Surgery

A patient arrives at the ambulatory surgery center for a scheduled laparoscopy procedure in outpatient surgery. Which information is of most concern to the nurse?

The patient is planning to drive home after surgery.

While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities? (Put a comma and a space between each answer choice [A, B, C, D].)

1. Have the patient sit down in a chair. 2. Take the patients blood pressure (BP). 3. Give the patient something to drink. 4. Notify the patients health care provider.

A patients blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D].)

1. Increase the IV infusion rate. 2. Increase the oxygen flow rate. 3. Assess the patients dressing. 4. Check the patients temperature.

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?

200 mL sanguineous fluid in the wound drain

A patient scheduled to undergo total knee replacement surgery under general anesthesia asks the nurse, Will the doctor put me to sleep with a mask over my face? Which response by the nurse is most appropriate?

A drug may be given to you through your IV line first. I will check with the anesthesia care provider.

A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. Which action by the nurse is most helpful?

Administer ordered analgesic medications before these activities.

A patient who had knee surgery received intramuscular ketorolac (Toradol) 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is best for the nurse to take at this time?

Administer the prescribed PRN IV morphine sulfate.

The nurse reviews the laboratory results for a patient on the first postoperative day after a hiatal hernia repair. Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing?

Albumin level 2.2 g/dL

While in the holding area, a patient reveals to the nurse that his father had a high fever after surgery. What action by the nurse is a priority?

Alert the anesthesia care provider of the family members reaction to surgery.

A patient who has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take?

Alert the surgery center about a possible latex allergy.

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patients oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate?

Assess for bladder distention.

The nasogastric (NG) tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. What action by the nurse is the mostappropriate?

Assist the patient to ambulate

The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time?

Auscultate for adventitious breath sounds.

Which action best describes how the scrub nurse maintains aseptic technique during surgery?

Changes gloves after touching the upper arm of the surgeons gown

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?

Check the oxygen (O2 ) saturation.

On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse ismost appropriate?

Continue to take vital signs every 15 minutes.

The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5 F (35.8 C). Which action should the nurse take?

Cover the patient with a warm blanket and put on socks.

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for abdominal surgery for an open cholecystectomy?

Deep breathing and coughing techniques

The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. The patient reports use of garlic and ginkgo biloba. Which action by the nurse is most appropriate?

Discuss the herb and supplement use with the patients health care provider.

An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, I do not know if I can take care of myself with this patch over my eye. Which action by the nurse ismost appropriate?

Discuss the specific concerns regarding self-care.

A patients T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is themost appropriate?

Document the color and amount of drainage.

. In the postanesthesia care unit (PACU), a patients vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first?

Encourage the patient to take deep breaths.

Which action should the perioperative nurse take to best protect the patient from burn injury during surgery?

Ensure correct placement of the grounding pad.

Which actions will the nurse include in the surgical time-out procedure before surgery (select all that apply)?

Have the patient state name and date of birth Verify the patient identification band number Ask the patient to state the surgical procedure Confirm the hospital chart identification number

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8 F. Which action should the nurse take first?

Have the patient use the incentive spirometer.

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit?

Help with the transfer of the patient onto a stretcher

Which data identified during the perioperative assessment alert the nurse that special protection techniques should be implemented during surgery?

History of spinal and hip arthritis

Which statement by a patient scheduled for surgery is most important to report to the health care provider?

I had a heart valve replacement last year.

Which statement, if made by a new circulating nurse, is appropriate?

I will assist in preparing the operating room for the patient.

Which action most effectively demonstrates that a new staff member understands the role of scrub nurse?

Keeps both hands above the operating table level

A patient received inhalation anesthesia during surgery. Postoperatively the nurse should monitor the patient for which complication?

Laryngospasm

A patient undergoing an emergency appendectomy has been using St. Johns wort to prevent depression. Which complication would the nurse expect in the postanesthesia care unit?

