chapter 17
The client's surgery has been delayed because of hyperkalemia. The client asks why. What is the nurse's best response?
"By making sure your potassium level is normal before surgery, your heartbeat will be strong and regular during your surgery."
The nurse is performing preoperative teaching with a client who will be having colon resection surgery the following day. The surgeon has ordered bowel preparation for the client to be taken that night. Which statement by the client indicates that additional teaching is needed?
"I will take my antibiotics with a glass of orange juice tonight."
The nurse has just completed preoperative teaching with a female client who will be having surgery the following day. Which statement by the client indicates that additional teaching is needed?
"I will wear my lucky earrings tomorrow during the surgery."
The preoperative client tells the nurse that he has an advance directive with durable power of attorney. The client asks how the advance directive will affect his surgery. What is the nurse's best response?
"If you are unable to make a decision, your designee will be asked."
The client asks why the nurse signs the operative consent form under her signature as a witness. What is the nurse's best response?
"It confirms that you voluntarily signed the form."
When the nurse brings the client's preoperative medications the client responds "I don't need that. I had a good night's sleep last night." What is the nurse's best response?
"The medication will help prevent some complications during surgery."
The client will be undergoing palliative surgery to debulk an abdominal tumor. The client's daughter asks why the surgery is considered to be palliative. What is the nurse's best response?
"The surgery will relieve the symptoms of the bowel obstruction. It will not cure your father."
The nurse applies antiembolism stockings to a preoperative client who complains that the hose is uncomfortable and that he wishes to have them removed. What is the nurse's best response?
"They will only be on your legs during surgery and they will be removed in the recovery room"
The nurse is performing preoperative teaching with a client who will be having sinus surgery the following day. Which is an accurate statement for the nurse to include in preoperative teaching?
"You may take your digoxin (Lanoxin) in the morning with a small sip of water."
Twenty minutes after the client has received a preoperative injection of atropine and midazolam (Versed) the client tells the nurse that he must be allergic to the medication because his mouth is dry and his heart seems to be beating faster than normal. Which is the nurse's priority action?
Assessing the client's pulse and blood pressure
The nurse is preparing to transfer a client to the operating room for surgery. The client has already received the preoperative medications and is becoming drowsy. What is the best method to verify the client's identity?
Check the client's medical record number and name with the chart and ID band.
A client is brought to the hospital unconscious and needs emergency surgery. The client's only family member cannot come to the hospital before the surgery. Which is the best option for obtaining informed consent for the client's emergent surgery?
Contact the family member by phone and obtain verbal consent with two witnesses.
A client is brought to the emergency department (ED) after a motorcycle accident. The client has suffered a ruptured spleen and requires surgery to stop the hemorrhaging. Which type of surgery will the client have?
Emergent surgery
The client receiving preoperative medication tells the nurse that she took all the following vitamins and herbs last night before going to bed. Which one will the nurse report to the surgical team?
Garlic
The nurse is caring for a client who will be having surgery on his right knee. What is the best method to ensure that the surgery is performed on the correct knee?
Have the surgeon and the client mark a "yes" and their initials with marker on the knee to be operated on.
During the preoperative assessment the client tells the nurse that he smokes three packs of cigarettes daily. The information alerts the nurse to which potential complication that the client may experience during surgery and recovery?
Increased risk for atelectasis and hypoxia
When examining an adult client's preoperative laboratory results the nurse notes that the potassium level is 2.9 mEq/mL. What is the nurse's best action?
Notifies the surgeon and anesthesiologist
The client undergoing preoperative assessment before an elective procedure tells the nurse that she has been taking 10 mg of prednisone daily for rheumatoid arthritis. What is the nurse's best action?
Notifies the surgeon and the anesthesiologist
The nurse is completing preoperative teaching for a client and it becomes apparent that the client does not understand the surgery that will be performed. What is the priority action for the nurse?
Notify the surgeon and note the finding in the client's chart.
The nurse reviews the client's laboratory results prior to surgery. Which finding will the nurse report immediately?
Prothrombin time (PT): 15.2 seconds
The nurse is caring for an older adult client with a history of emphysema who will be undergoing surgery the following day. Which nursing diagnosis is the highest priority for this client?
Risk for impaired gas exchange
The preoperative client tells the nurse that she has allergies to several substances. Which allergy presents the greatest potential problem considering the scheduled surgery?
Shrimp
The client scheduled to have surgery within the next 2 hours tells the nurse during the admission interview the following information. What information should the nurse be certain to communicate on the outside of the chart for the entire surgical team to know?
The client is hard of hearing.
The nurse is conducting a preoperative assessment for a client who will be having surgery in a few days. Which client is at high risk for developing a deep vein thrombosis (DVT) postoperatively?
The client undergoing hip replacement surgery
The nurse is caring for a client who will be undergoing emergency surgery. Which information is
What to expect in the operating and recovery room
The nurse is conducting preoperative teaching with a client who will be undergoing pelvic surgery. The nurse explains the use of antiembolism stockings and pneumatic compression devices. Which statements by the client indicate that additional teaching is needed?
a. "At least I will only have to wear the white stockings and SCD during surgery and not when I am recovering afterward." c. "Since I am wearing antiembolism stockings, I won't have to worry about putting my slippers on to go for a walk." f. "I'm glad that the stockings and SCD will be off during the night so I can sleep."
