Chapter 23-PrepU

The nurse is teaching a client who will undergo abdominal surgery to repair a hernia about leg exercises. When the client asks, "Why am I practicing leg exercises when I'm having hernia surgery?" what is the appropriate nursing response?

"Doing this reduces your risk of developing blood clots."

The nurse is performing a preoperative assessment for a client prior to surgery in the morning. What statement made by the client alerts the nurse that there is a potential for latex allergy? Select all that apply.

"I am allergic to banana's" "I had a rash after using a condom." "I broke out in hives after eating sliced avocado

The nurse is educating a client who is preparing for abdominal surgery tomorrow. A teaching demonstration has just been completed by the nurse related to splinting the incision site with a pillow. Which statement by the client best indicates the instructions provided by the nurse were effective?

"I will put the pillow on the incision then cough."

In order to prevent the possibility of venous stasis, a nurse is educating a surgical client on how to perform leg exercises. Which statement by the client indicates a sound understanding of leg exercises?

"I'll practice these now and try to start them as soon as I can after my surgery."

The nurse is preparing a client for a total hip arthroplasty and is obtaining data preoperatively. Which statement made by the client is most important for the nurse to immediately report to the health care provider?

"I've been taking ibuprofen for my hip pain twice a day."

A client is concerned about taking pain medication after surgery and asks, "Are there other things I can do to alleviate my pain?" Which is the best response by the nurse?

"Positioning and massage can also help to alleviate pain."

A client will be undergoing outpatient surgery in a few weeks. During this presurgical appointment, the nurse educates the client on necessary items regarding discharge to home after the procedure. What discharge information does the nurse teach the client?

"The center will not allow you to drive a car home. You should ask a responsible person to be available to accompany you home."

A client who is in the holding area awaiting knee replacement surgery tells the nurse, "I am afraid of getting HIV if I have to have a blood transfusion during this surgery." What is the appropriate nursing response?

"The risk of acquiring a blood-borne disease from a blood transfusion is very small."

The procedural physician has initiated performance of a time-out in the operating room before surgery. The student nurse asks the operating room nurse why this is important. What is the operating room nurse's best response?

"The time-out checks to be sure that we have the right client and procedure."

A postoperative client asks, "Why is it important to walk and exercise my legs?" Which is the best statement by the nurse?

"Walking and leg exercises will help prevent complications."

A young adult client has had an emergency appendectomy that caused the client to be out of work for 8 weeks. The client verbalizes stress over this unexpected situation. Which is the best response by the nurse?

"What have you done in the past to manage stress?"

The nurse is caring for a client after breast augmentation. Before performing a bowel assessment, what education will the nurse provide the client?

"You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By listening for bowel sounds, I can check for a return of peristalsis."

A nurse is educating a client about regional anesthesia. Which statement is accurate about this type of anesthesia?

"You will be awake and will not have sensation of the procedure."

A postoperative home care client has developed thrombophlebitis in the right leg. What new plan of care will need to be added because of this complication?

Anticoagulant treatment and education about the increased risk of bleeding

The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. What would be the nurse's most appropriate initial response?

Apply pressure to the surgical site to decrease bleeding.

A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first?

Apply warm blankets to the client.

A nurse is preparing a postoperative client to get out of bed and move to a chair for the first time. As the nurse assists the client in standing up, the client reports dizziness and becomes pale and diaphoretic. What would be most appropriate for the nurse to do?

Assist the client back into the bed.

A perioperative nurse is determining a plan of care for the client in the operating room. Which client outcome has priority?

Be free from injury and adverse effects.

A group of nursing students is reviewing information about the effects of surgery on thermoregulation. The students demonstrate understanding of the information when they identify which factors as contributing to the client's risk for hypothermia? Select all that apply.

Blood loss resulting from the surgery Decreased ambient temperature of operating room Body surface area exposure

The nurse is caring for a client in the postanesthesia care unit (PACU). The nurse uses specific interventions to avoid complications for each body system.

Body System/Intervention Cardiac/provide verbal stimulation Respiratory/Assess skin color. Neurologic/gently touch the client

While reviewing the medical record of a client who has had abdominal surgery, the nurse notes that the client has developed a paralytic ileus. The nurse interprets this information as indicative of what?

Bowel functioning is significantly decreased.

