(1) Perioperative
Which of the following primarily prevents postop complications? A.) Adequate fluid intake B.) Early ambulation C.) Well-balanced diet D.) Administration of antimicrobials
B
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A client with a perforated 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? 1. Obtain a court order for the surgery. 2. Have the charge nurse sign the informed consent immediately 3. Send the client to surgery without the consent form being signed 4. Obtain a telephone consent from a family member, followi
"4. 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 two persons who hear the family member's oral consent. The two 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 the client may not be able 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 tin this case it is not an emergency. Agency policies regarding informed consent should always be followed."
"A preoperative client asks if blood products will be used during the procedure. Which laboratory values should the nurse explain are used to determine the client's need for blood products? (SELECT ALL THAT APPLY) a. Hemoglobin b. Hematocrit c. Prothrombin time d. Red blood cell count e. Platelets"
"a. Hemoglobin b. Hematocrit d. Red blood cell count e. Platelets The diagnostic tests of platelets, hematocrit, hemoglobin, and red blood cell count are used to determine if a blood transfusion is needed during the surgical procedure. Prothrombin time is used to determine the client's risk for bleeding."
"A client is rushed into surgery following an MVA. The client must receive a blood transfusion to sustain life but is a Jehovah's Witness. What priority intervention by the nurse is the most appropriate? a. Obtain consent for an autologous blood transfusion b. Do not ask for consent; give the blood anyway c. Tell the family the client will die without the blood d. Do nothing; the family will not change their minds"
"a. Obtain consent for an autologous blood transfusion Many Jehovah's Witness clients, due to their beliefs, do not receive blood, even if it is a life saving measure. Some Jehovah's Witness clients sign only the consent to receive autologous blood. The perioperative nurse needs to understand and accept this belief. Therefore, when the nurse presents the Jehovah's Witness client with the blood consent to sign, the nurse cannot ask questions or try to persuade the client."
"The nurse measures the client's blood pressure, pulse, and capillary refill prior to sending the client to the operating room. Which concept related to perioperative care is the nurse implementing? a. Quality control b. Perfusion c. Safety d. Infection control"
"b. Perfusion The concept of perfusion is related to perioperative care. Nurses must be aware of the client's hemodynamic status and understand the guidelines for perfusion. The client's hemodynamic status is measured through blood pressure, pulse, and capillary refill. Measuring blood pressure, pulse, and capillary refill does not directly support the concepts of safety, quality control, or infection control."
A 65-year old client is having neck surgery. Which nursing diagnosis does the nurse include for this client? a. Risk for burns b. Risk for fluid volume: Deficient c. Ineffective pain control d. Risk for fluid volume: Excess
"b. Risk for fluid volume: Deficient Risk for Fluid Volume: Deficient is related to any blood loss during the client's surgery and NPO status. Risk for Burns is unrelated; there is no indication for Fluid Volume: Excess or Ineffective Pain Control."
The nurse is conducting the preoperative assessment. The client reports having a cup of black coffee before arriving for the scheduled surgery. What should the nurse do with this information? a. Instruct the client to refrain from further intake b. Administer the preoperative medication c. Notify the surgeon d. Document the fluid intake in the medical record
"c. Notify the surgeon The nurse should notify the surgeon with the information if the client has had anything to eat or drink within 8 hours prior to surgery, because this increases the client's risk of aspiration. The surgical procedure will be cancelled, especially if the surgery is elective. The client should not be given the preoperative medication until the surgeon in notified of the fluid intake. The nurse needs to do more than document the information in the medical record. The client should have been instructed to refrain from food or fluids for 8 hours before the surgery prior to arriving to the hospital for the procedure."
A 76-year old client is to undergo a hernia repair. The nurse knows that in order to aid in the healing process, the perioperative nurse must assist the client with which concept during what surgical phase? a. Perfusion therapy during the intraoperative phase b. Wound healing during the postoperative phase c. Wound healing during the preoperative and intraoperative phase d. Infection during the postoperative phase
"c. Wound healing during the preoperative and intraoperative phase Inadequate control of stress and coping mechanisms can prolong the perioperative healing process and a client's prognosis. Perioperative care includes assessing client stress and coping mechanisms during the preoperative phase and reassessing following the procedure. Postoperative infections may occur as a result of improper wound care or hospital acquired infections may occur as a result of infection control protocols not being followed. Adequate perfusion enhances wound healing and perioperative recovery. Nurses providing intraoperative and postoperative care must follow infection protocols."
