Chapter 14: Perioperative Care

A written informed consent is necessary for which of the following? Select all that apply. Invasive procedures Procedures requiring sedation Procedures requiring radiation IV insertion

Invasive procedures Procedures requiring sedation Procedures requiring radiation Correct response: Explanation: Informed consent is necessary in the following circumstances: invasive procedures, procedures requiring sedation and/or anesthesia, a nonsurgical procedure that carries more than slight risk to the patient, and procedures involving radiation. No written consent is needed for IV insertion.

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this client? Select all that apply. Establishing an IV line Verifying the surgical site with the client Taking measures to ensure the client's comfort Applying a grounding device to the client Preparing the medications to be given in the OR

correct response Establishing an IV line Verifying the surgical site with the client Taking measures to ensure the client's comfort Explanation: In the holding area, the nurse reviews charts, identifies clients, verifies surgical site per institutional policy, establishes IV lines, administers any prescribed medications, and takes measures to ensure each client's comfort. A grounding device is applied in the OR. A nurse in the preoperative holding area does not prepare medications to be given by anyone else.

The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply. nutritional status age physical condition gender health status ethnicity

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

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: first intention. second intention. third intention. fourth intention.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: first intention. second intention. third intention. fourth intention.

he OR personnel responsible for maintaining the safety of the client and the surgical environment is the: Anesthesiologist Circulating nurse Scrub nurse Surgeon

Correct response: Circulating nurse Explanation: The circulating nurse is responsible for maintaining the safety of the client and the surgical environment.

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

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

The PACU nurse is caring for a client who had minimally invasive knee surgery. Which actions are the responsibility of the nurse in the PACU? Select all that apply. Monitoring the safe recovery from anesthesia Answering family questions about recovery Ensuring that informed consent has been signed Providing light nourishment Assessing the operative site for hemorrhage

Monitoring the safe recovery from anesthesia Answering family questions about recovery Providing light nourishment Assessing the operative site for hemorrhage After surgery, the client is taken to the PACU, where the PACU nurse monitors the client for safe recovery from surgery and anesthesia. The PACU nurse also explains the equipment (such as an IV or sequential compression devices) to the client and family and answers their questions. The nurse brings the client, who has had nothing by mouth for 8 to 10 hours, light nourishment and assesses the client's response to eating. The PACU nurse also assesses the client's postoperative site for hemorrhage. Ensuring informed consent is the role of the nurse in the preoperative area. Reference:

The nurse in preadmission testing learns that a client scheduled for a total hip replacement in three weeks smokes one pack of cigarettes per day. Which action(s) should the nurse take? Select all that apply. Notify the surgeon that the client is a cigarette smoker. Encourage smoking cessation before surgery. Explain the increased risk for venous thromboembolism after surgery. Tell the client to stop smoking the day before surgery. Provide resources for smoking cessation.

Notify the surgeon that the client is a cigarette smoker. Encourage smoking cessation before surgery. Explain the increased risk for venous thromboembolism after surgery. Provide resources for smoking cessation. Because clients who smoke, especially clients having a total joint replacement, are more likely to experience complications, the surgeon needs to be informed about the client's smoking history. The client needs to be encouraged to stop smoking, especially before surgery, to reduce the risk of postoperative complications such as venous thromboembolism and pneumonia. Because stopping smoking the day before surgery will have minimal positive effects on the surgery, the client should be encouraged to stop smoking as soon as possible. The nurse should provide the client with resources, such as written information and support groups, to support the client in smoking cessation.

A nurse is teaching a client who is at risk for malignant hyperthermia subsequent to general anesthesia. What should the nurse include in the teaching? "The surgery can continue as long as your temperature is controlled." "There are reversal agents that will lessen the occurrence of the malignant hyperthermia." "The surgical team is aware of the risk, so the team is prepared." "Your vital signs will indicate if you need more inhalant medication."

Correct response: "The surgical team is aware of the risk, so the team is prepared." Explanation: Recognizing symptoms early and discontinuing anesthesia promptly are imperative in countering malignant hyperthermia. The surgical team being aware of the possibility is crucial for safe management. The Malignant Hyperthermia Association of the United States (MHAUS) publishes a treatment protocol that should be posted in the OR and be readily available on a malignant hyperthermia cart. However, if end-tidal CO2 monitoring and dantrolene sodium (Dantrium) are available and the anesthesiologist is experienced in managing malignant hyperthermia, the surgery may continue using a different anesthetic agent. Although malignant hyperthermia usually manifests about 10 to 20 minutes after induction of anesthesia, it can also occur during the first 24 hours after surgery. That the surgery can continue is true but does not provide client reassurance. The reversal agents are not true, but a different anesthetic agent will be used. Vital signs will not determine more medication but a change in anesthesia.

An obese client is undergoing abdominal surgery. During the procedure a surgical resident states, "The amount of fat we have to cut through is disgusting." What is the best response by the nurse? Ignore the comment. Report the resident to the attending surgeon. Discuss concerns regarding the comments with the charge nurse. Inform the resident that all communication needs to remain professional.

Correct response: Inform the resident that all communication needs to remain professional. Explanation: The nurse must advocate for the client, especially when the client cannot speak for themselves. By informing the resident that all communication needs to be professional, the nurse is addressing the comment at that moment in time, advocating for the client. Ignoring the comment is not appropriate. The nurse may need to address the concerns of unprofessional communication with the attending surgeon or the charge nurse if the behavior continues. The best action is to address the behavior when it happens.

The intraoperative nurse is transferring a client from the OR to the PACU after replacement of the right knee. The client is an older adult. The nurse should prioritize which of the following actions? Keeping the client sterile Keeping the client restrained Keeping the client warm Keeping the client hydrated

Correct response: Keeping the client warm Explanation: Special attention is given to keeping the client warm because elderly clients are more susceptible to hypothermia. It is always important for the nurse to pay attention to hydration, but hypovolemia does not occur as quickly as hypothermia. The client is never sterile, and restraints are very rarely necessary.

Which is the most common cause of anaphylaxis? Latex Medications Fibrin sealants Plastic

Correct response: Medications Explanation: Because medications are the most common cause of anaphylaxis, intraoperative nurses must be aware of the type and method of anesthesia used as well as the specific agents. Latex, fibrin sealants, and plastic are not the most common causes of anaphylaxis.

The nurse is conducting a preoperative assessment on a client scheduled for gallbladder surgery. The client reports a frequent cough producing green sputum for 3 days and denies fever. Upon auscultation, the nurse notes rhonchi throughout the right lung, with an occasional expiratory wheeze. Respiratory rate is 20, temperature is 99.8 (taken orally), heart rate is 87, and blood pressure is 124/70. What is the best action by the nurse? Notify the surgeon to possibly delay the surgery. Notify the primary physician about the assessment findings. Document the findings and continue moving the client through the preoperative phase. Wait 1 hour and complete the assessment again.

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

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

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

The postanesthesia care unit nurse is caring for a client who had a hernia repair. The client's blood pressure is now 164/92 mm Hg; the client has no history of hypertension prior to surgery and preoperative blood pressure was 112/68 mm Hg. The nurse should assess for which potential causes of hypertension following surgery? Dysrhythmias, blood loss, and hyperthermia Electrolyte imbalances and neurologic changes A parasympathetic reaction and low blood volumes Pain, hypoxia, and bladder distention

Correct response: Pain, hypoxia, and bladder distention Explanation: Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Dysrhythmias, blood loss, hyperthermia, electrolyte imbalances, and neurologic changes are not common postoperative reasons for hypertension. A parasympathetic reaction and low blood volumes would cause hypotension.

The perioperative nurse has a number of major responsibilities when a patient is admitted to a surgical unit or center. Which of the following is the most important function? Completes preoperative assessment Develops a plan of care Verifies that operative consent is signed Provides psychological support

Correct response: Verifies that operative consent is signed Explanation: All choices listed are essential but, without a signed consent form, surgery cannot occur.

