EAQ Preop, intraop, and postop

A nurse is caring for an older adult patient who had a knee replacement the previous day and denies any pain. Which response by the nurse would be most appropriate? "Excellent. You must be able to handle a lot of pain." "Great. It is wise to only take the pain medication if you need it." "It is important that you take pain medication. It will help you recover more quickly." "Almost everyone has pain after this surgery. Are you certain that you are not experiencing pain?"

"Almost everyone has pain after this surgery. Are you certain that you are not experiencing pain?" Thoroughly assessing the presence of pain is imperative, especially for those who deny any pain after surgery, especially the elderly. Gerontology patients may hesitate about reporting pain because of the belief that pain should be tolerated and is inevitable postsurgery. It is not appropriate to compliment the patient on being able to handle pain. The patient will not develop an addiction to pain medication, so it is not appropriate to tell the patient he or she should only take it when necessary. The nurse should not tell the patient that pain medication will help him or her recover quicker, because that could give the patient false reassurance.

Which explanation would the nurse give to a postoperative patient who is reluctant to get up and walk? "Early walking keeps your legs limber and strong." "Early ambulation will help you be ready to go home." "Early ambulation will help you get rid of your syncope and pain." "Early walking is the best way to prevent postoperative complications."

"Early walking is the best way to prevent postoperative complications." The best rationale is that early ambulation will prevent postoperative complications that then can be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and venous thromboembolism (VTE), speeds wound healing, increases vital capacity, and maintains normal respiratory function. These things help the patient to be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management always should occur before walking.

During the preoperative nursing assessment of a patient, which questions would the nurse ask to determine if the patient has a latex allergy? Select all that apply. "Do you take any herbal supplements?" "Have you ever had hay fever or asthma?" "Do you have a history of allergy to any specific drug?" "Do you work or have you worked in the rubber industry?" "Are you allergic to food items like eggs and chestnuts?"

"Have you ever had hay fever or asthma?" "Do you work or have you worked in the rubber industry?" "Are you allergic to food items like eggs and chestnuts?" To assess the patient for latex allergy, the nurse should ask the patient whether he or she has a history of hay fever or asthma, has worked in the rubber industry, and has allergies to any specific food. People coming in contact with latex, such as health professionals and those working in the rubber industry, are at highest risk of developing latex allergy. People who have a history of hay fever and asthma and have food allergies to eggs, bananas, avocados, and chestnuts may also be at risk. Questions about herbal supplements and hypersensitivity are asked in order to gather data about any potential drug interactions and drug allergies but are not specifically relevant to latex allergy.

A patient with diabetes is waiting in the preoperative holding area and asks the nurse if the daily insulin dose should be taken. Which response is the most appropriate? "Replace the insulin with an oral drug." "I will check with the surgeon and let you know." "Take half of the dose of insulin because you are fasting." "Avoid taking insulin because it may cause hypoglycemia."

"I will check with the surgeon and let you know." If a diabetic patient on insulin is due for surgery, it is important to get clear instructions from the surgeon regarding the insulin administration. The surgeon may choose to avoid the dose or give an adjusted dose based on the blood sugar levels. The nurse should not suggest taking a reduced dose, because it may cause a fluctuation in blood sugar levels. The insulin should not be replaced with oral drugs unless advised by the surgeon. The insulin dose may be skipped if this is what the surgeon advises.

A patient is instructed not to have anything to eat or drink eight hours prior to surgery. When arriving to the preoperative holding area, the patient informs the nurse they ate eggs and toast about two hours ago. Which response by the nurse is most appropriate? "We will do the surgery, but it will increase your risk of complications." "You were provided with strict instructions on what to do before surgery." "We will keep you in the hospital overnight to be sure you don't do that again." "I will inform the anesthesia care provider and surgeon to see what the options are."

"I will inform the anesthesia care provider and surgeon to see what the options are." The nurse should inform the anesthesia care provider and surgeon that the patient has ingested solid foods two hours prior to surgery so that the options for surgery can be discussed. The surgery will most likely be delayed, since this increases the patient's risk for complications, such as aspiration. The patient should not be demeaned or chastised about eating and will not be kept the hospital overnight to ensure that he or she does not eat again.

Which statement by the nurse reflects a correct understanding of the older adult surgical patient when teaching a preoperative class to a group of older adults? "I will watch the participants for signs of excessive anxiety." "This handout will do the explaining for me during the class." "I will make sure the lights are bright so that they can see the materials easily." "Older people are usually able to face surgeries more easily than younger people."

"I will watch the participants for signs of excessive anxiety." Be particularly alert when assessing and caring for the older adult surgical patient. An event that has little effect on a younger adult may be overwhelming to the older patient. Emotional reactions to impending surgery and hospitalization often intensify in the older adult. Help to decrease anxieties and fears, as well as maintain and restore the self-esteem of the older adult during the surgical experience. Simply reading a handout may not be sufficient. Consider that sensory deficits may be present, and bright lights may bother those with eye problems. These and other changes may require more time for the older adult to complete preoperative testing and understand preoperative instructions.

The nurse is preparing to administer a preoperative dose of cefazolin prior to an open cholecystectomy. Which explanation by the nurse about why the patient is receiving this medication is accurate? "It will prevent postoperative pneumonia." "It will treat your urinary tract infection (UTI)." "It will prevent postoperative surgical-site infection." "It will remove harmful bacteria from your intestines before surgery."

"It will prevent postoperative surgical-site infection." Cefazolin has enhanced activity against a wide variety of gram-negative organisms and is being used for perioperative prophylaxis against infection at the surgical site. The bowel has a wide variety of bacterial flora that could contaminate the abdominal cavity during surgery. This antibiotic is not used to prevent pneumonia. If the patient has a current infection (UTI), surgery may be postponed. The antibiotic will not remove all bacteria from the intestines but will reduce the risk of postoperative infection from intestinal bacteria.

A patient is admitted to the postanesthesia care unit (PACU) after bowel surgery and tells the nurse that he or she is going to "throw up." Which statement by the nurse reflects a priority nursing intervention? "I need to check your vital signs." "Let me help you turn to your side." "Here is a sip of ginger ale for you." "I can give you some anti-nausea medicine."

"Let me help you turn to your side." If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs. Checking vital signs does not address the nausea. It may not be appropriate to give the patient oral fluids immediately following bowel surgery. Administering an antiemetic may be appropriate after turning the patient to the side.

During a preoperative assessment, which explanation by the nurse is the correct reason for obtaining accurate documentation of the current medications being taken? "Some medications may alter the patient's perceptions about surgery." "Some anesthetics alter renal and hepatic function, causing toxicity of other drugs." "Some medications may interact with anesthetics, altering the potency and effect of the drugs." "Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery."

"Some medications may interact with anesthetics, altering the potency and effect of the drugs." Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that they have been communicated to the anesthesia care provider. Medications generally do not alter the patient's perceptions about surgery. The anesthetics may interact with the other medications, but they are not likely to alter renal and hepatic function. Routine medications are not always held during surgery, and dosage and schedule adjustments are not always necessary. Routine medications may or may not be prescribed for use the day of surgery.

A preoperative patient asks why the dose of warfarin is being withheld. Which response by the nurse is most accurate? "This medication is contraindicated with the type of anesthesia you are receiving." "This medication could cause excessive bleeding during surgery if it is not stopped beforehand." "All unnecessary medications are stopped before surgery to prevent you from vomiting under anesthesia." "This medication may increase respiratory depression associated with anesthetic agents and must be avoided."

"This medication could cause excessive bleeding during surgery if it is not stopped beforehand." Warfarin is an anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, the patient's clotting parameters are monitored as a means of ensuring that the effects of the medication are reversed. Warfarin is not associated with respiratory depression and does not interact with anesthesia. Medications are held before surgery; the most correct and complete reason for holding this medication is related to the increased risk of bleeding during and following surgery.

While performing preoperative teaching, the patient asks when to stop drinking water before the surgery. Which response by the nurse is accurate? "You need to have nothing my mouth after midnight." "You must have nothing by mouth after breakfast." "You can drink clear liquids up to two hours before surgery." "You can drink clear liquids up until you are moved to the operating room."

"You can drink clear liquids up to two hours before surgery." Practice guidelines for preoperative fasting state that the minimum fasting period for clear liquids is two hours. Evidence-based practice no longer supports the long-standing practice of requiring patients to have nothing by mouth after midnight.

A patient in the emergency room asks the nurse whether her or she will need anesthesia for the surgical reduction of a displaced shoulder. Which response by the nurse is accurate? "You will most likely be moderately sedated for the procedure." "There is no need for anesthesia because the reduction does not involve an incision." "Due to your age, you will likely be given a general anesthetic before reduction." "The primary care provider will most likely use an epidural or spinal block to numb the area for the procedure."

"You will most likely be moderately sedated for the procedure." Moderate to deep sedation (previously referred to as conscious sedation) is generally used for minor therapeutic procedures, such as fractures, in the emergency room. General anesthetics are usually neither necessary nor appropriate in this situation. Despite the lack of an incision, the patient will need some type of sedation for the procedure, which can be painful. An epidural or spinal block would not provide the necessary numbness needed in this situation.

The nurse would instruct a patient to stop taking multivitamins for how long before surgery? 1 day 1 week 4 weeks 8 weeks

1 day Multivitamin tablets can help increase nutritional status, and they can be taken until 1 day before surgery. There is no need to stop the use of multivitamins any sooner than a day before surgery.

The nurse needs to instill different eyedrops into a preoperative patient's eyes. How many minutes would the nurse wait between each set of eyedrops? 5 minutes 10 minutes 30 minutes There is no wait time between instillations.

5 minutes It is important to administer the drugs as ordered and on time to adequately prepare the eye for surgery. If there are multiple sets of eyedrops, the nurse has to maintain at least a 5-minute interval between each set of drops.

The nurse is doing a preoperative assessment on a patient who has type 2 diabetes mellitus, weighs 146 kg, and is 5 feet 8 inches tall. Which patient assessment is a priority related to anesthesia? A body mass index of 48.8 Having several seasonal allergies Having hemoglobin A1C of 8.5% A history of postoperative vomiting

A body mass index of 48.8 The patient's body mass index is the priority because it indicates the patient is severely obese. The patient's size may impair the anesthesiologist's ability to ventilate and medicate the patient properly, as well as the surgery room staff's ability to position the patient safely. An elevated hemoglobin A1C is important, but not a priority. Seasonal allergies are not a priority. History of postoperative vomiting is important when determining which postoperative drugs to give but is not a priority.

Before a patient is admitted to the operating room, which preoperative documentation must be attached to the chart, according to The Joint Commission? An electrocardiogram A complete physical examination Laboratory-test findings, including kidney- and liver-function parameters All nursing subjective objective assessment plan (SOAP) notes for this admission

A complete physical examination The Joint Commission requires that patients admitted to the OR have a documented physical examination report attached to the chart. This document explains in detail the overall status of the patient for the surgeon and other members of the surgical team. Laboratory test findings, SOAP notes, and electrocardiograms also may be included in the chart; however, the physical examination must always be completed and in the chart before surgery.

Which event observed by the circulating nurse requires immediate intervention? A glove contacts the leg of the table that supports the sterile field. The cuff of the scrub nurse's sterile gown contacts the sterile field. The sterile field was established at 6:50 and the current time is 9:00. The scrub nurse rests gloved hands on the chest on the front of his or her gown.

A glove contacts the leg of the table that supports the sterile field. Tables are sterile only at tabletop level. Areas below this are considered contaminated. The sterile gown below the point of 2 inches above the elbow is considered sterile. The passage of time in and of itself does not necessarily render a field contaminated.

Which pre-op patient would the nurse most closely monitor for bleeding as a result of medication being taken? A woman who takes metoprolol for the treatment of hypertension A man who is taking clopidogrel after the placement of a coronary artery stent A man whose type 1 diabetes is controlled with insulin injections four times daily A man who recently started taking finasteride for the treatment of benign prostatic hyperplasia

A man who is taking clopidogrel after the placement of a coronary artery stent Any drug that inhibits platelet aggregation, such as clopidogrel, represents a bleeding risk. Insulin, metoprolol, and finasteride are less likely to contribute to a risk for bleeding.

Which postoperative patient is at the greatest risk for development of atelectasis? A patient after a hypoxic episode during an acute asthma attack An older adult patient who has undergone cardiothoracic surgery A patient not adherent with the pulmonary regimen after surgery A patient experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD)

A patient not adherent with the pulmonary regimen after surgery Atelectasis is a common postoperative complication that is prevented by a pulmonary regimen of interventions such as deep breathing, coughing, turning, and using an incentive spirometer. Patients who have received general anesthesia and are noncompliant with a pulmonary regimen are at highest risk for atelectasis. Patients who have experienced a hypoxic episode during an acute asthma attack or with an acute exacerbation of chronic obstructive pulmonary disease are at lower risk for atelectasis than are postoperative patients. Postoperative older adults who have had cardiothoracic surgery are also at risk for atelectasis if they do not adhere to a pulmonary regimen.

The nurse in the postanesthesia care unit (PACU) assesses a patient with a history of asthma and finds the patient tachypneic, wheezing, and with reduced oxygen saturation. Which action will the nurse take to prevent further pulmonary complications? Administer bronchodilators. Provide incentive spirometry. Encourage chest physical therapy. Provide nebulization of histamine vapors.

Administer bronchodilators. The presence of wheeze, tachypnea, and reduced oxygen saturation indicates bronchospasm. The use of bronchodilators relieves bronchospasm and promotes a patent airway. Incentive spirometry is useful in managing atelectasis when the airway is patent. Chest physical therapy is helpful to clear secretions from the respiratory tract. Histamine vapors aggravate bronchospasm and therefore should be avoided.

The nurse is developing a care plan for the postoperative patient in order to prevent complications and promote ambulation, coughing, deep breathing, and turning. Which action is the most important for the nurse to provide to achieve these desired outcomes? Explain easily the rationale for these activities. Have family in the room for support and encouragement. Warn about pneumonia and clotting if the actions are not completed. Administer enough analgesics to promote relative freedom from pain.

Administer enough analgesics to promote relative freedom from pain. Even when a patient understands the importance of postoperative activities, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate. Warning the patient about pneumonia and clotting will not enhance proper activities if pain is not managed. Family encouragement and understanding of the rationale for completing these actions are important; however, pain control is the most helpful way to ensure that ambulation, coughing, deep breathing, and turning can be performed.

