Perioperative Care

The nurse is providing discharge instructions to the client who has had a pneumonectomy and prepares a list of postoperative instructions for the client. Which intervention should the nurse include in the list?

1. Report any signs of respiratory infection to the health care provider.

he nurse is caring for a client the day after a left total knee arthroplasty surgery. In reviewing the client's past medical history, the nurse notes that the client has a history of urinary incontinence and heart failure, which is managed with a potassium-retaining diuretic and a beta-adrenergic blocker. Which prescription, if not already prescribed, should the nurse contact the health care provider to obtain?

3. Resume the client's dose of metoprolol

A client has returned to the nursing unit after an abdominal hysterectomy. The client is lying supine. To thoroughly assess the client for postoperative bleeding, what is the primary nursing action?

3. Roll the client to one side and check her perineal pad.

A client has received atropine sulfate intravenously during a surgical procedure. The nurse should monitor the client for which side effect of the medication in the immediate postoperative period?

3. Urinary retention

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

Which finding in a postoperative client would be of concern to the nurse?

3. Blood pressure of 88/52 mm Hg

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

2. Serous drainage

The nurse is providing preoperative teaching to a client scheduled for a cholecystectomy. Which intervention would be of highest priority in the preoperative teaching plan?

2. Teaching coughing and deep breathing exercises

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

4. Semi Fowler's

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position?

4. Supine, with the residual limb supported with pillows

The home care nurse visits a client to perform a dressing change on a leg ulcer. The client has diabetes mellitus and a history of cardiac disease and is taking one aspirin daily in addition to other medications as prescribed. The client tells the nurse that dental surgery is scheduled and asks the nurse whether the aspirin should be discontinued. The nurse should make which statement to the client?

"Dental surgery can safely be done usually 10 days after stopping the aspirin, depending on the health care provider's preference."

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques?

1. "Use of an incentive spirometer will help prevent pneumonia."

A client is recovering well 24 hours after cranial surgery but is fatigued. The surgeon advances the client from nothing-by-mouth status to clear liquids. The nurse knows that which information is least reliable in determining the client's readiness to take in fluids?

1. Appetite

In preparation for ambulation, the nurse is planning to assist a postoperative client to progress from a lying position to a sitting position. Which nursing action is appropriate to maintain the safety of the client?

1. Assess the client for signs of dizziness and hypotension.

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?

1. Assess the patency of the airway.

The nurse is caring for a postoperative client who has just returned from the postanesthesia care unit after having nasal surgery. What priority action is essential for the nurse to perform?

1. Assessing how often the client swallows

The nurse is preparing a client for surgery scheduled in two hours. Which interventions are appropriate in the preoperative period? Select all that apply.

1. Assist the client to void before transfer to the operating room. 2. Check all surgeon's prescriptions to ensure they have been carried out. 4. Review the client's record for a history and physical report and laboratory reports.

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

1. Atenolol

The nurse is caring for a client who is postoperative following a pelvic exenteration and the health care provider changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse should check which priority item before administering the diet?

1. Bowel sounds

A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions should the nurse take in the care of the drain? Select all that apply.

1. Check the drain for patency. 2. Observe for bright red bloody drainage. 5. Maintain aseptic technique when emptying the drain.

A client has a risk for infection following radical vulvectomy. Therefore, the nurse should avoid which action when giving perineal care to this client?

1. Cleansing with warm tap water

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply.

1. Contact the surgeon. 2. Instruct the client to remain quiet. 3. Prepare the client for wound closure. 4. Document the findings and actions taken.

A client scheduled for surgery receives a dose of scopolamine. The nurse expects to note which side effects of the medication? Select all that apply.

1. Dry mouth 4. Pupillary dilation

The nurse is preparing a preoperative client for transfer to the operating room. The nurse should take which action in the care of this client at this time?

1. Ensure that the client has voided.

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed?

1. Hemoglobin, 8.0 g/dL (80 mmol/L)

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?