The operating room nurse acts in the circulating role during a client's scheduled cesarean section. For which task is this nurse responsible? Performing documentation Estimating the client's blood loss Setting up the sterile tables Gives the surgeon instruments during surgery

Correct response: Performing documentation Explanation: Main responsibilities of the circulating nurse include verifying consent; coordinating the team; and ensuring cleanliness, proper temperature and humidity, lighting, safe function of equipment, and the availability of supplies and materials. The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel as well as implementing fire safety precautions. The circulating nurse also monitors the client and documents specific activities throughout the operation to ensure the client's safety and well-being. Estimating the client's blood loss is the surgeon's responsibility; setting up the sterile tables is the responsibility of the first scrub; and giving the surgeon sterile instruments during surgery is the responsibility of the scrub nurse.

A client is scheduled for a bowel resection in the morning and the client's orders are for a cleansing enema be administered tonight. The client wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect? Preventing aspiration of gastric contents Preventing the accumulation of abdominal gas postoperatively Preventing potential contamination of the peritoneum Facilitating better absorption of medications TAKE ANOTHER QUIZ

Correct response: Preventing potential contamination of the peritoneum Explanation: The administration of a cleansing enema will allow for satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the peritoneum by feces. It will have no effect on aspiration of gastric contents or the absorption of medications. The client should expect to develop gas in the postoperative period.

The surgical client has been intubated and general anesthesia has been administered. The client exhibits cyanosis, shallow respirations, and a weak, thready pulse. The nurse recognizes that the client is in which stage of general anesthesia? Stage I Stage II Stage III Stage IV

Correct response: Stage IV Explanation: Stage IV: medullary depression is characterized by shallow respirations, a weak, thready pulse, dilated pupils that do not react to light, and cyanosis.

An unconscious patient with normal pulse and respirations would be considered to be in what stage of general anesthesia? Beginning anesthesia Excitement Surgical anesthesia Medullary depression

Correct response: Surgical anesthesia Explanation: Surgical anesthesia is reached by administration of anesthetic vapor or gas and supported by IV agents as necessary. The patient is unconscious and lies quietly on the table. The pupils are small but contract when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. In beginning anesthesia, as the patient breathes in the anesthetic mixture, warmth, dizziness, and a feeling of detachment may be experienced. The patient may have a ringing, roaring, or buzzing in the ears and, although still conscious, may sense an inability to move the extremities easily. The excitement stage, characterized variously by struggling, shouting, talking, singing, laughing, or crying, is often avoided if IV anesthetic agents are administered smoothly and quickly. The pupils dilate, but they contract if exposed to light; the pulse rate is rapid, and respirations may be irregular. Medullary depression is reached if too much anesthesia has been administered. Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer contract when exposed to light.

The nurse is caring for a preoperative older adult client who is exceptionally anxious prior to surgery. What should the nurse increase with this client to decrease her anxiety? Analgesia Therapeutic touch Preoperative medication Sleeping medication the night before surgery

Correct response: Therapeutic touch Explanation: Older clients report higher levels of preoperative anxiety; therefore, the nurse should be prepared to spend additional time, increase the amount of therapeutic touch utilized, and encourage family members to be present to decrease anxiety. For most clients, nonpharmacologic interventions should be attempted before administering medications.

The nurse cares for a client who is three hours post op abdominal hysterectomy and begins to develop hiccups. What nursing assessment will the nurse monitor more closely with the client's new symptoms? Temperature Respiratory rate Wound approximation Wound drainage

Correct response: Wound approximation Explanation: Hiccups are produced by intermittent spasms of the diaphragm, secondary to irritation of the phrenic nerve. Hiccups may be caused by surgery and are usually not problematic. However, persistent or forceful spasms may lead to wound dehiscence, or wound separation at the surgical incision. The other answer choices are things the nurse will monitor; however, the approximation of wound edges will be monitored more closely.

Preoperative medications are administered for very specific reasons with very specific outcomes expected. When an anticholinergic medication is administered, what is its expected effect? decreased respiratory secretions reduced preoperative anxiety decreased gastric acidity and volume enhanced proper sedation

Correct response: decreased respiratory secretions Explanation: Anticholinergics decrease respiratory tract secretions, dry mucous membranes, and interrupt vagal stimulation. Both sedatives and opioids decrease anxiety. Decreased gastric acidity and volume are the expected effect of histamine 2-receptor antagonists. Enhanced proper sedation is the expected effect of sedatives.

A postanesthesia care unit (PACU) nurse is caring for a client with the following assessment data: pale, cool, moist skin; thready pulse of 122; blood pressure 78/60; urine output of 25 mL/h; temperature 99.2°F. What interventions by the nurse are appropriate? Select all that apply. Raise the head of the bed 30 degrees. Maintain a patent airway. Frequently monitor neurological status. Administer blood products per orders. Apply oxygen per orders. Apply a warming blanket.

Maintain a patent airway. Frequently monitor neurological status. Administer blood products per orders. Apply oxygen per orders. Your selection: Explanation: The client is demonstrating signs and symptoms of shock. A client in shock may lose the ability to protect the airway. Frequent neurological assessment can provide information related to a decrease in oxygen to the brain. Administering blood products may reverse the signs and symptoms of shock. There is an increased need for oxygen when in shock, so it is appropriate to apply oxygen. The head of the bed should not be elevated. The client should be lying flat or in the Trendelenburg position.

What is the blood glucose level goal for a diabetic client who will be having a surgical procedure? 80 to 110 mg/dL 150 to 240 mg/dL 250 to 300 mg/dL 300 to 350 mg/dL

Correct response: 80 to 110 mg/dL Explanation: Although the surgical risk in the client with controlled diabetes is no greater than in the client without diabetes, strict glycemic control (80 to 110 mg/dL) leads to better outcomes. Frequent monitoring of blood glucose levels is important before, during, and after surgery.

The nurse is performing wound care on a postsurgical client. Which practice violates the principles of surgical asepsis? Holding sterile objects at chest level Allowing a sterile instrument to touch a sterile drape A circulating nurse touching a sterile drape Considering an unopened sterile package to be sterile

Correct response: A circulating nurse touching a sterile drape Explanation: Circulating nurses and unsterile items may only have contact with unsterile areas, not sterile areas. Gowns of the surgical team are considered sterile in front from the chest to the level of the sterile field, and sleeves are considered sterile from 2 inches above the elbow to the stockinette cuff. So, holding a sterile object at chest level does not violate the principles of surgical asepsis. Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile. An unopened sterile package is considered sterile; once it is opened, however, its edges are considered unsterile.

How does the nurse determine that the patient may have hidden fears about the impending surgical procedure? (Select all that apply.) The patient tells the nurse of concerns with the outcome of the procedure. The patient informs the nurse of problems with postoperative nausea in the past and that it was a bad experience. The patient avoids communication with the nurse. The patient repeatedly asks questions that have previously been answered. The patient talks incessantly.

Correct Response: The patient avoids communication with the nurse. The patient repeatedly asks questions that have previously been answered. The patient talks incessantly. Explanation: People express fear in different ways. Some patients may ask repeated questions, regardless of information already shared with them. Others may withdraw, deliberately avoiding communication by reading, watching television, or talking about trivialities. Consequently, the nurse must be empathetic, listen well, and provide information that helps alleviate concerns. If the patient talks about his or her fears, then they are no longer hidden.

What complication is the nurse aware of that is associated with deep venous thrombosis? Pulmonary embolism Immobility because of calf pain Marked tenderness over the anteromedial surface of the thigh Swelling of the entire leg owing to edema

Correct response: Pulmonary embolism Explanation: Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010).

