Perioperative Nursing
The PACU nurse caring for a client with a nasogastric (NG) tube notes 300 mL of bright red blood has collected. What is the appropriate nursing action? a. Immediately remove the NG tube. b. Place the client in Trendelenburg position. c. Call the client's surgeon to report the drainage. d. Document as a normal finding.
ANS: C Rationale: The presence of bright red blood reflects active bleeding. The nurse must report this to the surgeon immediately.
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? a. Recheck the vital signs in 15 minutes. b. Call the surgeon immediately. c. Shake the client gently to arouse. d. Cover the client with a warm blanket
ANS: A Rationale: A drop in blood pressure slightly below a client's preoperative baseline reading is common after surgery, especially considering medications given intra-op. The nurse should recheck the vital signs frequently post-operatively. Warm blankets are applied to maintain the client's body temperature, but this is not what needs to be done first. Level of consciousness can be assessed by the evaluation of the client's response to light touch and verbal stimuli. It is not necessary to contact the surgeon immediately. Test-Taking Strategy: Note the strategic word, first. Focus on the data in the question, and note that the vital signs are within normal limits following a surgical procedure; therefore, the nurse should plan to recheck the vital signs.
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? a. "Use of an incentive spirometer will help prevent pneumonia." b. "Close monitoring of your oxygen saturation will detect hypoxemia." c. "Administration of intravenous fluids will prevent or treat fluid imbalance." d. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."
ANS: A Rationale: Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps to prevent pneumonia and atelectasis. Hypoxemia is an inadequate concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help to detect hypoxemia, monitoring is not directly related to coughing and deep-breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to 1 or more lobes of the lung; this is usually due to clot formation. Early ambulation and administration of blood thinners helps to prevent this complication; however, it is not related to coughing and deep-breathing techniques.
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. a. Maintain aseptic technique when emptying the drain. b. Clamp the drain for 15 minutes every hour. c. Curl the drain tightly, and tape it firmly to the body. d. Check the drain for patency. e. Observe for bright red bloody drainage.
ANS: A, D, E Rationale: The nurse should check the tube or drain for patency to provide an exit for the fluid or blood to promote healing. The nurse should monitor the drainage characteristics. Usually the drainage from the wound is pale, red, and watery. Active bleeding will be bright red. The nurse must use aseptic technique for emptying the drainage container or changing the dressing to avoid contamination of the wound. A postoperative drain should not be curled tightly or obstructed in any way, such as with clamping. This could prevent the drain from functioning properly.
Which assessment data finding for a client scheduled for total knee replacement surgery is most important for the nurse to communicate to the surgeon and the anesthesia provider before the procedure? Select all that apply. a. The serum potassium level is 3.0 mEq/L (3.0 mmol/L). b. The oxygen saturation is 97%. c. The client requests to talk with a registered dietitian about weight loss. d. After receiving the preoperative medications, the client tells the nurse that he lied on the assessment form and that he really is a current smoker. e. The client took a total of 1300 mg of aspirin yesterday.
ANS: A, D, E Rationale: This is a low potassium value (3.0 mEq/L) which should be communicated to the surgeon and anesthesia provider prior to surgery. Taking aspirin prior to surgery can increase the risk for bleeding. This should be communicated to the surgeon and anesthesia provider prior to surgery. The client's smoking status can change important assessment information collected by the surgeon and anesthesia provider; therefore, this should be immediately communicated. The oxygen saturation level is normal, and it is acceptable that the regularly scheduled antihypertensive was taken with a sip of water 2 hours ago.
The nurse is preparing a client for surgery scheduled in two hours. Which interventions are appropriate in the preoperative period? Select all that apply. a. Teach postoperative breathing exercises before the client is pre-medicated. b. Review the client's record for a history and physical report and laboratory reports. c. Administer all the daily medications 2 hours before the scheduled time of the surgery. d. Assist the client to void before transfer to the operating room. e. Check all surgeon's prescriptions to ensure they have been carried out.
ANS: B, D, E Rationale: The nurse should assist the client to void before transfer to the operating room, if a Foley catheter is not in place. The nurse also checks the surgeon's prescriptions to ensure that they have been carried out; if a prescription has not been carried out, the nurse would have the time to ensure that it is. Two hours before the scheduled surgery time is not the time to teach breathing exercises. This should have been accomplished earlier. A history and physical needs to be in the record so that all health care providers involved in the surgical procedure will be familiar with the client's health status. Additionally, the results of any laboratory tests prescribed need to be documented. The nurse does not administer all daily medications. Rather, the health care provider writes a specific prescription outlining which medications may be given with a sip of water. Test-Taking Strategy: Focus on the subject, the preoperative period. Recall that teaching should be done prior to the day of surgery; this will assist to eliminate option 3. Next eliminate option 5 because of the closed-ended word, all.
