Chapter 50 Care of Surgical Patients Elsevier

A postoperative client complains of pain. What available actions would relieve pain in the client? Select all that apply. 1. Administer regional analgesia. 2. Administer nonsteroidal antiinflammatory drugs (NSAID). 3. Apply hot packs on the incision site. 4. Administer opioid analgesics. 5. Assist the client in repositioning.

1. Administer regional analgesia. 2. Administer nonsteroidal antiinflammatory drugs (NSAID). 4. Administer opioid analgesics. 5. Assist the client in repositioning. Regional analgesia such as epidural analgesia helps to relieve pain until the recovery occurs. Nonsteroidal antiinflammatory agents are another alternative to systemic opioids. It is common to administer opioid analgesics like morphine (Avinza) immediately after surgery to relieve pain. Repositioning is a nonpharmacological method of relieving pain. Immediately after surgery, the nurse should not apply a warm or hot pack. It can dilate the blood vessels around the incision and increase the risk of postoperative bleeding. Text Reference - p. 1284

A nurse is caring for a client who is at risk of developing deep vein thrombosis. How should the nurse care for this client? Select all that apply. 1. Apply elastic stockings. 2. Administer anticoagulants per the health care providers orders. 3. Teach leg exercises. 4. Limit fluid intake. 5. Ambulate and make the client sit frequently.

1. Apply elastic stockings. 2. Administer anticoagulants per the health care providers orders. 3. Teach leg exercises. Applying elastic stockings helps to increase the venous return and prevent venous pooling. Administering anticoagulants helps in preventing formation of clots. Leg exercises promote venous return and prevent the blood from pooling in the extremities. Limiting fluid intake may cause dehydration. Ambulation may dislodge any clot formed and result in formation of emboli. Text Reference - p. 1259

In the operating room, a client tells a circulating nurse that he is going to have the cataract in his left eye removed. If the nurse notes that the consent form indicates that surgery is to be performed on the right eye, what should be the nurse's first action? 1. Ask the client his name. 2. Notify the surgeon and anesthesiologist. 3. Check to see whether the client has received any preoperative medications. 4. Assume that the client is a little confused because he is older and has received midazolam intramuscularly.

1. Ask the client his name. Ensuring proper identification of a client is the responsibility of all members of the surgical team. In a specialty surgical setting where many clients undergo the same type of surgery each day, such as cataract removal, it is possible that the client and the record do not match. Nurses should not make assumptions in the care of their clients. The surgical team should perform a time out where all the team members participate in the identification of the client. The surgeon and the anesthesiologist are notified later, once the nurse confirms the client's name and identity. Preoperative medications can be checked after the client's identification. The nurse should not assume that the client is confused due to premedication. The client should first be identified and then further procedures should be carried out. Text Reference - p. 1270

The senior nurse is teaching a group of nursing students about palliative surgical procedures. Which surgical procedures are included in this category? Select all that apply. 1. Colostomy 2. Appendectomy 3. Repair of cleft palate 4. Resection of nerve roots 5. Debridement of necrotic tissue

1. Colostomy 4. Resection of nerve roots 5. Debridement of necrotic tissue Palliative surgery reduces the intensity of the disease or its symptoms, but is not intended to be curative. Colostomy, nerve root resection, and debridement of necrotic tissue are examples of palliative surgery. Colostomy is done for diversion of the fecal passage due to obstruction or necrosis of the distal part of the gastrointestinal tract. Nerve root resection is usually done for relieving symptoms related to irritation of the particular nerve. Debridement of necrotic tissue reduces the dead tissues and promotes healing. Appendectomy is an ablative surgery; it removes a diseased body part. A repair of cleft palate is a constructive surgery to restore the function lost or reduced as a result of congenital anomalies.

A client is admitted through the emergency department for multisystem trauma following a motorcycle crash with multiple orthopedic injuries. He goes to surgery for repair of fractures. He is postoperative day 3 from an open reduction internal fixation of bilateral femur fractures and external fixator to his unstable pelvic fracture. Interventions that are necessary for prevention of venous thromboembolism in this high-risk postsurgical client include: Select all that apply. 1. Intermittent pneumatic compression stockings. 2. Vitamin K therapy. 3. Subcutaneous heparin or enoxaparin (Lovenox). 4. Continuous heparin drip with a goal of an international normalized ratio (INR) 5 times higher than baseline. 5. Ambulation

1. Intermittent pneumatic compression stockings. 3. Subcutaneous heparin or enoxaparin (Lovenox). Combination therapy with mechanical and pharmacological prophylaxis is recommended for high-risk clients. Vitamin K therapy creates a higher risk for clotting, and the goal INR should not be 5 times higher than baseline. Text Reference - p. 1283 Box 50-8

After a surgical client has been given preoperative sedatives, which safety precaution should a nurse take? 1. Reinforce to the client to remain in bed or on the stretcher. 2. Raise the side rails and keep the bed or stretcher in the high position. 3. Determine if the client has any allergies to latex. 4. Obtain informed consent immediately after sedative administration.

1. Reinforce to the client to remain in bed or on the stretcher. It is important for safety in clients who have been given sedatives to inform them of the importance of remaining in bed after preoperative sedatives are administered. It is inappropriate to have a bed or stretcher in the high position because of the increased fall risk and potential for injury. Informed consent should be obtained and allergy assessment done before sedative administration. Text Reference - p. 1270

The registered nurse is teaching a group of student nurses about surgical procedures. Which student statement indicates the need for correction? 1. "Bunionectomy is an elective procedure, performed on basis of patient's choice." 2. "Cholecystectomy is an ablative procedure and involves diagnostic surgical exploration." 3. "Closure of atrial septal defect in heart is a constructive surgical procedure to restore heart function." 4. "Coronary artery bypass is a major surgical procedure involving extensive reconstruction or alteration in body parts."

2. "Cholecystectomy is an ablative procedure and involves diagnostic surgical exploration." Ablative procedures are performed to remove a diseased body part. Cholecystectomy is an ablative procedure, but does not involve diagnostic surgical exploration. This statement needs correction. Bunionectomy is an elective type of surgery, as it is performed upon patient's choice. Closure of atrial septal defect is an example of constructive surgery to restore heart function. Coronary artery bypass is an example of major surgery that involves extensive reconstruction or alteration in body parts. Text Reference - p. 1256

The nurse is assessing a patient who takes insulin and is scheduled for surgery. The nurse suspects that the patient may be at risk of hypoglycemia. Which patient statement supports the nurse's conclusion? 1. "I take ginkgo to improve memory." 2. "I take ginseng to lower my blood pressure." 3. "I am on warfarin (Coumadin) therapy for a prosthetic valve." 4. "I am on prednisone (Deltasone) therapy for a recurrent skin rash."