The nurse is preparing to change a client's abdominal dressing. The nurse recognizes that the first step is to provide the client with information regarding the procedure. Which explanation should the nurse provide to the client? "The dressing change is often painful, so we will give you pain medication beforehand." "I will provide privacy. The dressing change should not be painful; you may look at the incision and help." "The dressing change should not be painful, but you can never be sure, and infection is always a concern." "The best time for a dressing change is during lunch. I will provide privacy, and it should not be painful."

Correct response: "I will provide privacy. The dressing change should not be painful; you may look at the incision and help." Explanation: When having dressings changed, the client needs to be informed that the dressing change is a simple procedure with little discomfort; privacy will be provided; and the client is free to look at the incision or even assist in the dressing change itself. If the client decides to look at the incision, assurance is given that the incision will shrink as it heals and that the redness will likely fade. Dressing changes should not be painful, but giving pain medication prior to the procedure is always a good preventive measure. Telling the client that the dressing change "should not be painful, but you can never be sure, and infection is always a concern" does not offer the client any real information or options and serves only to create fear. The best time for dressing changes is when it is most convenient for the client; nutrition is important so interrupting lunch is probably a poor choice.

A client scheduled for surgery asks why blood tests are being done to evaluate liver function. Which response will the nurse make? "It is just a routine test done before every surgery." "It is done to determine if you need antibiotics prior to surgery." "It is to make sure that you haven't had any alcohol before the surgery." "It is because the anesthesia you will receive is cleared through the liver."

Correct response: "It is because the anesthesia you will receive is cleared through the liver." Explanation: The liver is one body organ that eliminates drugs and toxins and is important in the biotransformation of anesthetic compounds. Disorders of the liver may substantially affect how anesthetic agents are metabolized. Acute liver disease is associated with high surgical mortality. Careful assessment may include various liver function tests. Preoperative liver function tests may be routine but that does not explain the reason for the test to the client. Liver function tests are not done to determine prophylactic antibiotic therapy or to determine if the client had any alcohol before the surgery.

A client is having surgery through an ambulatory surgical center. Which information will the nurse provide to the client's family? "Be prepared to take the client home as soon as the surgery is over." "The client will go to the postanesthesia care unit after the surgery." "You can go home and I will call you in a day or two when the client can be discharged." "I will give you the name of the hospital that the client will be transferred to after the surgery."

Correct response: "The client will go to the postanesthesia care unit after the surgery." Explanation: Ambulatory surgery includes outpatient, same-day, or short-stay surgery not requiring admission for an overnight hospital stay but may entail observation in a hospital setting for 23 hours or less. The nurse needs to be sure that the client and family understand that the client will first go to the preoperative area before going to the OR for the surgical procedure and then will spend some time in the postanesthesia care unit before being discharged home with the family member later that day. The client will not be discharged immediately after the surgery is over. The client will not stay in the ambulatory care center for a day or two before being discharged to home. The client will not be transferred to a hospital after the surgery.

The nurse is preparing a client for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the client's signature on a consent form. Which comment by the client would best indicate informed consent? "I know I'll be fine because the health care provider has done this procedure hundreds of times." "I know I'll have pain after the surgery but they'll do their best to keep it to a minimum." "The health care provider is going to remove my uterus and told me about the risk of bleeding." "Because the health care provider isn't taking my ovaries, I'll still be able to have children."

Correct response: "The health care provider is going to remove my uterus and told me about the risk of bleeding." Explanation: The surgeon must explain the procedure and inform the client of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the client requests additional information, the nurse notifies the health care provider. In the correct response, the client is able to tell the nurse what will occur during the procedure and the associated risks. This indicates the client has a sufficient understanding of the procedure to provide informed consent. Clarification of information given may be necessary, but no additional information should be given. Confidence in the health care provider's experience is good, but does not indicate an understanding of the procedure or its risks. Also, the client's statement, "I know I'll be fine," indicates a lack of understanding of the risks of the procedure. Knowledge that the client will experience postoperative pain is good, but the client also needs to understand the procedure itself. Understanding that this procedure will not involve removal of the ovaries is good, but the client's belief that childbearing will still be possible is incorrect.

A client asks the nurse how an inhalant general anesthetic is expelled by the body. What is the best response by the nurse? "The kidneys will eliminate the inhalant with urination." "The lungs primarily eliminate the anesthesia." "The skin will eliminate the anesthesia through evaporation." "The liver will eliminate the inhalant anesthesia."

Correct response: "The lungs primarily eliminate the anesthesia." Explanation: When inhalant anesthetic administration is discontinued, the vapor or gas is eliminated through the lungs.

One of the things a nurse has taught to a client during preoperative teaching is to have nothing by mouth for a specified time before surgery. The client asks the nurse why this is important. What is the most appropriate response for the client? "You will need to have food and fluid restricted before surgery so you are not at risk for aspiration." "The restriction of food or fluid will prevent the development of pneumonia related to decreased lung capacity." "The presence of food in the stomach interferes with the absorption of anesthetic agents." "By withholding food for 8 hours before surgery, you will not develop constipation in the postoperative period."

Correct response: "You will need to have food and fluid restricted before surgery so you are not at risk for aspiration." Explanation: The major purpose of withholding food and fluid before surgery is to prevent aspiration. There is no scientific evidence that withholding food prevents the development of pneumonia or that food in the stomach interferes with absorption of anesthetic agents. Constipation in clients in the postoperative period is related to the anesthesia, not to having food within 8 hours before surgery, so withholding food or fluid would not necessarily prevent constipation.

A client is scheduled for a surgical procedure. When planning the client's care, the nurse should consider that which of the following conditions will increase the client's risk of complications after surgery? A history of diabetes A history of sensitivity to aspirin A history of osteoarthritis A history of chronic low back pain

Correct response: A history of diabetes Explanation: As a chronic condition that affects many body systems, diabetes is a risk factor for surgical complications. The client's blood glucose level and insulin requirements need to be closely monitored before and after surgery. Being sensitive to aspirin does not pose a risk for the client in surgery. Osteoarthritis is not a systemic condition and does not place the client at risk during surgery. Chronic low back pain is not a systemic condition that places the client at risk during surgery; however, it can be exacerbated by positioning on the operating room table.

What measurement should the nurse report to the physician in the immediate postoperative period? A systolic blood pressure lower than 90 mm Hg A temperature reading between 97°F and 98°F Respirations between 20 and 25 breaths/min A hemoglobin of 13.6

Correct response: A systolic blood pressure lower than 90 mm Hg Explanation: A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal.

he nurse is creating the plan of care for a postoperative client for reduction of a femur fracture. Which goal is the most important short-term goal for this client? Relief of pain Adequate respiratory function Resumption of activities of daily living (ADLs) Unimpaired wound healing

Correct response: Adequate respiratory function Explanation: Maintenance of the client's airway and breathing are imperative. Respiratory status is important because pulmonary complications are among the most frequent and serious problems encountered by the surgical client. Wound healing and eventual resumption of ADLs would be later concerns. Pain management is a high priority, but respiratory function is a more acute physiologic need.

The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client? Heart rate and rhythm Skin integrity Core body temperature Airway patency

Correct response: Airway patency Explanation: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).

As an OR nurse, you are required to assess the client continuously and protect them from developing potential complications, as much as humanly possible. To protect a client from malignant hyperthermia, you need to know the symptoms—what are the symptoms of malignant hyperthermia? All of the options are correct Cyanosis Hypotension Decreased urine output

Correct response: All of the options are correct Explanation: Symptoms of malignant hyperthermia include tachycardia, tachypnea, cyanosis, fever, muscle rigidity, diaphoresis, mottled skin, hypotension, irregular heart rate, decreased urine output, and cardiac arrest.

