MED SURG FINAL EXAM :)
A nurse is assessing a client brought to the emergency room by his daughter. Which statement by the daughter would most likely lead the nurse to suspect that the client may have an infection?
"All of a sudden my dad seemed to become confused." Due to age-related changes in the nervous system, a sudden onset of confusion may be the first symptom of an infection. Feeling dizzy on arising suggests orthostatic hypotension. A temperature of 97.6 degrees F may or may not suggest an infection. Typically older adults do not experience a traditional fever. Complaints of being tired could indicate numerous conditions.
The nurse notes that an older adult adds salt to all foods before eating a meal. Which question would the nurse ask this client?
"Have you tried adding herbs, garlic, or lemon to foods for added flavor?" The sense of taste is reduced in older adults. Blunted taste may contribute to the preference for salty foods, but herbs, garlic, onions, and lemon to foods can added as healthier substitutes for added flavor. Saying, "Don't you know that adding salt to your food is bad for you?" is not therapuetic nor helpful for this client; knowledge may not be the issue and this question will erode the therapuetic relationship. The older adult would not be unable to taste the flavor of salt anymore, but decreased sense of taste would be an expected finding and does not offer a solution. Not all older adults experience dry mouth, nor would the nurse expect added salt to help with dry mouth.
After teaching an older adult about measures to relieve constipation, which statement by the client indicates a need for additional teaching?
"I should use a laxative every other day." Factors that may cause constipation include prolonged use of laxatives. Therefore, the patient should avoid the regular use of laxatives. To promote gastrointestinal motility, the patient should ensure adequate fluid intake, engage in regular exercise, avoid foods high in fat.
A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective?
"I will support my incision with my hands when I cough and do my deep breathing exercises." Splinting of the incision provides support to the incision and helps to control pain, so this client statement is correct. Clients should take pain medication routinely and frequently after surgery. Pain medications for postoperative clients are given orally at home. Pain is a subjective feeling, so comparison is difficult.
After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements?
"I'll be sleepy but able to respond to your questions." With moderate sedation, the patient can maintain a patent airway (i.e., doesn't need a tube to help breathing), retain protective airway reflexes, and respond to verbal and physical stimuli. The patient is not unconscious with moderate sedation. Local anesthesia involves anesthetizing or numbing the area of the surgery.
A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse?
"It assists in preventing infection." A wound drain assists in preventing infection by removing the medium in which bacteria could grow. The purpose of the wound drain is not to remove necrotic tissue or to decrease the number of dressing changes. Stating that most surgeons use wound drains does not answer the client's question appropriately.
A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers:
"It indicates if a cancer is present." The carcinoembryonic antigen (CEA) blood test detects the presence of cancer by identifying the presence of a protein not normally detected in the blood of a healthy person. However, it does not indicate what type of cancer is present nor does it detect the functionality of the liver.
Which nursing statement would best ease a client's anxiety before an emergency operative procedure?
"Let me explain to you what will happen next." Many clients feel fearful of knowing little about the operative procedure and what to expect. This fear causes anxiety and can lead to a poorer response to surgery and surgical complications. Explanations of what the client is to expect can help to decrease anxiety. False reassurance of being fine does not diminish anxiety. Deep breathing and relaxation techniques can be helpful to the client, but addressing the source of the anxiety is more beneficial. Keeping the family informed helps the family and is not client focused.
A client asks the nurse about possible ill effects from general anesthesia. What is the best response by the nurse?
"Some possible negative effects include difficulty waking up and slow heart rate." Difficulty waking up (oversedation), allergic reaction, and slow heart rate (bradycardia) are potential adverse effects of surgery and anesthesia. There are a number of effects from general anesthesia. Analgesia is not an adverse effect of general anesthesia. Clients should not experience pain.
A client is having surgery through an ambulatory surgical center. Which information will the nurse provide to the client's family?
"The client will go to the postanesthesia care unit after the surgery." Ambulatory surgery includes outpatient, same-day, or short-stay surgery not requiring admission for an overnight hospital stay but may entail observation in a hospital setting for 23 hours or less. The nurse needs to be sure that the client and family understand that the client will first go to the preoperative area before going to the OR for the surgical procedure and then will spend some time in the postanesthesia care unit before being discharged home with the family member later that day. The client will not be discharged immediately after the surgery is over. The client will not stay in the ambulatory care center for a day or two before being discharged to home. The client will not be transferred to a hospital after the surgery.
A client with Alzheimer's disease is prescribed donepezil hydrochloride. When teaching the client and family about this drug, which of the following would the nurse include?
"The drug helps to control the symptoms of the disease." Donepezil hydrochloride is a cholinesterase inhibitor used to control symptoms of Alzheimer's disease. It does not cure or slow progression. Typically cognitive ability improves within 6 to 12 months of therapy, but if stopped, cognitive progression occurs. It is recommended that treatment continue at least through the moderate stage of the illness. However, it usually is not prescribed as life-long therapy.