2. "I take ginseng to lower my blood pressure." Ginseng is an herbal therapy, which helps relieve stress. However, ginseng stimulates the secretion of insulin, thereby reducing blood glucose levels and increasing the risk of hypoglycemia for a patient who takes insulin therapy. Ginkgo is an herbal supplement, which is useful for the treatment of dementia. However, ginkgo increases the risk of hemorrhage as it is an anticoagulant; it does not cause hypoglycemia. Warfarin (Coumadin) is an anticoagulant, which increases the risk of hemorrhage but does not cause hypoglycemia with insulin therapy. Prednisone (Deltasone) is a corticosteroid, which suppresses the immune system. Prednisone (Deltasone) is associated with the risk of hyperglycemia. Text Reference - p. 1261

A nurse observes that a client is unable to sleep the night before surgery is scheduled due to anxiety. Which nursing action is appropriate to relieve anxiety in the client? 1. Postpone the surgical procedure. 2. Administer alprazolam (Xanax) to the client. 3. Give herbal medicine to the client. 4. Leave the client alone to rest.

2. Administer alprazolam (Xanax) to the client. The client may be anxious due to surgery and needs to be calmed down. Therefore, the nurse should administer alprazolam to the client. Alprazolam acts on the cerebral cortex and limbic system to relieve anxiety. Postponing the surgery may worsen the client's condition. Some herbal medicines increase the risk of postoperative complications and should be avoided. Leaving the client alone is not likely to relieve anxiety. Text Reference - p. 1269

A client is scheduled for surgery. A nurse is administering preoperative medications to the client. What else does the nurse do after the administration of preoperative medications? 1. Give the client water to sip. 2. Restrict the client from leaving the bed. 3. Sign the client's consent form. 4. Remove metal items from the client.

2. Restrict the client from leaving the bed. After administering preoperative medications, the nurse should restrict the client from leaving the bed. Preoperative medications cause sedation, which increases the risk of fall. Nothing is allowed by mouth as it increases the risk of aspiration. The consent form is signed and metal items are removed before the administration of preoperative medications. Text Reference - p. 1270

The nurse is caring for a postoperative client. What measures should the nurse take to prevent venous stasis and thrombus formation in the client? Select all that apply. 1. Provide ample rest. 2. Encourage early ambulation. 3. Administer antibiotics. 4. Apply graded compression stockings. 5. Encourage client to perform leg exercises.

2. Encourage early ambulation. 4. Apply graded compression stockings. 5. Encourage client to perform leg exercises. Venous stasis and thrombus formation are serious circulatory complications after surgery. Measures should be taken to promote a healthy blood supply to the extremities. Early ambulation helps improve venous return and prevents stasis of blood. Graded compression stockings also help prevent stasis. Leg exercises are encouraged to promote normal venous return. Ample rest is not required after every surgery. Administration of antibiotics is a general precaution against infections and may not help to avoid circulatory complications. Text Reference - p. 1283

A client is scheduled for cholecystectomy. The client is a known hypertensive for the past 15 years. In what category should the client be placed based on the physical status classification of the American Society of Anesthesiologists? 1. P1 2. P3 3. P5 4. P6

2. P3 The physical status classification of the American Society of Anesthesiologists indicates the risk to a client if a surgery is performed. P3 category includes clients who suffer from severe systemic disorders like hypertension, diabetes, and obesity. The P1 category includes normal healthy clients. The P5 category includes moribund clients who cannot survive without the required surgery (cardiac, renal, or pulmonary disorder). P6 refers to a deceased client. Text Reference - p. 1256

A client has undergone surgery. Which components in the client's diet help in the wound healing process? Select all that apply. 1. Fat 2. Protein 3. Vitamin C 4. Vitamin E 5. Vitamin A

2. Protein 3. Vitamin C 5. Vitamin A Diet plays an important role in the wound healing process. A diet rich in protein, vitamin C, and vitamin A is helpful for healing wounds. Increasing the intake of these nutrients facilitates wound healing. Fats help provide padding for important organs but do not help heal wounds. Vitamin E is important for cardiovascular health, not wound healing. TEST-TAKING TIP: Calm yourself by closing your eyes, putting down your pencil (or computer mouse), and relaxing. Deep-breathe for a few minutes (or as needed, if you feel especially tense) to relax your body and to relieve tension. Text Reference - p. 1259

What is most likely to be effective in meeting a client's teaching and learning needs preoperatively? 1. Teaching the client 2. Teaching the client and family 3. Using brief verbal instructions 4. Using written instructions

2. Teaching the client and family A nurse should determine the learning needs preoperatively and teach both the client and the family before surgery. Teaching the family helps them to participate in client care postoperatively. Teaching only the client limits learning preoperatively because the client can be anxious and not receptive to new information. Brief verbal instructions are often forgotten. Using only written instructions does not provide the opportunity for learning evaluation. Other means of preoperative teaching include telephone calls, mailings, printed guidelines and checklists, and videotapes. 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. For this question, teaching the client and family includes teaching the client, and is also more effective. Text Reference - p. 1267 Nursing Care Plan Deficient Knowledge Regarding Preoperative and Postoperative Care Requirements Related to Lack of Exposure to Information

A client is scheduled for a coronary artery bypass graft surgery. While going through the client's medical records, the nurse finds that the client has a medical condition that may affect the outcome of the surgery. Which condition is the client likely suffering from? 1. Cervical spondylosis 2. Thrombocytopenia 3. History of urinary tract infection in the last 6 months 4. Hormone replacement therapy postmenopause 7 years ago

2. Thrombocytopenia Thrombocytopenia refers to a relative decrease of platelets in blood. It can cause serious complications during surgery. Cervical spondylosis, resolved urinary tract infections, and hormone replacement therapy do not interfere with surgery. Text Reference - p. 1258

A nurse is recovering a client who received conscious sedation for cosmetic surgery. Which of the following is an advantage that conscious sedation has over general anesthesia? 1. Loss of sensation at the surgical site 2. No need to maintain a patent airway 3. Amnesia and relief of pain 4. Monitoring in phase I recovery