The nurse is preparing the medical record for a client scheduled for surgery. Which item(s) will the nurse ensure are in the history and physical? Select all that apply. Allergies Surgical history Medical history Home care needs Current medications History of present illness

Correct response: Allergies Surgical history Medical history Current medications History of present illness A completed, updated and signed history and physical must be present prior to the client entering the operating room. Not more than 30 days before the date of the scheduled surgery, each client must have a comprehensive medical history and physical assessment. The primary provider is required to update the form within 24 hours of scheduled surgery on all non-inpatient clients. The history and physical consists of allergies, surgical history, medical history, current medications, and history of present illness. Home care needs are not a part of the history and physical.

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: Assisting with incentive spirometry every 6 hours Ambulating the client as soon as possible Positioning the client in a supine position Assessing breath sounds at least every 2 hours

Correct response: Ambulating the client as soon as possible Explanation: The nurse should assist the client to ambulate as soon as the client is able. Incentive spirometry should be performed every 1 to 2 hours. The client should be positioned from side to side and in semi-Fowler's position. While assessing breath sounds is essential, it does not help to prevent pneumonia.

When should the nurse encourage the postoperative patient to get out of bed? Within 6 to 8 hours after surgery Between 10 and 12 hours after surgery As soon as it is indicated On the second postoperative day

Correct response: As soon as it is indicated Explanation: Postoperative activity orders are checked before the patient is assisted to get out of bed, in many instances, on the evening following surgery. Sitting up at the edge of the bed for a few minutes may be all that the patient who has undergone a major surgical procedure can tolerate at first.

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate? Document the findings and reassess in 24 hours. Assess for signs and symptoms of fluid volume deficit. Assess for edema. Discontinue the nasogastric tube suctioning.

Correct response: Assess for signs and symptoms of fluid volume deficit. Explanation: The client's 24-hour intake is 1800 mL (75 x 24). The client's 24-hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Because the output is significantly higher than the intake, the client is at risk for fluid volume deficit. The nurse should not discontinue the nasogastric suctioning without a physician's order. The findings should be documented and reassessed, but the nurse needs to take more action to prevent complication. Edema is usually associated with fluid volume excess.

The nurse is performing the shift assessment of a postsurgical client. The nurse finds the client's mental status, level of consciousness, speech, and orientation are intact and at baseline, but the client appears unusually restless. What should the nurse do next? Assess the client's oxygen levels. Administer antianxiety medications. Page the client's health care provider. Initiate a social work referral.

Correct response: Assess the client's oxygen levels. Explanation: The nurse assesses the client's mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage. Antianxiety medications are not given until the cause of the anxiety is known. The health care provider is notified only if the reason for the anxiety is serious or if a prescription for medication is needed. A social work consult is inappropriate for addressing restlessness.

The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk? Atelectasis Anemia Dehydration Peripheral edema

Correct response: Atelectasis Explanation: Atelectasis occurs when the postoperative client fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia occurs rarely and usually in situations where the client loses a significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the client is most at risk for atelectasis

he anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered? Unresponsive to verbal or tactile stimuli Denies sensation to perineum and lower abdomen Yelling and pulling at equipment No movement in right lower leg

Correct response: Denies sensation to perineum and lower abdomen Explanation: A transsacral block anesthetizes the perineum and occasionally the lower abdomen. Yelling and pulling at equipment can be related to the excitement phase of general anesthesia. Lack of response to verbal or tactile stimuli and no movement in the right lower leg are not consistent with a transsacral conduction block.

The nurse is caring for a client who has just arrived for surgery. Which assessment finding indicates to the nurse that the client may be experiencing dehydration because of taking nothing by mouth after midnight for the surgery? Urine output 60 mL/hr Pulse 88 beats per minute Blood pressure 80/50 mm Hg Respiratory rate 20 breaths per minute

Correct response: Blood pressure 80/50 mm Hg Explanation: Assessment of a client's hydration status is essential preoperatively. The client's NPO (nothing by mouth or nil per os) status should be confirmed preoperatively. Preoperative fasting helps prevent the risk of aspiration but it also induces stress on the body, including the loss of glycogen stores, and the body sacrifices lean muscle to meet the energy needs of the surgery. This may lead to dehydration, which may be exhibited day of surgery by low blood pressure. A urine output of 60 mL/hr is within normal limits. A pulse of 88 beats per minute is within normal limits. A respiratory rate of 20 breaths per minute is within normal limits.

The nurse is preparing a client for surgery. The client reports being nervous and not really understanding the surgical procedure or its purpose. What is the most appropriate action for the nurse to take? Have the client sign the informed consent and place it in the chart. Call the health care provider to review the procedure with the client. Explain the procedure clearly to the client and the family. Provide the client with a pamphlet explaining the procedure.

Correct response: Call the health care provider to review the procedure with the client. Explanation: While the nurse may ask the client to sign the consent form and witness the signature, it is the surgeon's responsibility to provide a clear and simple explanation of what the surgery will entail prior to the client giving consent. The surgeon must also inform the client of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the client requests additional information, the nurse notifies the health care provider. The consent form should not be signed until the client understands the procedure that has been explained by the surgeon. The provision of a pamphlet will benefit teaching the client about the surgical procedure, but will not substitute for the information provided by the health care provider.

A nurse is preparing a client for surgery. The assessment is complete, all consents have been signed, and the client's family is present. Before administering preoperative medications, what is the nurse's first step? Check the client's ID bracelet. Ask about the client's drug allergies. Measure the client's vital signs. Ask the client to void.

Correct response: Check the client's ID bracelet. Explanation: Before administering any medication, including preoperative medications, always confirm administration of the meds to the right client.

Which is the least important issue concerning safety for the perioperative team before proceeding to the operating room? Client identification Surgical procedure Surgical site Client's ambulatory aids

Correct response: Client's ambulatory aids Explanation: It is imperative that the entire perioperative team participates in verifying the client's identity, the correct surgical procedure, and the appropriate surgical site before preceding to the OR. The client's ambulatory aids are not an important safety concern before proceeding to the OR.

A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate? Continue with frequent client assessments. Remove the oral airway. Notify the physician of impaired neurological status. Obtain vital signs, including pulse oximetry, every 5 minutes.

Correct response: Continue with frequent client assessments. Explanation: An immediate postoperative client may be transferred to the PACU with a hard, plastic oral airway in place. The airway should not be removed until the client shows signs of gagging or choking. The neurological status is appropriate for a client who received general anesthesia, and the nurse should continue with frequent client assessments. . None of the information provided requires the client to have vital signs measured more frequently than the standard 15 minutes.

What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities? Assisting the surgeon Coordinating the surgical team Setting up the sterile tables Passing instruments

Correct response: Coordinating the surgical team Explanation: The person in the scrub role, either a nurse or a surgical technician, provides sterile instruments and supplies to the surgeon during the procedure by anticipating the surgical needs as the surgical case progresses. The circulating nurse coordinates the care of the patient in the OR. Care provided by the circulating nurse includes planning for and assisting with patient positioning, preparing the patient's skin for surgery, managing surgical specimens, anticipating the needs of the surgical team, and documenting intraoperative events.

A nursing measure for evisceration is to: Apply an abdominal binder snugly so that the intestines can be slowly pushed back into the abdominal cavity. Approximate the wound edges with adhesive tape so that the intestines can be gently pushed back into the abdomen. Carefully push the exposed intestines back into the abdominal cavity. Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution.

Correct response: Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution. Explanation: If evisceration occurs, the nurse aseptically covers the abdominal contents with moist saline dressings to prevent drying of the bowel, notifies the surgical team immediately, and assesses the patient's vital signs including oxygen saturation. The patient remains in bed with knees bent to reduce abdominal muscle tension.

What medication should the nurse prepare to administer in the event the client has malignant hyperthermia? Dantrolene sodium Fentanyl citrate Naloxone Thiopental sodium

Correct response: Dantrolene sodium Explanation: Anesthesia and surgery should be postponed. However, if end-tidal carbon dioxide (CO2) monitoring and dantrolene sodium (Dantrium) are available and the anesthesiologist is experienced in managing malignant hyperthermia, the surgery may continue using a different anesthetic agent.