"A 5-year old client scheduled for a tonsillectomy asks the nurse if the operation is going to hurt. What is the best response by the nurse? a. Yes, but it will hurt less than the sore throat you have now b. No, you will have no pain c. Yes, but we will give you medicine to stop the pain before it starts d. Yes, but don't worry. I can give you a shot to help with the pain"
"c. Yes, but we will give you medicine to stop the pain before it starts Nurses preparing children for surgery should be honest regarding expectations about postoperative pain and how the care team is ready to respond and treat pain. The nurse should acknowledge that there will be pain but also explain that medicine can be used to stop the pain before it starts. Denying the presence of pain is not an honest response. Saying that the pain will be less than the client's current sore throat does not address how pain will be managed. Responding that pain medication will be provided with a shot could cause the child alarm."
A 55-year old woman with sleep apnea is having a double mastectomy with reconstruction performed today. What priority complication is important for this client? a. Loss of blood and infection complications b. Infection and airway complications c. Injury and loss of blood complications d. Airway and VTE complications
"d. Airway and VTE complications A double mastectomy with reconstruction can take from 9-12 hours. The client has sleep apnea, so the length of the procedure increases the client's risk for complications. Shorter procedures benefit clients of all ages: Less exposure time decreases the risk for physiologic complications and reduces the time required for healing. The longer the client is exposed to anesthesia, the more it lengthens recovery time and risk for complications. The client's risk of hypothermia increases with the time required for healing and increases the risk for venous thromboembolism (VTE). Procedures lasting 30 minutes or longer may call for clients to wear SCDs (mechanical method used to prevent venous thromboembolism (VTE)). The greater risk for blood loss necessitates a blood transfusion either intraoperatively or on admission to the medical unit."
"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 nursing 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 5. Place a sterile saline dressing and icepacks over the w
1, 2, 3 ,4 Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low fowlers position and the client is kept quite and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.
A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition? 1. Pneumonia 2. Hypoxemia 3. Fluid imbalance 4. Pulmonary embolism
1. 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 the retention of pulmonary secretions.
The nurse is reviewing a prescription sheet for preoperative client that states that he client must be NPO after midnight. The nurse would telephone the physician to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine (Flexeril) 4. Conjugated estrogen (Premarin)
1. Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. These last few medications may be withheld before surgery without undue effects on the client.
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 2. Check tubes or drains for patency 3. Check the dressing to assess for bleeding 4. Assess the vital signs to compare with preoperative measurements
1. The first action of the nurse is to assess the patency of the airway snd respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking of the dressing and tubes or drains.
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. Urine output of 20ml/hour 2. Temperature of 37.6 C 3. Blood pressure of 114/70 4. Serous drainage on the surgical dressing
1. Urine output should be maintained at a minimum of 30mL/hour for an adult. An output of less than that for each of 2 consecutive hours should be reported to the health care provider.
"The nurse assess 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? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm tender skin"
2 Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Wound infection usually appears 3 to 6 days after 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? 1. ""Aspirin can cause bleeding after surgery."" 2. ""Aspirin can cause my ability to clot blood to be abnormal."" 3. ""I need to continue to take the aspirin until the day of surgery."" 4. ""I need to check with my HCP about t
3. Anticoagulants altered normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. However, the client should always check with his or her health care provider regarding when to stop taking the aspirin when a surgical procedure is scheduled.
"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? 1. ""If it's any help, everyone is nervous before surgery."" 2. ""I will be happy to explain the entire surgical procedure with you."" 3. ""Can you share with me what you've been told about your surgery?"" 4. ""Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate"
3. Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications.
The nurse is developing 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? 1. Avoid oral hygiene and rinsing with mouthwash 2. Verify that the client has not eaten for the last 24 hours 3. Have the client void immediately before going into surgery 4. Report immediately any slight increase in BP or pulse
3. 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 before surgery instead of 24 hours. A slight increase in BP and pulse is common during the preoperative period due to anxiety.
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? 1. Inhale as rapidly as possible 2. Keep a loose seal between the lips and the mouthpiece 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees
4 For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowlers or high fowlers 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.
