NURB 3130 Exam 1 Perioperative Concepts - Brunner & Suddarth's text

The nurse is checking the informed consent for an older adult client who requires surgery and who has recently been diagnosed with Alzheimer disease. When obtaining informed consent, who is legally responsible for signing? A. The client's next of kin B. The client's spouse C. The client D. The surgeon

C. The client Rationale: Just because a client has been diagnosed with Alzheimer disease does not mean that the client is not competent to provide informed consent, although many Alzheimer clients are ultimately declared to be legally incompetent. Because there is no evidence that this client is legally incompetent, the client would be required to personally provide informed consent

In anticipation of a client's scheduled surgery, the nurse is teaching the client to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client? A. The client should take three deep breaths and cough hard three times, at least every 15 minutes for the immediate postoperative period. B. The client should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs. C. The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. D. The client should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly.

C. The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs. Rationale: The client assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to take a deep, slow breath and exhale slowly. After the client practices deep breathing several times, the nurse instructs the client to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs.

The nurse in the preoperative area places a warmed blanket on a client. Which reason does the nurse give the client for this action? A. Hypothermia assists in the induction of anesthesia. B. Warming reduces the risk of postoperative infection. C. The risk of bleeding is increased with hypothermia. D. The length of hospital stay is increased with warming.

C. The risk of bleeding is increased with hypothermia. Rationale: The nurse places a warmed blanket on the client to reduce adverse effects of unintentional hypothermia, such as increased risk of bleeding. Hypothermia does not assist with the induction of anesthesia. Warming does not reduce the risk of postoperative infection, although hypothermia may delay surgical wound healing. Unintended hypothermia may also increase the length of hospital stay.

An OR nurse will be participating in the intraoperative phase of a client's kidney transplant. What action will the nurse prioritize in this aspect of nursing care? A. Monitoring the client's physiologic status B. Providing emotional support to family C. Maintaining the client's cognitive status D. Maintaining a clean environment

A. Monitoring the client's physiologic status Rationale: During the intraoperative phase, the nurse is responsible for physiologic monitoring. The intraoperative nurse cannot support the family at this time and the nurse is not responsible for maintaining the client's cognitive status. The intraoperative nurse maintains an aseptic, not clean, environment.

A clinic nurse is conducting a preoperative interview with an adult client who will soon be scheduled to undergo cardiac surgery. What interview question most directly addresses the client's safety? A. "What prescription and nonprescription medications do you currently take?" B. "Have you previously been admitted to the hospital, either for surgery or for medical treatment?" C. "How long do you expect to be at home recovering after your surgery?" D. "Would you say that you tend to eat a fairly healthy diet?"

A. "What prescription and nonprescription medications do you currently take?" Rationale: It is imperative to know a preoperative client's current medication regimen, including OTC medications and supplements. None of the other listed questions directly addresses an issue with major safety implications.

One of the things a nurse has taught to a client during preoperative teaching is to have nothing by mouth for a specified time before surgery. The client asks the nurse why this is important. What is the most appropriate response for the client A. "You will need to have food and fluid restricted before surgery so you are not at risk for aspiration." B. "The restriction of food or fluid will prevent the development of pneumonia related to decreased lung capacity." C. "The presence of food in the stomach interferes with the absorption of anesthetic agents." D. "By withholding food for 8 hours before surgery, you will not develop constipation in the postoperative period."

A. "You will need to have food and fluid restricted before surgery so you are not at risk for aspiration." Rationale: The major purpose of withholding food and fluid before surgery is to prevent aspiration. There is no scientific evidence that withholding food prevents the development of pneumonia or that food in the stomach interferes with absorption of anesthetic agents. Constipation in clients in the postoperative period is related to the anesthesia, not to having food within 8 hours before surgery, so withholding food or fluid would not necessarily prevent constipation.

The nurse in preadmission testing is educating a client about a scheduled surgery. Which response should the nurse give when the client asks about pain management following surgery? A. "Your nurse will use a pain assessment scale to help rate and treat your pain." B. "Wait to ask for pain medication until the pain becomes intolerable." C. "Lying still in bed will help control your pain." D. "Don't worry—most clients do not have much pain from this surgery."

A. "Your nurse will use a pain assessment scale to help rate and treat your pain." Rationale: A pain assessment scale helps the nurse assess and effectively control the client's pain in the postoperative period. The nurse uses this scale to determine the effectiveness of pain control measures. The client should be instructed to take pain medication as prescribed rather than waiting until the pain reaches an intolerable level. Taking the medication on a regular schedule is more effective at controlling pain. The client should be taught to take pain medication so that the client is able to change position, cough and deep breathe, and ambulate to prevent postoperative complications. Therefore, the client should not lie in bed without moving. Because each client experiences pain in a unique way, the nurse should not teach that the client will not experience much pain.

A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which client most closely during the intraoperative period because of the increased risk for hypothermia? A. A 74-year-old client with a low body mass index B. A 17-year-old client with traumatic injuries C. A 45-year-old client having an abdominal hysterectomy D. A 13-year-old client undergoing craniofacial surgery

A. A 74-year-old client with a low body mass index Rationale: Older clients are at greatest risk during surgical procedures because they have an impaired ability to increase their metabolic rate and impaired thermoregulatory mechanisms, which increase susceptibility to hypothermia. The other clients are likely at a lower risk.

An intraoperative nurse is applying interventions that will address surgical clients' risks for perioperative positioning injury. What factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply. A. Absence of reflexes B. Diminished ability to communicate C. Loss of pain sensation D. Nausea resulting from anesthetic E. Reduced blood pressure

A. Absence of reflexes B. Diminished ability to communicate C. Loss of pain sensation Rationale: Loss of pain sense, reflexes, and ability to communicate subjects the intraoperative client to possible injury. Nausea and low blood pressure are not central factors that contribute to this risk, though they are adverse outcomes

The nurse is performing the shift assessment of a postsurgical client. The nurse finds the client's mental status, level of consciousness, speech, and orientation are intact and at baseline, but the client appears unusually restless. What should the nurse do next? A. Assess the client's oxygen levels. B. Administer antianxiety medications. C. Page the client's health care provider. D. Initiate a social work referral.

A. Assess the client's oxygen levels. Rationale: The nurse assesses the client's mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage. Antianxiety medications are not given until the cause of the anxiety is known. The health care provider is notified only if the reason for the anxiety is serious or if a prescription for medication is needed. A social work consult is inappropriate for addressing restlessness.

The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk? A. Atelectasis B. Anemia C. Dehydration D. Peripheral edema

A. Atelectasis Rationale: Atelectasis occurs when the postoperative client fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia occurs rarely and usually in situations where the client loses a significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the client is most at risk for atelectasis

The surgical nurse is preparing to send a client from the presurgical area to the OR and is reviewing the client's informed consent form. What are the criteria for legally valid informed consent? Select all that apply. A. Consent must be freely given. B. Consent must be notarized. C. Consent must be signed on the day of surgery. D. Consent must be obtained by a health care provider. E. Signature must be witnessed by a professional staff member.

A. Consent must be freely given. D. Consent must be obtained by a health care provider. E. Signature must be witnessed by a professional staff member. Rationale: Valid consent must be freely given, without coercion. Consent must be obtained by a health care provider, and the client's signature must be witnessed by a professional staff member. It does not need to be signed on the same day as the surgery and it does not need to be notarized.

The perioperative nurse is preparing to discharge a client home from day surgery performed under general anesthesia. Which instruction should the nurse give the client prior to the client leaving the hospital? A. Do not drive yourself home. B. Take an over-the-counter (OTC) sleeping pill for 2 nights. C. Attempt to eat a large meal at home to aid wound healing. D. Remain in bed for the first 48 hours' postoperative.

A. Do not drive yourself home. Rationale: During this time, the client should not drive a vehicle and should eat only as tolerated. Although recovery time varies depending on the type and extent of surgery and the client's overall condition, instructions usually advise limited activity for 24 to 48 hours. However, complete bed rest is contraindicated in most cases. The nurse does not normally make OTC recommendations for hypnotics.

