Ch 14: Perioperative Care

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required?

"I can resume my usual activities as soon as I get home."

The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus?

Absence of peristalsis

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?

Assess for signs and symptoms of fluid volume deficit.

A nurse is working as a member of the perioperative team and is wearing OR attire but is not wearing a sterile gown. What role is this nurse most likely performing?

Circulating nurse

The nurse is caring for an 88-year-old client who is recovering from an ileac-femoral bypass graft. The client is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the client, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What complication should the nurse suspect?

Postoperative delirium

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

auscultate bowel sounds.

The nurse is preparing to change a client's abdominal dressing. The nurse recognizes the first step is to provide the client with information regarding the procedure. Which of the following explanations should the nurse provide to the client?

"During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to."

A client asks the nurse how an inhalant general anesthetic is expelled by the body. What is the best response by the nurse?

"The lungs primarily eliminate the anesthesia."

The nurse just received a postoperative client from the PACU to the medical-surgical unit. The client is an 84-year-old woman who had surgery for a left hip replacement. What concern should the nurse prioritize for this client in the first few hours on the unit?

Close monitoring of neurologic status

An OR nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the OR?

Mask covering the nose and mouth

A client vomits postoperatively. What is the most important nursing intervention?

Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.

A client is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting "coffee-ground" like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the client most likely anticipate that the surgery will be scheduled?

Without delay because the bleed is emergent

A client has been transported to the operating room for emergent surgery. Which statement by the nurse best supports the need for emergent surgery?

"The client was unresponsive, had a distended abdomen, and had unstable vital signs after a motor vehicle accident."

The anesthetist is coming to the surgical admissions unit to see a client prior to surgery scheduled for tomorrow morning. What is the priority information that the nurse should provide to the anesthetist during the visit?

Latex allergy

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.

Position the client in Fowlers position. Don sterile gloves. Lubricate the sterile suction catheter. Insert suction catheter into the lumen of the tube. Apply intermittent suction while withdrawing the catheter.

The perioperative nurse knows that the National Patient Safety Goals have the potential to improve client outcomes in a wide variety of health care settings. Which of these goals has the most direct relevance to the OR?

Reduce the risk of fires

A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse:

continuously monitors the sedated client.

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound

dehisced

A nurse evaluates the potential effects of a client's medication therapies before surgery. Which drug classification may cause respiratory depression from an associated electrolyte imbalance during anesthesia?

diuretics

The nurse assesses a client to determine if there is increased risk for complications intraoperatively or postoperatively. Which are general risk factors? Select all that apply

physical condition health status age nutritional status

The nurse is providing preoperative teaching to a client scheduled for hip replacement surgery in 1 month. During the preoperative teaching, the client gives the nurse a list of medications she takes, the dosage, and frequency. What intervention provides the client with the most accurate information?

Instruct the client to stop taking St. John's wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents.

A client is scheduled for a surgical procedure. When planning the client's care, the nurse should consider that which of the following conditions will increase the client's risk of complications after surgery?

A history of diabetes

What is the priority action by the scrub nurse when the surgeon begins to close the surgical wound?

Count the sponges.

What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site?

Obtain the attention of all members of the surgical team.

The nurse is providing teaching about tissue repair and wound healing to a client who has a leg ulcer. Which of the following statements by the client indicates that teaching has been effective?

"I'll eat plenty of fruits and vegetables."

The nurse is caring for a client in the postoperative period following an abdominal hysterectomy. The client states, "I don't want to use my pain meds because they'll make me dependent and I won't get better as fast." Which response is most important when explaining the use of pain medication?

"You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is given for an extended period of time."

Maintaining an aseptic environment in the OR is essential to client safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field?

1 foot (30 cm)

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.

1. Position the client in Fowlers position. 2. Don sterile gloves. 3. Lubricate the sterile suction catheter. 4. Insert suction catheter into the lumen of the tube. 5. Apply intermittent suction while withdrawing the catheter.

What is the blood glucose level goal for a diabetic client who will be having a surgical procedure?

80 to 110 mg/dL

A surgical client has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). What must the client require for safe and effective use of PCA?

A clear understanding of the need to self-dose

As an OR nurse, you are required to assess the client continuously and protect them from developing potential complications, as much as humanly possible. To protect a client from malignant hyperthermia, you need to know the symptoms—what are the symptoms of malignant hyperthermia?

