Chapter 30, Surgical Client

During preoperative assessment for a 7:30 AM (0730) surgery, the nurse finds the patient drank a cup of coffee this morning. The nurse reports this information to the anesthesia provider. Which action does the nurse anticipatenext? a. A delay in or cancellation of surgery b. Questions regarding components of the coffee c. Additional questions about why the patient had coffee d. Instructions to determine what education was provided in the preoperative visit

A

A nurse is educating a preoperative client on how to cough effectively. What can the nurse tell the client to do to facilitate coughing? A) "Hold a pillow or folded bath blanket over the incision." B) "Get up and walk before you try to cough." C) "It would be best if you do not cough until you feel better." D) "When you cough, cover your nose and mouth with a tissue."

A) "Hold a pillow or folded bath blanket over the incision." Because postoperative coughing is often painful, the client should be taught how to splint the incision by supporting it with a pillow or folded bath blanket.

A postoperative home care client has developed thrombophlebitis in her right leg. What category of medications will probably be prescribed for this cardiovascular complication? A) Anticoagulants B) Antibiotics C) Antihistamines D) Antigens

A) Anticoagulants Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative clients. Nursing interventions include administering ordered medications, most often anticoagulants.

A client returning to the floor after orthopedic surgery is complaining of nausea. The nurse is aware that an appropriate intervention is to do which of the following? A) Avoid strong smelling foods. B) Provide clear liquids with a straw. C) Avoid oral hygiene until the nausea subsides. D) Hold all medications.

A) Avoid strong smelling foods. Nursing care for a xlient with nausea includes avoiding strong smelling foods, providing oral hygiene, administering prescribed medications (especially medications ordered for nausea and vomiting), and avoiding use of a straw.

The nurse is providing education to a client regarding pain control after surgery. What time does the nurse inform the client is the best time to request pain medication? A) Before the pain becomes severe B) When the client experiences a pain rating of "10" on a 1-to-10 pain scale C) When there is no pain, but it is time for the medication to be administered D) After the pain becomes severe and relaxation techniques have failed

A) Before the pain becomes severe If a pain medication is ordered p.r.n., the client should be instructed to ask for the medication before the pain becomes severe.

The telemetry unit nurse is reviewing laboratory results for a client who is scheduled for an operative procedure later in the day. The nurse notes on the laboratory report that the client has a serum potassium level of 6.5 mEq/L, indicative of hyperkalemia. The nurse informs the physician of this laboratory result because the nurse recognizes hyperkalemia increases the client's operative risk for which of the following? A) Cardiac problems B) Infection C) Bleeding and anemia D) Fluid imbalances

A) Cardiac problems Hyperkalemia or hypokalemia increases the client's risk for cardiac problems. A decrease in the hematocrit and hemoglobin level may indicate the presence of anemia or bleeding. An elevated white blood cell count occurs in the presence of infection. Abnormal urine constituents may indicate infection or fluid imbalances.

Upon assessment, a client reports that he drinks five to six bottles of beer every evening after work. Based upon this information, the nurse is aware that the client may require which of the following? A) Larger doses of anesthetic agents and larger doses of postoperative analgesics B) Larger doses of anesthetic agents and lower doses of postoperative analgesics C) Lower doses of anesthetic agents and lower doses of postoperative analgesics D) Lower doses of anesthetic agents and larger doses of postoperative analgesics

A) Larger doses of anesthetic agents and larger doses of postoperative analgesics Clients with a large habitual intake of alcohol require larger doses of anesthetic agents and postoperative analgesics, increasing the risk for drug-related complications.

A client scheduled for major surgery will receive general anesthesia. Why is inhalation anesthesia often used to provide the desired actions? A) Rapid excretion and reversal of effects B) Safe administration in the client's own room C) Involves only the respiratory system and skin D) Slow onset of action and maintains reflexes

A) Rapid excretion and reversal of effects General anesthesia involves the administration of drugs by inhalation and intravenous routes to produce central nervous system depression. Inhalation anesthesia is often used because it has the advantage of rapid excretion and reversal of effects.

A nurse in an outpatient surgical center is teaching a client about what will be necessary for discharge to home. What information should the nurse include about transportation? A) The client is not allowed to drive a car home. B) If the client is not dizzy, driving a car is allowed. C) Only adults over the age of 25 may drive home. D) None; this is not necessary information.