1. Increasing restlessness

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld?

1. Prednisone

A client has had an invasive abdominal surgery to relieve an obstruction of the common bile duct. The client's surgery is completed, and the client has been transferred to the postanesthesia care unit (PACU). The PACU nurse observes that the client suddenly appears red in the face and appears to be coughing despite the presence of an endotracheal tube and ventilator support. What action should the PACU nurse take first?

1. Suction the client through the endotracheal tube.

The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?

1. The passage of flatus

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?

1. Urinary output of 20 mL/hour

The nurse is developing a list of home care instructions for a client being discharged after a laparoscopic cholecystectomy. Which instructions should the nurse include include in the postoperative discharge plan of care? Select all that apply.

1. Wound care 2. Follow-up care 3. Activity restrictions 4. Dietary instructions

A postoperative client with a large abdominal wound requiring frequent dressing changes is starting to develop skin irritation in the area where the dressing tape is applied to the skin. The nurse determines that the client would benefit most from which measure?

2. The use of Montgomery straps

An 85-year-old client is hospitalized for a fractured right hip. During the postoperative period, the client's appetite is poor and the client refuses to get out of bed. Which nursing statement would be most appropriate to make to the client?

2. "It is important for you to get out of bed so that calcium will go back into the bone."

The nurse is assigned to change the surgical dressing on a client who has undergone abdominal surgery. After removing the old dressing, the nurse assesses the surgical site. Which should be the nurse's initial action if the appearance shown in the figure is observed? Refer to Figure. (Figure from Potter P, Perry A, Stockert P, Hall A: Fundamentals of Nursing, ed 8, St. Louis, 2013, Mosby.)

2. Apply a sterile nonadherent dressing.

Which assessment finding indicates that a client who had a mastectomy is experiencing a complication related to the surgery?

2. Arm edema on the operative side

The nurse has a prescription to remove the nasogastric (NG) tube from a client on the first postoperative day after cardiac surgery. The nurse should question the prescription if which finding was noted on assessment of the client?

2. Bowel sounds are absent.

The nurse is reviewing the blood tests of a generally healthy client who is scheduled for orthopedic surgery under general anesthesia. Besides a complete blood count (CBC), what preadmission blood tests would the preoperative nurse expect to be prescribed? Select all that apply.

2. Clotting studies 3. Glucose fasting 4. Electrolyte levels 6. Serum creatinine and blood urea nitrogen (BUN) levels

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan?

2. Elevate and immobilize the grafted extremity.

The nurse is discharging a client after an arthroscopy. The nurse needs to teach the client to watch for which potential complications? Select all that apply.

2. Infection 3. Swelling 4. Thrombophlebitis 6. Increased joint pain related to mechanical injury

he nurse is caring for an abdominal surgical client who has a Jackson-Pratt drain in place. Which interventions should the nurse include in the plan of care for this drain? Select all that apply.

2. Make sure suction is maintained. 3. Check that the drains are sutured in place. 5. Compress the reservoir to restore suction after emptying. 6. Record the amount and color of drainage according to agency protocol or health care provider's orders.

When a client is transferred from the postanesthesia care unit and arrives on the surgical unit, which should be the first action taken by the nurse?

2. Obtain the client's vital signs.

The nurse is caring for a 25-year-old client who will undergo bilateral orchidectomy for testicular cancer. Which statement by the nurse would be helpful in exploring the client's concerns about loss of reproductive ability?

3. "Can you share with me any concerns about how this surgery will affect you in the future?"

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

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

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement?

3. "I need to continue to take the aspirin until the day of surgery."

The nurse has provided discharge instructions to a client after radical vulvectomy. Which statement by the client indicates a need for further instruction?

3. "It is all right to ride in a car as much as I want, as long as I am not driving the car."

The nurse cares for a client prior to surgery. The client asks the nurse, "What is the advantage of spinal anesthesia over general anesthesia for controlling my pain?" Which is the best response by the nurse?

