Ch. 9

A post-op client has respiratory depression after receiving morphine for pain. Which medication and dose does the nurse prepare to administer? a. Flumazenil 0.2 to 1 mg b. Flumazenil 2 to 10 mg c. Naloxone 0.4 to 2 mg d. Naloxone 4 to 20 mg

c. Naloxone 0.4 to 2 mg Rationale: Flumazenil is a benzodiazepine antagonist.

A post-op client has just been admitted to the PACU. What assessment by the PACU nurse takes priority? a. Airway b. Bleeding c. Breathing d. Cardiac rhythm

a. Airway

A clinic nurse is teaching a client prior to surgery. The client dose not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again.

a. Assess the client for anxiety. Rationale: Anxiety can interfere with learning, coping, and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious.

The perioperative nurse manager and the post-op unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the nurse managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices.

a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. Rationale: The SCIP project contains core measures to reduce surgical complications. Examples of focus included administration of prophylactic antibiotics, correct hair removal processes, the timing of discontinuation of urinary catheterization after surgery, and venous thromboembolism prophylaxis. These practices are now standard in surgical care.

A nurse assesses a client in the pre-op holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best? a. Consult the primary health care provider about a dietitian referral. b. Document the findings thoroughly in the client's chart. c. Encourage the client to eat more after recovering from surgery. d. Refer the client to Meals on Wheels after discharge.

a. Consult the primary health care provider about a dietitian referral.

The PACU nurse is caring for an older adult client following a lengthy surgery. The client's pulse is 48 bpm which is 20 beats/min lower than the pre-op baseline. What assessment does the nurse take next? a. Temperature b. Level of consciousness c. Blood pressure d. Rate of IV infusion

a. Temperature Rationale: Bradycardia in the immediate postoperative client can indicate anesthesia effect or hypothermia. Older adults are at higher risk for hypothermia because of age-related changes in temperature regulation, decreased body fat, or prolonged exposure to cool environments, such as an OR suite. The nurse would first assess the client's temperature and take measures to correct any existing hypothermia.

A nurse is giving a client instructions for showering the night before surgery. What instruction is most appropriate? a. "After you wash the surgical site, shave that area with your own razor." b. "Use the prescribed solution and wash the area where you will have surgery very thoroughly." c. "Use a washcloth to wash the surgical site; do not take a full shower or bath." d. "Use warm water and scrub the surgical area vigorously."

b. "Use the prescribed solution and wash the area where you will have surgery very thoroughly." Rationale: One or two days before the scheduled surgery, the surgeon may ask the patient to shower using an antiseptic solution, often chlorhexidine gluconate. This cleaning reduces contamination of the surgical field and the number of organisms at the site. Hair removal if needed is done in the operating suite using evidence-based practices such as clipping or a depilatory agent. While the client should wash the area thoroughly, vigorous scrubbing might scrape the skin, increasing the risk of infection.

A post-op client vomited. After cleaning and comforting the client, which action is most important? a. Allow the client to rest. b. Auscultate lung sounds. c. Document the episode. d. Encourage the client to eat dry toast.

b. Auscultate lung sounds. Rationale: Vomiting after surgery has several complications, including aspiration. The nurse would listen to the client's lung sounds. The client should be allowed to rest after an assessment. Documenting is important, but the nurse needs to be able to document fully, including an assessment. The client should not eat until nausea has subsided.

A nurse on the postsurgical inpatient unit is observing a client perform leg exercises. What action by the client indicates a need for further instructions? a. Client states "This will help prevent blood clots in my legs." b. Bends both knees, pushes against the bed until calf and thigh muscles contract. c. Dorsiflexes and plantar flexes each foot several times an hour. d. Makes several clockwise then counterclockwise ankle circles with each foot.

b. Bends both knees, pushes against the bed until calf and thigh muscles contract. Rationale: The client should perform this leg exercise one leg at a time.

A client has a great deal of pain when coughing and deep breathing following abdominal surgery despite having pain meds. What action by the nurse is best? a. Call the primary health care provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallower breaths. d. Tell the client that a little pain is expected.

b. Demonstrate how to splint the incision. Rationale: Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should know that some pain is normal and expected after surgery, but that answer alone does not provide any interventions to help the client.

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the primary health care provider. c. Have the client sign the consent, and then call the primary health care provider. d. Remind the client of what teaching the primary health care provider has done.

b. Do not have the client sign the consent and call the primary health care provider.

