MS: Perioperative Care study

4. "Dental surgery can safely be done usually 10 days after stopping the aspirin, depending on the health care provider's preference." Rationale: Aspirin is an antiplatelet agent that affects the platelet for its life, which is 7 to 10 days. For an elective procedure such as dental surgery, aspirin therapy should be stopped approximately 10 days before the procedure (or as prescribed by the health care provider) to prevent bleeding complications. Option 1 is not an appropriate response and places the client's issue on hold. Options 2 and 3 are incorrect.

The home care nurse visits a client to perform a dressing change on a leg ulcer. The client has diabetes mellitus and a history of cardiac disease and is taking one aspirin daily in addition to other medications as prescribed. The client tells the nurse that dental surgery is scheduled and asks the nurse whether the aspirin should be discontinued. The nurse should make which statement to the client? 1. "The pharmacist should be called." 2. "There is no risk to having such a minor surgery while taking aspirin." 3. "Aspirin has no effect on the surgical procedure and may minimize discomfort." 4. "Dental surgery can safely be done usually 10 days after stopping the aspirin, depending on the health care provider's preference."

4. Semi Fowler's Rationale: The client who undergoes rhinoplasty experiences swelling in the affected area. To reduce swelling, the client would be placed in the semi Fowler's position. The Sims' position, which is side-lying, would not decrease swelling. The prone and supine positions would not decrease swelling because the client would be lying flat.

A client arrives at the surgical unit after undergoing rhinoplasty and has a nose splint and gauze drip (moustache dressing) in place. The nurse reviews the health care provider's prescriptions and anticipates that which client position will be prescribed? 1. Sims' 2. Prone 3. Supine 4. Semi Fowler's

3. Ask the client to limit motion in the hand attached to the pulse oximeter. Rationale: Several factors can interfere with the reading of accurate oxygen saturation levels on a pulse oximeter. To ensure accurate readings, the nurse should ask the client to limit motion of the area attached to the sensor. The nurse should apply the device to a warm area because hypotension, hypothermia, and vasoconstriction interfere with blood flow to the area. The nurse needs to know that very dark nail polish (black, brown-red, blue, green) interferes with accurate measurement. The nurse also should avoid placing the sensor distal to any invasive arterial or venous catheters, pressure dressings, or blood pressure cuffs.

A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry for a preoperative client. The nurse should perform which best action to ensure accurate readings on the oximeter? 1. Apply the sensor to a finger that is cool to the touch. 2. Apply the sensor to a finger with very dark nail polish. 3. Ask the client to limit motion in the hand attached to the pulse oximeter. 4. Place the sensor distal to an intravenous (IV) site with a continuous IV infusion.

1. Cleansing with warm tap water Rationale: A sterile solution such as normal saline should be used for perineal care using an aseptic syringe. This should be done regularly at least twice a day and after each voiding and bowel movement. The wound is intermittently exposed to air to permit drying and to prevent maceration. Once sutures are removed, sitz baths may be prescribed to stimulate healing and for the soothing effect.

A client has a risk for infection following radical vulvectomy. Therefore, the nurse should avoid which action when giving perineal care to this client? 1. Cleansing with warm tap water 2. Intermittently exposing the wound to air 3. Providing prescribed sitz baths after the sutures are removed 4. Providing perineal care after each voiding and bowel movement

1. Suction the client through the endotracheal tube. Rationale: The client is choking on his secretions, which should be removed by suctioning the endotracheal tube. The client is unable to use an incentive spirometer while an endotracheal tube is in place. The client's inability to breathe impairs ability to learn how to use a communication board. Turning the client assists in clearing his airway, but a supine position will worsen the airway problem. Suctioning the client is the best nursing intervention because it will have the most immediate effect.

A client has had an invasive abdominal surgery to relieve an obstruction of the common bile duct. The client's surgery is completed, and the client has been transferred to the postanesthesia care unit (PACU). The PACU nurse observes that the client suddenly appears red in the face and appears to be coughing despite the presence of an endotracheal tube and ventilator support. What action should the PACU nurse take first? 1. Suction the client through the endotracheal tube. 2. Instruct the client in the use of an incentive spirometer. 3. Turn the client from a 30-degree lateral position to a supine position. 4. Instruct the client to use a communication board to tell the nurse what is wrong.

4. Supine, with the residual limb supported with pillows Rationale: The residual limb is usually supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema. After the first 24 hours, the residual limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check health care provider prescriptions regarding positioning following amputation.

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? 1. Prone 2. Reverse Trendelenburg's 3. Supine, with the residual limb flat on the bed 4. Supine, with the residual limb supported with pillows

3. Urinary retention Rationale: Atropine sulfate is an anticholinergic medication that causes tachycardia, drowsiness, blurred vision, dry mouth, constipation, and urinary retention. The nurse monitors the client for any of these effects in the immediate postoperative period.

A client has received atropine sulfate intravenously during a surgical procedure. The nurse should monitor the client for which side effect of the medication in the immediate postoperative period? 1. Diarrhea 2. Bradycardia 3. Urinary retention 4. Excessive salivation

3. Roll the client to one side and check her perineal pad. Rationale: The nurse should roll the client to one side after checking the perineal pad and the abdominal dressing. This client position allows the nurse to check the rectal area, where blood may pool by gravity if the client is lying supine. Asking the client about a sensation of moistness is not a complete assessment. Vital signs will change with hemorrhage; they are a compensatory mechanism of change. Assess for external or most likely signs of bleeding first.

A client has returned to the nursing unit after an abdominal hysterectomy. The client is lying supine. To thoroughly assess the client for postoperative bleeding, what is the primary nursing action? 1. Check the heart rate. 2. Check the blood pressure. 3. Roll the client to one side and check her perineal pad. 4. Ask the client about sensation of moistness on her perineal pad.

