Chapter 30 Perioperative Nursing PrepU N400
A nurse is assessing a client who is experiencing pulmonary embolus. What would be the priority nursing intervention for this client? Attempt to overhydrate the client with fluids. Instruct the client to perform Valsalva maneuver. Place the client in semi-Fowler's position. Assist the client to ambulate every 2 to 3 hours.
Place the client in semi-Fowler's position. Explanation: Nursing interventions include notifying the physician 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).
A client is undergoing conscious sedation for an endoscopy. When the client becomes overly sedated, which medication does the nurse anticipate will be required? morphine midazolam lorazepam naloxone
naloxone Explanation: Naloxone is a reversal drug, as it is the antagonist for opiates like morphine. The other medications are inappropriate choices.
Which postoperative complications can be reduced by appropriate client teaching about deep-breathing exercises? Select all that apply. Atelectasis Pneumonia Bronchitis Severe hypoxemia Deep vein thrombophlebitis Wound infection
Atelectasis Pneumonia Bronchitis Severe hypoxemia Explanation: Deep-breathing exercises can decrease respiratory complications. Deep vein thrombophlebitis and wound infection are unrelated to deep-breathing exercises.
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? Immediately have the client sign the consent form. Have the client's family member sign the consent form. Ask the client if he still wants to proceed with the procedure. Notify the physician of the oversight.
Notify the physician 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.
A client who came in through the emergency department with a severely fractured leg will be transported to surgery within the hour. When the client asks how long hospitalization will occur after surgery, what is the appropriate nursing response? "Because you are having inpatient surgery, you will be hospitalized at least 1 day after surgery." "Outpatient surgery patients usually get to go home the same day." "With the type of injury you have sustained, you will be in the hospital about 4 days." "The anesthesiologist will be able to give you a better idea of how long you will be hospitalized."
"Because you are having inpatient surgery, you will be hospitalized at least 1 day after surgery." Explanation: With a severe fracture, the client will be considered as having inpatient surgery and will be hospitalized at least a day. The nurse should not give a definitive period of time for hospitalization, and the surgeon (not the anesthesiologist) will give the best predictor of length of stay.
The nurse is teaching a client who will undergo abdominal surgery to repair a hernia about leg exercises. When the client asks, "Why am I practicing leg exercises when I'm having hernia surgery?" what is the appropriate nursing response? "This technique will help with pain control." "Leg exercises facilitate quicker healing of the incision." "It prevents the postoperative risk for respiratory complications." "Doing this reduces your risk of developing blood clots."
"Doing this reduces your risk of developing blood clots." Explanation: Leg exercises help to promote circulation and reduce the risk for formation of a thrombus in the veins. Leg exercises do not help with pain control, facilitate quicker healing, or reduce the risk for respiratory complications.
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? "I will need to check with your health care provider about that." "Yes—you should be off all of your medications for 24 hours before surgery." "No—you should stay on your normal medication schedule before the surgery." "You should stay on your cholesterol medicine but stop taking all other medications 12 hours before surgery."
"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.
The adult male client with significant body hair is being prepared for abdominal surgery. The client states his dad had the same surgery many years ago and was shaved prior to the procedure. Which explanation would the nurse provide the client? "That practice is no longer standard, as shaving may cause breaks in the skin." "We no longer shave skin before procedures but we will apply a lotion that will remove the hair." "Your abdomen will be shaved in the operating room." "You will be shaved as well."
"That practice is no longer standard, as shaving may cause breaks in the skin." Explanation: A surgical "prep," or shaving of the hair in the affected area, was a common preoperative procedure a decade ago. Current research indicates that preoperative shaving increases the risk for surgical site infection by causing tiny breaks in skin integrity.
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? Determine the possible cause of the client's bleeding. Apply pressure to the surgical site to decrease bleeding. Assess the client's vital signs. Notify the health care provider.
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.
Which methods would the nurse anesthetist use when administering regional anesthesia to surgical clients? Select all that apply. Inhalation Spinal block Intravenous Oral route Nerve block Epidural block
Spinal block Nerve block Epidural 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.
