NSG 502_WK 4_PERIOPERATIVE CARE

2. A patients blood pressure in the PACU has dropped from an admission blood pressure of 138/84 to 100/58 with a pulse change of 68 to 94. SpO2 is 98% on 3L of oxygen. In which order should the nurse take these actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Raise the IV infusion rate. b. Assess the patients dressing. c. Increase the oxygen flow rate. d. Check the patients temperature.

ANS: A, C, B, D The first nursing action should be to increase the IV infusion rate. Since the most common cause of hypotension is volume loss, the IV rate should be increased. The next action should be to increase the oxygen flow rate to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient should be assessed for vasodilation caused by rewarming.

1. A patient complains of dizziness when ambulating in the room on the first postoperative day. In what order will the nurse accomplish the following activities? (All the activities are appropriate.) Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Take the patients blood pressure (BP). b. Have the patient sit down in a chair. c. Give the patient something to drink. d. Notify the patients health care provider.

ANS: B, A, C, D The first priority for the patient with syncope is to prevent a fall, so the patient should be assisted to a chair. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the fluid intake will help prevent orthostatic dizziness. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no urgent need to notify the health care provider.

A child with congestive heart failure is placed on a maintenance dosage of digoxin (Lanoxin). The dosage is 0.07 mg/kg/day, and the child's weight is 7.2 kg. The physician prescribes the digoxin to be given once a day by mouth. Each dose will be _____ milligrams. (Record your answer below using one decimal place.)

ANS: 0.5 Calculate the dosage by weight: 0.07 mg/day × 7.2 kg = 0.5 mg/day.

A physician's prescription reads, "ampicillin sodium 125 mg IV every 6 hours." The medication label reads, "1 g = 7.4 ml." A nurse prepares to draw up _____ milliliters to administer one dose. (Round your answer to two decimal places.)

ANS: 0.93 Convert 1 g to milligrams. In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal point three places to the right. 1 g = 1000 mg Formula: Desired × Volume = 125 mg/1000 mg × 7.4 ml = 0.925 round to 0.93 ml. Available

A 6-month-old infant is admitted to the pediatric unit with respiratory syncytial virus (RSV). The nurse places the infant on strict intake and output. The infant is in a size #2 diaper and the dry weight is 24 g. At the end of the shift, the infant has had two diapers with urine. One diaper weighed 56 g and one weighed 65 g. What is the total milliliter output for the shift? (Record your answer as a whole number below.)

ANS: 73 1 g of wet diaper weight = 1 ml of urine. The dry weight of the diaper is 24 g. 56 g - 24 g = 32 ml. 65 g - 24 g = 41 ml. 32 ml + 24 ml = 73 ml total output for the shift.

Which statement by a patient scheduled for surgery is most important to report to the health care provider? a. "I had a heart valve replacement last year." b. "I had bacterial pneumonia 3 months ago." c. "I have knee pain whenever I walk or jog." d. "I have a strong family history of breast cancer."

ANS: A A patient with a history of valve replacement is at risk for endocarditis associated with invasive procedures and may need antibiotic prophylaxis. A current respiratory infection may affect whether the patient should have surgery, but a history of pneumonia is not a reason to postpone surgery. The patient's knee pain is the likely reason for the surgery. A family history of breast cancer does not have any implications for the current surgery

17. The nurse is obtaining the health history for a patient who is scheduled for outpatient knee surgery. Which statement by the patient is most important to report to the health care provider? a. I had a heart valve replacement last year. b. I had bacterial pneumonia 6 months ago. c. I have knee pain whenever I walk or jog. d. I have a strong family history of breast cancer.

ANS: A A patient with a history of valve replacement is at risk for endocarditis associated with invasive procedures and may need antibiotic prophylaxis. A current respiratory infection may affect whether the patient should have surgery, but a history of pneumonia is not a reason to postpone surgery. The patients knee pain is the likely reason for the surgery. A family history of breast cancer does not have any implications for the current surgery.

16. When caring for a patient during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 100.8 F. Which action should the nurse take first? a. Have the patient use the incentive spirometer. b. Assess the surgical incision for redness and swelling. c. Administer the ordered PRN acetaminophen (Tylenol). d. Notify the patients health care provider about the fever.

ANS: A A temperature of 100.8 F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because evidence of wound infection does not usually occur before the third postoperative day, assessment of the incision is not likely to be useful.

7. On the day of surgery, the nurse is admitting a patient with a history of cigarette smoking. Which action is most important at this time? a. Auscultate for adventitious breath sounds. b. Ask whether the patient has smoked recently. c. Remind the patient about harmful effects of smoking. d. Calculate the cigarette smoking history in pack-years.

ANS: A Abnormal breath sounds may indicate the presence of an acute respiratory infection or chronic lung disease that will affect the choice of anesthesia and/or proceeding with the scheduled surgery. The other nursing actions also are appropriate but will not affect the immediate surgical procedure as much as the presence of abnormal breath sounds.

When liquid medication is given to a crying 10-month-old infant, which approach minimizes the possibility of aspiration? a. Administer the medication with a syringe (without needle) placed along the side of the infant's tongue. b. Administer the medication as rapidly as possible with the infant securely restrained. c. Mix the medication with the infant's regular formula or juice and administer by bottle. d. Keep the child upright with the nasal passages blocked for a minute after administration.

ANS: A Administer the medication with a syringe without needle placed along the side of the infant's tongue. The contents are administered slowly in small amounts, allowing the child to swallow between deposits. Medications should be given slowly to avoid aspiration. The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking or eating, it is difficult to determine how much medication was consumed. Essential foods also should not be used. Holding the child's nasal passages will increase the risk of aspiration.

A patient arrives at the ambulatory surgery center for a scheduled laparoscopy procedure in outpatient surgery. Which information is of most concern to the nurse? a. The patient is planning to drive home after surgery. b. The patient had a sip of water 4 hours before arriving. c. The patient's insurance does not cover outpatient surgery. d. The patient has not had surgery using general anesthesia before.

