Chapter 14, 15, 16 Care of The Procedural Patient PREP U
The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required? "I need to keep my follow-up appointment with the physician." "My incision should become less red and tender." "I can resume my usual activities as soon as I get home." "I should call my physician if I develop a fever."
"I can resume my usual activities as soon as I get home."
Which statement by the client indicates further teaching about epidural anesthesia is necessary? "I will be able to hear the surgeon during the surgery." "I will lose the ability to move my legs." "A needle will deliver the anesthetic into the area around my spinal cord." "I will become unconscious."
"I will become unconscious."
Which nursing statement would best ease a client's anxiety before an emergency operative procedure? "We will keep your family informed of your progress." "It is best to take deep breaths and relax before the procedure." "Let me explain to you what will happen next." "You will be just fine; the operating room nurses will take good care of you."
"Let me explain to you what will happen next."
Which question is most important for the nurse to ask the client when obtaining the preoperative admission history? "Who is here with you?" "Did you bring a copy of your health care power of attorney?" "Did you bring any valuables with you?" "When is the last time you ate or drank?"
"When is the last time you ate or drank?"
The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room? 5 7 6 4
7
A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery? 2 weeks 7 to 10 days 4 weeks 2 to 3 days
7 to 10 days
What is the blood glucose level goal for a diabetic client who will be having a surgical procedure? 250 to 300 mg/dL 80 to 110 mg/dL 300 to 350 mg/dL 150 to 240 mg/dL
80 to 110 mg/dL
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? >200 mL Between 75 and 100 mL Between 100 and 200 mL <30 mL
<30 mL
A patient with renal failure is scheduled for a surgical procedure. When would surgery be contraindicated for this patient due to laboratory results? A serum creatinine level of 0.9 mg/dL A urine creatinine level of 1.2 mg/dL A blood urea nitrogen level of 42 mg/dL A creatine kinase level of 120 U/L
A blood urea nitrogen level of 42 mg/dL
The nurse expects informed consent to be obtained for insertion of: An indwelling urinary catheter A nasogastric tube A gastrostomy tube An intravenous catheter
A gastrostomy tube
The nurse assesses an older adult patient who complains of dimmed vision. What does this alert the nurse to plan for? A safe environment Probable cataract extractions Referral to an ophthalmologist Restrictions of the patient's unassisted mobility activities
A safe environment
What measurement should the nurse report to the physician in the immediate postoperative period? A systolic blood pressure lower than 90 mm Hg Respirations between 20 and 25 breaths/min A temperature reading between 97°F and 98°F A hemoglobin of 13.6
A systolic blood pressure lower than 90 mm Hg
Several of the clients at the clinic are preparing to have surgery within the next 2 weeks. They are completing preoperative paperwork today with their visit. What are some of the reasons that people might need to have surgery? Select all that apply. A. Diagnostic B. Normative C. Palliative D. Cosmetic E. Causative
A. Diagnostic C. Palliative D. Cosmetic
An instructor is developing for a class a teaching plan about agents used for intravenous (IV) anesthesia. Which of the following would the instructor include in this plan about these agents and this type of anesthesia? Select all that apply. A. Need for little equipment B. Associated with more nausea C. Long duration of action D. More pleasant onset of anesthesia E. Ease of administration
A. Need for little equipment D. More pleasant onset of anesthesia E. Ease of administration
An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults? A. Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients. B. Aging processes reduce the chances that surgery will be successful for these clients. C. All older people face similar risks when undergoing surgeries. D. Neurologic and musculoskeletal complications are the leading cause of postoperative morbidity and mortality for older adults.
A. Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients.
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. A. age B. physical condition C. ethnicity D. nutritional status E. health status F. gender
A. age B. physical condition D. nutritional status E. health status
A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take? Discuss the risk for infection caused by wearing the ring. Remove the ring once the client is sedated. Allow the client to wear the ring and cover it with tape. Notify the surgeon to cancel surgery.
Allow the client to wear the ring and cover it with tape.
A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take? Discuss the risk for infection caused by wearing the ring. Remove the ring once the client is sedated. Notify the surgeon to cancel surgery. Allow the client to wear the ring and cover it with tape.
Allow the client to wear the ring and cover it with tape.
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? Document the findings and reassess in 24 hours. Assess for signs and symptoms of fluid volume deficit. Discontinue the nasogastric tube suctioning. Assess for edema.
Assess for signs and symptoms of fluid volume deficit.
When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O2 saturation monitor despite the client's breathing appearing normal, what action should the nurse take first? Notify the physician. Document the findings. Assess the client's heart rhythm and nail beds. Apply oxygen.
Assess the client's heart rhythm and nail beds.
