Chapter 30: Perioperative Nursing PrepU

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? -Ask the operating room staff to delay the procedure until the consent is signed. -Ask the client to sign the consent; witness the signature and inform the operating room staff of the modification in the procedure. -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. -Send the client to the operating room and inform the staff that the consent form needs to be 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. 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).

Which surgical clients will return to activities in their everyday lives more quickly? -Vaginal hysterectomy -Laparoscopic cholecystectomy -Right nephrectomy -Open-heart surgery

Laparoscopic cholecystectomy Clients who have surgery using a laparoscope are able to return to previous activity levels much sooner.

The nurse cares for a client following surgery to repair an abdominal aortic aneurysm. Which nursing intervention assists with healing and maintaining client comfort? -Maintaining a calm environment -Providing solid food during postoperative day 1 -Allowing family members to visit often -Keeping the client recumbent

Maintaining a calm environment The nurse should plan for adequate periods of rest and sleep and maintain a quiet, restful environment. Nursing interventions that can help promote rest include maintaining a calm environment and limiting interruptions to the client's sleep (including frequent family visits). Providing solid food and keeping the client recumbent will not assist with healing and maintaining client comfort and may be contraindicated.

A nurse asks a preoperative client which medications he is currently taking. Which statement describes an accurate guideline for client teaching regarding these medications? -Aspirin is generally stopped 1 month before surgery. -If the client is diabetic and takes insulin, the dose will be increased before surgery. -Many respiratory drugs may be taken the day of surgery per health care provider's order. -Cardiac drugs must be stopped for 1 week before surgery.

Many respiratory drugs may be taken the day of surgery per health care provider's order. Adjustments in taking medications may be needed before surgery. Anticoagulants are stopped days before surgery. Certain cardiac and respiratory drugs may be taken the day of surgery per health care provider's order. If the client is diabetic and takes insulin, the insulin dosage may be reduced.

After a client receives morphine sulfate for pain in the postanesthesia care unit (PACU), which assessment finding would the nurse obtain as a priority? -Auscultate bowel sounds. -Obtain temperature. -Measure respiratory rate. -Check the neurologic status.

Measure respiratory rate. The client who is receiving morphine sulfate for pain has a potential for decreased respiratory effort because of the side effect of respiratory depression; the client may also have constipation as a side effect, but this would not be a priority over respiratory depression. The postoperative client needs to be monitored for changes in their neurologic status and temperature, but this would not be a priority over the respiratory status.

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? -Monitor the client closely and promote fluid intake. -Increase the rate of the client's intravenous infusion. -Contact the physician to come assess the client. -Immediately administer a cleansing enema.

Monitor the client closely and promote fluid intake. Bowel function does not typically return immediately after surgery, but it can be promoted by encouraging fluid and fiber intake as appropriate to the client and his or her surgery. A medical assessment is likely unnecessary at this early postoperative stage, and an enema would likely be premature. The nurse may not independently increase the client's IV infusion, and doing so would not necessarily promote a bowel movement.

The healthy adult client is given an opioid prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first? -Notify the physician of the oversight. -Immediately have the client sign the consent form. -Ask the client if he still wants to proceed with the procedure. -Have the client's family member sign the consent form.

Notify the physician of the oversight. Do not administer any medications that might alter judgment or perception before the client signs the consent form because many drugs commonly administered as preoperative medications, such as opioids or barbiturates, can alter cognitive abilities and invalidate informed consent.

Which nursing action will best promote pain management for a client in the postoperative phase? -Performing relaxation techniques -Providing food and medication -Breathing into a paper bag -Dimming the lights

Performing relaxation techniques Performing relaxation techniques is the best nursing action to promote pain management for a client in the postoperative phase.

A client has arrived to the postanesthesia care unit (PACU) and is drowsy with a respiratory rate of 12 breaths per minute. What would be an accurate interpretation by the nurse? -The procedural physician should be notified immediately of client findings. -This is an expected finding in the immediate postoperative period. -The client should be returned to the operating room for further evaluation. -The client needs to have the neurologic status fully evaluated.

This is an expected finding in the immediate postoperative period. Having drowsiness and a respiratory rate of 12 breaths/minute are normal findings in the immediate postoperative period. The client needs to be monitored to ensure that there is no deterioration in respiratory status and the client awakens readily. As the anesthetics wear off, the client should return to a normal level of consciousness. The nurse would not need to notify the procedural physician or return the client to the operating room because this is not an emergent situation.