A) The client is not allowed to drive a car home. After outpatient surgery, clients may go home when they are no longer dizzy or drowsy, have stable vital signs, and have voided. Clients are not allowed to drive a car home.

The nurse is caring for a preoperative patient. The nurse teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurse's best next step? a. Encourage the patient to practice at a later date. b. Assess for the presence of anxiety, pain, or fatigue. c. Ask the patient why exercises are not being done. d. Evaluate the educational methods used to educate the patient.

B

A nurse working in a PACU is responsible for conducting assessments on immediate postoperative clients. What is the purpose of these assessments? A) To determine the length of time to recover from anesthesia B) To use intraoperative data as a basis for comparison C) To focus on cardiovascular data and findings D) To prevent complications from anesthesia and surgery

A) To determine the length of time to recover from anesthesia Immediate postoperative care in the PACU involves assessing the postoperative client with emphasis on preventing complications from the surgery.

The nurse is participating in a "time-out." In which activities will the nurse be involved? (Select all that apply.) a. Verify the correct site. b. Verify the correct patient. c. Verify the correct procedure. d. Perform "time-out" after surgery. e. Perform the actual marking of the operative site.

A,B,C

The operating room nurse is providing a hand-off report to the postanesthesia care unit (PACU) nurse. Which components will the operating room nurse include? (Select all that apply.) a. IV fluids b. Vital signs c. Insurance data d. Family location e. Anesthesia provided f. Estimated blood loss

A,B,E,F

The nurse is preparing for a patient who will be going to surgery. The nurse screens for risk factors that can increase a person's risks in surgery. What risk factors are included in the nurse's screening? (Select all that apply.) a. Age b. Race c. Obesity d. Nutrition e. Pregnancy f. Ambulatory surgery

A,C,D,E

The nurse is caring for a postoperative patient with an incision. Which actions will the nurse take to decrease wound infections? (Select all that apply.) a. Maintain normoglycemia. b. Use a straight razor to remove hair. c. Provide bath and linen change daily. d. Perform first dressing change 2 days postoperatively. e. Perform hand hygiene before and after contact with the patient. f. Administer antibiotics within 60 minutes before surgical incision.

A,E

The circulating nurse is caring for a patient intraoperatively. Which primary role of the circulating nurse will be implemented? a. Suturing the surgical incision in the OR suite b. Managing patient care activities in the OR suite c. Assisting with applying sterile drapes in the OR suite d. Handing sterile instruments and supplies to the surgeon in the OR suite

B

The nurse explains the pain relief measures available after surgery during preoperative teaching for a surgical patient. Which comment from the patient indicates the need for additional education on this topic? a. "I will be asked to rate my pain on a pain scale." b. "I will have minimal pain because of the anesthesia." c. "I will take the pain medication as the provider prescribes it." d. "I will take my pain medications before doing postoperative exercises."

B

The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which action will the nurse take to minimize skin breakdown? a. Encouraging the patient to bathe before surgery b. Securing attachments to the operating table with foam padding c. Periodically adjusting the patient during the surgical procedure d. Measuring the time a patient is in one position during surgery

B

The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Which priority goal is the nurse trying to achieve? a. Manage pain b. Prevent atelectasis c. Reduce healing time d. Decrease thrombus formation

B

The nurse is preparing a patient for surgery. Which goal is a priority for assessing the patient before surgery? a. Plan for care after the procedure. b. Establish a patient's baseline of normal function. c. Educate the patient and family about the procedure. d. Gather appropriate equipment for the patient's needs.

B

A nurse is assisting a physician during a cesarean section for a client. The client is administered epidural anesthesia. Which of the following is an advantage of epidural anesthesia? A) It counteracts the effects of conscious sedation. B) It decreases the risk of gastrointestinal complications. C) It prevents clients from remembering the initial recovery period. D) It acts on the central nervous system to produce loss of sensation.

B) It decreases the risk of gastrointestinal complications. Epidural anesthesia is a regional anesthesia administered to a client before surgery; it decreases the risk of gastrointestinal complications in clients. Reversal drugs are medications that counteract the effects of those used for conscious sedation. General anesthesia acts on the central nervous system to produce loss of sensation; it prevents clients from remembering their initial recovery period.

