Perioperative Nursing
During the initial assessment and admission questions, the nurse asks Maria for the time of her last oral intake. The patient replies, "I had dinner last night at 8 p.m., but I took a few sips of water this morning with my vitamins. The nurse's best response is which of the following? A. Explain to the patient that just a sip of water should not be a problem for anesthesia but that the vitamins may be a problem. We will pass that information on to the anesthesiologist. B. Tell the patient that the sip of water is not an issue because it was only a sip. C. Inform the patient that her surgery will not be performed today because the risk is too high for a negative outcome. D. Inform the patient that taking her vitamins before surgery was a good plan.
A Rationale: Patients are very often told to take certain daily medications with a sip of water early in the morning of surgery. They anesthesiologist will want the patient to have any hypertensive medications or corticosteroids if taken on a routine basis. The anesthesiologist will view the vitamin and non-essential and may wish to give other medications before anesthesia to help the stomach empty. It is imperative to give the anesthesiologist this information.
The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after three (3) tap water enemas. Which intervention should the nurse implement first? A. Notify the surgeon of the client's status. B. Continue giving enemas until clear. C. Increase the client's IV fluid rate. D. Obtain STAT serum electrolytes.
A The nurse should contact the surgeon because the client is at risk for fluid and electrolyte imbalance after three (3) enemas. Clients who are NPO, elderly clients, and pediatric clients are more likely to have these imbalances.
The nurse requests the client to sign a surgical informed consent form for an emergency appendectomy. Which statement by the client indicates further teaching is needed? A. "I will be glad when this is over so I can go home today." B. "I will not be able to eat or drink anything prior to my surgery." C. "I can practice relaxing by listening to my favorite music." D. "I will need to get up and walk as soon as possible."
A The client will be in the hospital for a few days. This is not a day-surgery procedure. The client needs more teaching.
When planning discharge education for a 65-year-old male who is having a hip replacement, it is appropriate for the nurse to consider which of the following?(Select all that apply.) A. The patient's resources at home for completing activities of daily living B. The number of stairs in the patient's home C. Transportation to follow-up appointments D. Preexisting medical conditions E. The number of bathrooms in the home
A, B, C, & D Rationale: When the nurse begins to make plans for the patient's discharge to home it is imperative to think about if they will have help with activities of daily living. If not, the patient may need to spend more time in the hospital or discharge to a rehabilitation center for a short time. If there are too many steps in the home they patient may require rehabilitation before returning home. Transportation to follow-up appointments will also impact the ability to go home or to a rehabilitation facility. Pre-exisiting medical conditions may indicate that the patient may require visiting nurses to follow not only the surgery but also the existing conditions.
The nurse should report the following findings from a patient's history as an increased risk for DVTs postoperatively. (Select all that apply.) A. History of smoking B. Age C. History of DVTs with previous pregnancy D. Borderline hypertension E. Allergies
A, C, & D Rationale: History of smoking causes vasoconstriction in a patient, which could be a perfect setting for a deep vein thrombosis (DVT). Decreased vessels size can lead to platelet and red blood cell clumping and leading to DVT. Any time there is a history of the DVT the patient requires prophylaxis before surgery. Hypertension causes injury to vessel walls. The body will place platelets and red blood cells over the injured vessel walls to protect the area. This will be the beginning of a DVT.
Jane is allergic to latex. What is the appropriate action to prevent an allergic reaction in the patient who is having surgery? A. Terminally clean the OR before her case and remove all the latex products B. Maria should be the first case of the day, and only non latex items should be used C. All surgical suites are latex free, o this is not a concern D. Anesthesia should be prepared to intubate and treat her if a reaction occurs because there is no way to assure a latex free environment
B
Maria expresses her anxiety about the procedure and anesthesia to her nurse. The most appropriate response is: A. Tell her that It's okay we do this every day B. Assure her that her fears are normal and encourage her to use her consultation time with the surgeon and anesthesiologist to address her concerns C. Share a story about your friend who had similar fears prior to her surgery D. Document her concerns in the chart so that the PACU nurse will expect her to be anxious during recovery
B
An example of an acceptable time-out is: A. Name, medical history, and procedure B. Name, birthday, and procedure including site C. Birthday, Social Security number, and surgeon's name D. Allergies, medical history, and procedure site
B Rationale: The name, birthdate, and the procedure, including the site are the best response. Allergies, medical history and Social Security number are not found on the patient's ID bracelet.
Maria's surgeon has asked that thromboembolic stockings (TEDs) be placed on the patient before surgery as well as sequential compression devices on both legs to the knees. Maria asks the nurse what they will do for her. Which response by the nurse is most appropriate? A. "They work together to make sure that you do not have a decrease in arterial blood flow in your legs during the surgery." B. "They complement each other to prevent blood from backing up in your legs and causing a deep vein thrombosis due to you not moving during the surgery." C. "They prevent deep tissue clotting during the surgery." D. "The two devices do the same thing, but one is better during the surgery and the other is better postoperatively."
B Rationale: Thromboembolic stockings compress superficial vessels in the legs and force blood to flow through deep vessels, which help prevent deep vein thrombosis. Sequential compression devices push blood through the blood vessels in an upward motion, which helps prevent venous stasis and deep vein thrombosis.
The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement? A. Notify the surgeon about the client's request to wear the medal. B. Tape the medal to the client and allow the client to wear the medal. C. Request the family member take the medal prior to surgery. D. Explain taking the medal to surgery is against the policy.