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? Type of surgery Age of client Client's support system Type of anesthesia
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.
The nurse knows the term perioperative phase refers to care given to the client: before, during, and after the operative phase. from the start of surgery until its conclusion. immediately before an operative procedure. immediately after the operative phase.
before, during, and after the operative phase. Explanation: Perioperative nursing includes three distinct phases: preoperative, intraoperative, and postoperative.
A nurse teaches deep breathing exercises to a client scheduled for surgery. In which perioperative phase would this action occur? preoperative intraoperative postoperative postanesthesia care unit (PACU)
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.
A nurse is caring for a client who is admitted to the health care facility for surgery. Which activities take place before inpatient surgery? Select all that apply. prior laboratory tests home care note diagnostic tests meet family members meet anesthesiologist
prior laboratory tests diagnostic tests meet anesthesiologist Explanation: Many people who have inpatient surgery undergo prior laboratory and diagnostic tests. Some clients meet the anesthesiologist or anesthetist, a nurse specialist who administers anesthesia under the direction of a physician. Most clients will have received preoperative instructions from either the surgeon's office nurse or a hospital nurse. Meeting family members is not part of inpatient surgery; neither is a home care note. A home care note is given to a client when he is discharged from the health care facility as part of the outpatient surgery routine.
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? side-lying position supine position Trendelenburg position prone position
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.
The nurse recognizes that palliative surgery is performed for what purpose? to remove a part of the body that is diseased to lessen the intensity of an illness to make or confirm a diagnosis to restore function to tissue that is traumatized
to lessen the intensity of an illness Explanation: Palliative surgery is performed to help lessen the intensity of an illness; it is not meant to be curative but will help improve the client's quality of life. A diagnostic surgery makes or confirms a diagnosis such as with a biopsy to check for cancer. A removal of a body part that is diseased is ablative surgery, such as an appendectomy. Restoring function to traumatized tissue is reconstructive surgery, such as with plastic surgery.
A nurse from the ambulatory surgical center is preparing discharge instructions for a client who has had pelvic surgery. Which criterion would the client need to demonstrate to ensure that she is ready for discharge? verbalize absence of pain void normally eat without nausea exhibit no bleeding
void normally Explanation: Before discharge from an ambulatory surgical unit, the client should be able to void normally after a pelvic surgery. It is natural for the client to experience pain after surgery; however, the client should also have the comfort level to control it. The client may not be in a position to eliminate nausea and vomiting completely before discharge, but should suffer minimally from them. The client may have some bleeding or drainage, which should not be excessive at the time of discharge from an ambulatory surgical unit.
Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? "I can have a hamburger and French fries as soon as I wake up." "The better I eat before surgery, the more likely I will heal." "I might be sick to my stomach and throw up after surgery." "When I can eat again, the best meal would include protein and vitamin C"
"I can have a hamburger and French fries as soon as I wake up." Explanation: Oral fluid and food may be withheld until intestinal motility resumes.
The nurse is educating a client who is preparing for abdominal surgery tomorrow. A teaching demonstration has just been completed by the nurse related to splinting the incision site with a pillow. Which statement by the client best indicates the instructions provided by the nurse were effective? "I should hold my breath and place the pillow over the incision when coughing." "I will place the pillow on the incision after I cough." "I have to move the pillow from one side of the incision to the other when coughing." "I will put the pillow on the incision then cough."
"I will put the pillow on the incision then cough." Explanation: Splinting the incision site when moving helps to minimize pain or discomfort postoperatively when coughing or moving. Clients should not hold their breath when trying to cough or move to prevent the Valsalva maneuver, which can change the heart rate and blood pressure of a client. Placing the pillow on the incision site after coughing is ineffective at reducing pain. The pillow should remain over the incision until the coughing exercises are completed.
A client who is in the holding area awaiting knee replacement surgery tells the nurse, "I am afraid of getting HIV if I have to have a blood transfusion during this surgery." What is the appropriate nursing response? "You should have given your own blood preoperatively." "Knee replacement surgeries usually do not require blood transfusions." "The risk of acquiring a blood-borne disease from a blood transfusion is very small." "Perhaps we can have one of your siblings donate blood in case you need it."
