Care of the Surgical Patient nclex

Nursing Interventions to Facilitate Postoperative Coping and Adaptation

*Accept each patient as a unique individual. *Identify through verbal and nonverbal cues patients who are at risk for alteration in self-concept. The risk is increased if the patient has little support from others, a visible alteration, or an alteration that will seriously affect functional ability. * Allow time for patients and families to verbalize their feelings about the alteration, and do not assume that all patients will have problems. Identify and support strengths and effective coping mechanisms. *Encourage the patient and family to be part of goal setting and decision-making throughout the surgical experience. *Provide teaching and honest information to the patient and family about all aspects of care. *Work collaboratively with other members of the health care team to provide referrals and resources as necessary to meet physical, psychological, and spiritual needs.

A postoperative client states "I don't understand why you are checking my skin on my back. My surgery was on my stomach." What is the nurse's best response? a) "We needed to be sure you didn't have any skin breakdown before surgery." b) "We wanted to be sure we didn't leave any sponges or syringes underneath you." c) "The operating table is a firm surface; we need to be sure your skin looks okay." d) "The covers underneath you need to be straightened out. They look messy."

Answer: " The operating table is a firm surface; we need to be sure your skin looks okay." Rationale: The client who has been on the operating table should be examined to ensure skin breakdown hasn't occurred. The client would not be told that his covers looked messy, or that the nurse was concerned about sponges or syringes underneath. The client's skin should be assessed on admission; after surgery would not be the time to do this initial assessment to document skin breakdown.

The nurse is preparing a client for surgery and asks if the client has an advance directive. The client asks "What is an advance directive?" What is the nurse's best response to this? a) "When you are going to have surgery, the hospital likes to have you fill out all paperwork needed beforehand." b) "An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so." c) "An advance directive is a living will. Some people already have one when they come to the hospital." d) "We are not sure if you will wake up after surgery so the advance directive will let us know your wishes just in case."

Answer: "An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so." Rationale: An advance directive allows the client to communicate instructions for health care postoperatively in case of an inability to do so. Although an advance directive is either a living will or a durable power of attorney for health care, and the hospital does like to determine if the client has these, these are not the best answers to the client's question. The nurse would not want to explain to the client that he or she may not wake up after surgery.

Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? a) "I might be sick to my stomach and throw up after surgery." b) "I can have a hamburger and French fries as soon as I wake up." c) "When I can eat again, the best meal would be steak and orange juice." d) "The better I eat before surgery, the more likely I will heal."

Answer: "I can have a hamburger and French fries as soon as I wake up." Rationale: Oral fluid and food may be withheld until intestinal motility resumes.

A 70-year-old male is scheduled for surgery. He says to the nurse, "I am so frightened—what if I don't wake up?" What would be the nurse's best response? a) "You have a wonderful doctor." b) "Let's talk about how you are feeling." c) "Everyone wakes up from surgery!" d) "Don't worry, you will be just fine."

Answer: "Let's talk about how you are feeling." Rationale: This answer allows the patient to talk about his feelings and fears, and is therapeutic.

The nurse has entered the room of a client who is postoperative day 1 and finds the client grimacing and guarding her incision. The client refuses the nurse's offer of p.r.n. analgesia and, on discussion, states that this refusal is motivated by his fear of becoming addicted to pain medications. How should the nurse respond to the client's concerns? a) "Actually, people who are not addicted to drugs before their surgery never develop a tolerance or addiction during their recovery." b) "You should remind yourself that treating your pain is important now, and that dealing with any resulting dependency can come later." c) "Research has shown that there is very little risk of clients becoming addicted to painkillers after they have surgery." d) "The hospital has excellent resources for dealing with any addiction that might result from the medications you take to control your pain."

Answer: "Research has shown that there is very little risk of clients becoming addicted to painkillers after they have surgery." Rationale: There is little danger of addiction to pain medications used in the postoperative management of pain.

A nurse is explaining pain control methods to a patient undergoing a bowel resection. The patient is interested in the PCA pump and asks the nurse to explain how it works. What would be the nurse's correct response? a) "The pump allows the patient to be completely free of pain during the postoperative period." b) "The pump allows the patient to take unlimited amounts of medication as needed." c) "The pump allows the patient to choose the type of medication given postoperatively." d) "The pump allows the patient to self-administer limited doses of pain medication."uu

Answer: "The pumps allows the patient to self-administer limited doses of pain medication." Rationale: PCA infusion pumps allow patients to self-administer doses of pain-relieving medication within physician-prescribed time and dose limits. Patients activate the delivery of the medication by pressing a button on a cord connected to the pump or a button directly on the pump.

The procedural physician has initiated performance of a time-out in the operating room before surgery. The student nurse asks the operating room nurse why this is important. What is the operating room nurse's best response? a) "The time-out checks to be sure that we have the right client and procedure." b) "We need to be sure the client has had the preoperative antibiotic." c) "We are checking the client's baseline vital signs during time-out." d) "The time-out allows us to make sure that the client has had adequate anesthesia."

Answer: "The time-out checks to be sure that we have the right client and procedure." Rationale: The time-out is a safety measure performed before any surgical procedure and allows the operating room staff to determine they have the right client, procedure, and side (if appropriate). The client's baseline vital signs should have already been performed. The anesthesia is managed by the anesthetist or anesthesiologist when the procedural physician is prepared for the beginning of the operation; however, this is not part of the time-out. The preoperative antibiotic should be administered within 60 minutes of the surgery but is also not part of the time-out.

The nurse is providing education for a postoperative client regarding pain management. Which teaching point should the nurse include? a) "Be sure to ask for your p.r.n. medication when the pain becomes severe." b) "If your pain is not relieved, ask your nurse to order a different medication." c) "You will receive pain medication by injection as long as you are n.p.o." d) "All postoperative pain control methods will be given by injection."