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? -Type of surgery -Age of client -Client's support system -Type of anesthesia

Type of surgery 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.

Which measure would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client? -Educate the client about the use of an incentive spirometer. -Encourage the client to elevate the head of the bed. -Elevate bilateral legs when the client is lying in bed. -Place graduated compression stockings on the client.

Place graduated compression stockings on the client. Use of graduated compression stockings and/or pneumatic compression devices on the client will help with prevention of DVT, which is a risk for clients after surgery. Elevating the client's legs will passively improve venous return but not prevent DVT if a client is not up and walking (to more actively promote the venous return). Elevating the head of the bed and using the incentive spirometer help prevent postoperative complications of atelectasis or pneumonia.

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? -Place the client in the prone position. -Place the client in a flat position with legs elevated 45 degrees. -Do not administer any further medication. -Remove extra coverings on the client to keep temperature down.

Place the client in a flat position with legs elevated 45 degrees. 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.

A nurse is assessing a client who is experiencing pulmonary embolus. What would be the priority nursing intervention for this client? -Assist the client to ambulate every 2 to 3 hours. -Place the client in semi-Fowler's position. -Instruct the client to perform Valsalva maneuver. -Attempt to overhydrate the client with fluids.

Place the client in semi-Fowler's position. Nursing interventions include notifying the physician immediately, calling the medical intervention team, maintaining the client on bed rest in the semi-Fowler's position, assessing vital signs frequently, administering oxygen, administering medications (e.g., anticoagulants, analgesics), and instructing the client to avoid Valsalva maneuver (this prevents increased intrathoracic pressure and, possibly, increased emboli).

A nurse is caring for an older adult following hip surgery. When teaching the client to use an incentive spirometer, the nurse should explain that this reduces the risk of what complication? -Bronchitis -Pneumonia -Asthma -DVT

Pneumonia In the older adult client, postoperative pneumonia can be a very serious complication resulting in death. Therefore, it is especially important to encourage and assist the client in using the incentive spirometer and with deep-breathing exercises. These exercises do not address the client's risk of DVT, bronchitis, or asthma.

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? -Offering emotional support to help minimize concern of abdominal pain -Providing support to abdominal and accessory respiratory muscles -Supporting the head and shoulders effectively to prevent muscle strain -Exhaling through the mouth with lips pursed to slowly empty the lungs

Providing support to abdominal and accessory respiratory muscles Coughing and deep breathing uses abdominal and accessory respiratory muscles, which may have been cut during surgery. Splinting, in this case with a pillow, supports the incision and surrounding tissues and reduces pain during coughing and deep breathing exercises. While providing emotional support is appropriate, doing so will not affect physiological pain resulting from the intervention. Exhaling with lips pursed increases resistance in the airways, which helps them stay open during exhalation. Supporting the head and shoulders adds to the client's comfort, but doing so does not address the primary source of pain produced by therapeutic coughing and deep breathing.

A nurse caring for a client postoperatively notes that the dressing on the client's incision was recently clean and dry but is now saturated with a large amount of fresh blood. What intervention should be taken by the nurse in this situation, along with notifying the primary care provider? -Remove the dressing. -Leave dressing as is. -Reinforce the dressing. -Change the dressing.

Reinforce the dressing. The nurse should not remove the dressing, but instead should reinforce the dressing with more bandages. Removing the bandage could dislodge any clot that is forming and lead to further blood loss.

Which nursing action will assist in pain management for a client in the postoperative phase? -Relaxation techniques -Client education -Dim lighting -Provide food and medication

Relaxation techniques Nursing interventions vital in helping clients cope with pain include administering medications, positioning, relaxation techniques, psychological support, distraction techniques, and appropriate referrals to other health professionals.

