Care of Perioperative Patients
A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.) a. "A malnourished client will have fragile skin." b. "Malnourished clients always have other problems." c. "Many drugs are bound to protein in the body." d. "Protein stores are needed for wound healing." e. "Weakness and fatigue are common in malnutrition."
a. "A malnourished client will have fragile skin." c. "Many drugs are bound to protein in the body." d. "Protein stores are needed for wound healing." e. "Weakness and fatigue are common in malnutrition." Malnutrition can lead to poorer surgical outcomes for several reasons, including fragile skin that might break down, altered pharmacokinetics, poorer wound healing, and weakness or fatigue that can interfere with recovery. Malnutrition can exist without other comorbidities.
During a surgical procedure, the nurse notices the sponge count is incorrect. One sponge is missing. What is the priority nursing intervention? a. Communicate the discrepancy to the surgical team immediately b. Complete appropriate documentation concerning the error in sponge count c. Examine the environmental distractions, refocus, and count the sponges again d. Anticipate that the surgeon will order an x-ray to look for the sponge postoperatively
a. Communicate the discrepancy to the surgical team immediately
A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best? a. "A rapid heart rate requires more effort by the heart." b. "Anesthesia has bad effects if the client is tachycardic." c. "The client may have an undiagnosed heart condition." d. "When the heart rate goes up, the blood pressure does too."
a. "A rapid heart rate requires more effort by the heart." Tachycardia increases the workload of the heart and requires more oxygen delivery to the myocardial tissues. This added strain is not needed on top of the physical and emotional stress of surgery. The other statements are not accurate.
The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? a. "Use of an incentive spirometer will help prevent pneumonia" b. "Close monitoring of your oxygen saturation will detect hypoxemia" c. "Administration of intravenous fluids will prevent or treat fluid imbalance" d. "Early ambulation and administration of blood thinners will prevent pulmonary embolism"
a. "Use of an incentive spirometer will help prevent pneumonia" * Postop respiratory problems are atelectasis, pneumonia, and pulmonary emboli.
A client in the operating room has developed malignant hyperthermia. The client's potassium is 6.5 mEq/L. What action by the nurse takes priority? a. Administer 10 units of regular insulin. b. Administer nifedipine (Procardia). c. Assess urine for myoglobin or blood. d. Monitor the client for dysrhythmias.
a. Administer 10 units of regular insulin. For hyperkalemia in a client with malignant hyperthermia, the nurse administers 10 units of regular insulin in 50 mL of 50% dextrose. This will force potassium back into the cells rapidly. Nifedipine is a calcium channel blocker used to treat hypertension and dysrhythmias, and should not be used in a client with malignant hyperthermia. Assessing the urine for blood or myoglobin is important, but does not take priority. Monitoring the client for dysrhythmias is also important due to the potassium imbalance, but again does not take priority over treating the potassium imbalance.
A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client? a. Allow the client to keep hearing aids in until anesthesia begins. b. Pad the table as appropriate for the surgical procedure. c. Position the client for maximum visualization of the site. d. Stay with the client, providing emotional comfort and support.
a. Allow the client to keep hearing aids in until anesthesia begins. Many older clients have sensory loss. To help prevent disorientation, facilities often allow older clients to keep their eyeglasses on and hearing aids in until the start of anesthesia. The other actions are appropriate for all operative clients.
A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again.
a. Assess the client for anxiety. Anxiety can interfere with learning and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious.
A client is having surgery. The circulating nurse notes the client's oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best? a. Assess the client's end-tidal carbon dioxide level. b. Document the findings in the client's chart. c. Inform the anesthesia provider of these values. d. Prepare to administer dantrolene sodium (Dantrium).
a. Assess the client's end-tidal carbon dioxide level. Malignant hyperthermia is a rare but serious reaction to anesthesia. The triad of early signs include decreased oxygen saturation, tachycardia, and elevated end-tidal carbon dioxide (CO2) level. The nurse should quickly check the end-tidal CO2 and then report findings to the anesthesia provider and surgeon. Documentation is vital, but not the most important action at this stage. Dantrolene sodium is the drug of choice if the client does have malignant hyperthermia.