Answer: "You will receive pain medication by injection as long as you are n.p.o." Rationale: As long as the client is n.p.o. pain medication will be administered in some form of injection, such as intramuscular and intravenous route. Clients should ask for their medication at the onset of pain for better pain control. While the nurse can ask for a different pain medication, alternative pain therapy methods (such as changing the client's position) may relieve pain. There are a variety of pain control methods, not just injectables.

Which surgical client does the nurse in the preoperative setting anticipate has the greatest potential for surgical complications? a) A 6-month-old client who has just been introduced to solid food b) A 50-year-old overweight client with controlled hypertension c) A 40-year-old client with type II diabetes mellitus and a history of anxiety d) A 76-year-old client with a history of renal failure and chronic bronchitis

Answer: A 76-year-old client with history of renal failure and chronic bronchitis Rationale: The client who is elderly with renal and lung disease has the most risk factors preoperatively for surgery. This client will have concerns over administration of anesthesia and medication with the kidneys being able to clear these from the body, as well as with the lungs and potential postoperative complications of atelectasis and pneumonia. Clients who are young, have chronic disease, or obese have risk factors as well, but not as many as the elderly client with both renal and pulmonary disease.

A scrub nurse is assisting a surgeon with a kidney transplant. What are the patient responsibilities of this surgical team member? Select all that apply. a) Maintaining sterile technique b) Draping and handling instruments and supplies c) Identifying and assessing the patient on admission d) Integrating case management e) Preparing the skin at the surgical site f) Providing exposure of the operative area

Answer: A, B Rationale: The scrub nurse is a member of the sterile team who maintains sterile technique while draping and handling instruments and supplies. Two duties of the circulating nurse are to identify and assess the patient on admission to the operating room and prepare the skin at the surgical site. The RNFA actively assists the surgeon by providing exposure of the operative area. The APRN coordinates care activities, collaborates with physicians and nurses in all phases of perioperative and postanesthesia care, and integrates case management, critical paths, and research into care of the surgical patient.

A nurse is caring for an inpatient client scheduled to undergo a surgery for the removal of a malignant tumor. What are the risk factors that increase the likelihood of perioperative complications? Select all that apply. a) Bleeding tendencies b) Anxiety c) Obesity d) Low hemoglobin e) Raised temperature

Answer: A, C, D Rationale: Certain surgical risk factors, such as obesity, bleeding tendencies, low hemoglobin, smoking, diabetes, cardiopulmonary disease, drug and alcohol abuse, and diabetes, increase the likelihood of perioperative complications. Raised temperature and anxiety are causes for postponing or cancelling the surgery.

A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice? a) positioning the client on the operating table b) administering inhalation anesthetics c) counting sponges before and after surgery d) administering regional nerve blocks e) monitoring the client's vital signs

Answer: A, C, E Rationale: The RN's role is a supportive one for the client, monitoring vital signs and positioning the client on the operating room table. The RN also helps maintain safety by counting sponges and instruments that may have been used during the surgery. The RN is unable to administer anesthetics, such as inhalation agents or regional nerve blocks, without an advanced practice degree.

Which methods would the nurse anesthetist use when administering regional anesthesia to surgical clients? Select all that apply. a) Nerve block b) Intravenous c) Spinal block d) Inhalation e) Oral route f) Epidural block

Answer: A, C, F Rationale: Regional anesthesia occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. Regional anesthesia includes spinal blocks, nerve blocks, and epidural blocks. Inhalation and intravenous administration of anesthesia are associated with general anesthesia. Anesthesia is not administered via the oral route.

A nurse is assessing clients in a PACU. Which nursing actions would the nurse perform in this phase of the perioperative period? Select all that apply. a) Prepare the client for home care. b) Arrange for a rehabilitative program for the client. c) Transfer the client to the recovery room. d) Admit the client to the postoperative care unit. e) Inform the client that surgical intervention is necessary. f) Assess for complications as the client emerges from anesthesia.

Answer: A, D, F Rationale: Outpatient/same-day surgery clients return home after full recovery in the PACU or phase 2 recovery. The critical role functions of the PACU nurse include vigilant monitoring during emergence from anesthesia and the first hours after surgery, pain management, fluid and electrolyte balance, stabilization of physiologic parameters (such as heart and respiratory rate), and preparation for the next level of care in the postoperative care unit. The client has already had the surgery when the PACU nurse receives the client. Informing a client that he needs surgery is not a nursing responsibility. Rehabilitative care is arranged by the postoperative care unit nurse.

A responsibility of the nurse is the administration of preoperative medications to patients. Which statements describe the action of these medications? Select all that apply. a) Diazepam is given to alleviate anxiety. b) Ranitidine is given to facilitate patient sedation. c) Atropine is given to decrease oral secretions. d) Morphine is given to depress respiratory function. e) Cimetidine is given to prevent laryngospasm. f) Fentanyl citrate-droperidol is given to facilitate a sense of calm.

Answer: A,C,F Rationale: Sedatives, such as diazepam (Valium), midazolam (Versed), or lorazepam (Ativan) are given to alleviate anxiety and decrease recall of events related to surgery. Anticholinergics, such as atropine and glycopyrrolate (Robinul) are given to decrease pulmonary and oral secretions and to prevent laryngospasm. Neuroleptanalgesic agents, such as fentanyl citrate-droperidol (Innovar) are given to cause a general state of calm and sleepiness. Histamine-2 receptor blockers, such as cimetidine (Tagamet) and ranitidine (Zantac) are given to decrease gastric acidity and volume. Narcotic analgesics, such as morphine, are given to facilitate patient sedation and relaxation and to decrease the amount of anesthetic agent needed.

Clients with a latex allergy may have intolerance to which items? Select all that apply a) Gloves b) Underwear c) Balloons d) Condoms

Answer: ALL Rationale: All of these substances may contain latex. Latex is found in the elastic of underwear.