A nurse is taking care of a client during the immediate post-operative period. Which of the following duties performed during the immediate post-operative period is most important? A) Ensure the safe recovery of surgical clients. B) Monitor the client for complications. C) Prepare a room for the client's return. D) Assess the client's health constantly.

B) Monitor the client for complications. The immediate post-operative period refers to the first 24 hours after surgery. During this time, the nurse monitors the client for complications as he or she recovers from anesthesia. Once the client is stable, the nurse prepares a room for the client's return and assesses the client to prevent or minimize potential complications. The nurse ensures the safe recovery of the client after the client has stabilized.

A nurse has been asked to ensure informed consent for a surgical procedure. What might be a role of the nurse? A) Securing informed consent from the client B) Signing the consent form as a witness C) Ensuring the client does not refuse treatment D) Refusing to participate based on legal guidelines

B) Signing the consent form as a witness The responsibility for securing informed consent from the client lies with the person who will perform the procedure, usually the physician. The nurse may sign as a witness, signifying that the client signed the consent form without coercion, and was alert and aware of the act.

A young woman has been in an automobile crash that resulted in an amputation of her left lower leg. She verbalizes grief and loss. What knowledge by the nurse is used to provide interventions to help the client cope? A) The client should be grateful to be alive. B) This is a normal, appropriate response. C) This is an abnormal, inappropriate response. D) Tissue healing will help the client adapt.

B) This is a normal, appropriate response. Many surgical clients have the same reaction to loss of a body part as they would to a death. A surgical client's grief is a normal, appropriate response. The nurse must be aware of the client's needs and provide interventions to meet those needs in coping with change.

The nurse is providing preoperative education and reviews with the patient what it will be like to be in the surgical environment. Which points should the nurse include in the teaching session? (Select all that apply.) a. The operative suite will be very dark. b. The family is not allowed in the operating suite. c. The operating table or bed will be comfortable and soft. d. The nurses will be there to assist you through this process. e. The surgical staff will be dressed in special clothing with hats and masks.

B,D,E

The nurse is using a forced air warmer for a surgical patient preoperatively. Which goals is the nurse trying to achieve? (Select all that apply.) a. Induce shivering. b. Reduce blood loss. c. Induce pressure ulcers. d. Reduce cardiac arrests. e. Reduce surgical site infection.

B,D,E

The nurse is caring for a patient in preadmission testing. The patient has been assigned a physical status classification by the American Society of Anesthesiologists of ASA III. Which assessment will support this classification? a. Normal, healthy patient b. Denial of any major illnesses or conditions c. Poorly controlled hypertension with implanted pacemaker d. Moribund patient not expected to survive without the operation

C

The nurse is caring for a postoperative patient on the medical-surgical floor. Which activity will the nurse encourage to prevent venous stasis and the formation of thrombus? a. Diaphragmatic breathing b. Incentive spirometry c. Leg exercises d. Coughing

C

The nurse is caring for a surgical patient, when the family member asks what perioperative nursing means. How should the nurse respond? a. Perioperative nursing occurs in preadmission testing. b. Perioperative nursing occurs primarily in the postanesthesia care unit. c. Perioperative nursing includes activities before, during, and after surgery. d. Perioperative nursing includes activities only during the surgical procedure.

C

A physician has ordered a nurse to administer conscious sedation to a client. Which of the following is possible after administering conscious sedation to a client? A) Client can respond verbally despite physical immobility. B) Client can tolerate long therapeutic surgical procedures. C) Client is relaxed, emotionally comfortable, and conscious. D) Client's consciousness level can be monitored by equipment.

C) Client is relaxed, emotionally comfortable, and conscious. Conscious sedation refers to a state in which the client is sedated in a state of relaxation and emotional comfort, but is not unconscious. The client is free of pain, fear, and anxiety and can tolerate unpleasant diagnostic and short therapeutic surgical procedures, such as an endoscopy or bone marrow aspiration. The client can respond verbally and physically. However, no equipment can replace a nurse's careful observations for monitoring clients.

A nurse is caring for a client who is scheduled to undergo a breast biopsy. Which of the following major tasks does the nurse perform immediately during the pre-operative period? A) Obtain a signature on the consent form. B) Review the surgical checklist. C) Conduct a nursing assessment. D) Reduce the dosage of toxic drugs.

