Chapter 17: Preoperative Care -- 121
The patient scheduled for a colectomy asks the nurse why cefazolin has been prescribed by the health care provider. What is the most appropriate response by the nurse?
"Cefazolin is being given for two days to prevent postoperative infection." -Cefazolin is a cephalosporin-type antibiotic that reduces the risk of postoperative infection. When used as prophylaxis, it commonly is used for 48 hours. It is not an antiinflammatory, an analgesic, or an acid-reducer.
A patient with diabetes is waiting in the preoperative holding area for a hernia operation. The patient asks the nurse if the daily insulin dose should be taken. Which response is the most appropriate?
"I will check with the surgeon and let you know." -If a diabetic patient on insulin is due for surgery, it is important to get clear instructions from the surgeon regarding the insulin administration. The surgeon may choose to avoid the dose or give an adjusted dose based on the blood sugar levels. The nurse should not suggest taking a reduced dose, because it may cause a fluctuation in blood sugar levels. The insulin should not be replaced with oral drugs unless advised by the surgeon. The insulin dose may be skipped if the surgeon advises that.
A patient is instructed not to have anything to eat or drink eight hours prior to surgery. When arriving to the preoperative holding area, the patient informs the nurse they ate eggs and toast about 2 hours ago. What is the best response by the nurse?
"I will inform the anesthesia care provider and surgeon to see what the options are." -The nurse should inform the anesthesia care provider and surgeon that the patient has ingested solid foods 2 hours prior to surgery so that the options for surgery can be discussed. The surgery will most likely be delayed since this increases the patient's risk for complications such as aspiration. The patient should not be demeaned or chastised about eating and will not be kept the hospital overnight to ensure they do not eat again.
The nurse is conducting a preoperative class for a group of older adults who are scheduled for hip replacement surgery. During the planning meeting for this class, which of the nurse's statements reflects a correct understanding of the older adult surgical patient?
"I will watch the participants for signs of excessive anxiety." -Be particularly alert when assessing and caring for the older adult surgical patient. An event that has little effect on a younger adult may be overwhelming to the older patient. Emotional reactions to impending surgery and hospitalization often intensify in the older adult. Help to decrease anxieties and fears, as well as maintain and restore the self-esteem of the older adult during the surgical experience. Simply reading a handout may not be sufficient. Consider that sensory deficits may be present, and bright lights may bother those with eye problems. These and other changes may require more time for the older adult to complete preoperative testing and understand preoperative instructions.
The nurse is preparing to administer a preoperative dose of cefazolin prior to an open cholecystectomy. What is the best explanation to the patient about why they are receiving this medication?
"It will prevent postoperative surgical-site infection." -Cefazolin has enhanced activity against a wide variety of gram-negative organisms and is being used for perioperative prophylaxis against infection at the surgical site. The bowel has a wide variety of bacterial flora that could contaminate the abdominal cavity during surgery. This antibiotic is not used to prevent pneumonia. If the patient has a current infection (UTI), surgery may be postponed. The antibiotic will not remove all bacteria from the intestines but will reduce the risk of postoperative infection from intestinal bacteria.
The nurse is performing a preoperative assessment for a patient scheduled for surgery. What does the nurse explain to the patient is the reason for obtaining accurate documentation of the current medications being taken?
"Some medications may interact with anesthetics, altering the potency and effect of the drugs." -Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that they have been communicated to the anesthesia care provider. Medications generally do not alter the patient's perceptions about surgery. The anesthetics may interact with the other medications, but they are not likely to alter renal and hepatic function. Routine medications are not always held during surgery, and dosage and schedule adjustments are not always necessary. Routine medications may or may not be prescribed for use the day of surgery. Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other examination questions.
An older adult patient is undergoing preoperative assessment and teaching. What nursing interventions are appropriate during the education process? Select all that apply.
-Coordinate assessment with the team of health care providers. -Speak slowly when giving preoperative instructions to the patient. -Understand that the patient may have sensory and cognitive deficits -Older adults need careful preoperative assessments and teaching, because they are more prone to surgery-related complications. Sensory and cognitive deficits may make their learning slow; therefore, the nurse should go slowly when teaching about preoperative care. Because older adults may have many physical and neurosensory problems, the nurse should coordinate with a team of health care providers to provide a complete assessment. The older patient should never be made to walk to the operating room; a stretcher or wheelchair should be used. Administering a sedative is a general measure and not specific to older adults.