ANS: A After outpatient surgery, the patient should not drive home and will need assistance with transportation and home care. The patient's experience with surgery is assessed, but it does not have as much application to the patient's physiologic safety. The patient's insurance coverage is important to establish, but this is not usually the nurse's role or a priority in nursing care. Having clear liquids a few hours before surgery does not usually increase risk for aspiration

The nurse gives an injection in a patient's room. The nurse should perform which intervention with the needle for disposal? a. Dispose of syringe and needle in a rigid, puncture-resistant container in the patient's room. b. Dispose of syringe and needle in a rigid, puncture-resistant container in an area outside of the patient's room. c. Cap needle immediately after giving injection and dispose of in a proper container. d. Cap needle, break from syringe, and dispose of in a proper container.

ANS: A All needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant container located near the site of use. Consequently, these containers should be installed in the patient's room. The uncapped needle should not be transported to an area distant from use. Needles are disposed of uncapped and unbroken. DIF: Cognitive Level: Apply REF: p. 590 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control

A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, what is the nurse's best action? a. Prepare child for conscious sedation during the test. b. Set up a tray with equipment the same size as for adults. c. Reassure the parents that the test is simple, painless, and risk free. d. Apply EMLA to the puncture site 15 minutes before the procedure.

ANS: A Because of the urgency of the child's condition, conscious sedation should be used for the procedure. Pediatric spinal trays have smaller needles than do adult trays. Reassuring the parents that the test is simple, painless, and risk free is incorrect information. A spinal tap does have associated risks, and analgesia will be given for the pain. EMLA (a eutectic mixture of anesthetics) should be applied approximately 60 minutes before the procedure. The emergency nature of the spinal tap precludes its use.

13. A patient who is just waking up after having a general anesthetic is agitated and confused. Which action should the nurse take first? a. Check the O2 saturation. b. Administer the ordered opioid. c. Take the blood pressure and pulse. d. Notify the anesthesia care provider.

ANS: A Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action.

The nurse is teaching a mother how to perform chest physical therapy and postural drainage on her 3-year-old child, who has cystic fibrosis. How should the nurse instruct the mother? a. Cover the skin with a shirt or gown before percussing. b. Strike the chest wall with a flat-hand position. c. Percuss over the entire trunk anteriorly and posteriorly. d. Percuss before positioning for postural drainage.

ANS: A For postural drainage and percussion, the child should be dressed in a light shirt to protect the skin and placed in the appropriate postural drainage positions. The chest wall is struck with a cupped-hand, not a flat-hand position. The procedure should be done over the rib cage only. Positioning precedes the percussion.

13. A patients family history reveals that the patient may be at risk for malignant hyperthermia (MH) during anesthesia. The nurse explains to the patient that a. anesthesia can be administered with minimal risks with the use of appropriate precautions and medications. b. as long as succinylcholine (Anectine) is not administered as a muscle relaxant, the reaction should not occur. c. surgery must be performed under local anesthetic to prevent development of a sudden, extreme increase in body temperature. d. surgery will be delayed until the patient is genetically tested to determine whether he or she is susceptible to malignant hyperthermia.

ANS: A General anesthesia can be administered to patients with MH as long as precautions to avoid MH are taken and preparations are made to treat MH if it does occur. Other factors besides succinylcholine administration are associated with MH. Predictions about whether MH will occur based on family history are inconsistent, and it may not be possible to delay surgery.

11. A patient with a dislocated shoulder is prepared for a closed, manual reduction of the dislocation with monitored anesthesia care (MAC). The nurse anticipates the administration of a. IV midazolam (Versed). b. inhaled desflurane (Suprane). c. epidural lidocaine (Xylocaine). d. eutectic mixture of local anesthetics (EMLA).

ANS: A IV sedatives such as the benzodiazipines are administered for MAC. Inhaled, epidural, and topical agents are not included in MAC.

Katie, 4 years old, is admitted to outpatient surgery for removal of a cyst on her foot. Her mother puts the hospital gown on her, but Katie is crying because she wants to leave on her underpants. What is the most appropriate nursing action? a. Allow her to wear her underpants b. Discuss with her mother why this is important to Katie c. Ask her mother to explain to her why she cannot wear them d. Explain in a kind, matter-of-fact manner that this is hospital policy

ANS: A It is appropriate for the child to leave her underpants on. This allows her some measure of control in this procedure, foot surgery. Further discussions may make the child more upset. Katie is too young to understand what hospital policy means. DIF: Cognitive Level: Apply REF: p. 578 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Health Promotion and Maintenance

A 6-year-old child is hospitalized for intravenous (IV) antibiotic therapy. He eats little on his "regular diet" trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. Which is the best nursing action? a. Request these favorite foods for him. b. Identify healthier food choices that he likes. c. Explain that he needs fruits and vegetables. d. Reward him with ice cream at the end of every meal that he eats.

ANS: A Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate nutrition, favorite foods should be requested for the child. These foods provide nutrition and can be supplemented with additional fruits and vegetables. Ice cream and other desserts should not be used as rewards or punishment. DIF: Cognitive Level: Apply REF: p. 608 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort

A 3-year-old child has a fever associated with a viral illness. Her mother calls the nurse, reporting a fever of 102° F even though she had acetaminophen 2 hours ago. The nurse's action should be based on which statement? a. Fevers such as this are common with viral illnesses. b. Seizures are common in children when antipyretics are ineffective. c. Fever over 102° F indicates greater severity of illness. d. Fever over 102° F indicates a probable bacterial infection.

ANS: A Most fevers are of brief duration, with limited consequences, and are viral. Little evidence supports the use of antipyretic drugs to prevent febrile seizures. Neither the increase in temperature nor its response to antipyretics indicates the severity or etiology of infection. DIF: Cognitive Level: Apply REF: p. 589 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

18. While caring for a patient who had abdominal surgery on the second postoperative day, which information about the patient is most important to communicate to the health care provider? a. The right calf is swollen, warm, and painful. b. The patients temperature is 100.3 F (37.9 C). c. The 24-hour oral intake is 600 ml greater than the total output. d. The patient complains of abdominal pain at level 6 (0-10 scale).

ANS: A The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require health care provider orders for diagnostic tests and anticoagulants. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3 F on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities.