C) Conduct a nursing assessment. During the immediate pre-operative period, the nurse conducts a nursing assessment. Nurses obtain the signature of the client, nearest blood relative, or someone with durable power of attorney before the administration of any pre-operative sedatives. They also administer medications as ordered by the physician regardless of their toxicity. They assist the client with psychosocial preparation and complete the surgical checklist, which is reviewed by the operating room personnel.

A nurse is reviewing results of preoperative screening tests and notes the client's potassium level is dangerously low. What should the nurse do next? A) Nothing; potassium levels have no influence on surgical outcome. B) Include the information in the postoperative end of shift report. C) Document the data and notify the physician who will do the surgery. D) Ask the client and family members why the potassium is low.

C) Document the data and notify the physician who will do the surgery. Either high or low levels of potassium put the surgical client at increased risk for cardiac problems during and after surgery. The nurse's role includes recording the data in the client's record and reporting abnormal findings.

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? A) Increased vascular rigidity B) Diminished chest expansion C) Lower total blood volume D) Decreased peripheral circulation

C) Lower total blood volume Infants are at a greater risk from surgery as a result of various physiologic factors. A major factor is that the infant has a lower total blood volume, making even a small loss of blood a serious consideration because of the risk for dehydration and the inability to respond to the need for increased oxygen during surgery.

A nurse is educating a surgical client on postoperative p.r.n. pain control. Which of the following should be included? A) "We will bring you pain medications; you don't need to ask." B) "Even if you have pain, you may get addicted to the drugs." C) "You won't have much pain so just tough it out." D) "You need to ask for the medication before the pain becomes severe."

D) "You need to ask for the medication before the pain becomes severe." If medication for pain is ordered p.r.n., there is a time restriction between doses. The client needs to ask for the medication and should do so before the pain becomes severe.

The nurse and the nursing assistive personnel (NAP) are caring for a group of postoperative patients who need turning, coughing, deep breathing, incentive spirometer, and leg exercises. Which task will the nurse assign to the NAP? a. Teach postoperative exercises. b. Do nothing associated with postoperative exercises. c. Document in the medical record when exercises are completed. d. Inform the nurse if the patient is unwilling to perform exercises.

D

The nurse and the nursing assistive personnel are assisting a postoperative patient to turn in bed. To assist in minimizing discomfort, which instruction should the nurse provide to the patient? a. "Close your eyes and think about something pleasant." b. "Hold your breath and count to three." c. "Grab my shoulders with your hands." d. "Place your hand over your incision."

D

The nurse is caring for a patient in the postanesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. How will the nurse classify this procedure? a. Major b. Urgent c. Elective d. Emergency

D

The nurse is caring for a patient in the preoperative holding area of an ambulatory surgery center. Which nursing action will be most appropriate for this area? a. Count the sterile surgical instruments. b. Empty the urinary drainage bag. c. Check the surgical dressing. d. Apply a warm blanket.

D

The nurse is encouraging a reluctant postoperative patient to deep breathe and cough. Which explanation can the nurse provide that may encourage the patient to comply? a. "If you don't deep breathe and cough, you will get pneumonia." b. "You will need to cough only a few times during this shift." c. "Let's try clearing the throat because that will work just as well." d. "Deep breathing and coughing will clear out the anesthesia."

D

After conducting a preoperative health assessment, the nurse documents that the client has physical assessments supporting the medical diagnosis of emphysema. Based on this finding, what postoperative interventions would be included on the plan of care? A) Perform sterile dressing changes each morning. B) Administer pain medications as needed. C) Conduct a head-to-toe assessment each shift. D) Monitor respirations and breath sounds.

D) Monitor respirations and breath sounds. Respiratory disorders, including emphysema, increase the risk for respiratory depression from anesthesia as well as postoperative pneumonia and atelectasis.

The nurse is caring for a group of postoperative patients on the surgical unit. Which patient assessments indicate the nurse needs to follow up? (Select all that apply.) a. Patient with abdominal surgery has patent airway. b. Patient with knee surgery has approximated incision. c. Patient with femoral artery surgery has strong pedal pulse. d. Patient with lung surgery has 20 mL/hr of urine output via catheter. e. Patient with bladder surgery has bloody urine within the first 12 hours. f. Patient with appendix surgery has thready pulse and blood pressure is 90/60

D,F

The nurse is providing preoperative teaching for the ambulatory surgery patient who will be having a cyst removed from the right arm. Which will be the best explanation for diet progression after surgery? a. "Start with clear liquids, soup, and crackers. Advance to a normal diet as tolerated." b. "Stay with ice chips for several hours. After that, you can have whatever you want." c. "Stay on clear liquids for 24 hours. Then you can progress to a normal diet." d. "Start with clear liquids for 2 hours and then full liquids for 2 hours. Then progress to a normal diet."

