Chapter 39

The nurse admits a client to the postoperative unit following gastric bypass surgery for weight loss. Based on the client's history, what is the priority nursing diagnosis for this client?

Risk for Infection

The nurse admits a client who is scheduled for surgery tomorrow morning. The nursing admission assessment indicates that the client is mildly anxious about the procedure, does not drink alcohol or smoke, is married with two children, and is allergic to kiwi, avocados, and penicillin. The nurse identifies the priority nursing diagnosis for this client as:

Risk for Latex Allergy Response

The circulating nurse is providing care to the surgical client during the interoperative phase. Which of the following are components of the circulating nurse's focus to prevent complications during the surgery? Select all that apply.

Monitor the client's intake and output. Create the operative field, cleanse the site. Maintain the "nontouch" field prior to surgery.

The client asks the preoperative nurse why all of the team members took a time-out before starting the procedure. Which of the following is the nurse's best response?

"This is one of our safety steps to verify you and your surgical procedure."

The preoperative nurse is preparing clients for surgery. Which client does the nurse classify as facing the highest surgical risk?

A 6-month-old with congenital heart anomaly and early stage liver disease

The surgical nurse manager is preparing the schedule based on classification. Surgeries are commonly classified by which of the following? Select all that apply.

Acuity Level of urgency Body system

The nurse is preparing the client for general anesthesia. The client asks what the desired effects of general anesthesia are. Select all that apply.

Analgesia Amnesia Muscle relaxation

A client is to have a sequential compression device (SCD) applied on the postoperative unit. The client is wearing knee-high elastic (antiembolism) stockings. When applying the SCD, what should the nurse do?

Apply the SCD over the knee-high antiembolism stockings.

To promote deep breathing, coughing, and turning by a postoperative client on the first postoperative day, what would be the best action by the nurse?

Assess the client's pain level before these activities.

The nurse is caring for a client who is wearing antiembolism compression stockings. The client repeatedly complains of discomfort caused by the stockings. What actions will the nurse take to improve comfort? Select all that apply.

Assess to determine whether the stockings are the correct size. Ensure there are no wrinkles or rolled areas in the stockings. Check that the stockings are on straight and the heel is in the right place.

A client had a colon resection for removal of a cancerous tumor. Postoperatively, on the surgical floor, which of the following activities would the nurse perform for the purpose of decreasing the risk of postoperative complications? Select all that apply.

Assist the client to turn, breathe deeply, and cough every 2 hours. Assess the drainage from the surgical site. Monitor vital signs on a regular basis.

The nurse is caring for a client with a Salem-sump double-lumen nasogastric (NG) tube to suction. The client complains of nausea and has mild abdominal distention. What is the nurse's priority action?

Check placement of the NG tube.

The staff RN is assigned to an operation with an operating room LPN. The physician employs another RN who will be first assistant for the operation. What role will the staff RN play?

Circulating nurse

A client had a hiatal hernia repair earlier today and is now in the postanesthesia care unit (PACU). The family asks the nurse why the client is in the PACU rather than back in his room on the postsurgical unit. What should the nurse inform the family?

Clients recover from the effects of anesthesia in the PACU and then return to the postsurgical unit for further care.

In the emergency department (ED), the client is diagnosed with a dislocated humerus. What type of anesthesia would the nurse anticipate will be used to repair the dislocation in the ED?

Conscious sedation

The client is scheduled for a bronchoscopy. The client states that they are mildly anxious but is afraid of "going to sleep and never waking up." Which type of anesthesia would be most appropriate for the client?

Conscious sedation

The nurse is caring for a client who had abdominal surgery 3 days ago and will be discharged home later today. The nurse will know that teaching is effective if the client does which of the following? Select all that apply.

Describes clinical findings associated with infection Performs the dressing change as prescribed Completes the regimen of prescribed antibiotics

The client tells the nurse, "I'm so nervous. I want to be knocked out for the surgery so that I don't know what is going on." When the nurse communicates with the surgeon and anesthetist, she tells them that the client desires which type of anesthesia?

General anesthesia

The postoperative client returned to the surgical nursing unit at 1:30 p.m. The evening shift nurse receives the report and begins working at 3:30 p.m. How often will the evening shift nurse take this client's vital signs?

Immediately, then every 30 minutes 2 more times, then hourly

A 2-year-old child is scheduled for a tonsillectomy. When determining the plan of care, what should the nurse do?

