Chapter 30 Perioperative Nursing

Which nursing action will best promote pain management for a client in the postoperative phase? A. Performing relaxation techniques B. Providing food and medication C. Breathing into a paper bag D. Dimming the lights

A. Performing relaxation techniques Explanation: Performing relaxation techniques is the best nursing action to promote pain management for a client in the postoperative phase. Reference: Chapter 30: Perioperative Nursing, p. 952.

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

A. Place the client in semi-Fowler's position. Explanation: Nursing interventions include notifying the health care provider immediately, calling the medical intervention team, maintaining the client on bed rest in the semi-Fowler's position, assessing vital signs frequently, administering oxygen, administering medications (e.g., anticoagulants, analgesics), and instructing the client to avoid Valsalva maneuver (this prevents increased intrathoracic pressure and, possibly, increased emboli). Reference: Chapter 30: Perioperative Nursing, p. 952.

An older adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client? A. Opioid overuse B. Delirium C. Boredom D. Dementia

B. Delirium Explanation: Delirium refers to acute confusion that is reversible. It is common in the acute postoperative period. Reference: Chapter 30: Perioperative Nursing, p. 958.

The nurse-anesthetist is monitoring the client during surgery. He notices a ventricular arrythmia and unstable blood pressure. He notifies the surgeon. The operative team suspects: A. Mitral valve prolapse B. Myocardial infarction C. Malignant hyperthermia D. Major blood loss

C. Malignant hyperthermia Explanation: The symptoms of malignant hyperthermia are masseter muscle rigidity, ventricular arrythmia, tachypnea, cyanosis, skin mottling, and unstable blood pressure. Reference: Chapter 30: Perioperative Nursing, p. 959.

The preoperative nurse is reviewing the chart of a client whose surgery is scheduled to begin in the next 15 minutes and notices that the consent form is not signed. The nurse contacts the surgeon who states, "We have already reviewed this procedure extensively, so ask the client to sign the consent form and I will verify it in the operating room." Which action by the nurse is appropriate? A. Ask the operating room staff to delay the procedure until the consent is signed. B. Ask the client to sign the consent; witness the signature and inform the operating room staff of the modification in the procedure. C. Send the client to the operating room and inform the staff that the consent form needs to be signed. D. Keep the client in the preoperative area and inform the surgeon that it is the health care provider's responsibility to obtain consent for surgery.

D. Keep the client in the preoperative area and inform the surgeon that it is the health care provider's responsibility to obtain consent for surgery. Explanation: If a consent form is not signed, the nurse should notify the surgeon. It is the health care provider's responsibility to obtain consent for surgery and anesthesia. Preoperative medications cannot be given until the consent form is signed. The client should not proceed to surgery without a signed consent form (unless it is an emergency). Reference: Chapter 30: Perioperative Nursing, p. 941, 955.

Which nursing action will assist in pain management for a client in the postoperative phase? A. Relaxation techniques B. Client education C. Provide food and medication D. Dim lighting

A. Relaxation techniques Explanation: Nursing interventions vital in helping clients cope with pain include administering medications, positioning, relaxation techniques, psychological support, distraction techniques, and appropriate referrals to other health professionals. Reference: Chapter 30: Perioperative Nursing, p. 952.

The preoperative nurse is teaching a client about deep-breathing exercises. The client asks, "Why do I need to learn about this?" Which response by the nurse is correct? A. "If you learn how to perform these exercises correctly, you will not need supplemental oxygen during surgery." B. "After surgery, deep-breathing exercises help to remove anesthetic gases and mucus and improve oxygen supply to body tissues." C. "These techniques will prevent trapped air from accumulating in your lungs." D. "These types of exercises help distract you from the postoperative pain."

B. "After surgery, deep-breathing exercises help to remove anesthetic gases and mucus and improve oxygen supply to body tissues." Explanation: Deep-breathing exercises are intended to help prevent postoperative complications, such as low oxygen levels, accumulation of secretions, and atelectasis. Reference: Chapter 30: Perioperative Nursing, p. 952.

A nurse is interacting with a client in the outpatient surgical unit intraoperatively. What is the nurse's priority responsibility? A. Educating the client about postoperative protocols B. Providing emotional support for the client and family C. Client safety D. Establishing a nurse-client rapport

C. Client safety Explanation: Client safety is the most important nurse responsibility during the intraoperative phase. Safety concerns include equipment, electrical, chemical, radiation, surgical verification, client transport and positioning, and continuous asepsis. Postoperative protocol education is done preoperatively. Establishing a nurse-client rapport and providing emotional support are important, but they are not the most important nursing responsibility during the intraoperative phase. Reference: Chapter 30: Perioperative Nursing, Outpatient/Same-Day Surgery, p. 942.

The nurse educates a client about what to expect after abdominal surgery. How will the nurse explain the progression of a client's diet in the postoperative period? A. You may eat anything you want following surgery. B. You will receive a diet high in vitamin B. C. In the immediate postoperative period, you will receive a soft diet high in carbohydrates. D. Food and liquids will be held in the immediate postoperative period.

D. Food and liquids will be held in the immediate postoperative period. Explanation: Intestinal manipulation, pain medications, and anesthetic agents may result in a decrease in intestinal motility. The client may experience nausea and vomiting. Therefore, after surgery, fluids and food are often withheld until gastric motility returns. A diet with sufficient amounts of protein and vitamins A and C (not vitamin B) helps to rebuild tissues and promotes wound healing. A soft diet with adequate (not high) carbohydrates for energy is started after the client has demonstrated tolerance to liquids well. Clients are not able to eat anything they want following surgery; the diet is usually progressed from NPO, to clear then full liquids, a soft diet, and finally a regular diet. Reference: Chapter 30: Perioperative Nursing, Fluid and Nutrition Needs, p. 964.

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

A. Apply warm blankets to the client. Explanation: The nurse should apply warm blankets to the client because the client is hypothermic with a temperature of 96.2°F (35.7°C). The client can be assessed further by checking vital signs and using an oxygen saturation monitor. The health care provider should be notified about the client's temperature but an intervention should be done first to ensure the client begins warming immediately. Reference: Chapter 30: Perioperative Nursing, p. 959.

The nurse is performing a preoperative assessment of a client who has been scheduled for a reduction mammoplasty (breast reduction). The client states, "I'm starting to wonder if I made the right decision in going ahead with this." What should the nurse do next? A. Explore the client's feelings and inform the surgeon. B. Assess the client's rationale and affirm that she has made a good decision. C. Ask the client about her understanding of the potential benefits of the surgery. D. Remind the client that she has signed the informed consent documents.

A. Explore the client's feelings and inform the surgeon. Explanation: The nurse should discuss this and notify the care provider. Clients should not undergo surgery until they are sure that surgery is what they want. Informed consent documents do not bind the client to an earlier decision. It would be inappropriate to try to convince the client to go through with the surgery if she is questioning her decision. Reference: Chapter 30: Perioperative Nursing, pp. 968-973.

The graduate nurse will be orienting to the role of circulator in perioperative services. What statements made by the nurse requires further education regarding the role of the circulator? Select all that apply. A. "I will be responsible for preparing the sterile surgical table for the procedure." B. "I will be responsible for maintaining the client's rights during the surgical procedure." C. "I will be responsible for assisting the surgeon with instruments and exposure during the procedure" D. "I will be responsible for accounting for all sponges and instruments following the surgical procedure" E. "I will be responsible for ensuring that the "time out" is performed prior to the procedure"

A. "I will be responsible for preparing the sterile surgical table for the procedure." C. "I will be responsible for assisting the surgeon with instruments and exposure during the procedure" Explanation: The circulating nurse ensures that the client's rights are protected and coordinates client care in the operating room. The circulating nurse and the scrub person are responsible for accounting for all sponges and instruments at the close of surgery. Reference: Chapter 30: Perioperative Nursing, p. 957.