A 2-year-old toddler just underwent a tonsillectomy and adenoidectomy surgery. The postanesthesia care unit (PACU) nurse is checking on him. What is the best course of action regarding the developmental care of this child? a) Administer acetaminophen before the child wakes. b) Extubate the child as soon as possible. c) Give the child a new teddy bear. d) Allow the parents into the PACU before the child wakes.

Answer: Allow the parents into the PACU before the child wakes. Rationale: Toddlers are prone to separation anxiety. Allowing the child to be with the parents will lower anxiety levels for all members of the family. This will subsequently ease the care for the bedside nurse

A client has presented to a clinic for a preoperative consult, during which the client has expressed concern about having to fast before surgery. Current recommendations for preoperative fasting include: a) Although fasting is still often recommended, it is medically unnecessary. b) no eating or drinking anything after midnight the night before surgery. c) allowing clear liquids up to 2 hours before surgery. d) allowing eating and drinking until just prior to anesthetic being administered.

Answer: Allowing clear liquids up to 2 hours before surgery. Rationale:Current practice is to allow clients to drink liquids or eat food up to 2 hours before surgery, depending on the type of surgery and with permission of the physician.

A 72-year-old woman who is scheduled for a hip replacement is taking several medications on a regular basis. Which drug category might create a surgical risk for this patient? a) Anticoagulants b) Antacids c) Laxatives d) Sedatives

Answer: Anticoagulants Rationale: Anticoagulant drug therapy would increase the risk for hemorrhage during surgery

A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first? a) Check the client's blood pressure. b) Apply warm blankets to the client. c) Notify the health care provider. d) Apply an oxygen saturation monitor.

Answer: Apply warm blankets to the client

Which nursing action should the PACU nurse take to prevent postoperative complications in clients? a) Avoid turning the client in bed until the incision is no longer painful. b) Assist the client to do leg exercises to increase venous return. c) Instruct the client to avoid coughing to prevent injury to the incision. d) Encourage the client to breathe shallowly to prevent collapse of the alveoli.

Answer: Assist the client to do leg exercise to increase venous return.

A nurse is preparing a patient for a cesarean section and teaches her the effects of the regional anesthesia she will be receiving. Which effects would the nurse expect? Select all that apply. a) Loss of consciousness b) Relaxation of skeletal muscles c) Reduction or loss of reflex action d) Localized loss of sensation e) Prolonged pain relief after other anesthesia wears off f) Infiltrates the underlying tissues in an operative area

Answer: B, C Rationale: A localized loss of sensation and possible loss of reflexes occurs with a regional anesthetic. Loss of consciousness and relaxation of skeletal muscles occurs with general anesthesia. Prolonged pain relief after other anesthesia wears off and infiltration of the underlying tissues in an operative area occur with topical anesthesia.

A nurse is preparing a patient for a cesarean section and teaches her the effects of the regional anesthesia she will be receiving. Which effects would the nurse expect? Select all that apply. a) A 92-year-old patient who is severely confused b) A 45-year-old patient who is oriented and alert c) A 10-year-old patient who is oriented and alert d) A 36-year-old patient who has had a narcotic premedication e) A 45-year-old mentally ill patient who has been ruled incompetent f) A 22-year old patient having an abortion against her partner's wishes

Answer: B, F Rationale: A consent form is not legal if the patient signing the form is confused, sedated, unconscious, or a minor.

A patient tells the nurse she is having pain in her right lower leg. How does the nurse assess for the presence of thrombophlebitis? a) By palpating the skin over the tibia and fibula b) By documenting daily calf circumference measurements c) By recording vital signs obtained four times a day d) By noting difficulty with ambulation

Answer: By documenting daily calf circumference measurements Rationale: Inflammation from thrombophlebitis increases the size of the affected extremity and can be assessed by measuring circumference on a regular basis.

The nurse is obtaining a history from a client before surgery. Which areas would be important for the nurse to ask about to determine potential risk factors? Select all that apply. a) Previous antibiotic use b) Family history of illness c) Previous surgeries d) Support systems e) Current medications f) Alcohol use

Answer: C, D, E, F Rationale: The client needs to be interviewed regarding his or her medication history, any prior surgeries, use of illegal substances, such as alcohol, and support systems to help determine any risk factors during and after surgery that need to be addressed. The client's family history of illness or previous antibiotic use is not a key area to address as a risk factor.

A client is in the preoperative area and states "I am not sure about having surgery." What is the nurse's best response? a) "Can you tell me what your feelings are about the surgery?" b) "Why wouldn't you want the surgery so you can feel better?" c) "You really need to have this surgery done." d) "I will tell the surgeon you changed your mind."

Answer: Can you tell me what your feelings are about the surgery? Rationale: The client who is unsure about surgery needs his or her feelings explored to determine why the client doubts the decision. After exploring these feelings, the nurse can then contact the procedural physician and make him or her aware of the client's concerns. Asking the client why he or she wouldn't want the surgery is phrased negatively and implies a judgment by the nurse on the client's feelings; likewise, the client wouldn't be told to have the surgery done without allowing him or her to express feelings

The nurse is preparing a client for a colonoscopy. The nurse is familiar with the colonoscopy procedures at the hospital and is aware that which type of anesthesia is commonly used for this procedure? a) Nerve block b) Epidural anesthesia c) Conscious sedation d) Spinal anesthesia commonly used for this procedure?

Answer: Conscious sedation Rationale: Moderate sedation/analgesia is also known as conscious sedation or procedural sedation. It is used for short-term and minimally invasive procedures such as endoscopy procedures (e.g., colonoscopy).