The nurse is assessing clients for postoperative complications. What is the most commonly assessed postanesthesia recovery emergency? -Wound infection -Respiratory obstruction -Cardiac distress -Dehydration

Respiratory obstruction 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 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? -Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact. -Explain the client's need for hip surgery to visitors and ask them for information about a durable power of attorney for health care. -Look on the chart for a living will if a durable power of attorney for health care cannot be located. -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. The client cannot give consent due to confusion. In most cases, the durable power of attorney for health care document is discussed and obtained during the admission process. The nurse should act as a client advocate by seeking someone with durable power of attorney to sign the informed consent form. It is the surgeon's responsibility to explain the surgical procedure and obtain the appropriate signature on the consent form; however, the nurse still acts as the client advocate to locate the designated person. A living will specifies the types of medical treatment the client wants should the client become unable to speak in a terminal or permanently unconscious medical condition, but it does not address matters related to client confusion. Telling visitors about the need for surgery may violate client confidentiality. If the nurse identifies who they have permission to disclose medical information to, they can ask that person about a durable power of attorney for health care.

A nurse is providing education to a client having same-day surgery. Which statement would be accurate regarding this type of surgery? -Same-day surgery must be performed in a hospital setting. -Older adult clients are generally not permitted to have same-day surgery. -Clients without a strong support system are not candidates for same-day surgery. -Some major surgeries can be done as same-day surgery.

Some major surgeries can be done as same-day surgery. Some major surgeries are performed now as same-day surgery. This can be done in a hospital setting or a free-standing surgery center. Older adult clients and those without a support system can have same-day surgery but need additional education to be prepared for going home the same day; they may also need home health services.

A client has been transported to the operating suite and is positioned on the operating table. Suddenly, the client states, "I do not want to do this. Get me out of here now!" Which statement would the nurse make to reassure the client? -"We will begin your anesthesia now. You will soon feel nothing." -"The surgeon will be here soon to calm you down. The procedure will be over soon." -"Did the surgeon explain the procedure to you?" -"Can you tell me what your concerns are about this procedure?"

"Can you tell me what your concerns are about this procedure?" The client has the right to ask any questions and to withdraw consent at any point before the surgery begins. Making statements like, "You will soon feel nothing" or "The surgeon will be here soon" will not help to reassure the client and belittles the client's fears. Open-ended questions can provide the nurse with answers needed to reassure the client and reduce anxiety.

A client is in the preoperative area and states, "I am not sure about having surgery." What is the nurse's best response? -"You really need to have this surgery done." -"Why wouldn't you want the surgery so you can feel better?" -"I will tell the surgeon you changed your mind." -"Can you tell me what your feelings are about the surgery?"

"Can you tell me what your feelings are about the surgery?" The client who is unsure about surgery needs their feelings explored to determine why the client doubts the decision. After exploring these feelings, the nurse can then contact the procedural physician and make this person aware of the client's concerns. Asking the client why the client wouldn't want the surgery is phrased negatively and implies a judgment by the nurse on the client's feelings; likewise, the client wouldn't be told to have the surgery done without allowing the client to express feelings.

Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction? -"I can have a hamburger and French fries as soon as I wake up." -"The better I eat before surgery, the more likely I will heal." -"I might be sick to my stomach and throw up after surgery." -"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." Oral fluid and food may be withheld until intestinal motility resumes.

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? -"I will need to check with your health care provider about that." -"Yes—you should be off all of your medications for 24 hours before surgery." -"No—you should stay on your normal medication schedule before the surgery." -"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." 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.

A nurse is caring for a client in the same-day surgery unit. The client asks the nurse, "Do I really need to be put to sleep for this surgery?" Which would be the nurse's best response? -"You do not have to worry. It will be fine." -"Tell me what you are most worried about." -"Have you ever had surgery before?" -"I will have the anesthesiologist talk to you."

"Tell me what you are most worried about." As the client's advocate, the nurse should first assess what the client is most worried about and then provide emotional support. The nurse would not offer false hope, reassurance, nor pass the client off to another team member. Asking if the client had surgery before would not reveal the concerns with this surgery.

A postoperative client states "I don't understand why you are checking my skin on my back. My surgery was on my stomach." What is the nurse's best response? -"We wanted to be sure we didn't leave any sponges or syringes underneath you." -"The operating table is a firm surface; we need to be sure your skin looks okay." -"The covers underneath you need to be straightened out. They look messy." -"We needed to be sure you didn't have any skin breakdown before surgery."

"The operating table is a firm surface; we need to be sure your skin looks okay." The client who has been on the operating table should be examined to ensure skin breakdown hasn't occurred. The client would not be told that his covers looked messy, or that the nurse was concerned about sponges or syringes underneath. The client's skin should be assessed on admission; after surgery would not be the time to do this initial assessment to document skin breakdown.