A nurse is assisting a physician when performing a laparoscopic surgery on a client in an ambulatory surgical unit. Which surgeries can now be performed in an ambulatory surgical center instead of a major health care center? Select all that apply.

Cholecystectomy Appendectomy Hernia repairs

A nurse is interacting with a client in the outpatient surgical unit intraoperatively. What is the nurse's priority responsibility?

Client safety

An older adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client?

Delirium

The nurse is caring for a 4-month-old client on the pediatric unit following repair of an umbilical hernia repair. The infant just woke up from anesthesia and is crying. What would be appropriate initial interventions? Select all that apply.

Have the parent hold the infant in a rocking chair. Offer a pacifier. Use distraction with a stuffed toy

Which statement accurately represents a recommended guideline when providing postoperative care for the following clients?

If vital signs are progressively increasing or decreasing from the baseline, notify the health care provider of possible internal bleeding.

The nurse has admitted a client to the postoperative unit following a bowel resection and is providing postoperative health education on coughing and deep breathing. What does the nurse explain to the client about why these actions are important?

If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia.

A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client?

Implement leg exercises and turn the client in bed every 2 hours.

A nurse is caring for an older adult client who had surgery for the removal of a cataract in the left eye. Which issue would prevent the client from being discharged on the day of surgery?

Inability to ambulate

The nurse is preparing to send a client to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the client's chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature from the client. What is the nurse's best action to the physician's request?

Inform the physician that it is their responsibility to obtain the signature.

The nurse is supervising a nursing student who is providing postoperative education to a client with an abdominal incision. The nurse sees the student coaching the client to perform coughing exercises, as pictured above. What is the nurse's best action?

Instruct the student to provide the client with a pillow or folded blanket to hug.

The nurse is teaching a client who will undergo abdominal surgery to repair a hernia about deep breathing. The client asks, "Why am I practicing breathing when I'm having hernia surgery." What is the appropriate nursing response?

It decreases the postoperative risk for respiratory complications."

A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding?

Monitor the client closely and promote fluid intake.

Which methods would the nurse anesthetist use when administering regional anesthesia to surgical clients? Select all that apply.

Nerve block Spinal block Epidural block

Which measure would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client?

Place graduated compression stockings on the client.

Which nursing interventions would be appropriate for a client recovering from a surgical procedure? Select all that apply.

Place the client in a semi-Fowler's position to perform deep-breathing exercises every 1 to 2 hours for the first 24 to 48 hours after surgery, and as necessary thereafter. Teach the client the appropriate leg exercises to increase venous blood return from the legs. Encourage the client to use incentive spirometry 10 times each waking hour for the first 5 days after surgery

A nurse is assessing a client who is experiencing pulmonary embolus. What would be the priority nursing intervention for this client?

Place the client in semi-Fowler's position.

A nurse teaches deep breathing exercises to a client scheduled for surgery. In which perioperative phase would this action occur?

Preoperative

The nurse is teaching the client who recently experienced abdominal surgery to deep breathe and cough effectively. What observable action serves to best minimize pain that may result from the intervention?

Providing support to abdominal and accessory respiratory muscles

A nurse is caring for a female client who will undergo a curative surgery for cholecystectomy. Which precaution should the nurse take before surgery to prevent venous stasis?

Recommend that the client wear antiembolism stockings.

The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency?

Respiratory obstruction

A nurse is reviewing postoperative protocols with the client, including an explanation and a demonstration of how to use an incentive spirometer. How does the nurse know that the teaching on the use of the incentive spirometer was effective?

The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed.

The nurse is caring for a postoperative client. The nurse monitors the client for thrombus formation. Which factor(s) in the client's health history signals to the nurse that the client is at increased risk? Select all that apply.

The client has limited mobility. The client has fluid restrictions. The client has cognitive impairment.

The nurse is caring for a client who had a procedure under moderate sedation at the ambulatory surgical center. Which assessment finding indicates to the nurse that the client may be ready for discharge to home?

The client is alert and oriented with a blood pressure 118/70 mm Hg and respirations 18 breaths/minute, is able to ambulate, is not nauseated or vomiting, pain is controlled with medication, and has no excessive bleeding and drainage is as expected.

The health care provider has prescribed the nurse to administer conscious sedation to a client that will have a closed reduction of the left shoulder. What outcome after administering conscious sedation to a client does the nurse hope to achieve?

The client is relaxed, emotionally comfortable, and conscious.

A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which characteristic applies to this type of surgery?