The operating room nurse is participating in the appendectomy of a client who has a dangerously low body mass index. The nurse recognizes the client's consequent risk for hypothermia. Which action should the nurse implement to prevent the development of hypothermia? A. Ensure that intravenous (IV) fluids are warmed to the client's body temperature. B. Transfuse packed red blood cells to increase oxygen-carrying capacity. C. Wrap the client in drape that has been soaked in hot water. D. Monitor the client's blood pressure and heart rate vigilantly.

A. Ensure that intravenous (IV) fluids are warmed to the client's body temperature. Rationale: Warmed IV fluids can prevent the development of hypothermia. Wet gowns and drapes should be removed promptly and replaced with dry materials because wet materials promote heat loss. The client is not transfused to prevent hypothermia. Bloodpressure and heart rate monitoring are important, but do not relate directly to the risk for hypothermia.

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this client? Select all that apply. A. Establishing an IV line B. Verifying the surgical site with the client C. Taking measures to ensure the client's comfort D. Applying a grounding device to the client E. Preparing the medications to be given in the OR

A. Establishing an IV line B. Verifying the surgical site with the client C. Taking measures to ensure the client's comfort Rationale: In the holding area, the nurse reviews charts, identifies clients, verifies surgical site per institutional policy, establishes IV lines, administers any prescribed medications, and takes measures to ensure each client's comfort. A grounding device is applied in the OR. A nurse in the preoperative holding area does not prepare medications to be given by anyone else.

The client's surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the surgical wound. This requires the nurse to prioritize assessments related to what complication? A. Hypothermia B. Anaphylaxis C. Infection D. Malignant hyperthermia

B. Anaphylaxis Rationale: Fibrin sealants are used in a variety of surgical procedures, and cyanoacrylate tissue adhesives are used to close wounds without the use of sutures. These sealants have been implicated in allergic reactions and anaphylaxis. There is not an increased risk of malignant hyperthermia, hypothermia, or infection because of the use of tissue adhesives

A client has just been admitted to the postanesthesia care unit following abdominal surgery. As the client begins to awaken, the client is uncharacteristically restless. The nurse checks the skin, and it is cold, moist, and pale. The nurse is concerned the client may be at risk for which condition? A. Hemorrhage and shock B. Aspiration C. Postoperative infection D. Hypertension and dysrhythmias

A. Hemorrhage and shock Rationale: The client with a hemorrhage presents with hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin. Aspiration would manifest in airway disturbance. Hypertension or dysrhythmias would be less likely to cause pallor and cool skin. An infection would not be present at this early postoperative stage

The nurse is planning the care of a client who has type 1 diabetes and who will be undergoing knee replacement surgery. This client's care plan should reflect an increased risk of what postsurgical complication(s)? Select all that apply. A. Hypoglycemia B. Delirium C. Acidosis D. Glucosuria E. Fluid overload

A. Hypoglycemia C. Acidosis D. Glucosuria Rationale: Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin. Other risks are acidosis and glucosuria. The risks of fluid overload and delirium are not normally increased

The nurse is preparing an elderly client for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the client? A. Hypothermia B. Pulmonary edema C. Cerebral ischemia D. Arthritis

A. Hypothermia Rationale: Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open body wounds or cavities, decreased muscle activity, advanced age, or the pharmaceutical agents used (e.g., vasodilators, phenothiazines, general anesthetics). Older adults are particularly susceptible to this. The anesthetist monitors for pulmonary edema and cerebral ischemia. Arthritis is not an adverse effect of surgical anesthesia.

The nurse is providing preoperative teaching to a client scheduled for hip replacement surgery in 1 month. During the preoperative teaching, the client gives the nurse a list of medications the client takes, along with their dosage and frequency. What intervention provides the client with the most accurate information? A. Instruct the client to stop taking St. John's wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents. B. Instruct the client to continue taking ephedrine prior to surgery due to its beneficial effect on blood pressure. C. Instruct the client to discontinue levothyroxine sodium due to its effect on blood coagulation and the potential for heart dysrhythmias. D. Instruct the client to continue any herbal supplements unless otherwise instructed, and inform the client that these supplements have a minimal effect on the surgical procedure.

A. Instruct the client to stop taking St. John's wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents. Rationale: Because of the potential effects of herbal medications on coagulation and potential lethal interactions with other medications, the nurse must ask surgical clients specifically about the use of these agents, document their use, and inform the surgical team and anesthesiologist, anesthetist, or nurse anesthetist. Currently, it is recommended that the use of herbal products be discontinued at least 2 weeks before surgery. Clients with uncontrolled thyroid disorders are at risk for thyrotoxicosis and respiratory failure. The administration of levothyroxine sodium is imperative in the preoperative period. The use of ephedrine in the preoperative phase can cause hypertension and should be avoided.

The PACU nurse is caring for a client who had minimally invasive knee surgery. Which actions are the responsibility of the nurse in the PACU? Select all that apply. A. Monitoring the safe recovery from anesthesia B. Answering family questions about recovery C. Ensuring that informed consent has been signed D. Providing light nourishment E. Assessing the operative site for hemorrhage

A. Monitoring the safe recovery from anesthesia B. Answering family questions about recovery D. Providing light nourishment E. Assessing the operative site for hemorrhage Rationale: After surgery, the client is taken to the PACU, where the PACU nurse monitors the client for safe recovery from surgery and anesthesia. The PACU nurse also explains the equipment (such as an IV or sequential compression devices) to the client and family and answers their questions. The nurse brings the client, who has had nothing by mouth for 8 to 10 hours, light nourishment and assesses the client's response to eating. The PACU nurse also assesses the client's postoperative site for hemorrhage. Ensuring informed consent is the role of the nurse in the preoperative area.

The nurse in preadmission testing learns that a client scheduled for a total hip replacement in three weeks smokes one pack of cigarettes per day. Which action(s) should the nurse take? Select all that apply. A. Notify the surgeon that the client is a cigarette smoker. B. Encourage smoking cessation before surgery. C. Explain the increased risk for venous thromboembolism after surgery. D. Tell the client to stop smoking the day before surgery. E. Provide resources for smoking cessation

A. Notify the surgeon that the client is a cigarette smoker. B. Encourage smoking cessation before surgery. C. Explain the increased risk for venous thromboembolism after surgery. E. Provide resources for smoking cessation Rationale: Because clients who smoke, especially clients having a total joint replacement, are more likely to experience complications, the surgeon needs to be informed about the client's smoking history. The client needs to be encouraged to stop smoking, especially before surgery, to reduce the risk of postoperative complications such as venous thromboembolism and pneumonia. Because stopping smoking the day before surgery will have minimal positive effects on the surgery, the client should be encouraged to stop smoking as soon as possible. The nurse should provide the client with resources, such as written information and support groups, to support the client in smoking cessation.

The operating room nurse acts in the circulating role during a client's scheduled cesarean section. For which task is this nurse responsible? A. Performing documentation B. Estimating the client's blood loss C. Setting up the sterile tables D. Gives the surgeon instruments during surgery

A. Performing documentation Rationale: Main responsibilities of the circulating nurse include verifying consent; coordinating the team; and ensuring cleanliness, proper temperature and humidity, lighting, safe function of equipment, and the availability of supplies and materials. The circulating nurse monitors aseptic practices to avoid breaks in technique while coordinating the movement of related personnel as well as implementing fire safety precautions. The circulating nurse also monitors the client and documents specific activities throughout the operation to ensure the client's safety and well-being. Estimating the client's blood loss is the surgeon's responsibility; setting up the sterile tables is the responsibility of the first scrub; and giving the surgeon sterile instruments during surgery is the responsibility of the scrub nurse.

The nurse is developing a plan of care for a client having surgery under general anesthesia. Which nursing diagnoses' would be appropriate? Select all that apply. A. Risk for compromised human dignity related to general anesthesia B. Risk for impaired nutrition: less than body requirements related to anesthesia C. Risk of latex allergy response related to surgical exposure D. Disturbed body image related to anesthesia E. Anxiety related to surgical concerns

A. Risk for compromised human dignity related to general anesthesia C. Risk of latex allergy response related to surgical exposure E. Anxiety related to surgical concerns Rationale: Nursing diagnoses that would be appropriate for the client having a surgical procedure using general anesthesia include risk for compromised human dignity related to general anesthesia, risk for latex allergy response related to surgical exposure, and anxiety related to surgical concerns. Surgery under general anesthesia typically does not cause malnutrition or disturbed body image related to anesthesia.