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? a. Dilates the major bronchi b. Enhances ciliary action in the tracheobronchial tree c. Maintains inflation of the alveoli d. Increases surfactant production
ANS: C Rationale: Sustained inhalation helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk for these conditions. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Focus on the subject, client teaching about an incentive spirometer. Recall the anatomy and physiology of respiration to answer this question. Knowing that the alveoli constitute the most distal portion of the respiratory tree will help you to choose this as the area to derive the benefit from maximum sustained inhalation.
A client is recovering well 24 hours after cranial surgery but is fatigued. The surgeon advances the client from nothing-by-mouth (NPO) status to clear liquids. The nurse knows that which information is least reliable in determining the client's readiness to take in fluids? a. Presence of bowel sounds b. Absence of nausea c. Appetite d. Presence of a swallow reflex
ANS: C Rationale: To begin to tolerate oral intake after cranial or any other type of surgery, the client must have bowel sounds. The client also must have intact swallow and gag reflexes and should be free of nausea and vomiting. The client is likely to be easily fatigued, which may decrease appetite. Thus appetite is the least reliable indicator regarding when intake should be started. Test-Taking Strategy: Focus on the subject, the assessment item that is of little use in directing nursing actions related to diet. Think about each item identified in the options and its effect on readiness for eating to direct you to the correct choice.
When a client is transferred from the post-anesthesia care unit and arrives on the surgical unit, which should be the first action taken by the nurse? a. Check the rate of the intravenous infusion. b. Administer oxygen to the client. c. Obtain the client's vital signs. d. Assess the client's pain.
ANS: C Rationale: When a client arrives on the nursing unit from the post-anesthesia care unit (PACU), the nurse receives the client and immediately checks the client's airway status. The nurse next performs an initial assessment consisting of vital signs. The results must be compared with the vital signs last obtained in the PACU. Once this has been done, the intravenous infusion is checked, and a pain, respiratory, neurological, wound, urinary, and safety assessment is performed. Oxygen is not needed for every postoperative client but may be administered to those who may have a compromised respiratory status. A decision regarding how to intervene to control pain cannot be made until vital signs are known. The nurse documents the findings, including the time that the client arrived from the PACU. Test-Taking Strategy: Note the strategic word, first. Think about the priority actions. Eliminate options 3 and 4 because the health care provider's prescription would have to be checked first. Next, select option 2 because it relates to the ABCs-airway, breathing, and circulation.
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? a. Obtain fingernail polish remover, remove the polish, and then obtain the pulse oximetry reading from a finger. b. Check labs, Hgb and Hct. c. Take the pulse oximetry reading from any finger. d. Obtain a pulse oximetry reading from another appropriate area, such as an earlobe. e. Remove one of the artificial nails and then obtain the reading from the finger.
ANS: D Rationale: A pulse oximetry reading may not provide an accurate measurement if it is measured on a finger that has dark polish and an artificial nail; therefore, option 1 is not the most appropriate action. It is not appropriate to remove an artificial nail; therefore, eliminate option 2. Removing the polish and taking the reading with the artificial nail may provide a better reading than taking the reading with the polish; however, this is not the most appropriate action from those provided, so option 4 can be eliminated. Although Hgb and Hct provide insight into the patient's oxygen carrying capacity, you would not forgo the pulse ox check as an initial priority assessment. Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the subject, obtaining a pulse oximetry reading. Think about this procedure. Recalling that there is more than one anatomical area to take a reading will direct you to option 3.
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? a. Elevate the head of the bed quickly to assist the client to a sitting position. b. Assist the client to move quickly from the lying position to the sitting position. c. Allow the client to rise from the bed to a standing position unassisted. d. Assess the client for signs of dizziness and hypotension.
ANS: D Rationale: Early ambulation should not exceed the client's tolerance. The client should be assessed before sitting. The client is assisted to rise from the lying position to the sitting position gradually until any evidence of dizziness, if present, has subsided. This position can be achieved by raising the head of the bed slowly. After sitting, the client may be assisted to a standing position. The nurse should be at the client's side to provide physical support and encouragement. Test-Taking Strategy: Eliminate options 3 and 4 because of the word quickly and option 2 because of the word unassisted. Additionally, the correct option is the only option that reflects assessment, the first step of the nursing process.