A

The nurse is reviewing the surgical consent with the patient during preoperative education and finds the patient does not understand what procedure will be completed. What is the nurse's best next step? a. Notify the health care provider about the patient's question. b. Explain the procedure that will be completed. c. Continue with preoperative education. d. Ask the patient to sign the form.

A

Which nursing assessment will indicate the patient is performing diaphragmatic breathing correctly? a. Hands placed on the border of the rib cage with fingers extended will touch as the chest wall contracts. b. Hands placed on the chest wall with fingers extended will separate as the chest wall contracts. c. The patient will feel upward movement of the diaphragm during inspiration. d. The patient will feel downward movement of the diaphragm during expiration.

A

In order to prevent the possibility of venous stasis, a nurse is teaching a surgical client how to perform leg exercises. Which of the client's following statements indicates a sound understanding of leg exercises? A) "I'll practice these now and try to start them as soon as I can after my surgery." B) "I'll try to do these lying on my stomach so that I can bend my knees more fully." C) "I'll make sure to do these, as long as my doctor doesn't tell me to stay on bed rest after my operation." D) "I'm pretty sure my stomach muscles are strong enough to lift both of my legs off the bed at the same time."

A) "I'll practice these now and try to start them as soon as I can after my surgery." Leg exercises should be begun as soon as possible after surgery, unless contraindications exist. Bed rest does not preclude the performance of leg exercises and the legs should be lifted individually, not simultaneously. The client should perform leg exercises in a semi-Fowler's, not prone, position.

Which of the following nursing interventions occurs in the postoperative phase of the surgical experience? A) Airway/oxygen therapy/pulse oximetry B) Teaching deep breathing exercises C) Reviewing the meaning of p.r.n. orders for pain medications D) Putting in IV lines and administering fluids

A) Airway/oxygen therapy/pulse oximetry Airway/oxygen therapy/pulse oximetry occur in the postanesthesia unit in the postoperative phase. Teaching deep- breathing exercises and reviewing the meaning of p.r.n. orders for medications occur in the preoperative phase. Putting in IV lines and administering fluids occurs in the intraoperative phase.

A client, scheduled for open-heart surgery, tells the nurse he does not want to be "saved" if he dies during surgery. What should the nurse do next? A) Discuss with and document the wishes of the client and family B) Administer the ordered oral and intravenous preoperative medications C) Notify the physician after completion of the surgical procedure D) Verbally report the client's wishes to the operating room supervisor

A) Discuss with and document the wishes of the client and family Advance directives allow the client to specify instructions for health care treatment if unable to communicate these wishes during or after surgery. It is important for the nurse to discuss and document exact do not resuscitate(DNR) wishes of the client and family before surgery.

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? A) Inform the physician that it is his or her responsibility to obtain the signature. B) Obtain the signature and ask another nurse to cosign the signature. C) Inform the physician that the nurse manager will need to obtain the signature. D) Call the house officer to obtain the signature.

A) Inform the physician that it is his or her responsibility to obtain the signature. The responsibility for securing informed consent from the client lies with the person who will perform the procedure. The nurse's best action is to inform the physician that it is his or her responsibility to obtain the signature.

The nurse is caring for a postoperative patient with an abdominal incision. The nurse provides a pillow to use during coughing. Which activity is the nurse promoting? a. Pain relief b. Splinting c. Distraction d. Anxiety reduction

B

The nurse is prescreening a surgical patient in the preadmission testing unit. The medication history indicates that the patient is currently taking an anticoagulant. Which action should the nurse take when consulting with the health care provider? a. Ask for a radiological examination of the chest. b. Ask for an international normalized ratio (INR). c. Ask for a blood urea nitrogen (BUN). d. Ask for a serum sodium (Na).