3. Amnesia and relief of pain Conscious sedation offers adequate sedation, reduction of fear and anxiety, amnesia, rapid recovery, and relief of pain. A patient under conscious sedation must independently maintain a patent airway and adequate ventilation and be able to respond appropriately to verbal stimuli or light tactile stimulation. Loss of sensation at the surgical site is an effect of local anesthesia. These clients usually only go through phase II recovery. Text Reference - p. 1273

Malignant hyperthermia is a genetic disorder. What are the symptoms of malignant hyperthermia? Select all that apply. 1. Diarrhea 2. Depression 3. Hypercarbia 4. Skin mottling 5. Muscular rigidity

3. Hypercarbia 4. Skin mottling 5. Muscular rigidity Malignant hyperthermia is a life-threatening complication of anesthesia. It is rarely observed. It is a genetic disorder and manifests as hypercarbia (elevated carbon dioxide level), skin mottling, and muscular rigidity. Diarrhea and depression are not symptoms of malignant hyperthermia. Text Reference - p. 1278

Which surgical complication does the nurse assess for in a client who took gingko prior to surgery? 1. Hypoglycemia 2. Electrolyte imbalances 3. Postoperative bleeding 4. Respiratory depression

3. Postoperative bleeding Use of herbal medicine may produce complications in surgery. Gingko can affect platelet activity and increase susceptibility to postoperative bleeding. Hypoglycemia can happen to a client with diabetes mellitus who has been without food or drink for several hours in preparation for surgery. Electrolyte imbalances can happen in clients with predisposing electrolyte disorders such as end-stage renal disease. Respiratory depression can occur in clients who have underlying respiratory disorders such as chronic obstructive pulmonary disease. Text Reference - p. 1261

A client is scheduled for surgery. The client has a history of epileptic seizures and has been taking phenytoin (Dilantin) for a prolonged period of time. What is the risk for this client? 1. Electrolyte imbalances 2. Bleeding and bruising 3. Hypoglycemia 4. Anesthesia complications

4. Anesthesia complications Table 50-3 Prolonged use of phenytoin can alter metabolism of anesthetic agents and may lead to complications. The client may require a smaller or larger dose of the anesthetic agent for the desired effect. Phenytoin does not cause electrolyte imbalances, hemorrhage, or hypoglycemia. Text Reference - p. 1261

The nurse is caring for a patient following a spinal surgery. Which routine nursing intervention does the nurse exclude from the patient's care plan in order to prevent complications? 1. Administering opioids for pain control 2. Maintaining a urine output of 1ml/kg/hr 3. Changing the patient's position every 2 hours 4. Encouraging coughing exercises every 2 hours

4. Encouraging coughing exercises every 2 hours Coughing and deep breathing exercises are usually prescribed after surgery to prevent pulmonary complications, but coughing may increase intracranial pressure and complicate the patient's recovery following a spinal surgery. For this reason, the nurse would not include coughing or deep breathing exercises in the plan of care. Pain control is important in the postoperative periods and may be achieved through opioids. A urine output of 1ml/kg/hr indicates good renal function. The patient's position should be changed every 2 hours to prevent pressure ulcers. Text Reference - p. 1259

You are a nurse in the postanesthesia care unit (PACU), and you note that your client has a heart rate of 130 beats/min and a respiratory rate of 32 breaths/min; you also assess jaw muscle rigidity and rigidity of limbs, abdomen, and chest. What do you suspect, and which intervention is indicated? 1. Infection: Notify surgeon and anticipate administration of antibiotics. 2. Pneumonia: Listen to breath sounds, notify surgeon, and anticipate order for chest radiography. 3. Hypertension: Check blood pressure, notify surgeon, and anticipate administration of antihypertensives. 4. Malignant hyperthermia: Notify surgeon/anesthesia provider immediately, prepare to administer dantrolene sodium (Dantrium), and monitor vital signs frequently.

4. Malignant hyperthermia: Notify surgeon/anesthesia provider immediately, prepare to administer dantrolene sodium (Dantrium), and monitor vital signs frequently. Malignant hyperthermia is a life-threatening complication of general anesthesia. It is a severe hypermetabolic condition that causes rigidity of skeletal muscles caused by an increase in intracellular calcium ion concentration and leads to hypercarbia, tachypnea, and tachycardia. Despite the name, an elevated temperature is a late sign, and an increase in the respiratory rate to eliminate carbon dioxide is one of the first signs. Dantrolene sodium (Dantrium) is a skeletal muscle relaxant that is used to treat this complication. Text Reference - p. 1278

The nurse is caring for a patient who is recovering in a postanesthesia care unit (PACU) immediately after undergoing surgery. Which intervention by the nurse may increase the risk of cardiovascular complications in the patient? 1. Hydrating the patient with fluids 2. Administering heparin to the patient 3. Encouraging ambulation for the patient 4. Placing pillows or rolled blankets under the knees

4. Placing pillows or rolled blankets under the knees Placing pillows or rolled blankets under the knees may lead to the compression of popliteal vessels in the knees, which can lead to thromboembolism. Keeping the patient hydrated helps prevent dehydration and improves the intravascular volume. Heparin is an anticoagulant, which reduces the risk of clot formation. Ambulation is recommended for a postoperative patient to reduce thrombi formation. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 1283

In the postanesthesia care unit (PACU) the nurse notes that the client is having difficulty breathing and suspects an upper airway obstruction. The nurse would first: 1. Suction the pharynx and bronchial tree. 2. Give oxygen through a mask at 4 L/min. 3. Ask the client to use an incentive spirometer. 4. Position the client on one side with the face down and the neck slightly extended so the tongue falls forward.