An operating room nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is which of the following? A. Sterile surfaces or articles may touch other sterile surfaces. B. Sterile supplies can be used on another client if the packages are intact. C. The outer lip of a sterile solution is considered sterile. D. The scrub nurse may pour a sterile solution from a nonsterile bottle.

A. Sterile surfaces or articles may touch other sterile surfaces. Rationale: Basic guidelines for maintaining sterile technique include that sterile surfaces or articles may touch other sterile surfaces only. The other options each constitute a break in sterile technique.

The admitting nurse in a short-stay surgical unit is responsible for numerous aspects of care. What must the nurse verify before the client is taken to the preoperative holding area? A. That preoperative teaching was performed B. That the family is aware of the length of the surgery C. That follow-up home care is not necessary D. That the family understands the client will be discharged immediately after surgery.

A. That preoperative teaching was performed Rationale: The nurse needs to be sure that the client and family understand that the client will first go to the preoperative holding area before going to the OR for the surgical procedure and then will spend some time in the PACU before being discharged home with the family later that day. Other preoperative teaching content should also be verified and reinforced, as needed. The nurse should ensure that any plans for follow-up home care are in place

The circulating nurse in an outpatient surgery center is assessing a client who is scheduled to receive moderate sedation. Which principle should guide the care of a client receiving this form of anesthesia? A. The client must never be left unattended by the nurse. B. The client should begin a course of antiemetics the day before surgery. C. The client should be informed that the client will remember most of the procedure. D. The client must be able to maintain the client's own airway.

A. The client must never be left unattended by the nurse. Rationale: The client receiving moderate sedation should never be left unattended. The client's ability to maintain the client's own airway depends on the level of sedation. The administration of moderate sedation is not an indication for giving an antiemetic. The client receiving moderate sedation does not remember most of the procedure.

A client waiting in the presurgical holding area asks the nurse, "Why exactly do they have to put a breathing tube into me? My surgery is on my knee." What is the best rationale for intubation during a surgical procedure that the nurse should describe? A. The tube provides an airway for ventilation. B. The tube protects the client's esophagus from trauma. C. The client may receive an antiemetic through the tube. D. The client's vital signs can be monitored with the tube.

A. The tube provides an airway for ventilation. Rationale: The anesthetic is given and the client's airway is maintained through an intranasal intubation, oral intubation, or a laryngeal mask airway. The tube also helps protect aspiration of stomach contents. The tube does not protect the esophagus. Because the tube goes into the lungs, no medications are given through the tube. The client's vital signs are not monitored through the tube.

A client who underwent a bowel resection to correct diverticula suffered irreparable nerve damage. During the case review, the team is determining if incorrect positioning may have contributed to the client's nerve damage. What surgical position places the client at highest risk for nerve damage? A. Trendelenburg B. Prone C. Dorsal recumbent D. Lithotomy

A. Trendelenburg Rationale: Shoulder braces must be well padded to prevent irreparable nerve injury, especially when the Trendelenburg position is necessary. The other listed positions are less likely to cause nerve injury

The nurse is performing a preadmission assessment of a client scheduled for a bilateral mastectomy. The nurse should recognize which purpose as a valid reason for preadmission assessment? A. Verifies completion of preoperative diagnostic testing B. Discusses and reviews client's financial status C. Determines the client's suitability as a surgical candidate D. Informs the client of need for postoperative transportation

A. Verifies completion of preoperative diagnostic testing Rationale: One purpose of preadmission testing (PAT) is to verify completion of preoperative diagnostic testing. The nurse's role in PAT does not normally involve financial considerations or addressing transportation. The health care provider determines the client's suitability for surgery

A client is being asked to choose between an ambulatory surgical center and a hospital-based surgical unit. What guidance should the nurse provide? A. "Clients who go to ambulatory surgery centers are more independent." B. "Clients admitted to the hospital for surgery usually have multiple health needs." C. "In most cases, only emergency and trauma clients are admitted to the hospital." D. "Clients who have surgery in the hospital are those who need to have anesthesia given."

B. "Clients admitted to the hospital for surgery usually have multiple health needs." Rationale: Clients admitted to the hospital have multiple needs and stay for a short period of time. Clients who have surgery in ambulatory centers do not necessarily have greater independence. It is not true that only trauma and emergency surgeries are done in the hospital. Ambulatory centers can administer anesthesia.

The nurse is preparing to change a client's abdominal dressing. The nurse recognizes that the first step is to provide the client with information regarding the procedure. Which explanation should the nurse provide to the client? A. "The dressing change is often painful, so we will give you pain medication beforehand." B. "I will provide privacy. The dressing change should not be painful; you may look at the incision and help." C. "The dressing change should not be painful, but you can never be sure, and infection is always a concern." D. "The best time for a dressing change is during lunch. I will provide privacy, and it should not be painful."

B. "I will provide privacy. The dressing change should not be painful; you may look at the incision and help." Rationale: When having dressings changed, the client needs to be informed that the dressing change is a simple procedure with little discomfort; privacy will be provided; and the client is free to look at the incision or even assist in the dressing change itself. If the client decides to look at the incision, assurance is given that the incision will shrink as it heals and that the redness will likely fade. Dressing changes should not be painful, but giving pain medication prior to the procedure is always a good preventive measure. Telling the client that the dressing change "should not be painful, but you can never be sure, and infection is always a concern" does not offer the client any real information or options and serves only to create fear. The best time for dressing changes is when it is most convenient for the client; nutrition is important so interrupting lunch is probably a poor choice.

A presurgical client asks, "Why will I go to the postanesthesia care unit (PACU) instead of just going straight up to the postsurgical unit?" Which response by the nurse would be best? A. "It allows recovery from anesthesia in a stimulating environment to facilitate awakening and reorientation." B. "It allows us to observe you until you're oriented and have stable vital signs and no complications." C. "The medical-surgical unit is short of beds, and the PACU is an excellent place to triage clients." D. "The surgeon likely will need to reinforce or alter the your incision in the hours following surgery."

B. "It allows us to observe you until you're oriented and have stable vital signs and no complications." Rationale: The PACU provides care for the client while the client recovers from the effects of anesthesia. The client must be oriented, have stable vital signs, and show no evidence of hemorrhage or other complications. The PACU does allow the client to recover from anesthesia, but the environment is calm and quiet, as clients are initially disoriented and confused as they begin to awaken and reorient. Clients are not usually placed in the medical-surgical unit for recovery and, although hospitals are occasionally short of beds, the PACU is not used for client triage. Incisions are very rarely modified in the immediate postoperative period.

The nurse is creating the plan of care for a postoperative client for reduction of a femur fracture. Which goal is the most important short-term goal for this client? A. Relief of pain B. Adequate respiratory function C. Resumption of activities of daily living (ADLs) D. Unimpaired wound healing

B. Adequate respiratory function Rationale: Maintenance of the client's airway and breathing are imperative. Respiratory status is important because pulmonary complications are among the most frequent and serious problems encountered by the surgical client. Wound healing and eventual resumption of ADLs would be later concerns. Pain management is a high priority, but respiratory function is a more acute physiologic need.

A postoperative client rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the client is experiencing a hemorrhage. What should be the nurse's first action? A. Stay with the client and promptly notify the health care provider. B. Attempt to determine the cause of hemorrhage. C. Begin resuscitation. D. Put the client in the Trendelenburg position.

B. Attempt to determine the cause of hemorrhage. Rationale: Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures, but these require notifying the health care provider. The nurse should stay with the client. Resuscitation is not necessarily required. The Trendelenburg position would be contraindicated.