A client is scheduled for a subtotal gastrectomy. In anticipation of clarifying information for client education, the nurse knows that vagotomy is done as part of the surgical treatment for peptic ulcers in order to A.) Decrease secretion of hydrochloric acid B.) Improve the tone of the GI muscles C.) Increase blood supply to the jejunum D.) Prevent the transmission of pain impulses
A
A fluid challenge is begun with a post-op gastric surgery client. Which assessment will give the best indication of client response to this treatment? A.) CVP readings and hourly urine output B.) Blood pressure and apical rate checks C.) Lung sounds and arterial blood gases D.) Electrolytes, BUN, creatinine results
A
Appendectomy is classified as A.) Ablative B.) Constructive C.) Reconstructive D.) Palliative
A
How frequent should the nurse monitor the VS of the patient in the recovery room? A.) Every 15 minutes B.) Every 30 mins C.) Every 45 mins D.) Every 60 mins
A
If wound eviscerations occurs, the immediate nursing action is: A.) Cover the wound with sterile gauze moistened with sterile NSS B.) Cover the wound with water-soaked gauze C.) Cover the wound with sterile dry gauze D.) Leave the wound uncovered and pull the skin edges together
A
Modified radical mastectomy involves: A.) Removal of the entire breast, axillarylymph nodes, pectorals muscle B.) Removal of the lump of the breast C.) Removal of the entire breast, axillary andneck lymph nodes, including pectorals muscles D.) Removal of the entire breast but nippleremains intact
A
Post operatively, a patient is expected to void after: A.) 6-8 hours B.) 2-4 hours C.) 12-24 hours D.) 10-12 hours
A
Post operatively, the client must be encouraged to turn, cough and deep breathe: A.) Every 1-2 hours B.) Every 4 hours C.) Every 30 Mins D.) Every 8 hours
A
The important nursing intervention prior to administration of pre-anesthetic medication is: A.) Ask patient to empty the bladder B.) Do deep breathing and coughing exercises C.) Regulate IVF accurately D.) Shave the skin
A
The patient has been observed pacing along the hallway, goes to the bathroomfrequently and asks questions repeatedly during preoperative assessment. The most likely cause of the behavior is: A.) She is anxious about the surgical procedure B.) She is worried about separation from the family C.) She has urinary tract infection D.) She has an underlying emotional problem
A
Which of the following assessment data ismost important to determine when caring for a patient who has received spinal anesthesia? A.) The time of return of motion andsensation in the legs and toes B.) The character of respiration C.) Level of consciousness D.) Amount of wound drainage
A
Which type of surgery is most likely to predispose a patient to postoperative atelectasis, pneumonia or respiratory failure? A.)Upper abdominal surgery on an obese patient with a long history of smoking B.)Upper abdominal surgery on a patientwith normal pulmonary function C.)Lower abdominal surgery on a young patient with diabetes mellitus D.)Surgery on the extremities of anonsmoking football player
A
Which of the following is experienced by the patient who is under spinal anesthesia? A.) The patient is unconscious B.) The patient is awake C.) The patient experiences amnesia D.) The patient experiences total loss of sensation
B
Which of the following is most dangerous complication during induction of spinal anesthesia? A.)Tachycardia B.)Hypotension C.)Hyperthermia D.)Bradypnea
B
Which of the following nursing actions would help the patient decrease anxiety during the preoperative period? A.) Explaining all procedures thoroughly in chronological order B.) Spending time listening to the patient and answering questions C.) Encouraging sleep and limiting interruptions D.) Reassuring the patient that the surgical staff are competent professional
B
Which of the following postop findings should the nurse report to the M.D.? A.) The patient pushes out the oral airway with his tongue B.) Urine output is 20ml/hr for the past two hours C.) VS are as follows:BP=110/70;PR=95;RR=19,Temp=36.8C D.) Wound drainage is serosanguinous
B
"A 40 y/o female client has arrived in the post anesthesia room following a cholecystectomy and a common bile duct exploration. She is semi conscious. Her vital signs are within normal limits. Which of the following nursing actions would be inappropriate? A.) Apply a warm blanket to her body B.) Place her in a semi-fowler's position C.) Attached her T-tube to gravity drainage D.) Set up low, intermittent suction for her NGT"
B
"To prevent headache after spinal anesthesia the patient should be positioned: A.) Semi-fowler's B.) Flat on bed for 6 to 8 hours C.) Prone position D.) Modified trendelenbur"
B