2. Which description best defines the role of the nurse anesthetist as a member of the surgical team? a. Functions independently in the administration of anesthetics b. Has the same credentials and responsibilities as an anesthesiologist c. Is responsible for intraoperative administration of anesthetics ordered by the anesthesiologist d. Requires supervision by the anesthesiologist or surgeon while administering anesthesia to a patient

ANS: A The certified registered nurse anesthetist (CRNA) is independently responsible for all aspects of the administration of anesthetic agents. Although the responsibilities of a CRNA and an anesthesiologist have some overlap, the credentialing and roles are different. No supervision by a health care provider is necessary during anesthetic administration by a CRNA. The CRNA assesses the patient and makes the choice of anesthetic agent.

8. A preoperative patient in the holding area asks the nurse, Will the doctor put me to sleep with a mask over my face? The most appropriate response by the nurse is, a. A drug will be given to you through your IV line, which will cause you to go to sleep almost immediately. b. Only your surgeon can tell you for sure what method of anesthesia will be used. Should I ask your surgeon? c. General anesthesia is now given by injecting medication into your veins, so you will not need a mask over your face. d. Masks are not used anymore for anesthesia. A tube will be inserted into your throat to deliver a gas that will put you to sleep.

ANS: A The first step in general anesthesia is the injection of an intravenous (IV) induction agent, which rapidly induces sleep. The anesthesiologist (not the surgeon) determines the method of anesthesia used. Masks may still be used for inhalation, although many patients are intubated. Total IV anesthesia may be used for some patients but inhalation anesthetics also are commonly used.

When teaching a mother how to administer eye drops, where should the nurse tell her to place them? a. In the conjunctival sac that is formed when the lower lid is pulled down b. Carefully under the eye lid while it is gently pulled upward c. On the sclera while the child looks to the side d. Anywhere as long as drops contact the eye's surface

ANS: A The lower lid is pulled down, forming a small conjunctival sac. The solution or ointment is applied to this area. The medication should not be administered directly on the eyeball.

14. The clinic nurse reviews the complete blood cell count (CBC) results for a patient who is scheduled for surgery in a few days. The results are white blood cell count (WBC) 10.2 103/L; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 103/L. Which action should the nurse take? a. Send the CBC results to the surgery facility. b. Call the surgeon and anesthesiologist immediately. c. Ask the patient about any symptoms of a recent infection. d. Discuss the possibility of blood transfusion with the patient.

ANS: A The nurse should be sure that the CBC results, which are normal, are available at the surgical facility to avoid delay of the procedure. With normal results, there is no need to notify the surgeon or anesthesiologist, discuss blood transfusion, or ask about recent infection.

The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time? a. Auscultate for adventitious breath sounds. b. Obtain the patient's blood pressure and temperature. c. Remind the patient about harmful effects of smoking. d. Ask the health care provider about prescribing a nicotine patch.

ANS: A The nurse should first ensure a patent airway and check for breathing and circulation (airway, breathing, and circulation [ABCs]). Circulation and temperature can be assessed after a patent airway and breathing have been established. The immediate postoperative period is not the optimal time for patient teaching about the harmful effects of surgery. Requesting a nicotine patch may be appropriate, but is not a priority at this time

The nurse is preparing a 12-year-old girl for a bone marrow aspiration. The girl tells the nurse she wants her mother with her "like before." What is the most appropriate nursing action? a. Grant her request b. Explain why this is not possible c. Identify an appropriate substitute for her mother d. Offer to provide support to her during the procedure

ANS: A The parent's preferences for assisting, observing, or waiting outside the room should be assessed, along with the child's preference for parental presence. The child's choice should be respected. If the mother and child are agreeable, then the mother is welcome to stay. An appropriate substitute for the mother is necessary only if the mother does not wish to stay. Support is offered to the child regardless of parental presence. DIF: Cognitive Level: Apply REF: p. 596 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Health Promotion and Maintenance

A patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which response by the nurse is most appropriate? a. "Tell me more about what happened to your mother." b. "You will receive medications to reduce your anxiety." c. "You should talk to the doctor again about the surgery." d. "Surgical techniques have improved a lot in recent years."

ANS: A The patient's statement may indicate an unusually high anxiety level or a family history of problems such as malignant hyperthermia, which will require precautions during surgery. The other statements may also address the patient's concerns, but further assessment is needed first

1. During the preoperative interview, a patient scheduled for an elective hysterectomy tells the nurse, I am afraid that I will die in surgery like my mother did! Which response by the nurse is most appropriate? a. Tell me more about what happened to your mother. b. You will receive medications to reduce your anxiety. c. You should talk to the doctor again about the surgery. d. Surgical techniques have improved a lot in recent years.

ANS: A The patients statement may indicate an unusually high anxiety level or a family history of problems such as malignant hyperthermia, which will require precautions during surgery. The other statements also may address the patients concerns, but further assessment is needed first.

16. Which nursing action should the operating room (OR) nurse manager delegate to the registered nurse first assistant (RNFA)? a. Make surgical incisions and suture incisions as needed. b. Coordinate transfer of the patient to the operating table. c. Provide postoperative teaching about coughing to the patient. d. Set up instrument tables at the beginning of the surgical procedure.

ANS: A The role of the RNFA includes skills such as making and suturing incisions and maintaining hemostasis. The other actions should be delegated to other staff members such as the circulating nurse, scrub nurse, or surgical technician.

10. Which action should the postanesthesia care unit (PACU) nurse delegate to nursing assistive personnel (NAP) who help with the transfer of a patient to the surgical unit? a. Help with the transfer of the patient onto a stretcher. b. Give a verbal report to the surgical unit charge nurse. c. Document the appearance of the patients incision in the chart. d. Ensure that the receiving nurse understands the postoperative orders.

ANS: A The scope of practice for nursing assistants includes repositioning and moving patients under the supervision of an RN. Providing report to another RN, assessing and documenting the wound appearance, and clarifying physician orders with another RN require RN level education and scope of practice.