The nurse needs to evaluate the effectiveness of a preoperative teaching session with a client scheduled for abdominal surgery. Which client statement indicates the need for further clarification? A. "While my pneumatic compression device is on, I don't need to do leg exercises." B. "I will sit up in bed before using my incentive spirometer." C. "I will splint my incision while I cough." D. "Every 2 hours while I am awake, I will take deep breaths and cough."

A. "While my pneumatic compression device is on, I don't need to do leg exercises." Explanation: Compression stockings and pneumatic compression devices help to decrease the formation of thrombus by helping to promote venous return to the heart. The nurse needs to clarify that the pneumatic compression device does not replace leg exercises because the exercises help keep the joints flexible and help strengthen muscles while the client is in bed. The client is correct that splinting the incision when coughing is important. The client should sit up in bed when using the incentive spirometer, taking deep breaths and coughing. The client should take deep breaths and cough at least every 2 hours while awake to help expand lungs, loosen secretions, and help prevent atelectasis and pneumonia. Reference: Chapter 30: Perioperative Nursing, p. 970.

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

A. Apply pressure to the surgical site to decrease bleeding. Explanation: It is essential that the nurse be prepared to address life-threatening needs of the client. Excessive bleeding is a life-threatening issue. Determining the cause of the client's bleeding, assessing the vital signs, and notifying the health care provider are important, but the life-threatening issue must be addressed first. Reference: Chapter 30: Perioperative Nursing, p. 961.

The nurse is caring for a client in the postanesthesia care unit (PACU). Which assessment is the priority for this client? A. Assess respiratory status. B. Auscultate bowel sounds. C. Obtain temperature. D. Check the neurologic status.

A. Assess respiratory status. Explanation: In the immediate postoperative period, the client is most at risk of respiratory compromise due to the effects of anesthesia; thus, a respiratory assessment takes priority. The client could have constipation postoperatively, but this is not a priority over respiratory status. Obtaining a temperature and neurologic status are important in the immediate postoperative period, but airway is priority. Reference: Chapter 30: Perioperative Nursing, pp. 955-980.

The acute care nurse is preparing a client for surgery. Which action is essential to complete before transferring the client to surgery? A. Assure that diagnostic testing has been completed and results are available. B. Place the client in a side-lying position. C. Mark the client's skin to indicate the location of the surgery. D. Remove graduated compression stockings.

A. Assure that diagnostic testing has been completed and results are available. Explanation: All prescribed diagnostic tests should be performed, and results made available before the client goes to surgery. Unless otherwise indicated, no special positioning is required preoperatively. Graduated compression stockings, if prescribed, should remain in place. The surgeon, not the nurse, is responsible for marking the skin. Reference: Chapter 30: Perioperative Nursing, pp. 968-973.

The preoperative nurse is admitting a client who is scheduled for surgery later in the day. The client is wearing contact lenses, has several body piercings, has fingernails covered with nail polish, and is wearing cosmetics, false eyelashes, and a wedding band. Which should the nurse instruct the client to remove before the surgery? Select all that apply. A. Body piercings B. Contact lenses C. Cosmetics D. Fingernail polish E. False eyelashes F. Wedding band

A. Body piercings B. Contact lenses C. Cosmetics D. Fingernail polish E. False eyelashes Explanation: The nurse should request that the client remove all but the wedding band. Cosmetics, jewelry, nail polish, and prostheses (such as contact lenses and false eyelashes) can interfere with assessment during surgery, so clients should be asked to remove them. Some facilities allow a wedding band to be taped to the finger. Reference: Chapter 30: Perioperative Nursing, p. 955.

The nurse is caring for a client admitted for an outpatient surgical procedure. Which action will the nurse include in the care? Select all that apply. A. Discuss discharge transportation during the preoperative period. B. Begin discharge education as soon as the procedure is completed. C. Allow family members to be present during discharge education. D. Begin discharge education in the preoperative period. E. Investigate the client's home care and discharge transportation following the procedure.

A. Discuss discharge transportation during the preoperative period. C. Allow family members to be present during discharge education. D. Begin discharge education in the preoperative period. Explanation: Client education begins during the preoperative period and continues throughout all perioperative phases of care. In the preoperative phase, assess the client's and family's readiness to learn and their knowledge base so that education can be individualized. If the client will be discharged on the day of surgery, be sure to identify someone who can take the client home and assist during the postoperative recovery period. Reference: Chapter 30: Perioperative Nursing, pp. 938-942.

A client is scheduled for hip replacement surgery this morning but admits to the nurse that he had a small piece of toast and some water after waking up. What is the nurse's most appropriate response? A. Inform the anesthesiologist or surgeon of this fact. B. Explain the rationale for preoperative fasting to the client. C. Assess the client's abdomen by inspection and auscultation. D. Have the OR postpone the surgery due to the risk of aspiration

A. Inform the anesthesiologist or surgeon of this fact. Explanation: The surgeon or anesthesiologist must be informed if a client has not adhered to preoperative fasting instructions, since this constitutes a risk for aspiration. There is no benefit to assessing the client's abdomen. Unilaterally postponing the surgery would be beyond the nurse's scope. Reference: Chapter 30: Perioperative Nursing, p. 955.

A nurse teaches deep breathing exercises to a preoperative client. Which action should the nurse perform? A. Instruct the client to exhale gently and completely before inhaling. B. Instruct the client to breathe in through the nose as deeply as possible and hold the breath for 10 seconds. C. Assist or place the client in a supine position for the exercises. D. Instruct the client to place the palms of both hands along the upper posterior rib cage.

A. Instruct the client to exhale gently and completely before inhaling. Explanation: The nurse should assist the client to sit up and place the palms of both hands along the lower anterior rib cage. The client should then exhale gently and completely inhale through the nose as deeply as possible, holding the breath for 3 seconds. Reference: Chapter 30: Perioperative Nursing, p. 952.

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

A. Place the client in a flat position with legs elevated 45 degrees. Explanation: Placing the client in a flat position with the legs elevated 45 degrees uses gravity to help direct blood to the vital organs. Removing extra coverings would cause the client's temperature to drop further during the blood loss occurring during shock. Medications will likely be ordered to help treat the shock. Prone position would be contraindicated. Reference: Chapter 30: Perioperative Nursing, p. 962.

The outpatient surgery nurse is preparing to discharge a client who has recovered from surgery. Which actions should the nurse plan to carry out before the client is discharged? Select all that apply. A. Provide verbal postoperative instructions. B. Provide instructions about caring for the intravenous (IV) catheter that will remain in place until the postoperative appointment. C. Provide a sterile specimen cup and instructions about collecting a routine postoperative urine sample. D. Ask the client to list home medications and allergies. E. Provide contact information to schedule a postoperative appointment with the surgeon. F. Provide written postoperative instructions.

A. Provide verbal postoperative instructions. F. Provide written postoperative instructions. E. Provide contact information to schedule a postoperative appointment with the surgeon. Explanation: The nurse should provide verbal and written discharge instructions and information about a follow-up appointment. Questions about home medications and allergies should be asked preoperatively. IV catheters are typically removed before discharge. Collecting a postoperative urine sample is not routine. Reference: Chapter 30: Perioperative Nursing, p. 955.

The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency? A. Respiratory obstruction B. Cardiac distress C. Dehydration D. Wound infection

A. Respiratory obstruction Explanation: Respiratory obstruction may occur as a result of secretion accumulation, obstruction by the tongue, laryngospasm (a sudden, violent contraction of the vocal cords), or laryngeal edema. Cardiac distress, wound infection, and dehydration are all possible postoperative complications, but respiratory obstruction is most common. Reference: Chapter 30: Perioperative Nursing, p. 959.