1. Check the drain for patency. 2. Observe for bright red bloody drainage. 5. Maintain aseptic technique when emptying the drain. Rationale: The nurse should check the tube or drain for patency to provide an exit for the fluid or blood to promote healing. The nurse should monitor the drainage characteristics. Usually the drainage from the wound is pale, red, and watery. Active bleeding will be bright red. The nurse must use aseptic technique for emptying the drainage container or changing the dressing to avoid contamination of the wound. A postoperative drain should not be curled tightly or obstructed in any way, such as with clamping. This could prevent the drain from functioning properly.

A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions should the nurse take in the care of the drain? Select all that apply. 1. Check the drain for patency. 2. Observe for bright red bloody drainage. 3. Clamp the drain for 15 minutes every hour. 4. Curl the drain tightly, and tape it firmly to the body. 5. Maintain aseptic technique when emptying the drain.

3. An anticoagulant Rationale: An anticoagulant suppresses coagulation by inhibiting clotting factors. A client admitted for elective surgery should have been instructed to discontinue the anticoagulant 7 to 10 days preoperatively. Even if this were unscheduled surgery, the nurse should notify the health care provider. Vitamin K can be given for reversal of its action, but the client may still have an increased risk of bleeding. The other medications listed are commonly taken and do not constitute an increased risk for the client.

A client is admitted to the ambulatory surgery center for elective surgery. The nurse asks the client whether any food, fluid, or medication was taken today. Which medication, if taken by the client, should indicate to the nurse the need to contact the health care provider? 1. A beta-blocker 2. An antibiotic 3. An anticoagulant 4. A calcium-channel blocker

1. Appetite Rationale: To begin to tolerate oral intake after cranial or any other type of surgery, the client must have bowel sounds. The client also must have intact swallow and gag reflexes and should be free of nausea and vomiting. The client is likely to be easily fatigued, which may decrease appetite. Thus appetite is the least reliable indicator regarding when intake should be started.

A client is recovering well 24 hours after cranial surgery but is fatigued. The surgeon advances the client from nothing-by-mouth status to clear liquids. The nurse knows that which information is least reliable in determining the client's readiness to take in fluids? 1. Appetite 2. Absence of nausea 3. Presence of bowel sounds 4. Presence of a swallow reflex

4. "Avoid having blood pressures taken on your right arm." Rationale: Option 4 is the correct answer, as lymphedema (accumulation of lymph in soft tissue) can occur as a result of the excision of lymph nodes, and clients should be taught measures to prevent and reduce lymphedema, including no blood pressure readings, venipunctures, or injections on the affected arm. Option 1 is incorrect, as it is important for clients to move the arm and promote lymphatic drainage. Clients should be instructed on exercises that are designed to prevent contractures and muscle shortening, maintain muscle tone, and improve lymph and blood circulation. Option 2 is incorrect because the surgical incision should be examined daily, not just once a week. Option 3 is incorrect, as this could cause pressure and harm the surgical site.

A client preparing to go home 2 days following a right mastectomy with dissection of axillary lymph nodes asks the nurse, "What should I do to minimize my chance for complications from this surgery?" Which response should the nurse make? 1. "Try to minimize moving your right arm." 2. "Examine the surgical incision once a week." 3. "Be sure to carry your purse over your right shoulder." 4. "Avoid having blood pressures taken on your right arm."

3. Changing dressings frequently around the Penrose drain Rationale: Frequent dressing changes around the Penrose drain are required to protect the skin against breakdown from the urinary drainage. If urinary drainage is excessive, an ostomy pouch may be placed over the drain to protect the skin. Placing the client on the affected side will prevent a free flow of urine through the drain. A Penrose drain is not irrigated. Weighing the dressings is not necessary.

A client returns to the nursing unit following a pyelolithotomy for removal of a kidney stone. A Penrose drain is in place. Which action should the nurse include in the client's postoperative plan of care? 1. Positioning the client on the affected side 2. Irrigating the Penrose drain using sterile procedure 3. Changing dressings frequently around the Penrose drain 4. Weighing dressings and adding the amount to the output

1. Dry mouth 4. Pupillary dilation Rationale: Scopolamine is an anticholinergic medication that causes frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. The other options are incorrect and are not side effects of this medication.

A client scheduled for surgery receives a dose of scopolamine. The nurse expects to note which side effects of the medication? Select all that apply. 1. Dry mouth 2. Diaphoresis 3. Profuse diarrhea 4. Pupillary dilation 5. Excessive urination

1. Contact the surgeon. 2. Instruct the client to remain quiet. 3. Prepare the client for wound closure. 4. Document the findings and actions taken. Rationale: Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply. 1. Contact the surgeon. 2. Instruct the client to remain quiet. 3. Prepare the client for wound closure. 4. Document the findings and actions taken. 5. Place a sterile saline dressing and ice packs over the wound. 6. Place the client in a supine position without a pillow under the head.

1. Hemoglobin, 8.0 g/dL (80 mmol/L) Rationale: Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All of these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Hemoglobin, 8.0 g/dL (80 mmol/L) 2. Sodium, 145 mEq/L (145 mmol/L) 3. Serum creatinine, 0.8 mg/dL (70.6 mmol/L) 4. Platelets, 210,000 mm3 (210 × 109/L)

4. Incorporates nonverbal forms of communication as needed Rationale: The client may experience temporary hoarseness after neck dissection. Goals for the client include using nonverbal forms of communication as needed, expressing willingness to ring the call bell for assistance, and using the services of a speech pathologist if prescribed. Options 1, 2, and 3 are incorrect.