4. Position the client on one side with the face down and the neck slightly extended so the tongue falls forward. Weak pharyngeal/laryngeal muscle tone from anesthetics can occur. Positional change helps to move the tongue forward to open the airway. The immediate intervention should be to open the airway. Suctioning the bronchial tree or providing oxygen does not alleviate an upper airway obstruction. Text Reference - p. 1280

A 40-year-old client needs surgical removal of an inflamed gall bladder. What screening tests should the nurse anticipate the surgeon to prescribe? Select all that apply. 1. Electrocardiogram 2. Electroencephalogram 3. Chest x-ray 4. Blood sugar levels 5. Bone density scan

Table 50-6 1. Electrocardiogram 3. Chest x-ray 4. Blood sugar levels The screening tests focus on the body systems that are likely to be affected by the surgery. Electrocardiogram (ECG) and chest x-ray help to determine the heart and lung function. Blood sugar levels help to determine postoperative wound healing and chances of infection. Electroencephalogram (EEG) is required in clients suffering from epilepsy and other brain related disorders. Bone density scan is performed in females after menopause and is not required for this type of procedure. Text Reference - p. 1264

A nurse is working in an ambulatory care setting and is ready to discharge a client who is wheelchair dependent. The client underwent dilation of an esophageal stricture. Her postanesthesia recovery score for ambulatory patients (PARSAP) score is 16. Her family is ready to go and eager to make the long road trip home. In determining if it is safe for the client to be discharged at this time, the nurse should decide which of the following? 1. The PARSAP score must be 18 or higher before being discharged. 2. The client's family is capable to care for her, and she understands her discharge instructions; thus the nurse proceeds with discharge. 3. Since the client hasn't been drinking much, the nurse is not concerned that she is unable to void and proceeds with discharge. 4. Since the client was admitted to the surgical center in a wheelchair, she can be discharged with a lower PARSAP score.

Table 50-8 4. Since the client was admitted to the surgical center in a wheelchair, she can be discharged with a lower PARSAP score. The PARSAP is an important functional screen to assess the function of the ambulatory surgery client. The total score must be at least 18 for a client to be discharged to home, unless the client is not walking or is unable to use extremities before surgery. Text Reference - p. 1276

Because an older adult is at increased risk for respiratory complications after surgery, the nurse should: 1. Withhold pain medications and ambulate the client every 2 hours. 2. Monitor fluid and electrolyte status every shift and vital signs with temperature every 4 hours. 3. Orient the client to the surrounding environment frequently and ambulate the client every 2 hours. 4. Encourage the client to turn, deep breathe, and cough frequently, and ensure adequate pain control.

Box 50-7 4. Encourage the client to turn, deep breathe, and cough frequently, and ensure adequate pain control. Adequate pain control is important to allow participation in postoperative exercises such as turning, frequent coughing, and deep breathing to prevent respiratory complications. Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. This question specifies that that client is at risk for respiratory complications. Only the correct answer addresses this risk. Text Reference - p. 1276

What are the responsibilities of a scrub nurse in managing the care of a client during surgery? Select all that apply. 1. Assists in applying sterile drapes 2. Counts the sponges and instruments 3. Reviews the preoperative assessment 4. Implements the plan of care 5. Hands instruments to the surgeon

1. Assists in applying sterile drapes 2. Counts the sponges and instruments 5. Hands instruments to the surgeon The scrub nurse assists in applying sterile drapes, counts the sponges and instruments, and hands instruments to the surgeon during the surgical procedure. Reviewing the preoperative assessment and implementing the plan of care are responsibilities of the circulating nurse. Text Reference - p. 1271

A nurse is attending to an elderly client scheduled for a hernia operation. The nurse understands that due to aging, the client may have rigidity of the blood vessel walls and a reduction in sympathetic and parasympathetic innervation to the heart. What risks would be increased in this client following a surgery? Select all that apply. 1. Hemorrhage 2. Increased systolic blood pressure 3. Increased diastolic blood pressure 4. Increased ability to eliminate drugs 5. Increased lung expansion

1. Hemorrhage 2. Increased systolic blood pressure 3. Increased diastolic blood pressure Table 50-4 As the body ages, the blood vessel walls become rigid, causing a reduction in sympathetic and parasympathetic innervation to the heart. These changes may increase the risk of hemorrhage following a surgery. The client may also develop an increase in systolic and diastolic pressures. Following a surgery, there could be a decreased ability to eliminate drugs due to reduced renal function. Lung expansion may be reduced due to decreased strength of the respiratory muscles. STUDY TIP: Be sure to consider the changes due to aging that affect each disease and a patient's responses to therapies. Text Reference - p. 1259

A patient is admitted to the postanesthesia care unit (PACU) immediately after undergoing surgery. The nurse finds shallow breathing and the pulse oximetry value is 90%. Which intervention does the nurse perform for effective treatment? 1. Inserting an oral or nasal airway 2. Providing oral fluids to the patient 3. Encouraging the patient to cough 4. Providing intravenous (IV) fluids to the patient

1. Inserting an oral or nasal airway Certain anesthetic agents can cause respiratory depression. The signs of respiratory depression are shallow breathing and abnormal pulse oximetry values. Normal pulse oximetry values range between 92% and 100% saturation. The nurse inserts a nasal or oral airway to maintain a patent airway and facilitate effective oxygenation of all tissues in the body. The patient's respiratory tract may be blocked due to the effect of anesthetic agents. Providing water to the patient may cause aspiration and aggravate the respiratory depression. Encouraging the patient to cough is an effective intervention only when the patient is awake. The nurse should provide IV fluids to the patient to avoid dehydration. However, it is not an effective intervention for treating respiratory depression. Text Reference - p. 1277

A patient diagnosed with appendicitis is advised to have surgery. After collecting the patient's medical history, the nurse anticipates that the surgery will be postponed. Which may necessitate surgery postponement? 1. The patient takes aspirin (Ecotrin) for cardiovascular disease. 2. The patient takes gentamicin (Garamycin) for infection. 3. The patient takes neomycin (Neo-Fradin) for infection. 4. The patient is on prednisone (Deltasone) therapy.

1. The patient takes aspirin (Ecotrin) for cardiovascular disease. Aspirin is an anticoagulant that increases the risk of bleeding during surgery. Therefore, the surgery should be delayed to reduce the risk of hemorrhage. Gentamicin (Garamycin) and neomycin (Neo-Fradin) are antibiotics, which do not cause any complications with the surgery. Prednisone (Deltasone) is a corticosteroid, which suppresses the immune system. However, the surgery need not be postponed because of this drug. Text Reference - p. 1261

A nurse is caring for an obese client who underwent a surgical procedure yesterday. What potential postoperative complications does the nurse assess for when caring for the client? Select all that apply. 1. Wound dehiscence 2. Fluid and electrolyte imbalances 3. Reduced cardiac function 4. Reduced ventilatory function 5. Increased enzyme activity

1. Wound dehiscence 3. Reduced cardiac function 4. Reduced ventilatory function Table 50-3 Obese clients are at high risk for postoperative complications because of poor blood supply, reduced cardiac function, and reduced ventilatory function. Due to the increased number of fatty tissues, blood supply is reduced and the wound edges can open. Poor blood supply slows delivery of antibodies, enzymes, and essential nutrients. It leads to poor wound healing and increases chances of wound infection. The lung expansion is compromised due to obesity, leading to cardiac dysfunction and reduced ventilatory function. An obese client is not at any higher risk for fluid and electrolyte imbalances than a client of normal body weight. There is no difference in the enzyme production or activity of an obese client. STUDY TIP: Eat breakfast or lunch before an exam. Avoid greasy, heavy foods and overeating. This will help keep you calm and give you energy. Text Reference - p. 1259

A client is scheduled for a coronary artery bypass graft surgery. Which are the questions that the nurse should ask the client when performing the assessment of cardiac history? Select all that apply. 1. "Do you include fruits in your diet?" 2. "Which medications are you taking?" 3. "Are your stools regular and normal?" 4. "Do you have any trouble breathing?" 5. "On a scale of 0-10, how severe would you rate your pain?"