Which actions would the nurse take for a postoperative patient who has an oxygen saturation of 85% and decreased breath sounds? Select all that apply. Restrict intake of fluid. Administer humidified oxygen therapy. Administer diuretics as advised. Encourage deep-breathing exercises. Assist the patient to walk around, if tolerated.

Administer humidified oxygen therapy. Encourage deep-breathing exercises. Assist the patient to walk around, if tolerated. Low oxygen saturation and decreased breath sounds may indicate atelectasis. Therefore the nurse should administer humidified oxygen therapy and encourage deep-breathing exercises. Deep breathing and coughing techniques help prevent alveolar collapse and move respiratory secretions to larger airway passages for expectoration. Assisting the patient to walk around will also help, because lying down will only settle secretions into the respiratory system. Fluid restriction and diuretics may not be required; these are therapies best used for pulmonary edema (PE).

Which preoperative medication would the nurse administer to a patient with valvular heart disease to prevent complications related to this condition? Multivitamins Anticoagulants Antibiotics Vasoactive drugs

Antibiotics If a patient has a history of valvular heart disease, antibiotics are administered before the surgery to decrease the risk of bacterial endocarditis. Multivitamins are okay to take until the day before surgery but will not affect complications related to valvular heart disease. The anticoagulants are withheld preoperatively but may be administered by IV during the perioperative period. Vasoactive drugs are given to patients who have a history of hypertension to maintain BP.

Which action would the nurse take to ensure oxygenation in a patient who develops inspiratory stridor and sternal retraction upon removal of the endotracheal tube? Select all that apply. Suction the airway. Administer oxygen therapy. Administer muscle relaxants. Tilt the head and thrust the jaw. Provide positive-pressure ventilation.

Administer oxygen therapy. Administer muscle relaxants. Provide positive-pressure ventilation. Inspiratory stridor and sternal retraction are due to laryngospasm associated with removal of the endotracheal tube. Oxygen therapy helps maintain the perfusion levels in the patient. Skeletal muscle relaxants help relax the muscles and relieve laryngospasm. Positive-pressure ventilation helps keep the patient oxygenated. Suctioning may increase laryngospasm. Tilting the head and thrusting the jaw does not help relieve laryngospasm.

A postoperative patient develops laryngeal edema after receiving a penicillin injection. Which treatments would be implemented to prevent further complications in the patient? Select all that apply. Suctioning the airway Administration of sedatives Administration of antihistamines Administration of corticosteroids Chest physical therapy

Administration of sedatives Administration of antihistamines Administration of corticosteroids The patient's laryngeal edema is caused by an anaphylactic reaction to the penicillin injection. Sedatives reduce the emotional disturbance and calm down the patient. Antihistamines and corticosteroids help reduce the allergic manifestation and the laryngeal edema. Suctioning helps in cases of increased secretions in the airways, not laryngeal edema. Chest physical therapy is helpful to drain the secretions in the airway, not with laryngeal edema.

An alert patient unable to be weaned from a ventilator needs a tracheostomy but is refusing the procedure. The family insists the surgery be performed. Which action would the nurse to take? Advocate for the patient's rights. Try to change the patient's mind. Tell the family that they cannot interfere. Call surgery to cancel the procedure.

Advocate for the patient's rights. The nurse must act as the patient's advocate and assist the patient with fulfilling their wishes. However, as the patient's advocate, the nurse must be sure the patient knows the risks and benefits of refusing tracheostomy. Trying to change the patient's mind is unethical because it is contrary to acting as an advocate. As long as the patient is lucid, the right of self-determination has to be upheld. Telling the family that they cannot interfere can aggravate or escalate the situation. Cancelling the procedure is not indicated until discussion with the patient and health care provider has occurred.

Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. Which action is the most appropriate for the nurse to take? Allow the patient to use the urinal/bedpan after explaining the need to maintain safety. Assist the patient to the bathroom and stay next to the door to assist the patient back to bed when done. Allow the patient to go to the bathroom because the onset of the medication will be more than five minutes. Ask the patient to hold the urine for a short period because a urinary catheter will be placed in the operating room.

Allow the patient to use the urinal/bedpan after explaining the need to maintain safety. The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance. Assisting the patient to the bathroom, allowing the patient to go to the bathroom, or asking the patient to hold the urine for a short period would not be safe for the patient.

Which nursing actions will help to treat the problem of abdominal distention and gas pains after abdominal surgery? Select all that apply. Ambulate the patient. Reposition frequently. Administer bisacodyl. Turn patient onto left side. Administer morphine sulfate. Discontinue the nasal gastric tube (NGT).

Ambulate the patient. Reposition frequently. Administer bisacodyl. Ambulating, repositioning the patient, and administering bisacodyl (Dulcolax) suppositories all help to relieve gas after surgery. Turning the patient onto the right side, not left side, helps the gas to move into the transverse colon and then into the rectum. Morphine sulfate tends to cause constipation and may increase abdominal pain because of distention. Discontinuing the NGT too early can increase abdominal distention.

A patient with diabetes who takes insulin is scheduled for a surgery. Which instruction would the nurse tell the patient about insulin injections around the time of the surgery? Insulin should be given only after the surgery. Insulin should be stopped one day before surgery. Insulin should be stopped at least one week before surgery. An adjusted insulin dose may be given before surgery based on the patient's history of glucose control.

An adjusted insulin dose may be given before surgery based on the patient's history of glucose control. The surgeon or the anesthesia care provider (ACP) may vary the usual insulin dose based on the patient's history of glucose control. Serum or capillary glucose levels are measured the morning of surgery to establish baseline levels. If insulin is given only after surgery, maintaining the sugar level during surgery would be difficult. Stopping insulin one day or one week before surgery is not advised.

Which factors contribute to a patient's risk for constipation postoperatively? Select all that apply. Anesthesia Opioid analgesics IV fluids Decreased mobility Diminished peristalsis

Anesthesia Opioid analgesics Decreased mobility Diminished peristalsis Causes of constipation in a patient who underwent surgery would be the anesthesia, opioid analgesics, decreased mobility, and diminished peristalsis. IV fluids could cause fluid volume excess.

A patient in the postanesthesia care unit (PACU) becomes delirious and restless and shouts at the nurse about pain. Which factor would the nurse consider may be a cause of this behavior? A new diagnosis of psychosis Decreased ability to tolerate pain Anesthetic agents used in surgery Overdose of analgesics

Anesthetic agents used in surgery Anesthetic agents used in surgery can cause short-term psychotic-type behaviors that are relieved after the anesthetic drugs have cleared the body. A new diagnosis of psychosis is not warranted in the acute phase following surgery. The patient may not be tolerating the pain, but the delirium, yelling, and restlessness denote short-term psychotic-like behavior caused by the anesthetic agents and postoperative pain. An overdose of pain medications would present as increased sedation and decreased respiratory rate.

While collecting a preoperative history, the patient reports to the nurse a history of diffuse skin rashes when hospitalized in the past as well as food allergies to bananas and avocados. Which action would the nurse take? Notify the anesthetist to evaluate the patient. Ask additional questions to assess for a possible latex allergy. No intervention is needed because the patient needs to have this surgery. Notify the operating room (OR) staff immediately so that latex-free supplies can be used.

Ask additional questions to assess for a possible latex allergy. The nurse would ask additional screening questions to determine the patient's risk for a latex allergy. Risk factors for latex allergy include a history of contact dermatitis and allergies to certain foods such as eggs, avocados, bananas, chestnuts, potatoes, and peaches. Latex precaution protocols should be used for patients identified as having a positive latex allergy test result or a history of signs and symptoms related to latex exposure. Many health care facilities have created latex-free product carts that can be used for patients with latex allergies. The anesthesiologist does not need to evaluate the patient. The nurse would not ignore the situation and do nothing. The OR staff would need to be notified if the patient does have a latex allergy, but the additional screening is needed prior to this.

Which activities would the circulating nurse perform during a surgical time-out? Select all that apply. Ask the patient to confirm name and date of birth. Assist the surgical team in putting on surgical attire. Teach the patient how to do deep-breathing exercises. Compare the hospital identity (ID) number with the patient's own ID band. Ask the patient to confirm the operative procedure and site and to give consent.

Ask the patient to confirm name and date of birth. Compare the hospital identity (ID) number with the patient's own ID band. Ask the patient to confirm the operative procedure and site and to give consent. During a surgical time-out, all members of the surgical team stop what they are doing, just before the procedure starts, to verify patient ID, surgical procedure, and surgical site. The patient is asked to confirm the name and date of birth, operative procedure site, and consent. The hospital ID number is compared with the patient's own ID band. Helping with surgical attire and teaching patients how to do deep-breathing exercises are important activities, but they do not occur during a surgical time-out.

Which nursing intervention is the highest priority for a patient just transferred to the postanesthesia care unit (PACU) after surgery? Assess intake, output, and fluid balance. Assess airway, breathing, and circulation status. Assess the surgical site and condition of the dressing. Note the presence of all IV lines and drainage catheters.

Assess airway, breathing, and circulation status. When the patient is shifted to the PACU after surgery, the nurse should first assess the patient's airway, breathing, and circulation status. Any evidence of respiratory or circulatory compromise needs immediate intervention. Thereafter, the nurse may assess the patient's intake, output, and fluid status and note the presence of IV lines and drainage bags. The nurse should also assess the surgical site and condition of the wound.

The nurse is caring for a patient in the postanesthesia care unit (PACU), when the BP drops from 110/60 mm Hg to 92/58 mm Hg. Which actions would the nurse take? Select all that apply. Assess electrocardiogram (ECG) tracing. Inspect the surgical site. Administer pain medication. Elevate the head of the bed. Have the patient take deep breaths. Administer IV fluid bolus per protocol.

Assess electrocardiogram (ECG) tracing. Inspect the surgical site. Have the patient take deep breaths. Administer IV fluid bolus per protocol. Assess ECG tracing; a change in the heart rhythm can cause a decrease in BP. Some of these rhythms include supraventricular tachycardia, sinus bradycardia, atrial fibrillation, and atrial flutter. Inspect the surgical site; hypotension can be caused by hemorrhage. Therefore it is important to inspect the surgical site for evidence of bleeding. Have the patient take deep breaths; hypoxemia can cause hypotension. Administer IV fluid boluses per protocol; fluid shifts during and after surgery can cause a drop in BP. Fluid boluses often are needed to correct for these shifts. Hypertension, not hypotension, is indicative of pain. A side effect of many pain medications is hypotension, which would exacerbate the patient's present hypotensive state. The head of the bed should be lowered to increase blood flow to the cerebrum.

A patient's BP increases from 110/76 mm Hg to 160/90 mm Hg two hours after a surgical procedure. Which action would the nurse take first? Assess pain level. Reassess the BP in 15 minutes. Decrease the IV fluid rate. Restart the patient's antihypertensive medication.

Assess pain level. Treatment for hypertension focuses on the source of the problem. Pain often causes a rise in BP. If a patient becomes hypertensive, the nurse should begin with assessing and treating the pain. Reassessing the BP in 15 minutes would not be done first but after treating the patient for pain. Per prescription of the health care provider, decreasing the IV fluid and administering an antihypertensive medication may be appropriate but are not the first nursing interventions.

Which actions would the nurse take when administering an analgesic to a postoperative patient? Select all that apply. Assess the location, quality, and intensity of pain. Monitor the patient for nausea, vomiting, and respiratory depression. Assess the patient's sleep/wake cycle and sensory and motor status. Assess the patient's level of orientation and ability to follow commands. Time the analgesic administration for effectiveness during painful activities.

Assess the location, quality, and intensity of pain. Monitor the patient for nausea, vomiting, and respiratory depression. Time the analgesic administration for effectiveness during painful activities. When administering analgesics to a postoperative patient, the nurse should assess the location, quality, and intensity of pain. The time of administration of the analgesic should be adjusted so that the patient is free of pain during activities like ambulation. The nurse should monitor the patient for analgesic side effects, including nausea, vomiting, and respiratory depression. Assessing the sleep/wake cycle, sensory and motor status, level of orientation, and ability to follow commands are part of a neurologic assessment and not a part of administering an analgesic.

The nurse is assessing a patient's surgical dressing on the first postoperative day and notes new, bright red drainage about 5 cm in diameter. Which action would the nurse implement first? Recheck in one hour for increased drainage. Assess the patient's BP and heart rate. Check agency policy to determine if the nurse can change the first dressing. Notify the health care provider of a potential hemorrhage.

Assess the patient's BP and heart rate. The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The priority assessment is to check BP and heart rate to determine possibility of significant blood loss/internal hemorrhaging. Following this, the nurse will contact the provider to report findings and can inquire at that time about a dressing change. Typically, the surgeon changes the first dressing postoperatively; the nurse reinforces it as needed until that first change has been done. Continued reassessment will be done on an ongoing basis.

Which duties are specific to a scrub nurse? Select all that apply. Monitor the draping procedure. Assist in the draping procedure. Assist in induction of anesthesia. Assist in preparing the operating room. Provide a hand-off report to the postanesthesia care unit (PACU) nurse.

Assist in the draping procedure. Assist in preparing the operating room. A scrub nurse always remains in a sterile environment. The scrub nurse has many duties, some of which include assisting in the draping procedure, assisting in preparing the operating room, and passing instruments to surgeons and assistants by anticipating their needs. Preparing the instrument table and maintaining a sterile environment are also the responsibilities of a scrub nurse. Assisting in induction of anesthesia, monitoring the draping procedure, and providing a hand-off report to the PACU nurse are the duties of a circulating nurse.

In caring for the postoperative patient on the clinical unit after transfer from the postanesthesia care unit (PACU), which care can be delegated to the unlicensed assistive personnel (UAP)? Monitor the patient's pain. Increase oxygen if needed. Assist the patient to take deep breaths and cough. Reinforce the dressing when there is excess drainage.

Assist the patient to take deep breaths and cough. The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The registered nurse (RN) would titrate oxygen, not the UAP. The licensed practical nurse (LPN) or RN will monitor and treat the patient's pain and change the dressings.

