CH. 30: Peri-op PrepU
A nurse from the ambulatory surgical center is preparing discharge instructions for a client who has had pelvic surgery. Which criterion would the client need to demonstrate to ensure that she is ready for discharge? a. verbalize absence of pain b. void normally c. eat without nausea d. exhibit no bleeding
void normally
Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? a. "I can have a hamburger and French fries as soon as I wake up." b. "The better I eat before surgery, the more likely I will heal." c. "I might be sick to my stomach and throw up after surgery." d. "When I can eat again, the best meal would include protein and vitamin C"
"I can have a hamburger and French fries as soon as I wake up."
A client who is scheduled to undergo coronary bypass surgery in a week asks the nurse whether he should discontinue taking his cholesterol medicine ahead of the surgery. Which should be the nurse's response? a. "I will need to check with your health care provider about that." b. "Yes-you should be off all of your medications for 24 hours before surgery." c. "No-you should stay on your normal medication schedule before the surgery." d. "You should stay on your cholesterol medicine but stop taking all other medications 12 hours before surgery."
"I will need to check with your health care provider about that." Explanation: The client may be permitted to take certain medications before surgery. The health care provider, not the nurse, should provide guidance about which medications should be taken and which ones should be held.
The circulating nurse calls for a time-out prior to the surgical procedure and the surgeon states, "I don't have time for this. I have another case to follow and need to get busy." What is the best response by the circulator? A. "I understand you are very busy, so we can move on without the time-out." B. "Whether you have time to do it or not, we will do it without you." C. "These time-outs are ridiculous anyway; we all know what the client is having done." D. "We all have the same goal and that is the safety of the client, so let's do the time-out."
"We all have the same goal and that is the safety of the client, so let's do the time-out." Explanation: Final verification just prior to beginning the procedure is referred to as the time-out. The time-out occurs immediately before starting the surgical procedure and is initiated by a designated member of the team. The surgeon, the anesthesia provider, the circulating nurse, the operating room technician, and any other active participants conduct the time-out assessment and ensure that there are no questions or concerns. During the time-out, all members of the surgical team must agree on the identity of the client, the correct surgical site, and the procedure that will be performed. The completion of the time-out is documented appropriately.
The licensed practical nurse (LPN) is observed by the registered nurse (RN) engaging in the reinforcement of teaching related to therapeutic deep breathing and coughing with a client who is recovering from abdominal surgery. Which statement by the RN best supports the LPN's role in the implementation of this intervention? A. "Let me know whether the client reported any pain during the implementation of this respiratory intervention." B. "You served as a good role model while showing the client the proper technique for this intervention." C. "Advocating for the client's recovery is an important role LPNs engage in when providing client care." D. "Be sure to chart your evaluation of the effectiveness of this postoperative intervention on the client's respiratory status."
"You served as a good role model while showing the client the proper technique for this intervention." Explanation: Appropriately demonstrating a technique is an example of role modeling. When demonstrating effective posturing, abdominal splinting, and breathing, the LPN is acting as a role and is reinforcing the implementation of the intervention. This is a component of the nurse's role to teach/educate the client. While advocacy and reporting client needs are both nursing responsibilities, neither are focused directly on client teaching as is role modeling. Evaluation is a RN responsibility and not delegated to the LPN.
A client is undergoing a knee replacement tomorrow morning and is ordered nothing by mouth (NPO) prior to surgery. The client asks the nurse how long before the procedure can water be taken in. Based on the nurse's knowledge of standard protocols, what is the nurse's best response? a. 2 hours b. 4 hours c. 6 hours d. 12 hours
2 hours Explanation: Two hours is a standard NPO time for clear liquids, though the nurse should always check with the institution's policy and the orders of the health care provider.
An 83-year-old client who wears glasses is scheduled for surgery. Which action should the nurse take to assure the client remains oriented? A. Allow the client to wear glasses until just before anesthetic is administered. B. Direct the client to leave glasses at home for safety. C. Give the glasses to the family until the client is returned to the room. D. Allow the client to wear glasses until after anesthetic is administered.
