Ch 37 Perioperative Nursing

1, 3, 5. 1. For the nasogastric tube placed to suction, the nurse should document the time suction was started. 3. For the nasogastric tube placed to suction, the nurse should document the pressure on the suction. 5. For the nasogastric tube placed to suction, the nurse should document the color and consistency of the drainage.

A client in the postanesthesia care unit is to have suction applied through a nasogastric tube. When documenting, the nurse should include which information? Select all that apply. 1. The time suction was started 2. Characteristics of wound drainage 3. Pressure on the suction 4. Integrity of the surgical dressing 5. Color and consistency of drainage

2, 4. 2. An advantage of general anesthesia is that the respiratory rate can be regulated easily. 4. An advantage of general anesthesia is that the anesthesia can be adjusted to the length of the procedure.

A client is anxious about receiving general anesthesia for a surgical procedure. What should the nurse explain are the advantages of having this type of anesthesia? Select all that apply. 1. The client remains conscious. 2. Respiratory rate can be regulated easily. 3. It is used for minor surgical procedures. 4. The anesthesia can be adjusted to the length of the operation. 5. It focuses on a single nerve or nerve group.

3. When the purpose of surgery is ablative, the diseased body part is removed.

A client is scheduled for a cholecystectomy. The nurse realizes that the purpose for this surgery is 1. diagnostic. 2. palliative. 3. ablative. 4. constructive.

1, 2, 3, 5. 1. The degree of risk involved in a surgical procedure is affected by the client's age. 2. The degree of risk involved in a surgical procedure is affected by the client's use of medications. 3. The degree of risk involved in a surgical procedure is affected by the client's general health. 5. The degree of risk involved in a surgical procedure is affected by the client's nutritional status.

A client is scheduled for lung resection surgery. What should the nurse keep in mind when determining this client's degree of risk for this major surgical procedure? Select all that apply. 1. Age 2. Medications 3. General health 4. Blood pressure 5. Nutritional status

1. By increasing lung expansion and preventing accumulation of secretions, deep breathing helps prevent pneumonia and atelectasis.

A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. What should the nurse respond? 1. "These exercises help prevent pneumonia." 2. "The doctor ordered the exercises." 3. "All surgical clients must do these exercises." 4. "These exercises prevent thrombophlebitis."

1. The reduction of breath sounds could indicate the pooling of secretions in the lower lobes. The nurse should coach the client to deep-breathe and cough.

During the assessment of a client recovering from surgery, the nurse notes decreased breath sounds in both lower lobes bilaterally. What should the nurse do? 1. Coach the client to deep-breathe and cough. 2. Restrict fluids. 3. Remind the client to perform leg exercises. 4. Maintain on bed rest.

4. A bowel movement that occurs within 48 hours after resuming a normal diet is evidence that postoperative constipation has been prevented.

The nurse determines that interventions to prevent postoperative constipation have been effective in a client recovering from surgery. What did the nurse assess to make this clinical decision? 1. Abdominal distention present. 2. Gas pains present. 3. Client vomiting. 4. Bowel movement occurred 24 hours after resuming a normal diet.

1, 2, 4, 5. 1. Maintaining the sterile field will support the goals of maintaining client safety and homeostasis 2. Performing instrument counts will support the goals of maintaining client safety and homeostasis 4. Positioning the client appropriately for surgery will support the goals of maintaining client safety and homeostasis. 5. Performing preoperative skin preparation will support the goals of maintaining client safety and homeostasis.

The nurse has identified the goals of maintaining client safety and homeostasis during the intraoperative phase of client care. What nursing activities would support these goals? Select all that apply. 1. Maintain the sterile field. 2. Perform instrument counts. 3. Instruct in postoperative exercises. 4. Position the client appropriately for surgery. 5. Perform preoperative skin preparation

3. Aspirating stomach contents and checking the acidity using a pH test strip is the most reliable test to confirm tube placement.

The nurse has just inserted a nasogastric tube for gastric suction. What is the most reliable test for confirming tube placement? 1. Place the stethoscope over the stomach and listen for a swishing sound while inserting water into the tube. 2. Place the stethoscope over the stomach and listen for a swishing sound while inserting air into the tube. 3. Aspirate stomach contents and check the acidity using a pH test strip. 4. Connect the tube to suction and observe the contents.

1, 2, 3, 4. 1. The nurse should document the number of sutures removed. 2. The nurse should document the appearance of the incision. 3. The nurse should document any client teaching. 4. The nurse should document the client's tolerance of the procedure.