2. "Which medications are you taking?" 4. "Do you have any trouble breathing?" 5. "On a scale of 0-10, how severe would you rate your pain?" In cardiac assessment, it is extremely important to know which medications the client is taking. Many medications alter the coagulation of blood, heart rate, and other factors which need to be considered before surgery. Asking if the person has trouble breathing is important while assessing the cardiac profile. In severe cardiac conditions, pulmonary function is also affected. Asking the client to score the pain indicates the severity of the pain and is important in assessment. Asking if the client eats fruit is a general question and is not specific to cardiac assessment. Asking about the elimination functions of the body is not directly related to cardiac function. Text Reference - p. 1258

A client reports a history of obstructive sleep apnea. Which position of sleeping is harmful for the client? 1. Prone position 2. Supine position 3. Lateral position 4. Upright position

2. Supine position The client has a history of obstructive sleep apnea. Sleeping in the supine position is harmful to the client as it may cause airway obstruction and impair the respiratory function. The prone, lateral, and upright positions are suitable for the client. Text Reference - p. 1280

A client underwent cholecystectomy and is in PACU. The nurse decides to assess the client's readiness for discharge from the PACU based on a modified Aldrete Score. The nurse finds out that the client can move all four extremities on command. The client is able to breathe deeply. The BP is 20% of pre-anesthetic level. The client arouses on calling and is able to maintain O2 saturation at 94% without an oxygen delivery device. What is the score for this client? 1. 7 2. 8 3. 9 4. 10

3. 9 Table 50-7 According to the Modified Aldrete Score, a score of 2 is appropriate if the client can move four extremities voluntarily or on command. The ability to breathe deeply and cough freely is scored a 2. A BP 20% of the pre-anesthetic level is scored a 2. If the client is arousable on calling, a score of 1 is given. If the client is able to maintain O2 saturation > 92% on room air, a score of 2 is given. Therefore, the total score is 9. STUDY TIP: Becoming a nursing student automatically increases stress levels because of the complexity of the information to be learned and applied and because of new constraints on time. One way to decrease stress associated with school is to become very organized so that assignment deadlines or tests do not come as sudden surprises. By following a consistent plan for studying and completing assignments, you can stay on top of requirements and thereby prevent added stress. Text Reference - p. 1275

What would be the most effective way for a nurse to validate informed consent? 1. Ask the family whether the client understands the procedure. 2. Check the chart for a completed and signed consent form. 3. Ask the client what he or she understands regarding the procedure. 4. Determine from the health care provider what was discussed with the client.

3. Ask the client what he or she understands regarding the procedure. Informed consent in the health care setting is a process whereby a client is informed of the risks, benefits, and alternatives of a certain procedure, and then gives consent for it to be done. The piece of paper is simply evidence that the informed consent process has been done. Asking the family does not provide information about client understanding of the procedure. A signed informed consent form does not always indicate that the client has understood the teaching. Asking the health care provider about previous discussions does not give information about the client's understanding. Text Reference - p. 1270

A client is fasting for surgery. The client forgot to take the prescribed antibiotic. What is the most appropriate nursing action in this situation? 1. Replace the medicine. 2. Avoid giving the antibiotic. 3. Give the antibiotic after surgery. 4. Give the antibiotic with a sip of water.

4. Give the antibiotic with a sip of water. Clients are advised to fast before surgery to prevent aspiration while receiving anesthesia. However, important medications that may affect the outcome of surgery are allowed with a sip of water. Therefore, antibiotics should be administered with a sip of water. It helps to prevent infection during and after the surgery. The medicine should not be replaced or avoided. If the antibiotic is prescribed to be administered before surgery, then it is of no use if it is given after the surgery. Text Reference - p. 1269

What are advantages of conscious sedation over general anesthesia? Select all that apply. 1. Client maintains independent airway 2. Ability to respond to verbal stimuli 3. Reduction of fear and anxiety 4. Loss of sensation at the surgical site 5. Inability to recall the surgery

1. Client maintains independent airway 2. Ability to respond to verbal stimuli 3. Reduction of fear and anxiety Advantages of conscious sedation include the client's ability to maintain an independently patent airway and respond to verbal stimuli. Conscious sedation usually results in a reduction of fear and anxiety associated with surgery compared with general anesthesia. Local anesthesia involves a loss of sensation at the surgical site. During conscious sedation the client is able to recall the surgical procedure. STUDY TIP: Avoid planning other activities that will add stress to your life between now and the time you take the licensure examination. Enough will happen spontaneously; do not plan to add to it. Text Reference - p. 1273

A nurse works in an ambulatory surgical center. The nurse checks the vital signs of clients in the preoperative period. What would the vital signs indicate? Select all that apply. 1. Client's stability 2. Correction of abnormalities 3. Fear and stress 4. Health of the client 5. Baseline for intraoperative assessment

1. Client's stability 4. Health of the client 5. Baseline for intraoperative assessment In the preoperative period, the nurse checks for the client's vital signs to ensure health and stability. It also serves as a baseline for intraoperative assessment. The vital signs do not indicate correction of abnormalities. The vital signs do not assess for fear and stress of the client. Text Reference - p. 1270

A client is being assessed for factors that may increase the risk of surgery. Which medical conditions increase the risk of surgery? Select all that apply. 1. Diabetes mellitus 2. Upper respiratory tract infection 3. Fever 4. Obstructive sleep apnea 5. Headache