The nurse is packing a client's abdominal wound with sterile, half-inch Iodoform gauze. During the procedure, the nurse drops some of the gauze onto the client's abdomen 2 inches (5 cm) away from the wound. What should the nurse do? Apply povidone-iodine (Betadine) to that section of the gauze and continue packing the wound. Pick up the gauze and continue packing the wound after irrigating the abdominal wound with Betadine solution. Continue packing the wound and inform the health care provider that an antibiotic is needed. Discard the gauze packing and repack the wound with new Iodoform gauze.

Correct response: Discard the gauze packing and repack the wound with new Iodoform gauze. Explanation: Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile; contact with unsterile objects at any point renders a sterile area contaminated. The sterile gauze became contaminated when it was dropped on the client's abdomen. It should be discarded and new Iodoform gauze should be used to pack the wound. Betadine should not be used in the wound unless prescribed.

What action by the nurse best encompasses the preoperative phase? Educating clients on signs and symptoms of infection Documenting the application of sequential compression devices (SCDs) Monitoring vital signs every 15 minutes Shaving the client using a straight razor

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

The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurse's preoperative assessment of an elderly client? Elderly clients have a smaller lung capacity than younger clients. Elderly clients require higher medication doses than younger clients. Elderly clients have less physiologic reserve than younger clients. Elderly clients have more sophisticated coping skills than younger clients

Correct response: Elderly clients have less physiologic reserve than younger clients. Explanation: The underlying principle that guides the preoperative assessment, surgical care, and postoperative care is that elderly clients have less physiologic reserve (the ability of an organ to return to normal after a disturbance in its equilibrium) than do younger clients. Elderly clients do not have larger lung capacities than younger clients. Elderly clients cannot necessarily cope better than younger clients and they often require lower doses of medications.

A client with osteoarthritis receives a recommendation to have joint replacement surgery. For which type of surgery will the nurse plan teaching for this client? Urgent Elective Required Emergent

Correct response: Elective Explanation: Elective surgery means that the client should have the surgery even though failure to have the surgery is not catastrophic. Urgent surgery means that prompt attention is required within 24 to 30 hours. Required surgery means that the client needs to have surgery within a few weeks or months. Emergent surgery means that the client requires immediate attention for a life-threatening disorder without delay.

A client will be undergoing a total hip arthroplasty later in the day and it is anticipated that the client may require blood transfusion during surgery. How can the nurse best ensure the client's safety if a blood transfusion is required? Prime IV tubing with a unit of blood and keep it on hold. Check that the client's electrolyte levels have been assessed preoperatively. Ensure that the client has had a current cross-match. Keep the blood on standby and warmed to body temperature.

Correct response: Ensure that the client has had a current cross-match. Explanation: Few clients undergoing an elective procedure require blood transfusion, but those undergoing high-risk procedures may require an intraoperative transfusion. The circulating nurse anticipates this need, checks that blood has been cross-matched and held in reserve, and is prepared to administer blood. Storing the blood at body temperature or in IV tubing would result in spoilage and potential infection.

Prior to a client's scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the client's care. What is the main rationale for organizing perioperative care in this collaborative manner? Historical precedent Client requests Health care providers' needs Evidence-based practice

Correct response: Evidence-based practice Explanation: Collaboration of the surgical team using evidence-based practice tailored to a specific case results in optimal client care and improved outcomes. None of the other listed factors is the basis for the collaboration of the surgical team.

The nurse is caring for a client who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the client's ribs and xiphoid process are prominent. The client reports exercising two to three times daily, and the client's parent indicates that the client is being treated for anorexia nervosa. How should the nurse best follow up on these assessment data? Inform the postoperative team about the client's risk for wound dehiscence. Evaluate the client's ability to manage pain level. Facilitate a detailed analysis of the client's electrolyte levels. Instruct the client on the need for a high-sodium diet to promote healing.

Correct response: Facilitate a detailed analysis of the client's electrolyte levels. Explanation: The surgical team should be informed of the client's medical history regarding anorexia nervosa. Any nutritional deficiency, such as malnutrition, should be corrected before surgery to provide adequate protein for tissue repair. The electrolyte levels should be evaluated and corrected to prevent metabolic abnormalities in the operative and postoperative phases. The risk of wound dehiscence is more likely associated with obesity. Instruction on proper nutrition should take place in the postoperative period, and a consultation should be made with a psychiatric specialist. Evaluation of pain management is always important, but not particularly significant in this scenario.

The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by: Granulation First intention Second intention Third intention

Correct response: First intention Explanation: First-intention healing is characterized by a closed incision with little tissue reaction and the absence of signs and symptoms of infection.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? First intention Second intention Third intention Fourth intention

Correct response: First intention Explanation: When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing.

Which would be included as a responsibility of the scrub nurse? Obtaining and opening wrapped sterile equipment Keeping all records and adjusting lights Handing instruments to the surgeon and assistants Coordinating activities of other personnel

Correct response: Handing instruments to the surgeon and assistants Explanation: The responsibilities of a scrub nurse are to assist the surgical team by handing instruments to the surgeon and assistants, preparing sutures, receiving specimens for laboratory examination, and counting sponges and needles. Responsibilities of a circulating nurse include obtaining and opening wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, and coordinating activities of other personnel.

You are admitting an insulin-dependent patient to the same-day surgical suite for carpal tunnel surgery. You know that this patient may be at risk for which metabolic disorder? Adrenal insufficiency Thyrotoxicosis Impaired acid base balance Hyperglycemia

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

he nurse admits a client to the postanesthesia care unit with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. This client is showing signs of what potential issue? Hypothermia Hypovolemic shock Neurogenic shock Malignant hyperthermia

Correct response: Hypovolemic shock Explanation: The client is exhibiting symptoms of hypovolemic shock; therefore, the nurse should notify the client's health care provider and anticipate orders for fluid and/or blood product replacement. Neurogenic shock does not normally result in tachycardia, and malignant hyperthermia would rarely present at this stage in the operative experience. Hypothermia does not cause hypotension and tachycardia.

A client is receiving general anesthesia. The nurse anesthetist starts to administer the anesthesia. The client begins giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings? I II III IV

Correct response: II Explanation: Stage II is the excitement stage, which is characterized by struggling, shouting, and laughing. Stage I is the beginning of anesthesia, during which the client breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia characterized by unconsciousness and quietness. Surgical anesthesia is achieved by continued administration of anesthetic vapor and gas. Stage IV is medullary depression.

Which stage of surgical anesthesia is also known as excitement? I II III IV

Correct response: II Explanation: Stage II is the excitement stage, which is characterized by struggling, shouting, and laughing. Stage II is often avoided if the anesthetic is administered smoothly and quickly. Stage I is the beginning of anesthesia, during which the client breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia, which is achieved by continued administration of anesthetic vapor and gas. Stage IV is medullary depression, in which the client is unconscious and lies quietly on the table.

The intraoperative nurse knows that the client's emotional state can influence the outcome of the surgical procedure. How should the nurse best address this? Teach the client strategies for distraction. Pair the client with another client who has better coping strategies. Incorporate cultural and religious considerations, as appropriate. Give the client antianxiety medication.

Correct response: Incorporate cultural and religious considerations, as appropriate. Explanation: Because the client's emotional state remains a concern, the care initiated by preoperative nurses is continued by the intraoperative nursing staff that provides the client with information and reassurance. The nurse supports coping strategies and reinforces the client's ability to influence outcomes by encouraging active participation in the plan of care incorporating cultural, ethnic, and religious considerations, as appropriate. "Buddying" a client is normally inappropriate and distraction may or may not be effective. Nonpharmacologic measures should be prioritized

The intraoperative nurse knows that the client's emotional state can influence the outcome of the surgical procedure. How should the nurse best address this? Teach the client strategies for distraction. Pair the client with another client who has better coping strategies. Incorporate cultural and religious considerations, as appropriate. Give the client antianxiety medication.