The nurse is caring for a client who had a procedure under moderate sedation at the ambulatory surgical center. Which assessment finding indicates to the nurse that the client may be ready for discharge to home? A. The client is alert and oriented with a blood pressure 118/70 mm Hg and respirations 18 breaths/minute, is able to ambulate, is not nauseated or vomiting, pain is controlled with medication, and has no excessive bleeding and drainage is as expected. B. The client is alert and oriented with a blood pressure of 136/90 mmHg and respirations 18 breaths/minute, states mild nausea but no vomiting, pain under control with pain medication, able to void and pass gas, and has mild expected drainage. C. The client is alert and oriented with a blood pressure 122/74 mm Hg and respirations 18 breaths/min, able to ambulate, is not nauseated or vomiting, reports a pain level of 5 on a 0-10 scale, and has no excessive bleeding or drainage. D. The client is alert and oriented with a blood pressure 102/60 mm Hg and respirations 18 breaths/minute, is slightly dizzy, but not nauseated or vomiting, denies pain, and has no excessive bleeding or drainage.

A. The client is alert and oriented with a blood pressure 118/70 mm Hg and respirations 18 breaths/minute, is able to ambulate, is not nauseated or vomiting, pain is controlled with medication, and has no excessive bleeding and drainage is as expected. Explanation: Stable vital signs, being alert and oriented, ability to ambulate, minimal nausea and vomiting, adequate pain control, and no excessive bleeding or drainage may indicate that the client is ready for discharge to home. The ability to void is a criterion after a spinal anesthesia or after pelvic surgery. Dizziness or inadequate pain control indicate that the client still needs to be monitored before discharge. Elevated blood pressure should be monitored and the client should not be discharged until stable. Reference: Chapter 30: Perioperative Nursing, Postoperative Nursing Care, p. 958.

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

A. The client will be admitted the day of surgery and return home the same day. Explanation: Outpatient surgeries, also known as ambulatory surgeries, are conducted with admission and discharge on the same day. Such surgeries have become increasingly common in recent years, and some surgeries of increasing complexity and risk are conducted on an outpatient basis. General anesthesia is possible and common. This approach is more common for elective surgeries than urgent surgeries. Reference: Chapter 30: Perioperative Nursing, p. 939.

When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of: A. a partial airway obstruction. B. the normal return of reflexes. C. the effects of anesthesia. D. the type of surgery.

A. a partial airway obstruction. Explanation: Loud, irregular respirations may indicate obstruction of the airway, possibly from emesis, accumulated secretions, or client positioning that allows the tongue to fall to the back of the throat. Reference: Chapter 30: Perioperative Nursing, pp. 944-959.

The nurse is assessing an obese client scheduled for heart surgery. Which priority surgical risk related to obesity should the nurse monitor? A. delayed wound healing and wound infection B. hemorrhage C. nutritional maintenance D. alterations in fluid and electrolyte balance

A. delayed wound healing and wound infection Explanation: Fatty tissue has a poor blood supply and, therefore, has less resistance to infection. As a result, postoperative complications of delayed wound healing, wound infection, and disruption in the integrity of the wound are more common. Alterations in fluid and electrolyte balance are more likely to occur with the malnourished client. Respiratory distress is a high risk for clients with preexisting respiratory conditions. Clients with cardiovascular disease are at an increased risk for hemorrhage. Reference: Chapter 30: Perioperative Nursing, p. 946.

The nurse has delegated to the unlicensed assistive personnel (UAP) the application of antiembolism stockings to a client who had an endarterectomy earlier in the day. Which UAP action requires the nurse to immediately intervene? A. massages legs prior to application B. cleanses hands with alcohol-based hand rub C. elevates the legs 15 minutes after applying stockings D. measures calf circumference

A. massages legs prior to application Explanation: Massaging the legs can dislodge clots. Other actions are appropriate and do not require intervention. Reference: Chapter 30: Perioperative Nursing, p. 965.

A nurse teaches deep breathing exercises to a client scheduled for surgery. In which perioperative phase would this action occur? A. preoperative B. intraoperative C. postoperative D. postanesthesia care unit (PACU)

A. preoperative Explanation: Exercises and physical activities occurring in the preoperative phase include deep breathing exercises, coughing, incentive spirometry, turning, leg exercises, and pneumatic compression stockings. The intraoperative phase is when the client is in the operating room. In the postoperative area and postanesthesia care unit areas, clients are monitored and deep breathing exercises begin. Reference: Chapter 30: Perioperative Nursing, p. 952.

An 83-year-old client who wears glasses is scheduled for surgery. Which action should the nurse take to assure the client remains oriented? A. Give the glasses to the family until the client is returned to the room. B. Allow the client to wear glasses until just before anesthetic is administered. C. Allow the client to wear glasses until after anesthetic is administered. D. Direct the client to leave glasses at home for safety.

B. Allow the client to wear glasses until just before anesthetic is administered. Explanation: If an adult client is visually impaired, the nurse should allow the client to leave the glasses on until just before an anesthetic is administered. Doing so maintains visual orientation and helps to decrease fear and increase confidence. If a client is having a regional or local anesthetic, operating room personnel may allow the client to wear glasses or contact lenses during the procedure. The nurse should note any visual impairment on the chart so that operating room personnel are aware of this deficit. Glasses should not be given to the family unless the client has requested that action and there is no need for the client to leave glasses at home. Reference: Chapter 30: Perioperative Nursing, Anesthesia, p. 940.

Which methods would the nurse anesthetist use when administering regional anesthesia to surgical clients? Select all that apply. A. Oral route B. Epidural block C. Inhalation D. Nerve block E. Intravenous F. Spinal block

B. Epidural block D. Nerve block F. Spinal block Explanation: Regional anesthesia occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. Regional anesthesia includes spinal blocks, nerve blocks, and epidural blocks. Inhalation and intravenous administration of anesthesia are associated with general anesthesia. Anesthesia is not administered via the oral route. Reference: Chapter 30: Perioperative Nursing, p. 941.

A nurse is giving preoperative information to a client scheduled for outpatient surgery. What are recommended education guidelines? Select all that apply. A. Continue with all medications routinely taken. B. Have someone available for transportation home after recovery from anesthesia. C. Wear clothing without buttons or zippers. D. Notify the surgeon's office if a cold or infection develops before surgery. E. List allergies and be sure the operating staff is aware of these.

B. Have someone available for transportation home after recovery from anesthesia. D. Notify the surgeon's office if a cold or infection develops before surgery. E. List allergies and be sure the operating staff is aware of these. Explanation: The nurse should list medications routinely taken and ask the health care provider which should be taken or omitted the morning of surgery. The nurse should also have the client notify the surgeon's office if a cold or infection develops before surgery. The nurse should list allergies and be sure the operating staff is aware of these. The nurse should tell the client to wear clothing that buttons in front. The nurse should tell the client to have someone available for transportation home after recovery from anesthesia. The nurse should also inform the client of limitations on eating or drinking before surgery, with a specific time to begin the limitations. Reference: Chapter 30: Perioperative Nursing, p. 942.

A nurse is preparing a client for endotracheal intubation. The anesthesiologist has ordered an anticholinergic medication for this client. What is an action of this medication? A. It promotes sleep or conscious sedation. B. It decreases respiratory secretions. C. It promotes induction of anesthesia. D. It decreases gastric acidity and volume.

B. It decreases respiratory secretions. Explanation: An anticholinergic medication decreases respiratory secretions and prevents vagal nerve stimulation during endotracheal intubation. Antianxiety drugs slow motor activity and promote the induction of anesthesia. Histamine-2 receptor antagonists decrease gastric acidity and volume. Sedatives promote sleep or conscious sedation. Reference: Chapter 30: Perioperative Nursing, p. 955.

A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding? A. Increase the rate of the client's intravenous infusion. B. Monitor the client closely and promote fluid intake. C. Contact the health care provider to come assess the client. D. Immediately administer a cleansing enema.