Longer time to recover from anesthesia

Which nursing action should the operating room (OR) nurse manager delegate to the registered nurse first assistant (RNFA) when caring for a surgical patient?

Make surgical incision and suture incisions as needed

When caring for a patient who has received a general anesthetic, the circulating nurse notes red, raised wheals on the patients arms. Which action should the nurse take immediately?

Notify the anesthesia care practitioner (ACP) immediately.

The nurse is preparing to witness the patient signing the operative consent form when the patient says, I do not really understand what the doctor said. Which action is best for the nurse to take?

Notify the surgeon that the informed consent process is not complete.

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first?

Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating

A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take?

Obtain a blood glucose measurement before any insulin administration.

When caring for a preoperative patient on the day of surgery, which actions included in the plan of care can the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.)

Obtain and document baseline vital signs Remove nail polish and apply pulse oximeter Transport the patient by stretcher to the operating room

Five minutes after receiving the ordered preoperative midazolam (Versed) by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate?

Offer a urinal or bedpan and position the patient in bed to promote voiding.

Which action included in the perioperative patient plan of care can the charge nurse delegate to a surgical technologist?

Pass sterile instruments and supplies to the surgeon.

A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed?

Patients breath sounds are clear to auscultation.

A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first?

Perform a bladder scan.

The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first?

Perform the jaw-thrust maneuver.

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient?

Potential complication: venous thromboembolism

Which action will the nurse take immediately after surgery for a patient who received ketamine (Ketalar) as an anesthetic agent?

Provide a quiet environment in the postanesthesia care unit.

The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife usually answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching?

Provide additional time for the patient to understand preoperative instructions and carry out procedures.

Which action best describes the role of the certified registered nurse anesthetist (CRNA) on the surgical care team?

Releases or discharges patients from the postanesthesia care area.

The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery in a few days. The results are white blood cell (WBC) count 10.2 10 3 /L; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 10 3 /L. Which action should the nurse take?

Send the patient to the holding area when the operating room calls.

A patient who takes a diuretic and a b-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery?

Serum potassium 3.2 mEq/L

Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a dislocated shoulder. What action does the nurse anticipate?

Starting a 20-gauge IV in the patients unaffected arm

As the nurse prepares a patient the morning of surgery, the patient refuses to remove a wedding ring, saying, I have never taken it off since the day I was married. Which response by the nurse is best?

Suggest that the patient give the ring to a family member to keep

A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first?

Take the patients vital signs.

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first?

Take the patients vital signs.

A patient scheduled for an elective hysterectomy tells the nurse, I am afraid that I will die in surgery like my mother did! Which response by the nurse is most appropriate?

Tell me more about what happened to your mother.

A patient has received atropine before surgery and complains of dry mouth. Which action by the nurse is best?

Tell the patient dry mouth is an expected side effect.

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful?

The new nurse turns an unconscious patient to the side upon arrival in the PACU.

Which information in the preoperative patients medication history is most important to communicate to the health care provider?

The patient takes garlic capsules daily but did not take any on the surgical day

The nurse interviews a patient scheduled to undergo general anesthesia for a hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery?

The patients father died after receiving general anesthesia for abdominal surgery.

A 38-year-old female is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery?

The patients statement that her last menstrual period was 8 weeks previously

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

The right calf is swollen, warm, and painful.

The nurse educator facilitates student clinical experiences in the surgical suite. Which action, if performed by a student, would require the nurse educator to intervene?

The student wears surgical scrubs in the semirestricted area.

A patient who is scheduled for a therapeutic abortion tells the nurse, Having an abortion is not right. Which functional health pattern should the nurse further assess?

Value-belief

A patient is being prepared for a spinal fusion. While in the holding area, which action by a member of the surgical team requires rapid intervention by the charge nurse?

Walking into the hallway outside an operating room without the hair covered

A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the postanesthesia care unit (PACU), what assessment finding is most important for the nurse to report?

Weak chest wall movement