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?
"The nurse will explain the details of the surgery before I sign a consent." Further instruction would be needed to clarify that the physician, not the nurse, explains the details of the surgery and obtains voluntary consent for the procedure. It is correct that preoperative instructions must be followed prior to surgery for the safety of the client, medical records are present for review prior to surgery, and the physician speaks with the family following the procedure and provides instructions for discharge.
A client reports to the nurse that her grandmother with Alzheimer's disease recently moved in with her and her two school-aged children. The client states the grandmother becomes agitated and starts yelling and crying frequently. The woman asks, "What can I do?" The nurse first responds:
"What precipitates the outbursts?" A client with Alzheimer's disease may respond to exciting or confusing events with a catastrophic reaction, such as screaming, crying, or becoming abusive. The nurse needs to assess the situation and what precipitates the catastrophic reactions to best address how to prevent these events. Other nursing interventions include telling the client's granddaughter to remain calm and to distract the grandmother with quiet music, stroking, or both
When developing a teaching plan for a patient scheduled for ambulatory surgery with epidural anesthesia, which of the following would the nurse include?
"You shouldn't experience a headache after this type of anesthesia." With epidural anesthesia, a headache usually does not occur. If the dura mater is punctured during epidural anesthesia and the anesthetic travels toward the head, high spinal anesthesia can occur, producing severe hypotension and respiratory depression and arrest, but this is a complication and not a typical reaction. The anesthetic is introduced into the epidural space surrounding the dura mater of the spinal cord; this is in contrast to spinal anesthesia, which involves injection through the dura mater into the subarachnoid space surrounding the spinal cord. It blocks sensory, motor, and autonomic functions.
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?
7-10 DAYS Aspirin, a common OTC medication that inhibits platelet aggregation, should be prudently discontinued 7 to 10 days before surgery; otherwise, the client may be at increased risk for bleeding.
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?
<30 mL If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL per hour are reported; if the patient is voiding, an output of less than 240 mL per 8-hour shift is reported.
The nurse expects informed consent to be obtained for insertion of:
A gastrostomy tube Informed consent is required for invasive procedures that require sedation and are associated with more than usual risk to the client.
What measurement should the nurse report to the physician in the immediate postoperative period?
A systolic blood pressure lower than 90 mm Hg A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal.
Which of the following is the primary function of the small intestine?
Absorption Absorption is the primary function of the small intestine. Digestion occurs in the stomach. Peristalsis occurs in the colon. The duodenum secretes enzymes.
To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:
Ambulating the client as soon as possible The nurse should assist the client to ambulate as soon as the client is able. Incentive spirometry should be performed every 1 to 2 hours. The client should be positioned from side to side and in semi-Fowler's position. While assessing breath sounds is essential, it does not help to prevent pneumonia.
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 Elderly patients require lower doses of anesthetic agents because of decreased tissue elasticity and reduced lean tissue mass. An increased amount of anesthetic would be needed with an increased anxiety level. Impaired thermoregulation increases the patient's susceptibility to hypothermia.
A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?
Assessing WBC count, temperature, and wound appearance The client has an increased risk for infection related to the surgical wound, which is classified as dirty. Assessing the WBC count, temperature, and wound appearance allows the nurse to intervene at the earliest sign of infection. The client will have special nutritional needs during wound healing and needs education on safe transfer procedures, but the need to monitor for infection is a higher priority. The client should receive pain medication as soon as possible after asking, but the latest literature suggests that pain medication should be given on a schedule versus "as needed."
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
Auscultate bowel sounds If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.
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?
Blood pressure 80/50 mm Hg Assessment of a client's hydration status is essential preoperatively. The client's NPO (nothing by mouth or nil per os) status should be confirmed preoperatively. Preoperative fasting helps prevent the risk of aspiration but it also induces stress on the body, including the loss of glycogen stores, and the body sacrifices lean muscle to meet the energy needs of the surgery. This may lead to dehydration, which may be exhibited day of surgery by low blood pressure. A urine output of 60 mL/hr is within normal limits. A pulse of 88 beats per minute is within normal limits. A respiratory rate of 20 breaths per minute is within normal limits.
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?
Call the health care provider. The client presents with a possible paralytic ileus, a serious condition where the intestines are paralyzed and peristalsis is absent. This may occur as a result of surgery, especially abdominal surgery. If the nurse is unable to auscultate bowel sounds and the client has pain and a rigid abdomen, the nurse will suspect an ileus and immediately call the health care provider. Re-attempting auscultation may occur, but only after the health care provider has been notified. The health care provider may order the placement of an NG tube, however, the nurse cannot do this without the provider's order. Administering a stool softener will not help the client and may make the condition worse.
When examining the skin of a client who is dehydrated due to fluid losses from the gastrointestinal tract, which of the following would be most important?
