Chapter 18: Peri-Op Nursing Care

4. the best results are achieved when sitting up or with the HOB elevated 45-90 degrees.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. Inhale as rapidly as possible 2. keep a loose seal between the lips and the mouthpiece 3. After maximum inspiration, hold the breath for 15 seconds and exhale 4. the best results are achieved when sitting up or with the HOB elevated 45-90 degrees.

3. Have the client void immediately before going into surgery

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash 2. Verify that the client has not eaten for the last 24 hours 3. Have the client void immediately before going into surgery 4. Report immediately any slight increase in BP or pulse

1. Increasing restlessness

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become *most* concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. A pulse of 86 bpm 3. BP of 110/70 mmHg 4. Hypoactive bowel sounds in all 4 quadrants

1. Prednisone

The nurse is reviewing a surgeon's prescription sheet for a pre-op client that states that the client must be NPO after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine 4. Conjugated estrogen

1. "Use of an incentive spirometer will help prevent pneumonia"

The nurse is teaching a client about coughing and deep-breathing techniques to prevent post-operative complications. Which statement is MOST APPROPRIATE for the nurse to make to the client at this time as it relates to these techniques? 1. "Use of an incentive spirometer will help prevent pneumonia" 2. "Close monitoring of your O2 saturation will detect hypoxemia". 3. "Administration of IV fluids will prevent or treat fluid imbalance." 4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."

1.Assess the patency of the airway

The nurse receives a telephone call from the post-anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action *first* on arrival of the client? 1.Assess the patency of the airway 2. Check tubes or drains for patency 3. Check the dressing to assess for bleeding 4. Assess the VS to compare with pre-op measurements

1. Contact the surgeons 2. Instruct the client to remain quiet 3. Prepare the client for wound closure 4. Document the findings and actions taken

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? *Select all that apply* 1. Contact the surgeons 2. Instruct the client to remain quiet 3. Prepare the client for wound closure 4. Document the findings and actions taken 5. Place a sterile saline dressing and ice packs over the wound 6. Place the client in a supine position without a pillow under the head

1. HgB, 8.0g/dL

A client who has undergone preadmission testing has has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. HgB, 8.0g/dL 2. Na+, 145 mEq/L 3. Serum creatinine, 0.8 mg/dL 4. platelets, 210,000

4. Obtain a telephone consent from a family member, following agency policy

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which MOST APPROPRIATE action in the care of this client? 1. Obtain a court order for the surgery 2. Have the charge nurse sign the informed consent immediately 3. Send the client to surgery without the consent form being signed 4. Obtain a telephone consent from a family member, following agency policy

3. "Can you share with me what you've been told about your surgery?"

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is MOST LIKELY to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery" 2. "I will be happy to explain the entire surgical procedure to you" 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate"

2. serous drainage

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. red, hard skin 2. serous drainage 3. purulent drainage 4. warm, tender skin

3. "I need to continue to take the aspirin until the day of surgery"

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client NEEDS ADDITIONAL TEACHING if the client makes which statement? 1. "aspirin can cause bleeding after surgery" 2. "aspirin can cause my ability to clot blood to be abnormal" 3. "I need to continue to take the aspirin until the day of surgery" 4. "I need to check with my HCP about the need to stop the aspirin before the scheduled surgery."

1. urinary output of 20 mL/hr

The nurse has just reassessed the condition of a post-operative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter MOST carefully during the next hour? 1. urinary output of 20 mL/hr 2. temperature of 37.6 C (99.6 F) 3. Blood pressure of 100/70 mmHg 4. Serous drainage on the surgical dressing