The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply. A. Afebrile B. Crackles C. Tachypnea D. Chills E. Wheezes
B. Crackles C. Tachypnea D. Chills
A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize? A. A distance of 3 feet must be maintained when moving around a sterile field. B. The edges of a sterile package, once opened, are considered unsterile. C. Circulating nurses may come in contact with the sterile field without contaminating it. D. If a tear occurs in a sterile drape, a new sterile drape is applied on top of it.
B. The edges of a sterile package, once opened, are considered unsterile.
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. A. ethnicity B. health status C. physical condition D. age E. gender F. nutritional status
B. health status C. physical condition D. age F. nutritional status
The nurse is caring for a client who has just arrived for surgery. Which assessment finding indicates to the nurse that the client may be experiencing dehydration because of taking nothing by mouth after midnight for the surgery? Respiratory rate 20 breaths per minute Pulse 88 beats per minute Blood pressure 80/50 mm Hg Urine output 60 mL/hr
Blood pressure 80/50 mm Hg
The nurse is caring for a client who has just arrived for surgery. Which assessment finding indicates to the nurse that the client may be experiencing dehydration because of taking nothing by mouth after midnight for the surgery? Urine output 60 mL/hr Blood pressure 80/50 mm Hg Respiratory rate 20 breaths per minute Pulse 88 beats per minute
Blood pressure 80/50 mm Hg
A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented? Registered nurse first assistant Circulating nurse Scrub nurse Surgeon
Circulating nurse
The OR personnel responsible for maintaining the safety of the client and the surgical environment is the: Scrub nurse Anesthesiologist Circulating nurse Surgeon
Circulating nurse
The OR personnel responsible for maintaining the safety of the client and the surgical environment is the: Scrub nurse Surgeon Anesthesiologist Circulating nurse
Circulating nurse
What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities? Passing instruments Setting up the sterile tables Coordinating the surgical team Assisting the surgeon
Coordinating the surgical team
What is the priority action by the scrub nurse when the surgeon begins to close the surgical wound? Label the tissue specimen. Prepare the necessary sutures. Hand equipment to the surgeon as needed. Count the sponges.
Count the sponges.
The nurse is reviewing a list of surgical clients. Which clients would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period? Select all that apply. A. The 43-year-old client with past surgeries. B. The 25-year-old client who occasionally smoked marijuana in high school. C. The 47-year-old client who stopped smoking 4 years ago. D. The 27-year-old client with non-insulin dependent diabetes. E. The 70-year-old client who takes no routine medications.
D. The 27-year-old client with non-insulin dependent diabetes. E. The 70-year-old client who takes no routine medications.
What medication should the nurse prepare to administer in the event the client has malignant hyperthermia? Dantrolene sodium Naloxone Thiopental sodium Fentanyl citrate
Dantrolene sodium
A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following? Decreased lean tissue mass Increased anxiety level Increased tissue elasticity Impaired thermoregulation
Decreased lean tissue mass
What action by the nurse best encompasses the preoperative phase? Educating clients on signs and symptoms of infection Documenting the application of sequential compression devices (SCDs) Monitoring vital signs every 15 minutes Shaving the client using a straight razor
Educating clients on signs and symptoms of infection
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 a smaller lung capacity than younger clients. Elderly clients have less physiologic reserve than younger clients. Elderly clients require higher medication doses than younger clients. Elderly clients have more sophisticated coping skills than younger clients.
Elderly clients have less physiologic reserve than younger clients.
A nurse asks a client who had abdominal surgery 1 day ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene? Apply moist heat to the client's abdomen. Encourage the client to ambulate as soon as possible after surgery. Notify the physician. Administer a tap water enema.
Encourage the client to ambulate as soon as possible after surgery.
When integrating the principles for maintaining surgical asepsis during surgery, which of the following would be most appropriate? Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff Allowing circulating nurses to contact sterile equipment Positioning the sterile drape on a table from back to front Considering the gown sterile from mid-thigh to neck
Ensuring gown sleeves remain sterile 2 inches above the elbow to cuff
Which term refers to the protrusion of abdominal organs through the surgical incision? Evisceration
Evisceration
A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for? Hypertension Hypoglycemia Glucosuria Dehydration
Hypoglycemia
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? IV II I III
II
Which stage of surgical anesthesia is also known as excitement? III II IV I
II
Which stage of surgical anesthesia is also known as excitement? IV I III II
II
Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis? Ineffective thermoregulation Decreased cardiac output Acute incisional pain Ineffective airway clearance
Ineffective thermoregulation
An obese client is undergoing abdominal surgery. During the procedure a surgical resident states, "The amount of fat we have to cut through is disgusting." What is the best response by the nurse? Report the resident to the attending surgeon. Discuss concerns regarding the comments with the charge nurse. Inform the resident that all communication needs to remain professional. Ignore the comment.