Checking if the mucous membranes are dry
A client is scheduled for several diagnostic tests to evaluate gastrointestinal function. After teaching the client about these tests, the nurse determines that the client has understood the teaching when the client identifies which test as not requiring the use of a contrast medium?
Colonoscopy A colonoscopy is a direct visual examination of the entire large intestine. It does not involve the use of a contrast agent. Contrast medium may be used with a small bowel series, computed tomography, and upper GI series.
A nurse is obtaining the health history of a 72-year-old woman who has come to the ambulatory care center for an evaluation. When obtaining information about the woman's sleep patterns, which of the following would the nurse expect to assess?
Complaints about frequently waking up during the night Older adults tend to take longer to fall asleep, awaken more frequently and easily, and spend less time in deep sleep. They may experience variations in their normal sleep-wake cycles. Coupled with the lack of quality of sleep at night, napping during the day is a common complaint.
An elderly client reports fatigue without shortness of breath with walking 30 minutes five times each week. The nurse assesses the resting heart rate as 72 beats per minute; 10 minutes after walking, the client's heart rate is 92 beats per minute. What should the nurse instruct the client to do next?
Continue to walk at his current level. Elderly clients may report fatigue with increased activity as a result of a slower heart rate recovery, which may be a physiological response to aging. An appropriate nursing intervention is to educate the client to exercise regularly but also to pace activities. The nurse does not want to tell the client not to exercise, to walk faster, or to decrease frequency.
A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?
Cover the protruding internal organs with sterile gauze moistened with sterile saline solution. Immediately covering the wound with moistened gauze prevents the organs from drying. The gauze and the saline solution must be sterile to reduce the risk of infection. Although providing support to reduce the client's anxiety is important, it isn't the priority nursing action. The organs shouldn't be pushed back into the abdomen; doing so may tear or damage them. Evisceration requires emergency surgery; therefore, the nurse should put the client on nothing-by-mouth status immediately.
A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes?
Decreased acetylcholine level A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy elderly clients and in the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia. Norepinephrine is associated with aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic.
An older adult has lost 10% of body weight because of diet changes and exercise. The nurse would provide anticipatory guidance regarding dosage changes in which of the client's daily medications based on this weight loss?
Diazepam Some medications are affected by the percentage of body fat. Even though the client has lost 10% of total body weight, the proportion of body fat increases with age, resulting in an increased ability to store fat-soluble medications, increased accumulation of the drug in the body, and delayed excretion. Medications affected include diazepam. Aspirin and acetaminophen are not among the fat-soluble medications affected by percentage of body fat. Vitamin B and C supplements are water-soluble vitamins and would not be affected by the percentage of body fat.
Which action by the nurse demonstrates ageism?
Directing all health decisions to the older adult's child When the nurse directs all health care-related decisions to the older adult's child, the nurse is not respecting the individual choice of the older adult. The nurse is also assuming that the older adult cannot understand the decisions to be made, which is a myth about the elderly. The nurse should provide high-quality care to all clients, no matter what the age of the client. Allowing the client adequate time to complete tasks is appropriate and individualized. The older adult should be encouraged to develop routines not associated with work to decrease the potential for feeling nonproductive.
A client with Alzheimer disease becomes agitated while the nurse is attempting to take vital signs. What action by the nurse is most appropriate?
Distract the client with a familiar object or music. The nurse should try to calm the patient by using distraction with a familiar object or music. Continuing to take the vital signs will cause further agitation and possible harm to the client or nurse. Placing the client in a secluded room may increase agitation and should not be used in this situation. The nurse should document the inability to assess vital signs and the reason why this should be done after the client's basic needs have been met.
What action by the nurse best encompasses the preoperative phase?
Educating clients on signs and symptoms of infection Educating clients on preventing or recognizing complications begins in the preoperative phase. Applying SCDs and frequently monitoring vital signs happen after the preoperative phase. Only electric clippers should be used to remove hair.
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 less physiologic reserve than younger clients. The underlying principle that guides the preoperative assessment, surgical care, and postoperative care is that elderly clients have less physiologic reserve (the ability of an organ to return to normal after a disturbance in its equilibrium) than do younger clients. Elderly clients do not have larger lung capacities than younger clients. Elderly clients cannot necessarily cope better than younger clients and they often require lower doses of medications.
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 Elective surgery means that the client should have the surgery even though failure to have the surgery is not catastrophic. Urgent surgery means that prompt attention is required within 24 to 30 hours. Required surgery means that the client needs to have surgery within a few weeks or months. Emergent surgery means that the client requires immediate attention for a life-threatening disorder without delay.
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?