A client is undergoing surgery for an appendectomy. This would be considered what type of surgery? a) Emergency surgery b) Diagnostic surgery c) Palliative surgery d) Elective surgery

Answer: Emergency surgery Rationale: An appendectomy is considered emergency or urgent surgery. Elective surgery can be scheduled in advance, and delay has no ill effects. Palliative surgery is done to relieve or reduce the intensity of an illness. Diagnostic surgery is done to make or confirm a diagnosis.

While assessing a patient in the PACU, a nurse notes increased wound drainage, restlessness, a decreasing blood pressure, and an increase in the pulse rate. The nurse interprets these findings as most likely indicating: a) Thrombophlebitis b) Atelectasis c) Infection d) Hemorrhage

Answer: Hemorrhage Rationale: Increased wound drainage, restlessness, decreasing blood pressure, and increasing pulse rate are assessment findings that indicate hemorrhage. Manifestations of thrombophlebitis are pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the affected area, elevated temperature, and an increase in the diameter of the involved extremity. Manifestations of atelectasis include decreased lung sounds over the affected area, dyspnea, cyanosis, crackles, restlessness, and apprehension. Signs of infection include elevated white blood count and fever.

A nurse is caring for an obese patient who has had surgery. The nurse monitors this patient for what postoperative complication? a) Hunger b) Impaired wound healing c) Hemorrhage d) Gas pains

Answer: Impaired wound healing Rationale: Fatty tissue is less vascular and, therefore, less resistant to infection and more prone to delayed wound healing

A nurse is explaining the rationale for performing leg exercises after surgery. Which reason would the nurse include in the explanation? a) Promote respiratory function b) Maintain functional abilities c) Provide diversional activities d) Increase venous return

Answer: Increase venous return Rationale: Leg exercises in the postoperative period increase venous return. As a result, the patient has a decreased risk for thrombophlebitis and emboli.

A nurse is dressing the wound of a client who is admitted to the outpatient surgical unit. What is a major advantage of outpatient surgery? a) It requires intensive preoperative education in a short time. b) It reduces the time for establishing a nurse-client rapport. c) It allows less opportunity for family contact and support. d) It interferes less with the client's daily routine.

Answer: It interferes less with the client's daily routine. Rationale: A major advantage of outpatient surgery is that it interferes less with the client's daily routine. It also allows more opportunity for family contact and support. Some disadvantages are that it reduces the time for establishing a nurse-client relationship and requires intensive preoperative education in a short time.

A perioperative nurse is preparing a patient for surgery for treatment of a ruptured spleen as the result of an automobile crash. The nurse knows that this type of surgery belongs in what category? a) Minor, diagnostic b) Minor, elective c) Major, emergency d) Major, palliative

Answer: Major, emergency Rationale: This surgery would involve a major body organ, has the potential for postoperative complications, requires hospitalization, and must be done immediately to save the patient's life. Elective surgery is a procedure that is preplanned by essentially healthy people. Diagnostic surgery is performed to confirm a diagnosis. Palliative surgery is not curative, rather it is done to relieve or reduce the intensity of an illness.

After a client receives morphine sulfate for pain in the postanesthesia care unit (PACU), which assessment finding would the nurse obtain as a priority? a) Auscultate bowel sounds. b) Check the neurological status. c) Obtain temperature. d) Measure respiratory rate.

Answer: Measure respiratory rate Rationale: The client who is receiving morphine sulfate for pain has a potential for decreased respiratory effort because of the side effect of respiratory depression; the client may also have constipation as a side effect but this would not be a priority over respiratory depression. The postoperative client needs to be monitored for changes in their neurological status and temperature but this would not be a priority over the respiratory status.

Which nursing action will best promote pain management for a client in the postoperative phase? a) Providing food and medication b) Breathing into a paper bag c) Performing relaxation techniques d) Dimming the lights

Answer: Performing relaxation techniques Rationale: Performing relaxation techniques is the best nursing action to promote pain management for a client in the postoperative phase.

A nurse is assessing a client who is experiencing pulmonary embolus. What would be the priority nursing intervention for this client? a) Place the client in semi-Fowler's position. b) Attempt to overhydrate the client with fluids. c) Instruct the client to perform Valsalva maneuver. d) Assist the client to ambulate every 2 to 3 hours.

Answer: Place the client in semi-fowler's position Rationale: Nursing interventions include notifying the physician immediately, calling the medical intervention team, maintaining the client on bed rest in the semi-Fowler's position, assessing vital signs frequently, administering oxygen, administering medications (e.g., anticoagulants, analgesics), and instructing the client to avoid Valsalva maneuver (this prevents increased intrathoracic pressure and, possibly, increased emboli).

A patient had a surgical procedure that necessitated a thoracic incision. The nurse anticipates that he will have a higher risk for postoperative complications involving which body system? a) Respiratory system b) Circulatory system c) Digestive system d) Nervous system

Answer: Respiratory system Rationale: A thoracic incision is an incision into the pleural space of the chest. It makes it more painful for the patient to take deep breaths or cough. Shallow respirations and ineffective coughing increase the risk for respiratory complications.

A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which characteristic applies to this type of surgery? a) The client will be admitted the day of surgery and return home the same day. b) The client must be previously healthy with low surgical risks. c) The surgery is classified as urgent rather than elective. d) The surgery will be conducted using moderate sedation rather than general anesthesia.

Answer: The client will be admitted the day of surgery and return home the same day. Rationale: Outpatient surgeries, also known as ambulatory surgeries, are conducted with admission and discharge on the same day. Such surgeries have become increasingly common in recent years, and some surgeries of increasing complexity and risk are conducted on an outpatient basis. General anesthesia is possible, and common. This approach is more common for elective surgeries than urgent surgeries.

A client has arrived to the postanesthesia care unit (PACU) and is drowsy with a respiratory rate of 12 breaths per minute. Which of the following would be an accurate interpretation by the nurse? a) The client should be returned to the operating room for further evaluation. b) The client needs to have his or her neurological status fully evaluated. c) The procedural physician should be notified immediately of patient findings. d) This is an expected finding in the immediate postoperative period.