B

The patient has presented to the ambulatory surgery center to have a colonoscopy. The patient is scheduled to receive moderate sedation (conscious sedation) during the procedure. How will the nurse interpret this information? a. The procedure results in loss of sensation in an area of the body. b. The procedure requires a depressed level of consciousness. c. The procedure will be performed on an outpatient basis. d. The procedure necessitates the patient to be immobile.

B

The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgical floor. Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this nursing action? a. This is done to complete the first action in a head-to-toe assessment. b. This is done to compare and monitor for vital sign variation during transport. c. This is done to ensure that the medical-surgical nurse checks on the postoperative patient. d. This is done to follow hospital policy and procedure for care of the surgical patient.

B

A diabetic client is undergoing surgery to amputate a gangrenous foot. This procedure would be considered which of the following categories of surgery based on purpose? A) Diagnostic B) Ablative C) Palliative D) Reconstructive

B) Ablative Ablative surgery is performed to remove a diseased body part. Diagnostic surgery is performed to make or confirm a diagnosis. Palliative surgery involves relieving or reducing intensity of an illness. Reconstructive surgery restores function to traumatized or malfunctioning tissue.

A nurse is providing ongoing postoperative care to a client who has had knee surgery. The nurse assesses the dressing and finds it saturated with blood. The client is restless and has a rapid pulse. What should the nurse do next? A) Document the data and apply a new dressing. B) Apply a pressure dressing and report findings. C) Reassure the family that this is a common problem. D) Make assessments every 15 minutes for four hours.

B) Apply a pressure dressing and report findings. Hemorrhage is an excessive internal or external loss of blood. Common indications of hemorrhage include a rapid, thready pulse. If bleeding occurs, the nurse should apply a pressure dressing to the site, report findings to the physician, and be prepared to return the client to the operating room if bleeding cannot be stopped or is massive.

Which of the following interventions are recommended guidelines for meeting client postoperative elimination needs? A) Assess abdominal distention, especially if bowel sounds are audible or are low pitched. B) Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake. C) Encourage food and fluid intake when ordered, especially dairy products and low-fiber foods. Assess for bladder distention by Palpating below the symphysis pubis if the client has not voided within eight hours after D) surgery.

B) Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake. Assess for the return of peristalsis by auscultating bowel sounds every four hours when the client is awake. Assess abdominal distention, especially if bowel sounds are inaudible or are high pitched. Encourage food and fluid intake when ordered, especially fruit juices and high-fiber foods. Assess for bladder distention by palpating above the symphysis pubis if the client has not voided within eight hours after surgery.

A female client is scheduled for liposuction surgery to reduce her weight. Based on urgency, how is this surgery classified? A) Urgent B) Elective C) Emergency D) Emergent

B) Elective A liposuction procedure is classified as elective surgery, in which the procedure is preplanned and based on the client's choice. Other classifications are urgent (surgery is necessary for the client's health but not an emergency) and emergency (the surgery must be done immediately to preserve life, body part, or body function).

Which of the following interventions is of major importance during preoperative education? A) Performing skills necessary for gastrointestinal preparation B) Encouraging the client to identify and verbalize fears C) Discussing the site and extent of the surgical incision D) Telling the client not to worry or be afraid of surgery

B) Encouraging the client to identify and verbalize fears A surgical procedure causes anxiety and fear. The nurse should encourage the client to identify and verbalize fears; often simply talking about fears helps to diminish their magnitude.

The nurse is making a preoperative education appointment with a patient. The patient asks if a family member should come to the appointment. Which is the best response by the nurse? a. "There is no need for an additional person at the appointment." b. "Your family can come and wait with you in the waiting room." c. "We recommend including family members at this appointment." d. "It is required that you have a family member at this appointment.

C

The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which action will be most appropriate for the nurse to take? a. Encourage copious amounts of water. b. Start an additional intravenous (IV) line. c. Measure and record all intake and output. d. Weigh the patient and compare with preoperative weight.

C

The nurse is preparing a patient for a surgical procedure on the right great toe. Which action will be mostimportant to include in this patient's preparation? a. Place the patient in a clean surgical gown. b. Ask the patient to remove all hairpins and cosmetics. c. Ascertain that the surgical site has been correctly marked. d. Determine where the family will be located during the procedure.