Encourage the client to ambulate as soon as possible after surgery. The nurse should encourage the client to ambulate as soon as possible after surgery. Ambulating stimulates peristalsis, which helps the bowels to move. It isn't appropriate to apply heat to a surgical wound. Moreover, heat application can't be initiated without a health care provider's order. A tap water enema is typically administered as a last resort after other methods fail. A health care provider's order is needed with a tap water enema as well. Notifying the health care provider isn't necessary at this point because the client is exhibiting bowel function by passing flatus.
You are caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?
Encourage the client to move legs frequently and do leg exercises. The nurse should encourage the client to move legs frequently and do leg exercises to prevent venous stasis and other circulatory complications. The nurse should not place pillows under the client's knees or calves unless ordered and should avoid placing pressure on the client's lower extremities. Placing the client in a side-lying position will not help prevent venous stasis and other circulatory complications in a client who has undergone 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 In the operating room, the sleeves of a gown are considered sterile from 2 inches above the elbow to the stockinette cuff. In addition, the gown is considered sterile in front from the chest to the level of the sterile field. When draping a table or patient, the sterile drape is held well above the surface to be covered and positioned from front to back. Circulating nurses and unsterile items contact only unsterile areas.
An older adult who is scheduled for the annual influenza vaccination has yet to receive the pneumococcal vaccination. Which action will the nurse take when the client is prescribed to receive both vaccinations?
Give the client the influenza vaccine first and then administer the pneumococcal vaccine in another site Influenza and pneumococcal vaccinations lower the risks of hospitalization and death in older adults. The influenza vaccine, which is prepared yearly to adjust for the specific immunologic characteristics of the influenza viruses at that time, should be given annually in autumn. The pneumococcal vaccine should be administered as recommended. Both of these injections can be received at the same time in separate injection sites. The vaccines are not mixed to be given as one injection. There is no reason for the client to return later to receive either the pneumococcal or influenza vaccinations.
Which would be included as a responsibility of the scrub nurse?
Handing instruments to the surgeon and assistants The responsibilities of a scrub nurse are to assist the surgical team by handing instruments to the surgeon and assistants, preparing sutures, receiving specimens for laboratory examination, and counting sponges and needles. Responsibilities of a circulating nurse include obtaining and opening wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, and coordinating activities of other personnel.
Which stage of surgical anesthesia is also known as excitement?
II Stage II is the excitement stage, which is characterized by struggling, shouting, and laughing. Stage II is often avoided if the anesthetic is administered smoothly and quickly. Stage I is the beginning of anesthesia, during which the client breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia, which is achieved by continued administration of anesthetic vapor and gas. Stage IV is medullary depression, in which the client is unconscious and lies quietly on the table.
Which stage of anesthesia is referred to as surgical anesthesia?
III Stage III may be maintained for hours with proper administration of the anesthetic. Stage I is beginning anesthesia, where the client breathes in the anesthetic mixture and experiences warmth, dizziness, and a feeling of detachment. Stage II is the excitement stage, which may be characterized by struggling, singing, laughing, or crying. Stage IV is a state of medullary depression and is reached when too much anesthesia has been administered.
Which nursing diagnosis takes highest priority for a client with hyperthyroidism?
Imbalanced nutrition: Less than body requirements related to thyroid hormone excess
An older adult female client tells the nurse, "I have lost an inch [2.5 cm] of height and have a hump on my back. What can I do about this?" What is the best response by the nurse?
In order to prevent further bone loss, eat a diet high in calcium and low in phosphorus." To promote musculoskeletal health, the nurse should tell the client to do the following: exercise regularly; eat a high-calcium diet; limit phosphorus intake; and take calcium and vitamin D supplements as prescribed.
n 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?
Inform the resident that all communication needs to remain professional. The nurse must advocate for the client, especially when the client cannot speak for themselves. By informing the resident that all communication needs to be professional, the nurse is addressing the comment at that moment in time, advocating for the client. Ignoring the comment is not appropriate. The nurse may need to address the concerns of unprofessional communication with the attending surgeon or the charge nurse if the behavior continues. The best action is to address the behavior when it happens.
An elderly female client has been taking prednisone for breathing problems for many years. The nurse notes that the client's current height is 64 inches. Two years ago, her height was 66 inches. The nurse assesses this loss in height is most likely the result of
Loss of bone density Elderly clients experience decreased bone density; they also may experience a loss of bone density from insufficient exercise. For this client, however, additional information indicates that she is taking prednisone, which may induce osteoporosis (loss of bone density). No information indicates that the client is not exercising or has experienced degeneration of bone joints. Degeneration in the efficiency of the bone joints and decreased muscle mass and joint cartilage would have more of an effect on increased pain than on decreased height.
An older adult was diagnosed with Alzheimer disease 2 years ago and the disease has progressed at an increasing pace in recent months. The client has lost 7.5 kg (16 pounds) over the past 3 months, leading to a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements. What intervention should the nurse include in this client's plan of care?
