Operative Care Questions

A client returns to the medical-surgical floor from the postanesthesia recovery room after a colon resection for adenocarcinoma. The client has comorbidities of stage 2 hypertension and a previous myocardial infarction. The first set of postoperative vital signs recorded are pulse rate of 110 bpm, respiration rate of 20/minute, blood pressure of 130/86 mm Hg, and temperature of 98° F (36.7° C). The surgeon calls to ask if the client needs a unit of packed red blood cells. The nurse's response should be based on which data? Select all that apply. a) Vital sign changes. b) Warm, dry skin. c) Cyanotic mucous membrane. d) Oxygen saturation. e) Intake and output.

• Cyanotic mucous membrane. • Vital sign changes. • Oxygen saturation. • Intake and output. When assessing a postoperative client for perfusion and the manifestation of shock, nursing assessment should include an inspection for cyanotic mucous membranes; cold, moist, pale skin; and the level of oxygen saturation in relation to hemoglobin. The nurse should also compare the client's postoperative vital signs with his preoperative vital signs to determine how much physiologic stress has occurred during the intraoperative period. A client who is perfusing well would have warm, dry skin. A client well hydrated would have good skin turgor. The nurse would also assess fluid status using the intake and output record. If hemoglobin and hematocrit were available, the values would be included in the assessment.

A client with type 1 diabetes mellitus is scheduled to have surgery. The client has been NPO since midnight. In the morning, the nurse notices the client's daily insulin has not been prescribed. Which action should the nurse do first? a) Obtain the client's blood glucose at the bedside. b) Inform the Post Anesthesia Care Unit (PACU) staff to obtain the insulin order. c) Contact the physician for further orders regarding insulin dosage. d) Give the client's usual morning dose of insulin.

a)

On the day of surgery, a client with diabetes who takes insulin on a sliding scale is ordered to have nothing by mouth and all medications withheld. The client's 6 a.m. glucose level is 300 mg/dl (16.65 mmol/l). The nurse should: a) Call the physician for specific orders based on the glucose level. b) Administer the insulin dose dictated by the sliding scale. c) Notify the surgery department. d) Withhold all medications as ordered.

a)

Prior to going to surgery, the client tells the nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response? a) Call the surgery unit to explain the client's concern and ask if she can wear her hearing aid to surgery. b) Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken. c) Explain to the client that she will have a premedication that will make her sleepy before she goes to surgery and she won't need to hear. d) Tell the client that she will bring the hearing aid to the postanesthesia care unit so that she can have it as soon as she wakes up.

a)

The nurse in the perioperative area is preparing a client for surgery and notices that the client looks sad. The client says, "I'm scared of having cancer. It's so horrible and I brought it on myself. I should have quit smoking years ago." What would be the nurse's best response to the client? a) "It's okay to be scared. What is it about cancer that you're afraid of?" b) "It's normal to be scared. I would be, too. We'll help you through it." c) "Do you feel guilty because you smoked?" d) "Don't be so hard on yourself. You don't know if your smoking caused the cancer."

a)

The nurse on the orthopedic unit is receiving a client from the Post Anesthesia Care Unit (PACU). Which of the following must occur to ensure a safe "hand-off"? a) Interactive communication between the nurse from the PACU and the nurse from the orthopedic unit. b) An email on the intranet from the nurse in the PACU from the receiving nurse on the orthopedic unit. c) Delegation of RN responsibility and accountability to a non-RN on the receiving unit. d) A page from a transporter who is bringing the client to the receiving nurse.

a)

Three days after mitral valve replacement surgery, the client tells the nurse there is a "clicking" noise coming from the chest incision. The nurse's response should reflect the understanding that the client may be experiencing which of the following? a) Anxiety related to altered health status. b) Altered tissue perfusion. c) Anxiety related to altered body image. d) Lack of knowledge regarding the postoperative course.

a) Verbalized concerns from this client may stem from her anxiety over the changes her body has gone through after open heart surgery. Although the client may experience anxiety related to her altered health status or may have a lack of knowledge regarding her postoperative course, she is pointing out the changes in her body image. The client is not concerned about altered tissue perfusion.

A nurse is caring for a client who has just returned from surgery to treat a fractured mandible. Which of the following items should always be available at this client's bedside? Select all that apply. a) Suction equipment. b) Oxygen cannula. c) Code cart. d) Nasogastric tube. e) Wire cutters.

a), b) Following surgery for a fractured mandible, the client's jaws will be wired. The nurse should be prepared to intervene quickly in case the client develops respiratory distress or begins to choke or vomit. Wire cutters or scissors should always be available in case the wires need to be cut in a medical emergency. Suction equipment should be available to help clear the client's airway if necessary. It is not necessary to keep a nasogastric tube or oxygen cannula at the client's bedside. Cardiopulmonary arrest is unlikely, so a code cart is not needed at the bedside.