The nurse is preparing a client for surgery. The client reports being nervous and not really understanding the surgical procedure or its purpose. What is the most appropriate action for the nurse to take? A. Have the client sign the informed consent and place it in the chart. B. Call the health care provider to review the procedure with the client. C. Explain the procedure clearly to the client and the family. D. Provide the client with a pamphlet explaining the procedure.

B. Call the health care provider to review the procedure with the client. Rationale: While the nurse may ask the client to sign the consent form and witness the signature, it is the surgeon's responsibility to provide a clear and simple explanation of what the surgery will entail prior to the client giving consent. The surgeon must also inform the client of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the client requests additional information, the nurse notifies the health care provider. The consent form should not be signed until the client understands the procedure that has been explained by the surgeon. The provision of a pamphlet will benefit teaching the client about the surgical procedure, but will not substitute for the information provided by the health care provider

A surgical nurse is preparing to enter the restricted zone of the operating room. Which surgical attire should this nurse wear? Select all that apply. A. Street clothes B. Cap C. Mask D. Shoe covers E. Scrub clothes

B. Cap C. Mask D. Shoe covers E. Scrub clothes Rationale: In the restricted zone of the operating room, all personnel should wear scrub clothes, shoe covers, caps, and masks to reduce transmission of microbes. Street clothes are appropriate attire for unrestricted zones

While the surgical client is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the client's weight. How should the nurse best respond? A. Ignore the comment because the client is unconscious. B. Discourage the colleague from making such comments. C. Report the comment immediately to a supervisor. D. Realize that humor is needed in the workplace.

B. Discourage the colleague from making such comments. Rationale: Clients, whether conscious or unconscious, should not be subjected to excess noise, inappropriate conversation, or, most of all, derogatory comments. The nurse must act as an advocate on behalf of the client and discourage any such remarks. Reporting to a supervisor, however, is not likely necessary

The nurse admits a client to the postanesthesia care unit with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. This client is showing signs of what potential issue? A. Hypothermia B. Hypovolemic shock C. Neurogenic shock D. Malignant hyperthermia

B. Hypovolemic shock Rationale: The client is exhibiting symptoms of hypovolemic shock; therefore, the nurse should notify the client's health care provider and anticipate orders for fluid and/or blood product replacement. Neurogenic shock does not normally result in tachycardia, and malignant hyperthermia would rarely present at this stage in the operative experience. Hypothermia does not cause hypotension and tachycardia.

The intraoperative nurse is implementing a care plan that addresses the surgical client's risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication? A. Impaired skin integrity B. Hypoxia C. Malignant hyperthermia D. Hypothermia

B. Hypoxia Rationale: If the client aspirates vomitus, an asthma-like attack with severe bronchial spasms and wheezing is triggered. Pneumonitis and pulmonary edema can subsequently develop, leading to extreme hypoxia. Vomiting can cause choking, but the question asks about aspirated vomitus. Malignant hyperthermia is an adverse reaction to anesthesia. Aspirated vomitus does not cause hypothermia. Vomiting does not result in impaired skin integrity

The nurse is performing a preoperative assessment on a client going to surgery. The client reports to the nurse drinking approximately two bottles of wine each day for the last several years. What postoperative difficulties should the nurse anticipate for this client? A. Nonadherence to prescribed treatment after surgery B. Increased risk for postoperative complications C. Alcohol withdrawal syndrome upon administration of general anesthesia D. Increased risk for allergic reactions

B. Increased risk for postoperative complications Rationale: Alcohol use increases the risk of complications. Withdrawal does not occur immediately upon administration of anesthesia. Alcohol does not increase the risk of allergies and is not necessarily a risk factor for nonadherence.

Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the client's accompanying documentation includes which of the following? A. Discharge planning B. Informed consent C. Analgesia prescription D. Educational resources

B. Informed consent Rationale: It is important to review the client's record for the following: correct informed surgical consent, with client's signature; completed records for health history and physical examination; results of diagnostic studies; and allergies (including latex). Discharge planning records and prescriptions are not normally necessary. Educational resources would not be included at this stage of the surgical process

The operating room nurse will be caring for a client who will receive a transsacral block. The use of a transsacral block for pain control would be most appropriate for a client undergoing which procedure? A. Thoracotomy B. Inguinal hernia repair C. Reduction mammoplasty D. Closed reduction of a right humerus fracture

B. Inguinal hernia repair Rationale: A transsacral block produces anesthesia for the perineum and lower abdomen. Both a thoracotomy and breast reduction are in the chest region, and a transsacral block would not provide pain control for these procedures. A closed reduction of a right humerus is a procedure on the right arm, and a transsacral block would not provide pain control

The anesthetist is coming to the surgical admissions unit to see a client prior to surgery scheduled for tomorrow morning. What is the priority information that the nurse should provide to the anesthetist during the visit? A. Last bowel movement B. Latex allergy C. Number of pregnancies D. Difficulty falling asleep

B. Latex allergy Rationale: Due to the increased number of clients with latex allergies, it is essential to identify this allergy early on so precautions can be taken in the OR. The anesthetist should be informed of any allergies. This is a priority over pregnancy history, insomnia, or recent bowel function, though some of these may be relevant.

A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery? A. Leg exercises increase the client's muscle mass postoperatively. B. Leg exercises improve circulation and prevent venous thrombosis. C. Leg exercises help to prevent pressure sores to the sacrum and heels. D. Leg exercise help increase the client's level of consciousness after surgery.

B. Leg exercises improve circulation and prevent venous thrombosis. Rationale: Exercise of the extremities includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side) unless contraindicated by type of surgical procedure (e.g., hip replacement). When the client does leg exercises postoperatively, circulation is increased, which helps to prevent blood clots from forming. Leg exercises do not prevent pressure sores to the sacrum or increase the client's level of consciousness. Leg exercises have the potential to increase strength and mobility but are unlikely to make a change to muscle mass in the short term.

The nurse is caring for a client who has just been transferred to the PACU from the OR. What is the highest nursing priority? A. Assessing for hemorrhage B. Maintaining a patent airway C. Managing the client's pain D. Assessing vital signs every 30 minutes

B. Maintaining a patent airway Rationale: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Assessing for hemorrhage and assessing vital signs are also important, but constitute lower priorities. Pain management is important but only after the client has been stabilized

An operating room (OR) nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. Which personal protective equipment should the nurse wear at all times in the restricted zone of the OR? A. Bubble mask B. Mask covering the nose and mouth C. Goggles D. Gloves

B. Mask covering the nose and mouth Rationale: Masks are worn at all times in the restricted zone of the OR. In hospitals where numerous total joint procedures are performed, a complete bubble mask may be used. This mask provides full-barrier protection from bone fragments and splashes. Goggles and gloves are worn as required, but not necessarily at all times.

A client is 2 hours' postoperative with an indwelling urinary catheter. The last hourly urine output recorded for this client was 10 mL. The tubing of the catheter is confirmed to be patent. What should the nurse do? A. Irrigate the catheter with 30 mL normal saline. B. Notify the health care provider and continue to monitor the hourly urine output. C. Decrease the intravenous fluid rate and massage the client's abdomen. D. Have the client sit in high-Fowler position.

B. Notify the health care provider and continue to monitor the hourly urine output. Rationale: If the client has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 25 mL/hr are reported. The urine output should continue to be monitored hourly by the nurse. Irrigation would not be warranted because it is known that the catheter is patent. There is no need to place the client in high-Fowler position (sitting straight up), which would likely be uncomfortable 2 hours' postoperative.

During the care of a preoperative client, the nurse has given the client a preoperative benzodiazepine. The client is now requesting to void. What action should the nurse take? A. Assist the client to the bathroom. B. Offer the client a bedpan or urinal. C. Wait until the client gets to the operating room and is catheterized. D. Have the client go to the bathroom.

B. Offer the client a bedpan or urinal. Rationale: If a preanesthetic medication is given, the client is kept in bed with the side rails raised because the medication can cause lightheadedness or drowsiness. If a client needs to void following administration of a sedative, the nurse should offer the client a bedpan. The client should not get out of bed because of the potential for lightheadedness

The nurse is caring for a client who is postoperative day 2 following a colon resection. While turning the client, wound dehiscence with evisceration occurs. What should be the nurse's first response? A. Return the client to the previous position and call the health care provider. B. Place saline-soaked sterile dressings on the wound. C. Assess the client's blood pressure and pulse. D. Pull the dehiscence closed using gloved hands.