All of the options are correct

A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?

Allow the client to wear the ring and cover it with tape.

The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk?

Atelectasis

The intraoperative nurse advocates for each client who receives care in the surgical setting. How can the nurse best exemplify the principles of client advocacy?

By maintaining the privacy of each client

The nurse is preparing a client for surgery. The client states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take?

Call the physician to review the procedure with the client.

What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities?

Coordinating the surgical team

The anesthesiologist administered a transsacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered?

Denies sensation to perineum and lower abdomen

The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurse's preoperative assessment of an elderly client?

Elderly clients have less physiologic reserve than younger clients.

Prior to a client's scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the client's care. What is the main rationale for organizing perioperative care in this collaborative manner?

Evidence-based practice

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

First intention

A client is receiving general anesthesia. The nurse anesthetist starts to administer the anesthesia. The client begins giggling and kicking her legs. What stage of anesthesia would the nurse document related to the findings?

II

A written informed consent is necessary for which of the following? Select all that apply.

Invasive procedures Procedures requiring sedation Procedures requiring radiation

A nurse is caring for a client following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache?

Keep the client positioned supine.

The nurse is preparing to send a client to the OR for a scheduled surgery. What should the nurse ensure is on the chart when it accompanies the client to surgery? Select all that apply.

Laboratory reports Nurses' notes Verification form

What is the primary objective of the health care team during the immediate postoperative period?

Maintaining ventilation

The nurse is caring for a hospice client who is scheduled for a surgical procedure to reduce the size of his spinal tumor in an effort to relieve his pain. The nurse should plan this client care with the knowledge that his surgical procedure is classified as which of the following?

Palliative

Which of the following is a classic sign of hypovolemic shock?

Pallor

The OR nurse acts in the circulating role during a client's scheduled cesarean section. For what task is this nurse solely responsible?

Performing documentation

Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery?

Physician

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?

Pneumonia

A client is scheduled for elective surgery. To prevent the complications of hypotension and cardiovascular collapse, the nurse should report the use of which medication?

Prednisone

A 79-year-old man is scheduled for surgical repair of an inguinal hernia. In light of this patient's age, the nurse will prioritize nursing interventions aimed at preventing:

Skin breakdown

A postoperative client rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the client is experiencing a hemorrhage. What should be the nurse's first action?

Quickly attempt to determine the cause of hemorrhage.

Which action should the nurse perform to prevent deep vein thrombosis in a client recovering from abdominal surgery?

Reinforce the need for the client to perform leg exercises every hour while awake

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing the dressing or applying pressure if bleeding is frank

There are four stages of general anesthesia. Select the stage during which the OR nurse knows not to touch the patient (except for safety reasons) because of possible uncontrolled movements.

Stage II: Excitement

Which stage of general anesthesia is reached when too much anesthesia has been administered?

Stage IV

The client vomits during the surgical procedure. The best action by the nurse is:

Suction the client to remove saliva and gastric secretions.

An unconscious patient with normal pulse and respirations would be considered to be in what stage of general anesthesia?

Surgical anesthesia

The nurse is providing preoperative teaching to a client scheduled for surgery. The nurse is instructing the client on the use of deep breathing, coughing, and the use of incentive spirometry when the client states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide?

To promote optimal lung expansion

A client at risk for malignant hyperthermia returns to the surgical unit. For what time period will the nurse monitor the client for development of malignant hyperthermia?

The client can develop malignant hyperthermia up to 24 hours after surgery.

The OR nurse is taking the client into the OR when the client informs the operating nurse that his grandmother spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client?

The client may be at risk for malignant hyperthermia.

The nurse is caring for an unconscious trauma victim who needs emergency surgery. The client is a 55-year-old man with an adult son. He is legally divorced and is planning to be remarried in a few weeks. His parents are at the hospital with the other family members. The physician has explained the need for surgery, the procedure to be done, and the risks to the children, the parents, and the fiancé. Who should be asked to sign the surgery consent form?

The son

The PACU nurse is caring for a client who has arrived from the OR. During the initial assessment, the nurse observes that the client's skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the client is not breathing. What is the priority intervention?

Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw.

A perioperative nurse is assigned to complete a preoperative assessment on a client who is scheduled for surgery for kidney stones the next day. What category of surgery does this procedure fall into?

Urgent