B. Monitor the client closely and promote fluid intake. Explanation: Bowel function does not typically return immediately after surgery, but it can be promoted by encouraging fluid and fiber intake as appropriate to the client and his or her surgery. A medical assessment is likely unnecessary at this early postoperative stage, and an enema would likely be premature. The nurse may not independently increase the client's IV infusion, and doing so would not necessarily promote a bowel movement. Reference: Chapter 30: Perioperative Nursing, p. 964.

The healthy adult client is given an opioid prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first? A. Immediately have the client sign the consent form. B. Notify the health care provider of the oversight. C. Have the client's family member sign the consent form. D. Ask the client if he still wants to proceed with the procedure.

B. Notify the health care provider of the oversight. Explanation: Do not administer any medications that might alter judgment or perception before the client signs the consent form because many drugs commonly administered as preoperative medications, such as opioids or barbiturates, can alter cognitive abilities and invalidate informed consent. Reference: Chapter 30: Perioperative Nursing, pp. 941-942.

Which measure would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client? A. Educate the client about the use of an incentive spirometer. B. Place graduated compression stockings on the client. C. Assist the client with ambulation hourly D. Elevate bilateral legs when the client is lying in bed.

B. Place graduated compression stockings on the client. Explanation: Use of graduated compression stockings and/or pneumatic compression devices on the client will help with prevention of DVT, which is a risk for clients after surgery. Elevating the client's legs will passively improve venous return but not prevent DVT if a client is not up and walking (to more actively promote the venous return). Elevating the head of the bed and using the incentive spirometer help prevent postoperative complications of atelectasis or pneumonia. Early ambulation is beneficial, but it is not necessary for the client to ambulate every hour. Reference: Chapter 30: Perioperative Nursing, p. 970.

A nurse caring for a client postoperatively notes that the dressing on the client's incision was recently clean and dry but is now saturated with a large amount of fresh blood. What intervention should be taken by the nurse in this situation, along with notifying the primary care provider? A. Change the dressing. B. Reinforce the dressing. C. Remove the dressing. D. Leave dressing as is.

B. Reinforce the dressing. Explanation: The nurse should not remove the dressing, but instead should reinforce the dressing with more bandages. Removing the bandage could dislodge any clot that is forming and lead to further blood loss. Reference: Chapter 30: Perioperative Nursing, pp. 973-978.

The nurse is caring for a confused older adult client who requires surgery for a broken hip. What steps does the nurse take to determine if the client has a durable power of attorney for health care and how to contact that person? A. Allow the surgeon to handle the issue as part of his or her legal responsibility for explaining the surgical procedure and obtaining the appropriate signature on the consent form. B. Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact. C. Explain the client's need for hip surgery to visitors and ask them for information about a durable power of attorney for health care. D. Look on the chart for a living will if a durable power of attorney for health care cannot be located.

B. Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact. Explanation: The client cannot give consent due to confusion. In most cases, the durable power of attorney for health care document is discussed and obtained during the admission process. The nurse should act as a client advocate by seeking someone with durable power of attorney to sign the informed consent form. It is the surgeon's responsibility to explain the surgical procedure and obtain the appropriate signature on the consent form; however, the nurse still acts as the client advocate to locate the designated person. A living will specifies the types of medical treatment the client wants should the client become unable to speak in a terminal or permanently unconscious medical condition, but it does not address matters related to client confusion. Telling visitors about the need for surgery may violate client confidentiality. If the nurse identifies who they have permission to disclose medical information to, they can ask that person about a durable power of attorney for health care. Reference: Chapter 30: Perioperative Nursing, Informed Consent and Advance Directives, p. 941.

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

B. a woman who takes daily anticoagulants to treat atrial fibrillation Explanation: Anticoagulants present a risk of hemorrhage. This risk supersedes that posed by thyroid supplements, ACE inhibitors, or most NSAIDs. Thyroid supplements assist with thyroid function. Angiotensin-converting enzyme (ACE) inhibitors help relax blood vessels and lower blood pressure. Nonsteroidal anti-inflammatory drugs (NSAIDs) are a drug class that reduce pain, decrease fever, prevent blood clots, and, in higher doses, decrease inflammation. Reference: Chapter 30: Perioperative Nursing, p. 946.

Upon admission for an appendectomy, the client provides the nurse with a document that specifies instructions for his health care team to follow in the event he is unable to communicate these wishes postoperatively. This document is best known as: A. a Patient's Bill of Rights. B. an advance directive. C. an insurance card. D. an informed consent.

B. an advance directive. Explanation: An advance directive, a legal document, allows the client to specify instructions for his or her health care treatment should he or she be unable to communicate these wishes postoperatively. The advance directive allows the client to discuss his or her wishes with the family members in advance of the surgery. Two common forms of advance directives include living wills and durable powers of attorney for health care. An informed consent is a document that the client and surgeon signs prior to surgery identifying and describing risks and benefits of surgery. A client's bill of rights is a list of guarantees for those receiving medical care. It may take the form of a law or a nonbinding declaration. An insurance card is an identifying card that specifies the type of insurance coverage guaranteed by the company. Reference: Chapter 30: Perioperative Nursing, p. 942.

The nurse is caring for a client who has been admitted to an acute care unit after surgery. When reviewing the client chart, what information will the nurse expect to find in the intraoperative record? A. performance of incentive spirometry B. completion of skin preparation C. initial assessment by an anesthesiologist D. vital signs assessment every hour

B. completion of skin preparation Explanation: The intraoperative phase begins when the client is transferred to the operating room bed and ends upon transfer to the post-surgical recovery area. One of the interventions performed in this phase is skin preparation. The preoperative phase provides client teaching regarding the surgical experience, including a visit by the anesthesiologist. The postoperative phase begins immediately after the surgical procedure is completed when assessments and therapies are performed, such as taking vital signs frequently and monitoring airway/oxygen therapy/pulse oximetry. In addition, it is during the postoperative phase that the client will be encouraged to use incentive spirometry to prevent lung stasis, which can lead to pneumonia. Reference: Chapter 30: Perioperative Nursing, p. 938.

A nurse preparing an older adult client for hip replacement surgery is aware of the surgical risks related to the client's age. Which of the following accurately describes these risks? Select all that apply. A. increased oxygenation of blood B. decreased peripheral circulation C. increased vascular rigidity D. increased cardiac output E. decreased thermoregulation ability

B. decreased peripheral circulation C. increased vascular rigidity E. decreased thermoregulation ability Explanation: Older adults have decreased cardiac output, decreased peripheral circulation, decreased oxygenation of blood, decreased thermoregulation ability, and decreased skin moisture and elasticity. Older adults have increased vascular rigidity. Reference: Chapter 30: Perioperative Nursing, p. 945

An operating room nurse is bringing a client to the nurse in the postanesthesia care unit (PACU). Which information would the operating room nurse provide during a hand-off report? Select all that apply. A. all personnel present in operating room B. drains inserted in surgery C. medications given in operating room D. length of surgery E. performance of time-out before surgery

B. drains inserted in surgery C. medications given in operating room D. length of surgery Explanation: The operating room nurse should give a hand-off report when bringing the client from the operating room and must include several critical pieces of information: medications given, the length of surgery, and any drains inserted. Other data that would be important include presenting condition of the client and any events that occurred during surgery. All personnel present in the operating room would not be an important detail to share; however, this is documented on the operating room record, as well as the time-out that was performed. Reference: Chapter 30: Perioperative Nursing, p. 960.

A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice? Select all that apply. A. administering inhalation anesthetics B. positioning the client on the operating table C. counting sponges before and after surgery D. administering regional nerve blocks E. monitoring the client's vital signs

B. positioning the client on the operating table C. counting sponges before and after surgery E. monitoring the client's vital signs The RN's role is a supportive one for the client, monitoring vital signs and positioning the client on the operating room table. The RN also helps maintain safety by counting sponges and instruments that may have been used during the surgery. The RN is unable to administer anesthetics, such as inhalation agents or regional nerve blocks, without an advanced practice degree. Reference: Chapter 30: Perioperative Nursing, p. 957.