The nurse receives a telephone call from the post anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? a. Assess the patency of the airway b. Check tubes and drains for patency c. Check the dressing to assess for bleeding d. Assess the vital signs to compare with preoperative measurements
a. Assess the patency of the airway * The first action of the nurse is to assess the patency of the airway and respiratory function
The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices.
a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. The SCIP project contains core measures that are mandatory for all surgical clients and focuses on preventing infection, serious cardiac events, and venous thromboembolism. The managers should start by reviewing charts to see if the guidelines of this project were implemented. The other actions may be necessary too, but first the managers need to assess the situation.
An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment? a. Change in behavior b. Daily white blood cell count c. Presence of fever and chills d. Tolerance of increasing activity
a. Change in behavior Older people have an age-related decrease in immune system functioning and may not show classic signs of infection such as increased white blood cell count, fever and chills, or obvious localized signs of infection. A change in behavior often signals an infection or onset of other illness in the older client.
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? (Select all that apply) a. Contact the surgeon b. Instruct the client to remain quiet c. Prepare the client for wound closure d. Document the findings and actions taken e. Place a sterile saline dressing and ice packs over the wound f. Place the client in a supine position without a pillow under the head
a. Contact the surgeon b. Instruct the client to remain quiet c. Prepare the client for wound closure d. Document the findings and actions taken * Ice is not used due to its vasoconstrictive effects
A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.) a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations e. Inability to adapt to changes
a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations Older adults have many age-related physiologic changes that put them at higher risk of falling and other complications after surgery. Some of these include decreased cardiac output, decreased oxygenation of tissues, nocturia, and mobility alterations. They also have a decreased ability to adapt to new surroundings, but that is not the same as being unable to adapt.
A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate? a. Explain the rationale for giving the medicine now. b. Leave the room and come back in 15 minutes. c. Provide holistic client care and come back later. d. Tell the client you must start the medication now.
a. Explain the rationale for giving the medicine now. The preoperative antibiotic must be given within 60 minutes of the surgical start time to ensure the proper amount is in the tissues when the incision is made. The nurse should explain the rationale to the client for this timing. The other options do not take this timing into consideration and do not give the client the information needed to be cooperative.
A client who has undergone permission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? a. Hgb, 8.0 g/dL b. Sodium, 145 mEq/L c. Serum creatinine, 0.8 mg/dL d. Platelets, 210,000 cells/mm3
a. Hgb, 8.0 g/dL * Hgb for males is normally 13.5-17.5 & for females 12.0-15.5. * If a client has a low hemoglobin level, the surgery likely could be postponed.
The nurse is monitoring the status of a postop client in the immediate postop period. The nurse would become most concerned with which sign that could indicate an evolving complication? a. Increasing restlessness b. A pulse of 86 bp c. Blood pressure of 110/70 mmHg d. Hypoactive bowel sounds in all 4 quadrants
a. Increasing restlessness * Increasing restlessness could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism.
A patient has had bowel surgery. Which symptom, assessed by the nurse, is the best indicator of intestinal activity? a. Passage of flatus or stool b. Patient's report of hunger c. Abdominal cramping with distention d. Detection of bowel sounds upon auscultation
a. Passage of flatus or stool * BEST indicator * Patient may have bowel sounds without intestinal activity. * Abdominal cramping with distention would be associated with a need for NG suctioning
The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be NPO after midnight. The nurse should call the surgeon to clarify which medication should be given to the client and not withheld? a. Prednisone b. Ferrous sulfate c. Cyclobenzaprine d. Conjugated estrogen
a. Prednisone * Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress (surgery). When stress is severe, corticosteroids are essential to life.
The nurse has just reassessed the condition of a postop client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? a. Urinary output of 20 mL/hour b. Temperature of 37.6 C (99.6 F) c. Blood pressure of 100/70 mmHg d. Serous drainage on the surgical dressing
a. Urinary output of 20 mL/hour * Urine output should be maintained at a minimum of 30 mL/hour * A temp higher than 100 F or lower than 97 F and a falling SBP (lower than 90 mmHg) are usually considered reportable immediately * Moderate or light serous drainage from the surgical site is considered normal
A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate? a. "After you wash the surgical site, shave that area with your own razor." b. "Be sure to wash the area where you will have surgery very thoroughly." c. "Use a washcloth to wash the surgical site; do not take a full shower or bath." d. "Wash the surgical site first, then shampoo and wash the rest of your body."
b. "Be sure to wash the area where you will have surgery very thoroughly." The entire proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap. Shaving, if absolutely necessary, should be done in the operative suite immediately before the operation begins, using sterile equipment. The client needs a full shower or bath (shower preferred). The client should wash the surgical site last; dirty water from shampooing will run over the cleansed site if the site is washed first.