A client who has undergone radical neck dissection is experiencing problems with verbal communication related to postoperative hoarseness. The nurse should formulate which outcome as the most appropriate goal for this client problem? 1. Uses nonverbal communication only 2. Describes that hoarseness will be permanent 3. Initiates communication only when necessary 4. Incorporates nonverbal forms of communication as needed

4. Obtain a telephone consent from a family member, following agency policy. Rationale: Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by 2 persons who hear the family member's oral consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but the data in the question do not indicate an emergency. Options 1, 2, and 3 are not appropriate in this situation. Also, agency policies regard

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? 1. Obtain a court order for the surgery. 2. Have the charge nurse sign the informed consent immediately. 3. Send the client to surgery without the consent form being signed. 4. Obtain a telephone consent from a family member, following agency policy.

3. Continue to monitor the drainage. Rationale: Following gastrectomy, drainage from the nasogastric tube is normally bloody for 24 hours postoperatively, changes to brown-tinged, and is then yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. The nurse does not need to notify the HCP at this time. Measuring abdominal girth is performed to detect the development of distention. Following gastrectomy, a nasogastric tube should not be irrigated unless there are specific HCP prescriptions to do so.

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action? 1. Measure abdominal girth. 2. Irrigate the nasogastric tube. 3. Continue to monitor the drainage. 4. Notify the health care provider (HCP).

2. The use of Montgomery straps Rationale: The use of Montgomery straps is recommended to prevent skin breakdown with frequent dressing changes. They limit the friction and shear that could irritate skin with frequent removal and reapplication of tape. Hypoallergenic tape is used on clients with thin, fragile skin; clients whose skin is sensitive to standard tape; and clients who require less frequent dressing changes. Cleansing with povidone-iodine and obtaining a wound culture are not indicated.

A postoperative client with a large abdominal wound requiring frequent dressing changes is starting to develop skin irritation in the area where the dressing tape is applied to the skin. The nurse determines that the client would benefit most from which measure? 1. Obtaining a wound culture 2. The use of Montgomery straps 3. The use of hypoallergenic tape 4. Cleansing the irritated area with povidone-iodine

3. "Can you share with me what you've been told about your surgery?" Rationale: Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the entire surgical procedure may increase the client's anxiety. Option 4 avoids the client's anxiety and is focused on postoperative care.

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure to you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

4. Dry oral mucous membranes Rationale: Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. The other options are incorrect.

A preoperative client has received a dose of scopolamine as prescribed by the anesthesiologist. The nurse should assess the client for which anticipated side effect of this medication? 1. Diaphoresis 2. Pupillary constriction 3. Increased urinary output 4. Dry oral mucous membranes

2. "It is important for you to get out of bed so that calcium will go back into the bone." Rationale: Early ambulation in the postoperative period is important because if a client does not increase activity, the bones will suffer from loss of calcium. Iron, not iodine, is recommended for hemoglobin synthesis because oxygen is necessary for wound healing. Increasing calcium intake would cause elevated amounts of calcium in the blood, which could lead to kidney stones. Clients who are not turned in bed will develop pressure ulcers. An 85-year-old who is immobile needs to be turned every 2 hours by the nursing staff; clients should not be expected to turn themselves.

An 85-year-old client is hospitalized for a fractured right hip. During the postoperative period, the client's appetite is poor and the client refuses to get out of bed. Which nursing statement would be most appropriate to make to the client? 1. "We need to give you iodine to help in hemoglobin synthesis." 2. "It is important for you to get out of bed so that calcium will go back into the bone." 3. "We need to increase your calcium intake because you are spending too much time in bed." 4. "You need to remember to turn yourself in bed every 2 hours to keep from getting so stiff."

3. Nerve and muscle damage Rationale: Part of the operating room nurse's role is to ensure that the safety needs of the client are met, which includes proper positioning. The client's extremities should not be allowed to dangle over the sides of the table because this may impair circulation to the local area or cause nerve and muscle damage. Options 1, 2, and 4 are unrelated to client positioning in this situation.

An operating room nurse is positioning a client on the operating room table to prevent the client's extremities from dangling over the sides of the table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to prevent which condition? 1. An increase in pulse rate 2. A drop in blood pressure 3. Nerve and muscle damage 4. Muscle fatigue in the extremities

1. Assess the client for signs of dizziness and hypotension. Rationale: Early ambulation should not exceed the client's tolerance. The client should be assessed before sitting. The client is assisted to rise from the lying position to the sitting position gradually until any evidence of dizziness, if present, has subsided. This position can be achieved by raising the head of the bed slowly. After sitting, the client may be assisted to a standing position. The nurse should be at the client's side to provide physical support and encouragement.

In preparation for ambulation, the nurse is planning to assist a postoperative client to progress from a lying position to a sitting position. Which nursing action is appropriate to maintain the safety of the client? 1. Assess the client for signs of dizziness and hypotension. 2. Allow the client to rise from the bed to a standing position unassisted. 3. Elevate the head of the bed quickly to assist the client to a sitting position. 4. Assist the client to move quickly from the lying position to the sitting position.

2. Serous drainage Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin

3. "Your pain can be managed without making you as sleepy." Rationale: An advantage of spinal anesthesia (a regional anesthesia) is pain control without any accompanying cognitive dysfunction. Thus, option 3 is the correct option. With spinal anesthesia the local anesthetic is administered directly into the cerebrospinal fluid, producing an autonomic, sensory, and motor blockade. The autonomic blockade causes vasodilation that can result in hypotension, so option 1 is incorrect. Option 2 is incorrect, as itching is a common side effect with morphine. Option 4 is incorrect, as the autonomic, sensory, and motor blockade produced by the spinal anesthesia can result in lack of bladder control and either urinary incontinence or retention.