B. Place saline-soaked sterile dressings on the wound. Rationale: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the health care provider and take the client's vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.

A client is on call to the OR for an aortobifemoral bypass and the nurse administers the prescribed preoperative medication. After administering a preoperative medication to the client, what should the nurse do? A. Encourage light ambulation. B. Place the bed in a low position with the side rails up. C. Tell the client that the client will be asleep before it is time to leave for surgery. D. Take the client's vital signs every 15 minutes.

B. Place the bed in a low position with the side rails up. Rationale: When the preoperative medication is given, the bed should be placed in low position with the side rails raised. The client should not get up without assistance. The client may not be asleep, but may be drowsy. Vital signs should be taken before the preoperative medication is given; vital signs are not normally required every 15 minutes after administration.

A surgical client has been given general anesthesia and is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage? A. Rub the client's back. B. Provide for client safety. C. Encourage the client to express feelings. D. Stroke the client's hand.

B. Provide for client safety. Rationale: In stage II, the client may struggle, shout, or laugh. The movements of the client may be uncontrolled, so it is essential that the nurse be ready to help to restrain the client for safety, if necessary. Rubbing the client's back, encouraging the client to express feelings, or stroking the client's hand do not protect client safety and therefore are not the priority.

The nurse knows that older clients are at higher risk for complications and adverse outcomes during the intraoperative period. What is the best rationale for this phenomenon? A. A more angular bone structure than a younger person B. Reduced ability to adjust rapidly to emotional and physical stress C. Increase susceptibility to hyperthermia D. Impaired ability to decrease one's metabolic rate

B. Reduced ability to adjust rapidly to emotional and physical stress Rationale: Factors that affect the older surgical client in the intraoperative period include the following: impaired ability to increase, not decrease, one's metabolic rate and impaired thermoregulatory mechanisms, which increase susceptibility to hypothermia, not hyperthermia. Reduced ability to adjust rapidly to emotional and physical stress influences surgical outcomes and requires meticulous observation of vital functions. Older adults do not have more angular bones than younger people.

The nurse is caring for an unconscious trauma client who needs emergency surgery. The client has an adult child, is legally divorced, and is planning to marry a partner in a few weeks. The client's parents are at the hospital with the other family members. The health care provider has explained the need for surgery, the procedure to be done, and the risks to the child, the parents, and the partner. Who should be asked to sign the surgery consent form? A. The partner B. The child C. The health care provider, acting as a surrogate D. The client's father

B. The child Rationale: The client personally signs the consent if of legal age and mentally capable. Permission is otherwise obtained from a surrogate, who most often is a responsible family member (preferably next of kin) or legal guardian. In this instance, the child would be the appropriate person to ask to sign the consent form as the child is the closest relative at the hospital. The partner is not legally related to the client as the marriage has not yet taken place. The father would only be asked to sign the consent if no children were present to sign. The health care provider would not sign if family members were available.

The nurse is taking the client into the operating room (OR) when the client informs the nurse that the client's grandparent spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client? A. The client may be experiencing presurgical anxiety. B. The client may be at risk for malignant hyperthermia. C. The grandparent's surgery has minimal relevance to the client's surgery. D. The client may be at risk for a sudden onset of postsurgical infection.

B. The client may be at risk for malignant hyperthermia. Rationale: Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents. Identifying clients at risk is imperative because the mortality rate is 50%. The client's anxiety is not relevant, the grandparent's surgery is very relevant, and all clients are at risk for postsurgical infections.

The postanesthesia care unit nurse is caring for a client who has arrived from the operating room. During the initial assessment, the nurse observes that the client's skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the client is not breathing. Which intervention is the priority? A. Check the client's oxygen saturation level, and monitor for apnea. B. Tilt the head back and push forward on the angle of the lower jaw. C. Assess the arterial pulses, and place the client in the Trendelenburg position. D. Reintubate the client, and perform a focused assessment.

B. Tilt the head back and push forward on the angle of the lower jaw. Rationale: When a nurse finds a client who is not breathing, the priority intervention is to open the airway and treat a possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the head back and then pushes forward on the angle of the lower jaw or performs the jaw thrust method to open the airway. This is an emergency and requires the basic life support intervention of airway, breathing, and circulation assessment. Arterial pulses should be checked only after airway and breathing have been established. Reintubation and resuscitation would begin after rapidly ruling out a hypopharyngeal obstruction.

The nurse is providing preoperative teaching to a client scheduled for surgery. The nurse is instructing the client on the use of deep breathing, coughing, and the use of incentive spirometry when the client states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide? A. To prevent chronic obstructive pulmonary disease (COPD) B. To promote optimal lung expansion C. To enhance peripheral circulation D. To prevent pneumothorax

B. To promote optimal lung expansion Rationale: One goal of preoperative nursing care is to teach the client how to promote optimal lung expansion and consequent blood oxygenation after anesthesia. COPD is not a realistic risk and pneumothorax is also unlikely. Breathing exercises do not primarily affect peripheral circulation

A client's coronary artery bypass graft has been successful, and discharge planning is underway. When planning the client's subsequent care, the nurse should know that the postoperative phase of perioperative nursing ends at what time? A. When the client is returned to the room after surgery B. When a follow-up evaluation in the clinical or home setting is done C. When the client is fully recovered from all effects of the surgery D. When the family becomes partly responsible for the client's care

B. When a follow-up evaluation in the clinical or home setting is done Rationale: The postoperative phase begins with the admission of the client to the PACU and ends with a follow-up evaluation in the clinical setting or home

The nurse is preparing a client for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the client's signature on a consent form. Which comment by the client would best indicate informed consent? A. "I know I'll be fine because the health care provider has done this procedure hundreds of times." B. "I know I'll have pain after the surgery but they'll do their best to keep it to a minimum." C. "The health care provider is going to remove my uterus and told me about the risk of bleeding." D. "Because the health care provider isn't taking my ovaries, I'll still be able to have children."

C. "The health care provider is going to remove my uterus and told me about the risk of bleeding." Rationale: The surgeon must explain the procedure and inform the client of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the client requests additional information, the nurse notifies the health care provider. In the correct response, the client is able to tell the nurse what will occur during the procedure and the associated risks. This indicates the client has a sufficient understanding of the procedure to provide informed consent.

The nurse just received a postoperative client from the postanesthesia care unit to the medical-surgical unit. The client had surgery for a left hip replacement. Which concern should the nurse prioritize for this client in the first few hours on the unit? A. Beginning early ambulation B. Maintaining clean dressings on the surgical site C. Closely monitoring neurologic status D. Resuming normal oral intake

C. Closely monitoring neurologic status Rationale: In the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding are primary concerns. A client who has had total hip replacement does not ambulate during the first few hours on the unit. Dressings are assessed but may have some drainage on them. Oral intake will take more time to resume.

Maintaining an aseptic environment in the OR is essential to client safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field? A. 2 feet (60 cm) B. 18 inches (45 cm) C. 1 foot (30 cm) D. 6 inches (15 cm)

C. 1 foot (30 cm) Rationale: Sterile areas must be kept in view during movement around the area. At least a 1-foot distance from the sterile field must be maintained to prevent inadvertent contamination

The nurse is performing wound care on a postsurgical client. Which practice violates the principles of surgical asepsis? A. Holding sterile objects at chest level B. Allowing a sterile instrument to touch a sterile drape C. A circulating nurse touching a sterile drape D. Considering an unopened sterile package to be sterile

C. A circulating nurse touching a sterile drape Rationale: Circulating nurses and unsterile items may only have contact with unsterile areas, not sterile areas. Gowns of the surgical team are considered sterile in front from the chest to the level of the sterile field, and sleeves are considered sterile from 2 inches above the elbow to the stockinette cuff. So, holding a sterile object at chest level does not violate the principles of surgical asepsis. Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile. An unopened sterile package is considered sterile; once it is opened, however, its edges are considered unsterile.

