1940 PreUp
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." "I will ask for pain medication when the pain becomes unbearable." "I will need to learn how to give myself pain medication by injection for when I go home." "The pain from my incision will be very similar to my arthritis pain."
"I will support my incision with my hands when I cough and do my deep breathing exercises." Explanation: 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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 114. Chapter 5: Perioperative Nursing - Page 114
The client asks the nurse how the spinal anesthesia will be administered. What is the best response by the nurse? "The anesthesiologist will inject the anesthetic into the space around your lower spinal cord." "The anesthesiologist will inject the anesthetic through your IV." "You will inhale the medication through a mask the anesthesiologist will place over your face and receive medication through your spinal vein." "The medication will be injected into the muscles near you back by the anesthesiologist."
"The anesthesiologist will inject the anesthetic into the space around your lower spinal cord." Explanation:The L4-L5 subarachnoid space is the usual location for the administration of spinal anesthesia. Intramuscular injection and inhalation are not part of spinal anesthesia. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 125. Chapter 5: Perioperative Nursing - Page 125
The surgical unit nurse is developing a postoperative plan of care. In which client's plan of care would the nurse document interventions of coughing and deep breathing, gastrointestinal assessment, and effective regulation of temperature? A client with gastrointestinal surgery and general anesthesia A client having a knee replacement and regional anesthesia A client having lower extremity muscle repair and spinal anesthesia A client with spinal stenosis and a regional nerve blockade
A client with gastrointestinal surgery and general anesthesia Explanation: General anesthesia acts on the central nervous system to produce a loss of sensation, reflexes, and consciousness. The anesthesiologist monitors the vital functions of breathing, circulation, and temperature. Following general anesthesia, nurses must closely monitor for effective breathing and oxygenation, temperature regulation, and adequate fluid balance. Nursing interventions for those clients with regional anesthesia, spinal anesthesia, and regional nerve blockades focus on assessing for allergic reactions, neurovascular assessments to specific body regions, and side effects of the medication. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 121. Chapter 5: Perioperative Nursing - Page 121
The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? Complete blood count Central venous pressure Upper endoscopy Chest x-ray
Central venous pressure Explanation:Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, level of consciousness, central venous pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output are monitored to provide information on the patient's respiratory and cardiovascular status. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 133. Chapter 5: Perioperative Nursing - Page 133
What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities? Assisting the surgeon Coordinating the surgical team Setting up the sterile tables Passing instruments
Coordinating the surgical team Explanation: The person in the scrub role, either a nurse or a surgical technician, provides sterile instruments and supplies to the surgeon during the procedure by anticipating the surgical needs as the surgical case progresses. The circulating nurse coordinates the care of the patient in the OR. Care provided by the circulating nurse includes planning for and assisting with patient positioning, preparing the patient's skin for surgery, managing surgical specimens, anticipating the needs of the surgical team, and documenting intraoperative events. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 112.
At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period? During the preoperative period Upon arrival to the surgical unit Following the surgical procedure At the time of discharge instructions
During the preoperative period Explanation: The best time to begin teaching about care needed in the postoperative period is during the preoperative time. At this time, the client is more alert and focused on the information provided by the nurse. Clients and family members can better be prepared and participate in the recovery period if they know what to expect. Anxiety is a factor on arrival to the surgical unit that could interfere with learning. Pain could interfere with the learning process, following a surgical procedure. At the time of discharge, both pain and timeliness may be an issue in understanding and obtaining care needed during the postoperative time. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 105. Chapter 5: Perioperative Nursing - Page 105
The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by: Granulation First intention Second intention Third intention
First intention Explanation:First-intention healing is characterized by a closed incision with little tissue reaction and the absence of signs and symptoms of infection. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 140. Chapter 5: Perioperative Nursing - Page 140
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? Adrenal insufficiency Thyrotoxicosis Impaired acid base balance Hyperglycemia
Hyperglycemia Explanation: 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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, Endocrine Function, p. 111. Chapter 5: Perioperative Nursing - Page 111
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? Adrenal insufficiency Thyrotoxicosis Impaired acid base balance Hyperglycemia
Hyperglycemia Explanation: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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, Endocrine Function, p. 111. Chapter 5: Perioperative Nursing - Page 111
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. Document what foods the client ate. Give the client plenty of water to aid digestion. Cancel the surgery.
Notify the surgeon. Explanation: Reference: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. Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 116. Chapter 5: Perioperative Nursing - Page 116
The scrub nurse is responsible for: Calling the "time-out" to verify the surgical site and procedure Monitoring the administration of the anesthesia Monitoring the operating-room personnel for breaks in sterile technique Preparing the sterile instruments for the surgical procedure
Preparing the sterile instruments for the surgical procedure Explanation: The scrub nurse is responsible for preparing the sterile instruments for the surgical procedure. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 118. Chapter 5: Perioperative Nursing - Page 118
A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse: continuously monitors the sedated client. performs a complete assessment of the client. obtains a surgical consent from the client's mother. assesses how well the client is recovering from anesthesia.
continuously monitors the sedated client. Explanation: Intraoperative care includes the entire surgical procedure. During sedation, the nurse continuously evaluates the client. Assessment of heart rate, respiratory rate, BP, oxygen saturation, and level of consciousness occurs during all phases of perioperative care. Obtaining consent would occur during the preoperative phase of perioperative care. During the postoperative phase the nurse would assess how the client is recovering from anesthesia. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 114. Chapter 5: Perioperative Nursing - Page 114
A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client? experiences pain within tolerable limits. exhibits wound healing without complications. resumes usual urinary elimination pattern. maintains adequate fluid status.