Offer the client only one food item at a time to promote focused eating. To avoid any "playing" with food, one dish should be offered at a time. Foods should be familiar and appealing, not bland. Tube feeding is not likely necessary at this time and a reward system is unlikely to be beneficial.
Why are IV solutions usually given at a slower rate to older adults?
Older adults may have cardiac or renal disorders. IV solutions usually are given at a slower rate to older adults because these clients usually have cardiac or renal disorders. Veins of older adults tend to be rigid and they have poor skin turgor, making venipuncture difficult; however, this factor does not affect infusion. Older adults do not find infusion more painful than other clients.
The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?
Ondansetron Ondansetron (Zofran) is used to treat nausea and vomiting.
Which of the following is an enzyme secreted by the gastric mucosa?
Pepsin Pepsin is secreted by the gastric mucosa. Trypsin is secreted by the pancreas. The salivary glands secrete ptyalin. The liver and gallbladder secrete bile.
The nurse recognizes that written informed consent is required for insertion of a(n)
Peripherally-inserted central catheter. Nonsurgical invasive procedures, such as insertion of a peripherally-inserted central catheter, that carry more than a slight risk to the client require written informed consent.
A client undergoing a diagnostic examination for gastrointestinal disorder was given polyethylene glycol/electrolyte solution as a part of the test preparation. Which of the following measures should the nurse take once the solution is administered?
Permit the client to drink only clear liquids. After polyethylene glycol/electrolyte solution is administered, the client should have clear liquids because this ensures watery stools, which are necessary for procedures like a barium enema. Allowing the client to ingest a fat-free meal is used in preparation for oral cholecystography. Instructing the client to have low-residue meals is a pretest procedure for barium enema. A client is offered saline gargles after esophagogastroduodenoscopy.
In what phase of postanesthesia care (PACU) is the client prepared for self-care or care in the hospital or an extended care setting?
Phase II PACU In some hospitals and ambulatory surgical centers, postanesthesia care is divided into three phases. In the phase I PACU, used during the immediate recovery phase, intensive nursing care is provided. In the phase II PACU, the patient is prepared for self-care or care in the hospital or an extended care setting. In phase III PACU, the patient is prepared for discharge. There is no phase IV PACU.
A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?
Pink to red and soft, noting that it bleeds easily Second-intention healing (granulation) occurs in infected wounds or in wounds in which the edges have not been approximated. Gradually, the necrotic material disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue. Healing is complete when skin cells grow over these granulations.
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 Hyperkalemia places the client at risk for surgical complications. The sodium level, calcium level, and white blood cell count are within normal limits.
A patient is to receive local anesthesia in combination with epinephrine. The nurse understands that epinephrine is used for which reason?
Prolongs the local action Epinephrine is added to a local anesthetic to constrict the blood vessels, which prevents rapid absorption of the local anesthetic agent and thus prolongs its local action. Rapid absorption of the anesthetic into the blood stream could cause seizures. Epinephrine does not reduce the amount of anesthetic needed. It also does not prevent anaphylaxis.
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. Older adult clients are at higher risk for complications from anesthesia and surgery compared with younger adult clients due to several factors. One factor is age-related decline in physiological reserve that weakens the normal response to stressors, acute illness, anesthesia, and surgery. Nursing management for the older surgical client in the intraoperative period includes careful transferring and positioning in the OR bed by protecting pressure points and bony prominences with extra padding. Intraoperative warming techniques should be used to reduce unintentional hypothermia during the case. Blood loss is to be accurately measured and not estimated. Antiembolic stockings are to be used during the case to prevent the development of venous thromboemboli.
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?
Reinforcing the dressing or applying pressure if bleeding is frank The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply will not help manage and minimize hemorrhage and shock. Monitoring vital signs every 15 minutes is an appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to determine the extent and progression of the problem.
A client is scheduled for bowel resection with anastomosis involving the large intestine. Because of the surgical site, the nurse formulates the nursing diagnosis of Risk for infection. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?
Related to the presence of bacteria at the surgical site The nurse should add "Related to the presence of bacteria at the surgical site" to the diagnosis of Risk for infection. The large intestine normally contains bacteria because its alkaline environment permits growth of organisms that putrefy and break down remaining proteins and indigestible residue. These organisms include Escherichia coli, Aerobacter aerogenes, Clostridium perfringens, and Lactobacillus. Although bowel resection with anastomosis is considered major surgery, it poses no greater risk of infection than any other type of major surgery. Malnutrition seldom follows bowel resection with anastomosis because nutritional absorption (except for some water, sodium, and chloride) is completed in the small intestine. An NG tube is placed through a natural opening, not a wound, and therefore doesn't increase the client's risk of infection.
A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?
Request that the surgeon come and answer the questions. It is the physician's responsibility to provide information pertaining to risks and benefits of surgery. It is not the responsibility of the nurse or nurse manager to discuss risks and benefits. The consent form should not be placed in the medical record until all of the client's questions are answered fully.