A patient who is scheduled for a therapeutic abortion tells the nurse, "Having an abortion is not right." Which functional health pattern should the nurse further assess? a. Value-belief b. Cognitive-perceptual c. Sexuality-reproductive d. Coping-stress tolerance

ANS: A The value-belief pattern includes information about conflicts between a patient's values and proposed medical care. In the cognitive-perceptual pattern, the nurse will ask questions about pain and sensory intactness. The sexuality-reproductive pattern includes data about the impact of the surgery on the patient's sexuality. The coping-stress tolerance pattern assessment will elicit information about how the patient feels about the surgery

5. Any patient guilt about having a therapeutic abortion may be identified when the nurse assesses the functional health pattern of a. value-belief. b. cognitive-perceptual. c. sexuality-reproductive. d. coping-stress tolerance.

ANS: A The value-belief pattern includes information about conflicts between a patients values and proposed medical care. In the cognitive-perceptual pattern, the nurse will ask questions about pain and sensory intactness. The sexuality-reproductive pattern includes data about the impact of the surgery on the patients sexuality. The coping-stress tolerance pattern assessment will elicit information about how the patient feels about the surgery.

The nurse wore gloves during a dressing change. What should the nurse do after the gloves are removed? a. Wash hands thoroughly b. Check the gloves for leaks c. Rinse gloves in disinfectant solution d. Apply new gloves before touching the next patient

ANS: A When gloves are worn, the hands are washed thoroughly after removing the gloves because both latex and vinyl gloves fail to provide complete protection. Gloves should be disposed of after use. Hands should be thoroughly washed before new gloves are applied. DIF: Cognitive Level: Apply REF: p. 612 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a child in droplet precautions. Which instructions should the nurse give to the unlicensed assistive personnel caring for this child? (Select all that apply.) a. Wear gloves when entering the room. b. Wear an isolation gown when entering the room. c. Place the child in a special air handling and ventilation room. d. A mask should be worn only when holding the child. e. Wash your hands upon exiting the room.

ANS: A, B, E Droplet transmission involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large-particle droplets (>5 mm) containing microorganisms generated from a person who has a clinical disease or who is a carrier of the microorganism. Droplets are generated from the source person primarily during coughing, sneezing, or talking and during procedures such as suctioning and bronchoscopy. Gloves, gowns, and a mask should be worn when entering the room. Hand washing when exiting the room should be done with any patient. Because droplets do not remain suspended in the air, special air handling and ventilation are not required to prevent droplet transmission.

The advantages of the ventrogluteal muscle as an injection site in young children include which considerations? (Select all that apply.) a. Less painful than vastus lateralis b. Free of important nerves and vascular structures c. Cannot be used when child reaches a weight of 20 pounds d. Increased subcutaneous fat, which increases drug absorption e. Easily identified by major landmarks

ANS: A, B, E The advantages of the ventrogluteal are being less painful, free of important nerves and vascular lateralis, and easily identified by major landmarks. The major disadvantage is lack of familiarity by health professionals and controversy over whether the site can be used before weight bearing. The use of the ventrogluteal has not been clarified. It has been used in infants, but clinical guidelines address the need for the child to be walking, thus generally being over 20 pounds. The site has less subcutaneous tissue, which facilitates intramuscular (rather than subcutaneous) deposition of the drug.

1. A 42-year-old patient is recovering from anesthesia in the postanesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure falls to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at this time is to a. increase the rate of the IV fluid replacement. b. continue to take vital signs every 15 minutes. c. administer oxygen therapy at 100% per mask. d. notify the anesthesia care provider (ACP) immediately.

ANS: B A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration.

2. A patient arrives at the ambulatory surgery center for a scheduled outpatient surgery. Which information is of most concern to the nurse? a. The patient has not had outpatient surgery before. b. The patient is planning to drive home after surgery. c. The patients insurance does not cover outpatient surgery. d. The patient had a glass of water a few hours before arriving.

ANS: B After outpatient surgery, the patient should not drive home and will need assistance with transportation and home care. The patients experience with outpatient surgery is assessed, but it does not have as much application to the patients physiologic safety. The patients insurance coverage is important to establish, but this is not usually the nurses role or a priority in nursing care. Having clear liquids a few hours before surgery does not usually increase risk for aspiration.

The nurse has just collected blood by venipuncture in the antecubital fossa. Which should the nurse do next? a. Keep the arm extended while applying a bandage to the site. b. Keep the arm extended, and apply pressure to the site for a few minutes. c. Apply a bandage to the site, and keep the arm flexed for 10 minutes. d. Apply a gauze pad or cotton ball to the site, and keep the arm flexed for several minutes.

ANS: B Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation. Pressure should be applied before bandage is applied.

11. When a patient is transferred from the postanesthesia care unit (PACU) to the clinical surgical unit, the first action by the nurse on the surgical unit should be to a. assess the patients pain. b. take the patients vital signs. c. read the postoperative orders. d. check the rate of the IV infusion.

ANS: B Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer.

A patient who has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take? a. Notify the dietitian about the food allergies. b. Alert the surgery center about a possible latex allergy. c. Reassure the patient that all allergies are noted on the medical record. d. Ask whether the patient uses antihistamines to reduce allergic reactions.

ANS: B Certain food allergies (e.g., eggs, avocados, bananas, chestnuts, potatoes, peaches) are related to latex allergies. When a patient is allergic to latex, special nonlatex materials are used during surgical procedures, and the staff will need to know about the allergy in advance to obtain appropriate nonlatex materials and have them available during surgery. The other actions also may be appropriate, but prevention of allergic reaction during surgery is the most important action

Which information in the preoperative patient's medication history is most important to communicate to the health care provider? a. The patient uses acetaminophen (Tylenol) occasionally for aches and pains. b. The patient takes garlic capsules daily but did not take any on the surgical day. c. The patient has a history of cocaine use but quit using the drug over 10 years ago. d. The patient took a sedative medication the previous night to assist in falling asleep.

ANS: B Chronic use of garlic may predispose to intraoperative and postoperative bleeding. The use of a sedative the previous night, occasional acetaminophen use, and a distant history of cocaine use will not usually affect the surgical outcome

19. Which information about medication use in a preoperative patient is most important to communicate to the health care provider? a. The patient uses acetaminophen (Tylenol) occasionally for aches and pains. b. The patient takes garlic capsules daily but did not take any on the surgical day. c. The patient has a history of cocaine use but quit using the drug over 10 years ago. d. The patient took a sedative medication the previous night to assist in falling asleep.