Allow the client to wear glasses until just before anesthetic is administered. Explanation: If an adult client is visually impaired, the nurse should allow the client to leave the glasses on until just before an anesthetic is administered. Doing so maintains visual orientation and helps to decrease fear and increase confidence. If a client is having a regional or local anesthetic, operating room personnel may allow the client to wear glasses or contact lenses during the procedure. The nurse should note any visual impairment on the chart so that operating room personnel are aware of this deficit. Glasses should not be given to the family unless the client has requested that action and there is no need for the client to leave glasses at home.
A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first? A. Apply an oxygen saturation monitor. B. Apply warm blankets to the client. C. Check the client's blood pressure. D. Notify the health care provider.
Apply warm blankets to the client. Explanation: The nurse should apply warm blankets to the client because the client is hypothermic with a temperature of 96.2°F (35.7°C). The client can be assessed further by checking vital signs and using an oxygen saturation monitor. The health care provider should be notified about the client's temperature but an intervention should be done first to ensure the client begins warming immediately.
A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first? 1. Notify the health care provider. 2. Apply warm blankets to the client. 3. Apply an oxygen saturation monitor. 4. Check the client's blood pressure.
Apply warm blankets to the client. Explanation: The nurse should apply warm blankets to the client because the client is hypothermic with a temperature of 96.2°F (35.7°C). The client can be assessed further by checking vital signs and using an oxygen saturation monitor. The health care provider should be notified about the client's temperature but an intervention should be done first to ensure the client begins warming immediately.
A nurse is teaching a client about the rationale for fasting from food and fluids prior to surgery. What condition does this measure attempt to avoid? a. Infection b. Respiratory distress c. Aspiration d. Bowel alterations
Aspiration
The nurse is caring for a client in the postanesthesia care unit (PACU). Which assessment is the priority for this client? 1. Check the neurologic status. 2. Auscultate bowel sounds. 3. Obtain temperature. 4. Assess respiratory status.
Assess respiratory status.
The nurse is caring for a client in the postanesthesia care unit (PACU). The nurse uses what specific intervention to avoid complications for the respiratory body system. 1. Check pupillary response 2. Auscultate bowel sounds 3. Monitor muscle strength 4. Assess skin color
Assess skin color. Explanation: Skin color can be assessed as a determinant of efficient or deficient oxygenation of tissues. Pupillary response is an assessment used to determine neurologic status. Bowel sounds are an indicator of bowel motility that must be established prior to the client taking food or drink by mouth. Monitoring muscle strength is a means of assessing neurologic status
The acute care nurse is preparing a client for surgery. Which action is essential to complete before transferring the client to surgery? A. Mark the client's skin to indicate the location of the surgery. B. Remove graduated compression stockings. C. Place the client in a side-lying position. D. Assure that diagnostic testing has been completed and results are available.
Assure that diagnostic testing has been completed and results are available. Explanation: All prescribed diagnostic tests should be performed, and results made available before the client goes to surgery. Unless otherwise indicated, no special positioning is required preoperatively. Graduated compression stockings, if prescribed, should remain in place. The surgeon, not the nurse, is responsible for marking the skin.
What information must be provided to a client to obtain informed consent? Select all that apply. A. The name and qualifications of the nurse providing perioperative care B. Customary insurance coverage for the procedure C. Explanation of the risks involved and how often they occur D. A description of the procedure or treatment, along with potential alternative therapies E. Explanation that a signed consent form is binding and cannot be withdrawn F. The underlying disease process and its natural course
Explanation of the risks involved and how often they occur The underlying disease process and its natural course A description of the procedure or treatment, along with potential alternative therapies Explanation: The informed consent provides a description of the procedure or treatment (its name, site, and side effects if applicable), along with potential alternative therapies; the underlying disease process and its natural course; the name and qualifications of the person performing the procedure or treatment; explanation of the common risks involved, including risk for damage, disfigurement, or death, and how often they occur; explanation that the client has the right to refuse treatment and that consent can be withdrawn; and explanation of expected outcome, recovery, and rehabilitation plan and course.
