Chapter 40 Preoperative Nursing Management

The nurse concludes that teaching about pain management was effective when the client states:

"I will support my incision with my hands when I do my coughing and deep breathing exercises."

The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed?

"The nurse will explain the details of the surgery before I sign a consent."

The parent of a 16-year-old client asks the nurse, "How could the surgeon operate without my consent?" What is the best response by the nurse?

"Your child had life-threatening injuries that required immediate surgery."

What is the blood glucose level goal for a diabetic patient who will be having a surgical procedure?

80 to 110 mg/dL

The nurse recognizes that which of the following clients is at least risk for perioperative complications?

A 65-year-old Caucasian man who has a history of arthritis. (A history of arthritis does not increase the risk for complications during the perioperative period.)

he nurse is triaging surgical clients. Which client would the nurse document as in need of urgent surgical care?

A client with an acute gallbladder infection

The nurse expects informed consent to be obtained for insertion of:

A gastrostomy tube

A client is scheduled for a surgical procedure. When planning the client's care, the nurse should consider that which of the following conditions will increase the client's risk of complications after surgery?

A history of diabetes

A nurse knows that she must obtain a signed informed consent for which of the following procedures? Select all that apply.

Arteriography Open reduction of a fracture Cystoscopy Paracentesis (Informed consent is not currently required for insertion of an intravenous or urethral catheter.)

During the preoperative assessment, the nurse learns that the client has been taking prednisone. The nurse realizes that the client is at risk for:

Cardiovascular collapse.

Which is the least important issue concerning safety for the perioperative team before proceeding to the operating room?

Client's ambulatory aids It is imperative that the entire perioperative team participates in verifying the client's identity, the correct surgical procedure, and the appropriate surgical site before preceding to the OR. The client's ambulatory aids are not an important safety concern before proceeding to the OR.

What action by the nurse best encompasses the preoperative phase?

Educating clients on signs and symptoms of infection

Purpose of Surgical Procedures

Emergency, Urgent, Required, Elective, Optional

The nurse concludes that further teaching about diaphragmatic breathing is needed when the client:

Exhales forcefully with a short expiration (Diaphragmatic breathing should be performed gently and fully.)

The nurse is reviewing a preoperative informed consent when preparing the client for surgery. Which contents of the informed consent are required? Select all that apply.

Explanation of procedure Potential risks Benefits of surgery Description of alternatives

Which domain of perioperative nursing practice focuses on clinical processes and outcomes?

Health care systems

A client taking chlorpromazine (Thorazine) is preparing to undergo surgery. Which of the following complications does the surgical team need to prepare to deal with before anesthetics are administered?

Hypotension

Bariatric-Special Considerations

Increased risk for:-wound infection (fatty tissue susceptible to infection)-technical/mechanical problems (dehiscence, moving client)-hypoventilation (breathe shallow when supine)•Increased cardiac demand•Difficulty intubating

Advanced Directives

Living will-Legally endorsed instructions for care (living will) if signer becomes incapacitated Proxy-Names proxy decision maker (durable power of attorney); court may serve as proxy both-Signed by person and 2 witnesses-Facilities required to provide client education (& documentation of teaching) re: advance directives at time of admission

Informed Consent

Nature of Treatment, Risks, Alternatives, Benefits, Opportunity for Questions

When caring for a patient with alcoholism, when should the nurse assess for symptoms of alcoholic withdrawal?

On the second or third day

The nurse recognizes that the client who takes hydrochlorothiazide (HydroDIURIL) to manage hypertension is predisposed for which interaction with anesthesia?

Respiratory depression

Which client would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period?

The 35-year-old client with non-insulin dependent diabetes.

Sudden withdrawal of which of the following may result in seizures?

Tranquilizers

The nurse is caring for a patient with liver disease who had a surgical procedure. When should the nurse alert the physician?

When the patient's blood ammonia concentration reaches 180 mg/dL

Client Education

Why? Why Now? Who?