ANS: B Chronic use of garlic may predispose to intraoperative and postoperative bleeding. The use of a sedative the previous night, occasional acetaminophen use, and a distant history of cocaine use will not usually affect the surgical outcome.

The nurse is planning to prepare a 4-year-old child for some diagnostic procedures. Guidelines for preparing this preschooler should include which action? a. Plan for a short teaching session of about 30 minutes. b. Tell the child that procedures are never a form of punishment. c. Keep equipment out of the child's view. d. Use correct scientific and medical terminology in explanations.

ANS: B Illness and hospitalization may be viewed as punishment in preschoolers. Always state directly that procedures are never a form of punishment. Teaching sessions for this age group should be 10 to 15 minutes in length. Demonstrate the use of equipment, and allow the child to play with miniature or actual equipment. Explain procedure in simple terms and how it affects the child.

A 2-year-old child comes to the emergency department with dehydration and hypovolemic shock. Which best explains why an intraosseous infusion is started? a. It is less painful for small children. b. Rapid venous access is not possible. c. Antibiotics must be started immediately. d. Long-term central venous access is not possible.

ANS: B In situations in which rapid establishment of systemic access is vital and venous access is hampered, such as peripheral circulatory collapse and hypovolemic shock, intraosseous infusion provides a rapid, safe, lifesaving alternative. The procedure is painful, and local anesthetics and systemic analgesics are given. Antibiotics could be given when vascular access is obtained. Long-term central venous access is time-consuming, and intraosseous infusion is used in an emergency situation.

In preparing to give "enemas until clear" to a young child, the nurse should select which solution? a. Tap water b. Normal saline c. Oil retention d. Fleet solution

ANS: B Isotonic solutions should be used in children. Saline is the solution of choice. Plain water is not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid overload. Oil-retention enemas will not achieve the "until clear" result. Fleet enemas are not advised for children because of the harsh action of the ingredients. The osmotic effects of the Fleet enema can result in diarrhea, which can lead to metabolic acidosis.

15. While caring for a patient with abdominal surgery the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this finding, the nurse should first a. reinforce the dressing. b. take the patients vital signs. c. recheck the dressing in 1 hour for increased drainage. d. notify the patients surgeon of a potential hemorrhage.

ANS: B New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patients vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeons orders or institutional policy. The nurse should not wait an hour to recheck the dressing.

A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take? a. Withhold the usual scheduled insulin dose because the patient is NPO. b. Obtain a blood glucose measurement before any insulin administration. c. Give the patient the usual insulin dose because stress will increase the blood glucose. d. Administer a lower dose of insulin because there will be no oral intake before surgery.

ANS: B Preoperative insulin administration is individualized to the patient, and the current blood glucose will provide the most reliable information about insulin needs. It is not possible to predict whether the patient will require no insulin, a lower dose, or a higher dose without blood glucose monitoring

13. A diabetic patient who uses insulin to control blood glucose has been NPO since midnight before having a mastectomy. The nurse will anticipate the need to a. withhold the usual scheduled insulin dose because the patient is NPO. b. obtain a blood glucose measurement before any insulin administration. c. give the patient the usual insulin dose because stress will increase the blood glucose. d. administer a lower dose of insulin because there will be no oral intake before surgery.

ANS: B Preoperative insulin administration is individualized to the patient, and the current blood glucose will provide the most reliable information about insulin needs. It is not possible to predict whether the patient will require no insulin, a lower dose, or a higher dose without blood glucose monitoring.

Using knowledge of child development, which is the best approach when preparing a toddler for a procedure? a. Avoid asking the child to make choices. b. Demonstrate the procedure on a doll. c. Plan for the teaching session to last about 20 minutes. d. Show necessary equipment without allowing the child to handle it.

ANS: B Prepare toddlers for procedures by using play. Demonstrate on a doll, but avoid the child's favorite doll because the toddler may think the doll is really "feeling" the procedure. In preparing a toddler for a procedure, allow the child to participate in care and help whenever possible. Teaching sessions for toddlers should be about 5 to 10 minutes. Use a small replica of the equipment, and allow the child to handle it. DIF: Cognitive Level: Apply REF: p. 578 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Health Promotion and Maintenance

Several types of long-term central venous access devices are used. Which is considered an advantage of a Hickman-Broviac catheter? a. No need to keep exit site dry b. Easy to use for self-administered infusions c. Heparinized only monthly and after each infusion d. No limitations on regular physical activity, including swimming

ANS: B The Hickman-Broviac catheter has several benefits, including that it is easy to use for self-administered infusions. The exit site must be kept dry to decrease risk of infection. The Hickman-Broviac catheter requires daily heparin flushes. Water sports may be restricted because of risk of infection.

A child is receiving total parenteral nutrition (TPN; hyperalimentation). At the end of 8 hours, the nurse observes the solution and notes that 200 ml/8 hr is being infused rather than the ordered amount of 300 ml/8 hr. The nurse should adjust the rate so that how much will infuse during the next 8 hours? a. 200 ml b. 300 ml c. 350 ml d. 400 ml

ANS: B The TPN infusion rate should not be increased or decreased without the practitioner being informed because alterations in rate can cause hyperglycemia or hypoglycemia. Any changes from the prescribed flow rate may lead to hyperglycemia or hypoglycemia.

10. When the nurse caring for a patient before surgery has a question about a sedative medication to be given before sending the patient to the surgical suite, the nurse will communicate with the a. surgeon. b. anesthesiologist. c. circulating nurse. d. registered nurse first assistant (RNFA).

ANS: B The anesthesiologist is responsible for prescribing preoperative medications. The RNFA and surgeon are responsible for the surgery, but not for the preoperative sedation. The circulating nurse does not have authority to make a change in any medication.

Which is an important nursing consideration when performing a bladder catheterization on a young boy? a. Clean technique, not standard precautions, is needed. b. Insert 2% lidocaine lubricant into the urethra. c. Lubricate catheter with water-soluble lubricant such as K-Y Jelly. d. Delay catheterization for 20 minutes while anesthetic lubricant is absorbed.

