(PrepU) Chapter 14: Preoperative Nursing Management

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

3.5 and 5.5 mmol/L Although the surgical risk in the patient with controlled diabetes is no greater than in the patient without diabetes, strict glycemic control (3.5 to 5.5 mmol/L) leads to better outcomes (Alvarex et al., 2010). Frequent monitoring of blood glucose levels is important before, during, and after surgery.

In which instance may a surgeon operate without informed consent?

Emergency situations In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the client's informed consent.

The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which laboratory value would be of greatest concern to the nurse?

potassium 6.2 mEq/L Hyperkalemia places the client at risk for surgical complications. The sodium level, calcium level, and white blood cell count are within normal limits.

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

Use diaphragmatic breathing. In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.

Which nursing statement would best ease a client's anxiety before an emergency operative procedure?

"Let me explain to you what will happen next." Many clients feel fearful of knowing little about the operative procedure and what to expect. This fear causes anxiety and can lead to a poorer response to surgery and surgical complications. Explanations of what the client is to expect can help to decrease anxiety. False reassurance of being fine does not diminish anxiety. Deep breathing and relaxation techniques can be helpful to the client, but addressing the source of the anxiety is more beneficial. Keeping the family informed helps the family and is not client focused.

A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery?

7 to 10 days Aspirin, a common OTC medication that inhibits platelet aggregation, should be prudently discontinued 7 to 10 days before surgery; otherwise, the client may be at increased risk for bleeding.

For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery?

7 Aspirin should be stopped at least 7 to 10 days before surgery. The other time frames are incorrect.

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

A gastrostomy tube Informed consent is required for invasive procedures that require sedation and are associated with more than usual risk to the client.

You are admitting an insulin-dependent patient to the same-day surgical suite for carpal tunnel surgery. You know that this patient may be at risk for which metabolic disorder?

Hyperglycemia The patient with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia. Hyperglycemia during the surgical procedure is a risk based on the body's defense mechanism to raise the blood sugar in the event of stress. Patients who have received corticosteroids are at risk of adrenal insufficiency. Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis. Because the kidneys are involved in excreting anesthetic medications and their metabolites and because acid-base status and metabolism are also important considerations in anesthesia administration, surgery is contraindicated when a patient has acute nephritis, acute renal insufficiency with oliguria or anuria, or other renal problems.

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

nutritional status age physical condition health status General surgical risk factors are related to age; nutritional status; use of alcohol, tobacco, and other substances; and physical condition.

In advance of a client's scheduled appendectomy, the nurse spends significant time explaining to the client what will happen, both before the procedure and after the procedure is complete. The primary reason the nurse puts so much effort into preoperative teaching is to:

increase the likelihood of a successful recovery. Teaching clients about their surgical procedure and expectations before and after surgery is best done during the preoperative period. Clients and family members can better participate in recovery if they know what to expect. Although preoperative teaching may minimize the time spent postoperatively on questions and help nurses improve their teaching skills, these are not the primary reasons for spending significant preoperative time on teaching. Clients must participate in their recovery process. Education encourages clients to participate in their own care in addition to giving important information to family. Absolving the hospital of legal responsibility would not be a primary nursing goal.

You are physically preparing a client for surgery and instruct the person to remove any jewelry. The client refuses to remove a wedding band. What should you do in this situation with approval from your facility?

Place gauze under and over the ring and apply adhesive tape over it. If the client is reluctant to remove a wedding band, the nurse may slip gauze under the ring, then loop the gauze around the finger and wrist or apply adhesive tape over a plain wedding band. You would not tell the client that he or she cannot go to the operating room wearing the ring. You would never medicate the client and then remove the ring against his or her will. It is not necessary to tell the physician and the anesthesiologist that the client does not want to remove the wedding band.

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

"The nurse will explain the details of the surgery before I sign a consent." Further instruction would be needed to clarify that the physician, not the nurse, explains the details of the surgery and obtains voluntary consent for the procedure. It is correct that preoperative instructions must be followed prior to surgery for the safety of the client, medical records are present for review prior to surgery, and the physician speaks with the family following the procedure and provides instructions for discharge.

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

A client who has a history of arthritis A history of arthritis does not increase the risk for complications during the perioperative period.

Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency?

Adrenal Clients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids does not occur in the pituitary, thyroid, or parathyroid glands.

