NCLEX RN: Perioperative Care

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 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 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 postanesthetic 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. 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.

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." 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 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." 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 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." 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 flow to 1 or more lobes of the lung; this is usually due to clot formation. Early ambulation and administration of blood thinners helps to prevent this complication; however, it is not related to coughing and deep-breathing techniques.

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." 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.

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 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.

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 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.

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 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.

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 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.

The nurse receives a telephone call from the postanesthetic 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. 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 is caring for a postoperative client who has just returned from the postanesthetic 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 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 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 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 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. 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 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? Refer to Figure.

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. 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 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. 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.

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) 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 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). 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.

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 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.

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 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.

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 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.

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 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 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 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 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 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.