The nurse is providing education about deep-breathing exercises to a postoperative client whose surgery took place earlier today. Which instruction should the nurse provide? -"If possible, lie flat on your back while you're doing your breathing exercises." -"Take off your oxygen nasal prongs during your exercises and replace them as soon as you're done." -"Try to do your exercises every 1 to 2 hours." -"It's best to do your exercises before a meal rather than after eating and drinking."

"Try to do your exercises every 1 to 2 hours." Instruct the client that deep-breathing exercises should be performed every 1 to 2 hours for the first 24 hours after surgery.

The nurse working in the holding area is performing an assessment on a client scheduled for surgery. Which question will the nurse ask prior to the client receiving general anesthesia? -"Which medications do you take daily?" -"When was the last time you had anything to eat or drink?" -"Can you tell me why you are here this morning?" -"Do you want me to call the hospital chaplain before you have anesthesia?"

"When was the last time you had anything to eat or drink?" Determining when the last time the client had anything by mouth is important when undergoing anesthesia. The client ideally should be NPO, nothing by mouth, at least 8 hours prior to a general anesthesia to avoid aspiration during intubation. Assessing daily medications is done before surgery, not in the holding area. Asking the client to verify orientation should have been completed prior to arriving in the holding area. Asking the client if a chaplain should be called is not an appropriate action to take in the holding area.

The nurse needs to evaluate the effectiveness of a preoperative teaching session with a client scheduled for abdominal surgery. Which client statement indicates the need for further clarification? -"I will splint my incision while I cough." -"I will sit up in bed before using my incentive spirometer." -"Every 2 hours while I am awake, I will take deep breaths and cough." -"While my pneumatic compression device is on, I don't need to do leg exercises."

"While my pneumatic compression device is on, I don't need to do leg exercises." Compression stockings and pneumatic compression devices help to decrease the formation of thrombus by helping to promote venous return to the heart. The nurse needs to clarify that the pneumatic compression device does not replace leg exercises because the exercises help keep the joints flexible and help strengthen muscles while the client is in bed. The client is correct that splinting the incision when coughing is important. The client should sit up in bed when using the incentive spirometer, taking deep breaths and coughing. The client should take deep breaths and cough at least every 2 hours while awake to help expand lungs, loosen secretions, and help prevent atelectasis and pneumonia.

The nurse is caring for a client after breast augmentation. Before performing a bowel assessment, what education will the nurse provide the client? -"You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By lightly pressing on the abdomen, I can check for a return of peristalsis." -"You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By pressing on the symphysis pubis, I can check for a return of peristalsis." -"You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By listening for bowel sounds, I can check for a return of peristalsis." -"You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By giving you sips of water periodically, I can promote the return of peristalsis."

"You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By listening for bowel sounds, I can check for a return of peristalsis." A postoperative client can typically have decreased or absent peristalsis because of bowel manipulation and/or administration of anesthetic agents or opioids. Auscultation of bowel sounds will help determine a return of peristalsis. Palpating the abdomen would not help with determining peristalsis return; the nurse may feel distention and firmness of the abdomen with decreased peristalsis, but this is not accurate in determining return of peristalsis. The symphysis pubis would be assessed to determine bladder fullness, not peristalsis. Giving the client sips of water would not help determine or promote the return of peristalsis; this also could be a safety issue if the client has decreased peristalsis due to emesis and subsequent potential aspiration.

A nurse is caring for a client who is preparing to have a hip replacement. What is the responsibility(ies) of the nurse related to informed consent? Select all that apply. -Ensuring the informed consent documentation is signed by client and a witness -Confirming the informed consent documentation is a part of the client's medical record before surgery -Acting as a witness for the client's signature on the informed consent -Explaining the surgical procedure prior to obtaining informed consent -Inspecting the informed consent documentation for completeness

-Inspecting the informed consent documentation for completeness -Ensuring the informed consent documentation is signed by client and a witness -Confirming the informed consent documentation is a part of the client's medical record before surgery The surgeon is legally responsible for explaining the surgical procedure and obtaining the client's signature on the consent form. The nurse should be knowledgeable about the organization's policy regarding informed consent and making sure that policy is followed. In some organizations, the nurse may witness the client's signature on the consent document; however, the nurse is not legally required to be a witness. The nurse is responsible for making sure that the consent form contains all the correct and necessary information, is properly signed and witnessed, and is part of the client's medical record prior to surgery.

