Med/Surg- Ch. 14

A new peri-operative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.)

1. Infection 2. Serious cardiac events 3. Thromboembolism

A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate?

Be sure to wash the area where you will have surgery very thoroughly

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care?

Older adult who lives at home despite some memory loss

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team?

Potassium: 2.9 mEq/L

A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client?

Raise the side rails on the bed

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met?

There is no redness, warmth, or drainage at the insertion site

A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.)

1. Allow the client to assume a position of comfort 2. Allow the clients family to remain at the bedside 3. Provide warm blankets or cool washcloths as desired 4. Pull the curtains around the bed to provide privacy

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.)

1. Check that consent is on the chart 2. Ensure the client has an armband on 3. Have the client help mark the surgical site 4. Allow the client to use the toilet before giving sedation

A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.)

1. Decreased cardiac output 2. Decreased oxygenation 3. Frequent nocturia 4. Mobility alterations

A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.)

1. Liver biopsy: diagnostic 2. Total shoulder replacement: restorative

A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.)

1. Metformin (Glucophage) 2. Phenytoin (Dilantin) 3. Pilocarpine hydrochloride (Isopto Carpine) 4. Warfarin (Coumadin)

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.)

1. Morbidly obese client 2. Client who underwent a prolonged surgical procedure 3. Client with severe heart failure 4. Wheelchair-bound client

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best?

Consult the surgeon about a postoperative dietitian referral

A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.)

1. A malnourished client will have fragile skin 2. Many drugs are bound to protein in the body 3. Protein stores are needed for wound healing 4. Weakness and fatigue are common in malnutrition

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best?

Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?

Assess the client for anxiety

A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best?

Ask the client to describe current feelings

An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment?

Change in behavior

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best?

Demonstrate how to splint the incision

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best?

Do not have the client sign the consent and call the surgeon

A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate?

Explain the rationale for giving the medicine now

A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)?

Give the client a back rub

A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best?

A rapid heart rate requires more effort by the heart

A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best?

Give the client a bedpan or urinal to use

A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best?

It helps prevent ulcers from the stress of the surgery

A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client?

Metoclopramide (Reglan)

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team?

Use of multiple herbs and supplements