The intraoperative nurse advocates for each client who receives care in the surgical setting. How can the nurse best exemplify the principles of client advocacy? A. By encouraging the client to perform deep breathing preoperatively B. By limiting the client's contact with family members preoperatively C. By maintaining the privacy of each client D. By eliciting informed consent from clients

C. By maintaining the privacy of each client Rationale: Client advocacy in the OR entails maintaining the client's physical and emotional comfort, privacy, rights, and dignity. Deep breathing is not necessary before surgery and obtaining informed consent is the purview of the health care provider. Family contact should not be limited

An older adult client is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding area to meet the client and quickly realizes that the client is profoundly anxious. What is the most appropriate intervention for the nurse to apply? A. Reassure the client that modern surgery is free of significant risks. B. Describe the surgery to the client in as much detail as possible. C. Clearly explain any information that the client seeks. D. Remind the client that the anesthetic will render the client unconscious.

C. Clearly explain any information that the client seeks. Rationale: The nurse can alleviate anxiety by supplying information as the client requests it. The nurse should not assume that every client wants as much detail as possible and false reassurance must be avoided. Reminding the client that they will be unconscious is unlikely to reduce anxiety

A client will be undergoing a total hip arthroplasty later in the day and it is anticipated that the client may require blood transfusion during surgery. How can the nurse best ensure the client's safety if a blood transfusion is required? A. Prime IV tubing with a unit of blood and keep it on hold. B. Check that the client's electrolyte levels have been assessed preoperatively. C. Ensure that the client has had a current cross-match. D. Keep the blood on standby and warmed to body temperature.

C. Ensure that the client has had a current cross-match. Rationale: Few clients undergoing an elective procedure require blood transfusion, but those undergoing high-risk procedures may require an intraoperative transfusion. The circulating nurse anticipates this need, checks that blood has been cross-matched and held in reserve, and is prepared to administer blood. Storing the blood at body temperature or in IV tubing would result in spoilage and potential infection.

The nurse is caring for a client who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the client's ribs and xiphoid process are prominent. The client reports exercising two to three times daily, and the client's parent indicates that the client is being treated for anorexia nervosa. How should the nurse best follow up on these assessment data? A. Inform the postoperative team about the client's risk for wound dehiscence. B. Evaluate the client's ability to manage pain level. C. Facilitate a detailed analysis of the client's electrolyte levels. D. Instruct the client on the need for a high-sodium diet to promote healing.

C. Facilitate a detailed analysis of the client's electrolyte levels. Rationale: The surgical team should be informed of the client's medical history regarding anorexia nervosa. Any nutritional deficiency, such as malnutrition, should be corrected before surgery to provide adequate protein for tissue repair. The electrolyte levels should be evaluated and corrected to prevent metabolic abnormalities in the operative and postoperative phases. The risk of wound dehiscence is more likely associated with obesity. Instruction on proper nutrition should take place in the postoperative period, and a consultation should be made with a psychiatric specialist. Evaluation of pain management is always important, but not particularly significant in this scenario.

The nurse is caring for a client who has had spinal anesthesia. The client is under a health care provider's order to lie flat postoperatively. When the client asks to go to the bathroom, the nurse encourages the client to adhere to the health care provider's order. Prevention of which outcome should the nurse include in the rationale for complying with this order? A. Hypotension B. Respiratory depression C. Headache D. Pain at the lumbar injection site

C. Headache Rationale: Lying flat reduces the risk of headache after spinal anesthesia. Hypotension and respiratory depression may be adverse effects of spinal anesthesia associated with the spread of the anesthetic, but lying flat does not help reduce these effects. Pain at the lumbar injection site typically is not a problem.

The perioperative nurse is constantly assessing the surgical client for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the client is developing malignant hyperthermia? A. Increased temperature B. Oliguria C. Tachycardia D. Hypotension

C. Tachycardia Rationale: The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. Tachycardia (heart rate greater than 150 beats per minute) is often the earliest sign. Oliguria, hypotension, and increased temperature are later signs of malignant hyperthermia.

The intraoperative nurse knows that the client's emotional state can influence the outcome of the surgical procedure. How should the nurse best address this? A. Teach the client strategies for distraction. B. Pair the client with another client who has better coping strategies. C. Incorporate cultural and religious considerations, as appropriate. D. Give the client antianxiety medication.

C. Incorporate cultural and religious considerations, as appropriate. Rationale: Because the client's emotional state remains a concern, the care initiated by preoperative nurses is continued by the intraoperative nursing staff that provides the client with information and reassurance. The nurse supports coping strategies and reinforces the client's ability to influence outcomes by encouraging active participation in the plan of care incorporating cultural, ethnic, and religious considerations, as appropriate. "Buddying" a client is normally inappropriate and distraction may or may not be effective. Nonpharmacologic measures should be prioritized.

The clinic nurse is doing a preoperative assessment of a client who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the client's medical history, the nurse notes that this client had a kidney transplant 8 years ago and that the client is taking immunosuppressive drugs. For what is this client at increased risk when having surgery? A. Rejection of the kidney B. Rejection of the implanted lens C. Infection D. Adrenal storm

C. Infection Rationale: Because clients who are immunosuppressed are highly susceptible to infection, great care is taken to ensure strict asepsis. The client is unlikely to experience rejection or adrenal storm.

The intraoperative nurse is transferring a client from the OR to the PACU after replacement of the right knee. The client is an older adult. The nurse should prioritize which of the following actions? A. Keeping the client sterile B. Keeping the client restrained C. Keeping the client warm D. Keeping the client hydrated

C. Keeping the client warm Rationale: Special attention is given to keeping the client warm because elderly clients are more susceptible to hypothermia. It is always important for the nurse to pay attention to hydration, but hypovolemia does not occur as quickly as hypothermia. The client is never sterile, and restraints are very rarely necessary.

The nurse is caring for a client in the postanesthesia care unit after abdominal surgery. The client's blood pressure has increased, and the client is restless. The client's oxygen saturation is 97%. Which factor should the nurse first suspect as the cause for this change in status? A. Hypothermia B. Shock C. Pain D. Hypoxia

C. Pain Rationale: An increase in blood pressure and restlessness are symptoms of pain. The client's oxygen saturation is 97%, so hypothermia, hypoxia, and shock are not likely causes of the client's restlessness

The nurse is caring for an older adult client in the postanesthesia care unit. The client begins to awaken and responds to their name, but is confused, restless, and agitated. Which principle should guide the nurse's subsequent assessment? A. Postoperative confusion in older adults is an indication of impaired oxygenation or possibly a stroke during surgery. B. Confusion, restlessness, and agitation are expected postoperative findings in older adults, and they will diminish in time. C. Postoperative confusion is common in the older adult client, but it could also indicate a significant blood loss. D. Confusion, restlessness, and agitation indicate an underlying cognitive deficit such as dementia.

C. Postoperative confusion is common in the older adult client, but it could also indicate a significant blood loss. Rationale: Postoperative confusion is common in the older adult client, but it could also indicate blood loss and the potential for hypovolemic shock; it is a critical symptom for the nurse to identify. Despite being common, it is not considered to be an expected finding. Postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery, but blood loss is more likely. A new onset of confusion, restlessness, and agitation does not necessarily suggest an underlying cognitive disorder.

The circulating nurse will be participating in a 78-year-old client's total hip replacement. Which consideration should the nurse prioritize during the preparation of the client in the operating room? A. The client should be placed in Trendelenburg position. B. The client must be firmly restrained at all times. C. Pressure points should be assessed and well padded. D. The preoperative shave should be done by the circulating nurse.

C. Pressure points should be assessed and well padded. Rationale: The vascular supply should not be obstructed nor nerves damaged by an awkward position or undue pressure on a body part. During surgical procedures, the client is at risk for impairment of skin integrity due to a stationary position and immobility. An older client is at an increased risk of injury and impaired skin integrity. Therefore, pressure points should be assessed and well padded. A Trendelenburg position is not indicated for this client. Once anesthetized for a total hip replacement, the client cannot move; restraints are not necessary. A preoperative shave is not performed; excess hair is removed by means of a clipper.