What action by the nurse best encompasses the preoperative phase?

Educating clients on signs and symptoms of infection Educating clients on preventing or recognizing complications begins in the preoperative phase. Applying SCDs and frequently monitoring vital signs happen after the preoperative phase. Only electric clippers should be used to remove hair.

A fractured skull would be classified under which category of surgery based on urgency?

Emergent Emergent surgery occurs when the client requires immediate attention. An elective surgery is classified as a surgery that the client should have. A required surgery means that the client needs to have surgery. An urgent surgery occurs when the client requires prompt attention.

A gunshot wound would be classified under which category of surgery based on urgency?

Emergent Emergent surgery occurs when the patient requires immediate attention. An elective surgery is classified as a surgery that the patient should have. A required surgery means that the patient needs to have surgery. An urgent surgery is one which the patient required prompt attention.

An anxious client being prepared for surgery is encouraged to concentrate on a pleasant experience or restful scene. What cognitive coping strategy would the nurse document as being used?

Imagery Imagery has proven effective for anxiety in surgical clients. Optimistic self-recitation is practiced when the client recites optimistic thoughts such as, "I know all will go well." Distraction is used when the client is encouraged to think of an enjoyable story or recite a favorite poem. Progressive muscular relaxation requires contracting and relaxing muscle groups and is a physical coping strategy as opposed to a cognitive strategy.

The nurse is conducting a preoperative assessment on a client scheduled for gallbladder surgery. The client reports a frequent cough producing green sputum for 3 days and denies fever. Upon auscultation, the nurse notes rhonchi throughout the right lung, with an occasional expiratory wheeze. Respiratory rate is 20, temperature is 99.8 (taken orally), heart rate is 87, and blood pressure is 124/70. What is the best action by the nurse?

Notify the surgeon to possibly delay the surgery. A respiratory infection can delay a nonemergent surgical procedure because the infection can increase the risk for respiratory complications. Therefore, the nurse should notify the surgeon about delaying the surgery. The primary physician may be called to provide care based on the assessment findings, but that should be done only after the surgeon has been notified. Continuing through the preoperative phase without notifying the surgeon and waiting 1 hour then repeating the assessment are not appropriate.

A client is undergoing preoperative assessment. During admission paperwork, the client reports having enjoyed a hearty breakfast this morning to be ready for the procedure. What is the nurse's next action?

Notify the surgeon. If the client has not carried out a specific portion of preoperative instructions, such as withholding foods and fluids, the nurse immediately notifies the surgeon. This scenario does not include information to support documentation of the client's food intake or giving the client water at this point. It is not the nurse's responsibility to cancel the surgery.

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

Optional Cosmetic surgery, including reduction mammoplasties, is optional, as the decision to have the surgery rests with the patient.

A client is scheduled for a cholecystectomy. Which finding by the nurse is least likely to contribute to surgical complications?

Osteoporosis Osteoporosis is likely not going to contribute to complications related to a cholecystectomy. Pregnancy decreases maternal reserves. Diabetes increases wound-healing problems and risks for infection. Urinary tract infection decreases the immune system's effectiveness, increasing the chance for infections.

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

Up to 72 hours after alcohol withdrawal Alcohol withdrawal delirium is associated with a significant mortality rate when it occurs postoperatively. Onset of symptoms depends on when alcohol was last consumed. Twenty-four hours is too short a time frame to consider alcohol withdrawal delirium as no longer a threat to a chronic alcoholic.

Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out?

Review the scheduled procedure, site, and client. According to the 2016 National Patient Safety Goals, accurate identification of the client, procedure, and operative site is essential.

When assessing a postoperative client, the nurse is correct to relate which surgical risk factor that would decrease if the surgical client maintained a blood glucose level under 8.3 mmol/L?

Wound healing In caring for a postoperative client, the nurse is correct to correlate hyperglycemia with an increased risk of surgical incision infections and delayed wound healing. There is no direct correlation between blood glucose levels and nutrient deficiencies, respiratory complications, and liver dysfunction.

A client is preparing for a surgical procedure is taking corticosteroids for Crohn's disease. What is most important for the nurse to monitor during the operative experience with the client?

adrenal insufficiency Clients who have received corticosteroids are at risk for adrenal insufficiency. They are not at greater risk for obstruction, infection, or hypoglycemia during the operative experience.