The nurse is completing a preoperative assessment. The nurse notices the client is tearful and constantly wringing their hands. The client states, "I'm really nervous about this surgery. Do you think it will be ok?" What is the nurse's best response?

"What are your concerns?"

Which question is most important for the nurse to ask the client when obtaining the preoperative admission history?

"When is the last time you ate or drank?"

A patient preparing for a surgical procedure is taking corticosteroids for Crohn's disease. What should the patient be monitored for?

Adrenal insufficiency

You are caring for a client preoperatively who is very anxious and fearful about their surgery. You know that this client's anxiety can cause problems with the surgical experience. What type of problems can this client have because of their anxiety and fear?

Anxious clients have a poor response to surgery and are prone to complications.

The nurse is preparing an elderly client for a scheduled removal of orthopedic hardware, a procedure that will be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the client?

Hypothermia

The nurse is creating a care plan for a 70-year-old client who has been admitted to the postsurgical unit following a colon resection. The client's age and increased body mass index mean that she is at increased risk for what complication in the postoperative period?

Infection

An inappropriate nursing action implemented to keep the client safe includes:

Moving the client swiftly

During the admission history the client reports to the nurse of taking the usual dose of warfarin (Coumadin) the previous day. The appropriate nursing action is:

Notify the surgeon that the client took warfarin the day before surgery. (Warfarin, an anticoagulant, places the client at risk for excessive bleeding during the intraoperative and postoperative periods.)

CV

Nursing Interventions-Assess hypotension, shock, arrhythmias, DVT, pulses, edema

Respiratory

Nursing Interventions-Cough and DB, Assess LS & respstatus

GI

Nursing Interventions-Encouragefluid intake, nutritious meals, soft diet; assess bowel function

A patient is scheduled for a reduction mammoplasty. What classification of surgery does the nurse understand that this is?

Optional

The nurse is caring for a client needing emergency surgery. Which preoperative teaching is least important to prepare the client for surgery?

Post-discharge diet

A client is scheduled for elective surgery. To prevent the complications of hypotension and cardiovascular collapse, the nurse should report the use of which medication?

Prednisone

An obese client is scheduled for open abdominal surgery. What priority education should the nurse provide to this client?

Prevention of respiratory complications

The nurse is aware that the amino acid, arginine,

Stimulates T cell response

Nursing assessment findings reveal that the client is afraid of dying during the surgical procedure. Which surgical team member would be most helpful in addressing the client's concern?

Surgeon

In anticipation of a client's scheduled surgery, the nurse is teaching her to perform deep breathing exercises and coughing to use postoperatively. What action should the nurse teach the client?

The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough deep from the lungs.

The patient is NPO prior to having a colonoscopy. The patient is to take a daily blood pressure pill prior to the procedure. Until when may water be given prior to the procedure?

Up to 2 hours before surgery

The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply.

nutritional status age physical condition health status

A client is undergoing a surgical procedure to repair an ulcerated colon. Which client education topics will be discussed preoperatively? Select all that apply.

postoperative pain control cough and deep-breathing exercises intravenous fluids and other lines and tubes (Preoperative teaching involves teaching clients about their upcoming surgical procedure and expectations. Topics include preoperative medications (when they are given and their effects); postoperative pain control; explanation and description of the post anesthesia recovery room or postsurgical area; and deep-breathing and coughing exercises.)

The nurse has just admitted a 12-year-old client who is going to have an above-the-knee amputation of their left leg due to osteosarcoma. The nurse knows that adequate preoperative teaching and learning is important for what reason?

Client will have a shorter recovery period.

The nurse is physically preparing a client for surgery. What area does the nurse know needs to be addressed before the client is taken to the operating room?

Elimination (When physically preparing a client for surgery these areas need to be addressed: skin preparation; elimination; attire/grooming; prosthesis; foods and fluids; and care of valuables. The physical preparation of a client for surgery does not include the areas of medication, activity, or the client's support system.)