B The medal should be taped and the client should be allowed to wear the medal because meeting spiritual needs is essential to this client's care.
The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select all that apply. A. Perform passive range-of-motion exercises. B. Discuss how to cough and deep breathe effectively. C. Tell the client he can have a meal in the PACU. D. Teach ways to manage postoperative pain. E. Discuss events which occur in the post-anesthesia care unit.
B, D, & E Coughing effectively aids in the removal of pooled secretions, which can cause pneumonia. Deep-breathing exercises keep the alveoli inflated and prevent atelectasis. The client having abdominal surgery will be NPO until bowel sounds return, which will not occur in the PACU; therefore, the client is not given a meal. The client's postoperative pain should be kept within a tolerable range.These interventions help decrease the client's anxiety.
The nurse recognizes teaching has been effective by which of the following statements? A. My neighbor was able to eat right up to the time of her procedure B. I know there is nothing you can do about nausea after the procedure C. So that IV line will stay in throughout the procedure? D. I know I will need blood during this procedure
C
The nurse must obtain surgical consent forms for the scheduled surgery. Which client would not be able to consent legally to surgery?A. The 65-year-old client who cannot read or write. B. The 30-year-old client who does not understand English. C. The 16-year-old client who has a fractured ankle. D. The 80-year-old client who is not oriented to the day.
C A 16-year-old client is not legally able to give permission for surgery unless the adolescent has been given an emancipated status by a judge. This information was not given in the stem.
Which of the following patients presents the greatest risk for a negative response to anesthesia? A. A 40-year-old male with high blood pressure B. A 20-year-old female with no prior surgical history C. A 29-year-old female with a history of stage IIacute renal failure D. An 85-year-old male who drinks one glass of scotch every night
C Rationale: Any patient with renal impairment will not be able to excrete anesthesia effectively. Anesthetics are excreted either through the liver or kidneys and impairment of either organ will mean the patient cannot rid the body of anesthesia. The anesthesiologist must reduce the amount of anesthesia used during the surgery.
The nurse is completing a preoperative assessment on a male client who states, "I am allergic to codeine." Which intervention should the nurse implement first? A. Apply an allergy bracelet on the client's wrist. B. Label the client's allergies on the front of the chart. C. Ask the client what happens when he takes the codeine. D. Document the allergy on the medication administration record.
C The nurse should first assess the events which occurred when the client took this medication because many clients think a side effect, such as nausea, is an allergic reaction.
The nurse is assessing a client in the day surgery unit who states, "I am really afraid of having this surgery. I'm afraid of what they will find." Which statement would be the most therapeutic response by the nurse? A. "Don't worry about your surgery. It is safe." B. "Tell me why you're worried about your surgery." C. "Tell me about your fears of having this surgery." D. "I understand how you feel. Surgery is frightening."
C This statement focuses on the emotion which that the client identified and is therapeutic.
The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply. A. The client has loose, decayed teeth. B. The client is experiencing anxiety. C. The client smokes two (2) packs of cigarettes a day. D. The client has had a chest x-ray which does not show infiltrates. E. The client reports using herbs.
C & E Smokers are at a higher risk for complications from anesthesia. No infiltrates on a chest x-ray is a normal finding and does not have to be reported. Herbs—for example, St. John's wort, licorice, and ginkgo have serious interactions with anesthesia and with bodily functions such as coagulation.
Because of Jane's smoking history the nurse understands she is at great risk for which of the following? Select all that apply A. Increased postoperative pain B. Difficulty with anesthesia C. Respiratory depression during the procedure D. Increased healing time after the procedure E. Deep vein thrombosis after the procedure
C, D, & E
The nurse is preparing a client for surgery. Which intervention should the nurse implement first? A. Check the permit for the spouse's signature. B. Take and document intake and output. C. Administer the "on call" sedative. D. Complete the preoperative checklist.
D Completing the preoperative checklist has the highest priority to ensure all details are completed without omissions.
You are preparing a patient for surgery and have asked her to verify her information on her patient identification band. She tells you that the birth date is incorrect on her identification band. The most appropriate action by the nurse at this time is which of the following? A. Cross out the birth date and put the correct one in its place with the nurse's initials. B. Ask the family members to validate the patient's birth date. C. Call the surgeon's office to validate the birthdate. D. Ask the admissions office to please send a corrected identification band.
D Rationale: It is imperative that the patient enters the operating room with all information absolutely correct. The admissions office must send a new identification band.
Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? A. Complete the preoperative checklist. B. Assess the client's preoperative vital signs. C. Teach the client about coughing and deep breathing. D. Assist the client to remove clothing and jewelry.
D The UAP can remove clothing and jewelry.
The nurse is caring for a client scheduled for total hip replacement. Which behavior indicates the need for further preoperative teaching? A. The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth. B. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves the feet in a circular motion. C. The client uses the incentive spirometer and inhales slowly and deeply so the piston rises to the preset volume. D. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.
D The correct way to get out of bed postoperatively is to roll onto the side, grasp the side rail to maneuver to the side, and then push up with one hand while swinging the legs over the side. The client needs further teaching.
Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery? A. Calcium 9.2 mg/dL. B. Bleeding time two (2) minutes. C. Hemoglobin 15 g/dL. D. Potassium 2.4 mEq/L.
D This potassium level is low and should be reported to the health-care provider be- cause potassium is important for muscle function, including the cardiac muscle.