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

B. prior to surgery Explanation: Though leg exercises are begun after surgery, such preventive measures should ideally be taught to the client during the preoperative period. In the postanesthesia care areas, the client has just arrived from the operating room where local or general anesthesia has been used. The client will be sedated but arousable and teaching would be inappropriate. Early signs of venous status is too late for leg exercises to begin, as the clot may have formed. Reference: Chapter 30: Perioperative Nursing, p. 952.

A client who is scheduled to undergo coronary bypass surgery in a week asks the nurse whether he should discontinue taking his cholesterol medicine ahead of the surgery. Which should be the nurse's response? A. "You should stay on your cholesterol medicine but stop taking all other medications 12 hours before surgery." B. "No—you should stay on your normal medication schedule before the surgery." C. "I will need to check with your health care provider about that." D. "Yes—you should be off all of your medications for 24 hours before surgery."

C. "I will need to check with your health care provider about that." Explanation: The client may be permitted to take certain medications before surgery. The health care provider, not the nurse, should provide guidance about which medications should be taken and which ones should be held. Reference: Chapter 30: Perioperative Nursing, pp. 968-973.

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

C. "The operating table is a firm surface; we need to be sure your skin looks okay." Explanation: The client who has been on the operating table should be examined to ensure skin breakdown hasn't occurred. The client would not be told that his covers looked messy, or that the nurse was concerned about sponges or syringes underneath. The client's skin should be assessed on admission; after surgery would not be the time to do this initial assessment to document skin breakdown. Reference: Chapter 30: Perioperative Nursing, p. 977.

The nurse is caring for a client after breast augmentation. Before performing a bowel assessment, what education will the nurse provide the client? A. "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By pressing on the symphysis pubis, I can check for a return of peristalsis." B. "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By giving you sips of water periodically, I can promote the return of peristalsis." C. "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By listening for bowel sounds, I can check for a return of peristalsis." D. "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By lightly pressing on the abdomen, I can check for a return of peristalsis."

C. "You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By listening for bowel sounds, I can check for a return of peristalsis." Explanation: A postoperative client can typically have decreased or absent peristalsis because of bowel manipulation and/or administration of anesthetic agents or opioids. Auscultation of bowel sounds will help determine a return of peristalsis. Palpating the abdomen would not help with determining peristalsis return; the nurse may feel distention and firmness of the abdomen with decreased peristalsis, but this is not accurate in determining return of peristalsis. The symphysis pubis would be assessed to determine bladder fullness, not peristalsis. Giving the client sips of water would not help determine or promote the return of peristalsis; this also could be a safety issue if the client has decreased peristalsis due to emesis and subsequent potential aspiration. Reference: Chapter 30: Perioperative Nursing, Nursing Assessments and Interventions to Meet Postoperative Elimination Needs, p. 964.

A client has presented to the outpatient surgical center for a scheduled procedure. Which action should the nurse perform prior to the procedure? A. Administer analgesia (pain medications). B. Have the client perform leg exercises every 30 minutes. C. Assess the client's allergy status. D. Encourage the client to create an advance directive.

C. Assess the client's allergy status. Explanation: The nurse should assess or confirm the client's allergy status prior to surgery. An advance directive may be in place, but one would not be created on the day of surgery if it were not already established. Analgesia is not normally given preoperatively. Leg exercises should be taught and modeled preoperatively, but they do not need to be performed during this phase. Reference: Chapter 30: Perioperative Nursing, p. 955.

Which preoperative task can the nurse delegate to the UAP (unlicensed assistive personnel)? A. Checking to be sure all diagnostic tests are completed B. Auscultating of the client's breath sounds C. Assisting the client to the bathroom before surgery D. Teaching about use of the incentive spirometer

C. Assisting the client to the bathroom before surgery Explanation: Preoperative tasks would include assessing the client, ensuring all diagnostic tests are complete, and teaching the client regarding the postoperative period. None of these tasks can be delegated to a UAP; however, the UAP can assist the client to the bathroom before transport to a preoperative area or the operating room. Reference: Chapter 30: Perioperative Nursing, p. 968.

The nurse has admitted a client to the postoperative unit following a bowel resection and is providing postoperative health education on coughing and deep breathing. What does the nurse explain to the client about why these actions are important? A. If you continue to breathe shallowly or cough ineffectively, this can lead to dizziness, falling, or an inability to ambulate because of shortness of breath. B. If you continue to breathe shallowly or cough ineffectively, this can lead to acute respiratory distress syndrome. C. If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia. D. If you continue to breathe shallowly or cough ineffectively, this can lead to deep vein thrombosis (DVT) by preventing poor oxygen exchange in the cardiac and peripheral circulatory system.

C. If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia. Explanation: Shallow breathing or an infective cough can lead to mucus plugging, atelectasis, hypoxemia, and pneumonia. Taking deep breaths helps to expand alveoli and an effective cough pushes secretions upward out of the lungs. A client experiencing postoperative pain may be unable or unwilling to take the deep breath needed to cough. Medications used to control pain and splinting the incision by hugging a pillow or blanket increase compliance to deep breathing and coughing exercises. Shallow breathing or ineffective cough does not lead to aspiration pneumonia, inability to ambulate, or DVT. Acute respiratory distress syndrome is caused by sepsis, inhaling harmful substances, injury, and severe pneumonia that has infiltrated all five lobes and is not specific to postoperative-related pneumonia. Reference: Chapter 30: Perioperative Nursing, Deep Breathing, pp. 952-953.

A nurse is caring for an older adult client who had surgery for the removal of a cataract in the left eye. Which issue would prevent the client from being discharged on the day of surgery? A. Voiding on a regular basis B. Inability to see from left eye C. Inability to ambulate D. Alert and oriented ×4

C. Inability to ambulate Explanation: Recovery from anesthesia is usually much quicker when shorter-acting IV anesthetic agents, such used in same-day surgery. Before discharge from an ambulatory surgical unit, the client should: void (after a spinal or epidural anesthetic or after pelvic surgery), be able to ambulate, be alert and oriented, have minimal nausea and vomiting, have adequate pain/comfort control and exhibit no excess bleeding or drainage. The left eye would be covered with a dressing and the client would not be expected to see from that eye immediately. Reference: Chapter 30: Perioperative Nursing, p. 942.

The nurse cares for a client following surgery to repair an abdominal aortic aneurysm. Which nursing intervention assists with healing and maintaining client comfort? A. Keeping the client recumbent B. Allowing family members to visit often C. Maintaining a calm environment D. Providing solid food during postoperative day 1

C. Maintaining a calm environment Explanation: The nurse should plan for adequate periods of rest and sleep and maintain a quiet, restful environment. Nursing interventions that can help promote rest include maintaining a calm environment and limiting interruptions to the client's sleep (including frequent family visits). Providing solid food and keeping the client recumbent will not assist with healing and maintaining client comfort and may be contraindicated. Reference: Chapter 30: Perioperative Nursing, General Condition, p. 960.

A client in the immediate postoperative period begins to report nausea and begins vomiting. Which is the priority nursing action? A. Administer an antiemetic medication B. Provide an emesis basin at the bedside C. Make client NPO and auscultate bowel sounds D. Document the characteristics of emesis

C. Make client NPO and auscultate bowel sounds Explanation: A concern regarding nausea and vomiting in the immediate postoperative period is paralytic ileus. As such, the nurse should immediately make the client NPO, auscultate bowel sounds, and notify the health care provider. Absent bowel sounds can indicate a paralytic ileus. Placing an emesis basin at the bedside is not the priority but is helpful. Administering the antiemetic is not the priority, as assessment should be done first. Documenting characteristics of the emesis should be done, but assessment of the abdomen takes priority. Reference: Chapter 30: Perioperative Nursing, Ongoing Postoperative Care, pp. 960-961.