C

A preoperative assessment finds a client to be 75 pounds overweight. The client is to have abdominal surgery. What nursing diagnosis would be appropriate based on the client's weight? A) Risk for Aspiration B) Risk for Imbalanced Body Temperature C) Risk for Infection D) Risk for Falls

C) Risk for Infection Fatty tissue in obese clients has a poor blood supply and, therefore, has less resistance to infections. Postoperative complications of delayed wound healing, wound infection, and disruption of the wound are more common in obese clients.

The nurse is completing a medication history for the surgical patient in preadmission testing. Which medication should the nurse instruct the patient to hold (discontinue) in preparation for surgery according to protocol? a. Warfarin b. Vitamin C c. Prednisone d. Acetaminophen

A

The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide first? a. Perform hand hygiene. b. Explain use of the mouthpiece. c. Instruct the patient to inhale slowly. d. Place in the reverse Trendelenburg position.

A

The nurse demonstrates postoperative exercises for a patient. In which order will the nurse instruct the patient to perform the exercises? 1. Turning 2. Breathing 3. Coughing 4. Leg exercises a. 4, 1, 2, 3 b. 1, 2, 3, 4 c. 2, 3, 4, 1 d. 3, 1, 4, 2

A

The nurse has completed a preoperative assessment for a patient going to surgery and gathers assessment data. Which will be the most important next step for the nurse to take? a. Notify the operating suite that the patient has a latex allergy. b. Document that the patient had a bath at home this morning. c. Administer the ordered preoperative intravenous antibiotic. d. Ask the nursing assistive personnel to obtain vital signs.

A

The nurse is assessing a postoperative patient with a history of obstructive sleep apnea for airway obstruction. Which assessment finding will best alert the nurse to this complication? a. Drop in pulse oximetry readings b. Moaning with reports of pain c. Shallow respirations d. Disorientation

A

The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient who had cataract surgery is coughing. b. A patient who had vascular repair of the right leg is not doing right leg exercises. c. A patient after knee surgery is wearing intermittent pneumatic compression devices and receiving heparin. d. A patient after surgery has vital signs taken every 15 minutes twice, every 30 minutes twice, hourly for 2 hours then every 4 hours.

A

The nurse is caring for a patient in the operating suite who is experiencing hypercarbia, tachypnea, tachycardia, premature ventricular contractions, and muscle rigidity. Which condition does the nurse suspect the patient is experiencing? a. Malignant hyperthermia b. Fluid imbalance c. Hemorrhage d. Hypoxia

A

The nurse is caring for a patient in the operating suite. Which outcome will be most appropriate for this patient at the end of the intraoperative phase? a. The patient will be free of burns at the grounding pad. b. The patient will be free of nausea and vomiting. c. The patient will be free of infection. d. The patient will be free of pain.

A

The nurse is caring for a patient in the postanesthesia care unit who has undergone a left total knee arthroplasty. The anesthesia provider has indicated that the patient received a left femoral peripheral nerve block. Which assessment will be an expected finding for this patient? a. Sensation decreased in the left leg b. Patient report of pain in the left foot c. Pulse decreased at the left posterior tibia d. Left toes cool to touch and slightly cyanotic

A

The nurse is caring for a patient in the postanesthesia care unit. The patient asks for a bedpan and states to the nurse, "I feel like I need to go to the bathroom, but I can't." Which nursing intervention will be most appropriate initially? a. Assess the patient for bladder distention. b. Encourage the patient to wait a minute and try again. c. Inform the patient that everyone feels this way after surgery. d. Call the health care provider to obtain an order for catheterization.

A

The nurse is caring for a postoperative patient who has had a minimally invasive carpel tunnel repair. The patient has a temperature of 97° F and is shivering. Which reason will the nurse most likely consider as the primary cause when planning care? a. Anesthesia lowers metabolism. b. Surgical suites have air currents. c. The patient is dressed only in a gown. d. The large open body cavity contributed to heat loss.

A

The nurse has administered a preoperative medication to the patient going to surgery. Which action will the nurse take next? a. Notify the operating suite that the medication has been given. b. Instruct the patient to call for help to go to the restroom. c. Waste any unused medication according to policy. d. Ask the patient to sign the consent for surgery.