The nurse cares for a client prior to surgery. The client asks the nurse, "What is the advantage of spinal anesthesia over general anesthesia for controlling my pain?" Which is the best response by the nurse? 1. "There is less risk of developing a low blood pressure." 2. "Itching, a side effect of the morphine, will be minimized." 3. "Your pain can be managed without making you as sleepy." 4. "You will be able to maintain control of your bladder function."

4. Place a pillow over the incision site during deep breathing and coughing. Rationale: Wound dehiscence occurs most frequently in the postoperative client after coughing, sneezing, vomiting, or getting up from a sitting position. Clients should be instructed to use caution during these activities and use a pillow to splint the incision. Therefore, option 4 is the correct option. Although wound infection can delay healing and contribute to dehiscence, options 1 and 2 are not priorities, and option 3 is appropriate to treat an evisceration but not to minimize the risk for dehiscence.

The nurse cares for a client who is at risk for wound dehiscence after abdominal surgery. Which action is the priority to minimize this risk? 1. Administer prescribed antibiotics. 2. Use sterile technique for dressing changes. 3. Keep sterile saline and sterile dressings at the bedside. 4. Place a pillow over the incision site during deep breathing and coughing.

2. Bowel sounds are absent. Rationale: The NG tube should remain in place until the client has bowel sounds. If NG suction is being used, the nurse should turn off the suction before listening to bowel sounds to prevent mistaking the sound of the suction for bowel sounds. If bowel sounds do not return, the client could have a paralytic ileus, which could result in distention and vomiting if the NG tube is discontinued. It is likely that the client may be drowsy after experiencing a stressor such as cardiac surgery. The abdomen is likely to be slightly distended after surgery, and it is normal for NG tube drainage to be Hematest negative.

The nurse has a prescription to remove the nasogastric (NG) tube from a client on the first postoperative day after cardiac surgery. The nurse should question the prescription if which finding was noted on assessment of the client? 1. The client is drowsy. 2. Bowel sounds are absent. 3. The abdomen is slightly distended. 4. NG tube drainage is Hematest negative.

3. "I need to continue to take the aspirin until the day of surgery." Rationale: Antiplatelets alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter platelet aggregation and should be discontinued at least 48 hours before surgery. However, the client should always check with his or her health care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client statements.

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? 1. "Aspirin can cause bleeding after surgery." 2. "Aspirin can cause my ability to clot blood to be abnormal." 3. "I need to continue to take the aspirin until the day of surgery." 4. "I need to check with my health care provider about the need to stop the aspirin before the scheduled surgery."

3. Maintains inflation of the alveoli Rationale: Sustained inhalation helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk for these conditions. Options 1, 2, and 4 are incorrect.

The nurse has instructed a preoperative client using an incentive spirometer to sustain the inhaled breath for 3 seconds. When the client asks about the rationale for this action, the nurse explains that this action achieves which function? 1. Dilates the major bronchi 2. Increases surfactant production 3. Maintains inflation of the alveoli 4. Enhances ciliary action in the tracheobronchial tree

1. Urinary output of 20 mL/hour Rationale: Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less than 30 mL for 2 consecutive hours should be reported to the health care provider. A temperature higher than 37.7°C (100°F) or lower than 36.1°C (97°F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 mL/hour 2. Temperature of 37.6°C (99.6°F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing

3. "It is all right to ride in a car as much as I want, as long as I am not driving the car." Rationale: The client should avoid activities such as sitting for long periods of time and doing heavy housework until approved by the health care provider (HCP) because of pressure and trauma at the surgical site. The client should be instructed to avoid sexual activity for 4 to 6 weeks or as indicated by the HCP. The client should keep the perineal area as clean and dry as possible and should wash the perineum with solutions such as peroxide and water or as prescribed after each urination or defecation to prevent infection. The client should be instructed to report any redness, swelling, drainage, odor, or increased soreness along the suture line because these are signs of infection.

The nurse has provided discharge instructions to a client after radical vulvectomy. Which statement by the client indicates a need for further instruction? 1. "I should avoid sexual activity for 4 to 6 weeks." 2. "I should wash the perineum after each voiding." 3. "It is all right to ride in a car as much as I want, as long as I am not driving the car." 4. "I need to report any redness, swelling, or drainage to the health care provider."

3. Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed Rationale: When the postoperative client arrives from the postanesthesia care unit, the nurse performs an initial assessment. Common time frames for continuing postoperative assessment activities are every 15 minutes the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed. However, agency policies should always be followed. Options 1 and 2 identify time frames that are too infrequent and that will not provide adequate assessment of the postoperative client. Option 4 identifies close time frames that are unnecessary.

The nurse in a surgical unit receives a postoperative client from the postanesthesia care unit. After the initial assessment of the client, the nurse should plan to continue with postoperative assessment activities how often? 1. Every hour for 2 hours and then every 4 hours as needed 2. Every 30 minutes for the first hour, every hour for 2 hours, and then every 4 hours as needed 3. Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed 4. Every 5 minutes for the first half-hour, every 15 minutes for 2 hours, every 30 minutes for 4 hours, and then every hour as needed

3. Alcohol abuse Rationale: A client with a history of alcohol abuse is at risk for liver disease, including altered metabolism and elimination of medications, impaired wound healing, and clotting and bleeding abnormalities. A client with this risk factor also would be at risk for experiencing alcohol withdrawal during the postoperative period. Clients with a pacemaker, osteoporosis, and peptic ulcer disease need to be monitored closely but are not at risk for major complications, as is the client with alcohol abuse and liver disease.