A patient due for surgery expresses concern about choosing between ambulatory surgery and inpatient regular surgery. Which information should the nurse include when comparing ambulatory to inpatient surgery for the patient? Select all that apply.
-It involves minimal laboratory tests -It requires fewer preoperative medications -It reduces the risk of hospital-acquired infections -Ambulatory surgeries are often preferred over inpatient surgeries. These surgeries are usually minimally invasive, involve minimal laboratory tests, and require fewer preoperative medications. Because the patient recovers comfortably at home, there is no risk of hospital-acquired infections. These surgeries are less costly for both patients and insurers. STUDY TIP: When forming a study group, carefully select members for your group. Choose students who have abilities and motivation similar to your own. Look for students who have a different learning style than you. Exchange names, email addresses, and phone numbers. Plan a schedule for when and how often you will meet. Plan an agenda for each meeting. You may exchange lecture notes and discuss content for clarity or quiz one another on the material. You could also create your own practice tests or make flash cards that review key vocabulary terms.
The nurse is to administer preoperative antibiotics to a group of patients. What patients are determined to require this medication? Select all that apply.
-Patients undergoing gastrointestinal surgery -Patients undergoing joint replacement surgery -Patients with a history of valvular heart diseases -In patients with a history of valvular heart disease, antibiotics may be administered to prevent infective endocarditis. Gastrointestinal surgery carries a risk of wound contamination and calls for antibiotic treatment. In joint replacement surgeries, wound infections can have serious consequences; therefore, it is prudent to give antibiotics. Patients undergoing cataract surgery may require eyedrops, and patients with a history of coronary artery disease may require beta blockers but not antibiotics.
A patient with a body mass index (BMI) of 45 is admitted for abdominal surgery. The nurse explains to the patient the potential complications of abdominal surgery caused by obesity. Which statements should the nurse include in the explanation? Select all that apply.
-The risk of wound infection is higher -Anesthesia administration is more difficult. -The risk of a postoperative incisional hernia may be higher. -It is difficult to administer anesthesia in obese patients due to the stress on the cardiopulmonary system caused by the increased body weight. Postoperatively, there is a high risk of incisional hernia due to increased stress on the sutures in obese patients. Because adipose tissue is less vascular than other tissue, the healing of the incisional site is slow, creating a high risk of wound infection. Due to fat deposits, access to the surgical site may be difficult in an obese patient. Some anesthetic agents are stored by adipose tissue and stay in the body for longer time, so the patient may recover slowly from anesthesia.
The nurse is preparing several patients for surgical procedures. What patient should the nurse most closely monitor for bleeding as a result of medication being taken?
A man who is taking clopidogrel after the placement of a coronary artery stent -Any drug that inhibits platelet aggregation, such as clopidogrel, represents a bleeding risk. Insulin, metoprolol, and finasteride are less likely to contribute to a risk for bleeding.
A patient with Alzheimer's disease arrives via ambulance from a long-term care center to the preoperative area for placement of a feeding tube. The ambulance service hands the nurse a chart and states the nursing home did not obtain consent for the procedure. The patient is confused. What is the nurse's best course of action?
Contact the family member identified as the patient's power of attorney on the patient's medical record to obtain consent. -The nurse should review the patient's medical record to locate next of kin or power of attorney to request consent. If the legal guardian has not been informed by the surgeon of the need for the procedure, possible complications, and alternative treatments, the consent cannot be obtained. Sending the patient back to the nursing home and rescheduling the procedure does not assist the patient in receiving appropriate care. It is illegal to obtain consent from a confused patient by getting him or her to sign an "X." Placement of a feeding tube is not an emergent surgery that can forego legal consent.
As the nurse is preparing a patient for outpatient surgery, the patient wants to give the patient's hearing aid to the spouse so it will not be lost during surgery. Which action by the nurse should be taken in this situation?
Encourage the patient to wear it for the surgery. -Although jewelry is removed before surgery, hearing aids should be left in place to allow the patient to better follow instructions given in the surgical suite and the postanesthesia care unit (PACU), as well as the dismissal instructions that will be given before the patient returns home for recovery. Removing the hearing aid could cause issues for the patient in following instructions in the surgical suite and PACU. Taping the hearing aid to the patient's ear is not necessary to prevent loss. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question.
A patient with obesity (BMI 26.1 kg/m 2) is scheduled for a laparoscopic hernia repair at an outpatient surgery setting. What should the nurse be prepared for prior to the surgery?