"Which of the following statements by a client recovering from a subtotal gastrectomy would indicate a need for additional teaching about the diet protocol for dumping syndrome? A.) ""I plan to eat a diet low in carbohydratesand high in protein and fat"" B.) ""I plan to eat a diet high in CHO and lowin CHON and fat"" C.) ""I will eat slowly and avoid drinking fluids during meals"" D.) ""I will try to assume a recumbent positionafter meals for 30 mins to 1 hour to enhancedigestion and relieve sym
B
During the immediate postoperative period following gastric surgery, why must the nurse be particularly conscientious about encouraging a client to cough and deep-breathe at regular intervals? A.) Marked changes in intrathoracic pressure will stimulate gastric drainage B.) The high abdominal incision will lead to shallow breathing to avoid pain C.) The phrenic nerve will have been permanently damaged during the surgical procedure D.) Deep-breathing will prevent post op vomiting and intestinal di
B
Immediately following spinal anesthesia,the greatest risk is: A.) Severe hemorrhage B.) Severe Hypotension C.) Severe Hypoglycemia D.) Hypertensive crisis
B
The best time to provide preoperative teaching on deep breathing, coughing and turning exercises is: A.) Before administration of preoperative medications B.) The afternoon or evening prior to surgery C.) Several days prior to surgery D.) Upon admission of the client in the recovery room
B
What is the primary reason for the gradual change of position of the patient after surgery? A.) To prevent muscle injury B.) To prevent sudden drop of BP C.) To prevent respiratory distress D.) To promote comfort
B
When the patient vomits, the most important nursing objective is to prevent: A.) Dehydration B.) Aspiration C.) Rupture of suture line D.) Met. Alkalosis
B
Which of the following characterizes excitement stage of anesthesia A.) Occurs from the administration of anesthesia to the loss of consciousness B.) Extends from the loss of consciousnessto the loss of lid reflex, characterized bystruggling and talking C.) From the loss of lid reflex to the loss of most reflexes D.) From the loss of most reflexes torespiratory and circulatory failure
B
Which of the following facts best explains why the duodenum is not removed during a subtotal gastrectomy? A.) The head of the pancreas is adherent tothe duodenal wall B.) The common bile duct empties into the duodenal lumen C.) The wall of the jejunum contains no intestinal villi D.) The jejunum receives its blood supply through the duodenum
B
"A client in shock must be placed in: A.) High-fowlers position B.) Sim's position C.) Modified trendelenburg D.) Prone position"
C
"Nursing measures to promote the client's respiratory function during recovery from anesthesia are the following EXCEPT: A.) Encourages deep breathing and coughing exercises B.) Administer Humidified oxygen C.) Place in semi-fowlers position D.) Place in supine position with head turned to the side without pillow support"
C
"The patient who has undergone TAHBSO complains of pain. Which of the following is an initial nursing action?A.) Administer the PRN analgesics B.) Instruct to do deep breathing exercises C.) Assess the VS D.) Change the patient's position"
C
Headache after spinal anesthesia is due to: A.) Paralysis of vasomotor nerves B.) Traction placed on structures within abdomen C.) Loss of CSF through dural hole D.) Administration of large amounts and heavy concentration of anesthetic agents
C
Nursing measures for post-opthrombophlebitis include the followingEXCEPT: A.) Maintain bedrest B.) Elevate affected leg with pillow support C.) Massage the painful extremities D.) Apply antiembolic stockings
C
The following ensure validity of informed written consent EXCEPT: A.) The patient is of legal age with proper mental disposition B.) The consent has been secured within 24hours before the surgery C.) If the patient is unable to write, secure the consent from a relative D.) The consent is secured before administration of any medication that alter the level of consciousness
C
The most important factor in the prevention of post op wound infection is: A.) Adequate fluid intake B.) Proper administration of antibiotics C.) Practice of strict aseptic technique D.) Frequent cleaning of the wound
C
The most important factor in the prevention of postop infection is: A.) Proper administration of antibiotics B.) Fluid intake of 2-3L/day C.) Practice of strict aseptic techniques D.) Frequent change of wound dressings
C
The skin is shaved prior to surgery inorder to: A.) Facilitate skin incision B.) Indicate the site to be draped C.) To prevent wound infection D.) Reduce post op scarring
C
The worst of all fears among clients undergoing surgery is: A.) Fear of financial burden B.) Fear of death C.) Fear of the unknown D.) Fear of loss of job