Correct response: Incorporate cultural and religious considerations, as appropriate. Explanation: Because the client's emotional state remains a concern, the care initiated by preoperative nurses is continued by the intraoperative nursing staff that provides the client with information and reassurance. The nurse supports coping strategies and reinforces the client's ability to influence outcomes by encouraging active participation in the plan of care incorporating cultural, ethnic, and religious considerations, as appropriate. "Buddying" a client is normally inappropriate and distraction may or may not be effective. Nonpharmacologic measures should be prioritized.

The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the postsurgical unit following a colon resection. This client's age and body mass index increase the risk for what complication in the postoperative period? Hyperglycemia Azotemia Falls Infection

Correct response: Infection Explanation: Like age, obesity increases the risk and severity of complications associated with surgery. During surgery, fatty tissues are especially susceptible to infection. In addition, obesity increases technical and mechanical problems related to surgery. Therefore, dehiscence (wound separation) and wound infections are more common. A postoperative client who is obese will not likely be at greater risk for hyperglycemia, azotemia, or falls.

A nurse is caring for a client following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache? Seat the client in a chair and have them perform deep breathing exercises. Ambulate the client as early as possible. Limit the client's fluid intake for the first 24 hours postoperatively. Keep the client positioned supine.

Correct response: Keep the client positioned supine. Explanation: Measures that increase cerebrospinal pressure are helpful in relieving headache. These include maintaining a quiet environment, keeping the client lying flat, and keeping the client well hydrated. Having the client sit or stand up decreases cerebrospinal pressure and would not relieve a spinal headache. Limiting fluids is incorrect because it also decreases cerebrospinal pressure and would not relieve a spinal headache.

A client reports getting a rash when eating kiwi and bananas. For which potential allergy will the nurse plan care for this client? Herbal supplements Latex Pesticides Antibiotics

Correct response: Latex Explanation: Known allergies and sensitivities to foods could avert an anaphylactic response. Clients may have early manifestations of a latex allergy and be unaware of this. If a client states an intolerance to kiwi, avocado, or banana, there may be an association with an allergy to latex. An intolerance to kiwi and bananas does not indicate an allergy to herbal supplements, pesticides, or antibiotics.

he patient is having a repair of a vaginal prolapse. What position does the nurse place the patient in? Left lateral Sim's Prone position Lithotomy position Trendelenburg

Correct response: Lithotomy position Explanation: The lithotomy position is used for nearly all perineal, rectal, and vaginal surgical procedures (see Fig. 18-5C). The patient is positioned on the back with the legs and thighs flexed. The position is maintained by placing the feet in stirrups.

A nurse is receiving a client to the postanesthesia unit. What initial nursing activity is most important in the postoperative recovery area? Maintain patient safety. Administer medications and fluids. Assess pain level. Inspect surgical site.

Correct response: Maintain patient safety. Explanation: The most important postoperative nursing function is maintenance of patent safety, with airway and circulation as priorities. Administering medications and fluids, assessing pain, and inspecting the surgical site are important nursing activities, but are not the priorities of client care.

What is the primary objective of the health care team during the immediate postoperative period? Maintaining ventilation Preventing hypovolemia Mobilizing the client as soon as possible Giving the family emotional support

Correct response: Maintaining ventilation Explanation: The primary objective in the immediate postoperative period is to maintain ventilation and thus prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). While preventing hypovolemia, mobilizing the client, and providing emotional support are all important, they are not as important as ensuring the client's respiratory status. Reference: Donnelly-Moreno, L.A., Timby's Introductory Medical-Surgical Nursing, 13th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 14: Perioperative Care, POSTOPERATIVE CARE, p. 192. Chapter 14: Perioperative Care - Page 192

An operating room (OR) nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the OR? Bubble mask Mask covering the nose and mouth Goggles Gloves

Correct response: Mask covering the nose and mouth Explanation: Masks are worn at all times in the restricted zone of the OR. In hospitals where numerous total joint procedures are performed, a complete bubble mask may be used. This mask provides full-barrier protection from bone fragments and splashes. Goggles and gloves are worn as required, but not necessarily at all times.

A laser is being used to excise tissue during a client's surgical procedure. Which item will the nurse apply to minimize personal risk due to the smoke from the device? Goggles Face shield N95 respiratory mask Second surgical mask

Correct response: N95 respiratory mask Explanation: Health care workers are exposed to surgical smoke. This smoke is created from thermal destruction of tissue. Smoke plumes may contain toxic gases and vapors such as benzene, hydrogen cyanide, formaldehyde, bioaerosols, dead and live cellular material, and viruses. Smoke evacuators are used in some procedures to remove the plume from the operative field. If a smoke evacuator is not available, surgical team members should don an N95 respirator mask rather than a surgical mask, which does not prevent smoke from entering the airway orifices. Goggles and a face shield will not prevent the potential damage from exposure to surgical smoke.

A client is 2 hours' postoperative with an indwelling urinary catheter. The last hourly urine output recorded for this client was 10 mL. The tubing of the catheter is confirmed to be patent. What should the nurse do? Irrigate the catheter with 30 mL normal saline. Notify the health care provider and continue to monitor the hourly urine output closely. Decrease the intravenous fluid rate and massage the client's abdomen. Have the client sit in high Fowler position.

Correct response: Notify the health care provider and continue to monitor the hourly urine output closely. Explanation: If the client has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 25 mL/hr are reported. The urine output should continue to be monitored hourly by the nurse. Irrigation would not be warranted because it is known that the catheter is patent. There is no need to place the client in high-Fowler position (sitting straight up), which would likely be uncomfortable 2 hours' postoperative.

A client scheduled for surgery has a blood pressure of 186/90 mm Hg. After documenting this in the medical record, which action will the nurse take? Provide preoperative medications early. Notify the health care provider of the blood pressure. Document the blood pressure in the medical record. Inform the operating room of the blood pressure when the client arrives.

Correct response: Notify the health care provider of the blood pressure. Explanation: Client preparation for surgical intervention includes ensuring that the cardiovascular system can support the oxygen, fluid, and nutritional needs of the perioperative period. Before surgery, the client's baseline vital signs and blood pressure are taken. In elective situations, surgery may be postponed if there is evidence of cardiac decomposition or unexplained elevated blood pressure. Blood pressure is documented in the medical record and then the health care provider should be informed of the client's blood pressure. The time to give preoperative medications should not be altered. The nurse needs to do more than document the blood pressure in the medical record. The blood pressure should be reported before transporting the client to the operating room.

The nurse notes that the consent form for surgery needs to be signed; however, the client just received preoperative medication. Which action will the nurse take? Ask the client to sign the consent form now. Ask a family member to sign the consent form. Notify the health care provider that the consent form has not been signed. Document that the client provided verbal consent to the surgery.

Correct response: Notify the health care provider that the consent form has not been signed. Explanation: Informed consent is the client's autonomous decision about whether to undergo a surgical procedure. Voluntary and written informed consent from the client is necessary before nonemergent surgery can be performed to protect the client from unsanctioned surgery and protect the health care provider from claims of an unauthorized operation or battery. Because of this, the health care provider should be notified that the consent form has not been signed. The consent form needs to be signed before administering psychoactive premedication because consent is not valid if it is obtained while the client is under the influence of medications that can affect judgment and decision-making capacity. A family member is not responsible for approving the client's surgery. Verbal agreement to a surgical procedure is not legal or appropriate.

During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take? Assist the client to the bathroom. Offer the client a bedpan or urinal. Wait until the client gets to the operating room and is catheterized. Have the client go to the bathroom.