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? a. Administer all the daily medications. b. Verify that the client has not eaten for the past 24 hours. c. Have the client practice postoperative breathing exercises. d. Ensure that the client has voided.
ANS: D Rationale: The nurse should ensure that the client has voided if a Foley catheter is not in place. The nurse does not administer all daily medications just before sending a client to the operating room. Rather, the health care provider writes a specific prescription outlining which medications may be given with a sip of water. The time of transfer to the operating room is not the time to practice breathing exercises; this should have been done earlier. The client has nothing by mouth for 6 to 8 hours before surgery, not 24 hours. Test-Taking Strategy: Focus on the subject, action to take just before transfer to the operating room. This tells you that you must prioritize your answer according to a time line. With this in mind, eliminate options 2 and 3. Choose correctly between the remaining options by knowing that the client must empty his or her bladder or by knowing that the client is likely to be anxious at this time, making it inappropriate to practice breathing exercises.
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? a. Check the blood pressure. b. Ask the client about sensation of moistness on her perineal pad. c. Check the heart rate. d. Roll the client to one side and check her perineal pad.
ANS: D Rationale: The nurse should roll the client to one side after checking the perineal pad for vaginal bleeding and the abdominal dressing. This client position allows the nurse to check the rectal area, where blood may pool by gravity if the client is lying supine. Asking the client about a sensation of moistness is not a complete assessment. Vital signs will change with hemorrhage; they are a compensatory mechanism of change. Assess for external or most likely signs of bleeding first. Test-Taking Strategy: Note the strategic word, primary. Focus on the subject, how to thoroughly assess the client for postoperative bleeding after an abdominal hysterectomy. Eliminate option 4 first because it relies on the client. Regarding the remaining options, note that the correct option addresses rolling the client, which would provide a thorough assessment. Thorough assessment also includes always visually assessing the surgical site.
The nurse is providing preoperative teaching to a client scheduled for a cholecystectomy (gall bladder removal). Which intervention would be of highest priority in the preoperative teaching plan? a. Teaching leg exercises b. Providing instructions regarding fluid restrictions c. Assessing the client's understanding of the surgical procedure d. Teaching coughing and deep breathing exercises
ANS: D Rationale: Although all answer choices are important, after cholecystectomy, respirations tend to be shallow because deep breathing is painful as a result of the location for the surgical procedure. Although all the options are correct, teaching coughing and deep breathing exercises is the highest priority. Test-Taking Strategy: Note the strategic words, highest priority. Use the ABCs-airway, breathing, and circulation-to answer the question. The correct option relates to airway. Additionally, recalling the anatomical location for the surgical procedure will assist in directing you to the correct option.
What client teaching will the nurse provide regarding postoperative leg exercises, to minimize the risk for development of deep vein thrombosis after surgery? a. Only perform each exercise one time to prevent overuse. b. Bend knee, and push heel of foot into the bed until the calf and thigh muscles contract. Repeat several times, then switch legs. c. Point toes of one foot toward bottom of bed, then point toes of same leg toward their face. Repeat several times, then switch legs. d. Begin exercises by sitting at a 90-degree angle on the side of the bed.
ANS: C Rationale: Exercises should be repeated several times for each leg. Clients should begin by lying in the bed in a 45-degree angle. Pointing toes, as described, promotes circulation. Clients should push the ball of the foot into the bed until the calf and thigh muscles contract.
A client is scheduled for surgery at noon. The surgeon is delayed and the surgery is now scheduled for 3:00 PM. How will the nurse plan to administer the preoperative prophylactic antibiotic? a. Give at noon as originally prescribed. b. Adjust the administration time to be given within one hour prior to surgery. c. Hold the preoperative antibiotic so it can be administered immediately following surgery. d. Cancel orders; preoperative prophylactic antibiotics are given optionally.
ANS: B Rationale: According to the Surgical Care Improvement Project (SCIP) guidelines, prophylactic antibiotics should be given within one hour before the surgical incision.
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? a. A beta-blocker b. An anticoagulant c. An antibiotic d. A calcium channel blocker
ANS: B Rationale: An anticoagulant suppresses coagulation by inhibiting clotting factors. A client admitted for elective surgery should have been instructed to discontinue the anticoagulant 7 to 10 days preoperatively. Even if this were unscheduled surgery, the nurse should notify the health care provider. Vitamin K can be given for reversal of its action, but the client may still have an increased risk of bleeding. The other medications listed are commonly taken and do not constitute an increased risk for the client.