The nurse educates a client about what to expect after abdominal surgery. How will the nurse explain the progression of a client's diet in the postoperative period? A. You may eat anything you want following surgery. B. You will receive a diet high in vitamin B. C. In the immediate postoperative period, you will receive a soft diet high in carbohydrates. D. Food and liquids will be held in the immediate postoperative period.
Food and liquids will be held in the immediate postoperative period.
@ The nurse educates a client about what to expect after abdominal surgery. How will the nurse explain the progression of a client's diet in the postoperative period? a. Food and liquids will be held in the immediate postoperative period. b. You will receive a diet high in vitamin B. c. In the immediate postoperative period, you will receive a soft diet high in carbohydrates. d. You may eat anything you want following surgery.
Food and liquids will be held in the immediate postoperative period. Explanation: Intestinal manipulation, pain medications, and anesthetic agents may result in a decrease in intestinal motility. The client may experience nausea and vomiting. Therefore, after surgery, fluids and food are often withheld until gastric motility returns. A diet with sufficient amounts of protein and vitamins A and C (not vitamin B) helps to rebuild tissues and promotes wound healing. A soft diet with adequate (not high) carbohydrates for energy is started after the client has demonstrated tolerance to liquids well. Clients are not able to eat anything they want following surgery; the diet is usually progressed from NPO, to clear then full liquids, a soft diet, and finally a regular diet.
The nurse is caring for a client in the postanesthesia care unit (PACU). The nurse uses what specific intervention to avoid complications for the neurological body system. 1. Encourage leg exercises 2. Gently touch the client 3. Assess dressing for drainage
Gently touch the client. Explanation: The nurse can verbally reorient the client following anesthesia using a gentle touch and addressing the client by name. Assessing the dressing for drainage can be an indicator of fluid loss which can adversly affect cardiovascular function. The performance of leg exercises helps to promote circulation.
A nurse is caring for an older adult client who had surgery for the removal of a cataract in the left eye. Which issue would prevent the client from being discharged on the day of surgery? A. Voiding on a regular basis B. Inability to see from left eye C. Inability to ambulate D. Alert and oriented ×4
Inability to ambulate Explanation: Recovery from anesthesia is usually much quicker when shorter-acting IV anesthetic agents, such used in same-day surgery. Before discharge from an ambulatory surgical unit, the client should: void (after a spinal or epidural anesthetic or after pelvic surgery), be able to ambulate, be alert and oriented, have minimal nausea and vomiting, have adequate pain/comfort control and exhibit no excess bleeding or drainage. The left eye would be covered with a dressing and the client would not be expected to see from that eye immediately.
The nurse has admitted a client to the postoperative unit following a bowel resection and is providing postoperative health education on coughing and deep breathing. What does the nurse explain to the client about why these actions are important? 1. If you continue to breathe shallowly or cough ineffectively, this can lead to deep vein thrombosis (DVT) by preventing poor oxygen exchange in the cardiac and peripheral circulatory system. 2. If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia. 3. If you continue to breathe shallowly or cough ineffectively, this can lead to acute respiratory distress syndrome. 4. If you continue to breathe shallowly or cough ineffectively, this can lead to dizziness, falling, or an inability to ambulate because of shortness of breath.
If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia. Explanation: Shallow breathing or an infective cough can lead to mucus plugging, atelectasis, hypoxemia, and pneumonia. Taking deep breaths helps to expand alveoli and an effective cough pushes secretions upward out of the lungs. A client experiencing postoperative pain may be unable or unwilling to take the deep breath needed to cough. Medications used to control pain and splinting the incision by hugging a pillow or blanket increase compliance to deep breathing and coughing exercises. Shallow breathing or ineffective cough does not lead to aspiration pneumonia, inability to ambulate, or DVT. Acute respiratory distress syndrome is caused by sepsis, inhaling harmful substances, injury, and severe pneumonia that has infiltrated all five lobes and is not specific to postoperative-related pneumonia.