A client comes to the postoperative area and reports chest pain and palpitations. What priority intervention(s) will the nurse perform? Select all that apply. A. Give sublingual nitroglycerin as prescribed B. Ask the client to rate pain on a scale from zero to ten C. Obtain vital signs, especially heart rate and blood pressure D. Review prior medical history E. Give pain medication as prescribed

C. Obtain vital signs, especially heart rate and blood pressure A. Give sublingual nitroglycerin as prescribed B. Ask the client to rate pain on a scale from zero to ten Explanation: A client having chest pain and palpitations needs to have vital signs (particularly blood pressure and heart rate) checked to ensure that the client is hemodynamically stable. These symptoms may indicate cardiac problems, so the client must be examined closely for any complications such as a myocardial infarction. Sublingual nitroglycerin, not pain medication, is used to treat episodes of chest pain by relaxing the blood vessels, which increases the supply of blood and oxygen to the heart. Having the client rate the pain on a pain scale is useful to evaluate and assess the pain to determine plan of care and evaluate the effectiveness of treatment. Reference: Chapter 30: Perioperative Nursing, Skill 30-2 Providing Postoperative Care (continued), p. 976.

A nurse is reviewing postoperative protocols with the client, including an explanation and a demonstration of how to use an incentive spirometer. How does the nurse know that the teaching on the use of the incentive spirometer was effective? A. The client explains the procedure should be completed first thing in the morning before rising from the bed. B. The client repeats the explanation and instructions in one's own words to demonstrate understanding. C. The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed. D. After taking a deep breath, the client demonstrates how to exhale into the mouthpiece while in the semi-Fowler position.

C. The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed. Explanation: Incentive spirometry improves lung expansion, helps expel anesthetic gases and mucus from the airway, and facilitates oxygenation of body tissues. The client is positioned in high Fowler or sitting position, inhales slowly and deeply through the mouth with lips tightly sealed around the mouthpiece of the spirometer, and exhales slowly while lips are no longer sealed around the mouthpiece. Spirometry is to be performed in the sitting position so conducting this before rising from the bed is inappropriate. Repeating instructions is a valid tool for verbal instructions, however when procedures and protocols are to be conducted the best method for determining understanding is to have the client return demonstration on how to appropriately perform the spirometry. Reference: Chapter 30: Perioperative Nursing, Deep Breathing, p. 952.

A nurse is caring for a postoperative client and preparing to apply a pneumatic compression device. How does the nurse explain the device to the client prior to application? A. The device fills with air supporting the legs during ambulation so blood flow will not pool in the legs and feet, thus preventing blood clots, and squeezes the legs, which increases blood flow through the veins of the legs. B. The device fills with air and squeezes the arms, which increases blood flow through the veins of the arms and helps to prevent blood clots. C. The device fills with air and squeezes the legs, which increases blood flow through the veins of the legs and helps to prevent blood clots. D. The device fills with air and squeezes the legs which increase blood flow through the veins of the legs and should be worn in bed and while ambulating to help prevent blood clots.

C. The device fills with air and squeezes the legs, which increases blood flow through the veins of the legs and helps to prevent blood clots. Explanation: A pneumatic compression device promotes the circulation of venous blood and relocation of excess fluid into the lymphatic vessels. The device is used on the legs and is worn while the client is in bed. Reference: Chapter 30: Perioperative Nursing, Box 30-5 Intermittent Pneumatic Compression Devices (IPCDs), p. 963.

Which factor is most important in the nurse's decision on assessment data, outcomes, and the monitoring needs of a client in preparing for surgery? A. Client's support system B. Type of anesthesia C. Type of surgery D. Age of client

C. Type of surgery Explanation: Although all of these factors would need to be taken into account in planning care for a client going to surgery, the type of surgery is the most important influence on what type of care the client will require after surgery. Anesthesia and age play a role in monitoring needs postoperatively. The client needs an adequate support system when leaving the hospital, but the type of surgery influences the client's needs overall. Reference: Chapter 30: Perioperative Nursing, p. 955.

As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site? A. informed consent B. operative site marking C. procedural pause (time-out) D. preoperative checklist

C. procedural pause (time-out) Explanation: The procedural pause (time-out) must be done prior to any procedure to ensure client safety and to verify the client identity, staff roles, and procedure being performed. Reference: Chapter 30: Perioperative Nursing, p. 956.

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

C. slow wound healing Explanation: Due to impaired circulation and high glucose levels, the client with diabetes is at an increased risk for slow wound healing. The surgical risk of fluid and electrolyte imbalances is often associated with clients who have kidney and liver disease. The risk of respiratory depression from surgery increases for clients with existing respiratory disorders. Altered metabolism may occur as a result of surgery for clients with kidney and liver diseases. Reference: Chapter 30: Perioperative Nursing, p. 645.

Who is legally responsible for obtaining the client's informed consent for a surgical procedure? A. the registered nurse B. any licensed person C. the surgeon D. the admissions clerk

C. the surgeon Explanation: The surgeon is legally responsible for obtaining the client's informed consent; however, the nurse should ensure the signed form has been obtained and is present in the client's chart and answer any questions or concerns the client may have concerning the upcoming procedure. Reference: Chapter 30: Perioperative Nursing, p. 133.

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

D. "An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so." Explanation: An advance directive allows the client to communicate instructions for health care postoperatively in case of an inability to do so. Although an advance directive is either a living will or a durable power of attorney for health care, and the hospital does like to determine if the client has them, these are not the best answers to the client's question. The nurse would not want to explain to the client that they may not wake up after surgery. Reference: Chapter 30: Perioperative Nursing, p. 942.

The nurse is preparing a client for a total hip arthroplasty and is obtaining data preoperatively. Which statement made by the client is most important for the nurse to immediately report to the health care provider? A. "My other hip will probably need to be done eventually." B. "I have not had anything to eat or drink for 8 hours." C. "My hip pain has prevented me from doing the things I enjoy." D. "I've been taking ibuprofen for my hip pain twice a day."

D. "I've been taking ibuprofen for my hip pain twice a day." Explanation: The nurse should immediately report the use of ibuprofen twice daily for the hip pain since this medication can cause the complication of postoperative bleeding. The history of hip pain and the inability to perform activities that were previously enjoyed are not relevant in determining complications. The intake of food or fluids is relevant, but the amount of time the client has been NPO is acceptable and reduces the risk of complications from anesthesia. Reference: Chapter 30: Perioperative Nursing, Managing Pharmacologic Relief Measures, p. 1255.

A nurse is caring for a client in the same-day surgery unit. The client asks the nurse, "Do I really need to be put to sleep for this surgery?" Which would be the nurse's best response? A. "Have you ever had surgery before?" B. "I will have the anesthesiologist talk to you." C. "You do not have to worry. It will be fine." D. "Tell me what you are most worried about."

D. "Tell me what you are most worried about." Explanation: As the client's advocate, the nurse should first assess what the client is most worried about and then provide emotional support. The nurse would not offer false hope, reassurance, nor pass the client off to another team member. Asking if the client had surgery before would not reveal the concerns with this surgery. Reference: Chapter 30: Perioperative Nursing, Coping Patterns and Support Systems, p. 947.

The nurse is providing education about deep-breathing exercises to a postoperative client whose surgery took place earlier today. Which instruction should the nurse provide? A. "If possible, lie flat on your back while you're doing your breathing exercises." B. "Take off your oxygen nasal prongs during your exercises and replace them as soon as you're done." C. "It's best to do your exercises before a meal rather than after eating and drinking." D. "Try to do your exercises every 1 to 2 hours."