The nurse has removed the sutures from a client's surgical wound. What should the nurse document about this procedure? Select all that apply. 1. Number of sutures removed 2. Appearance of the incision 3. Client teaching 4. Client tolerance of the procedure 5. Name of the surgeon

2. If the wound becomes warm, red, and edematous, the nurse should suspect an infection and notify the physician

The nurse is assessing an abdominal wound in the postoperative period. Which sign should indicate to the nurse that an infection is present? 1. Absence of bleeding 2. Edges warm to the touch 3. Edges well approximated 4. Sutures in place

1. Leg exercises may be implemented in the PACU to help prevent thrombophlebitis.

The nurse is caring for a client in the immediate postoperative period (PACU). Which intervention should the nurse implement to reduce the risk of thrombophlebitis 1. Leg exercises 2. Coughing every 2 hours 3. Ambulating every 2 hours 4. Oxygen by mask

3. The unconscious client should be positioned on the side, with the face slightly down

The nurse is caring for a client in the recovery area. In which position should the nurse place the unconscious client during the immediate postanesthesia phase? 1. Supine 2. Prone 3. Side-lying 4. Supine with a pillow under the head

3. When prioritizing, the nurse should remember the ABCs. Airway should always be the priority.

The nurse is caring for a client on the postoperative unit. Which nursing diagnosis is the priority for this client? 1. Self-Care Deficit 2. Disturbed Body Image 3. Ineffective Airway Clearance 4. Risk for Falls

1. The preoperative phase begins when the decision to have surgery is made and ends when the client is transferred to the operating table.

The nurse is caring for a client who is having surgery and is currently being transported to the operating room suite. The nurse should document that the client is in which operative phase? 1. Preoperative phase 2. Intraoperative phase 3. Postoperative phase 4. Perioperative phase

4, 5. 4. The nurse can ask the UP to report soiled dressings that need to be changed. 5. The nurse can ask the UP to report if the dressing is loose and needs to be reinforced.

The nurse is caring for a postoperative client with an abdominal wound and a drain. What can the nurse delegate to unlicensed assistive personnel? Select all that apply. 1. Clean the wound. 2. Assess the skin around the wound. 3. Determine the effectiveness of pain medication. 4. Report if the dressing is soiled. 5. Report if the dressing is loose.

1. The older adult has more physiological deficits, such as decreased kidney function and decreased thirst, and is at greater risk for fluid and electrolyte imbalances.

The nurse is caring for an 80-year-old client preparing for surgery. The nurse realizes this client is at increased risk for which reason? 1. The physiological deficits of aging increase the surgical risk for older adults. 2. The older adult has increased kidney function. 3. The older adult has an increase in sensory function. 4. The older adult will turn, cough, and deep-breathe more effectively.

1, 2, 3, 4. 1. When documenting the current health status, essential information includes general health status and the presence of any chronic diseases that might affect the client's response to surgery or anesthesia. 2. When documenting allergies, the nurse should include allergies to prescription 3. All current medications should be listed. Herbal remedies and over-the-counter preparations are also a part of this assessment. 4. The client's current mental status is a part of this assessment.

The nurse is completing a preoperative assessment with a client. What should this assessment include? Select all that apply. 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Respiratory rate

3. The absence of cramping or pain with ambulation indicates that leg exercises instructed prior to surgery were effective to prevent the onset of thrombophlebitis.

The nurse is evaluating the effectiveness of preoperative instruction regarding leg exercises with a client recovering from surgery. Which observation indicates that the instructions were effective? 1. The lower extremity is swollen and hot to touch. 2. The vein feels hard. 3. There is no cramping or pain with ambulation. 4. There is pain in the calf with dorsiflexion.

1, 2, 3, 4. 1. The client's current health status should be obtained when completing a preoperative assessment. 2. The client's allergies should be obtained when completing a preoperative assessment. 3. The client's current medications should be obtained when completing a preoperative assessment 4. The client's mental status should be obtained when completing a preoperative assessment.

The nurse is obtaining preoperative assessment data. What should be included in this assessment? Select all that apply. 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Mother's maiden name

1, 4, 5. 1. Discharge planning incorporates an assessment of the client's abilities for self- NURSINGTR COM 4. Discharge planning incorporates an assessment of the client's financial resources. 5. Discharge planning incorporates an assessment of the client's need for home health care.

The nurse is planning a perioperative client's needs upon discharge. What should be included when determining these needs? Select all that apply. 1. Client's abilities to provide self-care 2. Date of anticipated discharge 3. Physician performing the surgery 4. Financial resources 5. Need for home health care services

2. The goal of postoperative care is to assist the client to achieve the most optimal health status possible.

The nurse is planning care for a client during the postoperative period. What should the nurse identify as the goal of care for this client? 1. Provide necessary preoperative teaching. 2. Assist the client to achieve the most optimal health status possible. 3. Ensure client safety. 4. Maintain an aseptic environment.

2, 4, 5. 2. Before removing skin sutures, the nurse should verify that there is an order for suture removal. 4. Before removing skin sutures, the nurse should verify whether a dressing is to be applied following the suture removal. 5. Before removing skin sutures, the nurse should remove the dressing and clean the incision.