C
Which of the following criteria must be met before the client is released from the RR to the unit. A.) Breathes with ease, coughs freely B.) Has regained consciousness C.) Vital signs fluctuates erratically D.) Able to move four extremities
C
Which of the following is the earliest sign of poor respiratory function? A.) Cyanosis B.) Fast thready pulse C.) Restlessness D.) Faintness
C
Which of the following is the primary purpose of maintaining NPO for 6 to 8 hours before surgery? A.) To prevent malnutrition B.) To prevent electrolyte imbalance C.) To prevent aspiration pneumonia D.) To prevent intestinal obstruction
C
Which of the following nursing actions should be given highest priority when admitting the patient into the operating room? A.) Level of consciousness B.) Vital signs C.) Patient identification and correct operative consent D.) Positioning and skin preparation
C
"Prior to having a subtotal gastrectomy, a client is told about the dumping syndrome.The nurse explains that it is: A.) The body's absorption of toxins produced by liquefaction of dead tissue B.) Formation of an ulcer at the margin of the gastrojejunal anastomosis C.) Obstruction of venous flow from the stomach into the portal system D.) Rapid emptying of food and fluid from the stomach into the jejunum"
D
"Which of the following is not appropriate nursing intervention after modified radical mastectomy? A.) Place in semi fowler's position andelevate arm on the affected side with pillow support B.) Check behind the client for bleeding C.) Monitor output from wound suction drainage D.) Immobilize the arm on affected side inadduction"
D
Early signs of poor respiratory function include which of the following A.) Cyanosis B.) Hypotension C.) Loss of consciousness D.) Restlessness
D
Nursing measures to relieve hiccups include the following EXCEPT: A.) Exhale and inhale through a paper bag B.) Apply pressure over the eyeball through closed eye lids C.) Hold breath while taking a large pulp of water D.) Administer high concentration of oxygen
D
Situation: A female client, 23 y/o was admitted for the first time at the Fatima Hospital with the chief complaint of Right Iliac Pain, accompanied by nausea and vomiting, chills and fever. She was diagnosed to have acute appendicitis. She was scheduled to have emergency appendectomy under spinal anesthesia Pre-op instructions to the client would include the following EXCEPT: A.) Deep breathing and coughing exercise B.) Turning to sides C.) Foot and leg exercises D.) reassuring her that narcotic
D
The client gave her consent for the surgery. To ensure the legality of the consent, the following conditions must be met EXCEPT: A.) She gave her consent freely B.) She must understand the nature of the surgery C.) The consent must be signed by a witness D.) Signing should be done after the administration of pre-anesthesia med
D
The following are the appropriate nursing actions before administration of preoperative medications EXCEPT: A.) Ascertain the consent has been signed B.) Ensure that NPO has been maintained C.) Instruct patient to empty his bladder D.) Shave the skin at the site of surgery
D
Which of the following drugs is administered to minimize respiratory secretions prep? A.) Valium (Diazepam) B.) Nubain ( Nalbuphine HCL) C.) Phenergan (Promethazine) D.) Atropine Sulfate
D
Which of the following drugs is given to relieve nausea and vomiting? A.) Mepivacaine B.) Aquamephyton C.) Nubian D.) Plasil
D
"A client who has undergone preadmission testing, has had blood drawn for serum lab studies, including a complete blood count, coagulation studies and electrolytes and creatine levels. Which lab result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Sodium, 141mEq/L 2. Hemoglobin, 8.0 g/dL 3. Platelets, 210,000/mm3 4. Serum creatine, 0.8 mg/dL"
The complete blood count includes the hemoglobin analysis. All these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon
"What postoperative assessment would indicate to the nurse a change in a client's cardiovascular status? (SELECT ALL THAT APPLY) a. Capillary refill time greater than 3 seconds b. Vomiting moderate amount of green emesis c. Absent gag reflex d. Pedal pulse non-palpable e. Dropping blood pressure"
a. Capillary refill time greater than 3 seconds d. Pedal pulse non-palpable e. Dropping blood pressure Changes in cardiovascular status affect blood pressure, pulses, and capillary refill. Dropping blood pressure, non-palpable pedal pulse, and capillary refill time greater than 3 seconds reflect a change in the cardiovascular status. An absent gag reflex indicates a change in a protective neurological reflex. Vomiting indicates a change in gastrointestinal status.