The nurse is assessing a client who had abdominal surgery earlier in the day. Which preexisting medical condition would place the client at most risk for postoperative complications? 1. Pacemaker 2. Osteoporosis 3. Alcohol abuse 4. Peptic ulcer disease

1. The passage of flatus Rationale: Following abdominal perineal resection, the nurse would expect the colostomy to begin to function within 72 hours after surgery, although it may take up to 5 days. The nurse should assess for a return of peristalsis, listen for bowel sounds, and check for the passage of flatus. Absent bowel sounds would not indicate the return of peristalsis. The client would remain NPO (nothing by mouth) until bowel sounds return and the colostomy is functioning. Bloody drainage is not expected from a colostomy.

The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function? 1. The passage of flatus 2. Absent bowel sounds 3. The client's ability to tolerate food 4. Bloody drainage from the colostomy

2. Apply a sterile nonadherent dressing. Rationale: Wound dehiscence is partial or complete separation of the outer layers of the wound, sometimes described as splitting open of the wound. If this is noted, the nurse applies a sterile nonadherent dressing, such as a Telfa dressing or a saline dressing, to the wound and notifies the health care provider. The nurse would document the findings, but this would not be the initial action. A dry dressing could disrupt the integrity of the underlying tissues. Asking the client to cough could cause an extension of the separation of the outer layers of the wound.

The nurse is assigned to change the surgical dressing on a client who has undergone abdominal surgery. After removing the old dressing, the nurse assesses the surgical site. Which should be the nurse's initial action if the appearance shown in the figure is observed? 1. Document the findings. 2. Apply a sterile nonadherent dressing. 3. Redress the wound with a dry sterile dressing. 4. Ask the client to cough to assess for protrusion of the internal structures.

3. "Can you share with me any concerns about how this surgery will affect you in the future?" Rationale: One of the most helpful approaches in exploring client concerns is to use open-ended questions. These tend to elicit more descriptive responses on the part of the client. Option 1 imposes the nurse's opinion on the client and does not value the client's perspective. Options 2 and 4 are closed-ended questions that may be answered with a "yes" or "no" response.

The nurse is caring for a 25-year-old client who will undergo bilateral orchidectomy for testicular cancer. Which statement by the nurse would be helpful in exploring the client's concerns about loss of reproductive ability? 1. "You must be sad that you won't be able to have children after surgery." 2. "Has the health care provider told you that you will not be able to have children?" 3. "Can you share with me any concerns about how this surgery will affect you in the future?" 4. "Do you feel that the health care provider has told you all you need to know about the upcoming surgery?"

3. Resume the client's dose of metoprolol Rationale: According to The Joint Commission's Surgical Care Improvement Program's core measures, surgery clients on beta-blocker therapy prior to surgery should receive a beta blocker within 24 hours of surgery. Thus, option 3 is the correct option. Beta blockers have been found to decrease the risk for mortality associated with noncardiac surgery in high-risk clients. However, for treatment to be both safe and effective, dosing should begin before surgery and continue for at least 1 month after surgery. In this case, the client was already on the beta-blocker therapy prior to surgery, but it needs to be resumed postoperatively. Option 1 is incorrect, as the client is on a potassium-retaining diuretic so hypokalemia is unlikely to occur. Option 2 is incorrect, as a 12-lead electrocardiogram would have been done prior to surgery and there is no indication that another one i

The nurse is caring for a client the day after a left total knee arthroplasty surgery. In reviewing the client's past medical history, the nurse notes that the client has a history of urinary incontinence and heart failure, which is managed with a potassium-retaining diuretic and a beta-adrenergic blocker. Which prescription, if not already prescribed, should the nurse contact the health care provider to obtain? 1. Daily electrolytes 2. A 12-lead electrocardiogram 3. Resume the client's dose of metoprolol 4. Insertion of an indwelling urinary catheter

1. Bowel sounds Rationale: The client is kept NPO until peristalsis returns, usually in 4 to 6 days. When signs of bowel function return, clear fluids are given to the client. If no distention occurs, the diet is advanced as tolerated. The most important assessment is to assess bowel sounds before feeding the client. Options 2, 3, and 4 are unrelated to the data in the question.

The nurse is caring for a client who is postoperative following a pelvic exenteration and the health care provider changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse should check which priority item before administering the diet? 1. Bowel sounds 2. Ability to ambulate 3. Incision appearance 4. Urine specific gravity

4. Recheck the vital signs in 15 minutes. Rationale: A drop in blood pressure slightly below a client's preoperative baseline reading is common after surgery. The nurse should recheck the vital signs. Warm blankets are applied to maintain the client's body temperature. Level of consciousness can be assessed by the evaluation of the client's response to light touch and verbal stimuli. It is not necessary to contact the surgeon immediately.

The nurse is caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 91 beats/minute; and respirations, 16 breaths/minute. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/minute; and respirations, 20 breaths/minute. Which action should the nurse plan to take first? 1. Call the surgeon immediately. 2. Shake the client gently to arouse. 3. Cover the client with a warm blanket. 4. Recheck the vital signs in 15 minutes.

2. Elevate and immobilize the grafted extremity. Rationale: Autografts placed over joints or on lower extremities are elevated and immobilized following surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site.

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? 1. Maintain the client in a prone position. 2. Elevate and immobilize the grafted extremity. 3. Maintain the grafted extremity in a flat position. 4. Keep the grafted extremity covered with a blanket.

1. Assessing how often the client swallows Rationale: Assessing how often the client swallows after nasal surgery is a priority action because this is a sign of bleeding. Checking vital signs and looking at the external packing for bleeding are important but not a priority for nasal surgery clients. Determining if the client can breathe through the unaffected nostril is an essential reasonable postoperative assessment.