Which condition is the most likely reason for a patient having a partial pressure of arterial oxygen (PaO2) less than 60 mm Hg after surgery? Atelectasis Bronchospasm Pulmonary edema Pulmonary embolism

Atelectasis Atelectasis, partial collapse of the small airways, is the most common cause of hypoxemia after surgery and results from alveolar collapse, bronchial obstruction caused by retained secretions, decreased respiratory excursion, or general anesthesia. Bronchospasm, pulmonary edema, and pulmonary embolism are all causes of hypoxemia, but not as common as atelectasis.

A postoperative patient with bronchial obstruction has a pulse oximetry reading of 87%. Which complication would the nurse suspect is occurring with this patient? Atelectasis Bronchospasm Hypoventilation Pulmonary embolism

Atelectasis The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.

How would the nurse ensure a patient scheduled for surgery is not pregnant? By taking an x-ray By checking a hematocrit (Hct) level By checking international normalized ratio (INR) level By checking human chorionic gonadotropin (hCG) level

By checking human chorionic gonadotropin (hCG) level To check for pregnancy status, hCG levels are measured. X-rays of the abdomen are harmful to a fetus, so they should always be avoided in women of reproductive age if pregnancy is suspected. Hct levels indicate the hemoglobin level in the blood. INR is used to check for coagulation status.

Which occurrence might cause secondary heart dysfunction? Cardiac tamponade Certain medications Pulmonary embolism Myocardial infarction

Certain medications Certain medications, including β-adrenergic blockers, digoxin, or opioids, can cause secondary heart dysfunction. Cardiac tamponade, pulmonary embolism, and myocardial infarction are causes of primary heart dysfunction.

Prior to beginning surgery, which National Patient Safety Goal (NPSG) requirement is enacted with a surgical time-out? Prevention of infection Improve staff communication Identify patients at risk for suicide Check patient, surgical procedure, and site

Check patient, surgical procedure, and site

Which action would the nurse take first for a patient is admitted to the postanesthesia care unit (PACU) with a BP of 100/60 mm Hg? Rouse the patient. Assess the patient's pulse and skin color. Notify the anesthesiologist of the low BP. Check the medical record for the patient's baseline BP.

Check the medical record for the patient's baseline BP. The first action of the nurse is to identify what the patient's normal BP is. Interventions are dependent on the baseline variation. Rousing the patient is an intervention that can increase the BP, but would be done after determining the baseline BP. Hypotension accompanied by a normal pulse and warm, dry skin is usually from the residual vasodilating effects of anesthesia and suggests only a need for continued observation, but assessing the pulse and skin would not be done first. Before notifying the anesthesiologist of the BP, the nurse needs to check the baseline BP.

An older adult patient who had surgery is displaying manifestations of delirium. Which action would the nurse take first to provide the best care for this patient? Check the chart for intraoperative complications. Check the effectiveness of the analgesics received. Check which medications were used for anesthesia. Check the preoperative assessment for previous delirium or dementia.

Check the preoperative assessment for previous delirium or dementia. If the patient's airway, breathing, and circulation are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed, because these can all contribute to delirium.

Which member of the surgical team would inform the blood bank regarding the need for a blood transfusion during a surgery? Scrub nurse Circulating nurse Nurse anesthetist Anesthesiologist assistant

Circulating nurse A circulating nurse remains in an unsterile environment and performs activities involving touching unsterile equipment and patients. The nurse also forms an important link between anesthetic care providers and other departments like a blood bank. The scrub nurse, nurse anesthetist, and anesthesiologist assistant remain in a sterile environment.

Which member of the intraoperative team remains in the unsterile field? Scrub nurse Circulating nurse Surgeon's assistant Registered nurse first assistant

Circulating nurse The circulating nurse is not gowned and gloved and handles unsterile activities in the unsterile field during the intraoperative period. The scrub nurse is gowned and gloved and remains in the sterile field. The surgeon's assistant and registered nurse first assistant may handle and prepare surgical instruments and therefore remain in the sterile field during the intraoperative period.

For which type of infection would a postoperative patient who developed a fever, abdominal pain, and diarrhea despite being on long-term antibiotics be evaluated? Wound infection Urinary infection Respiratory infection Clostridium difficile infection

Clostridium difficile infection Prolonged use of antibiotics increases the risk of Clostridium difficile infection by damaging the normal flora of the intestine. The infection is manifested as fever, diarrhea, and abdominal pain. Wound infection, urinary infection, and respiratory infection may present with fever, but these infections rarely present with diarrhea and abdominal pain.

Which outcome is expected from the administration of midazolam during a surgery? Decreased vomiting Analgesic Conscious sedation Relaxation of skeletal muscles for facilitation of endotracheal intubation

Conscious sedation Midazolam is a benzodiazepine that is used widely for its ability to induce amnesia and provide moderate sedation (conscious sedation). Antiemetics prevent intraoperative vomiting. Opioids would be used for analgesic effect. Neuromuscular blocking agents facilitate endotracheal intubation.

A patient undergoing a surgical procedure with general anesthesia exhibits muscle rigidity, temperature of 103° F (39.4° C), pulse 100 beats/min, and a respiratory rate of 26 breaths/min. The symptoms subside with the administration of dantrolene. Which instruction would the nurse include in the patient's postoperative discharge plan? Taking antipyretics will bring your body temperature down. Do not have any future surgeries under general anesthesia. Consider getting genetic testing for malignant hyperthermia. You should refrain from using any products that may contain latex.

Consider getting genetic testing for malignant hyperthermia. Hyperthermia, tachycardia, and tachypnea, along with skeletal muscle rigidity induced by general anesthesia, are indications of malignant hyperthermia. The patient should undergo genetic testing to confirm the condition. These tests can help in taking preventive action in the future. Antipyretics may not help in bringing the body temperature down because the temperature is increased because of an imbalance in intracellular calcium in the skeletal muscles. The patient can receive general anesthesia with appropriate precautions in future surgeries. The manifestations of latex allergy may range from urticaria to anaphylactic reaction, but that is not a factor for this patient.

A patient scheduled for surgery reveals to the nurse fears about the projected length of time off work needed for recovery, as the patient is the primary source of income for the family. Which follow-up action would the nurse implement? Notify the health care provider about the patient's concerns. Notify family members that the patient is afraid to have surgery. Consult a psychiatrist to speak with the patient about these fears. Consult a social worker to identify financial options for the patient.

Consult a social worker to identify financial options for the patient. The nurse should consult a social worker. Social services can identify financial assistance for the patient and the family during recovery. The social worker can also help identify financial assistance for hospital charges. The health care provider can explain the procedure and possible physical consequences of the surgical procedure. Notifying a family member that the patient is afraid to have surgery would not communicate an accurate account of the situation and could betray the patient's confidence. Consulting a psychiatrist is not necessary, as fear is a normal part of the presurgical and postsurgical phases.

A patient with Alzheimer's dementia and confusion arrives via ambulance from a long-term care facility to the preoperative area for placement of a feeding tube, and there is no documentation of consent for the procedure. Which action would the nurse take? Help the patient sign an "X" on the consent form representing his or her legal signature. Send the patient back to the nursing home and reschedule the procedure for a future date. Contact the family member identified as the patient's power of attorney on the patient's medical record so the surgeon can obtain consent. Notify the nursing supervisor of the lack of consent and request special permission for emergent status so the surgical procedure can be completed.

Contact the family member identified as the patient's power of attorney on the patient's medical record so the surgeon can obtain consent. The nurse should review the patient's medical record to locate next of kin or power of attorney to request consent, which is obtained by the surgeon. If the legal guardian has not been informed by the surgeon of the need for the procedure, possible complications, and alternative treatments, the consent cannot be obtained. Sending the patient back to the nursing home and rescheduling the procedure does not assist the patient in receiving appropriate care. It is illegal to obtain consent from a confused patient by getting him or her to sign an "X." Placement of a feeding tube is not an emergent surgery that can forego legal consent.

Which nursing interventions would be included in the preoperative assessment and teaching plan for an older adult? Select all that apply. Administer a sedative to relieve fear and anxiety. Help the patient walk safely to the operating room. Coordinate assessment with the team of health care providers. Speak slowly when giving preoperative instructions to the patient. Understand that the patient may have sensory and cognitive deficits.

Coordinate assessment with the team of health care providers. Speak slowly when giving preoperative instructions to the patient. Understand that the patient may have sensory and cognitive deficits. Older adults need careful preoperative assessments and teaching because they are more prone to surgery-related complications. Because older adults may have many physical and neurosensory problems, the nurse should coordinate with a team of health care providers to provide a complete assessment. Sensory and cognitive deficits may make their learning slow; therefore the nurse should go slowly when teaching about preoperative care. The older patient should never be made to walk to the operating room; a stretcher or wheelchair should be used. Administering a sedative is a general measure and not specific to older adults.

Which clinical manifestation of pulmonary edema secondary to heart failure would the nurse assess in a postoperative patient? Early-morning cough Increased urine output Inspiratory stridor Crackles heard on auscultation

Crackles heard on auscultation The most common cause of pulmonary edema is left-sided congestive heart failure, which commonly manifests as shortness of breath and crackles in the lungs. An early-morning cough may be seen with respiratory infection or chronic obstructive pulmonary disease but is not usually a symptom of pulmonary edema. In pulmonary edema, urine output is typically decreased due to fluid retention. Inspiratory stridor is typically due to laryngospasm.

An older adult patient has a complication after a cardiac catheterization and has to remain in the postanesthesia care unit (PACU) for several days. Which complication is the patient most at risk for? Delirium Depression Alcohol withdrawal Aggressive behaviors

Delirium Older adult patients who spend prolonged amounts of time in the PACU are at risk for delayed emergence, a type of delirium caused by spending a longer amount of time in an ICU-like environment. Aggressive behaviors and depression can also be part of delayed emergence, but this disorder is most often characterized by delirium. There is not enough information in this scenario to determine if the patient is at risk for alcohol withdrawal.

Which activities would the circulating nurse be responsible for? Select all that apply. Preparing the instrument table Documenting intraoperative care Passing instruments to the surgeon and assistants Monitoring practices of aseptic technique in self and others Maintaining accurate counts of sponges, needles, and instruments

Documenting intraoperative care Monitoring practices of aseptic technique in self and others Maintaining accurate counts of sponges, needles, and instruments Documenting intraoperative care is a responsibility of the circulating nurse during surgery. Monitoring practices of aseptic technique in self and others, and maintaining accurate counts of sponges, needles, and instruments, is also a responsibility of the circulating nurse and is shared by the scrub nurse as well. Preparing the instruments and passing the instruments to the surgeon are responsibilities of the scrub nurse.

A patient with a history of deep vein thrombosis is recovering in the postanesthesia care unit (PACU) after surgery. Which symptoms would the nurse assess if this patient develops a pulmonary embolism (PE)? Select all that apply. Dyspnea Tachypnea Tachycardia Coarse crackles Noisy respirations

Dyspnea Tachypnea Tachycardia PE can be recognized by the presence of tachycardia, tachypnea, and dyspnea, especially if the patient is already receiving oxygen therapy. PE may occur in a postoperative patient who already has a history of deep vein thrombosis and is an older adult. Other symptoms of PE may include agitation, chest pain, hypotension, hemoptysis, dysrhythmias, and heart failure. Coarse crackles and noisy respirations may happen if thick secretions are present in the airway.

The nurse is educating a patient who had a coronary bypass graft (CABG) about the risk of venous thromboembolism (VTE). Which topic would the nurse include in the education to the patient? Early ambulation Turning every two hours Splinting chest while coughing Importance of taking pain medication

Early ambulation Activity has proven vital in helping to prevent postoperative VTE. Other forms of treatment include anticoagulants and sequential compression devices (SCDs). Splinting the chest while coughing, taking pain medication, and turning every two hours are important for the recovery of the coronary bypass patient but have little impact on preventing VTE.

A postoperative patient has absence of breath sounds on the left lung and an oxygen saturation of 86%. Which interventions would the nurse take to maintain adequate oxygen saturation? Select all that apply. Administer diuretics. Allow delayed ambulation. Instruct shallow breathing. Encourage incentive spirometry. Provide humidified oxygen therapy.

Encourage incentive spirometry. Provide humidified oxygen therapy. Decreased breath sounds and a low oxygen saturation level may indicate atelectasis due to retained secretions. Incentive spirometry helps lung expansion and promotes removal of secretions. Humidified oxygen therapy helps maintain the oxygen saturation levels. Diuretics help remove excess fluid in the body, but do not help in atelectasis. Late ambulation and shallow breathing aggravate atelectasis; therefore the patient should be mobilized early, and deep breathing should be encouraged.

Which action will the nurse take when the patient going for surgery wants to give their hearing aid to their spouse so it will not be lost during surgery? Encourage the patient to wear it for the surgery. Tape the hearing aid to the patient's ear to prevent loss. Give the hearing aid to the spouse as the patient wishes. Tell the surgery nurse that the patient has the hearing aid out.

Encourage the patient to wear it for the surgery. Although jewelry is removed before surgery, hearing aids should be left in place to allow the patient to better follow instructions given in the surgical suite and the postanesthesia care unit (PACU), as well as the dismissal instructions that will be given before the patient returns home for recovery. Removing the hearing aid could cause issues for the patient in following instructions in the surgical suite and PACU. Taping the hearing aid to the patient's ear is not necessary to prevent loss.

Which nursing intervention would help prevent postoperative atelectasis? Medicating the patient with a narcotic analgesic as prescribed Providing an abdominal binder to help the patient in ambulation Encouraging frequent use of an incentive spirometer Turning the patient from one side to the other at least every two to four hours

Encouraging frequent use of an incentive spirometer Use of an incentive spirometer after surgery encourages the patient to take deep, slow breaths, which facilitates the opening of terminal airways, mobilizes secretions, and prevents postoperative atelectasis. The patient should be instructed to perform 10 repetitions every hour. Narcotic analgesics, use of an abdominal binder for ambulation, and frequent turning in bed may indirectly support recovery and prevention of complications postoperatively. However, these interventions do not specifically address the prevention of atelectasis and pneumonia in the way that the use of an incentive spirometer does.

Which action would the nurse implement to maintain patient safety during a surgery that is related directly to the use of regional anesthesia? Apply grounding pad to unaffected leg. Assess peripheral pulses and skin color. Verify the last oral intake before surgery. Ensure a smooth surface under the patient.