1. Diabetes mellitus 2. Upper respiratory tract infection 3. Fever 4. Obstructive sleep apnea Diabetes mellitus increases the risk of developing infection and delays wound healing. Upper respiratory tract infections increase the risk of respiratory complications during anesthesia. Fever increases the risk of fluid and electrolyte imbalance. Obstructive sleep apnea may lead to airway obstruction if opioids are administered. A headache does not increase the risk of surgery. Text Reference - p. 1258 Table 50-3

Which of the following are common postoperative complications likely to be found in obese clients? Select all that apply. 1. Embolus 2. Atelectasis 3. Pneumonia 4. Hemorrhage 5. Electrolyte imbalance

1. Embolus 2. Atelectasis 3. Pneumonia Obese clients are more susceptible to the development of postoperative complications. Embolus forms from venous stasis in the lower extremities. Atelectasis and pneumonia occur because of immobility, reduced ventilatory function, increased secretions, and problems in lung expansion. Hemorrhage can happen in clients with bleeding disorders. An obese client is not at any higher risk of electrolyte imbalances than a client of normal body weight. Text Reference - p. 1259

You are caring for a client after surgery who underwent a liver resection. His prothrombin time (PT) or an activated partial thromboplastin time (APTT) is greater than normal. He has low blood pressure; tachycardia; thready pulse; and cool, clammy, pale skin; and he is restless. You assess his surgical wound, and the dressing is saturated with blood. Which immediate interventions should you perform? Select all that apply. 1. Notify the surgeon. 2. Maintain intravenous (IV) fluid infusion and prepare to give volume replacement. 3. Monitor the client's vital signs every 15 minutes or more frequently until his condition stabilizes. 4. Wean oxygen therapy. 5. Provide comfort through bathing.

1. Notify the surgeon. 2. Maintain intravenous (IV) fluid infusion and prepare to give volume replacement. 3. Monitor the client's vital signs every 15 minutes or more frequently until his condition stabilizes. Table 50-9 A common early complication of surgery is bleeding. It is important to continue oxygen therapy and notify the surgeon. Signs of bleeding include hypotension; tachycardia; and cool, clammy, pale skin. Signs of bleeding may be visible, or the bleeding may be internal. Be prepared to administer fluid or blood as needed and frequently monitor vital signs to assess the client's status. Text Reference - p. 1281

The nurse is evaluating the medical health records of four different postoperative patients. Which patient's medical record will require the nurse to obtain a more detailed medical history? Patient Condition/Probable Causes Patient A Venous Stasis/Decreased blood count Patient B Hypercoagulability/Decreased fluid volume Patient C Pneumonia/Inadequate lung expansion Patient D Inadequate Oxygenation/Reduced hemoglobin 1. Patient A 2. Patient B 3. Patient C 4. Patient D

1. Patient A Patient A with decreased blood count may not experience venous stasis. The main cause of venous stasis is immobilization that results in decreased muscular contraction in the lower extremities or smoking, which causes endothelial injury. Therefore, patient A should receive a detailed interview that would reveal more details of the medical history. Loss of fluids after surgery will result in decreased fluid volume and thereby increased tendency of clot formation. Therefore, the nurse need not obtain a more detailed medical history from patient B. Inadequate lung expansion is one of the leading causes of pneumonia. The lungs do not inflate during surgery, thereby resulting in inadequate lung expansion. Therefore, patient C's medical record does not indicate the need for an interview to reveal more details of the medical history. Hemoglobin plays an important role in providing oxygen to various organ cells. Reduced hemoglobin may result in inadequate oxygenation. Therefore, patient D's medical record does not indicate the need for an interview to reveal more details of the medical history. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. Text Reference - p. 1287

The operating room (OR) and postanesthesia care unit (PACU) are high-risk environments for clients with a latex allergy. Which safety measures to prevent a latex reaction should the nurse implement? Select all that apply. 1. Screening clients about food allergies known to have a cross-reactivity to latex such as kiwis and bananas 2. Having a latex allergy cart available at all times 3. Communicating with the operating room (OR) team as soon as 24 to 48 hours in advance of the surgery when a latex-sensitive client is identified 4. Scheduling the latex-sensitive client for the last operative case of the day 5. Notifying the pharmacy and central supply that the client is latex sensitive

1. Screening clients about food allergies known to have a cross-reactivity to latex such as kiwis and bananas 2. Having a latex allergy cart available at all times 3. Communicating with the operating room (OR) team as soon as 24 to 48 hours in advance of the surgery when a latex-sensitive client is identified 5. Notifying the pharmacy and central supply that the client is latex sensitive Table 30-1 Identifying clients with potential cross-reactivity is important since they may be unaware of their latex sensitivity. Having all necessary equipment easily accessible to staff is necessary to ensure that all items are available when needed. It is important for the operative team to be aware of the case so they can plan appropriate safeguards; scheduling the latex-sensitive client for the first case means that latex dust from the previous day was removed overnight before the latex-sensitive client's operation. Notifying the pharmacy and central supply that the patient for whom you are caring is latex sensitive allows these departments to use appropriate procedures when preparing medications and instruments. Text Reference - p. 1272

A client is scheduled for a laparoscopic cholecystectomy. What benefits of the ambulatory surgery should the nurse inform the client of? Select all that apply. 1. Shorter operative time 2. Cost saving 3. More recovery time 4. Less risk of health care-associated infections 5. Increased hospital stay

1. Shorter operative time 2. Cost saving 4. Less risk of health care-associated infections There are benefits for the patient who has ambulatory surgery. Anesthetic drugs that metabolize rapidly with few aftereffects allow shorter operative times and faster recovery time. Ambulatory surgery is also cost effective as it allows for a shorter hospital stay, and thus reduces the possibility of acquiring nosocomial infections. Major surgeries involving a longer stay in the hospital require a longer recovery time. TEST-TAKING TIP: If different choices oppose each other, they are not likely to both be correct. For instance in this question, two of the choices are "cost saving" and "increased hospital stay." An increased hospital stay would add costs and not be cost saving. Thus two of these choices are in conflict with each other, so only one of those two is likely to be correct. Because cost saving is a benefit and the question asks for benefits, it is the correct choice. Text Reference - p. 1255

Which symptoms are likely to be found in a client who has obstructive sleep apnea? Select all that apply. 1. Snoring 2. Nausea 3. Drowsiness 4. Muscle weakness 5. Morning headaches