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as

emergency Emergency surgery means that the client requires immediate attention and the disorder may be life threatening. Urgent surgery means that the client requires prompt attention within 24 to 30 hours. Required surgery means that the client needs to have surgery, and it should be planned within a few weeks or months. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.

When a client is encouraged to concentrate on a pleasant experience or restful scene, the client is using the cognitive coping strategy called

imagery Imagery has proven effective for oncology clients. Optimistic self-recitation is practiced when the client recites optimistic thoughts such as, "I know all will go well." Distraction is used when the client is encouraged to think of an enjoyable story or recite a favorite poem. Progressive muscular relaxation requires contracting and relaxing muscle groups and is a physical coping strategy as opposed to a cognitive strategy.

A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective?

"I will support my incision with my hands when I cough and do my deep breathing exercises." Splinting of the incision provides support to the incision and helps to control pain, so this client statement is correct. Clients should take pain medication routinely and frequently after surgery. Pain medications for postoperative clients are given orally at home. Pain is a subjective feeling, so comparison is difficult.

A patient is scheduled for a surgical procedure. For which surgical procedure should the nurse prepare an informed consent form for the surgeon to sign?

An open reduction of a fracture Informed consent is necessary in the following circumstances: invasive procedures, such as a surgical incision (such as would be involved in an open reduction of a fracture), a biopsy, a cystoscopy, or paracentesis; procedures requiring sedation and/or anesthesia (see Chapter 18 for a discussion of anesthesia); a nonsurgical procedure, such as an arteriography, that carries more than a slight risk to the patient; and procedures involving radiation. Non-invasive procedures such as insertion of an intravenous or urethral catheter or irrigation of the external ear canal would not require informed consent.

The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following?

Cheeseburger, french fries, coleslaw, and ice cream Important nutrients for wound healing include protein; vitamins A, B-complex, C, and K; arginine, magnesium, copper, and zinc; and water. The diet should be sufficient in carbohydrates and low to moderate in fats. The cheeseburger option is high in fat and low in vitamin C.

A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?

Request that the surgeon come and answer the questions. It is the physician's responsibility to provide information pertaining to risks and benefits of surgery. It is not the responsibility of the nurse or nurse manager to discuss risks and benefits. The consent form should not be placed in the medical record until all of the client's questions are answered fully.

A 79-year-old man is scheduled for surgical repair of an inguinal hernia. In light of this patient's age, the nurse will prioritize nursing interventions aimed at preventing:

Skin breakdown Skin breakdown is an important nursing consideration when providing care for all surgical patients. However, older adults face an increased risk of this problem due to age-related changes to the integumentary system. Age alone does not create a heightened risk of hyperglycemia or hypoglycemia. Overstimulation should generally be avoided but this is not directly related to age. Early ambulation is beneficial for patients of all ages.

A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?

Splint the incision site using a pillow during deep breathing and coughing exercises. Splinting the incision site will help decrease pain and support the incision. This will increase compliance with the deep breathing and coughing exercises that assist in preventing respiratory complications. Pain medication should be taken regularly, not only before deep breathing and coughing exercises. Deep breathing and coughing exercises should be done at least every 2 hours, more frequently if possible. While some clients will find the exercises relaxing, most clients find it painful to complete them.

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

Surgeon It is the surgeon's responsibility to explain the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts in obtaining informed consent from the client.

A nurse is teaching a client about diaphragmatic breathing. What client action indicates that further teaching is needed?

The client exhales forcefully with a short expiration. Diaphragmatic breathing should be performed gently and fully. Placing the hands on the lower chest to feel the rise and fall with breathing, performing diaphragmatic breathing in a semi-Fowler's position, and breathing deeply through the nose and mouth are all aspects of diaphragmatic breathing.

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

The client will leave the hospital sooner than in the past. Need for teaching is increased. The client must be prepared to take on more self-care than he or she may have done in the past. The increasing use of ambulatory, same-day, or short-stay surgery, means that clients leave the hospital sooner, which increases the need for teaching, discharge planning, preparation for self-care, and referral for home care and rehabilitation services.

When does the nurse understand the patient is knowledgeable about the impending surgical procedure?

The patient participates willingly in the preoperative preparation. The nurse knows that the patient understands the surgical intervention when the patient participates in preoperative preparation. The other answers pertain to the patient experiencing decreased fear or anxiety, not knowledge about the procedure.