Inform the resident that all communication needs to remain professional.
A client asks about the purpose of withholding food and fluid before surgery. Which response by the nurse is appropriate? It decreases urine output so that a catheter will not be needed. It prevents overhydration and hypertension. It prevents aspiration and respiratory complications. It decreases the risk of elevated blood sugar and slow wound healing.
It prevents aspiration and respiratory complications.
As a circulating nurse, what task are you solely responsible for? Estimating the client's blood loss. Handing instruments to the surgeon. Counting sponges and needles. Keeping records.
Keeping records.
A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention? Scrub top and drawstring are tucked into pants. Mask is placed over nose and extends to bottom lip. Shoe covers are used. Hair is pulled back and covered by a cap.
Mask is placed over nose and extends to bottom lip.
A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention? Shoe covers are used. Scrub top and drawstring are tucked into pants. Mask is placed over nose and extends to bottom lip. Hair is pulled back and covered by a cap.
Mask is placed over nose and extends to bottom lip.
The nurse has medicated a postoperative client who reported nausea. Which medication would the nurse document as having been given? Warfarin Prednisone Ondansetron Propofol
Ondansetron
Which is a classic sign of hypovolemic shock? Dilute urine Bradypnea High blood pressure Pallor
Pallor
The nurse positions the client in the lithotomy position in preparation for Perineal surgery Pelvic surgery Renal surgery Abdominal surgery
Perineal surgery
Which health care profession has the ultimate responsibility to provide appropriate information regarding a nonemergent surgery? Case manager Nurse Certified nurse's aide Physician
Physician
A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem? Pieces of vomitus Copious red blood in the sputum Pink color Foul smell
Pink color
The scrub nurse is responsible for: Preparing the sterile instruments for the surgical procedure Calling the "time-out" to verify the surgical site and procedure Monitoring the operating-room personnel for breaks in sterile technique Monitoring the administration of the anesthesia
Preparing the sterile instruments for the surgical procedure
The nurse is setting up a sterile field in the operating room (OR). Which action is correctly performed by the nurse? Educate other nurses that sterile field is 4 inches from the edge. Place sterile items at least 2 inches from the edge. Remind others sterile field is 12 inches from the edge. Place sterile items at least 6 inches from the edge.
Remind others sterile field is 12 inches from the edge.
A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention? Dangle at the bedside. Report early calf pain. Rely on the IV fluids for hydration. Take off the pneumatic compression devices for sleeping.
Report early calf pain.
A 55-year-old patient arrives at the operating room. The nurse is reviewing the medical record and notes that the patient has a history of osteoporosis in her lower back and hips. The patient is scheduled to receive epidural anesthesia. Which of the following nursing diagnoses would be a priority for this patient? Risk for perioperative positioning injury related to operative position Disturbed sensory perception related to sedation Anxiety related to the surgical experience Risk for injury related to effects of anesthetic agents
Risk for perioperative positioning injury related to operative position
Which of the following techniques least exhibits surgical asepsis? Adding only sterile items to a sterile field Keeping sterile gloved hands above the waist Suctioning the nasopharyngeal cavity of a client Placing the sterile field at least one foot away from personnel
Suctioning the nasopharyngeal cavity of a client
Which of the following techniques least exhibits surgical asepsis? Adding only sterile items to a sterile field Suctioning the nasopharyngeal cavity of a client Keeping sterile gloved hands above the waist Placing the sterile field at least one foot away from personnel
Suctioning the nasopharyngeal cavity of a client
A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member? Anesthetist Surgeon Circulating nurse Scrub nurse
Surgeon
Nursing assessment findings reveal that the client is afraid of dying during the surgical procedure. Which surgical team member would be most helpful in addressing the client's concern? Circulating nurse Surgeon Registered nurse first assistant Anesthesiologist
Surgeon
Which clinical manifestation is often the earliest sign of malignant hyperthermia? Tachycardia (heart rate >150 beats per minute) Oliguria Hypotension Elevated temperature
Tachycardia (heart rate >150 beats per minute)
The nurse is caring for a client during an intraoperative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately? Pulse rate of 110 beats/min Blood pressure of 104/62 mm Hg Temperature of 102.5°F (39°C) Respiratory rate of 18 breaths/min
Temperature of 102.5°F (39°C)
The nurse is caring for a client during an intraoperative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately? Temperature of 102.5°F (39°C) Respiratory rate of 18 breaths/min Blood pressure of 104/62 mm Hg Pulse rate of 110 beats/min
Temperature of 102.5°F (39°C)
Which client would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period? The 72-year-old client who takes no routine medications. The 47-year-old client who stopped smoking 2 years ago. The 35-year-old client with non-insulin dependent diabetes. The 28-year-old client who occasionally smoked marijuana in high school.