"The risk of acquiring a blood-borne disease from a blood transfusion is very small." Explanation: The nurse will teach that the chance of acquiring a blood-borne disease from a blood transfusion is very small. Giving blood preoperatively may have been ideal, but that does not address the client's immediate concern. Although transfusions are not commonly associated with knee replacement surgery, this does not address the client's concern. Siblings should not donate blood for a client because antigens in the transfused blood sensitizes the client recipient, which would rule them out as a future organ or tissue donor for the client.
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? "Take off your oxygen nasal prongs during your exercises and replace them as soon as you're done." "Try to do your exercises every 1 to 2 hours." "It's best to do your exercises before a meal rather than after eating and drinking." "If possible, lie flat on your back while you're doing your breathing exercises."
"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.
A postoperative home care client has developed thrombophlebitis in the right leg. What new plan of care will need to be added because of this complication? Anticoagulant treatment and education about the increased risk of bleeding Antibiotic treatment and education about finishing the full course of medication Antihistamine treatment and education about thrombophlebitis Antigens and education about the immune response of medication use
Anticoagulant treatment and education about the increased risk of bleeding Explanation: An anticoagulant is a drug (blood thinner) that treats, prevents, and reduces the risk of blood clots breaking off and traveling to vital organs of the body. Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative clients. Antibiotics are used for infection. Antihistamines block the histamine systematically, as in an allergic response and the histamine released by the stomach. An antigen is a toxin or other foreign substance that induces an immune response in the body, especially the production of antibodies.
The nurse is developing a plan of care for a client who had a splenectomy. The outcome is prevention of surgical site infection. Which interventions should be included in the client's plan of care? Select all that apply. Assess vital signs. Monitor white blood cell count. Use asepsis with dressing change. Monitor bowel sounds. Maintain hydration. Reposition client frequently.
Assess vital signs. Monitor white blood cell count. Use asepsis with dressing change. Maintain hydration. Explanation: The client with an outcome of prevention of surgical site infection needs adequate nutrition and fluid for healing. The client needs to be monitored for signs of infection with vital signs, white blood cell count, and surgical site. Asepsis needs to be used with dressing changes. Interventions for other potential complications include monitoring bowel sounds (which helps with recognition of peristalsis return) and repositioning the client frequently, which will help with prevention of atelectasis.
The acute care nurse is preparing a client for surgery. Which action is essential to complete before transferring the client to surgery? Assure that diagnostic testing has been completed and results are available. Place the client in a side-lying position. Remove graduated compression stockings. Mark the client's skin to indicate the location of the surgery.
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.
The nurse is assessing several clients for postsurgical risk factors. Which risk factor does the nurse identify that could create postoperative complications? Select all that apply. Cardiovascular diseases increase the risk for dehydration after surgery. Clients with respiratory disease may experience alterations in acid-base balance after surgery. Kidney and liver diseases influence the client's response to anesthesia. Endocrine diseases increase the risk for hyperglycemia after surgery. Endocrine diseases increase the risk for slow surgical wound healing. Pulmonary disorders increase the risk for hemorrhage and hypovolemic shock after surgery.
Clients with respiratory disease may experience alterations in acid-base balance after surgery. Kidney and liver diseases influence the client's response to anesthesia. Endocrine diseases increase the risk for slow surgical wound healing. Explanation: Acid-base balance alterations are more likely to occur in clients with respiratory diseases because of the effects of anesthesia. Kidney and liver diseases negatively influence the client's ability to metabolize and excrete anesthesia. Endocrine diseases, such as diabetes, increase the risk for slow wound healing and hypoglycemia. Cardiovascular diseases increase the risk for anesthesia complications, including hemorrhage and hypovolemic shock, hypotension, venous stasis, thrombophlebitis, and overhydration with IV fluids.
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? Explore the client's feelings and inform the surgeon. Assess the client's rationale and affirm that she has made a good decision. Remind the client that she has signed the informed consent documents. Ask the client about her understanding of the potential benefits of the surgery.