experiences pain within tolerable limits. Explanation: Because pain can contribute to postoperative delirium, adequate pain control without oversedation is essential. Nursing assessment of mental status and of all physiologic factors influencing mental status helps the nurse plan for care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult client. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 150. Chapter 5: Perioperative Nursing - Page 150
A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: first intention. second intention. third intention. fourth intention.
first intention. Explanation:Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 140. Chapter 5: Perioperative Nursing - Page 140
The nurse recognizes the client has reached stage III of general anesthesia when the client: lies quietly on the table displays agitation due to noise shouts, talks, or sings exhibits shallow respirations and a weak, thready pulse
lies quietly on the table Explanation: Understanding the stages of anesthesia is necessary for nurses because of the emotional support that the client may need. Stage III or surgical anesthesia is reached when the patient is unconscious and lies quietly on the table. The pupils are small but constrict when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. Clients in stage I of anesthesia may have a ringing, roaring, or buzzing in the ears and, although still conscious, may sense an inability to move the extremities easily. These sensations can result in agitation. Stage II of anesthesia is characterized variously by struggling, shouting, talking, singing, laughing, or crying, and is often avoided if IV anesthetic agents are given smoothly and quickly. Stage IV is reached if too much anesthesia is given. Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer constrict when exposed to light. Cyanosis develops and, without prompt intervention, death rapidly follows. If this stage develops, the anesthetic agent is discontinued immediately and respiratory and circulatory support is initiated to prevent death. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 182. Chapter 5: Perioperative Nursing - Page 182
The nurse understands that the purpose of the "time out" is to: verify all necessary supplies are available. identify the client's allergies. clarify the roles of the OR personnel. maintain the safety of the client.
maintain the safety of the client. Explanation: Verification of the identification of the client, procedure, and operative site are essential to maintain the safety of the client. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 118. Chapter 5: Perioperative Nursing - Page 118
Which statement by the client indicates further teaching about epidural anesthesia is necessary? "I will become unconscious." "I will lose the ability to move my legs." "I will be able to hear the surgeon during the surgery." "A needle will deliver the anesthetic into the area around my spinal cord."
"I will become unconscious." Explanation The client receiving epidural anesthesia will remain conscious during the procedure. Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 125. Chapter 5: Perioperative Nursing - Page 125
For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery? 1 3 5 7
7 Explanation: Aspirin should be stopped at least 7 to 10 days before surgery. The other time frames are incorrect. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 112. Chapter 5: Perioperative Nursing - Page 112
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? 2 weeks 4 weeks 7 to 10 days 2 to 3 days
7 to 10 days Explanation: 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. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 112. Chapter 5: Perioperative Nursing - Page 112
Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply. Ambulate the length of the client's house Get out of bed without assistance Be able to self-toilet Be able to drive to the grocery Pass a stress test
Ambulate the length of the client's house Get out of bed without assistance Be able to self-toilet Explanation:For a safe discharge to home, clients need to be able to ambulate a functional distance (e.g., length of the house or apartment), get in and out of bed unassisted, and be independent with toileting. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 140. Chapter 5: Perioperative Nursing - Page 140
A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding? Hernia Dehiscence Erythema Evisceration
Evisceration Explanation:Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, Wound Dehiscence and Evisceration, p. 148. Chapter 5: Perioperative Nursing - Page 148
The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching? Sore throat Itching Seizures Headache
Headache Explanation: Headache is a common effect following spinal anesthesia. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 125. Chapter 5: Perioperative Nursing - Page 125
The nurse is caring for the postoperative client in the post anesthesia care unit. Which of the following is the priority nursing action? Monitor vital signs for early detection of shock. Assess the incisional dressing to detect hemorrhage. Position the client to maintain a patent airway. Administer antiemetics to prevent nausea and vomiting.
Position the client to maintain a patent airway. Explanation: Maintaining a patent airway is the immediate priority in the PACU. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, pp. 131-132. Chapter 5: Perioperative Nursing - Page 131-132
When is the ideal time to discuss preoperative teaching Preadmission visit Day of surgery Prior to entering the pre-op area When the patient is comfortable and sedated
Preadmission visit Explanation:The ideal timing for preoperative teaching is not on the day of surgery but during the preadmission visit, when diagnostic tests are performed. Teaching should be done long before the patient enters the preop area. Preoperative teaching should not be done when the patient is sedated. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 114. Chapter 5: Perioperative Nursing - Page 114
A nurse who is part of the surgical team is involved in setting up the sterile tables. The nurse is functioning in which role? Registered nurse first assistant Scrub role Circulating nurse Anesthetist
Scrub role Explanation: The scrub role includes performing a surgical hand scrub, setting up the sterile tables, and preparing sutures, ligatures, and special equipment. The circulating nurse manages the operating room and protects patient safety. The registered nurse first assistant functions under the direct supervision of the surgeon. Responsibilities may include handling tissue, providing exposure of the operative field, suturing, and maintaining hemostasis. The anesthetist administers the anesthetic medications. Reference: Honan, L., Focus on Adult Health: Medical-Surgical Nursing, 2nd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 5: Perioperative Nursing, p. 119. Chapter 5: Perioperative Nursing - Page 119