The nurse should prepare the client for which of the following during the immediate postoperative care after reversal of a colostomy? Select all that apply. a) Nasogastric (NG) tube attached to low intermittent suction. b) Administration of I.V. fluids. c) Daily measurement of abdominal girth. d) Calculation of intake and output every 8 hours. e) Assessment of vital signs every 6 hours.

a), b), d)

A client is admitted on the day of surgery for an arthroscopy of the left knee. Which nursing activities should be completed to avoid wrong-site surgery? Select all that apply. a) Verbally ask the client to state his name, surgical site, and procedure. b) Verify the correct client with the correct operative site by medical records and radiographic diagnostic reports. c) Show the client an anatomic model of the surgery site. d) Ask the surgeon preoperatively to mark with a permanent marker the correct knee for the surgical site. e) Call a "time-out" in the operating room to have the surgeon verify the correct knee before making the incision.

a), e), b) The root cause of wrong-site surgery involves a breakdown in communication between the client and family and the health care team. Information retrieved from the client in the preoperative assessment, such as the client's name, surgical site, and procedure, should be verbally assessed and verified with medical records and radiographic diagnostic reports. This information should be compiled in a checklist that the intraoperative team can recheck, avoid unnecessary distraction and delay in the operating room. The nurse in the operating room is responsible for calling a "time-out" so that every surgical team member can double-check the correct site of surgery, verify the site using the operative consent form, and mark the operative site on the client. The client should mark the operative site in the preoperative period, not the surgeon, in order to avoid any miscommunication about the correct site of surgery. Showing the client an anatomic model will assist the client in understanding the location of the surgery, but it will not prevent anyone from identifying the wrong site on the client.

The nurse learns that a client who is scheduled for a tonsillectomy has been taking 40 mg of oral prednisone daily for the last week for poison ivy on his leg. What is the nurse's best action? a) Notify the surgeon of the poison ivy. b) Notify the anesthesiologist of the prednisone administration. c) Send the client to surgery. d) Document the prednisone with current medications.

b)

A client recently had a right total hip replacement. As a result of intraoperative blood loss, postoperative serum hemoglobin levels and hematocrit are low. The physician orders two units of packed red blood cells. During the infusion of the first unit of blood, the client develops a transfusion reaction and experiences urticaria, itching, and bronchospasm. The nurse discontinues the transfusion and notifies the physician. Which antihistamine does the nurse anticipate administering to treat this type I hypersensitivity reaction? a) Tripelennamine citrate (PBZ) b) Chlorpheniramine maleate (Chlor-Trimeton) c) Astemizole (Hismanal) d) Cyclizine (Marezine)

b) Chlorpheniramine maleate (Chlor-Trimeton) Explanation: The parenteral form of chlorpheniramine maleate is used to relieve symptoms of anaphylaxis and allergic reactions to blood or plasma. Tripelennamine citrate, astemizole, and cyclizine aren't used to treat blood transfusion reactions.

A client is admitted for an arthroscopy of the right shoulder through same-day surgery. Which nurse is responsible for starting the client's discharge planning? a) Preoperative nurse. b) Postoperative nurse. c) Preadmission nurse. d) Intraoperative nurse.

c)

The client has returned to the surgery unit from the Post Anesthesia Care Unit (PACU). The client's respirations are rapid and shallow, the pulse is 120, and the blood pressure is 88/52. The client's level of consciousness is deteriorating. The nurse should do which of the following first? a) Call the respiratory therapist. b) Call the Post Anesthesia Care Unit (PACU). c) Call the primary care physician. d) Call the Rapid Response Team.

d)

The client's identification armband was cut and removed to start an I.V. line as a part of the preoperative preparation. The transport team has arrived to transport the client to the operating room. The nurse notices that the client's identification band is not on either wrist. What is the nurse's best response? a) Send the removed armband with the chart and the client to the operating room. b) Send the client without an armband because the client is alert and can respond to questions about identity. c) Tape the cut armband back onto the client's wrist. d) Place a new identification armband on the client's wrist before transport.

d)

The nurse is discussing post operative care with the parents and their 5-year-old child who is going to have a tonsillectomy and adenoidectomy. The nurse should emphasize which of the following? a) Need for frequent coughing. b) Use of acetylsalicylic acid for pain, as needed. c) Ability to have ice cream right after surgery d) Use of sips of clear liquids when awake and alert.

d) Once the child is alert, he may have sips of clear liquids. Eating enhances the blood supply to the throat, which promotes rapid healing. However, the child should start with clear fluids. Coughing is discouraged because it disrupts the suture line and may cause bleeding. Acetylsalicylic acid is contraindicated because it interferes with platelet aggregation and promotes bleeding. Once the child is able to tolerate clear liquids, he can progress to a full liquid diet that would include ice cream.

Which nursing interventions would be most appropriate when caring for a client during the first 24 hours after an appendectomy? Select all that apply. a) Maintaining a clear-liquid diet for 48 hours. b) Monitoring temperature every 2 hours. c) Applying an abdominal binder. d) Teaching the client how to care for the incision. e) Placing the client in a semi-Fowler's position.

d) e) Following an appendectomy, the client should be placed in a semi-Fowler's position to relieve tension on the abdomen and the surgical incision and promote comfort. Because the client will likely be discharged within 24 to 48 hours of surgery, teaching the client how to care for the wound is a priority. The client does not need to be limited to a clear-liquid diet, but may resume a diet as desired following surgery. Although monitoring temperature is important, unless the temperature is elevated, it does not need to be assessed every 2 hours; every 4 hours is sufficient. An abdominal binder is typically not necessary following an appendectomy. (