B

The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patient's laboratory tests and allergies and prepares the patient for surgery. In which perioperative nursing phase is the nurse working? a. Perioperative b. Preoperative c. Intraoperative d. Postoperative

B

The nurse is caring for a patient who will undergo a removal of a lung lobe. Which level of care will the patient require immediately post procedure? a. Acute care—medical-surgical unit b. Acute care—intensive care unit c. Ambulatory surgery d. Ambulatory surgery—extended stay

B

A nurse is educating a client about regional anesthesia. Which of the following statements is accurate about this type of anesthesia? A) "You will be asleep and won't be aware of the procedure." B) "You will be asleep but may feel some pain during the procedure." C) "You will be awake but will not be aware of the procedure." D) "You will be awake and will not have sensation of the procedure."

D) "You will be awake and will not have sensation of the procedure." Regional anesthesia occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. The client remains awake but loses sensation in a specific area or region of the body.

A client with abdominal incisions experiences excruciating pain when he tries to cough. What should the nurse do to reduce the client's discomfort when coughing? A) Administer prescribed pain medication just before coughing. B) Ask the client to drink plenty of water before coughing. C) Ask the client to lie in a lateral position when coughing. D) Administer prescribed pain medication 30 minutes before deliberately attempting to cough.

D) Administer prescribed pain medication 30 minutes before deliberately attempting to cough. Coughing is painful for clients with abdominal or chest incisions. Administering pain medication approximately 30 minutes before coughing, or splinting the incision when coughing, can reduce discomfort. Making the client lie in a lateral position or asking the client to drink plenty of water is not helpful because it will make breathing and coughing even more difficult for the client.

A nurse is assisting a postoperative client with deep-breathing exercises. Which of the following is an accurate step for this procedure? A) Place the client in prone position, with the neck and shoulders supported. B) Ask the client to place the hands over the stomach, so he or she can feel the chest rise as the lungs expand. C) Ask the client to exhale rapidly and completely, and inhale through the nose rapidly and completely. D) Ask the client to hold his or her breath for three to five seconds and mentally count "one, one thousand, two, one thousand" and so forth.

D) Ask the client to hold his or her breath for three to five seconds and mentally count "one, one thousand, two, one thousand" and so forth. The nurse should place the client in semi-Fowler's position, with the neck and shoulders supported, and ask the client to place the hands over the rib cage, so he or she can feel the chest rise as the lungs expand. Then, ask the patient to exhale gently and completely, inhale through the nose gently and completely, hold his or her breath for three to five seconds, and mentally count "one, one thousand, two, one thousand" etc., then exhale as completely as possible through the mouth with lips pursed (as if whistling).

Which statement accurately represents a recommended guideline when providing postoperative care for the following clients? A) Force fluids for an adult client who has a urine output of less that 30 mL per hour. B) If client is febrile within 12 hours of surgery, notify the physician immediately. C) If the dressing was clean but now has a large amount of fresh blood, remove the dressing and reapply it. D) If vital signs are progressively increasing or decreasing from baseline, notify the physician of possible internal bleeding.

D) If vital signs are progressively increasing or decreasing from baseline, notify the physician of possible internal bleeding. Ablative surgery is performed to remove a diseased body part. Diagnostic surgery is performed to make or confirm a diagnosis. Palliative surgery involves relieving or reducing intensity of an illness. Reconstructive surgery restores function to traumatized or malfunctioning tissue.

A student is assessing a postoperative client who has developed pneumonia. The plan of care includes positioning the client in the Fowler's or semi-Fowler's position. What is the rationale for this position? A) It increases blood flow to the heart. B) The client will be more comfortable and have less pain. C) It facilitates nursing assessments of skin color and temperature. D) It promotes full aeration of the lungs.

D) It promotes full aeration of the lungs. Pneumonia may occur in the postoperative client from aspiration, immobilization, depressed cough reflex, infection, increased secretions from anesthesia, or dehydration. Nursing interventions include positioning the client in the Fowler or semi-Fowler position to promote full aeration of the lungs.

A cleansing enema is ordered for a client who is scheduled to have colon surgery. What is the rationale for this procedure? A) Surgical clients routinely are given a cleansing enema. B) Cleansing enemas are given before surgery at the client's request. C) There will be less flatus and discomfort postoperatively. D) Peristalsis does not return for 24 to 48 hours after surgery.

D) Peristalsis does not return for 24 to 48 hours after surgery. If the client is scheduled for gastrointestinal tract surgery, a cleansing enema is usually ordered. Peristalsis does not return for 24 to 48 hours after the bowel is handled, so preoperative cleansing helps decrease postoperative constipation.