Correct response: Offer the client a bedpan or urinal. Explanation: If a preanesthetic medication is given, the client is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness. If a client needs to void following administration of a sedative, the nurse should offer the client a urinal. The client should not get out of bed because of the potential for lightheadedness.

How would the operating room nurse place a patient in the Trendelenburg position? Flat on his back with his arms next to his sides On his back with his head lowered so that the plane of his body meets the horizontal on an angle On his back with his legs and thighs flexed at right angles On his side with his uppermost leg adducted and flexed at the knee

Correct response: On his back with his head lowered so that the plane of his body meets the horizontal on an angle Explanation: The Trendelenburg position usually is used for surgery on the lower abdomen and pelvis to obtain good exposure by displacing the intestines into the upper abdomen. In this position, the head and body are lowered. The patient is supported in position by padded shoulder braces (see Fig. 18-5B), bean bags, and foam padding.

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? Heart rate of 84 beats/minute Oxygen saturation (SaO2) of 85% Decreased cough and gag reflexes Blood-tinged stools

Correct response: Oxygen saturation (SaO2) of 85% Explanation: Normal SaO2 is 95% to 100%. Oxygen saturation of 85% indicates inadequate oxygenation, which may be a consequence of the moderate sedation. Appropriate nursing actions include rousing the client, if necessary, assisting the client with coughing and deep breathing, and evaluating the need for additional oxygen. A heart rate of 84 beats/minute is within normal limits. Colonoscopy doesn't affect cough and gag reflexes, although these reflexes may be slightly decreased from the administration of sedation. These findings don't require immediate intervention. Blood-tinged stools are a normal finding after colonoscopy, especially if the client had a biopsy.

The nurse is caring for a hospice client who is scheduled for a surgical procedure to reduce the size of a spinal tumor in an effort to relieve pain. The nurse should plan this client care with the knowledge that this surgical procedure is classified as which of the following? Diagnostic Laparoscopic Curative Palliative

Correct response: Palliative Explanation: A client on hospice will undergo a surgical procedure only for palliative care, which means to reduce pain or provide comfort, not to cure disease (curative). The reduction of tumor size to relieve pain is considered a palliative procedure. A laparoscopic procedure is a type of surgery that is utilized for diagnostic purposes or for repair. Diagnostic procedures are performed to help diagnose a condition. The excision of a tumor is classified as curative. This client is not having the tumor removed, only the size reduced. Reference:

Which is a classic sign of hypovolemic shock? Dilute urine Pallor High blood pressure Bradypnea

Correct response: Pallor Explanation: The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing.

Which of the following is a classic sign of hypovolemic shock? Pallor Dilute urine High blood pressure Bradypnea

Correct response: Pallor Explanation: The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing.

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? Necrotic and hard Pale yet able to blanch with digital pressure Pink to red and soft, bleeding easily White with long, thin areas of scar tissue

Correct response: Pink to red and soft, bleeding easily Explanation: In second-intention healing, necrotic material gradually disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue.

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? Necrotic and hard Pale yet able to blanch with digital pressure Pink to red and soft, noting that it bleeds easily White with long, thin areas of scar tissue

Correct response: Pink to red and soft, noting that it bleeds easily Explanation: Second-intention healing (granulation) occurs in infected wounds or in wounds in which the edges have not been approximated. Gradually, the necrotic material disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue. Healing is complete when skin cells grow over these granulations.

A client is on call to the OR for an aortobifemoral bypass and the nurse administers the prescribed preoperative medication. After administering a preoperative medication to the client, what should the nurse do? Encourage light ambulation. Place the bed in a low position with the side rails up. Tell the client that the client will be asleep before it is time to leave for surgery. Take the client's vital signs every 15 minutes.

Correct response: Place the bed in a low position with the side rails up. Explanation: When the preoperative medication is given, the bed should be placed in low position with the side rails raised. The client should not get up without assistance. The client may not be asleep, but may be drowsy. Vital signs should be taken before the preoperative medication is given; vital signs are not normally required every 15 minutes after administration.

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse? Position the client in the side-lying position. Administer an anti-emetic. Obtain an emesis basin. Ask the client for more clarification.

Correct response: Position the client in the side-lying position. Explanation: The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits. The nurse may also obtain an emesis basin and administered an anti-emetic if one is ordered; however, these will be done after the client is repositioned. There is no need for the nurse to ask the client for more clarification.

The nurse is caring for an 88-year-old client who is recovering from an iliac-femoral bypass graft. The client is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the client, it is clear that the client is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. Which complication should the nurse suspect? Postoperative delirium Postoperative dementia Senile dementia Senile confusion

Correct response: Postoperative delirium Explanation: Postoperative delirium, characterized by confusion, perceptual and cognitive deficits, altered attention levels, disturbed sleep patterns, and impaired psychomotor skills, is a significant problem for older adults. Dementia does not have a sudden onset. Senile confusion is not a recognized health problem.

The scrub nurse is responsible for: Calling the "time-out" to verify the surgical site and procedure Monitoring the administration of the anesthesia Monitoring the operating-room personnel for breaks in sterile technique Preparing the sterile instruments for the surgical procedure

Correct response: Preparing the sterile instruments for the surgical procedure Explanation: The scrub nurse is responsible for preparing the sterile instruments for the surgical procedure.

The circulating nurse will be participating in a 78-year-old client's total hip replacement. Which consideration should the nurse prioritize during the preparation of the client in the operating room? The client should be placed in Trendelenburg position. The client must be firmly restrained at all times. Pressure points should be assessed and well padded. The preoperative shave should be done by the circulating nurse.

Correct response: Pressure points should be assessed and well padded. Explanation: The vascular supply should not be obstructed nor nerves damaged by an awkward position or undue pressure on a body part. During surgical procedures, the client is at risk for impairment of skin integrity due to a stationary position and immobility. An older client is at an increased risk of injury and impaired skin integrity. Therefore, pressure points should be assessed and well padded. A Trendelenburg position is not indicated for this client. Once anesthetized for a total hip replacement, the client cannot move; restraints are not necessary. A preoperative shave is not performed; excess hair is removed by means of a clipper.

A client is scheduled for a bowel resection in the morning and the client's orders are for a cleansing enema be administered tonight. The client wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect? Preventing aspiration of gastric contents Preventing the accumulation of abdominal gas postoperatively Preventing potential contamination of the peritoneum Facilitating better absorption of medications

Correct response: Preventing potential contamination of the peritoneum Explanation: The administration of a cleansing enema will allow for satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the peritoneum by feces. It will have no effect on aspiration of gastric contents or the absorption of medications. The client should expect to develop gas in the postoperative period.

A surgical client has been given general anesthesia and is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage? Rub the client's back. Provide for client safety. Encourage the client to express feelings. Stroke the client's hand.

Correct response: Provide for client safety. Explanation: In stage II, the client may struggle, shout, or laugh. The movements of the client may be uncontrolled, so it is essential that the nurse be ready to help to restrain the client for safety, if necessary. Rubbing the client's back, encouraging the client to express feelings, or stroking the client's hand do not protect client safety and therefore are not the priority.

The nurse recognizes which of the following as clinical manifestations of shock? Rapid, weak, thready pulse Flushed face Warm, dry skin Increased urine output

Correct response: Rapid, weak, thready pulse Explanation: Pulse increases as the body tries to compensate. Pallor is an indicator of shock. Skin is generally cool and moist in shock. Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

The circulating nurse is unsure whether proper technique was followed when an object was placed in the sterile field during a surgical procedure. What is the best action by the nurse? Remove the item from the sterile field. Mark the client's chart for future review of infections. Remove the entire sterile field from use. Ask another nurse to review the technique used.

