because this can increase the risk of loosening a clot and causing a life-threatening pulmonary embolus. Splinting stabilizes and protects an injured body part.

The nurse is teaching a postoperative patient about the proper technique for splinting the incision site and coughing. Order the steps for this procedure in the correct sequence.

Answer: 1. Place a pillow, towel, or folded blanket over the surgical incision and hold the item firmly in place. 2.Take three slow, deep breaths to stimulate the cough reflex. 3.Inhale through the nose, and then exhale through the mouth. 4. On the third deep breath, cough to clear secretions while firmly holding the pillow or folded blanket against the incision. The purpose of coughing is to expel secretions, keep the lungs clear, allow full aeration, and prevent pneumonia and atelectasis. To properly cough while splinting the incision site, the patient first places a pillow, towel, or folded blanket over the surgical incision and holds the item firmly in place. Then, the patient takes three slow, deep breaths to stimulate the cough reflex. The patient inhales through the nose, and then exhales through the mouth. On the third deep breath, the patient is advised to cough to clear secretions while firmly holding the pillow or folded blanket against the incision.

A patient who received general anesthesia has arrived at the medical-surgical unit after discharge from the postanesthesia care unit. Which parameters need to be assessed by the nurse? Select all that apply.

Answer: Patient response to verbal stimuli Bleeding or drainage on the dressing Color, clarity, and volume of urine output The nurse should ask appropriate questions to assess the patient response to verbal stimuli, which helps detect alterations in the patient's mental status. Bleeding or drainage on the dressing determines surgical incision site and status. Observing the color, clarity, and volume of urine output provides evidence of returning kidney function and hydration status. A headache in the occipital region that is especially painful when patient sits in upright position indicates postdural puncture headache, which is one of the complications of spinal and epidural anesthesia. Asking the patient about an increase in back pain while coughing or straining helps detect complications of spinal and epidural anesthesia.

While gathering patient history during the preoperative phase, what statement would be most concerning pertaining to anesthesia?

Answer: "My mother spiked a fever right after her hip replacement." Malignant hyperthermia is an inherited condition that manifests while a patient is recovering from anesthesia and could become fatal. Symptoms may include a sudden rise in body temperature, rigidity, muscle aching, and dark-colored urine. While anemia decreases the blood's ability to carry oxygen, it can be easily managed with preoperative laboratory assessments such as a complete blood count (CBC) and medications given prior to date of surgery. Back pain while lying flat can be decreased with interventions such as elevating the knees and head slightly, and administering analgesic medications. Sleep apnea can pose difficulties for intubation by anesthesia, but will not change the surgical process.

How often does the nurse assess wound healing in a postoperative patient after the health care provider removes the initial dressing? Record your answer using a whole number. Every ___ hours

Answer: 8 The health care provider typically removes the dressing on the first or second day after surgery. Assessment of the incision is performed at least every 8 hours. Assessment of an undressed wound includes checking it for redness, increased warmth, swelling, tenderness or pain, and the type and amount of drainage

Which patient requires immediate attention in the postanesthesia care unit?

Answer: A patient with urine output of 400 mL per day The patient with inadequate urine output of 400 mL per day (normal range: 800-2000 mL per day) must be kept on continuous assessment to reduce complications. The patients with normal bleeding time (3 to 10 minutes), normal body temperature of 98.6° F, and stable blood pressure of 110/80 mm Hg may be discharged upon the primary health care provider's advice.

The nurse is providing preoperative care to a patient scheduled for cardiac surgery. Which nursing intervention is most critical to this patient?

Answer: Assessing for venous thromboembolism Conditions such as hypertension and venous thromboembolism can cause complications such as cardiac arrest during the surgery. Therefore, the nurse should assess for venous thromboembolism during the preoperative care. Explaining the surgical procedure to the patient can reduce anxiety but it is not as critical as assessing for venous thromboembolism. Involving the family in assessment upon the patient's consent can ensure comfort in the patient but it is not as critical as assessing for venous thromboembolism. Maintaining confidentiality about patient's health information ensures comfort in the patient but it is not as critical as assessing for venous thromboembolism.