A postanesthesia care unit (PACU) nurse is preparing to discharge a client home following ankle surgery. The client keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate?
Review the instructions with the client and an accompanying adult. The effects of anesthesia may impair a client's memory or concentration. It is important that the discharge instructions are covered with the client and an accompanying adult. Giving the instructions to a 16-year-old is not appropriate. Repeating the instructions until the client restates them does not ensure that the client will remember them, because anesthesia can impair memory. Asking whether the client understands the instructions only elicits an yes or no answer; it does not give insight into whether the client comprehends the instructions.
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?
Risk for perioperative positioning injury related to positioning in the OR Pressure ulcers, nerve and blood vessel damage, impeded respiration, hyperextended joints, and discomfort are risks associated with the prolonged, awkward positioning required for some surgical procedures. The other choices are also potential nursing diagnoses or concerns related to surgery, but they are not related to the duration of the surgery.
A client receiving moderate sedation for a minor surgical procedure begins to vomit. What should the nurse do first?
Roll the client onto his or her side. The client must be rolled to the side to prevent aspiration. All the other interventions are correct for a sedated client who is vomiting, but the highest priority is preventing aspiration.
Which zone of the surgical area only requires attire in the form of scrub clothes and caps?
Semi-restricted zone The semi-restricted zone is where attire consists of scrub clothes and caps. The unrestricted zone is where street clothes are allowed. The restricted zone is where scrub clothes, shoe covers, caps, and masks are worn. The surgeons and other surgical team members wear additional sterile clothing and protective devices during the operation.
A nurse is caring for a client in acute addisonian crisis. Which test result does the nurse expect to see?
Serum potassium level of 6.8 mEq/L A serum potassium level of 6.8 mEq/L indicates hyperkalemia, which can occur in adrenal insufficiency as a result of reduced aldosterone secretion. A BUN level of 2.3 mg/dl is lower than normal. A client in addisonian crisis is likely to have an increased BUN level because the glomerular filtration rate is reduced. A serum sodium level of 156 mEq/L indicates hypernatremia. Hyponatremia is more likely in this client because of reduced aldosterone secretion. A serum glucose level of 236 mg/dl indicates hyperglycemia. This client is likely to have hypoglycemia caused by reduced cortisol secretion, which impairs glyconeogenesis.
A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?
Splint the incision site using a pillow during deep breathing and coughing exercises. Splinting the incision site will help decrease pain and support the incision. This will increase compliance with the deep breathing and coughing exercises that assist in preventing respiratory complications. Pain medication should be taken regularly, not only before deep breathing and coughing exercises. Deep breathing and coughing exercises should be done at least every 2 hours, more frequently if possible. While some clients will find the exercises relaxing, most clients find it painful to complete them.
Which client would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period?
The 35-year-old client with non-insulin dependent diabetes. The client with diabetes is at risk for complications during the intraoperative or postoperative period. Hypoglycemia can develop during anesthesia or from inadequate carbohydrate intake or excess insulin administration postoperatively. Hyperglycemia can increase the risk for wound infection and delay wound healing. Smokers are encouraged to stop 4 to 8 weeks before surgery. Recent illicit drug use can increase the risk for adverse reactions to anesthesia. Healthy older adults are not at increased risk.
A nurse is assessing the postoperative client on the second postoperative day. What assessment finding requires the nurse to immediately notify the health care provider?
The client has an absence of bowel sounds. A nursing assessment finding of concern on the second postoperative day is the absence of bowel sounds, which may indicate a paralytic ileus. Other assessment findings may include abdominal pain and distention as fluids, solids, and gas do not move through the intestinal tract. Rales in the bases are a frequent finding postoperatively, especially if general anesthesia was administered. Encourage the client to cough and breathe deep. Pain is a common symptom following a surgical procedure. Serous drainage on the postoperative dressing needs to monitored and brought to the physician's attention when assessing the client.
A client recovering from surgery reports pain as 9 on a scale from 0 to 10. Which goal for pain control will the nurse identify as realistic for this client?
The client will be able to tolerate pain experienced Most clients experience some pain after a surgical procedure. Complete absence of pain in the area of the surgical incision may not occur for a few weeks, depending on the site and nature of the surgery. The degree and severity of postoperative pain and the client's tolerance for pain depend on the incision site, the nature of the surgical procedure, the extent of surgical trauma, the type of anesthesia, and the route of administration. A realistic goal for postoperative pain management is toleration rather than the elimination of pain. In the postoperative setting, the intravenous route is the first route of administration for analgesics as it acts the most quickly. A preventative approach should be used for pain medication. With this approach, the medication is given at prescribed intervals rather that when the pain becomes severe or unbearable.
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?