Answer: This is an expected finding in the immediate postoperative period Rationale: Having drowsiness and a respiratory rate of 12 breaths/minute are normal findings in the immediate postoperative period. The client needs to be monitored to ensure that there is no deterioration in respiratory status, and the client awakens readily. As the anesthetics wear off, the client should return to a normal level of consciousness. The nurse would not need to notify the procedural physician or return the client to the operating room because this is not an emergent situation.

Older adults often have reduced vital capacity as a result of normal physiologic changes. Which nursing intervention would be most important for the postoperative care of an older surgical patient specific to this change? a) Take and record vital signs every shift. b) Turn, cough, and deep breathe every 4 hours. c) Encourage increased intake of oral fluids. d) Assess bowel sounds daily.

Answer: Turn, cough, and deep breathe every 4 hours Rationale: Reduced vital capacity in older adults increases the risk for respiratory complications, including pneumonia and atelectasis. Having the patient turn, cough, and deep breathe every 4 hours maintains respiratory function and helps to prevent complications.

A nurse from the ambulatory surgical center is preparing discharge instructions for a client who has had pelvic surgery. Which criterion would the client need to demonstrate to ensure that she is ready for discharge? a) Exhibit no bleeding b) Void normally c) Eat without nausea d) Verbalize absence of pain

Answer: Void normally Rationale: Before discharge from an ambulatory surgical unit, the client should be able to void normally after a pelvic surgery. It is natural for the client to experience pain after surgery; however, the client should also have the comfort level to control it. The client may not be in a position to eliminate nausea and vomiting completely before discharge, but should suffer minimally from them. The client may have some bleeding or drainage, which should not be excessive at the time of discharge from an ambulatory surgical unit.

A nurse is teaching a man scheduled to have same-day surgery. Which teaching method would be most effective in preoperative teaching for ambulatory surgery? a) Lecture b) Discussion c) Audiovisuals d) Written instructions

Answer: Written instructions Rationale: Written instructions are most effective in providing information for same-day surgery.

Which client would a nurse monitor most closely for postoperative respiratory complications? a) a 55-year-old client with a history of asthma who had a colon resection b) a 31-year-old client with no medical problems who had an appendectomy c) a 75-year-old client with a history of hypertension who had a colonoscopy d) an 8-year-old client with no medical problems who had a tonsillectomy

Answer: a 55-year-old client with a history of asthma who had a colon resection Rationale: All of these clients have a potential for respiratory complications, which can occur with chest or abdominal surgery, preexisting cardiovascular or respiratory disease, and in older adults or obese clients. The client who has had abdominal surgery and has preexisting respiratory disease would be at the greatest risk for observation of any respiratory complications (due to having two factors instead of only one). The pediatric client having a tonsillectomy would need to be observed for any airway problems but would not be a greater risk than the client with two risk factors.

A client is going to surgery, and the nurse is having the client sign his informed consent. Which client would be appropriate to sign the informed consent for surgery? a) a 68-year-old client with dementia having a cholecystectomy b) a 16-year-old diabetic client having a tonsillectomy c) a 70-year-old hypertensive client having a colonoscopy d) a 45-year-old disoriented client having an appendectomy

Answer: a 70-year-old hypertensive client having a colonoscopy Rationale: The 70-year-old client having the colonoscopy has no indications that he is not competent for having the procedure. Clients who are minors or those who are confused or have dementia are unable to sign their informed consent; they must have their next of kin, as determined by state law, make this decision.

Which client most likely requires special preoperative assessment and treatment as a result of the existing medication regimen? a) a man who regularly treats his rheumatoid arthritis with over-the-counter nonsteriodal anti-inflammatory drugs (NSAIDs) b) a man who takes an angiotensin-converting enzyme (ACE) inhibitor because he has hypertension c) a woman who takes daily anticoagulants to treat atrial fibrillation d) a woman who takes daily thyroid supplements to treat her longstanding hypothyroidism

Answer: a woman who rakes daily anticoagulants to treat atrial fibrillation Rationale: Anticoagulants present a risk of hemorrhage. This risk supersedes that posed by thyroid supplements, ACE inhibitors, or most NSAIDs.

A nurse is preparing to receive a client in post-anesthesia care unit (PACU). The client is diabetic and has undergone knee surgery. Which information would be most important for the receiving nurse to obtain to develop an appropriate plan of care for this client? a) Chronic disease history b) Information about allergic agents c) Environment of the operating room d) Amount of blood loss

Answer: amount of blood loss Rationale: To plan care effectively in the postoperative period, the nurse needs to know about the amount of blood lost during the surgery, the type of surgery that was performed on the client, and whether there were any surgical or anesthetic complications. Information on chronic disease history and allergy history are done in the preoperative period, not in the postoperative period. Information on the environment in the operation room is checked by the circulatory nurse during the intraoperative care plan; it is not associated with the postoperative care plan.

The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. What would be the nurse's most appropriate initial response? a) Determine the possible cause of the client's bleeding. b) Assess the client's vital signs. c) Apply pressure to the surgical site to decrease bleeding. d) Notify the health care provider.

Answer: apply pressure to the surgical site to decrease bleeding. Rationale: It is essential that the nurse be prepared to address life-threatening needs of the client. Excessive bleeding is a life-threatening issue. Determining the cause of the client's bleeding, assessing the vital signs, and notifying the health care provider are important, but the life-threatening issue must be addressed first.

The nurse knows the term perioperative phase refers to care given to the client: a) immediately before an operative procedure. b) from the start of surgery until its conclusion. c) immediately after the operative phase. d) before, during, and after the operative phase.