The nurse is caring for four clients who will undergo surgery today. Which client does the nurse recognize as at highest risk for surgical complication? a. 69-year-old who will be discharged after surgery to an extended care facility b. 58-year-old who has well-controlled Type II diabetes c. 52-year-old who takes aspirin daily d. 64-year-old who has just received pre-surgical prophylactic antibiotics
ANS: C Rationale: Aspirin and NSAIDs taken before surgery may increase clotting time and risk for hemorrhage.
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? a. Obtain a court order for the surgery. b. Have the charge nurse sign the informed consent immediately. c. Send the client to surgery without the consent form being signed. d. Obtain a telephone consent from a family member, following agency policy.
ANS: D Rationale: Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by 2 persons who hear the family member's oral consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but the data in the question do not indicate an emergency. Options 1, 2, and 3 are not appropriate in this situation. Also, agency policies regarding informed consent should always be followed.
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? a. Inhale as rapidly as possible. b. Keep a loose seal between the lips and the mouthpiece. c. After maximum inspiration, hold the breath for 15 seconds and exhale. d. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.
ANS: D Rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.
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? a. Verify that the client has not eaten for the last 24 hours. b. Report immediately any slight increase in blood pressure or pulse. c. Avoid oral hygiene and rinsing with mouthwash. d. Have the client void immediately before going into surgery.
ANS: D Rationale: The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours (or longer as prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.
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? a. Temperature of 37.6°C (99.6°F) b. Serous drainage on the surgical dressing c. Blood pressure of 100/70 mm Hg d. Urinary output of 20 mL/hour
ANS: D Rationale: Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less than 30 mL for 2 consecutive hours should be reported to the health care provider. A temperature higher than 37.7°C (100°F) or lower than 36.1°C (97°F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. 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.
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? a. Apply a sterile dressing soaked in povidone-iodine. b. Irrigate the wound and apply a sterile dry dressing. c. Leave the incision open to the air to dry the area. d. Apply a sterile dressing soaked with normal saline.
ANS: D Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the visible appearance of underlying tissues. Dehiscence usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and to avoid coughing or straining. The client should be positioned to prevent further stress on the wound (semi Fowler's position). Sterile dressings soaked with sterile normal saline should be used to cover the wound. The nurse must notify the health care provider after applying this initial dressing to the wound. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Focus on the subject, wound dehiscence. Note the strategic word, initial. Eliminate option 1 first because this action would dry the wound and would also present a risk of infection to the underlying tissues. Eliminate options 2 and 4 next because a dry dressing or a dressing soaked with povidone-iodine would irritate the exposed body tissues.
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? a. Alcohol Abuse b. Osteoporosis c. Pacemaker d. Peptic Ulcer Disease
ANS: A Rationale: A client with a history of alcohol abuse is at risk for liver disease, including altered metabolism and elimination of medications, impaired wound healing, and clotting and bleeding abnormalities. A client with this risk factor also would be at risk for experiencing alcohol withdrawal during the postoperative period. Clients with a pacemaker, osteoporosis, and peptic ulcer disease need to be monitored closely but are not at risk for major complications, as is the client with alcohol abuse and liver disease. Test-Taking Strategy: Note the strategic word, most, and focus on the subject, the client at risk for complications after abdominal surgery. Thinking about the pathophysiological alterations that occur as a result of alcohol abuse will direct you to the correct option.
Which finding in a postoperative client would be of concern to the nurse? a. Temperature of 37.6°C (99.6°F) b. Blood pressure of 88/52 mm Hg c. Urinary output of 40 mL/hr d. Moderate drainage on the surgical dressing
ANS: B Rationale: The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A falling systolic blood pressure, under 90 mm Hg, is considered reportable because it could be an indication of bleeding and potential shock. Urine output should be maintained at a minimum of 30 mL/hr for an adult, so 40 mL per hour is adequate. An output of less than 30 mL/hr for each of two consecutive hours should be reported to the health care provider. A temperature above 37.7°C (100°F) or below 36.1°C (97°F) is a concern and would be reportable. Moderate or light serous drainage from the surgical site is considered normal. Test-Taking Strategy: Focus on the subject, the assessment finding that is of concern to the nurse. To answer this question correctly, you must know the normal ranges for temperature, blood pressure, urinary output, and wound drainage. Then you can determine that the blood pressure is the only observation that is not within the normal range