Include the parents or caregivers in the plan of care.

The preoperative nurse is preparing a client for surgery. Identify the interventions the nurse will perform. Select all that apply.

Inform the family to wait in the surgical waiting room. Remove the client's dentures and contact lenses Describe who will be in the operating suite.

A client is admitted from a local skilled nursing facility to the outpatient surgery center for surgical debridement of a stage 4 sacral pressure ulcer. The perioperative nurse discovers that the client does not have a signed consent form for the surgery on the chart or in the surgery center. The client says that she has not talked to the surgeon and that she has many questions regarding her surgery. When informed of this, the surgeon tells the nurse to have the client sign the informed consent form, and he will review it prior to the surgery. What should the nurse do?

Inform the surgeon that she will have the client sign after he discusses the surgery with the client.

The nurse is gathering preoperative data on a client that is scheduled for abdominal surgery tomorrow. The nurse learns that the client takes the following medications daily: warfarin, a multivitamin, and vitamin E. The client reports that he stopped taking the anticoagulant 4 days ago, as instructed by the surgeon. He has continued to take the multivitamin and vitamin E. Based on the information given, why does the nurse notify the surgeon?

Is concerned about the vitamin E

Identify the type of surgery a terminally ill client will undergo if the purpose is removal of tissue to relieve pain

Palliative

The intraoperative nurse observes the anesthesiologist administer general anesthesia, insert the endotracheal tube, and take control of the airway. The nurse understands that the next important nursing intervention for this client is to:

Position the client.

The nurse is providing care to the client in the preoperative phase. Which of the following are the nurse's activities related to this phase?

Prepare the client mentally and physically for surgery.

The perioperative nurse maintains the safety of the client during surgery with which of the following goals? Select all that apply.

Preventing infection Improving the accuracy of client identification Preventing mistakes in surgery

The nurse is providing care to a client scheduled for repair of a torn rotator cuff. The nurse understands that this surgery will be classified as what?

Reconstructive, minor, elective

The nurse is preparing client care for several surgical cases. The nurse is aware that knowing the type of surgery helps identify needs to plan client care. Which of the following surgeries would pose a higher risk for infection?

Repair of a stab wound to the lower leg

The nurse is assessing a client admitted for a total hip arthroplasty under general anesthesia. The client reports that her spouse had a "nasty cold" last week and states she now has a cough and "little tickle" in their throat. The nurse notes mild rhonchi in both bases of the lung fields. Which of the following nursing diagnoses would best explain why the nurse contacted the surgeon and anesthesiologist for a possible postponement of the surgery?

Risk for infection related to exposure to infection and cough

The client is scheduled for outpatient cholecystectomy (gall bladder removal) in 2 weeks. Based on the client's history, the nurse includes which of the following in the preoperative plan of care?

Tell the client to inform the surgeon of allergies and chronic health conditions.

The nurse is assessing the client who is status 4 hours post total knee arthroplasty. The assessment is as follows: blood pressure (BP) 90/60 mm Hg, pulse (P) 94 beats/min; respirations (R) 16 breaths/min; temperature (T) 98.6°F, dressing is saturated with frank red blood. The nurse reinforces the dressing and contacts the surgeon. What is the nurse's main concern regarding this client?

The client may be hemorrhaging.

The preoperative phase encompasses which period of time?

The decision to have surgery until entry to the operating suite

Which of the following describes the Perioperative Nursing Data Set (PNDS)? Select all that apply.

The first specialized nursing language recognized by the American Nurses Association (ANA) A standardized language designed to describe the care of perioperative clients

A client has chronic confusion secondary to dementia. As a result, he is unable to sign an informed consent for surgery. What is required in this situation?

The person with power of attorney should sign the informed consent.

The postoperative client is admitted to the postanesthesia care unit (PACU) with an oral airway in place, an indwelling urinary catheter, IV fluid infusing via two different sites, and a Jackson-Pratt drain pinned to the gown near the wound dressing. What is the nurse's priority action after the client is moved to the bed?

Turn the client's head to the side.

A client returns from surgery with a nasogastric tube and intermittent gastric suction to provide abdominal decompression. Which of the following are correct nursing activities for managing the equipment and drainage? Select all that apply.

Wear nonsterile gloves when emptying the drainage container. Apply water-soluble lubricant if the client's lips are dry. Document the consistency and amount of drainage.