Chapter 14: Perioperative Care

A 90-year-old female client is scheduled to undergo a partial mastectomy for the treatment of breast cancer. What nursing diagnosis should the nurse prioritize when planning this client's postoperative care? Risk for Delayed Growth and Development related to prolonged hospitalization Risk for Decisional Conflict related to discharge planning Risk for Impaired Memory related to old age Risk for Infection related to reduced immune function

Risk for infection related to reduced immune function

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

Second-intention healing

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? <30 mL Between 75 and 100 mL Between 100 and 200 mL >200 mL

<30 mL

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.

Ensure that the client has had a current cross-match

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

Pulmonary edema

The nurse is caring for a client on the medical-surgical unit postoperative day 5. During each client assessment, the nurse evaluates the client for infection. Which of the following would be most indicative of infection? Presence of an indwelling urinary catheter Rectal temperature of 99.5ºF (37.5ºC) Red, warm, tender incision White blood cell (WBC) count of 8,000/mL

Red, warm, tender incision

A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse? Report the infection to an immediate supervisor. Ensure the infection is covered with a dressing. Return to work after taking antibiotics for 24 hours. Request a role change to circulating nurse.

Report the infection to an immediate supervisor

There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements. Stage I: beginning anesthesia Stage II: excitement Stage III: surgical anesthesia Stage IV: medullary depression

Stage II: excitement

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

Stage IV

Which statement by the client indicates further teaching about epidural anesthesia is necessary? "I will become unconscious." "I will lose the ability to move my legs." "I will be able to hear the surgeon during the surgery." "A needle will deliver the anesthetic into the area around my spinal cord."

"I will become unconscious"

The nurse is providing teaching about tissue repair and wound healing to a client who has a leg ulcer. Which of the following statements by the client indicates that teaching has been effective? "I'll make sure to limit my intake of protein." "I'll make sure that the bandage is wrapped tightly." "My foot should feel cool or cold while my leg's healing." "I'll eat plenty of fruits and vegetables."

"I'll eat plenty of fruits and vegetables."

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

"The health care provider is going to remove my uterus and told me about the risk of hemorrhage"

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."

"The lungs will eliminate the anesthesia through evaporation."

The nurse is caring for a client in the postoperative period following an abdominal hysterectomy. The client states, "I don't want to use my pain meds because they'll make me dependent and I won't get better as fast." Which response is most important when explaining the use of pain medication? "You will need the pain medication for at least 1 week to help in your recovery. What do you mean you feel you won't get better faster?" "Pain medication will help to decrease your pain and increase your ability to breath. Dependency is a risk with pain medication, but you are young and won't have any problems." "Pain medication can be given by mouth to prevent the risk of dependency that you are worried about. The pain medication has not been shown to affect your risk of a slowed recovery." "You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is given for an extended period of time."

"You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is given for an extended period of time."

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."

"the surgical team is aware of the risk, so the team is prepared."

The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room? 4 5 6 7

7

A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery? 2 weeks 4 weeks 7 to 10 days 2 to 3 days

7 to 10 days

A patient with renal failure is scheduled for a surgical procedure. When would surgery be contraindicated for this patient due to laboratory results? A blood urea nitrogen level of 42 mg/dL A creatine kinase level of 120 U/L A serum creatinine level of 0.9 mg/dL A urine creatinine level of 1.2 mg/dL

A blood urea nitrogen level of 42 mg/dL

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

All of the options are correct

In preparing the client for transfer to the operating room, which of the following actions by the nurse is inappropriate? Allow the client to wear dentures. Remove all jewelry. Have the client void. Have client wear hospital gown.

Allow the client to wear dentures

A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take? Discuss the risk for infection caused by wearing the ring. Allow the client to wear the ring and cover it with tape. Notify the surgeon to cancel surgery. Remove the ring once the client is sedated.

Allow the client to wear the ring and cover it with tape

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

As soon as it is indicated

The nurse is planning client teaching for a client who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching? Upon the client's admission to the postanesthesia care unit (PACU) When the client returns from the PACU During the intraoperative period As soon as possible before the surgical procedure

As soon as possible before the surgical procedure

The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply.) Assisting the patient with leg exercises Encouraging early ambulation Massaging the legs every 4 hours Avoiding placement of pillows or blanket rolls under the patient's knees Applying compression stockings only at night

Assisting the patient with leg exercises Encouraging early ambulation Avoiding placement of pillows or blanket rolls under the patient's knees

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

Atelectasis

The intraoperative nurse advocates for each client who receives care in the surgical setting. How can the nurse best exemplify the principles of client advocacy? By encouraging the client to perform deep breathing preoperatively By limiting the client's contact with family members preoperatively By maintaining the privacy of each client By eliciting informed consent from clients

By maintaining the privacy of each client

The nurse is preparing a client for surgery. The client states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take? Have the client sign the informed consent and place it in the chart. Call the physician to review the procedure with the client. Explain the procedure clearly to the client and her family. Provide the client with a pamphlet explaining the procedure.