The edges of a sterile package, once opened, are considered unsterile. To maintain surgical asepsis, the edges of a sterile package, once opened, are considered unsterile. When moving around a sterile field, individuals must maintain a distance of at least 1 foot from the sterile field. If a tear occurs in a sterile drape, it must be replaced. Only scrubbed personnel and sterile items may come in contact with sterile areas. Circulating nurses can only contact unsterile areas.
What action during a surgical procedure requires immediate intervention by the circulating nurse?
The scrub nurse calling the blood bank to obtain blood products The scrub nurse is "scrubbed" in and should only come in contact with sterile equipment. Using the phone to call the blood bank is the responsibility of the circulating nurse and it would break the sterility of the scrub nurse. The surgeon has "scrubbed" in and should only touch items within the sterile field. The anesthesiologist should monitor blood gas levels as needed, and it is appropriate for the registered nurse's first assistant to suture the surgical wound.
A client is to have an upper GI procedure with barium ingestion and abdominal ultrasonography. While scheduling these diagnostic tests, the nurse must consider which factor?
The ultrasonography should be scheduled before the GI procedure. Both an upper GI procedure with barium ingestion and an ultrasonography may be completed on the same day. The ultrasonography test should be completed first, because the barium solution could interfere with the transmission of the sound waves. The ultrasonography test uses sound waves that are passed into internal body structures, and the echoes are recorded as they strike tissues. Fluid in the abdomen prevents transmission of ultrasound.
A client vomits postoperatively. What is the most important nursing intervention?
Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs. When a client vomits, the nurse should turn the client's head to the side to prevent aspiration; the vomitus is collected in the emesis basin. Measuring the vomitus is not helpful to the client. Offering fluids is not advised with vomiting. Supporting the wound is important, but not a priority with vomiting.
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?
Up to 72 hours after alcohol withdrawal Alcohol withdrawal delirium is associated with a significant mortality rate when it occurs postoperatively. Onset of symptoms depends on when alcohol was last consumed. Twenty-four hours is too short a time frame to consider alcohol withdrawal delirium as no longer a threat to a chronic alcoholic.
A client is brought to the operating room for an elective surgery. What is the priority action by the circulating nurse?
Verify the consent Surgery cannot be performed without consent. Documentation of the start of surgery can only happen once the surgery has started. Blood products must be administered within an allotted time frame and therefore should not be acquired unless needed. The sponge and syringe count is a safety issue that should be completed before surgery and while the wound is being sutured, but if the client has not consented, the surgery should not take place.
A client is transferred from the postanesthesia care unit (PACU) to an inpatient care unit. What will the nurse assess first?
breathing The nurse will assess the client being transferred from the PACU to an inpatient care unit. The priority is to assess breathing and administer oxygen if prescribed because this provides a baseline and helps identify for the development of respiratory distress. Pain level is assessed after the surgical site and level of consciousness are assessed.
The nurse recognizes that the older adult is at risk for surgical complications due to:
decreased renal function Renal function declines with age, resulting in slowed excretion of waste products and anesthetic agents.
An older adult seeks medical attention for a new onset of epigastric distress and bilateral arm pain. Which action will the nurse complete?
assess cardiovascular function Careful assessment of older adults is necessary because they often present with different symptoms than those seen in younger clients. Rather than the typical substernal chest pain associated with myocardial ischemia, older adults may report burning or sharp pain or discomfort in an area of the upper body. When a client reports symptoms related to digestion and breathing and upper extremity pain, cardiac disease must be considered. Because the absence of chest pain in an older client is not a reliable indicator of the absence of heart disease, the client should not be encouraged to ambulate or recommended to take an over-the-counter antacid. Time should not be wasted reviewing the contents of the client's most recent meal.
The OR personnel responsible for maintaining the safety of the client and the surgical environment is the:
circulating nurse The circulating nurse is responsible for maintaining the safety of the client and the surgical environment.
What medication should the nurse prepare to administer in the event the client has malignant hyperthermia?
dantrolene sodium Anesthesia and surgery should be postponed. However, if end-tidal carbon dioxide (CO2) monitoring and dantrolene sodium (Dantrium) are available and the anesthesiologist is experienced in managing malignant hyperthermia, the surgery may continue using a different anesthetic agent.
Which is an age-related change associated with the cardiovascular system?
decreased cardiac output Age-related changes associated with the cardiovascular system include decreased cardiac output, increased blood pressure, decreased compliance of the heart muscle, and thickening of the heart valves.
When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as
emergency Emergency surgery means that the client requires immediate attention and the disorder may be life threatening. Urgent surgery means that the client requires prompt attention within 24 to 30 hours. Required surgery means that the client needs to have surgery, and it should be planned within a few weeks or months. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.
Which term refers to the protrusion of abdominal organs through the surgical incision?
evisceration Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.