Ensure a smooth surface under the patient. Regional anesthesia decreases sensation to the anesthetized area without impairing the level of consciousness, which means the affected leg will have a decrease in sensation while the anesthetic is effective. A double tourniquet on the affected leg is used to restrict blood flow. This increases the patient's risk of impaired skin integrity because the patient has a decrease in sensation and cannot identify discomfort or foreign objects and will not be moving during surgery. The nurse's role includes positioning the patient for correct alignment, exposure of the surgical site, and preventing injury. Applying a grounding pad to the unaffected leg, assessing peripheral pulses and skin color, and verifying the last oral intake before surgery will be occurring but are not related directly to the regional anesthesia.

An older adult wakes up in the postanesthesia care unit (PACU) and becomes restless and agitated and starts thrashing and shouting. The nurse finds that the patient was administered benzodiazepines during surgery. Which interventions would the nurse include on the patient's plan of care? Select all that apply. Ensure patient safety. Administer an antianxiety drug. Administer a narcotic analgesic. Administer an antipsychotic drug. Use drugs to reverse the benzodiazepines.

Ensure patient safety. Use drugs to reverse the benzodiazepines. The patient's presentation of restlessness, agitation, thrashing, and shouting indicates emergence delirium. It is due to the prolonged action of opioids and benzodiazepines during the surgery. The use of opioid and benzodiazepine antagonists may reverse the effect and alleviate agitation in the patient. Until the patient is fully conscious, the nurse should ensure the patient's safety by raising the side rails of the bed and securing the equipment, such as the IV line. Antianxiety drugs are less helpful in managing emergence delirium. Emergence delirium is not a psychotic condition; therefore antipsychotic drugs are not useful. Narcotic analgesics would further enhance the action of opioids that were used during surgery.

An older adult patient is being prepared for a cholecystectomy. Which patient information would the nurse include as part of the preoperative assessment? Select all that apply. Fluid balance history Foods the patient dislikes Current mobility problems Current cognitive function

Fluid balance history Current mobility problems Current cognitive function Preoperative fluid balance history is especially critical for older adults because they have reduced adaptive capacity, which puts them at greater risk for overhydration and underhydration. Mobility problems must be assessed to assist with intraoperative and postoperative positioning and ambulation. Preoperative assessment of the older person's baseline cognitive function is especially crucial for intraoperative and postoperative evaluation, because the older patient is more prone to adverse outcomes during and after surgery from the stressors of the surgery, dehydration, hypothermia, and anesthesia. Foods the patient dislikes are not important unless the patient is allergic to them, but this is no more important for older patients than it is for all patients.

Which symptom indicates that a patient is exhibiting signs of malignant hyperthermia while receiving general anesthesia? Hypocapnia Temperature of 97° F Muscle rigidity Heart rate of 46

Muscle rigidity Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles from altered control of intracellular calcium occurring as a result of exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercapnia, and ventricular dysrhythmias also may be seen with this disorder. Since the patient is in a hypermetabolic state, the heart rate will be elevated and not bradycardic.

When prepping the skin of a patient preoperatively, which principle would be followed to ensure proper cleansing? From the area distal to the incision to the site of incision Around the area of the incision From the site of the incision to the area distal to the incision Around the area distal to the incision

From the site of the incision to the area distal to the incision It is important to scrub the skin appropriately in the process of skin preparation. The principle used here is to scrub a liberal area of skin from the clean area (i.e., the site of the incision) to the dirty area (i.e., the site distal to the incision) with an antimicrobial agent. This should be done in this way to reduce the microorganism migration to the surgical wound. Cleaning from the area distal to the incision to the site of the incision may contaminate the incision site. Cleaning just around the incision site or just around the area distal to the incision is not sufficient.

Before asking a patient who had abdominal surgery to perform postoperative breathing exercises, which evaluation or intervention would the nurse perform first? Gauging the patient's level of pain Evaluating the patient's vital signs Assisting the patient out of bed and into a chair Reviewing the health care provider's plan of care

Gauging the patient's level of pain Pain management is essential to postoperative care. Assessing the level of pain and offering an analgesic before performing postoperative breathing exercises or any activities will ease pain and facilitate compliance, thus decreasing the risk of complications. Checking vital signs, assisting the patient into a chair, and reviewing the health care provider's plan of care are all appropriate after the patient's pain level has been assessed.

Which action would the nurse take when administering a preoperative medication orally? Give the medicine with a glass of milk. Give the medicine with a small sip of water. Give the medicine the night before surgery. Give the medicine five minutes before going to the operating room.

Give the medicine with a small sip of water. The preoperative medication should be given with a small sip of water 60 to 90 minutes before shifting the patient to the operating room. The medication should not be given only five minutes before going to the operating room, because effects of the medication will not yet begin to potentiate. The patient should not be given large amounts of fluid or milk orally because it can increase the chances of regurgitation and asphyxia during surgery under the effects of anesthetics.

Which action will the nurse take for a patient who takes diuretics and is going for surgery? Administer antibiotic prophylaxis. Have a serum potassium level drawn. Apply a compression device to the legs. Administer vasoactive drugs as advised.

Have a serum potassium level drawn. People who take diuretics are at risk of developing low potassium levels due to fluid and sodium loss. Low potassium levels may be detrimental to cardiac health, and surgery may pose additional harm. Antibiotic prophylaxis is given if the patient has valvular heart disease. Compression devices can be applied to the legs if the patient has a risk of deep vein thrombosis. Vasoactive drugs are administered if the patient has hypertension.

Which nursing action would the perioperative nurse assist with during the induction stage of anesthesia? Administer appropriate drugs. Secure the airway of the patient. Help with the application of monitors. Position the patient for surgical procedure.

Help with the application of monitors. General anesthesia has four different phases, including preinduction, induction, maintenance, and emergence phases. In each stage, the anesthesia care provider and perioperative nurse have different roles. In the induction stage, the duty of the perioperative nurse is to help with the application of monitors (noninvasive and invasive). Securing the airway, administering appropriate drugs, and positioning the patient for the surgical procedure are the duties of the anesthesia care provider.

Which factor is associated with the highest risk for respiratory complication following surgery? General anesthesia used during surgery Hydromorphone patient-controlled analgesia (PCA) for pain control Correct History of obstructive sleep apnea Endotracheal intubation for surgery

History of obstructive sleep apnea A history of obstructive sleep apnea would be associated with the highest risk for postoperative respiratory complication. General anesthesia, a PCA with hydromorphone, and endotracheal intubation are also risk factors, but sleep apnea poses the highest risk.

The nurse would monitor the patient for which indicators of autonomic nervous system blockade when spinal anesthesia is administered? Select all that apply. Nausea Vomiting Bradycardia Hypotension Hyperglycemia

Nausea Vomiting Bradycardia Hypotension Spinal anesthesia involves administering an anesthetic agent into the cerebrospinal fluid. It may produce an autonomic, sensory, or motor blockade. The signs of autonomic blockade include nausea, bradycardia, hypotension, and vomiting. Hyperglycemia is not a sign of autonomic blockade.

A patient was administered propofol, ranitidine, and metoclopramide during a tubal ligation. Which assessment finding may be related to the medications? Increased bleeding during surgery Hypotension Low grade fever Tachycardia

Hypotension Hypotension may be caused by propofol. It is ideal as an anesthetic used for short outpatient procedures, like tubal ligation. This may cause hypotension, bradycardia, apnea, transient phlebitis, nausea and vomiting, and hiccups. The nurse should monitor for hypotension and bradycardia in this patient. Ranitidine is an H2 receptor blocker and does not cause any of these assessment findings. Metoclopramide is an antiemetic and may cause headache, dizziness, dysphoria, dry mouth, or central nervous system sedation. A low-grade fever, tachycardia, or increased bleeding are not associated with any of these medications.

Which symptom would the nurse monitor in a patient who was given a benzodiazepine as an adjunct to general anesthesia? Select all that apply. Insomnia Hypotension Tachycardia Pulse oximetry Abdominal distention

Hypotension Tachycardia Benzodiazepines can cause hypotension, tachycardia, and respiratory depression. Therefore the nurse should monitor for hypotension and tachycardia in this patient. Insomnia and abdominal distention are monitored in the case of dexamethasone administration. Pulse oximetry is monitored in the case of opioid drug administration.

When educating a patient regarding the advantages of minimally invasive surgery (laparoscopic) over conventional surgery, which information would the nurse include? Select all that apply. Robotics are used. Incisions are smaller. Blood loss is reduced. Recovery time is prolonged. Postoperative pain is decreased.

Incisions are smaller. Blood loss is reduced. Postoperative pain is decreased. Using a minimally invasive surgical technique, such as laparoscopy, incisions are smaller, there is less blood loss, and postoperative pain is less than in traditional surgeries. The recovery time is also shortened. Robotics are used in robotic-assisted surgeries.

Which step occurs in the initial stage when a patient is receiving general anesthesia? The patient is intubated immediately. Induction is performed with an IV agent. The patient is given an oral tablet before the procedure. Induction is performed by delivering an inhalation agent via a face mask.

Induction is performed with an IV agent. Routine general anesthesia usually begins with an IV induction agent, which may be a hypnotic, anxiolytic, or dissociative agent. When used during the initial period of anesthesia, these agents induce a pleasant sleep with a rapid onset of action that patients find desirable. The patient is immediately intubated. An oral tablet would be contraindicated before surgery. Agents delivered via face mask are used but not during initial stage.

The nurse is preparing a patient for surgery when they state, "I am terrified to be put to sleep. What if I don't wake up?" Which priority action would the nurse take? Administer an antianxiety medication to the patient. Teach the patient to use guided imagery to help manage fear. Describe the type of anesthesia expected with the patient's particular surgery. Inform the anesthesia care provider (ACP) so that he or she can talk further to the patient.

Inform the anesthesia care provider (ACP) so that he or she can talk further to the patient. If the nurse identifies that the patient has fear of anesthesia, inform the ACP immediately so that he or she can talk further with the patient. Reassure the patient that a nurse and ACP will be present at all times during surgery. The nurse could use guided imagery to help manage fear or administer an antianxiety medication (if prescribed), but these interventions do not address directly the reason behind the patient's fear, so they would not be the priority. It is not within the nurse's scope of practice to describe the type of anesthesia that the patient will receive.

A patient going for surgery today informs the nurse she they took kava last night to help her sleep. Which action would the nurse take? Tell the patient that using kava for insomnia is helpful. Inform the anesthesiologist of the patient's recent use of kava. Tell the patient that the kava should continue to help with relaxation before surgery. Inform the patient about the dangers of taking herbal medicines without consulting a health care provider.

Inform the anesthesiologist of the patient's recent use of kava. Kava may prolong the effects of certain anesthetics. Thus the anesthesiologist needs to be informed of recent ingestion of this herbal supplement. While kava may be helpful for managing mild insomnia, the nurse should reinforce that this type of supplement should not be taken within 24 hours of a surgical procedure due to its potential interaction with anesthesia. Patients should not take anything before surgery without the health care provider's knowledge.

A patient is scheduled for surgery in one week and reports that he takes a fish oil capsule daily. Which intervention would be the priority? Tell the patient to stop taking the dietary supplement on the day before surgery. Notify the anesthesia care provider because this product interferes with anesthetics. Ask the patient if he has noticed any side effects from taking this dietary supplement. Inform the health care provider because the procedure may need to be rescheduled.

Inform the health care provider because the procedure may need to be rescheduled. Fish oil dietary supplements can increase bleeding during and after surgery. The health care provider should determine how long it should be discontinued before surgery. Telling the patient to stop taking the fish oil 1 day before surgery would still place the patient at risk for bleeding. Fish oil does not interfere with anesthetics. The nurse could ask the patient if he has any side effects from the fish oil, but it is not a priority.

A patient who is being prepared for surgery tells the nurse: "I am afraid that I may die during surgery without being able to confess my sins. I don't want to die without receiving absolution." Which action by the nurse would best meet this patient's needs? Reassure the patient that the surgery is minor and the risk of death is minimal. Inform the surgeon that the patient wants to cancel the surgery until he or she can receive absolution from his or her religious leader. Inform the surgeon of the patient's fears and contact the appropriate religious leader to talk with the patient before surgery if possible. Inform the patient that it is too late at this point; the room is scheduled, the surgical team is waiting, and any delays will delay surgeries for other patients.

Inform the surgeon of the patient's fears and contact the appropriate religious leader to talk with the patient before surgery if possible. Inform the surgeon of the patient's fears and contact the appropriate religious leader to talk with the patient before surgery if possible.

Which action would the nurse take upon learning that a patient scheduled for surgery uses the herb ginkgo regularly? Tell the patient that consuming herbs is an unhealthy practice. Tell the patient to discontinue the herb and return the next day. Inform the surgeon, because the surgery would need to be rescheduled. Tell the patient that the herb is safe and continue with surgery preparation.

Inform the surgeon, because the surgery would need to be rescheduled. Ginkgo tends to cause increased bleeding; therefore the nurse should inform the surgeon if the patient has been using it so that the surgery can be rescheduled. Any herb should be discontinued two to three weeks before the surgery because it may have adverse effects. The nurse should not comment on whether the practice of taking the herb is healthy or not.

After signing a witnessed consent for surgery, the patient decides they no longer want to have the procedure. The patient has one adult child but no other immediate family. Which action would the nurse take next? Inform the surgeon. Inform the adult child. Try to persuade the patient to continue with the surgery. Inform the senior nurse who witnessed the consent from the patient.

Inform the surgeon. The patient has the right to revoke the consent at any time; however, this should be reported to the medical staff who obtained the consent, because knowing this would help in planning the next steps. The information need not be given to the patient's adult child if they did not witness the informed consent. The nurse would not try to persuade the patient to have the surgery; all the pertinent information should already have been provided to the patient. The senior nurse need not be notified.

Postoperative hypotension can be managed with which intervention? Infusion of IV fluids Assessment of a basic metabolic panel (BMP) Administration of oxygen Performing an electrocardiogram (ECG)

Infusion of IV fluids Hypotension that occurs postoperative is mainly due to fluid and/or blood loss. Administration of IV fluids helps to increase the blood pressure. A BMP monitors electrolytes and renal function, but these imbalances in a postoperative patient are less likely a contributing cause of hypotension. Administration of oxygen will not improve hypotension. An ECG would detect abnormal heart rhythms, but this is unlikely to contribute to hypotension in a postoperative patient.