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.
A client who has been experiencing a gradual decrease in mobility has been scheduled for elective knee replacement surgery in 3 weeks. Which teaching points should the nurse choose for the outpatient group education session? Select all that apply. How to cleanse skin with a special soap solution Time for limitations with eating and drinking When and where to arrive for surgery What to expect before, during, and after surgery Where to park, so upon discharge can drive home
How to cleanse skin with a special soap solution Time for limitations with eating and drinking When and where to arrive for surgery What to expect before, during, and after surgery Explanation: During a group outpatient education session for clients scheduled for elective surgery, the nurse would cover general topics, including use of surgical skin cleanser; timing for limitations for eating and drinking before surgery; where to arrive and what to expect before, during, and after surgery. The nurse would discuss the importance of having a responsible adult accompany the client to the surgical unit so that person will take them home once the client is discharged. The client would not be expected to park a car and drive home later because the effects of anesthesia and pain medications would impair his or her judgment. The effects of surgery would impair his or her ability to drive a car safely.
After conducting a preoperative health assessment, the nurse documents that the client has physical assessments supporting the medical diagnosis of emphysema. Based on this finding, which is the priority risk of complications in the postoperative period? Urinary retention Constipation Impaired physical mobility Impaired gas exchange
Impaired gas exchange Explanation: A nurse should complete a focused assessment on previous medical issues, especially the respiratory system, after surgery. Respiratory disorders, such as emphysema, increase the risk for respiratory depression from anesthesia as well as postoperative pneumonia and atelectasis, causing impaired gas exchange. Impaired physical mobility, constipation and urinary retention would be of concern but not as important as impaired gas exchange related to the diagnosis of emphysema.
A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client? Position the client in bed with pillows placed under his knees to hasten venous return. Keep the client from ambulating until the day after surgery. Implement leg exercises and turn the client in bed every 2 hours. Keep the client cool and uncovered to prevent elevated temperature.
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.
The preoperative nurse has prepared a client for surgery and has been notified that the operating room staff is ready for the client. The client states, "My bladder feels full. I need to go to the bathroom!" Which action by the nurse is appropriate? Inform the operating room staff and assist the client to the bathroom. Inform the client that anesthesia will prevent the bladder from emptying during surgery. Insert a catheter into the bladder. Remind the client that bladder fullness is a common preoperative sensation.
Inform the operating room staff and assist the client to the bathroom. Explanation: Clients should empty the bowel and bladder before surgery. A urinary catheter is not indicated. The remaining statements are untrue.
The nurse is preparing a client for coronary artery bypass graft cardiac surgery. Which interventions should the nurse provide during the preoperative phase? Select all that apply. Instruct the client how to use the incentive spirometer. Measure the legs for graduated compression stockings. Prep the skin of the chest and legs with surgical prep. Explain what to expect after the surgery. Assess the midsternal and leg dressings.
Instruct the client how to use the incentive spirometer. Measure the legs for graduated compression stockings. Explain what to expect after the surgery. Explanation: During the preoperative phase the nurse would instruct the client on what to expect after surgery, including lines, chest tubes, and mechanical ventilator. The nurse would instruct the client on how to use the incentive spirometer and mark on it the client's maximum volume, so the goal after surgery is that the client can reach that level. This ensures that the client is taking a sufficient deep breath. Measurements for graduated compression stockings are made before surgery since the client will wear them after surgery. Surgical skin prep is intraoperative. Midsternal and leg dressings are assessed during the postoperative phase.
A nurse teaches deep breathing exercises to a preoperative client. Which action should the nurse perform? Assist or place the client in a supine position for the exercises. Instruct the client to place the palms of both hands along the upper posterior rib cage. Instruct the client to exhale gently and completely before inhaling. Instruct the client to breathe in through the nose as deeply as possible and hold the breath for 10 seconds.
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.
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? It promotes induction of anesthesia. It decreases gastric acidity and volume. It promotes sleep or conscious sedation. It decreases respiratory secretions.