Which of the following nursing activities would not be part of the preoperative phase of care? Select all that apply.

Ensuring that the sponge, needle, and instrument counts are correct Administering medications, fluid, and blood component therapy, if prescribed

GU

Nursing Interventions-Encouragefluid intake, nutritious meals, soft diet; assess bowel function

Integument

Nursing Interventions-Provide blankets, Lift not slide, assess hydration

An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults?

Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients.

The nurse should determine that a client is coughing effectively after surgery if the nurse observes which of the following activities?

The client takes a deep abdominal breath and then "huff" or "hack" coughs three or four times.

How does the nurse determine that the patient may have hidden fears about the impending surgical procedure? (Select all that apply.)

The patient avoids communication with the nurse. The patient repeatedly asks questions that have previously been answered. The patient talks incessantly.

Following diagnostic testing, a patient requires a cholecystectomy. This surgical procedure would be categorized as which of the following?

Urgent Acute gallbladder infection would be categorized as an urgent surgery. Emergent surgeries include severe bleeding, bladder or intestinal obstruction, and a fractured skull. Required surgeries include thyroid disorders and cataracts. Elective surgeries include repair of scars, simple hernia, and vaginal repair.

Several of the clients at the clinic are preparing to have surgery within the next 2 weeks. They are completing preoperative paperwork today with their visit. What are some of the reasons that people might need to have surgery? Select all that apply.

Cosmetic Diagnostic Palliative

he perioperative nurse has a number of major responsibilities when a patient is admitted to a surgical unit or center. Which of the following is the most important function?

Verifies that operative consent is signed

The physician schedules an elective surgical procedure for a patient who smokes cigarettes. When should the nurse recommend that the patient cease smoking before the surgical procedure to minimize risks associate with cigarette smoking?

1 to 2 months

Which of the following medications may increases the hypotensive action of anesthesia?

Chlorpromazine (Thorazine)

Purpose of Surgical Procedures

Diagnostic-Biopsy Curative-remove diseased tissue or organ Reconstructive- Rebuild Palliative-reduces/relieves but does not cure Rehabilitative-Transplant Cosmetic-improves appearance

Which of the following activities are nursing activities in the preoperative phase of care? Select all that apply.

Discussing and reviewing the advanced directive document Establishing an intravenous line Beginning discharge planning

The nurse recognizes that written informed consent is required for insertion of a(n):

Peripherally-inserted central catheter. Nonsurgical invasive procedures, such as insertion of a peripherally-inserted central catheter, that carry more than a slight risk to the client require written informed consent.

The nurse is preparing a client for surgery. The nurse would notify the surgeon if the client made which of the following statements?

"I took my Coumadin as usual last evening." "I took two aspirins for joint pain this morning." The nurse needs to alert the surgeon to any medications the client has taken that increase the client's risk for bleeding. Aspirin inhibits platelet aggregation and should be stopped at least 7 to 10 days prior to surgery. Coumadin (warfarin) interferes with the synthesis of vitamin K-dependent clotting factors. The type of surgical procedure and the medical condition of the client determine when the Coumadin should be stopped prior to surgery.

The nurse is caring for a patient who is obese prior to a surgical procedure. What surgical complications positively correlated with obesity should the nurse monitor for? (Select all that apply.)

Cardiovascular system Gastrointestinal system Pulmonary system (Like age, obesity increases the risk and severity of complications associated with surgery. The estimation of about 25 additional miles of blood vessels needed for every 30 pounds of excess weight results in increased cardiac demand (Alvarex, Brodsky, Lemmens, et al., 2010). The patient tends to have shallow respirations when supine, increasing the risk of hypoventilation and postoperative pulmonary complications. The acquired physical characteristics of short thick necks, large tongues, recessed chins, and redundant pharyngeal tissue, associated with increased oxygen demand and decreased pulmonary reserves, impedes intubation (Haupt & Reed, 2010). Obesity also affects the gastrointestinal system.)