The 35-year-old client with non-insulin dependent diabetes.
A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition? The client is displaying early signs of shock. The client is showing signs of a medication reaction. The client is displaying late signs of shock. The client is showing signs of an anesthesia reaction.
The client is displaying early signs of shock.
A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition? The client is showing signs of a medication reaction. The client is showing signs of an anesthesia reaction. The client is displaying late signs of shock. The client is displaying early signs of shock.
The client is displaying early signs of shock.
A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia? To prevent seizures To prevent confusion To prevent cerebrospinal fluid (CSF) leakage To prevent cardiac arrhythmias
To prevent cerebrospinal fluid (CSF) leakage
When a client with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the client may show signs of alcohol withdrawal delirium during which time period? Upon awakening in the postanesthesia care unit Immediately upon admission Up to 24 hours after alcohol withdrawal Up to 72 hours after alcohol withdrawal
Up to 72 hours after alcohol withdrawal
The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what? Urinary infection Calculus formation Urine retention Requirement of intermittent catheterization
Urine retention
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? Use chest breathing. Use diaphragmatic breathing. Make inhalation longer than exhalation. Exhale through an open mouth.
Use diaphragmatic breathing.
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? Use diaphragmatic breathing. Make inhalation longer than exhalation. Use chest breathing. Exhale through an open mouth.
Use diaphragmatic breathing.
Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective? Bowel sounds present and active; denies nausea and vomiting Vital signs within normal limits; absence of chills and cough Alert and oriented; peripheral pulses present and strong Bladder non—distended; Foley catheter draining clear, yellow urine
Vital signs within normal limits; absence of chills and cough
At what point does the preoperative period end? When the decision is made to proceed with surgery When the client signs the consent form When the client is admitted to the PACU When the client is transferred onto the operating table
When the client is transferred onto the operating table
The nurse recognizes that the older adult is at risk for surgical complications due to: decreased adipose tissue increased skeletal mass increased cardiac output decreased renal function
decreased renal function
A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client? resumes usual urinary elimination pattern. exhibits wound healing without complications. experiences pain within tolerable limits. maintains adequate fluid status.
experiences pain within tolerable limits.
A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: third intention. first intention. fourth intention. second intention.
first intention.
A patient is to undergo surgery on his kidney. The patient would be placed in which position for the surgery?
lateral position (side)
The nurse recognizes the client has reached stage III of general anesthesia when the client: lies quietly on the table displays agitation due to noise exhibits shallow respirations and a weak, thready pulse shouts, talks, or sings
lies quietly on the table
The nurse understands that the purpose of the "time out" is to: clarify the roles of the OR personnel. identify the client's allergies. verify all necessary supplies are available. maintain the safety of the client.
maintain the safety of the client.
The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which laboratory value would be of greatest concern to the nurse? potassium 6.2 mEq/L white blood cell count 7.2 cells/mm sodium 138 mEq/L calcium 9.8 mg/dL
potassium 6.2 mEq/L
An example of a curative surgical procedure is: placement of gastrostomy tube. a face-lift. a biopsy. tumor excision.
tumor excision.
A nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which post-surgical risk factor would decrease if the surgical client maintained strict blood glycemic control? nutrient deficiencies liver dysfunction respiratory complications wound healing
wound healing
A nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which post-surgical risk factor would decrease if the surgical client maintained strict blood glycemic control? wound healing nutrient deficiencies respiratory complications liver dysfunction
wound healing
The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed? A. "The nurse will explain the details of the surgery before I sign a consent." B. "If I do not follow the instructions, my surgery could be cancelled." C. "My medical records will be sent to the ambulatory care center prior to my surgery." D. "The physician will update my family after the procedure and provide specific discharge instructions."
A. "The nurse will explain the details of the surgery before I sign a consent."
Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency? Thyroid Adrenal Parathyroid Pituitary
Adrenal
A client asks the nurse about possible ill effects from general anesthesia. What is the best response by the nurse? A. "Clients can experience pain and loss of consciousness." B. "Some possible negative effects include difficulty waking up and slow heart rate." C. "Few negative effects occur with general anesthesia." D. "Amnesia and analgesia are some of the negative effects of anesthesia."
B. "Some possible negative effects include difficulty waking up and slow heart rate."
A client is transferred from the postanesthesia care unit (PACU) to an inpatient care unit. What will the nurse assess first? Surgical site Level of consciousness Breathing Pain level
Breathing
A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action? Prepare to insert a nasogastric tube. Call the health care provider. Re-attempt to auscultate bowel sounds. Prepare to administer a stool softener.