Which fact should the nurse keep in mind when obtaining consent forms from clients scheduled to undergo surgery? a. A consent form is legal, even if the client is confused or sedated. b. The form that is signed is not a legal document and would not hold up in court. c. In emergency situations, the doctor may obtain consent over the telephone. d. the responsibility for securing informed consent from the client lies with the nurse.
In emergency situations, the doctor may obtain consent over the telephone.
The preoperative nurse has prepared a client for surgery and has been notified that the operating room staff is ready for the client. The client states, "My bladder feels full. I need to go to the bathroom!" Which action by the nurse is appropriate? a. Inform the operating room staff and assist the client to the bathroom. b. Inform the client that anesthesia will prevent the bladder from emptying during surgery. c. Insert a catheter into the bladder. d. Remind the client that bladder fullness is a common preoperative sensation.
Inform the operating room staff and assist the client to the bathroom. Explanation: Clients should empty the bowel and bladder before surgery. A urinary catheter is not indicated. The remaining statements are untrue.
The preoperative nurse is reviewing the chart of a client whose surgery is scheduled to begin in the next 15 minutes and notices that the consent form is not signed. The nurse contacts the surgeon who states, "We have already reviewed this procedure extensively, so ask the client to sign the consent form and I will verify it in the operating room." Which action by the nurse is appropriate? 1. Keep the client in the preoperative area and inform the surgeon that it is the health care provider's responsibility to obtain consent for surgery. 2. Ask the client to sign the consent; witness the signature and inform the operating room staff of the modification in the procedure. 3. Send the client to the operating room and inform the staff that the consent form needs to be signed. 4. Ask the operating room staff to delay the procedure until the consent is signed.
Keep the client in the preoperative area and inform the surgeon that it is the health care provider's responsibility to obtain consent for surgery. Explanation: If a consent form is not signed, the nurse should notify the surgeon. It is the health care provider's responsibility to obtain consent for surgery and anesthesia. Preoperative medications cannot be given until the consent form is signed. The client should not proceed to surgery without a signed consent form (unless it is an emergency).
A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding? a. Monitor the client closely and promote fluid intake. b. Contact the health care provider to come assess the client. c. Immediately administer a cleansing enema. d. Increase the rate of the client's intravenous infusion.
Monitor the client closely and promote fluid intake
Which nursing action will best promote pain management for a client in the postoperative phase? a. Breathing into a paper bag b. Performing relaxation techniques c. Dimming the lights d. Providing food and medication
Performing relaxation techniques
A nurse caring for clients in a PACU assesses a client who is displaying signs and symptoms of shock. What is the priority nursing intervention for this client? A. Place the client in the prone position. B. Do not administer any further medication. C. Remove extra coverings on the client to keep temperature down. D. Place the client in a flat position with legs elevated 45 degrees.
Place the client in a flat position with legs elevated 45 degrees. Explanation: Placing the client in a flat position with the legs elevated 45 degrees uses gravity to help direct blood to the vital organs. Removing extra coverings would cause the client's temperature to drop further during the blood loss occurring during shock. Medications will likely be ordered to help treat the shock. Prone position would be contraindicated.
The nurse is caring for a client in the postanesthesia care unit (PACU). The nurse uses what specific intervention to avoid complications for the cardiac body system. 1. Monitor urinary function 2. Use side lying position for lethargic clients 3. Provide verbal stimulation 4. Note response to stimulation
Provide verbal stimulation. Explanation: Providing verbal stimulation helps to expel anesthetic gases, facilitate an increase in consciousness, and subsequently increase blood pressure. Noting the response to stimulation is a means of assessing a client's neurologic status. Monitoring urinary function will help to determine renal function.