The nurse is caring for a postoperative client who has just returned from the postanesthesia care unit after having nasal surgery. What priority action is essential for the nurse to perform? 1. Assessing how often the client swallows 2. Checking vital signs per agency protocol 3. Viewing the external packing for bleeding 4. Determining if the client can breathe through the unaffected nostril

2. Make sure suction is maintained. 3. Check that the drains are sutured in place. 5. Compress the reservoir to restore suction after emptying. 6. Record the amount and color of drainage according to agency protocol or health care provider's orders. Rationale: Interventions include making sure suction is maintained, checking that the drains are sutured in place, compressing the reservoir to restore suction after emptying, and recording the amount and color of drainage according to agency protocol or health care provider's orders. The other interventions are not appropriate.

The nurse is caring for an abdominal surgical client who has a Jackson-Pratt drain in place. Which interventions should the nurse include in the plan of care for this drain? Select all that apply. 1. Secure the drain to the sheet. 2. Make sure suction is maintained. 3. Check that the drains are sutured in place. 4. Use clean technique to empty the reservoir. 5. Compress the reservoir to restore suction after emptying. 6. Record the amount and color of drainage according to agency protocol or health care provider's orders.

4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. Rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. Inhale as rapidly as possible. 2. Keep a loose seal between the lips and the mouthpiece. 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

3. Have the client void immediately before going into surgery. Rationale: The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours (or longer as prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash. 2. Verify that the client has not eaten for the last 24 hours. 3. Have the client void immediately before going into surgery. 4. Report immediately any slight increase in blood pressure or pulse.

1. Wound care 2. Follow-up care 3. Activity restrictions 4. Dietary instructions Rationale: The type of planning and instructions required vary with the individual client and the type of surgery. Specific instructions that this client needs to receive before discharge should include wound care, activity restrictions, dietary instructions, postoperative medication instructions, personal hygiene, and follow-up appointments. Deep-breathing exercises are taught in the preoperative period.

The nurse is developing a list of home care instructions for a client being discharged after a laparoscopic cholecystectomy. Which instructions should the nurse include include in the postoperative discharge plan of care? Select all that apply. 1. Wound care 2. Follow-up care 3. Activity restrictions 4. Dietary instructions 5. Deep-breathing exercises

4. Apply a cloth barrier to the client's arm under a blood pressure cuff when taking the blood pressure. Rationale: If a client has a latex allergy, a cloth barrier should be applied to his or her arm under a blood pressure cuff to prevent skin contact with the cuff. Medications from glass ampules are safe to use, and medications from ampules with rubber stoppers are unsafe to use. Latex-safe intravenous tubing made of polyvinyl chloride should be used for a client with a latex allergy. Additionally, agency procedures should be followed for a client with a latex allergy; usually, a latex allergy cart containing latex-free supplies is kept in the client's room.

The nurse is developing a plan of care for a preoperative client who has a latex allergy. Which intervention should be included in the plan? 1. Avoid using medications from glass ampules. 2. Use medications that are from ampules with rubber stoppers. 3. Avoid using intravenous tubing that is made of polyvinyl chloride. 4. Apply a cloth barrier to the client's arm under a blood pressure cuff when taking the blood pressure.

2. Infection 3. Swelling 4. Thrombophlebitis 6. Increased joint pain related to mechanical injury Rationale: Postoperative complications to watch for after an arthroscopy include infection, swelling, thrombophlebitis, and increased joint pain related to mechanical injury. Backache and decreased appetite are not included. Backache may be a result of lying on a hard table during the procedure, but it is not a complication. Decreased appetite is a normal reaction due to the effects of anesthesia and pain medications. The HCP usually sees the client about 1 week after the procedure for follow-up care.

The nurse is discharging a client after an arthroscopy. The nurse needs to teach the client to watch for which potential complications? Select all that apply. 1. Backache 2. Infection 3. Swelling 4. Thrombophlebitis 5. Decreased appetite 6. Increased joint pain related to mechanical injury

1. Increasing restlessness Rationale: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all 4 quadrants are a normal occurrence in the immediate postoperative period.

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. A pulse of 86 beats/minute 3. Blood pressure of 110/70 mm Hg 4. Hypoactive bowel sounds in all 4 quadrants

3. Obtain a pulse oximetry reading from another appropriate area, such as an earlobe. Rationale: A pulse oximetry reading may not provide an accurate measurement if it is measured on a finger that has dark polish and an artificial nail; therefore, option 1 is not the most appropriate action. It is not appropriate to remove an artificial nail; therefore, eliminate option 2. Removing the polish and taking the reading with the artificial nail may provide a better reading than taking the reading with the polish; however, this is not the most appropriate action from those provided, so option 4 can be eliminated.

The nurse is obtaining a pulse oximetry reading from a postoperative client who appears short of breath. The client has dark fingernail polish on top of artificial nails. What is the most appropriate action? 1. Take the pulse oximetry reading from any finger. 2. Remove one of the artificial nails and then obtain the reading from the finger. 3. Obtain a pulse oximetry reading from another appropriate area, such as an earlobe. 4. Obtain fingernail polish remover, remove the polish, and then obtain the pulse oximetry reading from a finger.