1. Snoring 3. Drowsiness 5. Morning headaches Obstructive sleep apnea is a periodic, partial, or complete obstruction of the upper airway during sleep. Snoring, drowsiness, and morning headaches are symptoms of obstructive sleep apnea. Clients with obstructive sleep apnea do not typically experience nausea. Clients who have difficulty tolerating anesthesia may experience nausea. Muscular weakness is not related to obstructive sleep apnea. Clients with underlying musculoskeletal disorders may develop increased weakness after surgery. Text Reference - p. 1260

A nurse is performing preoperative assessment of clients who are scheduled for surgery the next day. Which clients are most at risk for a latex allergy? Select all that apply. 1. The client with a history of spina bifida 2. The client who has diabetes mellitus 3. The client who has an allergy to apples 4. The client who has a spinal cord injury 5. The client who has urogenital abnormality

1. The client with a history of spina bifida 4. The client who has a spinal cord injury 5. The client who has urogenital abnormality The client with spina bifida, the client who has a spinal cord injury, and the client with urogenital abnormality should be assessed for latex allergy. Clients with spina bifida, spinal cord injuries, and urogenital abnormalities have had repeated exposure to latex products throughout their lives. These clients have been exposed to latex urinary catheters and examination gloves. This repeated exposure may lead to the development of a latex allergy. Clients who have diabetes mellitus do not use latex products for managing their disease, so they do not have an increased risk. Clients who have allergies to bananas, chestnuts, kiwi fruit, avocados, and tomatoes may have a cross-sensitivity to latex. STUDY TIP: A mnemonic for the allergies that show cross-sensitivity to latex is "T-BACK": Tomatoes, Bananas, Avocados, Chestnuts, and Kiwi. Think of a silly visual to accompany the mnemonic, such as a latex bandage on the BACK of a T-shirt. Text Reference - p. 1261

A client who is latex-sensitive is scheduled for a cholecystectomy. What special precautions are required for the client? Select all that apply. 1. Use stopcocks to inject the medications. 2. Draw the medications from well-closed vials. 3. Remove all latex products from the operating room. 4. Use a nonlatex breathing circuit with a plastic mask and bag. 5. Schedule the surgery as the last case of the day.

1. Use stopcocks to inject the medications. 3. Remove all latex products from the operating room. 4. Use a nonlatex breathing circuit with a plastic mask and bag. Special care should be taken for a client who has a latex sensitivity. Using stopcocks to inject drugs rather than latex ports reduces the chances of a latex allergy reaction. Removing all latex products from the operating room helps to prevent severe reactions in the client. Using a nonlatex breathing circuit with a plastic mask and bag helps to prevent latex reactions. All of the contents must be latex free. Medication should not be drawn from well-closed vials as it increases the chances of latex allergic reactions. Medications should be drawn directly from opened vials. Scheduling the surgery as the first case of the day in the operating room ensures that any latex dust has been removed from the room overnight by ventilation. Text Reference - p. 1261

Hand-off communications that occur between the postanesthesia care unit (PACU) nurse and the nurse on the postoperative nursing unit should be done when a client returns to the nursing unit. What are the appropriate components of a safe and effective hand-off? Select all that apply. 1. Vital signs, the type of anesthesia provided, blood loss, and level of consciousness 2. Uninterrupted time to review the recent pertinent events and ask questions 3. Verification of the client using one identifier and the type of surgery performed 4. Review of pertinent events occurring in the operating room (OR) while at the nurses' station 5. Review of anesthesia medications delivered during surgery

1. Vital signs, the type of anesthesia provided, blood loss, and level of consciousness 2. Uninterrupted time to review the recent pertinent events and ask questions 5. Review of anesthesia medications delivered during surgery Box 50-5 A standardized approach or tool for hand-off communication helps providers provide accurate information about the care received in the OR and the PACU before coming to the postoperative nursing unit. Proper identification of the client requires using a standard of two identifiers and explaining the surgery performed and information about the type of anesthesia provided, blood loss, and level of consciousness. Allowing appropriate time for questions and communication free of distraction improves the quality of the hand-off. It must occur at the client's bedside. The surgical team's report when the client is admitted to the PACU includes a review of anesthetic agents administered so the PACU nurse is able to anticipate how quickly a client should regain consciousness and analgesic needs. Text Reference - p. 1287

You have been given the following postoperative clients to care for on your shift. Based on the information provided, which client should you see first? 1. A 75-year-old following hip replacement surgery who is complaining of moderate pain in the surgical site, with a heart rate of 92 2. A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous patient-controlled analgesia (PCA) with a history of OSA. The pulse oximeter has been alarming and reading 85. 3. A 36-year-old following bladder neck suspension who is 30 minutes late to receive her postoperative dose of antibiotic 4. A 48-year-old following total knee replacement who needs help repositioning in bed

2. A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous patient-controlled analgesia (PCA) with a history of OSA. The pulse oximeter has been alarming and reading 85. The client with OSA has a risk of airway obstruction, which takes immediate precedence. She is symptomatic of oxygen desaturation. Text Reference - p. 1260 Table 50-9

You are caring for a 65-year-old client 2 days after surgery and helping him walk down the hallway. The surgeon has ordered exercise as tolerated. Your assessment indicates that the client's heart rate at baseline is 88. After walking approximately 30 yards down the hallway, the heart rate is 110. What should be your next action? 1. Stop exercise immediately and have him sit in a nearby chair. 2. Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue exercise. 3. Tell him that he needs to walk further to reach a heart rate of 120. 4. Have him walk slower; he has reached his maximum.

2. Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue exercise. The client's maximum heart rate with exercise should be 220 - 65 = 155. He is still in a safe range. An assessment of how the client feels is good practice. The client can safely continue to walk. Test-Taking Tip: To memorize the formula (220 - age) for maximum heart rate, remind yourself of this formula when you exercise to monitor your own heart rate. Then you will have rehearsed it enough to be able to apply it to questions like this one. As long as a client's heart rate is well below the expected maximum, you can ask the client how s/he feels before discontinuing the exercise. Text Reference - p. 1283

An operating room nurse is caring for a client during the induction phase. What action does the nurse anticipate the anesthesiologist will perform? 1. Position the client. 2. Insert an endotracheal tube. 3. Start weaning back the anesthetic. 4. Insert an intravenous line.