Which methods would the nurse anesthetist use when administering regional anesthesia to surgical clients? Select all that apply. -Inhalation -Spinal block -Intravenous -Oral route -Nerve block -Epidural block

-Spinal block -Nerve block -Epidural block 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.

The nurse is performing a preoperative screening of laboratory work prior to a client's surgery in the morning. What test results should be immediately discussed with the surgeon and anesthesia care provider? Select all that apply. -a sodium level of 128 mEq/L -increased hemoglobin level, indicating infection -a BUN of 9 mg/dL -a hemoglobin of 7.2 gm/dL -a white blood cell count of 18,000 -a potassium level of 4.2 mEq/L

-a white blood cell count of 18,000 -a hemoglobin of 7.2 gm/dL -a sodium level of 128 mEq/L Significant abnormal findings include an elevated white blood cell count (presence of infection), decreased hemoglobin level (presence of bleeding, anemia), and a sodium level of 128 mEq/L which is dangerously low and can lead to seizures or death if not corrected. A BUN/ of 9 is within normal range as is a potassium level of 4.2.

A nurse preparing an older adult client for hip replacement surgery is aware of the surgical risks related to the client's age. Which of the following accurately describes these risks? Select all that apply. -decreased peripheral circulation -decreased thermoregulation ability -increased oxygenation of blood -increased cardiac output -increased vascular rigidity

-decreased peripheral circulation -increased vascular rigidity -decreased thermoregulation ability Older adults have decreased cardiac output, decreased peripheral circulation, decreased oxygenation of blood, decreased thermoregulation ability, and decreased skin moisture and elasticity. Older adults have increased vascular rigidity.

A client with a diagnosis of breast cancer has been scheduled for a unilateral mastectomy during an axillary lymph node dissection. Which categorizations of surgical procedures are represented in this client's case? Select all that apply. -palliative -reconstructive -diagnostic -constructive -curative

-diagnostic -curative Curative surgery involves the removal of a diseased body part (e.g., breast tissue). Diagnostic surgery, such as biopsy of a lymph node, involves the removal of tissue for determining a diagnosis or the extent of disease involvement. This client is not receiving constructive, reconstructive, or palliative surgery at this time.

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. -administering inhalation anesthetics -positioning the client on the operating table -counting sponges before and after surgery -administering regional nerve blocks -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 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.

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? -Remind the client of the serious complications that can result from ineffective coughing and deep breathing. -Teach the client how to splint the abdomen while coughing. -Administer respiratory treatments to encourage coughing. -Assist the client to a side-lying position to cough.

Teach the client how to splint the abdomen while coughing. Splinting the abdomen decreases discomfort while coughing. Telling the client about complications will be less effective than teaching splinting techniques. Respiratory treatments are not indicated for cough production. Side-lying position is less effective than upright positioning to clear secretions and expand the lungs.

An 83-year-old client who wears glasses is scheduled for surgery. Which action should the nurse take to assure the client remains oriented? -Allow the client to wear glasses until just before anesthetic is administered. -Direct the client to leave glasses at home for safety. -Give the glasses to the family until the client is returned to the room. -Allow the client to wear glasses until after anesthetic is administered.

Allow the client to wear glasses until just before anesthetic is administered. 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.

The nurse enters a postoperative client's room and finds that the client is bleeding profusely from the surgical incision. What would be the nurse's most appropriate initial response? -Determine the possible cause of the client's bleeding. -Apply pressure to the surgical site to decrease bleeding. -Assess the client's vital signs. -Notify the health care provider.

Apply pressure to the surgical site to decrease bleeding. It is essential that the nurse be prepared to address life-threatening needs of the client. Excessive bleeding is a life-threatening issue. Determining the cause of the client's bleeding, assessing the vital signs, and notifying the health care provider are important, but the life-threatening issue must be addressed first.

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? -Check the client's blood pressure. -Apply an oxygen saturation monitor. -Apply warm blankets to the client. -Notify the health care provider.