Answer: before, during, and after the operative phase Rationale: Perioperative nursing includes three distinct phases: preoperative, intraoperative, and postoperative.

A nurse is reinforcing wound edges and applying a blinder to the separated incisions of a client after a surgery. Which postoperative complication has the client developed? a) Shock b) Dehiscence c) Hypoxemia d) Evisceration

Answer: dehiscence Rationale: The nurse is taking care of a client with dehiscence. Hypoxemia develops when there is inadequate oxygenation of blood. Evisceration occurs when there is protrusion of abdominal organs through a separated wound. A client has shock when there is inadequate blood flow.

Ames is an 87-year-old man who underwent a hip replacement today. He is telling the nurse that his parents, who are deceased, are coming to visit him today. He continues to tell the nurse that he needs to cut the lawn and run errands. The last time the nurse entered the room, Ames was trying to climb over the bed rail. Which term best describes Ames' condition? a) Delirium b) Dementia c) Boredom d) Narcotic overuse

Answer: delirium Rationale: Delirium refers to acute confusion that is reversible. It is common in the acute postoperative period

A client comes to the postoperative area and complains of chest pain and palpitations. Which assessment information does the nurse need to obtain? a) heart rate and blood pressure b) current medications c) temperature and urine output d) prior medical history

Answer: heart rate and blood pressure Rationale: A client having chest pain and palpitations needs to have his vital signs (particularly blood pressure and heart rate) checked to ensure that he is hemodynamically stable. These symptoms may indicate cardiac problems so the client must be examined closely for any complications such as a myocardial infarction. Urine output and temperature would not indicate the client's stability related to the symptoms being experienced. Although prior medical history and medications may give indications on why the client is experiencing chest pain, the client needs an accurate assessment of the hemodynamic status first

A client has been taking aspirin since his heart attack in 1997. The client is at risk for: a) blood clots. b) hemorrhage. c) thrombophlebitis. d) infection.

Answer: hemorrhage Rationale: Current medication use, especially use of medications that can affect coagulation status (warfarin, nonsteroidal anti-inflammatory drugs, aspirin) is important and should be reported to the surgeon.

A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client? a) Keep the client from ambulating until the day after surgery. b) Implement leg exercises and turn the client in bed every 2 hours. c) Position the client in bed with pillows placed under his knees to hasten venous return. d) Keep the client cool and uncovered to prevent elevated temperature.

Answer: implement leg exercise and turn the client in bed every 2 hours Rationale: Ambulation and leg exercises increase circulation, which prevents cardiovascular complications. The nurse should provide covers, forced warm air, or other warming devices/techniques as necessary to prevent shivering and hypothermia caused by the surgical procedure, the procedure's length, anesthetic agents, a cool environment, the client's age, or the use of cool irrigating/infusion fluids. Pillows placed under the knees can cause venous pooling, leading to thrombophlebitis.

A nurse administers anticholinergics to a patient as a postoperative medication. What condition does this medication help to prevent? a) Laryngospasm b) Shock c) Nausea d) Cardiovascular complications

Answer: larygospasm Rationale: Anticholinergics, such as atropine and glycopyrrolate (Robinul), to decrease pulmonary and oral secretions and to prevent laryngospasm. Cardiovascular complications, nausea, and shock are not affected by anticholinergic medications.

Which postoperative exercise promotes venous return and decreases complications related to venous stasis? a) Incentive spirometry b) Coughing c) Deep breathing d) Leg exercises

Answer: leg exercise Rationale: Leg exercises assist in preventing muscle weakness, promote venous return, and decrease complications related to venous stasis. Coughing helps remove retained mucus from the respiratory tract. Incentive spirometry and deep-breathing exercises improve lung expansion and volume.

Which nursing action provides the greatest assistance in healing? a) maintaining a restful environment b) providing solid food in the first day c) keeping the client recumbent d) allowing family members to visit often

Answer: maintaining a restful environment Rationale: The nurse should plan for adequate periods of rest and sleep, maintaining a quiet, restful environment.

In the postoperative phase of abdominal surgery, the client reports severe abdominal pain. In the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect? a) Normal response b) Paralytic ileus c) Hernia development d) Abdominal infection

Answer: paralytic ileus Rationale: A potential complication after surgery is paralytic ileus, a condition in which there is decreased bowel functioning.

Which measure would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client? a) Elevate bilateral legs when client is lying in bed. b) Place graduated compression stockings on the client. c) Educate the client about the use of incentive spirometer. d) Encourage the client to elevate the head of bed.

Answer: place graduated compression stockings on the client. Rationale: Use of graduated compression stockings and/or pneumatic compression devices on the client will help with prevention of DVT, which is a risk for clients after surgery. Elevating the client's legs will passively improve venous return but not prevent DVT if a client is not up and walking (to more actively promote the venous return). Elevating the head of the bed and using the incentive spirometer help prevent postoperative complications of atelectasis or pneumonia.

A nurse caring for patients in a PACU assesses a patient who is displaying signs and symptoms of shock. What is the priority nursing intervention for this patient? a) Place the patient in the prone position. b) Place the patient in a flat position with legs elevated 45 degrees. c) Do not administer any further medication. d) Remove extra coverings on the patient to keep temperature down.

Answer: place the patine in a flat position with legs elevated 45 degrees Rationale: Placing the patient in a flat position with the legs elevated 45 degrees uses gravity to help direct blood to the vital organs. Removing extra coverings would cause the patients temperature to drop further during the blood loss occurring during shock. Medications will likely be ordered to help treat the shock. Prone position would be contraindicated.Placing the patient in a flat position with the legs elevated 45 degrees uses gravity to help direct blood to the vital organs. Removing extra coverings would cause the patients temperature to drop further during the blood loss occurring during shock. Medications will likely be ordered to help treat the shock. Prone position would be contraindicated.