D. "Try to do your exercises every 1 to 2 hours." Explanation: Instruct the client that deep-breathing exercises should be performed every 1 to 2 hours for the first 24 hours after surgery. Reference: Chapter 30: Perioperative Nursing, p. 952.

The nurse assists a client to turn in the bed. The client has just returned from abdominal surgery. How does the nurse instruct the client? A. "Change your position frequently." B. "Raise the head of the bed before turning." C. "Wait for assistance before moving in bed." D. "Use a pillow to splint the incision."

D. "Use a pillow to splint the incision." Explanation: The client needs to use a pillow to splint the incision during movement to reduce pain. The client needs to change position every 2 hours or less; "frequently" could be misinterpreted by the client. It is easier to turn laterally when the head of the bed is flat. Independence is encouraged, so if the client feels capable, he or she may move in the bed on his or her own. Reference: Chapter 30: Perioperative Nursing, pp. 968-973.

The circulating nurse calls for a time-out prior to the surgical procedure and the surgeon states, "I don't have time for this. I have another case to follow and need to get busy." What is the best response by the circulator? A. "I understand you are very busy, so we can move on without the time-out." B. "These time-outs are ridiculous anyway; we all know what the client is having done." C. "Whether you have time to do it or not, we will do it without you." D. "We all have the same goal and that is the safety of the client, so let's do the time-out."

D. "We all have the same goal and that is the safety of the client, so let's do the time-out." Explanation: Final verification just prior to beginning the procedure is referred to as the time-out. The time-out occurs immediately before starting the surgical procedure and is initiated by a designated member of the team. The surgeon, the anesthesia provider, the circulating nurse, the operating room technician, and any other active participants conduct the time-out assessment and ensure that there are no questions or concerns. During the time-out, all members of the surgical team must agree on the identity of the client, the correct surgical site, and the procedure that will be performed. The completion of the time-out is documented appropriately. Reference: Chapter 30: Perioperative Nursing, p. 956.

The nurse working in the holding area is performing an assessment on a client scheduled for surgery. Which question will the nurse ask prior to the client receiving general anesthesia? A. "Do you want me to call the hospital chaplain before you have anesthesia?" B. "Can you tell me why you are here this morning?" C. "Which medications do you take daily?" D. "When was the last time you had anything to eat or drink?"

D. "When was the last time you had anything to eat or drink?" Explanation: Determining when the last time the client had anything by mouth is important when undergoing anesthesia. The client ideally should be NPO, nothing by mouth, at least 8 hours prior to a general anesthesia to avoid aspiration during intubation. Assessing daily medications is done before surgery, not in the holding area. Asking the client to verify orientation should have been completed prior to arriving in the holding area. Asking the client if a chaplain should be called is not an appropriate action to take in the holding area. Reference: Chapter 30: Perioperative Nursing, Nutrition and Fluids, p. 954.

A client is undergoing a knee replacement tomorrow morning and is ordered nothing by mouth (NPO) prior to surgery. The client asks the nurse how long before the procedure can water be taken in. Based on the nurse's knowledge of standard protocols, what is the nurse's best response? A. 4 hours B. 12 hours C. 6 hours D. 2 hours

D. 2 hours Explanation: Two hours is a standard NPO time for clear liquids, though the nurse should always check with the institution's policy and the orders of the health care provider. Reference: Chapter 30: Perioperative Nursing, p. 965.

A nurse is teaching a client about the rationale for fasting from food and fluids prior to surgery. What condition does this measure attempt to avoid? A. Bowel alterations B. Respiratory distress C. Infection D. Aspiration

D. Aspiration Explanation: Food and fluid are restricted before surgery to ensure that the stomach contains a minimal amount of gastric secretions. This restriction is important to reduce the risk of aspiration. Reference: Chapter 30: Perioperative Nursing, pp. 968-973.

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

D. Implement leg exercises and turn the client in bed every 2 hours. Explanation: Ambulation and leg exercises increase circulation, which prevents cardiovascular complications. The nurse should provide covers, forced warm air, or other warming devices/techniques as necessary to prevent shivering and hypothermia caused by the surgical procedure, the procedure's length, anesthetic agents, a cool environment, the client's age, or the use of cool irrigating/infusion fluids. Pillows placed under the knees can cause venous pooling, leading to thrombophlebitis. Reference: Chapter 30: Perioperative Nursing, p. 953.

Which fact should the nurse keep in mind when obtaining consent forms from clients scheduled to undergo surgery? A. A consent form is legal, even if the client is confused or sedated. B. The responsibility for securing informed consent from the client lies with the nurse. C. The form that is signed is not a legal document and would not hold up in court. D. In emergency situations, the doctor may obtain consent over the telephone.

D. In emergency situations, the doctor may obtain consent over the telephone. Explanation: Informed consent is the client's voluntary agreement to undergo a particular procedure or treatment, and it protects the client, the health care provider, and the health care institution. In an emergency situation the health care provider can obtain consent from the next of kin, legal guardian, or power of attorney. Consent forms cannot be obtained from confused or sedated clients. The responsibility for securing a consent form lies with the health care provider; the nurse may witness the client signing a consent form. Reference: Chapter 30: Perioperative Nursing, p. 955.

A nurse asks a preoperative client which medications he is currently taking. Which statement describes an accurate guideline for client teaching regarding these medications? A. Cardiac drugs must be stopped for 1 week before surgery. B. Aspirin is generally stopped 1 month before surgery. C. If the client is diabetic and takes insulin, the dose will be increased before surgery. D. Many respiratory drugs may be taken the day of surgery per health care provider's order.

D. Many respiratory drugs may be taken the day of surgery per health care provider's order. Explanation: Adjustments in taking medications may be needed before surgery. Anticoagulants are stopped days before surgery. Certain cardiac and respiratory drugs may be taken the day of surgery per health care provider's order. If the client is diabetic and takes insulin, the insulin dosage may be reduced. Reference: Chapter 30: Perioperative Nursing, pp. 968-973.

A client states having a latex allergy. Which action does the nurse take to communicate this allergy to hospital staff caring for the client? A. Inform the client to tell the anesthesiologist. B. Obtain latex-free gloves for the client's room. C. Place a sign on the client's bed. D. Note the allergy on the client's record.

D. Note the allergy on the client's record. Explanation: Assessing the client for allergies to medications, food, and latex when in a health care facility is an important task of the nurse. Clearly marking the client's allergies on the client's record will communicate to all health care personnel who interact with the client. It is not the client's responsibility to notify the anesthesiologist; the allergy should be clearly noted on the medical record. Obtaining latex-free gloves for the client's room is an appropriate intervention, but it will not communicate to all hospital staff the client's allergy. Placing a sign on the client's bed will inform bedside caregivers of the allergy, but clearly marking the medical record will inform all health care staff of the client's allergy. Reference: Chapter 30: Perioperative Nursing, Nursing Care Plan for Gabrielle McAllister 30-1 (continued), p. 967.

The nurse is caring for a client in the postanesthesia care unit (PACU). The nurse uses specific interventions to avoid complications for each body system. Cardiac: A. Note response to stimulation. B. Monitor urinary function. C. Use sidelying position for lethargic clients. D. Provide verbal stimulation Respiratory: A. Auscultate bowel sounds. B. Assess skin color. C. Check pupillary response. D. Monitor muscle strength. Neurologic: A. Encourage leg exercises. B. Gently touch the client. C. Assess the dressing for drainage. D. Encourage leg exercises.