The nurse is caring for a patient who underwent abdominal surgery. How does the nurse assist the patient with early recovery?

Answer: Assist the patient to turn every 2 hours and take deep breaths. The nurse can assist the patient to turn from one side to the other every 2 hours if the patient is unable to get out of bed. The patient should also be encouraged to take deep breaths to facilitate lung expansion. The patient is generally asked to get out of bed the day or the first day after surgery to help remove secretions. The patient is given pain medication 30 minutes before, not after, a walk. The nurse should teach the patient to splint the incision when coughing to prevent harm to incisions.

An older adult patient who is scheduled for abdominal surgery may have a risk for pulmonary complications. Which appropriate intervention may help the patient to reduce pulmonary complications post-surgery?

Answer: Coughing and deep-breathing exercises Coughing and deep-breathing exercises can help prevent pulmonary complications in older adults. Changing positions at least every 2 hours helps to prevent reduced blood flow to an area and changes external pressure patterns, reducing the risk of skin-related complications. Turning and positioning help to prevent complications resulting from immobility. Observing urine color is required for the proper assessment of any potential renal or urinary complications.

A patient is scheduled for back surgery. Which factors may increase the risk for surgical or postoperative complications? Select all that apply.

Answer: Diabetes, Cardiac disease, Antihypertensive drugs, Age older than 65 years Chronic illnesses increase surgical risks and should be considered when planning care. A diabetic patient needs more extensive bowel preparation due to decreased intestinal motility. Cardiac disease impairs the patient's ability to withstand hemodynamic changes and alters the response to anesthesia. Antihypertensive drugs are withheld on the day of surgery to reduce adverse effects on blood pressure during surgery. Age also increases the risk for complications because the normal aging process decreases immune system functioning and delays wound healing. In addition, reductions in muscle mass and body water increase the risk for dehydration. Marital status does not play any role in complication risks.

What condition is indicated by the presence of a pulse deficit when assessing the vital signs of a postoperative patient?

Answer: Dysrhythmia A pulse deficit is a difference between the apical and peripheral pulses. While assessing the vital signs of a patient who is not being monitored continuously, the rate, rhythm, and quality of the apical pulse is compared with the rate, rhythm, and quality of a peripheral pulse. A pulse deficit can indicate a dysrhythmia. The presence of a pulse deficit is not due to dyspnea, or shortness of breath. Hypothermia is not indicated by the difference in the pulse. Deep vein thrombosis is assessed by peripheral vascular assessment before anesthesia.

An unidentified patient from the emergency department requires immediate surgery, but he is not conscious and no one is with him. What must the nurse, who is verifying the informed consent, do?

Answer: Ensure written consultation of two noninvolved physicians. In a life-threatening situation in which every effort has been made to contact the person with medical power of attorney, consent is desired but not essential. In place of written or oral consent, written consultation by at least two physicians who are not associated with the case may be requested by the health care provider. It is not within the nurse's role to make a judgment about the patient based on the surgeon's consult. Signing documents on the patient's behalf is not legal. Withholding surgery is not in this patient's best interests.

What is the purpose of having a patient sign an informed consent form before surgery?

Answer: It protects the patient from unwanted procedures. The informed consent form helps protect the patient from unwanted procedures. The patient expresses a willingness for surgery by signing the informed consent form after the health care provider, surgeon, and nurse have provided the patient with adequate information about the purpose of the surgery, procedure, and complications involved. The informed consent form does not contain information about the surgical procedure, risks and complications, or details about any anesthetic to be administered.

The nurse is caring for a patient who is scheduled for back surgery. The patient's medical history includes gastroesophageal reflux disease (GERD). During transport to the operating room, the patient complains of burning chest pain which he rates as "8" on a pain scale of 0 to 10. Which nursing action is most appropriate?