A 9-month-old baby is scheduled for heart surgery. When preparing this patient for surgery, the nurse should consider which surgical risk associated with infants? a) Congestive heart failure b) Prolonged wound healing c) Gastrointestinal upset d) Potential for hypothermia or hyperthermia

Answer: potential for hypothermia or hyperthermia Rationale: Infants have difficulty maintaining stable body temperature during surgery because the shivering reflex is not well developed, making hypothermia or hyperthermia more likely. They are not at an increased risk for prolonged wound healing, congestive heart failure, or gastrointestinal upset.

A nurse teaches deep breathing exercises to a client scheduled for surgery. In which perioperative phase would this action occur? a) Preoperative b) Intraoperative c) Postoperative d) Postanesthesia care unit (PACU)

Answer: preoperative rationale: Exercises and physical activities occurring in the preoperative phase include deep-breathing exercises, coughing, incentive spirometry, turning, leg exercises, and pneumatic compression stockings.

The nurse recognizes the value of leg exercises in the prevention of postoperative thrombophlebitis. When should the nurse teach the correct technique for leg exercises to a client? a) in postanesthesia recovery b) upon transfer from postanesthesia care unit (PACU) to the postoperative unit c) prior to surgery d) when early signs of venous stasis are evident

Answer: prior to surgery Rationale: Though leg exercises are begun after surgery, such preventative measures should ideally be taught to the client during the preoperative period.

As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site? a) Informed consent b) Operative site marking c) Procedural pause (time-out) d) Preoperative checklist

Answer: procedural pause (time-out) Rationale: The procedural pause (time-out) must be done prior to any procedure to ensure client safety and to verify the client identity, staff roles, and procedure being performed.

A nurse is applying a pneumatic compression device to a client. What is the purpose of a pneumatic compression device? a) reduces swelling and pain b) promotes circulation of venous blood c) enables the client to void d) pumps liquid diet to the client

Answer: promotes circulation of venous blood Rationale: A pneumatic compression device promotes the circulation of venous blood and relocation of excess fluid into the lymphatic vessels. The device does not pump a liquid diet to the client, help the client to void, or reduce swelling and pain.

When educating a client in the postoperative period, it is important to educate the client to consume a diet high in: a) bicarbonate. b) potassium. c) calcium. d) protein.

Answer: protein Rationale: After surgery, a diet with sufficient amounts of protein and vitamins A and C helps rebuild tissues and promotes wound healing.

A nurse is working with a group of clients in the preoperative area. Which client task would be the highest priority? a) Inserting a Foley catheter in a client before major surgery b) Measuring a diabetic client's blood glucose c) Obtaining a list of home medications from a client d) Raising the stretcher side rails when administering a sedative

Answer: raising the stretcher side rails when administering a sedative Rationale: Although all of these are important to do, making sure of client safety with raising the side rails of the client's bed when administering a sedative is most important. Inserting the Foley catheter before surgery, obtaining a list of home medications, and measuring a blood glucose on a client could potentially prevent safety issues as well but are not as direct an intervention as raising the side rails of the bed to prevent a patient fall.

Avery is a 15-year-old client with acute lymphocytic leukemia (ALL). Avery is a practicing Jehovah's Witness and has asked not to receive blood products. You know that the prognosis for ALL is very good but clients often require blood products during treatment. What is the most appropriate action? a) Tell Avery that her request will be upheld. b) Document Avery's request in her medical record. c) Request an ethics consultation. d) Tell Avery that her request is not appropriate.

Answer: request an ethics consultation Rationale: This request is beyond your scope of practice as a nurse. There are many ethical considerations in this case, including the fact that Avery is considered a minor and that her request will likely place her life in danger. An ethics team may help the client and family arrive at a plan of care that upholds Avery's religious beliefs, except in an extreme life-threatening emergency.

A nurse is caring for an infant who is postoperative following cardiac surgery. What is the most common postoperative complication found in this age group? a) Renal complications b) Respiratory complications c) Infection d) Circulatory complications

Answer: respiratory complications Rationale: According to Dunn (2005), most postoperative complications are related to the respiratory system in infants. After receiving general anesthesia, premature infants are at greater risk for apnea.

The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency? a) Respiratory obstruction b) Wound infection c) Dehydration d) Cardiac distress

Answer: respiratory obstruction Rationale: Respiratory obstruction may occur as a result of secretion accumulation, obstruction by the tongue, laryngospasm (a sudden, violent contraction of the vocal cords), or laryngeal edema. Cardiac distress, wound infection, and dehydration are all possible postoperative complications, but respiratory obstruction is most common.

A patient is scheduled for cardiac surgery in an acute-care facility. What intervention would occur in the intraoperative phase of this patient's perioperative care? a) Visit by the anesthesiologist b) Frequent vital signs/assessments c) Airway/oxygen therapy/pulse oximetry d) Skin preparation

Answer: skin preparation Rationale: The intraoperative phase begins when the patient is transferred to the OR bed until transfer to the postsurgical recovery area. One of the interventions performed in this phase is skin preparation. The preoperative phase provides patient teaching regarding the surgical experience, including a visit by the anesthesiologist. The postoperative phase begins immediately after the surgical procedure is completed. Assessments and therapies (listed in answers A and C) are performed in this phase.

When preparing a client who has diabetes mellitus for surgery, the nurse should be aware of what surgical risk associated with this disease? a) respiratory depression from anesthesia b) fluid and electrolyte imbalance c) altered metabolism and excretion of drugs d) slow wound healing

Answer: slow wound healing Rationale: Due to impaired circulation and high glucose levels, the client with diabetes is at an increased risk for slow wound healing. The surgical risk of fluid and electrolyte imbalances is often associated with clients who have kidney and liver disease. The risk of respiratory depression from surgery increases for clients with existing respiratory disorders. Altered metabolism may occur as a result of surgery for clients with kidney and liver diseases.