The nurse is planning to remove the sutures from a client's surgical wound. What should the nurse do before removing the sutures? Select all that apply. 1. Apply clean gloves. 2. Verify the order for suture removal. 3. Ambulate the client to the bathroom. 4. Read the order to determine whether a dressing is to be applied after removal. 5. Remove the dressing and clean the incision

1. A pregnancy test is done on all female clients of childbearing age.

The nurse is preparing a 23-year-old female client for surgery. The nurse should anticipate which diagnostic test to be prescribed for this client? 1. Pregnancy test 2. EEG 3. EKG 4. Pulmonary function tests

2. Play is an effective teaching tool with children.

The nurse is preparing a 6-year-old child for a tonsillectomy. Which strategy should the nurse use for teaching this client? 1. Pamphlets 2. Play 3. Books 4. Videotapes

2. This is the priority nursing diagnosis for the client having surgery. The risk for aspiration would impact the client's airway and breathing.

The nurse is preparing a care plan for a client about to undergo surgery. Which nursing diagnosis would take priority during the intraoperative phase of surgery? 1. Ineffective Protection 2. Risk for Aspiration 3. Impaired Skin Integrity 4. Risk for Falls

4. Conscious sedation is often used for procedures such as endoscopies and incision and drainage of abscesses.

The nurse is preparing a client for an upper GI endoscopy. For which type of anesthesia should the nurse prepare the client to receive? 1. Local anesthesia 2. Spinal anesthesia 3. Epidural anesthesia 4. Conscious sedation

3. The purpose of a surgical skin preparation is to reduce the risk of postoperative wound infection.

The nurse is preparing the skin of a client for surgery. The nurse knows the purpose of the surgical skin preparation is to 1. sterilize the skin. 2. assess the surgical site before surgery. 3. reduce the risk of postoperative wound infection. 4. clean any moles the client may have.

2. Before applying antiembolic stockings, determine any potential or present circulatory problems and the surgeon's orders involving the lower extremities.

The nurse is preparing to apply antiembolic stockings to a postoperative client. What should be done first, before applying the stockings? 1. Measure the calf. 2. Assess for circulatory problems. 3. Assess the client's blood pressure. 4. Clean the stockings.

5, 2, 6, 4, 1, 3.

The nurse is preparing to change the dressing on a client's postoperative wound. Place in order the steps the nurse should perform when removing the soiled dressing. 1. Assess the location, type, and odor of wound drainage. 2. Remove the outer dressing. 3. Discard the under dressing in a moisture-proof bag, and remove and discard gloves. 4. Remove the under dressing. 5. Apply clean gloves. 6. Place the soiled dressing in a moisture-proof bag.

1, 2, 3, 4. 1. A brief or "mini" mental status examination provides valuable baseline data for evaluating the client's mental status and alertness after surgery. It is also important to evaluate the client's ability to understand what is happening. 2. Assessment of hearing helps guide the effectiveness of perioperative teaching. 3. Respiratory assessment not only provides baseline data for evaluating the client's postoperative status but may alert care providers to a problem that may affect the client's response to surgery and anesthesia. 4. The gastrointestinal status provides baseline data.

The nurse is preparing to complete a physical assessment before surgery. Which assessments should the nurse obtain? Select all that apply. 1. Mini mental status 2. Assessment of hearing 3. Assessment of the respiratory system 4. Gastrointestinal assessment 5. Maintain NPO status

1. The nurse should provide information related to what will happen to the client, when, and what the client will experience.

The nurse is preparing to conduct preoperative teaching. What should be included in this teaching? 1. Information related to what will happen to the client 2. Referral of the client to the physician for any misconceptions the client may have 3. The role of the nurse during surgery 4. How to perform activities of daily living (ADLs) following surgery

1, 2, 4, 5. 1. Before beginning to teach leg exercises, the nurse needs to determine the type of surgery. 2. Before beginning to teach leg exercises, the nurse needs to determine the time of the surgery. 4. Before beginning to teach leg exercises, the nurse needs to determine preoperative orders. 5. Before beginning to teach leg exercises, the nurse needs to determine the name of the surgeon.

The nurse is preparing to instruct a client on leg exercises to be used when recovering from abdominal surgery. What should the nurse determine before beginning this teaching? Select all that apply. 1. Type of surgery 2. Time of surgery 3. Postoperative diet 4. Preoperative orders 5. Name of the surgeon

4. Early ambulation, leg exercises, antiembolic stockings, SCDs, and adequate fluid intake are all interventions to reduce the risk for thrombophlebitis.

The nurse wants to ensure that a client recovering from surgery does not develop thrombophlebitis. Which action should the nurse take to reduce the client's risk of this postoperative complication? 1. Administer an anticoagulant. 2. Assist the client to cough every 2 hours. 3. Monitor intake and output every 2 hours. 4. Provide for early ambulation.

1. The nurse should assess the client's level of consciousness first.

Which assessment should the nurse perform first? 1. Level of consciousness 2. Dressing 3. Drains 4. Skin color