The family of an older adult seeks medical attention for the client because of an increase in inappropriate responses and avoidance of social interactions. On which body area will the nurse focus when assessing the client?
hearing Presbycusis is a gradual sensorineural loss that progresses from loss of the ability to hear high-frequency tones to a generalized loss of hearing. Hearing loss may cause older adults to respond inappropriately, misunderstand conversations, and avoid social interaction. This behavior may be erroneously interpreted as confusion. The nurse should focus on assessing the client's hearing. Inappropriate responses and avoidance of social interaction are not assessment findings associated with changes in the digestive, genitourinary, or respiratory systems.
Which term describes a gastric secretion that combines with vitamin B12 so that it can be absorbed?
intrinsic factor Intrinsic factor, secreted by the gastric mucosa, combines with dietary vitamin B12 so that the vitamin can be absorbed in the ileum. In the absence of intrinsic factor, vitamin B12 cannot be absorbed and pernicious anemia results. Amylase is an enzyme that aids in the digestion of starch. Pepsin, an important enzyme for protein digestion, is the end product of the conversion of pepsinogen from the chief cells. Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein.
As a circulating nurse, what task are you solely responsible for?
keeping records The circulating nurse wears OR attire but not a sterile gown. Responsibilities include obtaining and opening wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, receiving specimens for laboratory examination, and coordinating activities of other personnel, such as the pathologist and radiology technician. It is the responsibility of the scrub nurse to hand instruments to the surgeon and count sponges and needles. It is the responsibility of the surgeon to estimate blood loss.
One of the most frequently occurring complications (55% occurrence) of primary hyperparathyroidism is:
kidney stones Kidney stones occur in 55% of patients with primary hyperparathyroidism. They are caused by renal damage from the precipitation of calcium phosphate in the renal pelvis and parenchyma.
The nurse recognizes the client has reached stage III of general anesthesia when the client:
lies quietly on the table Understanding the stages of anesthesia is necessary for nurses because of the emotional support that the client may need. Stage III or surgical anesthesia is reached when the patient is unconscious and lies quietly on the table. The pupils are small but constrict when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. Clients in stage I of anesthesia may have a ringing, roaring, or buzzing in the ears and, although still conscious, may sense an inability to move the extremities easily. These sensations can result in agitation. Stage II of anesthesia is characterized variously by struggling, shouting, talking, singing, laughing, or crying, and is often avoided if IV anesthetic agents are given smoothly and quickly. Stage IV is reached if too much anesthesia is given. Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer constrict when exposed to light. Cyanosis develops and, without prompt intervention, death rapidly follows. If this stage develops, the anesthetic agent is discontinued immediately and respiratory and circulatory support is initiated to prevent death.
The nurse understands that the purpose of the "time out" is to:
maintain the safety of the client Verification of the identification of the client, procedure, and operative site are essential to maintain the safety of the client.
Hypothermia may occur as a result of
open body wounds Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open wounds or cavities, decreased muscle activity, advanced age, or particular pharmaceutical agents.
What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?
pneumonia Older clients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Delirium, pneumonia, decline in functional ability, exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and falls are all threats to recovery in the older adult.
What complication is the nurse aware of that is associated with deep venous thrombosis
pulmonary embolism Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010).
When assessing an older adult, the nurse anticipates an increase in which component of respiratory status?
residual lung volume With an increase in residual lung volume the client experiences fatigue and breathlessness with sustained activity. The nurse anticipates decreased vital capacity. The nurse anticipates decreased gas exchange and diffusing capacity resulting in impaired healing of tissues due to decreased oxygenation. The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.
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?
tolerance Postoperative ambulatory activities are essential but planned according to the older adult's tolerance, which usually is less than that of a younger person. The respiratory depressive effects should be considered when administering certain drugs for the older adults. The convalescent period usually is longer for older adults. Therefore, they may require positive reinforcement throughout the postoperative period as well as extensive discharge planning. The convalescent period of older adults and detailed medication history may not be necessary to consider when planning the postoperative ambulatory activities.
The client describes a test previously completed to detect a small bowel obstruction prior to admission to the hospital. The client states that the test involved insertion of a tube through the nose and lasted over 6 hours. The nurse determines which test name should be documented?
upper GI enteroclysis Enteroclysis is a double contrast study where a duodenal tube is inserted and 500 to 1000 mL of thin barium sulfate suspension and then methylcellulose is infused. Fluoroscopy is used to visualize the filling of the intestinal loops over a period of up to 6 hours. The test is used for detection of small bowel obstruction and diverticuli. Abdominal ultrasound, magnetic resonance imaging, and positron emission tomography do not involve insertion of a duodenal tube.
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 In caring for a postoperative client, the nurse is correct to correlate hyperglycemia with an increased risk of surgical incision infections and delayed wound healing. Strict control of glycemic blood levels at the therapeutic range of 80-110 mg/dL would reduce this risk factor. There is no direct correlation between blood glucose levels and nutrient deficiencies, respiratory complications, or liver dysfunction.
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 Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.