3. "Your pain can be managed without making you as sleepy."

The nurse is teaching a graduate nurse in the operating room about the components of Universal Protocol, one of The Joint Commission's National Patient Safety Goals. What specific component should the nurse include in the instructions?

3. A time-out should be performed in the operating room before the procedure.

The nurse is assessing a client who had abdominal surgery earlier in the day. Which preexisting medical condition would place the client at most risk for postoperative complications?

3. Alcohol abuse

A client is admitted to the ambulatory surgery center for elective surgery. The nurse asks the client whether any food, fluid, or medication was taken today. Which medication, if taken by the client, should indicate to the nurse the need to contact the health care provider?

3. An anticoagulant

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

3. Apply a sterile dressing soaked with normal saline.

A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry for a preoperative client. The nurse should perform which best action to ensure accurate readings on the oximeter?

3. Ask the client to limit motion in the hand attached to the pulse oximeter.

The nurse is providing home care instructions to the parents of an infant who had a surgical repair of an inguinal hernia. What instruction should the nurse include to prevent infection at the surgical site?

3. Change the diapers as soon as they become damp.

A client returns to the nursing unit following a pyelolithotomy for removal of a kidney stone. A Penrose drain is in place. Which action should the nurse include in the client's postoperative plan of care?

3. Changing dressings frequently around the Penrose drain

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action?

3. Continue to monitor the drainage.

The nurse in a surgical unit receives a postoperative client from the postanesthesia care unit. After the initial assessment of the client, the nurse should plan to continue with postoperative assessment activities how often?

3. Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?

3. Have the client void immediately before going into surgery.

The nurse has instructed a preoperative client using an incentive spirometer to sustain the inhaled breath for 3 seconds. When the client asks about the rationale for this action, the nurse explains that this action achieves which function?

3. Maintains inflation of the alveoli

An operating room nurse is positioning a client on the operating room table to prevent the client's extremities from dangling over the sides of the table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to prevent which condition?

3. Nerve and muscle damage

The nurse is obtaining a pulse oximetry reading from a postoperative client who appears short of breath. The client has dark fingernail polish on top of artificial nails. What is the most appropriate action?

3. Obtain a pulse oximetry reading from another appropriate area, such as an earlobe.

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?

4. Obtain a telephone consent from a family member, following agency policy.

The nurse cares for a client who is at risk for wound dehiscence after abdominal surgery. Which action is the priority to minimize this risk?

4. Place a pillow over the incision site during deep breathing and coughing.

The nurse is caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 91 beats/minute; and respirations, 16 breaths/minute. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/minute; and respirations, 20 breaths/minute. Which action should the nurse plan to take first?

4. Recheck the vital signs in 15 minutes.

A client preparing to go home 2 days following a right mastectomy with dissection of axillary lymph nodes asks the nurse, "What should I do to minimize my chance for complications from this surgery?" Which response should the nurse make?

4. "Avoid having blood pressures taken on your right arm."

The nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates that he or she will take which action?

4. After maximal inspiration, hold the breath for 10 seconds and then exhale.

The nurse is developing a plan of care for a preoperative client who has a latex allergy. Which intervention should be included in the plan?

4. Apply a cloth barrier to the client's arm under a blood pressure cuff when taking the blood pressure.

The nurse prepares a client 1 hour prior to surgery. Which assessment finding does the nurse need to communicate to the health care provider (HCP) at this time?

4. Daily garlic capsules, last dose yesterday morning

A preoperative client has received a dose of scopolamine as prescribed by the anesthesiologist. The nurse should assess the client for which anticipated side effect of this medication?

4. Dry oral mucous membranes

A client who has undergone radical neck dissection is experiencing problems with verbal communication related to postoperative hoarseness. The nurse should formulate which outcome as the most appropriate goal for this client problem?

4. Incorporates nonverbal forms of communication as needed