During a preoperative assessment, a patient reports a history of drinking whiskey in large quantities for 10 years. Which nursing intervention would help prevent postoperative complications related to the patient's alcohol history? Instruct the patient to replace whiskey with a less potent beverage. Permit the patient to consume alcohol until the day before surgery. Recommend to the patient reducing the frequency of alcohol intake. Instruct the patient to stop consuming alcohol under medical supervision.

Instruct the patient to stop consuming alcohol under medical supervision. Chronic alcohol use can place the surgical patient at risk due to existing lung, gastrointestinal, or liver damage. When liver function is decreased, metabolism of anesthetic agents is prolonged, nutritional status is altered, and the chances for postoperative complications are increased. Refraining from alcohol consumption may lead to fewer complications during lengthy surgery or in the postoperative period, but alcohol withdrawal can be dangerous. The risks can be avoided with appropriate planning and management, and doing so under a provider's care. Replacement of the beverage is not an option, because doing so may have unintended negative consequences. Reducing the frequency of alcohol intake also increases the chances of complications. If the patient continues to consume alcohol before the day of surgery, he may experience complications during the perioperative period.

When teaching a patient about the benefits of ambulatory surgery compared to inpatient surgery, which information is accurate? Select all that apply. It involves minimal laboratory tests. It requires fewer preoperative medications. It reduces the risk of hospital-acquired infections. It helps patients recover comfortably in the hospital. It is more expensive for both patients and insurers.

It involves minimal laboratory tests. It requires fewer preoperative medications. It reduces the risk of hospital-acquired infections. Ambulatory surgeries are often preferred over inpatient surgeries. These surgeries are usually minimally invasive, involve minimal laboratory tests, and require fewer preoperative medications. Because the patient recovers comfortably at home, there is no risk of hospital-acquired infections. These surgeries are less costly for both patients and insurers.

A nurse has opened a suturing package in an operating room and places it in a pocket of the surgical gown below the level of the tabletop. Which statement is accurate about this suturing package? It is contaminated because the nurse opened it. It is sterile because it is placed in a sterile gown. It is sterile because it is still in the suture packet. It is contaminated because it is placed below the level of the table.

It is contaminated because it is placed below the level of the table. A nurse should be aware that the only sterile parts of a gown are in front from the chest up to the level of the table; therefore, the nurse's pocket is contaminated. If a sterile suture package is placed in a contaminated area, it will be considered contaminated. Once a sterile package is opened, its edges are considered contaminated unless it is placed in a sterile environment. It is not contaminated because it is opened by the nurse. It is contaminated because it is placed below the level of the table. It is not sterile because it is placed in a sterile gown and is still in the suture packet.

Which benefits of early ambulation would the nurse explain to a postoperative patient? Select all that apply. It stimulates circulation. It improves muscle tone. It promotes venous stasis. It decreases vital capacity. It prevents thrombus embolism.

It stimulates circulation. It improves muscle tone. It prevents thrombus embolism. Early ambulation is the most significant general nursing measure to prevent postoperative complications. Early ambulation increases muscle tone and strength and promotes venous return. This is turn improves circulation, which prevents formation of thrombus in the blood vessels. Early ambulation increases vital capacity by promoting lung expansion and prevents venous stasis.

A patient scheduled for surgery has been NPO since midnight, and the surgery is delayed for several hours. The patient reports being hungry and having a headache due to missing morning coffee. Which actions would the nurse implement in this situation? Select all that apply. Offer soft foods to the patient. Give black coffee to the patient. Give clear liquids to the patient. Keep the patient apprised of the situation. Tell the anesthesia care provider about the situation.

Keep the patient apprised of the situation. Tell the anesthesia care provider about the situation. NPO restrictions are used to prevent aspiration and vomiting during surgery. All food, including soft foods, should be avoided before surgery because it can lead to these complications. Patients who are NPO from midnight frequently complain of hunger and thirst while waiting for surgery. The nurse should keep the patient updated on the situation and aware that he or she has not been forgotten. Patients who regularly drink caffeine in the morning often experience a "caffeine withdrawal" headache when fasting. The nurse should talk to the anesthesia care provider and ask if the patient can consume clear liquids; if permission is given, clear liquids and coffee should be offered, but not until after the anesthesia care provider has approved it.

Which intraoperative nursing responsibilities would be performed by the scrub nurse? Select all that apply. Documenting intraoperative care Keeping track of irrigation solutions for monitoring of blood loss Coordinating the flow and activities of members of the surgical team in the surgical suite Passing instruments and supplies to the health care provider by anticipating his or her needs Performing the count of sponges, needles, and instruments used during the surgical procedure

Keeping track of irrigation solutions for monitoring of blood loss Passing instruments and supplies to the health care provider by anticipating his or her needs Performing the count of sponges, needles, and instruments used during the surgical procedure The scrub nurse is responsible for keeping track of irrigation solutions for monitoring of blood loss. Both the scrub nurse and the circulating nurse will participate in counting surgical sponges, needles, and instruments, whereas passing instruments to the surgeon and other sterile activities are the exclusive responsibility of the scrub nurse. The circulating nurse takes primary responsibility for the coordination of the surgical suite and documentation.

A patient begins having hallucinations and agitation after receiving dissociative anesthesia. Which anesthetic agent is associated with this complication? Ketamine Halothane Thiopental Nitrous oxide

Ketamine A disadvantage of ketamine is the associated risk of agitation, hallucinations, and nightmares. These unwanted effects are not associated with the use of thiopental, halothane, or nitrous oxide.

In the postanesthesia care unit (PACU), which position would be the safest to place an unconscious postoperative patient immediately after the operation? Supine Lateral Semi-Fowler's High Fowler's

Lateral Unless contraindicated by the surgical procedure, the unconscious patient is positioned in lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient usually is returned to a supine position with the head of the bed elevated. Supine, semi-Fowler's, and high Fowler's positions are all supine; they are not as helpful in keeping the airway open and reducing the risk of aspiration.

Which position would the nurse place a patient who is still drowsy from anesthesia and has been vomiting? High Fowler's Prone Supine Lateral recovery position

Lateral recovery position Aspiration of the vomitus is a concern in the drowsy patient and can be prevented by placing the patient in the lateral recovery position. This position helps the vomitus escape through the mouth. Supine and prone positions are less helpful in preventing aspiration than the lateral recovery position. High Fowler's position would not be recommended for a drowsy patient and would not be helpful in preventing aspiration.

Which intervention is effective in managing abdominal pain in a postoperative patient during ambulation? Aromatherapy Use of a gait belt Splinting the incision Use of a walker

Splinting the incision Managing abdominal pain during ambulation can be accomplished by holding a pillow over the incision (splinting) to provide support. Aromatherapy can be used in the room, but not with ambulation. A gait belt and an assistive device prevent the patient from falling.

The nurse places an abdominal binder on a patient after colon surgery. After approximately an hour, the nurse assesses that the patient has shallow respirations, is hypoxemic, and hypercapnic. How would the nurse promote optimal breathing in this patient? Select all that apply. Loosen the binder. Reposition the patient. Provide music therapy. Elevate the foot end of bed. Raise the head end of the bed.

Loosen the binder. Reposition the patient. Raise the head end of the bed. The hypoventilation observed in this patient is due to mechanical restriction caused by the abdominal binder. Therefore the patient should be repositioned to improve comfort and the binder should be loosened to relieve the constriction. Raising the head end of the bed would promote lung expansion and facilitate breathing. Music therapy may relax the patient but would not relieve the mechanical restriction. Elevating the foot end of the bed would further aggravate the patient's condition.

During surgery, a patient is administered ketamine hydrochloride, 60 mg, IV. Which intervention would the nurse implement during recovery? Monitor the patient for hyperthermia. Maintain a calm and quiet environment. Assess the patient's ability to move limbs. Monitor blood sugar levels for hypoglycemia.

Maintain a calm and quiet environment. Ketamine is a common dissociative anesthetic and can cause hallucinations, nightmares, and agitation; therefore, it is important to maintain a calm and quiet environment. Ketamine does not cause hyperthermia or changes in blood sugar levels. It does not have a musculoskeletal effect that requires monitoring of musculoskeletal strength.

Which nursing intervention is important to prevent syncope in a postoperative patient? Administer oxygen therapy. Administer analgesics before ambulation. Make changes in the patient's position slowly. Encourage deep-breathing and coughing exercises.

Make changes in the patient's position slowly. To prevent syncope in a postoperative patient, the nurse should slowly change the patient's position. Progression to ambulation can be achieved by first raising the head of the patient's bed for one to two minutes and then assisting the patient to sit, with legs dangling, while monitoring the pulse rate. If no changes or complaints are noted, start ambulation with ongoing monitoring of the pulse. Oxygen therapy and deep-breathing and coughing exercises are interventions to improve pulmonary function, not to prevent syncope. Administering analgesics before ambulation makes the activity painless and encourages the patient to become more active.

A patient is having elective cosmetic surgery performed on the face. Which action is the nurse's postoperative priority for this patient? Manage patient pain. Control the bleeding. Maintain fluid balance. Manage oxygenation status.

Manage oxygenation status. The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise the patient's ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase the risk for upper airway edema, causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.

A certified registered nurse anesthetist would be responsible for which functions related to surgery? Select all that apply. Passing instruments to surgeons and assistants Managing a patient's airway and pulmonary status Preparing the operating room and the instrument table Selecting and initiating the planned anesthetic technique Monitoring the patient's emergence and recovery from the anesthesia

Managing a patient's airway and pulmonary status Selecting and initiating the planned anesthetic technique Monitoring the patient's emergence and recovery from the anesthesia A certified registered nurse anesthetist is responsible for maintaining a patient's airway and pulmonary status, managing the emergence and recovery from anesthesia, and selecting and initiating the planned anesthetic technique. Passing instruments to the surgeon and preparing the instrument table are responsibilities of the scrub nurse.

Which type of anesthesia is a nurse able to administer without the presence of an anesthesia care provider (ACP)? Moderate sedation General anesthesia Regional anesthesia Monitored anesthesia care

Moderate sedation An ACP is responsible for administering anesthesia. An ACP can be an anesthesiologist, nurse anesthetist, or anesthesiologist assistant. Moderate sedation involves administering sedatives, anxiolytics, or analgesics. It is used for procedures performed outside the operating room and does not require the presence of an ACP. A registered nurse who is educated in moderate sedation and is permitted by institution protocols and state nurse acts can perform this. However, general anesthesia, regional anesthesia, and monitored anesthesia care require the presence of an ACP.

Which nursing care measures are useful in the prevention of postoperative respiratory complications? Select all that apply. Monitor oxygen saturation. Measure intake and output. Assess bilateral lung sounds. Ambulate the halls with patient. Instruct on incentive spirometer use.

Monitor oxygen saturation. Assess bilateral lung sounds. Ambulate the halls with patient. Instruct on incentive spirometer use. The nurse assesses oxygen saturation levels and lung sounds to monitor for atelectasis and respiratory complications. Ambulation and incentive spirometry promote lung expansion and reduce the risk for postoperative atelectasis and pneumonia. Measuring intake and output is useful in assessing for and preventing renal or cardiac complications.

Which nursing care measures are useful in the prevention of postoperative respiratory complications? Select all that apply. Monitor oxygen saturation. Measure intake and output. Assess bilateral lung sounds. Ambulate the halls with patient. Instruct on incentive spirometer use.

Monitor oxygen saturation. Assess bilateral lung sounds. Ambulate the halls with patient. Instruct on incentive spirometer use. The nurse assesses oxygen saturation levels and lung sounds to monitor for atelectasis and respiratory complications. Ambulation and incentive spirometry promote lung expansion and reduce the risk for postoperative atelectasis and pneumonia. Measuring intake and output is useful in assessing for and preventing renal or cardiac complications.

Which type of anesthesia would be used for a colonoscopy in the endoscopy clinic? Local anesthesia Moderate sedation General anesthesia Monitored anesthesia care

Monitored anesthesia care Monitored anesthesia care would be used for the patient having a colonoscopy done in endoscopy because it can match the sedation level to the patient needs and procedural requirements. Local anesthesia would not be used because the area affected by a colonoscopy is larger than loss of sensation could be provided for with topical, intracutaneous, or subcutaneous application. Moderate sedation is used for procedures performed outside the operating room and the patient remains responsive. General anesthesia is not needed for a colonoscopy, and it requires advanced airway management.

Which criteria must a patient meet in order to be discharged from the postanesthesia care unit (PACU) (Phase I) to the clinical unit? Select all that apply. No nausea or vomiting No respiratory depression Oxygen saturation above 90% Written discharge instructions understood Patient reports pain level of 4 on a 1 to 10 scale

No respiratory depression Oxygen saturation above 90% Patient reports pain level of 4 on a 1 to 10 scale Discharge criteria from Phase I are listed in Table 19.8 and include no respiratory depression, oxygen saturation above 90%, and pain that is controlled or acceptable. Nausea and vomiting should be controlled. Understanding written discharge instructions are part of Phase II discharge criteria.

Prior to a first-ever surgery, a patient reports taking alprazolam the night before for anxiety. Preoperative vital signs include BP 158/88, heart rate (HR) 96, and respiratory rate (RR) 24. Which action would the nurse take? Review the surgery with the patient. Administer another dose of alprazolam. Notify the anesthesia care provider (ACP). Reassure the patient that everything will go well with the surgery.

Notify the anesthesia care provider (ACP). In determining the psychologic status of the patient, the nurse notes the patient's anxiety, which is supported by restlessness and the elevated BP and HR. The nurse should notify the ACP after assessing the cause of the anxiety or fear that the patient is experiencing. The patient may only need to talk about surgery, about concerns with the unknown or with body image, or about past experiences in order to relieve the anxiety; the nurse cannot assume that lack of knowledge is the cause of the anxiety. Medication administration will be prescribed by the ACP if needed, but medications also can be administered during surgery. Reassuring the patient is not taking the patient's needs into account.

When reviewing preoperative forms, the nurse notices that the patient's informed consent is not signed. Which action would the nurse take? Have the patient sign the consent form. Have the family sign the form for the patient. Notify the health care provider to obtain consent for surgery. Teach the patient about the surgery and get verbal permission.

Notify the health care provider to obtain consent for surgery. The informed consent for the surgery must be obtained by the health care provider. The nurse can witness the signature on the consent form and verify that the patient (or the caregiver if the patient is a minor, unconscious, or mentally incompetent to sign) understands the informed consent. Verbal consent is not enough. The state's nurse practice act and agency policies must be followed.