Apply warm blankets to the client. 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? -Bowel alterations -Aspiration -Infection -Respiratory distress

Aspiration Food and fluid are restricted before surgery to ensure that the stomach contains a minimal amount of gastric secretions. This restriction is important to reduce the risk of aspiration.

A client has presented to the outpatient surgical center for a scheduled procedure. Which action should the nurse perform prior to the procedure? -Assess the client's allergy status. -Encourage the client to create an advance directive. -Have the client perform leg exercises every 30 minutes. -Administer analgesia (pain medications).

Assess the client's allergy status. The nurse should assess or confirm the client's allergy status prior to surgery. An advance directive may be in place, but one would not be created on the day of surgery if it were not already established. Analgesia is not normally given preoperatively. Leg exercises should be taught and modeled preoperatively, but they do not need to be performed during this phase.

A nurse is interacting with a client in the outpatient surgical unit intraoperatively. What is the nurse's priority responsibility? -Establishing a nurse-client rapport -Client safety -Educating the client about postoperative protocols -Providing emotional support for the client and family

Client safety Client safety is the most important nurse responsibility during the intraoperative phase. Safety concerns include equipment, electrical, chemical, radiation, surgical verification, client transport and positioning, and continuous asepsis. Postoperative protocol education is done preoperatively. Establishing a nurse-client rapport and providing emotional support are important, but they are not the most important nursing responsibility during the intraoperative phase.

An older adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client? -Boredom -Delirium -Opioid overuse -Dementia

Delirium Delirium refers to acute confusion that is reversible. It is common in the acute postoperative period.

The nurse is performing a preoperative assessment of a client who has been scheduled for a reduction mammoplasty (breast reduction). The client states, "I'm starting to wonder if I made the right decision in going ahead with this." What should the nurse do next? -Explore the client's feelings and inform the surgeon. -Assess the client's rationale and affirm that she has made a good decision. -Remind the client that she has signed the informed consent documents. -Ask the client about her understanding of the potential benefits of the surgery.

Explore the client's feelings and inform the surgeon. The nurse should discuss this and notify the care provider. Clients should not undergo surgery until they are sure that surgery is what they want. Informed consent documents do not bind the client to an earlier decision. It would be inappropriate to try to convince the client to go through with the surgery if she is questioning her decision.

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? -You will receive a diet high in vitamin B. -Food and liquids will be held in the immediate postoperative period. -In the immediate postoperative period, you will receive a soft diet high in carbohydrates. -You may eat anything you want following surgery.

Food and liquids will be held in the immediate postoperative period. 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 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? -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 acute respiratory distress syndrome. -If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia. -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.

If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia. 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.

A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client? -Keep the client from ambulating until the day after surgery. -Implement leg exercises and turn the client in bed every 2 hours. -Position the client in bed with pillows placed under his knees to hasten venous return. -Keep the client cool and uncovered to prevent elevated temperature.

Implement leg exercises and turn the client in bed every 2 hours. Ambulation and leg exercises increase circulation, which prevents cardiovascular complications. The nurse should provide covers, forced warm air, or other warming devices/techniques as necessary to prevent shivering and hypothermia caused by the surgical procedure, the procedure's length, anesthetic agents, a cool environment, the client's age, or the use of cool irrigating/infusion fluids. Pillows placed under the knees can cause venous pooling, leading to thrombophlebitis.

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? -Inability to ambulate -Inability to see from left eye -Alert and oriented ×4 -Voiding on a regular basis

Inability to ambulate 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.

A client is scheduled for hip replacement surgery this morning but admits to the nurse that he had a small piece of toast and some water after waking up. What is the nurse's most appropriate response? -Assess the client's abdomen by inspection and auscultation. -Explain the rationale for preoperative fasting to the client. -Inform the anesthesiologist or surgeon of this fact. -Ask the client if he did not understand the preoperative instructions.

Inform the anesthesiologist or surgeon of this fact. The surgeon or anesthesiologist must be informed if a client has not adhered to preoperative fasting instructions, since this constitutes a risk for aspiration. There is no benefit to assessing the client's abdomen or exploring the rationale for his actions.

The nurse is supervising a nursing student who is providing postoperative education to a client with an abdominal incision. The nurse sees the student coaching the client to perform coughing exercises, as pictured above. What is the nurse's best action? -Instruct the student to provide the client with a pillow or folded blanket to hug. -Help the student assist the client into a high Fowler's position. -Help the client determine whether she is able to dangle at the side of the bed. -Remind the student to support the client while she performs the exercises.