The nurse is teaching the client who recently experienced abdominal surgery to deep breathe and cough effectively. What observable action serves to best minimize pain that may result from the intervention? 1. Offering emotional support to help minimize concern of abdominal pain 2. Providing support to abdominal and accessory respiratory muscles 3. Exhaling through the mouth with lips pursed to slowly empty the lungs 4. Supporting the head and shoulders effectively to prevent muscle strain
Providing support to abdominal and accessory respiratory muscles
The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency? 1. Respiratory obstruction 2. Wound infection 3. Dehydration 4. Cardiac distress
Respiratory obstruction Explanation: Respiratory obstruction may occur as a result of secretion accumulation, obstruction by the tongue, laryngospasm (a sudden, violent contraction of the vocal cords), or laryngeal edema. Cardiac distress, wound infection, and dehydration are all possible postoperative complications, but respiratory obstruction is most common.
The nurse is caring for a client who had abdominal surgery yesterday and is reluctant to cough and perform deep breathing. Which strategy will most likely increase the client's willingness to cough and perform deep breathing? 1. Remind the client of the serious complications that can result from ineffective coughing and deep breathing. 2. Administer respiratory treatments to encourage coughing. 3. Assist the client to a side-lying position to cough. 4. Teach the client how to splint the abdomen while coughing.
Teach the client how to splint the abdomen while coughing.
The nurse is caring for a confused older adult client who requires surgery for a broken hip. What steps does the nurse take to determine if the client has a durable power of attorney for health care and how to contact that person? a. Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact. b. Explain the client's need for hip surgery to visitors and ask them for information about a durable power of attorney for health care. c. Look on the chart for a living will if a durable power of attorney for health care cannot be located. d. Allow the surgeon to handle the issue as part of his or her legal responsibility for explaining the surgical procedure and obtaining the appropriate signature on the consent form.
Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact.
Which methods would the nurse anesthetist use when administering regional anesthesia to surgical clients? Select all that apply. A. Oral route B. Inhalation C. Spinal block D. Epidural block E. Intravenous F. Nerve block
Spinal block nerve block epidural block Explanation: Regional anesthesia occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. Regional anesthesia includes spinal blocks, nerve blocks, and epidural blocks. Inhalation and intravenous administration of anesthesia are associated with general anesthesia. Anesthesia is not administered via the oral route.
@A nurse is reviewing postoperative protocols with the client, including an explanation and a demonstration of how to use an incentive spirometer. How does the nurse know that the teaching on the use of the incentive spirometer was effective? 1. The client repeats the explanation and instructions in one's own words to demonstrate understanding. 2. After taking a deep breath, the client demonstrates how to exhale into the mouthpiece while in the semi-Fowler position. 3. The client explains the procedure should be completed first thing in the morning before rising from the bed. 4. The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed.
The client completes a return demonstration and inhales with lips tightly sealed around the mouthpiece while sitting upright in bed.
A nurse is caring for a postoperative client and preparing to apply a pneumatic compression device. How does the nurse explain the device to the client prior to application? 1. The device fills with air and squeezes the arms, which increases blood flow through the veins of the arms and helps to prevent blood clots. 2. The device fills with air and squeezes the legs which increase blood flow through the veins of the legs and should be worn in bed and while ambulating to help prevent blood clots. 3. The device fills with air supporting the legs during ambulation so blood flow will not pool in the legs and feet, thus preventing blood clots, and squeezes the legs, which increases blood flow through the veins of the legs. 4. The device fills with air and squeezes the legs, which increases blood flow through the veins of the legs and helps to prevent blood clots.
The device fills with air and squeezes the legs, which increases blood flow through the veins of the legs and helps to prevent blood clots. Explanation: A pneumatic compression device promotes the circulation of venous blood and relocation of excess fluid into the lymphatic vessels. The device is used on the legs and is worn while the client is in bed.
Which factor is most important in the nurse's decision on assessment data, outcomes, and the monitoring needs of a client in preparing for surgery? A. Type of anesthesia B. Age of client C. Type of surgery D. Client's support system
Type of surgery Explanation: Although all of these factors would need to be taken into account in planning care for a client going to surgery, the type of surgery is the most important influence on what type of care the client will require after surgery. Anesthesia and age play a role in monitoring needs postoperatively. The client needs an adequate support system when leaving the hospital, but the type of surgery influences the client's needs overall.