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.
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? 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. Ask the client to sign the consent; witness the signature and inform the operating room staff of the modification in the procedure. Send the client to the operating room and inform the staff that the consent form needs to be signed. Ask the operating room staff to delay the procedure until the consent is signed.
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).
A nurse asks a preoperative client which medications he is currently taking. Which statement describes an accurate guideline for client teaching regarding these medications? Aspirin is generally stopped 1 month before surgery. Cardiac drugs must be stopped for 1 week before surgery. Many respiratory drugs may be taken the day of surgery per health care provider's order. If the client is diabetic and takes insulin, the dose will be increased before surgery.
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.
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? Monitor the client closely and promote fluid intake. Contact the physician to come assess the client. Immediately administer a cleansing enema. Increase the rate of the client's intravenous infusion.
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.
Which nursing action will best promote pain management for a client in the postoperative phase? Breathing into a paper bag Performing relaxation techniques Dimming the lights Providing food and medication
Performing relaxation techniques Explanation: Performing relaxation techniques is the best nursing action to promote pain management for a client in the postoperative phase.
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? Remove extra coverings on the client to keep temperature down. Place the client in a flat position with legs elevated 45 degrees. Do not administer any further medication. Place the client in the prone position.
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.
The nurse is caring for a client who just returned from the postanesthesia care unit following surgery to repair a fractured arm. Place the following interventions in order of highest priority to lowest priority. A) Measure oxygen B) Assess for pain and administer prescribed analgesics, if indicated C) Measure pulse, blood pressure, respirations, and temperature D) Assess neurovascular status to the affected arm E) Place the client in a position that facilitates breathing F) Assess dressing for bleeding or other drainage
Place the client in a position that facilitates breathing. Measure pulse, blood pressure, respirations, and temperature. Measure oxygen saturation. Assess neurovascular status to the affected arm. Assess dressing for bleeding or other drainage. Assess for pain and administer prescribed analgesics, if indicated. Explanation: Priority of assessment is airway, breathing, circulation (ABC). Thus, the correct order of interventions is as follows: 1) Place the client in a position that facilitates breathing. 2) Measure pulse, blood pressure, respirations, and temperature. 3) Measure oxygen saturation. 4) Assess neurovascular status to the affected arm. 5) Assess dressing for bleeding or other drainage. 6) Assess for pain and administer prescribed analgesics, if indicated.
A nurse is caring for an older adult following hip surgery. When teaching the client to use an incentive spirometer, the nurse should explain that this reduces the risk of what complication? Bronchitis DVT Pneumonia Asthma
Pneumonia Explanation: In the older adult client, postoperative pneumonia can be a very serious complication resulting in death. Therefore, it is especially important to encourage and assist the client in using the incentive spirometer and with deep-breathing exercises. These exercises do not address the client's risk of DVT, bronchitis, or asthma.
The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency? Respiratory obstruction Cardiac distress Wound infection Dehydration
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.
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? Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact. Explain the client's need for hip surgery to visitors and ask them for information about a durable power of attorney for health care. Look on the chart for a living will if a durable power of attorney for health care cannot be located. 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.
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.
A health care provider schedules an emergency surgery for a client with intestinal perforation. Which action should the nurse take to prepare the client for immediate surgery? Start an intravenous line Discuss discharge planning with the family Obtain informed consent Administer pain medication
Start an intravenous line Explanation: Nurses are responsible for preparing the client physically and emotionally to ensure optimal conditions for surgery. Specific client preparation is prescribed by the surgeon or indicated by health care facility policy, but usually it includes placing the client on NPO status, starting an IV line, preparing the intestinal tract and skin, and administering preoperative medications. Pain medication would be withheld immediately prior to surgery so it does not combine with preoperative medication. The nurse may be involved in obtaining consent, usually by witnessing the client's signature on the consent document. The health care provider will obtain the consent by explaining the procedure.
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? The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed. After taking a deep breath, the client demonstrates how to exhale into the mouthpiece while in the semi-Fowler position. The client explains the procedure should be completed first thing in the morning before rising from the bed. The client repeats the explanation and instructions in one's own words to demonstrate understanding.