A post-op patient has an abdominal surgery drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met? a. Drainage from the surgical site is 30 mL less than yesterday. b. There is no redness, warmth, or drainage at the insertion site. c. The client reports adequate pain control with medications. d. Urine is clear yellow and urine output is greater than 40 mL/hr.

b. There is no redness, warmth, or drainage at the insertion site. Rationale: The skin is the body's first line of defense against infection and a drain of any type increases this risk. The priority client problem related to a surgical drain is the potential for infection. An insertion site that is free of redness, warmth, and drainage indicates that goals for this client problem are being met. The other assessments are normal, but not related to the drain.

The post-anesthesia care unit (PACU) charge nurse notes vital signs on four post-op clients. Which client would the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96° F (35.6° C)

c. Client with a respiratory rate of 6 breaths/min Rationale: The respiratory rate is the most important vital sign for any client who has undergone general anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low and indicates respiratory depression.

A client had a surgical procedure with spinal anesthesia. The client's BP was 122/78 mm Hg 30 minutes ago and is now 138/60 and the client reports nausea. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Notify the primary health care provider. d. Nothing; this is expected.

c. Notify the primary health care provider. Rationale: A widening pulse pressure (44 to 78 mm Hg) and nausea may indicate autonomic blockade, a complication of spinal anesthesia causing widespread vasodilation. The nurse would notify the primary health care provider. The Rapid Response Team is not yet warranted; the nurse would not increase the IV rate without a prescription.

A nurse works on the post-op floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the heath care team for post-discharge care? a. Married young adult who is the primary caregiver for children. b. Middle-age client who is post-knee replacement, and needs physical therapy. c. Older adult who lives alone at home despite some memory loss. d. Young client who lives alone, and has family and friends nearby.

c. Older adult who lives alone at home despite some memory loss. Rationale: The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen.

A pre-op nurse is reviewing morning labs on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL (106.1 umol/L) b. Hemoglobin: 14.8 mg/dL (148 mmol/L) c. Potassium: 2.9 mEq/L (2.9 mmol/L) d. Sodium: 134 mEq/L (134 mmol/L)

c. Potassium: 2.9 mEq/L (2.9 mmol/L) Rationale: The potassium level is critically low and can affect cardiac and respiratory status.

An RN is watching a new nurse change a dressing and perform care around a Penrose drain. What action by the new nurse warrants an intervention? a. Cleaning around the drain per agency protocol b. Placing a new sterile gauze under the drain c. Securing the drain's safety pin to the sheets d. Using sterile technique to empty the drain

c. Securing the drain's safety pin to the sheets Rationale: The safety pin that prevents the drain from slipping back into the client's body would not be pinned to the client's bedding. Pinning it to the sheets will cause it to pull out when the client turns.

A post-op nurse is caring for a client who received a neuromuscular blocking agent during surgery. On assessment the nurse notes the client has weak hand grasps. What assessment does the nurse conduct next? a. Ability to raise head off the bed b. Blood pressure and pulse c. Signs of oxygenation d. Level of orientation

c. Signs of oxygenation Rationale: When neuromuscular blocking agents are retained, muscle weakness could affect the diaphragm and impair gas exchange. Symptoms include the inability to maintain a head lift, weak hand grasps, and an abdominal breathing pattern. Since the client has weak hand grasps, the nurse would assess for signs of systemic oxygenation next. The nurse would assess head lift ability, but this does not take priority over oxygenation. Blood pressure, pulse, and level of orientation are all important in the postoperative period, but oxygenation would come first.

The post-op nurse is caring for a client who reports feeling 'something popped' after vomiting. What action by the nurse is best? a. Administer an antiemetic medication. b. Call the primary health care provider. c. Instruct client to avoid coughing. d. Gather sterile nonadhesive dressings.

d. Gather sterile nonadhesive dressings. Rationale: The client may have a wound dehiscence. The nurse would gather needed supplies and assess the wound under the dressing. If the incision has dehisced, the nurse would cover it with a sterile nonadherent dressing or saline-moistened gauze dressing then call the primary health care provider. The client may need an antiemetic, but this is not the most important action at this time.

A client has arrived in the inpatient post-op unit. What action by the inpatient nurse takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report

d. Participating in hand-off report Rationale: Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The inpatient nurse and postanesthesia care nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the client is warm is a lower priority.

A pre-op nurse is assessing a client prior to surgery. Which info would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements

d. Use of multiple herbs and supplements