The client will be admitted the day of surgery and return home the same day.

A nurse is caring for a postoperative client and preparing to apply a pneumatic compression device. How does the nurse explain the device to the client prior to application?

The device fills with air and squeezes the legs, which increases blood flow through the veins of the legs and helps to prevent blood clots.

Which client in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse?

a 26-year-old client who is exhibiting a crowing sound

Which client would a nurse monitor most closely for postoperative respiratory complications?

a 55-year-old client with a history of asthma who had a colon resection

Which of these clients in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse?

a client who is pale and diaphoretic with a heart rate of 115 beats/minute

Which nursing intervention occurs in the postoperative phase of the surgical experience?

airway/oxygen therapy/pulse oximetry

A client has presented to a clinic for a preoperative consult, during which the client has expressed concern about having to fast before surgery. What should the nurse discuss with the client reflecting current standards by the American Society of Anesthesiologists related to fasting prior to surgery?

allowing clear liquids up to 2 hours before surgery with an order by the health care provider

A nurse explains the effects of conscious sedation to a client undergoing a colonoscopy. Which of the following occurs with conscious sedation?

altered mood

Nurses teach clients to restrict food and fluids before surgery. What condition does this measure attempt to avoid?

aspiration

The nurse is preparing a client for a colonoscopy. The nurse is familiar with the colonoscopy procedures at the hospital and is aware that which type of anesthesia is commonly used for this procedure?

conscious sedation

A nurse preparing an older adult client for hip replacement surgery is aware of the surgical risks related to the client's age. Which of the following accurately describes these risks? Select all that apply.

decreased peripheral circulation decreased thermoregulation ability increased vascular rigidity

The nurse is assessing an obese client scheduled for heart surgery. Which priority surgical risk related to obesity should the nurse monitor?

delayed wound healing and wound infection

A client is undergoing surgery for an appendectomy. This would be considered what type of surgery?

emergency surgery

A nurse preparing an older adult client for hip replacement surgery is aware of the surgical risks related to the client's age. Which of the following accurately describes these risks? Select all that apply.

increased vascular rigidity decreased peripheral circulation decreased thermoregulation ability

An operating room nurse is preparing for a surgical procedure on an infant. The nurse's perioperative care is based on what physiologic factor that puts infants at greater risk from surgery than adults?

lower total blood volume

The nurse has delegated to the unlicensed assistive personnel (UAP) the application of antiembolism stockings to a client who had an endarterectomy earlier in the day. Which UAP action requires the nurse to immediately intervene?

massages legs prior to application

An operating room nurse is bringing a client to the nurse in the postanesthesia care unit (PACU). Which information would the operating room nurse provide during a hand-off report? Select all that apply.

medications given in operating room length of surgery drains inserted in surgery

A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice? Select all that apply.

monitoring the client's vital signs counting sponges before and after surgery positioning the client on the operating table

A client is undergoing conscious sedation for an endoscopy. When the client becomes overly sedated, which medication does the nurse anticipate will be required?

naloxone

A nurse is caring for an older adult following hip surgery. Which serious complication would the nurse attempt to avoid by encouraging use of the incentive spirometer?

pneumonia

A nurse teaches deep breathing exercises to a client scheduled for surgery. In which perioperative phase would this action occur?

preoperative

The nurse recognizes the value of leg exercises in the prevention of postoperative thrombophlebitis. When should the nurse teach the correct technique for leg exercises to a client?

prior to surgery

As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site?

procedural pause (time-out)

Following a successful coronary artery bypass graft (CABG), a 71-year-old male client has been transferred to the postanesthesia care unit (PACU). What is the priority for the client's nursing care during this stage of his recovery?

protecting and maintaining the client's airway

When preparing a client who has diabetes mellitus for surgery, the nurse should be aware of what surgical risk associated with this disease?

slow wound healing

The nurse recognizes that palliative surgery is performed for what purpose?

to lessen the intensity of an illness

A nurse working in a PACU is responsible for conducting assessments on immediate postoperative clients. What is the purpose of these assessments?

to prevent complications from anesthesia and surgery

A nurse from the ambulatory surgical center is preparing discharge instructions for a client who has had pelvic surgery. Which criterion would the client need to demonstrate to ensure that she is ready for discharge?

void normally

What is the nurse's role in the informed consent process for a surgical procedure?

witnessing the signed informed consent document