Explain to the patient that surgery will use minimally invasive techniques -Many operative procedures are performed as ambulatory surgery (i.e., same-day or outpatient surgery). The case implied that a laparoscopic technique will be used that involves several small incisions and meets the requirement of a minimally invasive technique. No portions of the colon will be removed during this type of surgery. Obesity is not a contraindication for surgery in the outpatient setting. This patient is not classified as obese based on the BMI.
. A patient who normally takes an oral antidiabetic agent twice a day, at morning and at bedtime, asks the nurse what to do about the dose the morning of the surgery. What is the best response by the nurse?
Get instructions from the health care provider for any special instructions. -Insulin or oral hypoglycemic agents may require dose or agent adjustments during the perioperative period because of increased body metabolism, decreased oral intake, stress, and anesthesia. Health care providers may instruct patients to withhold these medications before surgery. The nurse will need to contact the health care provider for any special instructions. It is not within the nurse's scope of practice to tell the patient to skip the dose or take the medication. Test-Taking Tip: Become familiar with reading questions on a computer screen. Familiarity reduces anxiety and decreases errors.
The nurse is administering a preoperative medication orally. What nursing action is appropriate when performing this intervention?
Give the medicine with a small sip of water. -The preoperative medication should be given with a small sip of water 60 to 90 minutes before shifting the patient to the operating room. The medication should not be given only 5 minutes before going to the operating room, because effects of the medication will not begin to potentiate yet. The patient should not be given large amounts of fluid or milk orally, because it can increase the chances of regurgitation and asphyxia during surgery under the effects of anesthetics. Test-Taking Tip: Attempt to select the answer that is most complete and includes the other answers within it. For example, a stem might read, "A child's intelligence is influenced by:" and three options might be genetic inheritance, environmental factors, and past experiences. The fourth option might be multiple factors, which is a more inclusive choice and therefore the correct answer.
The nurse is doing a preoperative assessment on a patient who has type 2 diabetes mellitus, weighs 146 kg, and is 5 feet 8 inches tall. Which patient assessment is a priority related to anesthesia?
Has body mass index of 48.8 -The patient's body mass index is the priority because it indicates the patient is severely obese. The patient's size may impair the anesthesiologist's ability to ventilate and medicate the patient properly, as well as the surgery room staff's ability to position the patient safely. An elevated hemoglobin A1C is important, but not a priority. Seasonal allergies are not a priority. History of postoperative vomiting is important when determining which postoperative drugs to give, but is not a priority.
The nurse is preparing a patient for surgery when they state, "I am terrified to be put to sleep. What if I don't wake up?" What is the priority action by the nurse?
Inform the anesthesia care provider (ACP) so that he or she can talk further to the patient. -If the nurse identifies that the patient has fear of anesthesia, inform the ACP immediately so that he or she can talk further with the patient. Reassure the patient that a nurse and ACP will be present at all times during surgery. The nurse could use guided imagery to help manage fear or administer an antianxiety medication (if prescribed), but these interventions do not address directly the reason behind the patient's fear, so they would not be the priority. It is not within the nurse's scope of practice to describe the type of anesthesia that the patient will receive.
The nurse is admitting a patient to the same-day surgery unit and informs the nurse that they took kava last night to help them sleep. Which nursing action would be most appropriate?
Inform the anesthesiologist of the patient's recent use of kava -Kava may prolong the effects of certain anesthetics. Thus the anesthesiologist needs to be informed of recent ingestion of this herbal supplement. Patients should not take anything before surgery without the health care provider's knowledge.
A woman is admitted to the hospital for an elective surgery. Her laboratory reports reveal that she is pregnant. An ultrasound of the abdomen shows that the fetus is 4 weeks old. What action should the nurse take immediately?
Inform the surgeon -Because anesthetics can put the mother and fetus at risk, exposure to anesthetics should be avoided. In this case, the priority is safety of the patient and fetus, so the nurse should immediately inform the surgeon. The surgeon will make the decision regarding the surgery. The husband and the anesthetist can be informed later. Congratulating the woman is important but is not the first priority.
A patient is scheduled for a gastrectomy. During the preoperative evaluation, the patient reports taking ginseng regularly. What should the nurse do?