ANS: B The anxiety, fear, and discomfort experienced during catheterization can be significantly decreased by preparation of the child and parents, by selection of the correct catheter, and by appropriate technique of insertion. Generous lubrication of the urethra before catheterization and use of lubricant containing 2% lidocaine may reduce or eliminate the burning and discomfort associated with this procedure. Catheterization is a sterile procedure, and standard precautions for body-substance protection should be followed. Water-soluble lubricants do not provide appropriate local anesthesia. Catheterization should be delayed 2 to 3 minutes only. This provides sufficient local anesthesia for the procedure.

17. Which of these actions included in the perioperative patient plan of care can the perioperative nurse delegate to a surgical technologist? a. Complete the patients admission assessment. b. Pass sterile instruments and supplies to the surgeon. c. Teach the patient about what to expect in the operating room (OR). d. Give the postoperative report to the postanesthesia care unit (PACU) nurse.

ANS: B The education and certification for a surgical technologist includes the scrub and circulating functions in the OR. Patient teaching, communication with other departments about a patients condition, and the admission assessment require RN level education and scope of practice.

14. A postoperative patient has not voided for 7 hours after return to the postsurgical unit. Which action should the nurse take first? a. Notify the surgeon. b. Perform a bladder scan. c. Assist the patient to ambulate to the bathroom. d. Insert a straight catheter as indicated on the PRN order.

ANS: B The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Catheterization should only be done after other measures have been tried without success because of the risk for urinary tract infection. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful.

A venipuncture will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. What information should the nurse include in her response to the child? a. It is unsafe. b. It is helpful to relax the child. c. It is against hospital policy. d. It is unnecessary because of child's age.

ANS: B The mother's preference for assisting, observing, or waiting outside the room should be assessed along with the child's preference for parental presence. The child's choice should be respected. This will most likely help the child through the procedure. If the mother and child agree, then the mother is welcome to stay. Her familiarity with the procedure should be assessed and potential safety risks identified (mother may sit in chair). Hospital policies should be reviewed to ensure that they incorporate family-centered care. The child should determine whether parental support is necessary.

Guidelines for intramuscular administration of medication in school-age children include which action? a. Inject medication as rapidly as possible. b. Insert needle quickly, using a dart like motion. c. Penetrate skin immediately after cleansing site, before skin has dried. d. Have child stand, if possible, and if child is cooperative.

ANS: B The needle should be inserted quickly in a dart like motion at a 90-degree angle unless contraindicated. Inject medications slowly. Allow skin preparation to dry completely before skin is penetrated. Place child in lying or sitting position.

8. A patient is seen at the health care providers office several weeks before hip surgery for preoperative assessment. The patient reports use of echinacea, saw palmetto, and glucosamine/chondroitin. The nurse should a. ascertain that there will be no interactions with anesthetic agents. b. discuss the supplement use with the patients health care provider. c. teach the patient that these products may be continued preoperatively. d. advise the patient to stop the use of all herbs and supplements at this time.

ANS: B The nurse should discuss the medication use with the patients health care provider because saw palmetto is used to decrease prostatic hyperplasia, and the patient may need to continue taking the medication or a prescription medication to prevent urinary retention. The nurse should not advise the patient to stop the supplements or to continue them without consulting with the health care provider. Determining the interactions between the supplements and anesthetics is not within the nurses scope of practice.

4. A 75-year-old is to be discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, I do not know if I can take care of myself with this patch over my eye. The most appropriate nursing action is to a. refer the patient for home health care services. b. discuss the specific concerns regarding self-care. c. give the patient written instructions regarding care. d. assess the patients support system for care at home.

ANS: B The nurses initial action should be to assess exactly the patients concerns about self-care. Referral to home health care and assessment of the patients support system may be appropriate actions but will be based on further assessment of the patients concerns. Written instructions should be given to the patient, but these are unlikely to address the patients stated concern about self-care.

12. An 83-year-old who had a surgical repair of a hip fracture 2 days previously has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for the patient as a. potential complication: hypovolemic shock. b. potential complication: venous thromboembolism. c. potential complication: fluid and electrolyte imbalance. d. potential complication: impaired surgical wound healing.

ANS: B The patient is older and relatively immobile, two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient.

11. Ten minutes after receiving the ordered preoperative opioid by intravenous (IV) injection, the patient asks to get up to go to the bathroom to urinate. The most appropriate action by the nurse is to a. assist the patient to the bathroom and stay with the patient to prevent falls. b. offer a urinal or bedpan and position the patient in bed to promote voiding. c. allow the patient up to the bathroom because the onset of the medication takes more than 10 minutes. d. ask the patient to wait because catheterization is performed at the beginning of the surgical procedure.

ANS: B The patient will be at risk for a fall after receiving the opioid, so the best nursing action is to have the patient use a bedpan or urinal. Having the patient get up either with assistance or independently increases the risk for a fall. The patient will be uncomfortable and risk involuntary incontinence if the bladder is full during transport to the operating room.

Five minutes after receiving the ordered preoperative midazolam (Versed) by IV injection, the patient asks to get up to go to the bathroom to urinate. Which action by the nurse is most appropriate? a. Assist the patient to the bathroom and stay with the patient to prevent falls. b. Offer a urinal or bedpan and position the patient in bed to promote voiding. c. Allow the patient up to the bathroom because medication onset is 10 minutes. d. Ask the patient to wait because catheterization is performed just before the surgery.

ANS: B The patient will be at risk for a fall after receiving the sedative, so the best nursing action is to have the patient use a bedpan or urinal. Having the patient get up either with assistance or independently increases the risk for a fall. The patient will be uncomfortable and risk involuntary incontinence if the bladder is full during transport to the operating room.

6. Data that were obtained during the perioperative nurses assessment of a patient in the preoperative holding area that would indicate a need for special protection techniques during surgery include a. a stated allergy to cats and dogs. b. a history of spinal and hip arthritis. c. verbalization of anxiety by the patient. d. having a sip of water 2 hours previously.