A nurse is caring for a patient who had a bowel resection 10 hours before. The patient weighs 200 pounds (91 kg) and has a urine output of 240 cc for the past eight hours. Which action would the nurse take? Encourage oral (PO) fluids. Continue to monitor the urine output. Notify the health care provider. Administer a 500 cc normal saline IV bolus.

Notify the health care provider. The formula for determining adequate urine output is 0.5 mL/kg/hr. This patient, weighing 91 kg, needs to have 45 cc per hour or about 365 cc of urine in eight hours. It often takes three to five days for the bowel to begin working post-abdominal surgery; therefore it would be inappropriate at this time to encourage PO fluids. Continuing to monitor the urine output, instead of calling the health care provider, would delay identifying and treating the cause for the low urine output. The nurse must obtain a prescription for the normal saline bolus before administration.

A patient underwent a laparoscopic surgical procedure two days ago and is now experiencing chills and a temperature of 102.2 °F (39 °C). Which nursing action is priority? Administer the final dose of antibiotic. Notify the health care provider. Have the patient deep breathe and cough. Administer as needed acetaminophen (Tylenol).

Notify the health care provider. The patient is demonstrating signs of septicemia. Therefore the priority nursing action is to notify the health care provider so tests and treatments can be prescribed. Administering the antibiotic and having the patient deep breathe and cough help prevent infections, but the patient is exhibiting signs and symptoms of infection in spite of these interventions. Acetaminophen treats the fever but not the source of the problem.

The nurse is caring for a patient with renal dysfunction who is scheduled for surgery. Which nursing interventions are a priority in this situation? Select all that apply. Obtain renal function test preoperatively. Evaluate coagulation studies preoperatively. Check for the serum potassium levels preoperatively. Report to the perioperative team if the patient has a problem voiding. Ready the sequential compression device in the preoperative holding area.

Obtain renal function test preoperatively. Report to the perioperative team if the patient has a problem voiding. Many drugs are metabolized and excreted by the kidneys. A decrease in renal function can lead to altered drug response and unpredictable drug elimination. Hence, a renal function test is necessary before the surgery. If the patient has a problem voiding, the nurse should inform the perioperative team because the patient might exhibit improper voiding postoperatively. Coagulation studies of the patient should be on the chart before the patient is brought in for surgery in case of cardiovascular problems. Serum potassium levels of a patient are checked in case the patient is on diuretic medication to check the electrolyte imbalance. A sequential compression device is used preoperatively with patients who are predisposed to venous thromboembolism (VTE).

Which action is the responsibility of the circulating nurse? Ongoing assessment of the patient during the surgical procedure Implementing specific tasks related to surgical policies and procedures Ensuring that the patient has been assessed for safe administration of anesthesia Performing a preoperative history and physical assessment to identify patient needs

Ongoing assessment of the patient during the surgical procedure A primary role of the circulating nurse when caring for the patient undergoing surgery is to provide ongoing assessment of the patient. This activity is essential because the patient's condition may change quickly. Implementing specific tasks related to surgical policy and procedures is not within the scope of practice. It is also not within the nurse's scope of practice to assess for safe administration of anesthesia; the anesthesia care provider will perform this task. The health care provider will perform a preoperative history and physical assessment to identify patient needs.

In which surgical area will the patient's skin be prepped for surgery, and which clothing will the person doing the prepping wear? Surgical suite, wearing a lab coat Preoperative holding area, wearing street clothes Postanesthesia care unit (PACU), wearing scrubs Operating room, wearing surgical attire and masks

Operating room, wearing surgical attire and masks Surgical attire includes pants and shirts (or scrubs), a cap or hood, masks, and protective eyewear. All surgical attire is worn when the patient's skin is being prepped in the operating room to avoid contamination of the site. The surgical suite includes semirestricted and restricted areas of the controlled surgical environment. Lab coats are usually worn by the staff over their scrubs when they leave the surgical area. The staff will not wear street clothes in the preoperative holding area, although the family might. The holding area and PACU will not include prepping the patient for surgery.

During a preoperative teaching session, a patient asks the nurse about the effects of opioid medications. Which information would the nurse include in the explanation? Select all that apply. Opioids cause amnesia. Opioids decrease intraoperative pain. Opioids decrease the risk of infections. Opioids relieve pain during preoperative procedures. Opioids decrease intraoperative anesthetic requirements.

Opioids decrease intraoperative pain. Opioids relieve pain during preoperative procedures. Opioids decrease intraoperative anesthetic requirements. Opioid drugs are often used before surgery to decrease intraoperative pain and anesthetic requirements. They also help relieve pain during preoperative procedures. Opioids do not have amnestic or sedative actions. Opioids have no effect on the risk of postoperative infections.

Which finding would the nurse expect to assess in a postoperative patient with acute pulmonary edema? Bradypnea Rhonchi Oxygen saturation 89% Dry, hacking cough

Oxygen saturation 89% The patient experiencing acute pulmonary edema would most likely have a decreased oxygen saturation, such as 89%. The patient would have shortness of breath with tachypnea, not bradypnea. Auscultation of lungs would reveal crackles due to fluid overload, not rhonchi. The cough associated with pulmonary edema will be moist and productive; in severe cases, this may present as pink and frothy sputum.

Which medication or therapy would the nurse administer to a patient who is having acute tachypnea, dyspnea, tachycardia, and decreased oxygen saturation following a major orthopedic procedure? Select all that apply. Lidocaine Oxygen therapy Bronchodilators Anticoagulant therapy Skeletal muscle relaxant

Oxygen therapy Anticoagulant therapy Dyspnea associated with tachypnea, tachycardia, hypotension, and reduced oxygen saturation following a major orthopedic surgery indicates a pulmonary embolism. A pulmonary embolism could be a result of dislodgment of thrombus from the peripheral veins. Oxygen therapy helps improve oxygen saturation. Anticoagulant therapy prevents the blood from clotting further. Lidocaine, a local anesthetic, helps relieve laryngospasm but may not relieve pulmonary embolism. Bronchodilators help to dilate the airways but have no effect on embolism because it is associated with the compromised pulmonary circulation. IV skeletal muscle relaxants help relax the muscles to relieve laryngeal spasm but do not help relieve pulmonary embolism.

Which action would the nurse take for a patient who has not voided eight hours after having surgery? Encourage oral (PO) fluid intake. Palpate the suprapubic area for bladder distention. Use a straight catheter to assess for retention. Check the medical record to determine the type of anesthetic given.

Palpate the suprapubic area for bladder distention. The nurse needs to know first if there is urine in the bladder. The assessment can be done by palpating or scanning the suprapubic area. Encouraging PO fluid intake is appropriate if the patient can tolerate PO fluids and there is no bladder distention. Because of the risk of infection, a straight catheter would be used for to relieve known urine retention but not for assessment purposes. No matter what type of anesthetic was administered, the nurse needs to determine if the patient has not voided because of a lack of urine output or if the issue is an alteration in micturition.

Alteration in which electrolyte level may be associated with occurrence of postoperative dysrhythmia? Blood urea nitrogen Sodium Chloride Potassium

Potassium Potassium is an electrolyte that maintains electrical conductivity of the heart. Hypokalemia (low serum potassium) from urinary and gastrointestinal fluid losses during and after surgery may result in cardiac dysrhythmia. Alterations in blood urea nitrogen, sodium, and chloride will be assessed for, but are not linked to cardiac dysrhythmias.

Which factor would determine if an older patient who is having problems with concentration and memory after an extensive surgery is experiencing delirium or postoperative cognitive dysfunction? Preexisting cognitive impairment identified before surgery Ability of the patient to state name, location, and date Ability to ambulate in the halls and follow commands An undisturbed sleep/wake cycle in the critical care unit

Preexisting cognitive impairment identified before surgery Dementia should be assessed preoperatively so interventions can be established after surgery to help the patient meet outcomes. Preexisting cognitive impairment is a factor that contributes to postoperative cognitive dysfunction (POCD). Orientation of name, location, and date and ability to ambulate in halls and follow commands do not determine if it is dementia or POCD. A disturbed sleep/wake cycle may be a sign of postoperative delirium.

In which phase of general anesthesia are H2 blockers used? Induction Emergence Preinduction Maintenance

Preinduction To prevent aspiration of gastric contents during surgery, the surgeon administers H2 blockers in the preinduction phase of anesthesia. The induction phase is the period in which medications are given to render the patient unconscious. Benzodiazepines, opioids, and barbiturates are administered in the induction phase of anesthesia. The emergence phase is the period of completion of surgical procedure. The patient is prepared to be brought back to the preoperative state. Sympathomimetics, anticholinergics, and anticholinesterases are given during the emergence phase of anesthesia. The maintenance phase is the period of ongoing surgical procedure. Benzodiazepines, opioids, and barbiturates are administered in the maintenance phase.

An unconscious patient needs to undergo emergency surgery and has no family members or friends available. Which action would the nurse take regarding obtaining consent for the surgery? Call the local magistrate to get consent for the surgery. Obtain consent from a legally appointed representative. Avoid giving any treatment because it is illegal to treat without consent. Proceed with plans for surgery; consent is not required for a true medical emergency.

Proceed with plans for surgery; consent is not required for a true medical emergency. A true medical emergency may override the need to obtain consent. When immediate medical treatment is needed to preserve life and the patient is incapable of giving consent, the next of kin may give consent. If reaching the next of kin is not possible, the health care provider may begin treatment without written consent. Calling the local magistrate to get consent for the surgery is not necessary. Treatment should not be avoided; the priority should be to save the life of the patient. If a patient is unconscious, a legally appointed representative or responsible family member may give written permission, but in this case, no one is available.

In which position would the nurse place the patient for a laminectomy? Prone Supine Lateral Lithotomy

Prone Many positions are used in surgery; the choice is based on the type of surgery to be performed. For a laminectomy, the patient would be placed in the prone position because it gives easy access to the back. The supine position is suited for surgery involving the abdomen, heart, or breast. The lateral position is best for surgery that involves one side of the body or the other. The lithotomy position is used for some types of pelvic organ surgery.

Which interventions would the nurse take to prevent pulmonary complications in a patient who has just been admitted to the postanesthesia care unit and develops coarse crackles? Select all that apply. Teach abdominal exercises. Provide IV hydration. Suction the airways. Administer sedatives. Administer cough suppressants.

Provide IV hydration. Suction the airways. Coarse crackles and noisy respiration are caused by increased respiratory secretions due to use of irritant anesthetic drugs. Suctioning helps clear the airway of secretions. IV hydration helps keep the secretions in liquid form, allowing them to be easily suctioned. Sedatives and cough suppressants would hinder clearing the secretions in the airways; therefore they should not be used. Chest physical therapy, rather than abdominal exercises, would be helpful to clear secretions.

Which actions would the nurse take for a patient in the postanesthesia care unit (PACU) to ensure that this patient has a patent airway? Select all that apply. Suctioning the airway Administering sedatives Putting in an artificial airway Administering oxygen therapy Tilting the head and thrusting the jaw

Putting in an artificial airway Tilting the head and thrusting the jaw The physical repositioning of a patient to reestablish the patency of the airway involves tilting the head and thrusting the jaw. If the physical repositioning does not help, the patient may need an artificial airway to assist in breathing. Suctioning is helpful for patients with increased secretions; it may not help a patient with an airway obstruction. Oxygen therapy does not help unless the airway is patent. Sedatives would worsen the airway prolapse.

The nurse is caring for a patient postoperatively after major abdominal trauma sustained during a motor vehicle crash. The patient begins to pick at the air and asks the nurse why there are so many bugs in the room. Which nursing actions are a priority at this time? Select all that apply. Provide a calm, quiet environment. Obtain an order for a benzodiazepine. Monitor the patient for increased heart rate and BP. Assess the patient for cardiopulmonary and respiratory depression. Observe the patient for transient skeletal muscle movements (myoclonia).

Provide a calm, quiet environment. Obtain an order for a benzodiazepine. Monitor the patient for increased heart rate and BP. Hallucinations and nightmares are common side effects of ketamine, a dissociative anesthetic given to trauma patients to increase their heart rate and maintain cardiac output. Based on the patient diagnosis and symptomology, the nurse would determine that ketamine was likely used as an anesthetic agent and that the patient is experiencing adverse effects. A calm, quite environment and the administration of benzodiazepines will help address the patient's hallucinations. Because ketamine can also cause an increased heart rate and BP, the nurse should also monitor the patient's heart rate and BP. Cardiopulmonary and respiratory depression are adverse reactions of volatile inhalational agents, not ketamine. Transient skeletal muscle movements are adverse effects of nonbarbiturate hypnotics, not ketamine.

Which action would the nurse take to assist an older adult postoperative patient who has difficulty with memory and the ability to concentrate? Select all that apply. Provide adequate nutrition. Encourage delayed mobility. Provide bowel and bladder care. Sedate the patient for long durations. Monitor fluid and electrolyte disturbance.

Provide adequate nutrition. Encourage delayed mobility. Provide bowel and bladder care. Sedate the patient for long durations. Monitor fluid and electrolyte disturbance. The patient suffers from postoperative cognitive dysfunction, which dissipates over a few weeks. The nurse should provide supportive care during this period, such as bowel and bladder care, adequate nutrition, and fluid and electrolyte monitoring. Early mobilization should be encouraged to prevent pulmonary complications. Sedatives should not be used because they further add to cognitive dysfunction.

A patient scheduled for heart valve replacement surgery voices general concern about the surgery. Which method would be useful to help decrease this patient's anxiety? Share the story of another patient who had the same surgery. Assure the patient that it is normal to have fears prior to surgery. Provide web-based and audio-visual teaching materials about the surgery. Reassure the patient that this surgery doesn't usually result in a large blood loss.

Provide web-based and audio-visual teaching materials about the surgery. Providing web-based and audio-visual teaching materials about the surgery is an effective way to help address and individualize the patient's concerns and to decrease anxiety. Assuring the patient that it is normal to have fears prior to surgery does not individualize this patient's experience. Sharing the surgical story of another patient takes the focus off the patient and doesn't address the patient's needs, which may be different from the other patient's needs. The nurse does not know what the blood loss will be during surgery and therefore should not provide false reassurance.

