Perioperative Nursing Care Practice Test
The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation? A urinary output of 20 mL/hour Serous drainage on the surgical dressing A blood pressure of 100/70 mm Hg A temperature of 37.6° C (99.6° F)
Urine output is maintained at a minimum of at least 30 mL/hour for an adult. An output of less than 30 mL/hour for each of 2 consecutive hours should be reported to the surgeon. A temperature more than 37° C (100° F) or less than 36.1° C (97° F) and a falling systolic blood pressure less than 90 mm Hg are to be reported. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.
The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions would the nurse take to deal with this event? Select all that apply. Turn the client to the side with the knees bent. Apply a sterile dressing soaked with normal saline to the wound. Notify the registered nurse (RN) and primary health care provider (PHCP) at once. Gently explore the wound with a cotton-tipped applicator to determine whether evisceration has occurred. Explain to the client that obesity is a risk factor and weight loss should be a future goal.
Wound dehiscence is the separation of the wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. It usually occurs as a complication 6 to 8 days after surgery. The client should be instructed to remain quiet and avoid coughing or straining, and he or she should be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The registered nurse (RN) and primary health care provider (PHCP) need to be notified. The client should assume a low-Fowler's position with knees bent to avoid further stress on the incision. Obesity is a risk factor for dehiscence, but now is not the appropriate time for this teaching. The nurse should not explore the incision because this may actually cause evisceration, a more serious complication.
The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound. Which actions would the nurse take in the care of the drain? Select all that apply. Check the drain for patency. Check that the drain is decompressed. Secure the drain by curling or folding it and taping it firmly to the body. Observe for bright red, bloody drainage. Empty the drain when it is half full and every 8 to 12 hours. Maintain aseptic technique when emptying.
A drain is a tube that is placed to drain out fluid and blood near the surgical site that could lead to infection. The tube is connected to a bulb, which is compressed to create a vacuum and pull out the fluid. The nurse should check for patency and that fluid is being pulled out. The bulb should be, and look, compressed in order to create the vacuum. The drainage usually is dark red as a result of blood content, but may be pale yellow with serous fluid. Aseptic technique must be used when emptying the drainage container to avoid contamination of the wound. The bulb of the drain should be emptied when it is half full and at least every 8 to 12 hours. The amount of drainage is documented in the client medical record under intake and output. Curling or folding the drain prevents the flow of the drainage.
The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply. Slight redness along the incision The client states that the incision itches. Tender firmness palpable around the incision The client states that he feels cold. A temperature of 98.8° F (37.1° C) The presence of purulent drainage
A wound infection occurs when healing is delayed and pathogens such as bacteria grow in the wound. Signs and symptoms of a wound infection include warmth, redness, swelling, and tenderness of skin around the incision. The client may have fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a wound that was contaminated before surgical exploration; it appears 3 to 6 days after surgery. Slight redness along an incision is a sign of inflammation and should be monitored to determine whether it progresses. A temperature of 98.8° F (37.1° C) is not an abnormal finding in a postoperative client. Itching around a wound may be from irritation or dryness and is not associated with infection. The fact that a client feels cold is not indicative of an infection, although chills and fever are signs of infection. The room temperature may be too cold for client comfort.
A client arrives to the surgical nursing unit after surgery. What would be the initial nursing action after surgery? Check dressing for bleeding or drainage. Obtain vital signs to compare with those recorded preoperatively. Check tubes or drains for patency. Assess patency of the airway.
If the airway is not patent, immediate measures must be taken for the survival of the client. After checking the client's airway, the nurse would then check the client's vital signs, followed by the dressings, tubes, and drains.
The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Vital signs are: temperature: 37.9° C (100.2° F), pulse 104 beats per minute, respirations 22 breaths per minute, blood pressure 128/74 mm Hg. Oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem? Atelectasis Hypoxia Pneumonia Fluid overload
Pneumonia is a postoperative condition caused by inflammation and infection in the lungs. Frequently it results from shallow breathing that leads to atelectasis (the alveoli partially collapse and eventually become fluid-filled). This fluid is good medium for bacteria. Pneumonia usually occurs 3 to 7 days postoperatively. Signs and symptoms include fever, productive cough, painful breathing, and an increased respiratory effort and rate. Fine crackles may be audible over the lung area involved. Treatment includes coughing up the purulent sputum, deep breathing, antibiotics, and adequate hydration. Hypoxia is inadequate concentration of oxygen in the blood and usually occurs as an acute process, such as respiratory depression as a result of anesthesia or analgesia, or the pulmonary oxygen saturation is relatively below normal, less than 92%. Atelectasis occurs 1 to 2 days postoperatively, and auscultation reveals diminished breath sound and/or crackles that clear with coughing. Fluid overload is excessive blood volume with too much fluid in the circulation. It causes coarse crackles and severe dyspnea.