"A 43-year old client is undergoing a CABG. What priority understanding does the nurse have about perioperative documentation? a. If it was not written, it was not done b. It includes all steps of the nursing process c. It's a legal document subject to internal review d. It keeps the nurse and patient safe"
b. It includes all steps of the nursing process All answers are correct; however, the priority understanding of perioperative documentation is that it includes all steps of the nursing process including assessment, diagnosis, identified outcomes, planning, implementation, and evaluation.
"The nurse is preparing a client for a surgical procedure to remove a portion of the transverse colon. Which priority actions should the nurse include to reduce the client's risk of developing a postoperative complication? (SELECT ALL THAT APPLY) a. Observe for muscle twitching b. Monitor body temperature c. Monitor blood pressure and heart rate d. Ensure aseptic technique is used for the procedure e. Monitor urine concentration"
b. Monitor body temperature c. Monitor blood pressure and heart rate d. Ensure aseptic technique is used for the procedure Open procedures place the client at a higher risk for blood loss, hypothermia and surgical site infections (SSIs). The nurse should monitor body temperature, blood pressure, and heart rate and ensure aseptic technique is used for the procedure. Urine concentration is used to monitor for hypernatremia and hypovolemia. Muscle twitching is associated with hyponatremia.
A client diagnosed with gallbladder disease decides to undergo a laparoscopic cholecystectomy as opposed to an open procedure. The nurse realizes the client chose the laparoscopic surgery due to what reason? a. The laparoscopic surgery has a higher infection rate b. The laparoscopic surgery requires a shorter hospital stay and recovery c. The open surgery is more expensive d. The open surgery scars are less noticeable
b. The laparoscopic surgery requires a shorter hospital stay and recovery Laparoscopic surgeries are less invasive and usually require a shorter hospital stay and recovery. Also, due to the small incision sites the patient is at a lower risk for acquiring a surgical site infection (SSI) and experiences less blood loss. Open procedures usually require a longer hospital stay and longer recovery period. Open procedures also place the client at a higher risk for blood loss. Larger incisions place the client at a higher risk for complications, such as hypothermia and surgical site infections.
The circulating nurse is ensuring that a client is adequately positioned for surgery and determines that the procedure is going to take longer than 30 minutes to complete. What did the nurse assess to make this determination? a. Client is in the lithotomy position b. Client has a device on a finger to measure oxygen saturation c. Client is wearing sequential compression devices d. Client has pillows placed under the knees
c. Client is wearing sequential compression devices For procedures expected to last 30 minutes or longer, clients may be prescribed to wear sequential compression devices to reduce the risk of venous thromboembolism development from prolonged inactivity. The use of the lithotomy position does not determine the length of the surgical procedure. Placing pillows under the knees is a preventive action for the client in the supine position for a surgical procedure. Most clients receiving anesthesia will have oxygen saturation monitored during the surgical procedure.
A 26-year old client comes into the clinic prior to a tonsillectomy. Which action is priority during this phase of surgery? a. Intraoperative consent signed b. Intraoperative medication c. Preoperative assessment d. Postoperative assessment
c. Preoperative assessment The client is in the preoperative phase of surgery and must be assessed and prepared for surgery. The client may have labs drawn, medication administered, and consent forms signed. The intraoperative phase is the actual surgery; the client is anesthetized, prepped, draped, and surgery performed. The postoperative phase is the recovery phase of surgery where the client continues to recover until maximum health is achieved.
"The nurse identifies the postoperative client as being at an increased risk for impaired oxygenation. Which is the best nursing intervention to address this client's problem? a. Provide antibiotics as prescribed b. Medicate for pain as prescribed c. Administer 1 unit platelets as prescribed d. Apply oxygen 2 liters by face mask as prescribed"
d. Apply oxygen 2 liters by face mask as prescribed For a client at risk of impaired oxygenation, applying oxygen 2 liters by face mask would be the appropriate intervention to implement. Providing an antibiotic as prescribed would be applicable if the client were at risk for an infection. Medicating for pain would address the problem of comfort. Providing platelets would be appropriate for perfusion or coagulation problems.
An 18-year old client is admitted to the emergency room for an emergency appendectomy. The nurse knows that which assessment is priority with each perioperative phase a. Medication assessment b. Pain assessment c. History and physical d. Systems assessment
d. Systems assessment While the other assessments are important, a systems assessment is priority and can be completed with each perioperative phase, making sure the client remains at baseline throughout.