Call the physician to review the procedure to the client and her family

The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system? Cardiovascular system Endocrine system Gastrointestinal system Genitourinary system

Cardiovascular system

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? Complete blood count Central venous pressure Upper endoscopy Chest x-ray

Central venous pressure

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.

Check the client's ID bracelet

The nurse just received a postoperative client from the PACU to the medical-surgical unit. The client is an 84-year-old woman who had surgery for a left hip replacement. What concern should the nurse prioritize for this client in the first few hours on the unit? Beginning early ambulation Maintaining clean dressings on the surgical site Close monitoring of neurologic status Resumption of normal oral intake

Close monitoring of neurlogic status

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

Dantrolene sodium

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound dehisced. eviscerated. pustulated. hemorrhaged.

Dehisced

When creating plans of nursing care for clients who are undergoing surgery using general anesthetic, what nursing diagnoses should the nurse identify? Select all that apply. Disturbed sensory perception related to anesthetic Risk for impaired nutrition: less than body requirements related to anesthesia Risk of latex allergy response related to surgical exposure Disturbed body image related to anesthesia Anxiety related to surgical concerns

Disturbed sensory perception related to anesthetic Risk of latex allergy response related to surgical exposure Anxiety related to surgical concerns

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

Educating clients on signs and symptoms of infection

A gunshot wound would be classified under which category of surgery based on urgency? Emergent Elective Required Urgent

Emergent

The surgeon's preoperative assessment of a client has identified that the client is at a high risk for venous thromboembolism. Once the client is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the client's risk of this complication? Maintain the head of the bed at 45 degrees or higher. Encourage early ambulation. Encourage oral fluid intake. Perform passive range-of-motion exercises every 8 hours.

Encourage early ambulation

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

Establishing an IV line Verifying the surgical site with the client Taking measures to ensure the client's comfort

Which term refers to the protrusion of abdominal organs through the surgical incision? Hernia Dehiscence Erythema Evisceration

Evisceration

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

First intention

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

First intention

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

First intention

A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for? Dehydration Hypertension Hypoglycemia Glucosuria

Hypoglycemia

The nurse is preparing an elderly client for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the client? Hypothermia Pulmonary edema Cerebral ischemia Arthritis

Hypothermia

The nurse admits a client to the PACU 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. Of what is the client showing signs? Hypothermia Hypovolemic shock Neurogenic shock Malignant hyperthermia

Hypovolemic shock

The intraoperative nurse is implementing a care plan that addresses the surgical client's risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication? Impaired skin integrity Hypoxia Malignant hyperthermia Hypothermia

Hypoxia

The clinic nurse is doing a preoperative assessment of a client who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the client's medical history, the nurse notes that this client had a kidney transplant 8 years ago and that the client is taking immunosuppressive drugs. For what is this client at increased risk when having surgery? Rejection of the kidney Rejection of the implanted lens Infection Adrenal storm

Infection

A 21-year-old client is positioned on the OR bed prior to knee surgery to correct a sports-related injury. The anesthesiologist administers the appropriate anesthetic. The OR nurse should anticipate which of the following events as the team's next step in the care of this client? Grounding Making the first incision Giving blood Intubating

Intubating

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

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? Have the client sit in a chair and 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.

Keep the client positioned supine

The nurse is preparing to send a client to the OR for a scheduled surgery. What should the nurse ensure is on the chart when it accompanies the client to surgery? Select all that apply. Laboratory reports Nurses' notes Verification form Social work assessment Dietitian's assessment

Laboratory reports Nurses' notes Verification form

A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery? Leg exercises increase the client's muscle mass postoperatively. Leg exercises improve circulation and prevent venous thrombosis. Leg exercises help to prevent pressure sores to the sacrum and heels. Leg exercise help increase the client's level of consciousness after surgery.

Leg exercises improve circulation and prevent venous thrombosis

Which action should not be allowed when wearing masks in the operating room? Covering the nose and mouth completely Letting masks hang around the neck Changing masks between treating clients Wearing the mask fitted tight

Letting masks hang around the neck

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order. Lubricate the sterile suction catheter. Don sterile gloves. Apply intermittent suction while withdrawing the catheter. Position the client in Fowlers position. Insert suction catheter into the lumen of the tube. Apply intermittent suction while withdrawing the catheter.

Position the client in Fowlers position. Don sterile gloves. Lubricate the sterile suction catheter. Insert suction catheter into the lumen of the tube. Apply intermittent suction while withdrawing the catheter.

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.

Position the client in the side-lying position

The nurse is performing wound care on a 68-year-old postsurgical client. Which of the following practices violates the principles of surgical asepsis? Holding sterile objects above the level of the nurse's waist Considering a 1 inch (2.5 cm) edge around the sterile field as being contaminated Pouring solution onto a sterile field cloth Opening the outermost flap of a sterile package away from the body

Pouring solution onto a sterile field cloth

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

Preparing the sterile instruments for the surgical procedure

The circulating nurse will be participating in a 78-year-old client's total hip replacement. What consideration should the nurse prioritize during the preparation of the client in the OR? 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.