1. Assist the client to void before transfer to the operating room. 2. Check all surgeon's prescriptions to ensure they have been carried out. 4. Review the client's record for a history and physical report and laboratory reports. Rationale: The nurse should assist the client to void before transfer to the operating room, if a Foley catheter is not in place. The nurse also checks the surgeon's prescriptions to ensure that they have been carried out; if a prescription has not been carried out, the nurse would have the time to ensure that it is. Two hours before the scheduled surgery time is not the time to teach breathing exercises. This should have been accomplished earlier. A history and physical needs to be in the record so that all health care providers involved in the surgical procedure will be familiar with the client's health status. Additionally, the results of any laboratory tests prescribed need to be docu

The nurse is preparing a client for surgery scheduled in two hours. Which interventions are appropriate in the preoperative period? Select all that apply. 1. Assist the client to void before transfer to the operating room. 2. Check all surgeon's prescriptions to ensure they have been carried out. 3. Teach postoperative breathing exercises before the client is premedicated. 4. Review the client's record for a history and physical report and laboratory reports. 5. Administer all the daily medications 2 hours before the scheduled time of the surgery.

1. Ensure that the client has voided. Rationale: The nurse should ensure that the client has voided if a Foley catheter is not in place. The nurse does not administer all daily medications just before sending a client to the operating room. Rather, the health care provider writes a specific prescription outlining which medications may be given with a sip of water. The time of transfer to the operating room is not the time to practice breathing exercises; this should have been done earlier. The client has nothing by mouth for 6 to 8 hours before surgery, not 24 hours.

The nurse is preparing a preoperative client for transfer to the operating room. The nurse should take which action in the care of this client at this time? 1. Ensure that the client has voided. 2. Administer all the daily medications. 3. Verify that the client has not eaten for the past 24 hours. 4. Have the client practice postoperative breathing exercises.

1. Report any signs of respiratory infection to the health care provider. Rationale: After a pneumonectomy, if any signs of respiratory infection occur, the health care provider should be notified. The client is instructed to perform breathing exercises for the first 3 weeks at home and to space activities to allow for frequent rest periods. The client also should be instructed to avoid heavy lifting of any objects more than 20 pounds until the muscles of the chest wall have healed completely, which takes about 3 to 6 months. The client should be told to expect feelings of weakness and fatigue for the first 3 weeks after surgery.

The nurse is providing discharge instructions to the client who has had a pneumonectomy and prepares a list of postoperative instructions for the client. Which intervention should the nurse include in the list? 1. Report any signs of respiratory infection to the health care provider. 2. Avoid breathing exercises to allow the diaphragm to strengthen. 3. Avoid lifting any objects greater than 30 pounds for at least 3 weeks. 4. Contact the health care provider if any feelings of weakness and fatigue occur.

3. Change the diapers as soon as they become damp. Rationale: Changing diapers as soon as they become damp helps prevent infection at the surgical site. Parents are instructed to change diapers more frequently than usual during the day and once or twice during the night. A fever may indicate the presence of an infection, but measuring the temperature does not prevent an infection. No restrictions on the infant's activity are needed. Parents are instructed to give the infant sponge baths instead of tub baths for 2 to 5 days.

The nurse is providing home care instructions to the parents of an infant who had a surgical repair of an inguinal hernia. What instruction should the nurse include to prevent infection at the surgical site? 1. Report a fever immediately. 2. Restrict the infant's physical activity. 3. Change the diapers as soon as they become damp. 4. Soak the infant in a tub bath twice a day for the next 5 days.

2. Teaching coughing and deep breathing exercises Rationale: After cholecystectomy, respirations tend to be shallow because deep breathing is painful as a result of the location for the surgical procedure. Although all the options are correct, teaching coughing and deep breathing exercises is the highest priority.

The nurse is providing preoperative teaching to a client scheduled for a cholecystectomy. Which intervention would be of highest priority in the preoperative teaching plan? 1. Teaching leg exercises 2. Teaching coughing and deep breathing exercises 3. Providing instructions regarding fluid restrictions 4. Assessing the client's understanding of the surgical procedure

1. Prednisone Rationale: Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily and may be given parenterally rather than orally. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. These last 3 medications may be withheld before surgery without undue effects on the client.

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine 4. Conjugated estrogen

1. Assess the patency of the airway. Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway. 2. Check tubes or drains for patency. 3. Check the dressing to assess for bleeding. 4. Assess the vital signs to compare with preoperative measurements

2. Clotting studies 3. Glucose fasting 4. Electrolyte levels 6. Serum creatinine and blood urea nitrogen (BUN) levels Rationale: The most common blood tests prescribed preoperatively include CBC, clotting studies, glucose fasting, electrolyte levels, and serum creatinine and BUN levels. A urinalysis is also prescribed. Preoperative blood tests do not include ABG and D-dimer assay. Clotting studies must be prescribed to determine if the surgical client may experience major hemorrhage from prolonged bleeding or clotting times. Glucose fasting must be done because many forms of stress such as general anesthesia can cause increased serum glucose levels. Electrolyte imbalances such as potassium levels (both increased and decreased) can affect the cardiac system leading to dysrhythmias, especially with the use of anesthesia. Any potassium imbalance—hypokalemia or hyperkalemia—must be corrected before surgery. Serum c

The nurse is reviewing the blood tests of a generally healthy client who is scheduled for orthopedic surgery under general anesthesia. Besides a complete blood count (CBC), what preadmission blood tests would the preoperative nurse expect to be prescribed? Select all that apply. 1. D-dimer assay 2. Clotting studies 3. Glucose fasting 4. Electrolyte levels 5. Arterial blood gas (ABG) 6. Serum creatinine and blood urea nitrogen (BUN) levels

1. Atenolol Rationale: Atenolol is a beta-blocker. Beta-blockers should not be stopped abruptly, and the health care provider should be contacted about the administration of this medication before surgery. If a beta-blocker is stopped abruptly, the myocardial need for oxygen is increased. Atorvastatin is a cholesterol-lowering medication used to treat high cholesterol. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. The other three medications may be withheld before surgery without undue effects on the client.