ANS: B The patient with arthritis may require special positioning to avoid injury and postoperative discomfort. Preoperative anxiety and having a sip of water 2 to 3 hours before surgery are not unusual for the preoperative patient. An allergy to cats and dogs will not impact the care needed during the intraoperative phase.

2. During recovery from anesthesia in the postanesthesia care unit (PACU), a patients vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take at this time? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient from the PACU. d. Increase the rate of the postoperative IV fluids.

ANS: B The patients borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable BP and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU is not appropriate.

15. As the nurse prepares a patient the morning of surgery, the patient refuses to remove a wedding ring, saying, I have never taken it off since the day I was married. The nurse should a. have the patient sign a release and leave the ring on. b. tape the wedding ring securely to the patients finger. c. tell the patient that the hospital is not liable for loss of the ring. d. suggest that the patient give the ring to a family member to keep.

ANS: B The ring can be taped to the patients finger and noted on the preoperative checklist. There is no need for a release form or to discuss liability with the patient. Wearing the ring is obviously important to the patient, so the nurse should tape the ring in place rather than have a family member keep the ring for the patient.

The nurse is preparing to witness the patient signing the operative consent form when the patient says, "I do not really understand what the doctor said." Which action is best for the nurse to take? a. Provide an explanation of the planned surgical procedure. b. Notify the surgeon that the informed consent process is not complete. c. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications. d. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure.

ANS: B The surgeon is responsible for explaining the surgery to the patient, and the nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurse's legal scope of practice to explain the surgical procedure. No preoperative medications should be administered until the patient understands the surgical procedure and signs the consent form.

9. Before the administration of preoperative medications, the nurse is preparing to witness the patient signing the operative consent form when the patient says, I do not really understand what the doctor said. Which action is best for the nurse to take? a. Provide an explanation of the planned surgical procedure. b. Notify the surgeon that the informed consent process is not complete. c. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications. d. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure.

ANS: B The surgeon is responsible for explaining the surgery to the patient, and the nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurses legal scope of practice to explain the surgical procedure. No preoperative medications should be administered until the patient signs the consent form.

3. A 36-year-old woman is admitted for an outpatient surgery. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery? a. The patients lack of knowledge about postoperative pain control measures b. The patients statement that her last menstrual period was 8 weeks previously c. The patients history of a postoperative infection following a prior cholecystectomy d. The patients concern that she will be unable to care for her children postoperatively

ANS: B This statement suggests that the patient may be pregnant, and pregnancy testing is needed before administration of anesthetic agents. Although the other data also may be communicated with the surgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery.

A 38-year-old female is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery? a. The patient's lack of knowledge about postoperative pain control measures b. The patient's statement that her last menstrual period was 8 weeks previously c. The patient's history of a postoperative infection following a prior cholecystectomy d. The patient's concern that she will be unable to care for her children postoperatively

ANS: B This statement suggests that the patient may be pregnant, and pregnancy testing is needed before administration of anesthetic agents. Although the other data may also be communicated with the surgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery

4. A patient who is scheduled for surgery in a week tells the nurse doing the preoperative assessment about an allergy to bananas, kiwifruit, and latex products. Which action is most important for the nurse to take? a. Notify the dietitian about the food allergies. b. Alert the surgery center about the latex allergy. c. Reassure the patient that all allergies are noted on the medical record. d. Ask whether the patient uses antihistamines to reduce allergic reactions.

ANS: B When a patient is allergic to latex, special nonlatex materials are used during surgical procedures and the staff will need to know about the allergy in advance to obtain appropriate nonlatex materials and have them available on the surgical date. The other actions also may be appropriate, but prevention of allergic reaction (either contact dermatitis or anaphylaxis) during surgery is the most important action.

6. Following gallbladder surgery, a patients T-tube is draining dark green fluid. Which action should the nurse take? a. Place the patient on bed rest. b. Notify the patients surgeon. c. Document the color and amount of drainage. d. Irrigate the T-tube with sterile normal saline.

ANS: C A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary.

The nurse is caring for an unconscious child. Skin care should include which action? a. Avoid use of pressure reduction on bed. b. Massage reddened bony prominences to prevent deep tissue damage. c. Use draw sheet to move child in bed to reduce friction and shearing injuries. d. Avoid rinsing skin after cleansing with mild antibacterial soap to provide a protective barrier.

ANS: C A draw sheet should be used to move the child in the bed or onto a gurney to reduce friction and shearing injuries. Do not drag the child from under the arms. Pressure-reduction devices should be used to redistribute weight. Bony prominences should not be massaged if reddened. Deep tissue damage can occur. Pressure-reduction devices should be used instead. The skin should be cleansed with mild non-alkaline soap or soap-free cleaning agents for routine bathing. DIF: Cognitive Level: Apply REF: p. 586 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort

5. After removal of the nasogastric (NG) tube on the second postoperative day, the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. Which action should the nurse take? a. Reinsert the NG tube. b. Give the PRN IV opioid. c. Assist the patient to ambulate. d. Place the patient on NPO status.

ANS: C Ambulation encourages peristalsis and the passing of flatus, which will relieve the patients discomfort. If distention persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains.

16. A patient is to receive atropine before surgery. The nurse teaches the patient to expect a. dizziness. b. weakness. c. dry mouth. d. forgetfulness.

ANS: C Anticholinergic medications decrease oral secretions, so the patient is taught that a dry mouth is an expected side effect. Weakness, forgetfulness, and dizziness are side effects associated with other preoperative medications such as opioids and benzodiazepines.

In some genetically susceptible children, anesthetic agents can trigger malignant hyperthermia. The nurse should be alert in observing that, in addition to an increased temperature, what is an early sign of this disorder? a. Apnea b. Bradycardia c. Muscle rigidity d. Decreased blood pressure

ANS: C Early signs of malignant hyperthermia include tachycardia, increasing blood pressure, tachypnea, mottled skin, and muscle rigidity. Apnea is not a sign of malignant hyperthermia. Tachycardia, not bradycardia, is an early sign of malignant hyperthermia. Increased blood pressure, not decreased blood pressure, is characteristic of malignant hyperthermia. DIF: Cognitive Level: Understand REF: p. 583 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

Tepid water or sponge baths are indicated for hyperthermia in children. What is the priority nursing action? a. Add isopropyl alcohol to the water. b. Direct a fan on the child in the bath. c. Stop the bath if the child begins to chill. d. Continue the bath for 5 minutes.