Instruct the student to provide the client with a pillow or folded blanket to hug. Because coughing is often painful, the student should teach the client how to splint the incision (i.e., support the incision with a pillow or folded bath blanket). It is not normally necessary to physically support the client, and it may be unsafe for the client to dangle. The client should not be in a supine or in a low Fowler's position, but the client does not necessarily need to be fully upright.

Which client in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse? -an 80-year-old client who is disoriented to place and time -a 6-year-old client who is crying for a parent to visit -a 26-year-old client who is exhibiting a crowing sound -a 30-year-old client who is drowsy and reporting pain

a 26-year-old client who is exhibiting a crowing sound 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.

Surgery can lead to hypothermia. Which client is at greatest risk for hypothermia? -a woman experiencing a cesarean birth -an adolescent having arthroscopic surgery -a young adult with a fractured leg -an older adult man with a fractured hip

an older adult man with a fractured hip The risk of hypothermia increases in the very young and the very old.

The nurse is assessing an obese client scheduled for heart surgery. Which priority surgical risk related to obesity should the nurse monitor? -delayed wound healing and wound infection -alterations in fluid and electrolyte balance -nutritional maintenance -hemorrhage

delayed wound healing and wound infection Fatty tissue has a poor blood supply and, therefore, has less resistance to infection. As a result, postoperative complications of delayed wound healing, wound infection, and disruption in the integrity of the wound are more common. Alterations in fluid and electrolyte balance are more likely to occur with the malnourished client. Respiratory distress is a high risk for clients with preexisting respiratory conditions. Clients with cardiovascular disease are at an increased risk for hemorrhage.

A client scheduled for surgery has been taking aspirin since his heart attack in 1997. The client is at risk for: -infection. -thrombophlebitis. -hemorrhage. -blood clots.

hemorrhage. Current medication use, especially use of medications that can affect coagulation status (warfarin, nonsteroidal anti-inflammatory drugs, aspirin), is important and should be reported to the surgeon.

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? -cleanses hands with alcohol-based hand rub -measures calf circumference -massages legs prior to application -elevates the legs 15 minutes after applying stockings

massages legs prior to application Massaging the legs can dislodge clots. Other actions are appropriate and do not require intervention.

The nurse has been waiting until after the administration of a toddler's anesthesia before removing the child's clothing and applying monitoring equipment. Doing these actions after the administration of anesthesia will: -minimize blood loss. -enhance thermoregulation. -provide more accurate baseline vital signs. -prevent anxiety.

prevent anxiety. Relaxation can be enhanced by removing the child's clothing, applying the grounding pad, and applying monitoring devices after the child is anesthetized. This action has no effect on vital signs, thermoregulation, or blood loss.

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? -operative site marking -procedural pause (time-out) -preoperative checklist -informed consent

procedural pause (time-out) 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.

Who is legally responsible for obtaining the client's informed consent for a surgical procedure? -the admissions clerk -the surgeon -the registered nurse -any licensed person

the surgeon The surgeon is legally responsible for obtaining the client's informed consent; however, the nurse should ensure the signed form has been obtained and is present in the client's chart and answer any questions or concerns the client may have concerning the upcoming procedure.

A nurse is discussing a surgical procedure with a client who needs to sign his informed consent. Which of these tasks is part of the nursing role? -explaining to the client about potential risks of having the surgery -describing how the client will benefit from the surgical procedure -determining for the client what other treatment options exist -witnessing the client signature with their consent for surgery

witnessing the client signature with their consent for surgery The nursing role with informed consent is to witness the client signature on the form. The procedural physician is responsible for explaining the procedure, any alternative treatment, and the risks and benefits of having the surgery. The nurse may clarify information, but if in-depth explanation is needed, the procedural physician should be notified.

What is the nurse's role in the informed consent process for a surgical procedure? -explaining what takes place during the procedure -providing benefits and risks of the procedure -witnessing the signed informed consent document -granting permission for surgery to be done

witnessing the signed informed consent document The nurse may witness the signed informed consent document. The health care provider will explain what takes place during the procedure, and provide benefits and risks. The client grants permission for surgery to be done.