The nurse is reviewing the health care provider's prescription sheet for a preoperative client, which states that the client must be NPO (nothing by mouth) after midnight. Which medication should the nurse clarify to be given and not withheld? 1. Atenolol 2. Atorvastatin 3. Cyclobenzaprine 4. Conjugated estrogen

1. "Use of an incentive spirometer will help prevent pneumonia." Rationale: Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps to prevent pneumonia and atelectasis. Hypoxemia is an inadequate concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help to detect hypoxemia, monitoring is not directly related to coughing and deep-breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? 1. "Use of an incentive spirometer will help prevent pneumonia." 2. "Close monitoring of your oxygen saturation will detect hypoxemia." 3. "Administration of intravenous fluids will prevent or treat fluid imbalance." 4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."

3. A time-out should be performed in the operating room before the procedure. Rationale: Universal Protocol is one of The Joint Commission's National Patient Safety Goals. It is a protocol that is followed to prevent wrong site, wrong procedure, and wrong surgery. Option 3 is the correct option because part of Universal Protocol involves performing a time-out in the operating room to identify the correct client, the correct surgical site, and the correct procedure. Although options 1, 2, and 4 are also safety procedures, they are not specific components of Universal Protocol.

The nurse is teaching a graduate nurse in the operating room about the components of Universal Protocol, one of The Joint Commission's National Patient Safety Goals. What specific component should the nurse include in the instructions? 1. Surgical site should be marked preoperatively. 2. Surgical sponges should be counted at the end of the surgery. 3. A time-out should be performed in the operating room before the procedure. 4. Preoperative antibiotic should be administered within 1 hour of the incision.

4. Daily garlic capsules, last dose yesterday morning Rationale: Option 4 is the correct answer, as garlic can increase bleeding and should be discontinued for 2 to 3 weeks before surgery. Options 1 and 3 are incorrect, as they are not findings that the HCP needs to be immediately notified of because neither warrants a delay or cancellation of the surgery. Option 2 is incorrect because it is a normal potassium level.

The nurse prepares a client 1 hour prior to surgery. Which assessment finding does the nurse need to communicate to the health care provider (HCP) at this time? 1. Allergy to peanuts 2. Potassium is 3.6 mEq/L (3.6 mmol/L) 3. History of obstructive sleep apnea 4. Daily garlic capsules, last dose yesterday morning

4. After maximal inspiration, hold the breath for 10 seconds and then exhale. Rationale: For optimal lung expansion with the incentive spirometer, the client should assume a semi Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should hold the breath for 2 or 3 seconds and then exhale slowly.

The nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates that he or she will take which action? 1. Sit upright when using the device. 2. Inhale slowly, maintaining a constant flow. 3. Place the lips completely over the mouthpiece. 4. After maximal inspiration, hold the breath for 10 seconds and then exhale.

2. Obtain the client's vital signs. Rationale: When a client arrives on the nursing unit from the postanesthesia care unit (PACU), the nurse receives the client and immediately checks the client's airway status. The nurse next performs an initial assessment consisting of vital signs. The results must be compared with the vital signs last obtained in the PACU. Once this has been done, the intravenous infusion is checked, and a pain, respiratory, neurological, wound, urinary, and safety assessment is performed. Oxygen is not needed for every postoperative client but may be administered to those who may have a compromised respiratory status. The nurse documents the findings, including the time that the client arrived from the PACU.

When a client is transferred from the postanesthesia care unit and arrives on the surgical unit, which should be the first action taken by the nurse? 1. Assess the client's pain. 2. Obtain the client's vital signs. 3. Administer oxygen to the client. 4. Check the rate of the intravenous infusion.

3. Apply a sterile dressing soaked with normal saline. Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the visible appearance of underlying tissues. Dehiscence usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and to avoid coughing or straining. The client should be positioned to prevent further stress on the wound (semi Fowler's position). Sterile dressings soaked with sterile normal saline should be used to cover the wound. The nurse must notify the health care provider after applying this initial dressing to the wound. Options 1, 2, and 4 are incorrect.

When performing a surgical dressing change on a client's abdominal dressing, the nurse notes an increased amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should take which action in the initial care of this wound? 1. Leave the incision open to the air to dry the area. 2. Irrigate the wound and apply a sterile dry dressing. 3. Apply a sterile dressing soaked with normal saline. 4. Apply a sterile dressing soaked in povidone-iodine.

2. Arm edema on the operative side Rationale: Arm edema on the operative side (lymphedema) is a complication after mastectomy. It can occur immediately postoperatively or months to even years after surgery. The remaining options are expected occurrences after mastectomy and do not indicate a complication.

Which assessment finding indicates that a client who had a mastectomy is experiencing a complication related to the surgery? 1. Pain at the incisional site 2. Arm edema on the operative side 3. Sanguineous drainage in the Jackson-Pratt drain 4. Complaints of decreased sensation near the operative site

3. Blood pressure of 88/52 mm Hg Rationale: The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A falling systolic blood pressure, under 90 mm Hg, is considered reportable because it could be an indication of bleeding and potential shock. Urine output should be maintained at a minimum of 30 mL/hr for an adult, so 40 mL per hour is adequate. An output of less than 30 mL/hr for each of two consecutive hours should be reported to the health care provider. A temperature above 37.7°C (100°F) or below 36.1°C (97°F) is a concern and would be reportable. Moderate or light serous drainage from the surgical site is considered normal.

Which finding in a postoperative client would be of concern to the nurse? 1. Urinary output of 40 mL/hr 2. Temperature of 37.6°C (99.6°F) 3. Blood pressure of 88/52 mm Hg 4. Moderate drainage on the surgical dressing