A patient taking warfarin and digoxin for treatment of atrial fibrillation is instructed to discontinue the use prior to surgery. The nurse would closely monitor this patient for which complication? Pulmonary embolism Increased BP Excessive bleeding from incision sites Increased peripheral vascular resistance

Pulmonary embolism Warfarin is an anticoagulant that is used to prevent mural thrombi from forming on the walls of the atria during atrial fibrillation. Once the medication is terminated, thrombi could form again. If one or more detach from the atrial wall, they could travel as arterial emboli from the left atrium or as pulmonary emboli from the right atrium. Excessive bleeding would occur from excess warfarin administration, not withholding. BP and peripheral vascular resistance are not affected by warfarin.

Which assessment data require the most immediate attention in a patient who is about to be transferred to the clinical unit from the postanesthesia care unit (PACU). Oxygen saturation of 94% Pulse rate of 128 beats/minute Respiratory rate of 13/minute Temperature of 99.8° F (37.7° C)

Pulse rate of 128 beats/minute The most important aspect of the cardiovascular assessment is frequent monitoring of vital signs. They usually are monitored every 15 minutes in Phase I, or more often until stabilized, and then at less frequent intervals in Phase II. Notify the anesthesia care provider (ACP) or the health care provider if the pulse rate is less than 60 beats/minute or greater than 120 beats/minute. The oxygen saturation should be above 90%, so 94% is good. A respiratory rate of 13 is normal. A temperature of 99.8 is expected.

The nurse is caring for a patient in the postanesthesia care unit (PACU) when he becomes agitated. Which priority actions would the nurse take? Select all that apply. Put the side rails up. Evaluate respiratory status. Monitor fluid intake and output. Use clocks to orient the patient if needed. Sedate the patient, if the patient is not hypoxemic.

Put the side rails up. Evaluate respiratory status. Use clocks to orient the patient if needed. Sedate the patient, if the patient is not hypoxemic. Hypoxemia is the most common cause of postoperative agitation. Therefore the nurse should first evaluate the respiratory status of the patient. If the patient is not hypoxemic, and other causes are ruled out, sedation can be given to calm the patient. It is important to ensure patient safety at this time, so the nurse should put the side rails up, secure all equipment, and monitor the physiologic status. Clocks are used to orient the patient who experiences postoperative cognitive dysfunction or delirium. Monitoring fluid intake and output is a general activity during the postoperative period but is not specific to delirium.

During a preoperative assessment, the patient states that he developed allergic skin rashes when exposed to rubber gloves a few years ago. Which concern would the nurse review the patient's medical record for? Herbal use Sulfur allergy Reactions to latex Respiratory diseases

Reactions to latex A patient with a history of any allergic reactions has a greater potential for hypersensitivity to drugs given during anesthesia. Patients need to be screened specifically for latex allergies by checking the history of reactions that suggest an allergy to latex. Checking the history of sulfur allergy, herbal medication, and respiratory diseases would not help, because these conditions do not cause skin reactions.

Which nursing actions are important to carry out when preparing a patient for surgery? Select all that apply. Remove cosmetics, nail polish, and artificial nails. Remove hearing aids to prevent damage or loss of the devices. Remove jewelry in piercings if electrocautery devices will be used. Remove all prosthetics, including dentures, contact lenses, and glasses. Ascertain that the patient has an empty bladder before going to operating room.

Remove cosmetics, nail polish, and artificial nails. Remove jewelry in piercings if electrocautery devices will be used. Remove all prosthetics, including dentures, contact lenses, and glasses. Ascertain that the patient has an empty bladder before going to operating room. The patient should remove all cosmetics to facilitate observation of skin color during surgery. Nail polish and artificial nails should be removed to help in assessing capillary refill and pulse oximetry. If electrocautery devices will be used, all jewelry in piercings should be removed as a safety measure. All prostheses, including dentures, contact lenses, and glasses, should be removed to prevent loss and damage. The nurse should ascertain that the patient's bladder is empty before going to the operating room because involuntary voiding can happen under the effect of sedatives administered during surgery. If the patient uses a hearing aid, it should be left intact to help the patient hear properly and be able to follow instructions.

Which action will the nurse take for a postoperative patient who has low oxygen saturation and has crackles on auscultation? Suction the airway. Restrict fluid intake. Monitor mental status. Place the patient in lateral recovery position.

Restrict fluid intake Pulmonary edema in a postoperative patient is due to fluid overload. Therefore fluid restriction is the appropriate intervention. In addition, oxygen therapy and diuretics can be administered. The airway is suctioned if there is any secretion retained in the system. Monitoring of mental status is done in the early postoperative period to determine emergence from anesthesia. Lateral recovery position is used in the early postoperative period to keep the airway patent and prevent aspiration in case the patient vomits..

A patient received a large amount of IV fluid during surgery. In the postanesthesia care unit (PACU), the nurse assesses that the patient has reduced oxygen saturation, crackles on auscultation, and infiltrates on chest x-ray. Which actions would the nurse take to relieve the patient's breathing discomfort and promote oxygen saturation? Select all that apply. Restrict fluids. Administer prescribed diuretics. Administer oxygen therapy. Administer prescribed bronchodilators. Implement anticoagulant therapy.

Restrict fluids. Administer prescribed diuretics. Administer oxygen therapy. The breathing difficulty in the patient is due to the development of pulmonary edema caused by the infusion of a large volume of fluids. The patient would be relieved of pulmonary edema by fluid restriction. Use of diuretics would reduce the volume load. Oxygen therapy would help maintain adequate oxygenation saturation levels. Bronchodilators may help patients with constriction of the bronchi, but that is not the case with this patient. Anticoagulant therapy prevents the blood from clotting but may not be helpful in relieving pulmonary edema.

As part of a preoperative history, a patient reports that their father died due to sudden cardiac arrest. Which action would the nurse take? Check the platelet count. Check the hematocrit level. Review the electrocardiogram. Continue with the history.

Review the electrocardiogram. Because the patient's father died due to sudden cardiac arrest, there is a chance that the patient may have a similar predisposition or condition. Reviewing the electrocardiogram of the patient is essential because it can give information about cardiac disease. Some diseases run in families, and the patient's risk of developing them should be determined. The platelet count report gives information about coagulation status. The hematocrit report gives information about anemia, immune status, and infection. The patient may be affected, so the nurse shouldn't just continue with the admission without reviewing the electrocardiogram.

A patient scheduled for surgery has been using a nonsteroidal antiinflammatory drug (NSAID) for pain. Which effect might the NSAID have postoperatively? Risk for postoperative infection will increase. Postoperative atelectasis will be a problem. Risk for postoperative bleeding will increase. Deep vein thrombosis is more likely to occur.

Risk for postoperative bleeding will increase. Although analgesics are required for surgical patients, the use of NSAIDs should be stopped before surgery because these drugs are associated with increased postoperative bleeding. NSAID use prior to surgery is not associated with postoperative infection, atelectasis, or increased blood clotting.

Which concern would be the first priority for the nurse when transporting a patient to the operating room? Premedication Laboratory tests Safety of the patient Preoperative assessments

Safety of the patient When transporting the patient to the operating room, the nurse's primary concern should be the patient's safety. The nurse should help the patient to move from the hospital bed to the stretcher. The side rails should be raised. The patient may be transported to the operating room by stretcher or wheelchair. If no sedatives have been given, the patient may even walk accompanied to the operating room. Premedication, assessments, and laboratory values are major concerns during the preoperative period but not when transporting the patient.

Which action would the nurse take for a postoperative patient who has not voided for eight hours? Select all that apply. Scan the bladder with a portable ultrasound. Help the patient to use a bedside commode. Reassure the patient regarding the ability to void. Obtain a prescription and insert an indwelling catheter Use techniques like pouring warm water over the perineum.

Scan the bladder with a portable ultrasound. Help the patient to use a bedside commode. Reassure the patient regarding the ability to void. Use techniques like pouring warm water over the perineum. It is very important that the patient voids within six to eight hours postoperatively. The nurse should scan the bladder to assess bladder fullness. The nurse should reassure the patient regarding the ability to void and help the patient using techniques like providing privacy and pouring warm water over the perineum. The patient should be helped to use a bedside commode if comfortable. A straight catheterization as compared to an indwelling catheter is preferred, to limit the risk for catheter-associated urinary tract infection (CAUTI).

Which actions would the nurse use to promote infection control when performing a surgical scrub? Select all that apply. Scrub from elbows to hands. Scrub the fingers and hands first. Scrub without mechanical friction. Scrub for a minimum of 10 minutes. Hold the hands higher than the elbows.

Scrub the fingers and hands first. Hold the hands higher than the elbows. To perform a surgical scrub, the fingers and hands should be scrubbed first, progressing to the forearms and elbows. The hands should be held away from surgical attire and higher than the elbows at all times to prevent contamination from clothing or from detergent suds and water draining from the unclean area above the elbows to the clean and previously scrubbed areas of the hands and fingers. Scrubbing from the elbows to the hands, without mechanical friction, and for a minimum of 10 minutes are not correct actions.

A patient is refusing to remove her wedding ring on the morning of surgery. Which action would the nurse take first? Ask the patient's husband to convince her to remove the ring. Secure the ring according to agency policy and document the encounter. Have the patient's mental status assessed in preparation for surgery. Note the presence of the ring in the nurses' notes section of the chart.

Secure the ring according to agency policy and document the encounter. Secure the ring according to agency policy; it is customary to tape a patient's wedding band to the finger and make a notation on the preoperative checklist that the ring has been taped in place. This request does not imply altered mental status. It is not appropriate to ask the husband to convince his wife to remove the ring, because the patient has the right to refuse to remove the ring. It should be documented in the chart after the ring is taped securely to the finger.

According to the National Patient Safety Goals, which documents must be in the chart prior to the beginning of a surgery? Select all that apply. Electrocardiogram Signed consent form Functional status evaluation Renal and liver function tests A history and physical report

Signed consent form A history and physical report The National Patient Safety Goals require documentation of a history and physical, signed consent form, and nursing and preanesthesia assessment in the chart of a patient going for surgery. The physical examination explains in detail the overall status of the patient before surgery for the health care provider and other members of the surgical team. An electrocardiogram, functional status evaluation, and renal and liver function tests are not required.

To prevent perioperative complications in a patient who is a chronic smoker, the nurse would instruct the patient to refrain from smoking for how long before surgery? One week Two weeks Six weeks Six months

Six weeks Smokers are at increased risk for respiratory complications during and after surgery. The health care professionals should encourage smokers to quit smoking permanently or for at least six weeks before surgery to decrease the complications.

Which area is of special concern for the older adult who is having surgery? Sterility Paralysis Urine output Skin integrity

Skin integrity Skin of older adults has lost elasticity and is at increased risk for injury from tape, electrodes, warming or cooling blankets, and dressings. Pooling cleansing solution may create skin burns or abrasions. The nurse is responsible for monitoring patient safety and adjusting patient position as necessary to prevent pressure or misalignment. Sterility and urine output would be monitored for all patients. Paralysis would not be unusual during some types of surgery but would not be of special concern just for the older adult.

Two days after abdominal surgery, the patient reports gas pains and abdominal distention. The nurse plans care for the patient on the basis of the knowledge that these symptoms occur as a result of which condition? Constipation Hiccups Slowed gastric emptying Inflammation of the bowel at the anastomosis site

Slowed gastric emptying Until peristalsis returns to normal after anesthesia, the patient may experience slowed gastric motility, leading to gas pains and abdominal distention. Hiccups are intermittent spasms of the diaphragm caused by irritation of the phrenic nerve, which may be irritated after surgery by gastric distention but does not cause gas pains. The bowel should not be inflamed following surgery unless infection is present. Constipation may occur following surgery; however, with bowel manipulation, slowed gastric emptying is the most common reason for gas pains and abdominal distention because of gas.

Which factor must the nurse be aware of regarding a patient's medication regimen and preparation for surgery? All medications are held on the day of surgery. Some medications are contraindicated for use with anesthetics. Medications may cause the patient to be unable to make informed decisions. The patient's healing may be delayed if medications are taken before surgery.

Some medications are contraindicated for use with anesthetics. Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that it has been communicated to the anesthesiologist. Although most medications are not administered on the day of surgery, and some medications (mainly steroids) may delay healing or cause the patient to be unable to make informed decisions, these are not absolutes and don't apply to all medications.

Which instruction regarding deep-breathing and coughing techniques would the nurse include in a teaching plan for a patient who has an abdominal incision? Splint the abdominal incision with a pillow. Perform the technique two times every waking hour. Limit fluid intake to thicken the secretions and membranes. Encourage deep breathing and coughing if the patient is in pain or feels the urge to clear secretions.

Splint the abdominal incision with a pillow. When performing deep-breathing and coughing exercises, the patient should splint the abdominal incision site with a pillow or folded blankets to support the incision. The patient may be instructed to perform the technique 10 times every hour if the condition allows. The patient should be instructed to drink sufficient water to keep the secretions thin. Patients should not do deep breathing and coughing only when they feel the urge to clear secretions or when they feel pain.

Which intervention would the nurse take for a postoperative patient who was given a large dose of an opioid for pain and now has a decreased oxygenation saturation? Administer a benzodiazepine. Stimulate patient to take deep breaths. Place patient in supine position. Suction the patient to clear the airway.

Stimulate patient to take deep breaths. Shallow respiration associated with hypoxemia and reduced respiratory rate in a patient who received doses of opioids indicates hypoventilation due to medullary depression. Stimulating the patient to take deep breaths is one of the first steps the nurse would take to see if the oxygen saturation level rises. Benzodiazepines should be avoided because they further aggravate medullary depression. Patients in respiratory distress should not be placed supine (flat) but have the head of the bed elevated to maximize expansion of the thorax. There is nothing in the scenario to indicate that the patient has an occluded airway, therefore suctioning would not help.

Which information about the risk of postoperative bleeding would the nurse include in the teaching plan for a patient who is scheduled for surgery in two weeks? Take fish oils to help prevent postoperative bleeding. Continue taking ginseng because it helps lower BP before surgery. Stop taking herbal medicines; they may increase the risk of postoperative bleeding. Continue to take aspirin for pain; it will not affect postoperative bleeding.

Stop taking herbal medicines; they may increase the risk of postoperative bleeding. Herbal medicines increase the risk of bleeding, so the patient should be advised to stop all herbal supplements two to three weeks before any surgical procedure. Ginseng can increase BP before surgery, so it should not be taken. Aspirin has antiplatelet action and can cause bleeding, so it should be avoided during perioperative care. Other supplements that increase the risk of bleeding include fish oil, garlic, vitamin E, and ginkgo.