A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best? a. "All preoperative clients get this medication." b. "It helps prevent ulcers from the stress of the surgery." c. "Since you don't have ulcers, I will have to ask." d. "The physician prescribed this medication for you."
b. "It helps prevent ulcers from the stress of the surgery." Ulcer prophylaxis is common for clients undergoing long procedures or for whom high stress is likely. The nurse is not being truthful by saying all clients get this medication. If the nurse does not know the information, it is appropriate to find out, but this is a common medication for which the nurse should know the rationale prior to administering it. Simply stating that the physician prescribed the medication does not give the client any useful information.
A client is in stage 2 of general anesthesia. What action by the nurse is most important? a. Keeping the room quiet and calm b. Being prepared to suction the airway c. Positioning the client correctly d. Warming the client with blankets
b. Being prepared to suction the airway During stage 2 of general anesthesia (excitement, delirium), the client can vomit and aspirate. The nurse must be ready to react to this potential occurrence by being prepared to suction the client's airway. Keeping the room quiet and calm does help the client enter the anesthetic state, but is not the priority. Positioning the client usually occurs during stage 3 (operative anesthesia). Keeping the client warm is important throughout to prevent hypothermia.
On admission to the preoperative area, the client scheduled for a hip replacement tells the nurse that three autologous blood donations for this surgery have been made in the past 3 weeks. What is the nurse's best action? a. Check the client's international normalized ratio (INR). b. Call the laboratory to ensure that the blood is physically at the operating facility. c. Ensure that the client has given consent to receive blood if a transfusion is necessary. d. Inform the client that an autologous transfusion does not eliminate the risk for development of blood borne diseases.
b. Call the laboratory to ensure that the blood is physically at the operating facility.
The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority? a. Allergies noted and allergy band on b. Consent for MIS procedure only c. No prior anesthesia exposure d. NPO status for the last 8 hours
b. Consent for MIS procedure only All MIS procedures have the potential for becoming open procedures depending on findings and complications. The client's consent should include this possibility. The nurse should report this finding to the surgeon prior to surgery taking place. Having allergies noted and an allergy band applied is standard procedure. Not having any prior surgical or anesthesia exposure is not the priority. Maintaining NPO status as prescribed is standard procedure.
A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. Call the provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallower breaths. d. Tell the client a little pain is expected.
b. Demonstrate how to splint the incision. Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should know some pain is normal and expected after surgery, but that answer alone does not provide any interventions to help the client.
An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the surgeon. c. Have the client sign the consent, then call the surgeon. d. Remind the client of what teaching the surgeon has done.
b. Do not have the client sign the consent and call the surgeon. In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the surgeon. The nurse should notify the surgeon to come back and answer the client's questions before the client signs the consent form. The other actions are not appropriate.
A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.) a. Hemorrhage b. Infection c. Serious cardiac events d. Stroke e. Thromboembolism
b. Infection c. Serious cardiac events e. Thromboembolism
A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.) a. Hemicolectomy: diagnostic b. Liver biopsy: diagnostic c. Mastectomy: restorative d. Spinal cord decompression: palliative e. Total shoulder replacement: restorative
b. Liver biopsy: diagnostic e. Total shoulder replacement: restorative A diagnostic procedure is used to determine cell type of cancer and to determine the cause of a problem. An example is a liver biopsy. A restorative procedure aims to improve functional ability. An example would be a total shoulder replacement or a spinal cord decompression (not palliative). A curative procedure either removes or repairs the causative problem. An example would be a mastectomy (not restorative) or a hemicolectomy (not diagnostic). A palliative procedure relieves symptoms but will not cure the disease. An example is an ileostomy. A cosmetic procedure is done to improve appearance. An example is rhinoplasty (a "nose job").