Call the health care provider.
A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action? Re-attempt to auscultate bowel sounds. Prepare to insert a nasogastric tube. Prepare to administer a stool softener. Call the health care provider.
Call the health care provider.
The client is undergoing a surgical procedure that is expected to last several hours. Which nursing diagnosis is most related to the duration of the procedure? A. Risk of latex allergy response related to possible exposure in the OR environment B. Disturbed sensory perception related to the effects of general anesthesia C. Anxiety related to ineffective coping with surgical concerns D. Risk for perioperative positioning injury related to positioning in the OR
D. Risk for perioperative positioning injury related to positioning in the OR
A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following? Decreased lean tissue mass Increased tissue elasticity Increased anxiety level Impaired thermoregulation
Decreased lean tissue mass
The nurse is monitoring a presurgical patient for electrolyte imbalance. Which classification of medication may cause electrolyte imbalance? Diuretics Corticosteroids Insulin Phenothiazines
Diuretics
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? Fourth intention Third intention First intention Second intention
First intention
A client has been administered ketamine for moderate sedation. What is the priority nursing intervention? Frequently monitoring vital signs Administering oxygen Assessing for hallucinations Providing a quiet dark room for recovery
Frequently monitoring vital signs
The nurse is aware that loss of consciousness occurs with which type of anesthesia? Moderate sedation General Local Regional
General
Nursing students are reviewing information about agents used for anesthesia. The students demonstrate understanding when they identify which of the following as an inhalation anesthetic? Succinylcholine Halothane Fentanyl Propofol
Halothane
A nurse suspects malignant hyperthermia in a patient who underwent surgery approximately 18 hours ago. Which of the following would the nurse identify as a late, ominous sign? Muscle rigidity Oliguria Tachycardia Rapid rise in body temperature
Rapid rise in body temperature
You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult? Detailed medication history Respiratory depressive effects Convalescent period Tolerance
Tolerance
When a client with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the client may show signs of alcohol withdrawal delirium during which time period? Immediately upon admission Upon awakening in the postanesthesia care unit Up to 72 hours after alcohol withdrawal Up to 24 hours after alcohol withdrawal
Up to 72 hours after alcohol withdrawal
The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing? Hyperthermia Wound infection Uncontrolled pain Atelectasis
Wound infection
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? anticoagulants insulin diuretics corticosteroids
diuretics
During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication? hypothermia fluid volume excess infection malignant hyperthermia
malignant hyperthermia
A client is to receive general anesthesia with sevoflurane. What does the nurse anticipate would be given with the inhaled anesthesia? lidocaine rocuronium alfentanil oxygen
oxygen
The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed? A. "The nurse will explain the details of the surgery before I sign a consent." B. "My medical records will be sent to the ambulatory care center prior to my surgery." C. "If I do not follow the instructions, my surgery could be cancelled." D. "The physician will update my family after the procedure and provide specific discharge instructions."
A. "The nurse will explain the details of the surgery before I sign a consent."
A 78-year-old client is undergoing surgery to repair a right hip fracture. What nursing action is appropriate during the intraoperative phase? A. Appropriately position the client using adequate padding and support. B. Maintain an operating room temperature of 18°C to prevent hypothermia. C. Withhold pain medication due to decreased renal function. D. Discuss with the anesthesiologist the need for higher doses of anesthetic agents.
A. Appropriately position the client using adequate padding and support.
The nurse is preparing the medical record for a client scheduled for surgery. Which item(s) will the nurse ensure are in the history and physical? Select all that apply. A. History of present illness B. Home care needs C. Current medications D. Surgical history E. Allergies F. Medical history
A. History of present illness C. Current medications D. Surgical history E. Allergies F. Medical history
The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed? A. "My medical records will be sent to the ambulatory care center prior to my surgery." B. "The physician will update my family after the procedure and provide specific discharge instructions." C. "If I do not follow the instructions, my surgery could be cancelled." D. "The nurse will explain the details of the surgery before I sign a consent."
D. "The nurse will explain the details of the surgery before I sign a consent."
The nurse would intervene when making which of the following observations in the surgical environment? A. A staff member fails to wear a mask in the semirestricted zone. B. A staff member is wearing a surgical mask and shoe covers in the restricted zone. C. A staff member is wearing scrub clothes in the semirestricted zone. D. A staff member dressed in street clothes enters the semirestricted zone.