In which position would the nurse place a postoperative, conscious patient in order to prevent respiratory problems? Lithotomy position Lateral recovery position Prone position with extra pillows Supine position with head elevated

Supine position with head elevated If the patient is conscious, the patient should be positioned in supine position with the head elevated. This position helps to maximize the expansion of the thorax by decreasing the pressure of abdominal contents on the diaphragm. Lateral recovery position is usually used in unconscious patients to keep the airway open and reduce the risk of aspiration if vomiting occurs. Prone and lithotomy positions are not used in postsurgery patients.

Which attire is proper for the restricted area of the surgery department? Street clothing Surgical attire and head cover Surgical attire, head cover, and mask Surgical attire, with the addition of shoe covers

Surgical attire, head cover, and mask In the restricted area of the surgical suite, masks are required to supplement surgical attire, which also includes covering all head and facial hair. The restricted area can include the operating room (OR), scrub sink area, and clean core. The unrestricted area is where people in street clothes can interact with those in surgical attire. These areas typically include the points of entry for patients (e.g., holding area), staff (e.g., locker rooms), and information (e.g., nursing station or control desk). The semirestricted area includes the surrounding support areas and corridors. Only authorized staff are allowed access to the semirestricted areas. All staff in the semirestricted area must wear surgical attire and cover all head and facial hair.

Which assessment data requires the notification of the health care provider? A widened pulse pressure Systolic BP of 95 mm Hg Systolic BP of 170 mm Hg A pulse of 80 beats/minute

Systolic BP of 170 mm Hg The nurse would notify the health care provider if the patient's systolic BP is higher than 170 mm Hg. It is a narrowed pulse pressure, rather than a widened one, that might necessitate a call to the health care provider. A systolic BP of 95 mm Hg is perfectly acceptable; one that is less than 90 or greater than 160 indicates a problem. A pulse of 80 beats/minute is also acceptable; a pulse that is less than 60 or over 120 can be problematic.

Which symptom indicates that a patient may have a pulmonary embolism? Lethargy Tachypnea Bradycardia Hypertension

Tachypnea Tachypnea indicates a potential pulmonary embolism. Agitation, rather than lethargy, is a symptom of pulmonary embolism. A patient with a pulmonary embolism would be more likely to present with tachycardia and hypotension rather than bradycardia and hypertension.

For an older adult during hip replacement surgery, which special considerations would be followed to prevent complications? Select all that apply. Teach the patient about postoperative care. Ask the patient about a family history of bone diseases. Take greater care in preparing and positioning the patient. Maintain clear and concise communication with the patient. Use warming devices to prevent perioperative hypothermia.

Take greater care in preparing and positioning the patient. Maintain clear and concise communication with the patient. Use warming devices to prevent perioperative hypothermia. The care and vigilance of the entire surgical team are needed in preparing and positioning the older patient. Some older adults may have difficulty communicating and following directions as a result of alterations in hearing or vision. These factors increase the need for clear and concise communication in the operating room. Some older adults are at a greater risk of perioperative hypothermia, and warming devices should be considered. Asking the patient about a family history and teaching postoperative care are not appropriate activities to be done in the operating room. These activities should be done during the preoperative assessment.

Which priority action would the nurse on the clinical unit take when receiving a patient transferred from the postanesthesia care unit (PACU)? Assess the patient's pain. Take the patient's vital signs. Check the rate of the IV infusion. Check the health care provider's postoperative prescriptions.

Take the patient's vital signs. The priority action by the nurse is to assess the physiologic stability of the patient. This is in part accomplished by taking the patient's vital signs. Assessing the patient's pain, checking the prescriptions, and checking the rate of IV infusion can take place in a rapid sequence after taking the vital signs.

A patient is being discharged after having laparoscopic surgery. The nurse would instruct the patient to notify the surgeon immediately if which condition develops? Constipation Right shoulder pain Decreased appetite Temperature of 103°F (39.4°C)

Temperature of 103°F (39.4°C) The health care provider should be notified immediately if the patient experiences an increase in temperature higher than 101°F (38.3°C) because this may be indicative of an infectious process that will require immediate interventions to resolve. Right shoulder pain is expected after a laparoscopic surgery and is resolved within 48 to 72 hours. Constipation and decreased appetite may occur; if these do not resolve after discharge, the patient should be instructed to contact the health care provider.

A patient scheduled for surgery asks the nurse where his or her family can be in the surgical suite. Which response by the nurse is accurate? The family is not allowed to talk to the nurse at the nursing station. The family can be with the patient in the preoperative holding area. The family cannot be with the patient until the postanesthesia care unit. The family is allowed only in the conference room for preoperative teaching.

The family can be with the patient in the preoperative holding area. The perioperative nurse should explain to the patient that his or her family can be in the preoperative holding area with him or her before surgery, which includes talking to the nurse at the nursing station. Families also are taken to the conference room for preoperative and postoperative meetings, including teaching, with the staff.

Which is the primary reason the anesthesia care provider prescribes naloxone for a nurse to administer postoperatively? To decrease postoperative pain To maintain normal BPs To reverse opioid-induced respiratory depression To reduce the incidence of postoperative infection

To reverse opioid-induced respiratory depression Narcan is the antidote of opioids. It contains naloxone. Opioid overdose induces respiratory depression. Narcan is prescribed to reverse this. Narcan is not useful in reducing postoperative pain or postoperative infection, or in maintaining BP.

The nurse assesses a patient's serum potassium level prior to surgery. Which reason in the patient's history would prompt this nurse's action? The patient is a chronic smoker. The patient is on diuretic therapy. The patient has a prosthetic heart valve. The patient is on antihypertensive medication.

The patient is on diuretic therapy. A patient who is on diuretic therapy needs to be evaluated for serum potassium levels to assess if there is an electrolyte imbalance. A patient who is a chronic smoker may develop pulmonary complications during or after the surgery and should stop smoking at least six weeks before the surgery. A serum potassium analysis is not required. Patients with prosthetic heart valves are at risk of developing valvular heart disease; therefore a cardiology consultation is often required before the surgery. Patients who are on antihypertensive medication must discontinue the medication before the surgery. The antihypertensive medication taken with anesthetic agents will predispose the patient to shock.

Which assessment finding in a patient who has just been admitted to the postanesthesia care unit (PACU) requires the nurse's immediate action? The patient is groggy but arouses to voice. The patient indicates that he or she is in pain. The patient is restless, agitated, and hypotensive. The Jackson-Pratt is draining serosanguinous fluid.

The patient is restless, agitated, and hypotensive. Assessment in the PACU begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Restlessness, agitation, and hypotension are clinical manifestations of inadequate oxygenation. Identification of inadequate oxygenation and ventilation or respiratory compromise requires prompt intervention. Pain, sedation, and draining serosanguinous fluid are expected findings.

Which actions are critical to the patient's safety before and during a surgical procedure? Select all that apply. Verify that the patient has adequate health insurance. Confirm that the anesthesia care provider is an anesthesiologist. The patient's allergies are conveyed to the surgical team. The surgeon marks the surgical site with the patient's involvement. The surgical team confirms the patient's identity before anesthesia is administered.

The patient's allergies are conveyed to the surgical team. The surgeon marks the surgical site with the patient's involvement. The surgical team confirms the patient's identity before anesthesia is administered. Intraoperative nursing care includes determining the patient's allergy status in response to food, drugs, and latex. Preventing wrong site, wrong procedure, and wrong surgery has become known as the Universal Protocol. The Universal Protocol is part of a global patient safety initiative. A surgical time-out is performed before the induction of anesthesia during which the patient is asked to confirm name, birth date, operative procedure and site, and consent, and the patient's hospital ID number is compared with the patient's own ID band and chart. Determining whether the patient has health coverage and identifying that the anesthesia care provider is an anesthesiologist does not apply to patient safety.

Which statements would the nurse include when teaching a patient with a body mass index (BMI) of 45 about the potential complications of abdominal surgery caused by obesity? Select all that apply. Access to the surgical site is easy. Recovery from anesthesia is faster. The risk of wound infection is higher. Anesthesia administration is more difficult. The risk of a postoperative incisional hernia may be higher.

The risk of wound infection is higher. Anesthesia administration is more difficult. The risk of a postoperative incisional hernia may be higher. Because adipose tissue is less vascular than other tissue, the healing of the incisional site is slow, creating a high risk of wound infection. It is difficult to administer anesthesia in obese patients due to the stress on the cardiopulmonary system caused by the increased body weight. Postoperatively, there is a high risk of incisional hernia due to increased stress on the sutures in obese patients. Due to fat deposits, access to the surgical site may be difficult in an obese patient. Some anesthetic agents are stored by adipose tissue and stay in the body for longer time, so the patient may recover slowly from anesthesia.

Which statement is accurate regarding the hydration status of an older adult being prepared for surgery? It is difficult to find IV access in older patients. Skin turgor assessment is not a reliable measure for dehydration in this patient. There is an increased loss of water and electrolytes through sweating in older adults. There is a narrow margin of safety between overhydration and underhydration in elderly patients.

There is a narrow margin of safety between overhydration and underhydration in elderly patients. The capacity to adapt to changes in fluid levels is low in older adult patients. The safety margin is very low between dehydration and overhydration, so the nurse should focus on the preoperative fluid balance history of this patient. Finding IV access in older patients may not be difficult. Older people do not sweat more than young people. Skin turgor assessment is a reliable measure for dehydration in these patients.

A postoperative patient who is an alcoholic is restless, irritable, and having auditory hallucinations Which statement is accurate regarding this patient? These effects are due to alcohol withdrawal. The situation is normal, due to the anesthetic drugs. The patient is suffering from a psychotic disorder. The patient is suffering from pain and needs an analgesic.

These effects are due to alcohol withdrawal. The patient is irritable and restless due to loss of the inhibitory effects of alcohol; this is also causing the hallucinations. The patient is not stated to have a history of psychotic illness; therefore the symptoms cannot be attributed to a psychotic disorder. Anesthetic drugs may cause delirium, but not hallucinations. Pain may cause restlessness and irritability but not hallucinations.

A postoperative patient who has been transferred from surgery to the postanesthesia care unit is cold and shivering. The patient's plan of care includes a prescription for morphine to be administered for pain relief. When managing this patient, which interventions would the nurse perform? Select all that apply. Use forced air warmers. Administer oxygen therapy. Administer warmed IV fluids. Use warmed cotton blankets. Withhold morphine until shivering stops.

Use forced air warmers. Administer oxygen therapy. Administer warmed IV fluids. Use warmed cotton blankets. Administering warm liquids and using forced air warmers are active warming methods. Using warmed cotton blankets is a passive warming measure. Oxygen therapy is needed to meet the increased oxygen demand during shivering. Opioids are used to treat shivering in the immediate postoperative period, so the nurse should not withhold the morphine dose.

Which activities would be included in a surgical time-out prior to surgery? Select all that apply. Verify patient identification. Complete a fire-risk assessment. Verify surgical site and procedure. Ensure that consent for the specific procedure was obtained. Ensure that a significant other is available if needed for consultation.

Verify patient identification. Verify surgical site and procedure. Ensure that consent for the specific procedure was obtained. Just before a surgical procedure, all surgical team members complete a surgical time-out to prevent wrong patient, wrong site, and wrong procedure. The team must also ensure that consent was obtained. The operating room (OR) staff also completes a fire-risk assessment to identify and reduce the potential for a fire, but this is not an aspect of the surgical time-out process. Although a significant other may be present for a consultation if needed, this action is not an aspect of the surgical time-out process.

Which criteria support that a patient is ready for discharge from an ambulatory surgery center? Select all that apply. Vital signs baseline or stable Minimal nausea and vomiting Wants to go to the bathroom at home Responsible adult taking patient home Comfortable after IV opioid 15 minutes ago

Vital signs baseline or stable Minimal nausea and vomiting Responsible adult taking patient home Ambulatory surgery discharge criteria include meeting Phase I postanesthesia care unit (PACU) discharge criteria, which include vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria include a responsible adult driving patient, no IV opioid drugs for the last 30 minutes, ability to void, ability to ambulate if not contraindicated, and receiving written discharge instruction, with patient understanding confirmed.

When can a patient revoke the consent for the surgery? Select all that apply. After the surgery has started When the patient is partially informed Just before the scheduled surgery time After the patient has signed the consent form When the patient is in the preoperative holding area

When the patient is partially informed Just before the scheduled surgery time After the patient has signed the consent form When the patient is in the preoperative holding area Patients can revoke the consent at any time before the scheduled surgery. Patients can refuse the surgery even when they are in the preoperative holding room, assuming they are conscious and able to make the decision for themselves. The informed consent can be revoked whether a patient has received full or partial information, even at the very last minute. Once the surgery has started and the patient is under general anesthesia, he or she will not be able to revoke the consent.

An older adult patient has been admitted for a bilateral mastectomy and breast reconstruction surgery. Which topics would the nurse include in the patient's preoperative teaching plan? Select all that apply. Various options for reconstructive surgery The risks and benefits of her particular surgery Risk factors for breast cancer and the role of screening Where in the hospital she will be taken postoperatively How to perform postoperative deep-breathing and coughing exercises

Where in the hospital she will be taken postoperatively How to perform postoperative deep-breathing and coughing exercises During preoperative teaching, it is important to introduce the role of deep-breathing and coughing exercises and to inform the patient about the different locations involved in her hospital stay. The specific risks and benefits of her surgery and reconstruction options should be addressed by her health care provider. Teaching about breast cancer screening would be inappropriate, and likely insensitive, at this point in her disease trajectory.

A 17-year-old patient that is an emancipated minor with an arm fracture is scheduled for surgery and shows the nurse a statement from the court for verification. Which intervention by the nurse is most appropriate? Notify the health care provider that the patient is below 18 years old. Witness the operative permit after the health care provider obtains consent. Call a parent or legal guardian to sign the permit because the patient is under 18. Investigate the state's nurse practice act related to emancipated minors and informed consent.

Witness the operative permit after the health care provider obtains consent. An emancipated minor may sign his or her own permit. The nurse should be available to witness the signature, but no further action is required. The health care provider does not need to know the patient is under 18. The parent or guardian does not have the legal right to sign the consent. The nurse practice act for each state may vary, but an emancipated minor may sign for himself or herself legally.