A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.) a. Client with a humerus fracture b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client
b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client All surgical clients should be assessed for VTE risk. Those considered at higher risk include those who are obese; are over 40; have cancer; have decreased mobility, immobility, or a spinal cord injury; have a history of any thrombotic event, varicose veins, or edema; take oral contraceptives or smoke; have decreased cardiac output; have a hip fracture; or are having total hip or knee surgery. Prolonged surgical time increases risk due to mobility and positioning needs.
A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important? a. Assist with administering muscle relaxants to the client. b. Place the client on a cardiac monitor and pulse oximeter. c. Prepare to administer intravenous antiemetics to the client. d. Prevent the client from experiencing postoperative shivering.
b. Place the client on a cardiac monitor and pulse oximeter. Intravenous anesthetic agents have the potential to cause respiratory and circulatory depression. The nurse should ensure the client is on a cardiac monitor and pulse oximeter. Muscle relaxants are not indicated for this client at this time. Intravenous anesthetics have a lower rate of postoperative nausea and vomiting than other types. Shivering can occur in any client, but is more common after inhalation agents.
A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client? a. Document giving the drug. b. Raise the siderails on the bed. c. Record the client's vital signs. d. Teach relaxation techniques.
b. Raise the side rails on the bed. All actions are appropriate for a preoperative client. However, for client safety, the nurse should raise the siderails on the bed because hydroxyzine can make the client sleepy.
The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? a. Red, hard skin b. Serous drainage c. Purulent drainage d. Warm, tender skin
b. Serous drainage
The client who had abdominal surgery for colon cancer is transferred to the medical-surgical unit after 4 hours in the PACU. The nurse notes all the following assessment findings. For which one should the nurse notify the surgeon, anesthesia provider, or Rapid Response Team? a. There is a large amount of serosanguineous drainage on the dressing around the ostomy stoma. b. SpO2 is 80% when measured by pulse oximetry on the fingers, nose, and ears. c. The client is confused and trying to pull out the nasogastric tube. d. Bowel sounds are absent in all 4 quadrants.
b. SpO2 is 80% when measured by pulse oximetry on the fingers, nose, and ears.
A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? a. "If it's any help, everyone is nervous before surgery" b. "I will be happy to explain the entire surgical procedure to you" c. "Can you share with me what you've been told about your surgery?" d. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate"
c. "Can you share with me what you've been told about your surgery?"
The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? a. "Aspirin can cause bleeding after surgery" b. "Aspirin can cause my ability to clot blood to be abnormal" c. "I need to continue to take the aspirin until the day of surgery" d. "I need to check with my health care provider about the need to stop the aspirin before the scheduled surgery"
c. "I need to continue to take the aspirin until the day of surgery"
The client has entered the surgical suite about 30 minutes after she has received atropine and midazolam as preoperative drugs. The OR schedule lists that she is to have a vaginal hysterectomy. When the nurse asks her what kind of surgery she is having today, her response is "I am going to have a hemorrhoidectomy." What is the nurse's next best action? a. Notify the surgeon that the client is uninformed and that consent must be obtained again. b. Ask the client to describe what the surgery is supposed to be in her own words. c. Ask the client her name and compare it with the name on the chart. d. Delay further preparations until the preoperative drugs have worn off.
c. Ask the client her name and compare it with the name on the chart.
The nurse is monitoring a patient who is receiving moderate sedation. An expected outcome for conscious sedation is: a. Blocked multiple peripheral nerves in a specific region b. Decreased motor function in the targeted limb c. Decreased level of consciousness, yet able to respond to verbal commands d. CNS depression, resulting in analgesia and amnesia, with loss of muscle tone and reflexes
c. Decreased level of consciousness, yet able to respond to verbal commands a. LOCAL b. REGIONAL d. GENERAL
A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best? a. Allow the client to walk to the bathroom. b. Delegate assisting the client to the nurse's aide. c. Give the client a bedpan or urinal to use. d. Insert a urinary catheter now instead of waiting.
c. Give the client a bedpan or urinal to use. Although possibly uncomfortable or embarrassing for the client, the client should not be allowed out of bed after receiving sedation. The nurse should get the client a bedpan or urinal. The client may or may not need a urinary catheter.
The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? a. Avoid oral hygiene and rinsing with mouthwash. b. Verify that the client has not eaten for the last 24 hours. c. Have the client void immediately before going into surgery. d. Report immediately any slight increase in blood pressure or pulse.
c. Have the client void immediately before going into surgery.