2. Insert an endotracheal tube. The three phases of anesthesia are the induction phase, emergence phase, and maintenance phase. The induction phase involves administration of an anesthetic agent and endotracheal intubation. The client is positioned during the maintenance phase. In the emergence phase anesthetics are decreased, and the client begins to awaken. An intravenous line is inserted prior to the surgical procedure so that the anesthetics can be administered. Text Reference - p. 1272

What client preparation is needed on the day of surgery involving general anesthesia? 1. Ask the client to wear personal nightwear. 2. Provide a partial bath. 3. Instruct the client to drink clear liquids. 4. Ask the client to tie hair with clips.

2. Provide a partial bath. A partial bath is refreshing and relaxes the client. The client should wear a clean hospital gown; personal nightwear is restricted in an operating room. The client should be fasting and is not provided with clear liquids to drink. The client should remove all clips from the hair, as they can cause burns due to electrocautery. Text Reference - p. 1269

An older client who is admitted in the postsurgery care unit has decreased bladder capacity. What can the nurse do to help the client avoid a urinary tract infection? Select all that apply. 1. Determine baseline urinary output for 24 hours. 2. Keep the call light and bedpan within easy reach of the client. 3. Turn or reposition the client every 2 hours. 4. Instruct the client to notify the nurse immediately when he or she experiences bladder fullness. 5. Ensure the client attempts to void urine every 2 hours.

2. Keep the call light and bedpan within easy reach of the client. 4. Instruct the client to notify the nurse immediately when he or she experiences bladder fullness. 5. Ensure the client attempts to void urine every 2 hours. Keeping the call light and bedpan within easy reach and instructing the client to notify the nurse immediately when his or her bladder is full helps to avoid urine stagnancy. Asking the client to void every 2 hours will also help to prevent stagnation of urine and urinary tract infections. Keeping a record of baseline urinary output and repositioning the client will not help to avoid urinary tract infection. TEST-TAKING TIP: Do not read information into questions, and avoid speculating. Reading into questions creates errors in judgment. Text Reference - p. 1259

Which food allergy indicates that a client is susceptible to latex allergy? Select all that apply. 1. Orange 2. Kiwi fruit 3. Pineapple 4. Chestnuts 5. Avocados

2. Kiwi fruit 4. Chestnuts 5. Avocados The client with an allergy to kiwi fruit, chestnuts, and avocados shows a cross-sensitivity to latex. If the client has an allergy to these foods, then the client needs to be assessed for latex allergy as well. Allergies to oranges and pineapples do not show a cross-sensitivity to latex. STUDY TIP: A mnemonic for the allergies that show cross-sensitivity to latex is "T-BACK": Tomatoes, Bananas, Avocados, Chestnuts, and Kiwi. Think of a silly visual to accompany the mnemonic, such as a latex bandage on the BACK of a T-shirt. Text Reference - p. 1261

The nurse is reviewing the laboratory reports of a patient who is scheduled for surgery and suspects that the patient has an increased risk of bleeding. Which laboratory finding supports the nurse's conclusion? 1. Prothrombin time (PT)—11 seconds 2. Platelet count—100,000 cells/mm3 3. International normalized ratio (INR)—0.86 4. Partial thromboplastin time (PTT)—35 seconds

2. Platelet count—100,000 cells/mm3 The normal platelet count is 150,000-400,000 cells/mm3. However, the patient has a platelet count of 100,000 cells/mm3 indicating an increased risk of hemorrhage. The normal prothrombin time is 11 to 12.5 seconds. Therefore, the patient's PT is in the normal range. The normal international normalized ratio (INR) is 0.86 to 1.27. Therefore, the patient's INR is normal. The normal partial thromboplastin time is 30 to 40 seconds. The patient has a partial thromboplastin time of 35 seconds, which is normal. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect. Text Reference - p. 1264

Obesity places clients at an increased surgical risk because of which of the following factors? Select all that apply. 1. Risk for bleeding is increased. 2. Ventilatory capacity is reduced. 3. Fatty tissue has a poor blood supply. 4. Metabolic demands are increased. 5. The thicker adipose layer makes it harder to close the surgical wound.

2. Ventilatory capacity is reduced. 3. Fatty tissue has a poor blood supply. 5. The thicker adipose layer makes it harder to close the surgical wound. A decreased blood supply in adipose tissue slows the delivery of essential nutrients, antibodies, and enzymes needed for wound healing. A decreased ventilatory capacity allows for alveolar collapse, which can lead to pneumonia. It is often difficult to close the surgical wound of a patient who is obese because of the thick adipose layer; thus he or she is at risk for dehiscence (opening of the suture line) and evisceration (abdominal contents protruding through surgical incision). Text Reference - p. 1263

A client is in a postanesthesia care unit. How does the nurse assess whether the client has a normal gag reflex? 1. Ask the client to cough and deep breathe. 2. Give crackers and applesauce to the client to eat. 3. Give a sip of water to the client to swallow. 4. Assess the ability of the client to spit out the airway.

4. Assess the ability of the client to spit out the airway. Anesthesia may result in the temporary loss of the gag reflex. The client is not given anything orally unless the gag reflex returns to prevent aspiration. The ability of the client to spit out the airway signifies that the gag reflex has returned. The ability to cough does not indicate the return of the gag reflex. The nurse should not give solid food or anything to drink to the client, as food or drink may get aspirated due to impaired swallowing. TEST-TAKING TIP: Increasing your chance of getting the correct answer is the approach to take when you are unsure. Start by eliminating unlikely responses. For this question, because it is unknown if the gag reflex is intact, giving food or drink to the client would not make sense. Thus you have eliminated the choices that give the client food and water. Now you have a 50-50 chance of getting the correct answer. Reevaluate the remaining choices, and you may recall that spitting out the airway shows return of the gag reflex. Text Reference - p. 1277

Malignant hyperthermia is a potentially lethal condition. Which medicine is helpful in treating malignant hyperthermia? 1. Morphine (Astramorph) 2. Clonidine (Catapres) 3. Succinylcholine (Anectine) 4. Dantrolene sodium (Dantrium)

4. Dantrolene sodium (Dantrium) Table 50-9 Malignant hyperthermia is a genetic disorder. Symptoms of malignant hyperthermia include tachycardia, tachypnea, elevated carbon dioxide levels, jaw muscle rigidity, and body rigidity of the limbs, abdomen, and chest. It can occur in a client who receives an inhaled anesthetic agent. Administration of dantrolene sodium may help to treat malignant hyperthermia. Morphine is used to treat moderate to severe pain; Clonidine is used to control hypertension. Succinylcholine can cause malignant hyperthermia. Text Reference - p. 1278