Inform the surgeon -The priority intervention is to inform the surgeon. The gastrectomy needs to be rescheduled. The next priority is to suggest that the patient discontinue the use of ginseng because ginseng increases blood pressure before and during surgery. Vitamin E should not be taken because it can increase bleeding. Decreasing the dose of ginseng will not remove the risk. Use of any herbal product should be discontinued 2 to 3 weeks before surgery because such medicines may increase the risk of postoperative bleeding.
A patient asks the nurse whether it is alright to take regularly scheduled insulin on the morning of surgery. What is the most appropriate nursing action?
Inform the surgeon of the patient's insulin use and ask whether the dose needs to be adjusted. -If the patient is taking insulin for diabetes, the nurse should inform the surgeon in order to obtain prescriptions concerning the insulin dose to be given on the day of surgery. Low or high blood sugar can lead to complications during surgery; therefore, blood sugar should be strictly controlled. The patient should not skip or reduce the dose himself or herself but should consult the surgeon and adjust the dose, if advised.
A patient is scheduled for gastrointestinal surgery. Upon checking the patient's history, it is found that the patient is on long-term anticoagulation therapy. What action should the nurse take?
Instruct the patient to discontinue the anticoagulation therapy and expect to administer IV heparin during the perioperative period. -In the case of a patient on long-term anticoagulant therapy, IV heparin therapy can be used during the perioperative period in place of the anticoagulants. Herbal therapy increases the risk of postoperative bleeding, so should not be used. Discontinuing the anticoagulation therapy 1 week before surgery and continuing the anticoagulation therapy 1 month after surgery could increase the chance of complications.
During the preoperative assessment of a patient, the patient informs the nurse they have been drinking whiskey in large quantities for 10 years. How should the nurse help prevent postoperative complications related to alcohol intake?
Instruct the patient to stop consuming alcohol under medical supervision. -Chronic alcohol use can place the patient at risk because of lung, gastrointestinal, or liver damage. When liver function is decreased, metabolism of anesthetic agents is prolonged, nutritional status is altered, and the chances for postoperative complications are increased. Refraining from alcohol consumption may lead to alcohol withdrawal complications during lengthy surgery or in the postoperative period. Alcohol withdrawal can be dangerous, but the risk can be avoided with appropriate planning and management. Replacement of the beverage is not an option because doing so may have unintended negative consequences. Reducing the frequency of alcohol intake also increases the chances of complications. If the patient continues to consume alcohol before the day of surgery, he may experience complications during the perioperative period.
A diabetic patient taking insulin is scheduled for a thyroidectomy. What should the nurse tell the patient about insulin injections around the time of the surgery?
Insulin will be given after arrival in the preoperative holding area. -Blood glucose levels should be well maintained in diabetic patients, so they should be given a dose of insulin in the preoperative holding room or operating room. Insulin is injected subcutaneously. If insulin is given only after surgery, maintaining the sugar level during surgery would be difficult. Stopping insulin one day or one week before surgery is not advised.
A patient is admitted to the hospital for elective surgery. The patient is taking nonsteroidal antiinflammatory drugs (NSAIDs) for knee pain. The nurse recognizes that NSAID use will have what effect on a postoperative patient?
It may increase risk of postoperative bleeding. -Although analgesics are required for surgical patients, the use of NSAIDS should be stopped before surgery because these drugs are associated with increased postoperative bleeding. NSAIDS do not increase the risk of infections. NSAIDS do not cause atelectasis postoperatively. NSAIDS do not increase blood clotting.
A patient is about to undergo surgery for the first time and reports anxiety and taking alprazolam at bedtime last night. The vital signs show blood pressure (BP) 158/88, heart rate (HR) 96, and respiratory rate (RR) 24. What is the priority action by the nurse?
Notify the anesthesia care provider (ACP). -In determining the psychologic status of the patient, the nurse notes the patient's anxiety, which is supported by the elevated BP and heart rate, and restlessness. The nurse should notify the ACP after assessing the cause of the anxiety or fear the patient is experiencing. The patient may only need to talk about surgery, about concerns with the unknown or with body image, or about past experiences, to relieve the anxiety, but the nurse cannot assume that lack of knowledge is the cause of the anxiety. Medication administration will be prescribed by the ACP if needed, but medications also can be administered during surgery. Reassuring the patient is not taking the patient's needs into account.
The nurse asks the patient scheduled for a total hip replacement to sign the operative permit as directed in the health care provider's preoperative prescriptions. The patient states that the health care provider has not really explained what is involved in the surgical procedure. What is the most appropriate action by the nurse?