Correct response: Remove the entire sterile field from use. Explanation: If any doubt exists about the maintenance of sterility, the field should be considered not sterile. Because the object in question was placed in the sterile field, the sterile field must be removed from use. Removing the individual item is not appropriate, as the entire field was potentially contaminated. Reviewing the client's chart at a later date does not decrease the chance of infection. Although another nurse could observe the technique used to put objects in a sterile field, it does not resolve the immediate concern.

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? Primary-intention healing First-intention healing Second-intention healing Third-intention healing

Correct response: Second-intention healing Explanation: When wounds dehisce, they are allowed to heal by secondary intention. Primary or first-intention healing is the method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation. Third-intention healing is a method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by bringing apposing granulations together.

A nurse is planning care for a client scheduled to undergo a thoracotomy. After tolerating full liquids, which dietary recommendation will the nurse consider? Small, frequent low-fat meals Small, frequent full-fat meals Three low-sodium meals Three full-fat meals

Correct response: Small, frequent full-fat meals Explanation: Clients undergoing thoracotomy may have poor nutritional status before surgery due to shortness of breath, increased sputum production, and decreased appetite. It is for these reasons that nutrition is very important for clients undergoing thoracotomy. Small, frequent full-fat meals provide adequate nutrition while also allowing frequent rest periods. Larger, less frequent meals may fatigue the clients more easily. There is no reason for the clients to have low-sodium or low-fat meals.

Which stage of general anesthesia is reached when too much anesthesia has been administered? Stage IV Stage I Stage II Stage III

Correct response: Stage IV Explanation: Stage IV, medullary depression is reached when too much anesthesia has been administered. Cyanosis develops and, without prompt intervention, death rapidly follows. Stage I, beginning anesthesia, occurs when the patient breathes in the anesthetic mixture; warmth, dizziness, and a feeling of detachment may be experienced. Stage II is the excitement stage, characterized by struggling, shouting, talking, singing, laughing, or crying. Stage III is surgical anesthesia. Surgical anesthesia is reached by continued administration of the anesthetic vapor or gas.

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition? The client is displaying early signs of shock. The client is showing signs of a medication reaction. The client is displaying late signs of shock. The client is showing signs of an anesthesia reaction.

Correct response: The client is displaying early signs of shock. Explanation: The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated. Medication or anesthesia reactions may cause client symptoms similar to these; however, these causes are not as likely as early shock.

he nurse is taking the client into the operating room (OR) when the client informs the nurse that the client's grandparent spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client? The client may be experiencing presurgical anxiety. The client may be at risk for malignant hyperthermia. The grandparent's surgery has minimal relevance to the client's surgery. The client may be at risk for a sudden onset of postsurgical infection.

Correct response: The client may be at risk for malignant hyperthermia. Explanation: Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying clients at risk is imperative because the mortality rate is 50%. The client's anxiety is not relevant, the grandparent's surgery is very relevant, and all clients are at risk for surgical

A nurse is providing preoperative care for a client who is scheduled for cholecystectomy under general anesthesia. When the nurse instructs that the client will need to remove face makeup before the surgery, the client complains by saying, "They're not operating on my face." What would the nurse tell this client? The surgical team needs to observe the natural color of the client's face and lips while the client is under anesthesia. Hospital policy dictates the removal of cosmetics under all circumstances, and compliance is mandatory. It is possible that the surgical team can make an exception in this case. The cosmetics will cause an adverse reaction with the anesthesia and therefore must be removed.

Correct response: The surgical team needs to observe the natural color of the client's face and lips while the client is under anesthesia. Explanation: Removal of cosmetics assists the surgical team to observe the client's lips, face, and nail beds for cyanosis, pallor, or other signs of decreased oxygenation. Declaring that makeup removal is mandatory hospital policy does promote client teaching and is especially not appropriate for a client who is already likely anxious about surgery. It is not appropriate to suggest that an exception could be made. Cosmetics would not cause an adverse reaction with anesthesia.

A client in the postanesthesia care unit (PACU) develops noisy and irregular respirations. Which action will the nurse take? Allow the client to come to consciousness naturally. Place the client in a prone position. Tilt the head back and lift the lower jaw. Increase the percentage of supplemental oxygen.

Correct response: Tilt the head back and lift the lower jaw. Explanation: Clients who have experienced prolonged anesthesia usually are unconscious, with all muscles relaxed. This relaxation extends to the muscles of the pharynx. When the client lies on the back, the lower jaw and the tongue fall backward and the air passages become obstructed. This is called hypopharyngeal obstruction. Signs of occlusion include choking; noisy and irregular respirations. The treatment of hypopharyngeal obstruction involves tilting the head back and pushing forward on the angle of the lower jaw, as if to push the lower teeth in front of the upper teeth. This maneuver pulls the tongue forward and opens the air passages. Allowing the client to come to consciousness naturally will not address the noisy and irregular respirations. The prone position will not open the airway. Increasing the percentage of supplemental oxygen will not improve the hypopharyngeal obstruction.

The nurse is providing preoperative teaching to a client scheduled for surgery. The nurse is instructing the client on the use of deep breathing, coughing, and the use of incentive spirometry when the client states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide? To prevent chronic obstructive pulmonary disease (COPD) To promote optimal lung expansion To enhance peripheral circulation To prevent pneumothorax

Correct response: To promote optimal lung expansion Explanation: One goal of preoperative nursing care is to teach the client how to promote optimal lung expansion and consequent blood oxygenation after anesthesia. COPD is not a realistic risk and pneumothorax is also unlikely. Breathing exercises do not primarily affect peripheral circulation.

A client is admitted to the ED reporting severe abdominal pain and vomiting "coffee-ground" like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that they need surgery. When can the client most likely anticipate that the surgery will be scheduled? Within 24 hours Within the next week Without delay As soon as all the day's elective surgeries have been completed

Correct response: Without delay Explanation: Emergency surgeries are unplanned and occur with little time for preparation for the client or the perioperative team. An active bleed, which is indicated by the "coffee-ground" emesis, is considered an emergency, and the client requires immediate attention because the disorder may be life threatening. The surgery would not likely be deferred until after elective surgeries have been completed.

A client is undergoing a splenectomy. To complete preoperative paperwork, the nurse documents the client's desired outcomes. Which would not be an appropriate nursing goal for a perioperative client? assuring the client that he will be free of pain throughout recovery minimizing the client's anxiety before surgery preparing the client physically for surgery assisting the client in an uncomplicated recovery

Correct response: assuring the client that he will be free of pain throughout recovery Explanation: Being totally free of pain throughout recovery is not a realistic outcome. The other options represent appropriate goals for perioperative clients. Reference:

A nurse evaluates the potential effects of a client's medication therapies before surgery. Which drug classification may cause respiratory depression from an associated electrolyte imbalance during anesthesia? corticosteroids diuretics insulin anticoagulants

Correct response: diuretics Explanation: Diuretics during anesthesia may cause excessive respiratory depression resulting from an associated electrolyte imbalance. Corticosteroids, insulin, and anticoagulants are not known to cause respiratory depression during anesthesia.

During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication? malignant hyperthermia hypothermia infection fluid volume excess

Correct response: malignant hyperthermia Explanation: Malignant hyperthermia is an inherited disorder that occurs when body temperature, muscle metabolism, and heat production increase rapidly, progressively, and uncontrollably in response to stress and some anesthetic agents. If the client's temperature begins to rise rapidly, anesthesia is discontinued, and the OR team implements measures to correct physiologic problems, such as fever or dysrhythmias. Hypothermia is a lower than expected body temperature. Signs of infection would not present during the procedure. Increased body temperature would not indicate fluid volume excess.

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse? Position the client in the side-lying position. Administer an anti-emetic. Obtain an emesis basin. Ask the client for more clarification.

orrect response: Position the client in the side-lying position. Explanation: The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits. The nurse may also obtain an emesis basin and administered an anti-emetic if one is ordered; however, these will be done after the client is repositioned. There is no need for the nurse to ask the client for more clarification.