Pressure points should be assessed and well padded

A client is scheduled for a bowel resection in the morning and the client's orders include a cleansing enema 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

Preventing potential contamination of the peritoneum

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

Rapid, weak, thready pulse

A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate? Answer the client's questions. Request that the surgeon come and answer the questions. Place the consent form in the client's medical record. Notify the nurse manager of the client's questions.

Request that the surgeon come and answer the questions.

A 79-year-old man is scheduled for surgical repair of an inguinal hernia. In light of this patient's age, the nurse will prioritize nursing interventions aimed at preventing: Overstimulation Skin breakdown Hyperglycemia or hypoglycemia Early ambulation

Skin breakdown

The client vomits during the surgical procedure. The best action by the nurse is: Increase the IV infusion rate to compensate for lost fluids. Suction the client to remove saliva and gastric secretions. Lower the head of the operating table to promote circulation to the brain. Administer an anti-emetic to alleviate nausea.

Suction the client to remove saliva and gastric secretions

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The child's parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed? A social worker should temporarily sign the informed consent. Consent should be obtained from the hospital's ethics committee. Surgery should be done without informed consent. Surgery should be delayed until the parents arrive.

Surgery should be done without informed consent

Which clinical manifestation is often the earliest sign of malignant hyperthermia? Tachycardia (heart rate >150 beats per minute) Hypotension Elevated temperature Oliguria

Tachycardia (heart rate >150 beats per minute)

The nurse is checking the informed consent for an older adult client who requires surgery and who has recently been diagnosed with Alzheimer disease. When obtaining informed consent, who is legally responsible for signing? The client's next of kin The client's spouse The client The surgeon

The client

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client? The client can be discharged from the PACU. The client must remain in the PACU. The client should be transferred to an intensive care area. The client must be put on immediate life support.

The client can be discharged from the PACU

The OR nurse is taking the client into the OR when the client informs the operating nurse that his grandmother 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 grandmother's surgery has minimal relevance to the client's surgery. The client may be at risk for a sudden onset of postsurgical infection.

The client may be at risk for malignant hyperthermia

The nurse admitting a client who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this client's diagnosis of type 1 diabetes affect the care that the nurse plans? The nurse should administer a bolus of dextrose IV solution preoperatively. The nurse should keep the client NPO for at least 8 hours preoperatively. The nurse should initiate a subcutaneous infusion of long-acting insulin. The nurse should assess the client's blood glucose levels vigilantly.

The nurse should assess the clients' blood glucose levels vigilantly

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

Therapeutic touch

A client vomits postoperatively. What is the most important nursing intervention? Measure the amount of vomitus to estimate fluid loss, in order to accurately monitor fluid balance. Offer tepid water and juices to replace lost fluids and electrolytes. Support the wound area so that unnecessary strain will not disrupt the integrity of the incision. Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.

Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.

At what point does the preoperative period end? When the decision is made to proceed with surgery When the client is transferred onto the operating table When the client is admitted to the PACU When the client signs the consent form

When the client is transferred onto the operating table

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

Without delay because the bleed is emergent

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing? Hyperthermia Atelectasis Wound infection Uncontrolled pain

Wound infection

A surgical client has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). What must the client require for safe and effective use of PCA? A clear understanding of the need to self-dose An understanding of how to adjust the medication dosage A caregiver who can administer the medication as prescribed An expectation of infrequent need for analgesia

a clear understanding of the need to self-dose

Hypothermia may occur as a result of the infusion of warm fluids. increased muscle activity. open body wounds. being young.

open body wounds

A client is in the post anesthesia care unit following abdominal surgery. The client is showing frank, increased bleeding, and the client's blood pressure is plummeting. Which intervention will the nurse perform to manage and minimize hemorrhage and shock? reinforce dressing and apply pressure elevate the head of bed provide back rub encourage deep breathing

reinforce dressing and apply pressure

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

Pallor

Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery? Nurse Physician Case manager Certified nurse's aide

Physician

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

Pink to red and soft, bleeding easily

A fractured skull would be classified under which category of surgery based on urgency? Elective Required Urgent Emergent

Emergent

The nurse is educating a community group about types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true? A biopsy A face-lift Tumor excision Placement of gastrostomy tube

Tumor excision

What is the highest priority nursing intervention for a client in the immediate postoperative phase? Maintaining a patent airway Monitoring vital signs at least every 15 minutes Assessing urinary output every hour Assessing for hemorrhage

Maintaining a patent airway

Fentanyl is categorized as which type of intravenous anesthetic agent? Tranquilizer Opioid Dissociative agent Neuroleptanalgesic

Opioid

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

adrenal insufficiency

The nurse understands that the purpose of the "time out" is to: verify all necessary supplies are available. identify the client's allergies. clarify the roles of the OR personnel. maintain the safety of the client.

maintain the safety of the client

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

malignant hyperthermia