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.
Which client in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse? a 30-year-old client who is drowsy and reporting pain a 6-year-old client who is crying for a parent to visit an 80-year-old client who is disoriented to place and time a 26-year-old client who is exhibiting a crowing sound
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.
Which client would a nurse monitor most closely for postoperative respiratory complications? a 75-year-old client with a history of hypertension who had a colonoscopy an 8-year-old client with no medical problems who had a tonsillectomy a 55-year-old client with a history of asthma who had a colon resection a 31-year-old client with no medical problems who had an appendectomy
a 55-year-old client with a history of asthma who had a colon resection Explanation: All of these clients have a potential for respiratory complications, which can occur with chest or abdominal surgery, preexisting cardiovascular or respiratory disease, and in older adults or obese clients. The client who has had abdominal surgery and has preexisting respiratory disease would be at the greatest risk for observation of any respiratory complications (due to having two factors instead of only one). The pediatric client having a tonsillectomy would need to be observed for any airway problems but would not be a greater risk than the client with two risk factors.
Which of these clients in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse? a client reporting incisional pain rated 8/10 and no medication orders a client reporting nausea who requests an antiemetic a client with snoring respirations who arouses readily a client who is pale and diaphoretic with a heart rate of 115 beats/minute
a client who is pale and diaphoretic with a heart rate of 115 beats/minute Explanation: All of these clients need attention, but the one who is pale and diaphoretic with an elevated heart rate is the most unstable; this client needs further assessment to determine if there is a fluid volume deficit, which could be due to active bleeding or inadequate fluid replacement during surgery.
A client is undergoing surgery for an appendectomy. This would be considered what type of surgery? emergency surgery elective surgery palliative surgery diagnostic surgery
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.
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. administering inhalation anesthetics positioning the client on the operating table administering regional nerve blocks counting sponges before and after surgery monitoring the client's vital signs
positioning the client on the operating table counting sponges before and after surgery monitoring the client's vital signs Explanation: 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.
When preparing a client who has diabetes mellitus for surgery, the nurse should be aware of what surgical risk associated with this disease? fluid and electrolyte imbalance slow wound healing respiratory depression from anesthesia altered metabolism and excretion of drugs
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.
When reviewing a client's history prior to surgery to correct a wrist fracture, which factors does the nurse identify that place the client at a higher risk for perioperative complications? Select all that apply. father suffered from alcohol use disorder BMI of 23 smokes cigarettes, ½ pack per day hemoglobin 14 g/dL (1.4 g/L) 23 years of age had surgery 2 years ago to repair torn anterior cruciate ligament skin turgor 4 seconds
smokes cigarettes, ½ pack per day skin turgor 4 seconds Explanation: Smoking is a factor that may increase the client's risk for perioperative complications. Skin turgor of 4 seconds may reflect mild dehydration, which also increases the risk. A family history of alcohol use disorder does not increase the client's risk unless the client also consumes alcohol. The BMI and hemoglobin presented are normal. The client's age is not a risk factor. A history of previous surgery without noted complications does not necessarily increase the risk for perioperative complications associated with the upcoming surgery.
A surgical client has been ordered a dose of IV cephalosporin. Why is it important that this drug be administered as close as possible to the time of surgery? to prevent the development of atelectasis postoperatively . to prevent the development of aspiration intraoperatively. to allow for decreased level of white blood cells. to maximize serum levels of the medication during surgery.
to maximize serum levels of the medication during surgery. Explanation: A cephalosporin antibiotic is administered just before the surgical procedure so that the level of medication circulating in the client's blood will be high during surgery.
What is the nurse's role in the informed consent process for a surgical procedure? explaining what takes place during the procedure providing benefits and risks of the procedure witnessing the signed informed consent document granting permission for surgery to be done
witnessing the signed informed consent document Explanation: The nurse may witness the signed informed consent document. The health care provider will explain what takes place during the procedure, and provide benefits and risks. The client grants permission for surgery to be done.