NCLEX Perioperative Care

A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

"Can you share with me what you've been told about your surgery?"

The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which actions would the nurse take? Select all that apply.

- Ask how the client feels and inquire about any feelings of dizziness - Review the client record to determine time and type of analgesia last received. - Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU).

The nurse is caring for a client following an abdominal surgery performed 1 day ago. An intravenous (IV) line is infusing, and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse would perform which actions? Select all that apply.

- Ask the client whether he has passed any flatus. - Document the finding and continue to check for bowel sounds.

The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL through an indwelling urinary catheter for the last 2 hours. Based on this finding, which would be the nurse's actions at this time? Select all that apply.

- Check the client's overall intake and output record. - Gather data about the urinary catheter and check for patency.

The nurse is monitoring the status of the postoperative client after abdominal surgery earlier in the day. Which signs or symptoms noted by the nurse would indicate an evolving complication associated with hypovolemia? Select all that apply.

- Increasing restlessness - Blood pressure of 104/66 mm Hg with a pulse of 106 beats per minute

The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation?

A urinary output of 20 mL/hour

When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse would plan to take which action in the initial care of the wound?

Apply a sterile dressing soaked in normal saline.

The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How would the nurse initially address the client's concerns?

Ask the client to discuss information known about the planned surgery.

When positioning for a surgical procedure, the nurse understands that the client's respiratory system is most at risk for dysfunction in which position?

Lithotomy

The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action would the nurse take first?

Lower the head of the bed slowly until the dizziness is relieved. Rationale: Dizziness or feeling faint is not uncommon when a postoperative client is positioned upright for the first time after surgery. If this occurs, the nurse relieves the feeling by lowering the head of the bed slowly until the dizziness subsides. The nurse would then check the pulse and blood pressure. Because the problem is circulatory, not respiratory, options 2 and 3 are not the first actions to take.

The student nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action would be appropriate?

Notify the registered nurse. Rationale: Sanguineous drainage is bright red and indicates active bleeding. If active bleeding is present, the registered nurse should be notified. Covering the wound and reassessing in 1 hour will delay needed intervention. Leaving a wound open to air can lead to infection, and the blood will not be contained.

The nurse, caring for a client with a postoperative abdominal wound, observes that the dressing has Montgomery ties in place. The nurse determines this intervention will decrease the risk of which complication?

Skin irritation surrounding the wound

The nurse is caring for a postoperative client who has been NPO, and the primary health care provider (PHCP) has prescribed a clear liquid diet. When planning to initiate this diet, which priority item would the nurse place at the client's bedside?

Suction equipment

Following a surgical procedure, the nurse applies sequential compression devices to both lower extremities and turns the machine on. The nurse implements this intervention for which purpose?

To prevent thrombosis formation in the veins Rationale: Compression devices, whether sequential, pneumatic, or intermittent, are external devices applied to the lower extremities to compress the calves of the legs and return blood to the heart similar to the way walking promotes venous return. These compression devices are used for clients who are in bed, especially during surgery and postoperatively, to prevent the complication of venous thrombotic embolism. This embolism can become a pulmonary embolism and cause death during the postoperative recovery period. Heart function determines arterial circulation. The compression devices are not significant in preventing muscle cramps or maintaining muscle strength.

The nurse is reinforcing instructions to a client following mastectomy who will be discharged with an axillary drain in place. The client will be receiving home care visits from the nurse to monitor drainage and perform dressing changes. Which client statement indicates a need for further teaching?

"I need to begin full range-of-motion (ROM) exercises to my upper arm as soon as I get home." Rationale: The client should be instructed to limit upper arm ROM to the level of the shoulder only. After the axillary drain is removed, the client can begin full ROM exercises to the upper arm as prescribed by the primary health care provider. Elevating the arm above the heart level while sitting or lying down, massaging the area with cocoa butter after the incision is completely healed if prescribed by the primary health care provider, and having pain in the absent breast (phantom pain) are correct measures following a mastectomy.

Which types of nourishment would the nurse include when initiating a prescribed clear liquid diet for a postoperative client who has a gag reflex after surgery under general anesthesia? Select all that apply.

- Coffee - Ice Chips - Beef broth - Lemon flavored gelatin Rationale: A clear liquid diet includes fluids or frozen fluids that are clear at room temperature. These food sources are easy to digest and less likely to cause vomiting in a postoperative client. The nurse should assess for the return of the gag reflex first before initiating any oral intake. Coffee, ice chips, beef broth, plain tea, and gelatins are included in a clear liquid diet. Dairy products such as milk or yogurt are included in a full liquid diet.

The nurse is preparing a client for surgery. Which would be components of the plan of care? Select all that apply.

- Instruct the client not to swallow water with oral hygiene on the morning of surgery. - Document that any medications the client was instructed to take before surgery are given.

The nurse is reinforcing instructions to a client and family regarding home care following cataract removal with lens implantation in the left eye. The nurse would provide the client with instructions to contact the surgeon promptly for which signs or symptoms? Select all that apply.

- New floaters - Increasing redness in the eye Rationale: Following cataract surgery, in which the cloudy lens is removed and a new lens is implanted in the eye, clients are sent home to recover. Clients should contact the surgeon immediately if there is the presence of new floaters (seeing small dots) because this could be a sign of a detached retina. Some redness in the eye may be present, but increased redness could indicate bleeding or infection and should also be promptly reported. Clients usually experience improved vision, a sensation of grittiness in the eye, and pain that is controlled with acetaminophen.

A client who 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 nursing interventions would the nurse take? Select all that apply.

- Notify the registered nurse immediately. - Document the client's complaint with the exact times. - Prepare the client for wound closure by notifying surgery department. Instruct the client to remain quiet and reassure the situation is being taken care of.

The nurse is caring for a postoperative client who had a pelvic exenteration. The primary health care provider has changed the client's diet from nothing by mouth (NPO) to clear liquids. The nurse checks for which information before administering the clear liquids? Select all that apply.

- Presence of bowel sounds - Whether the client has passed flatus

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply.

- The presence of purulent drainage - Tender firmness palpable around the incision

The nurse is reinforcing instructions to a client with pneumonia about the use of an incentive spirometer in the postoperative period. The nurse would include which information in discussions with the client? Select all that apply.

- Use the incentive spirometer for 5 to 10 breaths every hour while awake. - The best results are achieved when sitting at least halfway or fully upright. Rationale: An incentive spirometer is a volume- or flow-oriented device used to encourage deep breathing by giving visual feedback to the client during its use. For optimal lung expansion with an incentive spirometer, the client should assume the semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely while the client inhales slowly with a constant flow through the unit. The breath should be held for 2 to 3 seconds before exhaling slowly. The client is taught to use the incentive spirometer for 5 to 10 breaths every hour while awake to prevent post-operative atelectasis and pneumonia.

A client's preoperative vital signs are temperature 98.6°F (37°C) orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which action would the nurse take first?

Compare these values to those previously recorded.