D. A staff member dressed in street clothes enters the semirestricted zone.
You are caring for a client preoperatively who is very anxious and fearful about their surgery. You know that this client's anxiety can cause problems with the surgical experience. What type of problems can this client have because of their anxiety and fear? A. Anxious clients need psychological counseling after surgery. B. Anxiety and fear can affect a client positively during and after surgery. C. Anxiety and fear increases the need for anesthesia and postoperative medications. D. Anxious clients have a poor response to surgery and are prone to complications.
D. Anxious clients have a poor response to surgery and are prone to complications.
A patient has a wound that has hemorrhaged. What does the nurse understand is the cause of the patient's increased risk of infection? Reduced amounts of oxygen and nutrients are available Retrograde bacterial contamination may occur Dead space and dead cells provide a culture medium The tissue becomes less resilient
Dead space and dead cells provide a culture medium
A client scheduled for surgery follows a vegan eating plan. For which potential postoperative complication will the nurse plan care for this client? Hypoactive bowel sounds Blood clots Stasis pneumonia Delayed wound healing
Delayed wound healing
The nurse is monitoring a presurgical patient for electrolyte imbalance. Which classification of medication may cause electrolyte imbalance? Insulin Phenothiazines Diuretics Corticosteroids
Diuretics
A client with osteoarthritis receives a recommendation to have joint replacement surgery. For which type of surgery will the nurse plan teaching for this client? Elective Emergent Required Urgent
Elective
As a circulating nurse, what task are you solely responsible for? Handing instruments to the surgeon. Keeping records. Estimating the client's blood loss. Counting sponges and needles.
Keeping records.
A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member? Anesthetist Scrub nurse Surgeon Circulating nurse
Surgeon
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: palpate the abdomen. change the client's position. insert a rectal tube. auscultate bowel sounds.
auscultate bowel sounds.
A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse: obtains a surgical consent from the client's mother. performs a complete assessment of the client. assesses how well the client is recovering from anesthesia. continuously monitors the sedated client.
continuously monitors the sedated client.
A laser is being used to excise tissue during a client's surgical procedure. Which item will the nurse apply to minimize personal risk due to the smoke from the device? N95 respiratory mask Goggles Second surgical mask Face shield
N95 respiratory mask
The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? Necrotic and hard Pink to red and soft, bleeding easily Pale yet able to blanch with digital pressure White with long, thin areas of scar tissue
Pink to red and soft, bleeding easily
The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? White with long, thin areas of scar tissue Pink to red and soft, bleeding easily Pale yet able to blanch with digital pressure Necrotic and hard
Pink to red and soft, bleeding easily
A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? White with long, thin areas of scar tissue Pale yet able to blanch with digital pressure Pink to red and soft, noting that it bleeds easily Necrotic and hard
Pink to red and soft, noting that it bleeds easily
The nurse is preparing an older adult for a surgical procedure. Which action will the nurse take to protect the client from injury during the operative period? Protect bony prominences with extra padding. Estimate amount of blood loss during the procedure. Apply a warm blanket after the procedure. Provide antiembolic stockings to be applied postoperatively.
Protect bony prominences with extra padding.
The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to: Respond verbally during the procedure Be anxious throughout the procedure Need pain control throughout the procedure Need an endotracheal tube
Respond verbally during the procedure
During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer: potassium chloride an acetaminophen suppository dantrolene sodium (Dantrium) verapamil (Isoptin)
dantrolene sodium (Dantrium)
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 eviscerated. dehisced. hemorrhaged. pustulated.
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? insulin diuretics corticosteroids anticoagulants
diuretics
A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client? exhibits wound healing without complications. resumes usual urinary elimination pattern. experiences pain within tolerable limits. maintains adequate fluid status.
experiences pain within tolerable limits.
The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room? 7 4 5 6
7
What is the blood glucose level goal for a diabetic client who will be having a surgical procedure? 80 to 110 mg/dL 250 to 300 mg/dL 300 to 350 mg/dL 150 to 240 mg/dL
80 to 110 mg/dL
A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take? Remove the ring once the client is sedated. Discuss the risk for infection caused by wearing the ring. Allow the client to wear the ring and cover it with tape. Notify the surgeon to cancel surgery.
Allow the client to wear the ring and cover it with tape.
A client with osteoarthritis receives a recommendation to have joint replacement surgery. For which type of surgery will the nurse plan teaching for this client? Elective Emergent Urgent Required
Elective
A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client? The client should be transferred to an intensive care area. The client must remain in the PACU. The client must be put on immediate life support. The client can be discharged from the PACU.
The client can be discharged from the PACU.
A client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse? Verify consent. Acquire ordered blood products. Document the start of surgery. Count sponges and syringes.