The nurse is providing preoperative care to a client who is anxious about total hip replacement surgery. "What if I can never walk again? I don't want to end up like my father!" What are some ways the nurse might help alleviate the client's anxiety? Select all that apply.

Make sure the client understands what will happen during surgery. Listen empathetically to the client's concerns about the procedure. Review the client's postoperative goals following the procedure. Ask the client if he would like to speak with a clergyperson. (Preparing the client emotionally and spiritually is as important as doing so physically. Anxiety and fear, if extreme, can affect a client's condition during and after surgery. Careful preoperative teaching and listening by the nurse about what will happen and what to expect can help allay some of these fears and anxieties.)

The hazards of surgery for the aged increase as the number and severity of coexisting health problems increase. Which of the following are structural or functional changes in the elderly that impact the surgical experience? Select all that apply.

b. Increased fatty tissue prolongs elimination of anesthesia. c. Decreased ability to compensate for hypoxia increases the risk of an embolism. e. Loss of collagen increases the risk of skin complications. f. Reduced tactile sensitivity can lead to assessment and communication problems.

The nurse is educating clients who require surgery for various ailments about the perioperative experience. What education provided by the nurse is most appropriate?

Three phases of surgery and safety measures for each phase

When a client with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the client may show signs of alcohol withdrawal delirium during which time period?

Up to 72 hours after alcohol withdrawal

Common Preoperative Lab and Diagnostic Tests

Urinalysis, Pregnancy, Serum Creatinine and BUN, FBS< Blood Type and Cross Matching, Clotting Studies, ABGs, ECG, CBC, Serum Electrolytes, Chest X-Ray

The nurse is aware that which of the following nutrients promotes normal blood clotting?

Vitamin K

Diabetic-Special Considerations

Withholding insulin•NPO status•Monitoring plasma glucose

A client with a history of alcoholism is scheduled for urgent surgery. The client asks the nurse, "Why is everyone so concerned about how much I drink?" What is the best response by the nurse?

"It is important for us to know how much and how often you drink to help prevent surgical complications."

The nurse is teaching leg exercises to the client preoperatively. The client asks why the exercises are important. The best response by the nurse is:

"Leg exercises help prevent blood clots in your legs." Leg exercises improve circulation of the lower extremities by preventing venous stasis, which can lead to deep vein thrombosis in the postoperative client.

The nurse recognizes that the client most at risk for mortality associated with surgery is the:

Client with chronic alcoholism The client with chronic alcoholism who experiences alcohol withdrawal symptoms is at significant risk for mortality, which can be attributed to cardiac dysrthymias, cardiomyopathy, and bleeding tendencies.

The nurse is assigned a client scheduled for an outpatient colonoscopy in an ambulatory care setting. During which phase of perioperative care would the nurse document the admission vital signs in the recovery room?

During the postoperative phase The nurse realizes that documentation of vital signs in the recovery room begins the postoperative phase of perioperative care. The preoperative phase occurs until the client reaches the operating area. The intra operative phase includes the entire surgical procedure until the transfer to the recovery area. There is no transfer phase of perioperative care.

As a nurse working in an ambulatory surgery center, you are admitting a client who is going to have a biopsy of a skin lesion. What is an important part of the preoperative process?

Review preoperative instructions. (On admission, the nurse reviews preoperative instructions, such as diet restrictions and skin preparations, to ensure the client has followed them. The preoperative nurse does not give postoperative instructions; teach dressing changes or give instructions to caregivers.)

A client is being prepared for a same-day surgical procedure and is discussing with the nurse what potential ramifications this type of surgery has. Which of the following would the nurse correctly identify? Select all that apply.

The client will leave the hospital sooner than in the past. Need for teaching is increased. The client must be prepared to take on more self-care than he or she may have done in the past.

When assessing a postoperative client, the nurse is correct to relate which surgical risk factor that would decrease if the surgical client maintained a blood glucose level under 150 mg/dL?

Wound healing