A client in the immediate postoperative period begins to report nausea and ultimately begins vomiting. The nausea and vomiting are most likely related to: a) movement of bowels during surgery. b) inactivity and emotional upset. c) severe pain at the operative site. d) the effects of anesthetic agents.

Answer: the effects of anesthetic agents Rationale: Nausea and vomiting can occur postoperatively from the effects of anesthetic agents.

The nurse recognizes that palliative surgery is performed for what purpose? a) to remove a part of the body that is diseased b) to lessen the intensity of an illness c) to make or confirm a diagnosis d) to restore function to tissue that is traumatized

Answer: the lessen the intensity of an illness Rationale: Palliative surgery is performed to help lessen the intensity of an illness; it is not meant to be curative but will help improve the client's quality of life. A diagnostic surgery makes or confirms a diagnosis such as with a biopsy to check for cancer. A removal of a body part that is diseased is ablative surgery, such as an appendectomy. Restoring function to traumatized tissue is reconstructive surgery, such as with plastic surgery.

A nurse is caring for an older adult client who had surgery for the removal of a cataract in the left eye. When can the client return home after outpatient surgery? a) after 10 days b) after 1 week c) after 2 days d) the same day

Answer: the same day Rationale: Outpatient surgery, also called ambulatory surgery and same-day surgery, is the term used for operative procedures performed on clients who return home the same day. It generally is reserved for clients in an optimal state of health whose recovery is expected to be uneventful.

A nurse is discussing a surgical procedure with a client who needs to sign his informed consent. Which of these tasks is part of the nursing role? a) determining for the client what other treatment options exist b) describing how the client will benefit from the surgical procedure c) explaining to the client about potential risks of having the surgery d) witnessing the client signature with their consent for surgery

Answer: witnessing the client signature with their consent for surgery Rationale: The nursing role with informed consent is to witness the client signature on the form. The procedural physician is responsible for explaining the procedure, any alternative treatment, and the risks and benefits of having the surgery. The nurse may clarify information, but if in-depth explanation is needed, the procedural physician should be notified.

Which factors should the nurse consider when assessing patients for postsurgical risks? (Select all that apply.) a) Endocrine diseases increase the risk for hyperglycemia after surgery. b) Cardiovascular diseases increase the risk for dehydration after surgery. c) Kidney and liver diseases influence the patient's response to anesthesia. d) Patients with respiratory disease may experience alterations in acid-base balance after surgery. e) Endocrine diseases increase the risk for slow surgical wound healing. f) Pulmonary disorders increase the risk for hemorrhage and hypovolemic shock after surgery.

Answer: • Patients with respiratory disease may experience alterations in acid-base balance after surgery. • Kidney and liver diseases influence the patient's response to anesthesia. • Endocrine diseases increase the risk for slow surgical wound healing.

Nursing Assessments and Interventions to meet Postoperative Elimination Needs

Bowel Elimination *Assess for the return of peristalsis by auscultating bowel sounds every 4 hours when the patient is awake. Assess abdominal distention, especially if bowel sounds are not audible or are high pitched (indicative of possible paralytic ileus, which is an absence of intestinal peristalsis). *Assess ability to pass flatus and stool. *Assist with movement in bed and ambulation to relieve gas pains, a common postoperative discomfort. Encourage food and fluid intake when ordered, especially fruit juices and high-fiber foods. *Maintain privacy when patient is using the bedpan, urinal, commode, or bathroom. *Administer suppositories, enemas, or medications, such as stool softeners, as prescribed. Urinary Elimination *Monitor patterns of intake and output. *Assist in assuming normal position to void by using an upright position when on a bedpan and using a bedside commode or bathroom when able, or by assisting the male patient to stand upright to void with a urinal. *Assess for bladder distention by palpating above the symphysis pubis if the patient has not voided within 8 hours after surgery or if the patient has been voiding frequently in amounts of less than 50 mL; notify the physician of abnormal assessment results. *Maintain prescribed intravenous fluid infusion rates. *Encourage oral fluid intake when prescribed. *Provide privacy when the patient is using bedpan, bedside commode, urinal, or bathroom. Initiate urinary catheterization, if prescribed.

How to promote postoperative rest and comfort.

Nausea and Vomiting Avoid giving large amounts of fluids or food at one time, especially after being NPO. Administer prescribed medications. Provide oral hygiene, as needed. Maintain clean environment. Avoid use of a straw. Avoid strong-smelling food. Assess for possible allergy to medications, such as antibiotics or analgesics. Maintain bowel elimination. Thirst Offer sips of water or ice chips when NPO (if permitted). Maintain oral hygiene. Hiccups Have the patient do the following: Take several swallows of water while holding the breath (if not NPO). Rebreathe into a paper bag. Eat a teaspoon of granulated sugar. Surgical Pain Assess pain frequently; administer prescribed analgesics every 2 to 4 hours on a regular schedule during the first 24 to 36 hours after surgery. Reinforce preoperative teaching for pain management. Offer nonpharmacologic measures to supplement medications: massage, position changes, relaxation, guided imagery, meditation, music.

A nurse asks a preoperative patient what medications he is currently taking. Which of the following is an accurate guideline for patient teaching regarding these medications? a) Cardiac drugs must be stopped for 1 week before surgery. b) If the patient is diabetic and takes insulin, the dose may be increased before surgery. c) Certain respiratory drugs may be taken the day of surgery per physician's order. d) Aspirin is generally stopped 1 month before surgery.

answer: Certain respiratory drugs may be taken the day of surgery per physician's order. Rationale: Adjustments in taking medications may be needed before surgery. Anticoagulants are stopped days before surgery. Certain cardiac and respiratory drugs may be taken the day of surgery per physician's order. If the patient is diabetic and takes insulin, the insulin dosage may be reduced.