Verify consent
A client scheduled for surgery asks why blood tests are being done to evaluate liver function. Which response will the nurse make? "It is because the anesthesia you will receive is cleared through the liver." "It is just a routine test done before every surgery." "It is to make sure that you haven't had any alcohol before the surgery." "It is done to determine if you need antibiotics prior to surgery."
"It is because the anesthesia you will receive is cleared through the liver."
The nurse is aware that infection is a potential complication of surgery. Which intervention should the nurse implement to prevent infection? Select all that apply. A. Avoid touching sterile items unless necessary. B. Wear a long-sleeved, sterile gown and gloves. C. Remove hair from the surgical site using a razor. D. Keep artificial nails clean and in good repair. E. Alert the surgical team of any breaches of sterile technique.
A. Avoid touching sterile items unless necessary. B. Wear a long-sleeved, sterile gown and gloves. E. Alert the surgical team of any breaches of sterile technique.
A nursing measure for evisceration is to: A. Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution. B. Carefully push the exposed intestines back into the abdominal cavity. C. Apply an abdominal binder snugly so that the intestines can be slowly pushed back into the abdominal cavity. D. Approximate the wound edges with adhesive tape so that the intestines can be gently pushed back into the abdomen.
A. Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution.
An OR nurse needs to assist a patient to the Trendelenburg position. Which of the following is the correct position? A. On his back, with his head lowered, so that the plane of his body meets the horizontal on an angle B. On his side, with his uppermost leg adducted and flexed at the knee C. On his back, with his legs and thighs flexed at right angles D. Flat on his back with his arms next to his sides
A. On his back, with his head lowered, so that the plane of his body meets the horizontal on an angle
A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications? A. Splint the incision site using a pillow during deep breathing and coughing exercises. B. Deep breathing and coughing exercises may be used as relaxation techniques. C. Deep breathing and coughing exercises should be completed every 8 hours. D. Pain medication should be taken before completing deep breathing and coughing exercises.
A. Splint the incision site using a pillow during deep breathing and coughing exercises.
The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan? A. Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. B. Family members can be involved in the administration of pain medications with patient-controlled analgesia. C. There are no advantages of patient-controlled analgesia over a PRN dosing schedule. The client can self-administer oral pain medication as needed with patient-controlled analgesia.
A. Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.
The nursing instructor is talking with her class about spinal anesthesia. What would be the nursing care intervention required when caring for a client recovering from spinal anesthesia? Select all that apply. A. Encourage the client to increase activity if complaining of a headache. B. Instruct the client to stay in bed until sensation and movement returns. C. Monitor respiratory rate and sensation every 2 hours or as per ordered. D. Assist the client to a sitting position at the side of the bed. E. Turn the client from side to side at least every 2 hours, if permitted.
B. Instruct the client to stay in bed until sensation and movement returns. C. Monitor respiratory rate and sensation every 2 hours or as per ordered. D. Assist the client to a sitting position at the side of the bed. E. Turn the client from side to side at least every 2 hours, if permitted.
How would the operating room nurse place a patient in the Trendelenburg position? A. On his back with his legs and thighs flexed at right angles B. On his back with his head lowered so that the plane of his body meets the horizontal on an angle C. On his side with his uppermost leg adducted and flexed at the knee D. Flat on his back with his arms next to his sides
B. On his back with his head lowered so that the plane of his body meets the horizontal on an angle
A nurse is teaching a client about diaphragmatic breathing. What client action indicates that further teaching is needed? A. The client places the hands on the lower chest to feel the rise and fall with breathing. B. The client exhales forcefully with a short expiration. C. The client breathes in deeply through the nose and mouth. D. The client performs diaphragmatic breathing in a semi-Fowler's position.
B. The client exhales forcefully with a short expiration.
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dL, and a blood pressure lying in bed of 110/70 mm Hg. The nurse suspects abnormal orthostatic changes when the client gets out of bed and reports vertigo. What vital sign value most supports the client's orthostatic changes? Blood pressure of 110/80 mm Hg Blood pressure of 150/100 mm Hg Blood pressure of 120/90 mm Hg Blood pressure of 90/50 mm Hg
Blood pressure of 90/50 mm Hg
A client is having surgery through an ambulatory surgical center. Which information will the nurse provide to the client's family? A. "Be prepared to take the client home as soon as the surgery is over." B. "You can go home and I will call you in a day or two when the client can be discharged." C. "The client will go to the postanesthesia care unit after the surgery." D. "I will give you the name of the hospital that the client will be transferred to after the surgery."