A client is scheduled for a bowel resection in the morning and the client's orders are for a cleansing enema be administered tonight. The client wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect? A. Preventing aspiration of gastric contents B. Preventing the accumulation of abdominal gas postoperatively C. Preventing potential contamination of the peritoneum D. Facilitating better absorption of medications

C. Preventing potential contamination of the peritoneum Rationale: The administration of a cleansing enema will allow for satisfactory visualization of the surgical site and to prevent trauma to the intestine or contamination of the peritoneum by feces. It will have no effect on aspiration of gastric contents or the absorption of medications. The client should expect to develop gas in the postoperative period

The nurse is caring for a client who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear external pneumatic compression stockings. The nurse should explain that refusing to wear external pneumatic compression stockings increases the risk of which postsurgical complication? A. Sepsis B. Infection C. Pulmonary embolism D. Hematoma

C. Pulmonary embolism Rationale: Clients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of external pneumatic compression stockings significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection or sepsis would not be affected by external pneumatic compression stockings. A hematoma or bruise would not be affected by external pneumatic compression stockings unless the stockings were placed directly over the hematoma.

The nurse is caring for a client on the medical-surgical unit postoperative day 5. During each client assessment, the nurse evaluates the client for infection. Which of the following would be most indicative of infection? A. Presence of an indwelling urinary catheter B. Oral temperature of 99.5°F (37.5°C) C. Red, warm, tender incision D. White blood cell (WBC) count of 8,000/mL

C. Red, warm, tender incision Rationale: Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a client to infection, but by itself does not indicate infection. An oral temperature of 99.5°F may not signal infection in a postoperative client because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/mL.

The nurse is caring for a 78-year-old client who has had an outpatient cholecystectomy. The nurse is getting the client up for the first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the client do? A. Sit in a chair for 10 minutes prior to ambulating. B. Drink plenty of fluids to increase circulating blood volume. C. Stand upright for 2 to 3 minutes prior to ambulating. D. Perform range-of-motion exercises for each joint.

C. Stand upright for 2 to 3 minutes prior to ambulating. Rationale: Older adults are at an increased risk for orthostatic hypotension secondary to age-related changes in vascular tone. The client should sit up and then stand for 2 to 3 minutes before ambulating to alleviate orthostatic hypotension. The nurse should assess the client's ability to mobilize safely, but full assessment of range of motion in all joints is not normally necessary. Sitting in a chair and increasing fluid intake are insufficient to prevent orthostatic hypotension and consequent falls

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The child's parents are thought to be en route to the hospital but have not yet arrived. No other family members are present, and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to survive. How should the need for informed consent be addressed? A. A social worker should temporarily sign the informed consent. B. Consent should be obtained from the hospital's ethics committee. C. Surgery should be done without informed consent. D. Surgery should be delayed until the parents arrive.

C. Surgery should be done without informed consent. Rationale: In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the client's informed consent. However, every effort must be made to contact the client's family. In such a situation, contact can be made by electronic means. In this scenario, the surgery is considered lifesaving, and the parents are on their way to the hospital and not available. A delay would be unacceptable. Neither a social worker nor a member of the ethics committee may sign.

The nurse is caring for a client who anticipates pain and anxiety following surgery. Which intervention should the nurse implement in the postoperative period to reduce the client's pain and anxiety? A. Administer NSAIDs for mild-to-moderate pain. B. Encourage the client to increase activity. C. Use guided imagery along with pain medication. D. Teach deep breathing and coughing exercises.

C. Use guided imagery along with pain medication. Rationale: The use of guided imagery will enhance pain relief and assist in reduction of anxiety. The use of NSAIDs is appropriate for controlling mild-to-moderate pain, but will not reduce anxiety. Deep breathing and coughing are not pain control or anxiety relief measures. Rather, they help prevent postoperative pulmonary complications

The operating room nurse is providing care for a major trauma client who has been involved in a motorcycle accident. Which intraoperative change may suggest the presence of anesthesia awareness? A. Respiratory depression B. Sudden hypothermia and diaphoresis C. Vital sign changes and client movement D. Bleeding beyond what is anticipated

C. Vital sign changes and client movement Rationale: Indications of the occurrence of anesthesia awareness include an increase in the blood pressure, rapid heart rate, and client movement. Respiratory depression, hypothermia and bleeding are not associated with this complication.

The nurse is caring for a trauma victim in the ED who will require emergency surgery due to injuries. Before the client leaves the ED for the OR, the client goes into cardiac arrest. The nurse assists in a successful resuscitation and proceeds to release the client to the OR staff. When can the ED nurse perform the preoperative assessment? A. When the nurse has the opportunity to review the client's electronic health record B. When the client arrives in the OR C. When assisting with the resuscitation D. Preoperative assessment is not necessary in this case

C. When assisting with the resuscitation Rationale: The only opportunity for preoperative assessment may take place at the same time as resuscitation in the ED. Preoperative assessment is necessary, but the nurse could not normally enter the OR to perform this assessment. The health record is an inadequate data source.

A client is admitted to the ED reporting severe abdominal pain and vomiting "coffee-ground" like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that they need surgery. When can the client most likely anticipate that the surgery will be scheduled? A. Within 24 hours B. Within the next week C. Without delay D. As soon as all the day's elective surgeries have been completed

C. Without delay Rationale: Emergency surgeries are unplanned and occur with little time for preparation for the client or the perioperative team. An active bleed, which is indicated by the "coffee-ground" emesis, is considered an emergency, and the client requires immediate attention because the disorder may be life threatening. The surgery would not likely be deferred until after elective surgeries have been completed.

The nurse's aide notifies the nurse that a client has decreased oxygen saturation levels. The nurse assesses the client and finds that the client is tachypneic, has crackles on auscultation, and has frothy and pink sputum. The nurse should suspect which complication? A. Pulmonary embolism B. Atelectasis C. Laryngospasm D. Flash pulmonary edema

D. Flash pulmonary edema Rationale: Flash pulmonary edema occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation; tachypnea; tachycardia; decreased pulse oximetry readings; frothy, pink sputum; and crackles on auscultation. Laryngospasm does not cause crackles or frothy, pink sputum. The client with atelectasis has decreased breath sounds over the affected area; the scenario does not indicate this. A pulmonary embolism does not cause this symptomatology.

The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the postsurgical unit following a colon resection. This client's age and body mass index increase the risk for what complication in the postoperative period? A. Hyperglycemia B. Azotemia C. Falls D. Infection

D. Infection Rationale: Like age, obesity increases the risk and severity of complications associated with surgery. During surgery, fatty tissues are especially susceptible to infection. In addition, obesity increases technical and mechanical problems related to surgery. Therefore, dehiscence (wound separation) and wound infections are more common. A postoperative client who is obese will not likely be at greater risk for hyperglycemia, azotemia, or falls

The nurse is planning teaching for a client who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching? A. Upon the client's admission to the post-anesthesia care unit (PACU) B. When the client returns from the PACU C. During the intraoperative period D. As soon as possible, and before the surgical procedure

D. As soon as possible, and before the surgical procedure Rationale: Teaching is most effective when provided before surgery. Preoperative teaching is initiated as soon as possible, beginning in the health care provider's office, clinic, or at the time of preadmission testing when diagnostic tests are performed. Upon admission to the PACU, the client is usually drowsy, making this an inopportune time for teaching. Upon the client's return from the PACU, the client may remain drowsy. During the intraoperative period, anesthesia alters the client's mental status, rendering teaching ineffective

The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client? A. Heart rate and rhythm B. Skin integrity C. Core body temperature D. Airway patency

D. Airway patency Rationale: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).

Prior to a client's scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the client's care. What is the main rationale for organizing perioperative care in this collaborative manner? A. Historical precedent B. Client requests C. Health care providers' needs D. Evidence-based practice

D. Evidence-based practice Rationale: Collaboration of the surgical team using evidence-based practice tailored to a specific case results in optimal client care and improved outcomes. None of the other listed factors is the basis for the collaboration of the surgical team.