Notify the health care provider about the conversation with the patient and delay the signature. -The patient should not be asked to sign a consent form unless the procedure has been explained to his or her satisfaction. The nurse should notify the health care provider, who has the responsibility for obtaining consent. The health care provider must provide the information and clarify any confusion. It is not acceptable for the family to explain the procedure. The nurse cannot explain the procedure or ask the patient to sign the form without proper instruction and information.
The patient who is a devout Catholic is having surgery the following day for a heart valve replacement. The patient voices general concern about the surgery. Which is the best method for the nurse to use to help decrease the patient's anxiety?
Provide web-based and audiovisual teaching materials about the surgery. -Providing web-based and audiovisual teaching materials about the surgery is an effective way to help address and individualize the patient's concerns and to decrease anxiety. Assuring the patient that it is normal to have fears of dying during surgery does not individualize this patient's experience. Sharing the surgical story of a neighbor takes the focus off the patient and doesn't address the patient's needs, which may be different from the neighbor's. The nurse does not know what the blood loss will be during surgery and should therefore not provide false reassurances.
A patient is scheduled for an appendectomy. During the preoperative assessment, the patient states they developed allergic skin rashes when exposured to rubber gloves when admitted to the hospital a few years ago. The nurse should review the patient's medical record for a history of what?
Reactions to latex -A patient with a history of any allergic reactions has a greater potential for hypersensitivity to drugs given during anesthesia. Patients need to be screened specifically for latex allergies by checking the history of reactions that suggest an allergy to latex. Checking the history of sulfur allergy, herbal medication, and respiratory diseases would not help, because these conditions do not cause skin reactions.
A patient is scheduled for knee replacement surgery. The patient states that 5 years ago their father died due to sudden cardiac arrest. What is the most appropriate action by the nurse?
Review the electrocardiogram of the patient -Because the patient's father died due to sudden cardiac arrest, there is a chance that the patient may have a similar predisposition or condition. Reviewing the electrocardiogram of the patient is essential because it can give information about cardiac disease. Some diseases run in families, and the patient's risk of developing them should be determined. The platelet count report gives information about coagulation status. The hematocrit report gives information about anemia, immune status, and infection.
The nurse is transporting a patient to the operating room. What concern should be the first priority for the nurse?
Safety of the patient -When transporting the patient to the operating room, the nurse's primary concern should be the patient's safety. The nurse should help the patient to move from the hospital bed to the stretcher. The side rails should be raised. The patient may be transported to the operating room by stretcher or wheelchair. If no sedatives have been given, the patient may even walk accompanied to the operating room. Premedication, assessments, and laboratory values are major concerns during the preoperative period but not when transporting the patient. Test-Taking Tip: Watch for grammatical inconsistencies. If one or more of the options is not grammatically consistent with the stem, the alert test taker can identify it as a probable incorrect option. When the stem is in the form of an incomplete sentence, each option should complete the sentence in a grammatically correct way.
An older adult female patient has come to the ambulatory surgery center for surgery. Based on the assessment record below, what test should the nurse obtain for the health care provider before this patient's surgery?
Serum potassium -The nurse should seek a serum potassium level because the patient takes a diuretic. An electrocardiogram (ECG) also would be appropriate to seek with a history of hypertension and cigarette smoking. There are no indications for the need of blood glucose, pregnancy, or serum albumin tests.
A patient is a chronic smoker and is scheduled to have a benign tumor on the neck removed. To prevent perioperative complications, the nurse should instruct the patient to refrain from smoking for how many weeks before surgery?
The patient should stop smoking at least 6 weeks before surgery. -Smokers are at increased risk for respiratory complications during and after surgery. The health care professions should encourage smokers to quit smoking permanently or for at least 6 weeks before surgery to decrease the complications.
An older adult patient is admitted to the surgical unit for a right hemicolectomy. The nurse is concerned regarding the hydration status of this patient. What reason does the nurse have for this concern?
There is a narrow margin of safety between overhydration and underhydration in elderly patients. -The capacity to adapt to changes in fluid levels is low in elderly patients. The safety margin is very low between dehydration and over hydration, so the nurse should focus on the preoperative fluid balance history of this patient. Finding intravenous access in older patients may not be difficult. Old people do not sweat more than young people. Skin turgor assessment is a reliable measure for dehydration in this patient.