C. "The client will go to the postanesthesia care unit after the surgery."
The policies and procedures on a preoperative unit are being amended to bring them closer into alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most directly addresses the priorities of the SCIP? A. Actions aimed at increasing interdisciplinary collaboration B. Actions aimed at increasing participation of families in planning care C. Actions aimed at preventing surgical site infections D. Actions aimed at promoting the use of complementary and alternative medicine (CAM)
C. Actions aimed at preventing surgical site infections
The policies and procedures on a preoperative unit are being amended to bring them closer into alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most directly addresses the priorities of the SCIP? A. Actions aimed at increasing participation of families in planning care B. Actions aimed at promoting the use of complementary and alternative medicine (CAM) C. Actions aimed at preventing surgical site infections D. Actions aimed at increasing interdisciplinary collaboration
C. Actions aimed at preventing surgical site infections
A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications? A. Deep breathing and coughing exercises should be completed every 8 hours. B. Deep breathing and coughing exercises may be used as relaxation techniques. C. Splint the incision site using a pillow during deep breathing and coughing exercises. D. Pain medication should be taken before completing deep breathing and coughing exercises.
C. Splint the incision site using a pillow during deep breathing and coughing exercises.
A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage? A. The client has been lying on his side for 2 hours with the drain positioned upward. B. There is a moderate amount of dry drainage on the outside of the dressing. C. The Hemovac drain isn't compressed; instead it's fully expanded. D. The client has a nasogastric (NG) tube in place that drained 400 ml.
C. The Hemovac drain isn't compressed; instead it's fully expanded.
A nurse is teaching a client about diaphragmatic breathing. What client action indicates that further teaching is needed? A. The client places the hands on the lower chest to feel the rise and fall with breathing. B. The client breathes in deeply through the nose and mouth. C. The client exhales forcefully with a short expiration. D. The client performs diaphragmatic breathing in a semi-Fowler's position.
C. The client exhales forcefully with a short expiration.
The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following? Cheeseburger, french fries, coleslaw, and ice cream Baked chicken, mashed potatoes, broccoli, and strawberries Turkey breast, baked sweet potato, asparagus, and an orange Grilled salmon, rice pilaf, green beans, and cantaloupe
Cheeseburger, french fries, coleslaw, and ice cream
What medication should the nurse prepare to administer in the event the client has malignant hyperthermia? Dantrolene sodium Thiopental sodium Fentanyl citrate Naloxone
Dantrolene sodium
A client scheduled for surgery follows a vegan eating plan. For which potential postoperative complication will the nurse plan care for this client? Stasis pneumonia Delayed wound healing Hypoactive bowel sounds Blood clots
Delayed wound healing
A fractured skull would be classified under which category of surgery based on urgency? Urgent Elective Required Emergent
Emergent
Informed consent from the surgical client is essential in all of the following categories of surgery except: Required surgery Urgent surgery Elective surgery Emergent surgery
Emergent surgery
The nurse is caring for a postoperative client with a Hemovac. The Hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to: Empty and measure the drainage and compress the Hemovac. Remove the Hemovac because it is expanded. Assess the client's wound and apply a pressure dressing. Notify the surgeon that the Hemovac is not functioning.
Empty and measure the drainage and compress the Hemovac.
Which would be included as a responsibility of the scrub nurse? Coordinating activities of other personnel Obtaining and opening wrapped sterile equipment Keeping all records and adjusting lights Handing instruments to the surgeon and assistants
Handing instruments to the surgeon and assistants
Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis? Prolonged dangling of the legs over the edge of the bed Hourly leg exercises Fluid restriction Use of blanket rolls to elevate the lower extremities
Hourly leg exercises
A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse? Ask the client for more clarification. Administer an anti-emetic. Obtain an emesis basin. Position the client in the side-lying position.
Position the client in the side-lying position.
A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse? Ask the client for more clarification. Administer an anti-emetic. Position the client in the side-lying position. Obtain an emesis basin.
Position the client in the side-lying position.
A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse? Position the client in the side-lying position. Administer an anti-emetic. Ask the client for more clarification. Obtain an emesis basin.
Position the client in the side-lying position.
What complication is the nurse aware of that is associated with deep venous thrombosis? Swelling of the entire leg owing to edema Pulmonary embolism Immobility because of calf pain Marked tenderness over the anteromedial surface of the thigh
Pulmonary embolism
The nurse is aware that which of the following nutrients promotes normal blood clotting? Zinc Magnesium Vitamin C Vitamin K
Vitamin K
Which of the following is an inappropriate nursing action by the surgical nurse? Changing shoe covers that become torn Wearing a surgical jacket with knitted cuffs on the sleeves Wearing sterile gloves over artificial nails Covering the hair with a surgical cap
Wearing sterile gloves over artificial nails
The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing? Wound infection Hyperthermia Atelectasis Uncontrolled pain
Wound infection