D. Provide verbal stimulation B. Assess skin color. B. Gently touch the client. Explanation: Providing verbal stimulation helps to expel anesthetic gases, facilitate an increase in consciousness, and subsequently increase blood pressure. Skin color can be assessed as a determinant of efficient or deficient oxygenation of tissues. The nurse can verbally reorient the client following anesthesia using a gentle touch and addressing the client by name. Noting the response to stimulation is a means of assessing a client's neurologic status. Monitoring urinary function will help to determine renal function. The nurse can help to prevent aspiration or airway obstruction by placing lethargic or uncounscious clients in a sidelying position. Constant reorientation in the postoperative period helps to provide psychologic comfort. Pupillary response is an assessment used to determine neurologic status. Bowel sounds are an indicator of bowel motility that must be established prior to the client taking food or drink by mouth. Monitoring muscle strength is a means of assessing neurologic status. Interventions such as monitoring reflexes will help the nurse to identify when anesthetics are wearing off. Assessing the dressing for drainage can be an indicator of fluid loss which can adversly affect cardiovascular function. The performance of leg exercises helps to promote circulation. Provision of a warm blanket helps to reduce shivering, which can contribute to hemodynamic stress and cardiac disturbances. Monitoring laboratory values, for example hematocrit, to help assess circulatory status. Reference: Chapter 30: Perioperative Nursing, Immediate Postoperative Assessment and Care, pp. 958-960.

The nurse is caring for a client who returned from the postanesthesia care unit 3 hours ago. The surgical dressing was dry and intact upon arrival to the postoperative unit, but now it is saturated with fresh blood. Which actions should the nurse take first? A. Measure vital signs. B. Draw a circle around the drainage and note the time. C. Remove the dressing and inspect the wound. D. Reinforce the dressing with more bandages until the bleeding stops.

D. Reinforce the dressing with more bandages until the bleeding stops. Explanation: In this situation, the nurse should not remove the dressing but should reinforce it with more bandages. Removing the bandage could dislodge any clot that is forming and lead to further blood loss. Measuring vital signs would be of lower priority than reinforcing the dressing to stop the bleeding. Drawing a circle around the drainage and noting the time is not the proper first action. Reference: Chapter 30: Perioperative Nursing, pp. 973-978.

The nurse is caring for a client who had abdominal surgery yesterday and is reluctant to cough and perform deep breathing. Which strategy will most likely increase the client's willingness to cough and perform deep breathing? A. Administer respiratory treatments to encourage coughing. B. Assist the client to a side-lying position to cough. C. Remind the client of the serious complications that can result from ineffective coughing and deep breathing. D. Teach the client how to splint the abdomen while coughing.

D. Teach the client how to splint the abdomen while coughing. Explanation: Splinting the abdomen decreases discomfort while coughing. Telling the client about complications will be less effective than teaching splinting techniques. Respiratory treatments are not indicated for cough production. Side-lying position is less effective than upright positioning to clear secretions and expand the lungs. Reference: Chapter 30: Perioperative Nursing, p. 952.

The nurse is teaching a client about postoperative pain management. The client states, "I would like to use as little medication as possible after surgery. Will anything else help to relieve my pain?" Which response is appropriate? A. "There are nonpharmacologic methods, but they only work when clients have practiced them extensively beforehand." B. "Your pain needs to be managed with medication for the first 24 hours, then you can try nonpharmacologic methods." C. Are you afraid of becoming addicted to pain medications?" D. There are several nonpharmacologic methods to reduce pain and anxiety. Let me teach you about some of them."

D. There are several nonpharmacologic methods to reduce pain and anxiety. Let me teach you about some of them." Explanation: Nonpharmacologic measures may reduce anxiety and reduce the need for pain medication at any time during the postoperative period. Asking about fear of addiction does not address the client's question. Nonpharmacologic methods can be implemented postoperatively regardless of prior client experience. Reference: Chapter 30: Perioperative Nursing, pp. 973-978.

Which client in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse? A. an 80-year-old client who is disoriented to place and time B. a 30-year-old client who is drowsy and reporting pain C. a 6-year-old client who is crying for a parent to visit D. a 26-year-old client who is exhibiting a crowing sound

D. a 26-year-old client who is exhibiting a crowing sound Explanation: A client with a crowing sound is exhibiting stridor, which is an indication of an airway obstruction and can be a respiratory emergency. This client needs immediate attention. The client with disorientation needs to be frequently reoriented and observed for safety reasons but is not a priority over respiratory distress. The client who needs pain medication or the pediatric client requesting a parent are also not priority over a client in respiratory distress. Reference: Chapter 30: Perioperative Nursing, p. 944.

The nurse is performing a preoperative screening of laboratory work prior to a client's surgery in the morning. What test results should be immediately discussed with the surgeon and anesthesia care provider? Select all that apply. A. increased hemoglobin level, indicating infection B. a sodium level of 128 mEq/L C. a hemoglobin of 7.2 gm/dL D. a white blood cell count of 18,000 E. a BUN of 9 mg/dL F. a potassium level of 4.2 mEq/L

D. a white blood cell count of 18,000 C. a hemoglobin of 7.2 gm/dL B. a sodium level of 128 mEq/L Explanation: Significant abnormal findings include an elevated white blood cell count (presence of infection), decreased hemoglobin level (presence of bleeding, anemia), and a sodium level of 128 mEq/L which is dangerously low and can lead to seizures or death if not corrected. A BUN/ of 9 is within normal range as is a potassium level of 4.2. Reference: Chapter 30: Perioperative Nursing, p. 948.

A client is undergoing surgery for an appendectomy. This would be considered what type of surgery? A. diagnostic surgery B. palliative surgery C. elective surgery D. emergency surgery

D. emergency surgery Explanation: An appendectomy is considered emergency or urgent surgery. Elective surgery can be scheduled in advance, and a delay has no ill effects. Palliative surgery is done to relieve or reduce the intensity of an illness. Diagnostic surgery is done to make or confirm a diagnosis. Reference: Chapter 30: Perioperative Nursing, p. 940.

The nurse has been waiting until after the administration of a toddler's anesthesia before removing the child's clothing and applying monitoring equipment. Doing these actions after the administration of anesthesia will: A. provide more accurate baseline vital signs. B. enhance thermoregulation. C. minimize blood loss. D. prevent anxiety.

D. prevent anxiety. Explanation: Relaxation can be enhanced by removing the child's clothing, applying the grounding pad, and applying monitoring devices after the child is anesthetized. This action has no effect on vital signs, thermoregulation, or blood loss. Reference: Chapter 30: Perioperative Nursing, p. 940.

The PACU nurse has received a semiconscious client from the operating room and reviews the chart for orders related to positioning of the client. There are no specific orders on the chart related to the client's position. In this situation, in what position will the nurse place the client? A. Trendelenburg position B. supine position C. prone position D. side-lying position

D. side-lying position Explanation: If the client is not fully conscious, place the client in the side-lying position unless there is an ordered position on the client's chart. The supine position means lying horizontally with the face and torso facing up, as opposed to the prone position, which is face down. In the Trendelenburg position, the client is laid supine, or flat on the back with the feet higher than the head by 15-30 degrees. Reference: Chapter 30: Perioperative Nursing, p. 960.

The nurse is caring for a client who has had abdominal surgery. Which intervention(s) will the nurse include to prevent complications for this client? Select all that apply. A. Turn the client and change position frequently. B. Ensure the client remains in bed. C. Administer analgesic medication as required. D. Encourage the client to lie in supine position only. E. Assist the client with the use of incentive spirometry.

E. Assist the client with the use of incentive spirometry. A. Turn the client and change position frequently. C. Administer analgesic medication as required. Explanation: Various interventions are needed to prevent postoperative complications. After abdominal surgery, some primary concerns are pain management, prevention of thromboembolism, prevention on pneumonia and constipation. The nurse will plan for interventions that will prevent these potential primary complications from happening. Mobility is critical to the prevention of pneumonia, thromboembolism and constipation. The client should not be encouraged to remain in bed at all times or to lay in the supine position, because these two actions are risk factors for the named complications. Reference: Chapter 30: Perioperative Nursing, p. 396.