Answer: Notify the surgeon and anticipate a cardiology consult The nurse should always inform the surgeon of any potential changes in the patient condition. Although the patient has a history of gastroesophageal reflux disease, the patient could also be displaying cardiac symptomology that may place the patient in danger during the surgery. Further assessment will likely require a cardiology consultation. Cancellation of the surgery may be necessary, however, further assessment is needed. Prior to administration of medication, further assessment is needed to determine the cause of the patient's chest pain. Sitting the patient upright may be appropriate; however, delaying treatment may place the patient in danger if the patient is experiencing a cardiac event.

Colostomy surgery is categorized as what type of surgery?

Answer: Palliative Palliative surgery is performed to relieve symptoms of a disease process, but does not cure the disease. Colostomy surgery would be categorized as palliative. Cosmetic surgery is performed primarily to alter or enhance personal appearance. Curative surgery is performed to resolve a health problem by repairing or removing the cause. Diagnostic surgery is performed to determine the origin and cause of a disorder or the cell type for cancer.

What is the primary reason for the placement of drains in the perioperative patient?

Answer: Removing fluid from the surgical site Drains help remove fluid from the surgical site. Vascular access is used for the delivery of medication and general anesthetic during surgery. Drains do not help in reducing the chances for infection.

The nurse is attending to a patient who had an appendectomy. What nursing intervention does the nurse perform for this patient?

Answer: Teaches the patient to splint the wound when turning in bed. The patient should be taught to splint the wound when turning in bed; pain drugs will be given as needed to reduce anxiety and pain during this activity. The patient is generally encouraged to get out of bed the day after surgery; the nurse can assist the patient into a chair or with ambulation. The patient should be taught to perform leg exercises with the head of the bed elevated to 45 degrees, and instructed to turn at least every 2 hours after surgery when confined to bed.

A patient is scheduled for a below the knee amputation. What is best practice regarding site preparation?

Answer: The surgeon and the patient confirm and mark the site. Whenever possible, best practice dictates that the surgical site should be marked by an independent licensed practitioner and the patient prior to the procedure. While having two independent licensed practitioners is adequate for marking a surgical site, it is not the best practice per The Joint Commission's National Patient Safety Goals (NPSGs). The patient is normally instructed to wash with special soap one to two days before the surgery. Electric clippers are to be used for hair removal because shaving increases the risk for infection by creating skin abrasions.

A 56-year-old male is to undergo right total hip replacement after falling at home. He reports his last drink of alcohol was three days ago. Which patient assessment would be most concerning to the nurse in the preoperative stage?

Answer: Tremors and restlessness Tremors and restlessness, seizures, disorientation, sweating, headache, and nausea and vomiting are all signs of delirium tremens, a possibly fatal complication of acute alcohol withdrawal. A urine output of greater than 30 ml/hour signifies normal kidney perfusion. Although both the patient's hematocrit (39-50%) and sodium (136-145 mEq/L) are slightly higher than normal, this is probably due to mild dehydration and would not take precedence to delirium tremens, which is an acute emergency that may be fatal if not corrected immediately.

A patient is scheduled for surgery. Which laboratory and/or diagnostic tests are routinely carried out before any surgery is performed? Select all that apply.

Answer: Urinalysis, Electrolyte levels, Hemoglobin level, Blood type and screen Laboratory tests before the surgery help to obtain baseline data about the patient's health and help to predict potential complications. Urinalysis provides information about any abnormal substances in the urine; any imbalance in electrolyte levels may affect anesthesia and the outcome of surgery. Hemoglobin level is essential to know if the body can tolerate hemodynamic changes during the surgery. Blood type and screen must be known in case a blood transfusion is required. An MRI examination would be performed only based on patient need, medical history, and the nature of the procedure; it is not a routine test before surgery.