The nurse is packing a client's abdominal wound with sterile, half-inch Iodoform gauze. During the procedure, the nurse drops some of the gauze onto the client's abdomen 2 inches (5 cm) away from the wound. What should the nurse do? A. Apply povidone-iodine (Betadine) to that section of the gauze and continue packing the wound. B. Pick up the gauze and continue packing the wound after irrigating the abdominal wound with Betadine solution. C. Continue packing the wound and inform the health care provider that an antibiotic is needed. D. Discard the gauze packing and repack the wound with new Iodoform gauze.

D. Discard the gauze packing and repack the wound with new Iodoform gauze. Rationale: Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile; contact with unsterile objects at any point renders a sterile area contaminated. The sterile gauze became contaminated when it was dropped on the client's abdomen. It should be discarded and new Iodoform gauze should be used to pack the wound. Betadine should not be used in the wound unless prescribed.

A nurse is caring for a client following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache? A. Seat the client in a chair and have them perform deep breathing exercises. B. Ambulate the client as early as possible. C. Limit the client's fluid intake for the first 24 hours' postoperatively. D. Keep the client positioned supine.

D. Keep the client positioned supine. Rationale: Measures that increase cerebrospinal pressure are helpful in relieving headache. These include maintaining a quiet environment, keeping the client lying flat, and keeping the client well hydrated. Having the client sit or stand up decreases cerebrospinal pressure and would not relieve a spinal headache. Limiting fluids is incorrect because it also decreases cerebrospinal pressure and would not relieve a spinal headache.

An adult client is scheduled for a hemorrhoidectomy. The OR nurse should anticipate assisting the other team members with positioning the client in what manner? A. Dorsal recumbent position B. Trendelenburg position C. Sims position D. Lithotomy position

D. Lithotomy position Rationale: The lithotomy position is used for nearly all perineal, rectal, and vaginal surgical procedures. The Sims or lateral position is used for renal surgery, and the Trendelenburg position usually is used for surgery on the lower abdomen and pelvis. The usual position for surgery, called the dorsal recumbent position, is flat on the back, but this would be impracticable for rectal surgery

The postanesthesia care unit nurse is caring for a client who had a hernia repair. The client's blood pressure is now 164/92 mm Hg; the client has no history of hypertension prior to surgery and preoperative blood pressure was 112/68 mm Hg. The nurse should assess for which potential causes of hypertension following surgery? A. Dysrhythmias, blood loss, and hyperthermia B. Electrolyte imbalances and neurologic changes C. A parasympathetic reaction and low blood volumes D. Pain, hypoxia, and bladder distention

D. Pain, hypoxia, and bladder distention Rationale: Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Dysrhythmias, blood loss, hyperthermia, electrolyte imbalances, and neurologic changes are not common postoperative reasons for hypertension. A parasympathetic reaction and low blood volumes would cause hypotension.

The nurse is caring for a hospice client who is scheduled for a surgical procedure to reduce the size of a spinal tumor in an effort to relieve pain. The nurse should plan this client care with the knowledge that this surgical procedure is classified as which of the following? A. Diagnostic B. Laparoscopic C. Curative D. Palliative

D. Palliative Rationale: A client on hospice will undergo a surgical procedure only for palliative care, which means to reduce pain or provide comfort, not to cure disease (curative). The reduction of tumor size to relieve pain is considered a palliative procedure. A laparoscopic procedure is a type of surgery that is utilized for diagnostic purposes or for repair. Diagnostic procedures are performed to help diagnose a condition. The excision of a tumor is classified as curative. This client is not having the tumor removed, only the size reduced.

The nurse is caring for a client who is scheduled to have a needle biopsy of the pleura. The client has had a consultation with the anesthesiologist, and a conduction block will be used. Which local conduction block can be used to block the nerves leading to the chest? A. Transsacral block B. Brachial plexus block C. Pudendal block D. Paravertebral block

D. Paravertebral block Rationale: Examples of common local conduction blocks include paravertebral anesthesia, which produces anesthesia of the nerves supplying the chest, abdominal wall, and extremities; brachial plexus block, which produces anesthesia of the arm; and transsacral (caudal) block, which produces anesthesia of the perineum and, occasionally, the lower abdomen. A pudendal block was used in obstetrics before the almost-routine use of epidural anesthesia

A 90-year-old client is scheduled to undergo surgery. Prevention of which potential complication should the nurse prioritize when planning this client's postoperative care? A. Reduced concentration related to stress B. Delayed growth and development due to a prolonged hospitalization C. Decision conflict related to discharge planning D. Pneumonia due to reduced respiratory reserve

D. Pneumonia due to reduced respiratory reserve Rationale: The reduced physiologic reserve of older adults results in an increased risk for pneumonia postoperatively. This physiologic consideration is a priority over psychosocial considerations of impaired growth and development and decisional conflict, which may or may not be applicable. Reduced concentration should also be addressed, but the priority is first to assure adequate pulmonary function.

The perioperative nurse knows that the National Client Safety Goals have the potential to improve client outcomes in a wide variety of health care settings. Which of these goals has the most direct relevance to the OR? A. Improve safety related to medication use. B. Reduce the risk of client harm resulting from falls. C. Reduce the incidence of health care-associated infections. D. Reduce the risk of fires.

D. Reduce the risk of fires. Rationale: The National Client Safety Goals all pertain to the perioperative areas, but the one with the most direct relevance to the OR is the reduction of the risk of surgical fires.

The nurse is doing preoperative client education with a client who has a 40 pack-year history of cigarette smoking. The client will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this client? A. Reduce smoking by 50% to prevent the development of pneumonia. B. Continue smoking so as to help manage stress levels before and after surgery. C. Aim to quit smoking in the postoperative period to reduce the chance of surgical complications. D. Stop smoking as soon as possible before the scheduled surgery to enhance pulmonary function and decrease infection.

D. Stop smoking as soon as possible before the scheduled surgery to enhance pulmonary function and decrease infection. Rationale: Stopping smoking before the surgery will enhance pulmonary function and reduce the risk of infection in the postoperative period. Merely reducing smoking by 50% would not be as effective as stopping, nor would waiting until after the surgery to stop smoking. Although smoking may help the client manage stress, the pulmonary function and infection risks that it poses far outweigh any benefit it may offer related to stress reduction.

The nurse is admitting a client who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this client's diagnosis of type 1 diabetes affect the care that the nurse plans? A. The nurse should administer a bolus of dextrose IV solution preoperatively. B. The nurse should keep the client NPO for at least 8 hours preoperatively. C. The nurse should initiate a subcutaneous infusion of long-acting insulin. D. The nurse should assess the client's blood glucose levels frequently.

D. The nurse should assess the client's blood glucose levels frequently. Rationale: The client with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia. Close glycemic monitoring is necessary. Dextrose infusion and prolonged NPO status are contraindicated. There is no specific need for an insulin infusion preoperatively.

A client is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The client's vital signs and level of consciousness have stabilized, but the client then reports severe nausea and begins to vomit. What should the nurse do next? A. Administer a dose of intravenous analgesic. B. Apply a cool cloth to the client's forehead. C. Offer the client a small amount of ice chips. D. Turn the client to one side.

D. Turn the client to one side. Rationale: Turning the client to one side allows collected fluid to escape from the side of the mouth if the client vomits. After turning the client to the side, the nurse can offer a cool cloth to the client's forehead. Ice chips can increase feelings of nausea. An analgesic is not given for nausea and vomiting.

The circulating nurse is admitting a client prior to surgery and proceeds to greet the client and discuss what the client can expect in surgery. Which aspect of therapeutic communication should the nurse implement? A. Wait for the client to initiate dialogue. B. Avoid making eye contact. C. Give preoperative medications prior to discussion. D. Use a tone that decreases the client's anxiety.

D. Use a tone that decreases the client's anxiety. Rationale: When discussing what the client can expect in surgery, the nurse uses basic communication skills, such as touch, tone, and eye contact, to reduce anxiety. The nurse should not withhold communication until the client initiates dialogue; the nurse most often needs to initiate and guide dialogue, while still responding to the client's leading. Giving medication is not a communication skill