The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How would the nurse initially address the client's concerns? Tell the client that preoperative fear is normal. Ask the client to discuss information known about the planned surgery. Provide explanations about the procedures involved in the planned surgery. Explain all nursing care and possible discomfort that may result.
The client is concerned about having surgery and needs to discuss it. This will offer the client the opportunity to verbalize his or her current and specific understanding. Explanations should begin with the information that the client knows. Option 1 is a block to communication and minimizes the client's feelings. Giving unsolicited explanations may produce additional anxiety and not address the real concerns of the client.
The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse would include which activities in the nursing care plan for the client on the day of surgery? Select all that apply. Determine that the client has signed the informed consent for the surgical procedure. Avoid oral hygiene and rinsing with mouthwash. Verify that the client has not eaten for the last 24 hours. Report immediately any slight increase in blood pressure or pulse from the client's baseline vital signs. Have the client void before surgery.
The nurse caring for clients who will be having surgery must ensure that the client is properly identified and prepared according to the prescription(s) by the surgeon and anesthesiologist. The nurse should assist the client with voiding before surgery so that the bladder is empty at the beginning of the procedure. The nurse should verify that the client has signed the consent for the procedure. If the client has not signed a consent, no preoperative medications should be given, and the surgeon can obtain the consent before proceeding. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 8 hours before surgery rather than 24 hours (often NPO after midnight). A slight increase in blood pressure and pulse is common during the preoperative period; this is generally the result of anxiety. The nurse should verify what the normal blood pressure and pulse rate are for this client.
The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which actions would the nurse take? Select all that apply. Ask how the client feels and inquire about any feelings of dizziness. Ask if the client is thirsty and assist with drinking a glass of water. Assist the client to perform leg exercises and then recheck the blood pressure and pulse rate. Review the client record to determine time and type of analgesia last received. Review the client record to determine whether the client has voided postoperatively. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU).
In a clinical situation, the nurse must evaluate the vital signs of each postoperative client individually. If complications such as hemorrhage or shock are developing, early intervention is extremely important. Determining how the client feels and asking about dizziness lets the nurse evaluate how the client is tolerating these vital signs. Accessing the medical record to determine the most recent analgesic administration is pertinent because hypotension is a frequent side/adverse effect of analgesics, especially opioids. Reviewing the client's record gives the nurse data on the client's vital signs during and after surgery in the PACU, and the nurse can evaluate whether there has been a change. Giving the client oral fluids is an intervention if the client has a fluid volume deficit and this has not been established. Oral fluids would not correct the problem as quickly as administering IV fluids would. Collecting data about the client voiding is not directly related to the vital signs. Encouraging leg exercises is a correct postoperative intervention, but is not appropriate for evaluating the vital signs.
The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and would be reported to the primary health care provider before the surgery? Select all that apply. History of deep venous thrombosis in right leg 10 years earlier Wonders if the surgery could cause incontinence Takes daily multivitamin and calcium supplement. Is allergic to penicillin History of tonsillectomy at the age of 7 years Quit smoking 3 months earlier
The nurse conducts an interview and reviews current health practices and health history preoperatively with clients. Specific client data that are likely to affect a surgery are communicated promptly. The nurse reports any client allergies, especially an antibiotic allergy, to avoid an allergic reaction perioperatively. The fact that the client was a smoker until recently is pertinent because it may affect how the client tolerates and recovers from anesthesia. The nurse should communicate any client concerns about the effects of the surgery so that the matter can be discussed and understood clearly before the surgery (informed consent). A history of a deep venous thrombosis (DVT) is pertinent because of an increased risk for DVT after the planned surgery, and precautions should be prescribed. A history of a childhood tonsillectomy and routine vitamin and mineral supplementation are part of the client history but are not pertinent data that need to be reported specifically.