The nurse is developing a plan of care for a client who had a splenectomy. The outcome is prevention of surgical site infection. Which interventions should be included in the client's plan of care? Select all that apply. A. Reposition client frequently. B. Use asepsis with dressing change. C. Monitor white blood cell count. D. Monitor bowel sounds. E. Assess vital signs. F. Maintain hydration.
Use asepsis with dressing change. Monitor white blood cell count. Assess vital signs. Maintain hydration. Explanation: The client with an outcome of prevention of surgical site infection needs adequate nutrition and fluid for healing. The client needs to be monitored for signs of infection with vital signs, white blood cell count, and surgical site. Asepsis needs to be used with dressing changes. Interventions for other potential complications include monitoring bowel sounds (which helps with recognition of peristalsis return) and repositioning the client frequently, which will help with prevention of atelectasis.
Which client in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse? A. a 26-year-old client who is exhibiting a crowing sound B. an 80-year-old client who is disoriented to place and time C. a 30-year-old client who is drowsy and reporting pain D. a 6-year-old client who is crying for a parent to visit
a 26-year-old client who is exhibiting a crowing sound Explanation: A client with a crowing sound is exhibiting stridor, which is an indication of an airway obstruction and can be a respiratory emergency. This client needs immediate attention. The client with disorientation needs to be frequently reoriented and observed for safety reasons but is not a priority over respiratory distress. The client who needs pain medication or the pediatric client requesting a parent are also not priority over a client in respiratory distress.
When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of: a. the effects of anesthesia. b. the normal return of reflexes. c. a partial airway obstruction. d. the type of surgery.
a partial airway obstruction. Explanation: Loud, irregular respirations may indicate obstruction of the airway, possibly from emesis, accumulated secretions, or client positioning that allows the tongue to fall to the back of the throat.
The nurse has delegated to the unlicensed assistive personnel (UAP) the application of antiembolism stockings to a client who had an endarterectomy earlier in the day. Which UAP action requires the nurse to immediately intervene? 1. cleanses hands with alcohol-based hand rub 2. measures calf circumference 3. massages legs prior to application 4. elevates the legs 15 minutes after applying stockings
massages legs prior to application
An operating room nurse is bringing a client to the nurse in the postanesthesia care unit (PACU). Which information would the operating room nurse provide during a hand-off report? Select all that apply. A. drains inserted in surgery B. all personnel present in operating room C. medications given in operating room D. performance of time-out before surgery E. length of surgery
medications given in operating room length of surgery drains inserted in surgery Explanation: The operating room nurse should give a hand-off report when bringing the client from the operating room and must include several critical pieces of information: medications given, the length of surgery, and any drains inserted. Other data that would be important include presenting condition of the client and any events that occurred during surgery. All personnel present in the operating room would not be an important detail to share; however, this is documented on the operating room record, as well as the time-out that was performed.
A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice? Select all that apply. 1. administering inhalation anesthetics 2. positioning the client on the operating table 3. monitoring the client's vital signs 4. counting sponges before and after surgery 5. administering regional nerve blocks
positioning the client on the operating table counting sponges before and after surgery monitoring the client's vital signs
A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice? Select all that apply. A. administering regional nerve blocks B. positioning the client on the operating table C. administering inhalation anesthetics D. counting sponges before and after surgery E. monitoring the client's vital signs
positioning the client on the operating table counting sponges before and after surgery monitoring the client's vital signs Explanation: The RN's role is a supportive one for the client, monitoring vital signs and positioning the client on the operating room table. The RN also helps maintain safety by counting sponges and instruments that may have been used during the surgery. The RN is unable to administer anesthetics, such as inhalation agents or regional nerve blocks, without an advanced practice degree.
As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site? a. operative site marking b. preoperative checklist c. procedural pause (time-out) d. informed consent
procedural pause (time-out) Explanation: The procedural pause (time-out) must be done prior to any procedure to ensure client safety and to verify the client identity, staff roles, and procedure being performed.