The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate? a. Ask the surgeon to change the sterile gown. b. Do nothing; this is acceptable sterile procedure. c. Inform the surgeon that the sterile field has been broken. d. Obtain a new pair of sterile gloves for the surgeon to put on.
c. Inform the surgeon that the sterile field has been broken.
A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client? a. Hydroxyzine (Atarax) b. Lorazepam (Ativan) c. Metoclopramide (Reglan) d. Morphine sulfate
c. Metoclopramide (Reglan) Reglan increases gastric emptying, an important issue for this client who was eating just prior to the operation. The other drugs are appropriate for any surgical client.
A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care? a. Married young adult who is the primary caregiver for children b. Middle-aged client who is post knee replacement, needs physical therapy c. Older adult who lives at home despite some memory loss d. Young client who lives alone, has family and friends nearby
c. Older adult who lives at home despite some memory loss The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The client's physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed. The other clients all have evidence of a support system and no known potential for serious safety issues.
A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL b. Hemoglobin: 14.8 mg/dL c. Potassium: 2.9 mEq/L d. Sodium: 134 mEq/L
c. Potassium: 2.9 mEq/L A potassium of 2.9 mEq/L is critically low and can affect cardiac and respiratory status. The nurse should communicate this laboratory value immediately. The creatinine is at the high end of normal, the hemoglobin is normal, and the sodium is only slightly low (normal low being 136 mEq/L), so these values do not need to be reported immediately.
When positioning to decrease pain in the postoperative patient, which intervention is most appropriate? a. Raise the knee watch of the bed b. Place pillows under the patient's knees c. Reposition the patient at least every 2 hours d. Allow the patient to get out of bed as soon as possible
c. Reposition the patient at least every 2 hours
For which client permission testing laboratory result does the nurse take immediate action? a. INR 0.9 b. WBC 8500/mm3 c. Serum K+ level 2.8 mEq/L d. Serum Na+ 132 mEq/L
c. Serum K+ level 2.8 mEq/L * Defined limits of K+ = 3.0-5.5 mEq/L
While the nurse is taking the client's history before elective cosmetic surgery, the client reports all the following facts. Which one should be reported to the surgeon and may result in a cancellation of this surgery? a. She delivered a baby 8 weeks ago and still has some vaginal discharge. b. She has three large "boils" (furuncles) on the skin of her left shoulder. c. She has been taking oral contraceptives for the last 2 weeks. d. She is allergic to aspirin, dust, peanuts, and fall pollens.
c. She has been taking oral contraceptives for the last 2 weeks. * oral contraceptives create a hypercoagulability state (Virchow's Triad)
A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of the client? a. Obtain a court order for the surgery. b. Have the charge nurse sign the informed consent immediately. c. Send the client to surgery without the consent form being signed. d. Obtain a telephone consent from a family member, following agency policy.
d. Obtain a telephone consent from a family member, following agency policy.
A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best? a. Administer anxiolytics. b. Give the client warm blankets. c. Introduce the surgical staff. d. Remain with the client.
d. Remain with the client. The nurse can provide emotional support by remaining with the client until anesthesia has been provided. An extremely anxious client may need anxiolytics, but not all clients require this for emotional support. Physical comfort and introductions can also help decrease anxiety.
The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? a. Inhale as rapidly as possible b. Keep a loose seal between the lips and the mouthpiece c. After maximum inspiration, hold the breath for 15 seconds and exhale d. The best results are achieved when sitting up or with the HOB elevated 45-90 degrees
d. The best results are achieved when sitting up or with the HOB elevated 45-90 degrees * For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler's or high Fowler's position. * The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. * The breath should be held for 5 seconds before exhaling slowly
The client scheduled for knee replacement surgery today performed all of the following actions yesterday. Which action is most important for the nurse to report to the surgeon? a. Took 50 mg of diphenhydramine (Benadryl) at bedtime. b. Smoked one pack of cigarettes instead of two. c. Drank two 12-ounce glasses of beer. d. Took two aspirins three times.
d. Took two aspirins three times.
A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements
d. Use of multiple herbs and supplements Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered. Lack of experience with surgery may increase anxiety and may require higher teaching needs, but is not the priority over client safety.