ANS: C Environmental measures such as sponge baths can be used to reduce temperature if tolerated by the child and if they do not induce shivering. Shivering is the body's way of maintaining the elevated set point. Compensatory shivering increases metabolic requirements above those already caused by the fever. Ice water and isopropyl alcohol are potentially dangerous solutions. Fans should not be used because of the risk of the child developing vasoconstriction, which defeats the purpose of the cooling measures. Little blood is carried to the skin surface, and the blood remains primarily in the viscera to become heated. The child is placed in a tub of tepid water for 20 to 30 minutes. DIF: Cognitive Level: Apply REF: p. 589 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

12. Which action will the nurse include in the plan of care immediately after surgery for a patient who received ketamine (Ketalar) as an anesthetic agent? a. Administer larger doses of analgesic agents. b. Monitor for severe slowing of the heart rate. c. Provide a quiet environment in the postanesthesia care unit. d. Avoid the use of benzodiazepines in the postoperative period.

ANS: C Hallucinations are an adverse effect associated with the dissociative anesthetics such as ketamine, so the postoperative environment should be kept quiet to decrease the risk of hallucinations. Since ketamine causes profound analgesia lasting into the postoperative period, larger doses of analgesics are not needed. Ketamine causes an increase in heart rate. Benzodiazepine use with ketamine may be used to decrease the incidence of hallucinations and nightmares.

What is an appropriate method for administering oral medications that are bitter to an infant or small child? a. Mix in a bottle of formula or milk. b. Mix with any food the child is going to eat. c. Mix with a small amount (1 teaspoon) of a sweet-tasting substance such as jam or ice cream. d. Mix with large amounts of water to dilute medication sufficiently.

ANS: C Mix the drug with a small amount (about 1 teaspoon) of sweet-tasting substance. This will make the medication more palatable to the child. The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking or eating, it is difficult to determine how much medication was consumed. Medication should not be mixed with essential foods and milk. The child may associate the altered taste with the food and refuse to eat in the future.

8. The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when the a. patient drinks 2 to 3 L of fluid in 24 hours. b. patient uses the spirometer 10 times every hour. c. patients breath sounds are clear to auscultation. d. patients temperature is less than 100.4 F orally.

ANS: C One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or wheezes, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems.

What is a nursing consideration related to the administration of oxygen in an infant? a. Humidify oxygen if the infant can tolerate it. b. Assess the infant to determine how much oxygen should be given. c. Ensure uninterrupted delivery of the appropriate oxygen concentration. d. Direct oxygen flow so that it blows directly into the infant's face in a hood.

ANS: C Oxygen is a prescribed medication. It is the nurse's responsibility to ensure that the ordered concentration is delivered and the effects of therapy are monitored. Oxygen is drying to the tissues. Oxygen should always be humidified when delivered to a patient. A child receiving oxygen therapy should have the oxygen saturation monitored at least as frequently as vital signs. Oxygen is a medication, and it is the responsibility of the practitioner to modify dosage as indicated. Humidified oxygen should not be blown directly into an infant's face.

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for abdominal surgery for an open cholecystectomy? a. Care for the surgical incision b. Medications used during surgery c. Deep breathing and coughing techniques d. Oral antibiotic therapy after discharge home

ANS: C Preoperative teaching, demonstration, and redemonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. The patient does not usually need information about medications that are used intraoperatively

10. Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for a colon resection? a. Care for the surgical incision b. Medications used during surgery c. Deep breathing and coughing techniques d. Oral antibiotic therapy after discharge home

ANS: C Preoperative teaching, demonstration, and redemonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. The patient does not usually need information about medications that are used intraoperatively.

A nurse must do a venipuncture on a 6-year-old child. What is an important consideration in providing atraumatic care? a. Use an 18-gauge needle if possible. b. If not successful after four attempts, have another nurse try. c. Restrain the child only as needed to perform venipuncture safely. d. Show the child equipment to be used before the procedure.

ANS: C Restrain the child only as needed to perform the procedure safely; use therapeutic hugging. Use the smallest-gauge needle that permits free flow of blood. A two-try-only policy is desirable, in which two operators each have only two attempts. If insertion is not successful after four punctures, alternative venous access should be considered. Keep all equipment out of sight until used.

A patient undergoing an emergency appendectomy has been using St. John's wort to prevent depression. Which complication would the nurse expect in the postanesthesia care unit? a. Increased pain b. Hypertensive episodes c. Longer time to recover from anesthesia d. Increased risk for postoperative bleeding

ANS: C St. John's wort may prolong the effects of anesthetic agents and increase the time to waken completely after surgery. It is not associated with increased bleeding risk, hypertension, or increased pain

6. During the preoperative assessment of a patient scheduled for a colon resection, the patient tells the nurse about using St. Johns wort to prevent depression. The nurse should alert the staff in the postanesthesia recovery area that the patient may a. experience increased pain. b. have hypertensive episodes. c. take longer to recover from the anesthesia. d. have more postoperative bleeding than expected.

ANS: C St. Johns wort may prolong the effects of anesthetic agents and increase the time to waken completely after surgery. It is not associated with increased bleeding risk, hypertension, or increased pain.

The nurse must suction a child with a tracheostomy. What is the appropriate technique? a. Encourage the child to cough to raise the secretions before suctioning. b. Select a catheter with diameter three-fourths as large as the diameter of the tracheostomy tube. c. Ensure each pass of the suction catheter should take no longer than 5 seconds. d. Allow the child to rest after every five times the suction catheter is passed.

ANS: C Suctioning should require no longer than 5 seconds per pass. Otherwise, the airway may be occluded for too long. If the child is able to cough up secretions, suctioning may not be indicated. The catheter should have a diameter one-half the size of the tracheostomy tube. If it is too large, it might block the child's airway. The child is allowed to rest for 30 to 60 seconds after each aspiration to allow oxygen tension to return to normal. Then the process is repeated until the trachea is clear.

The Allen test is performed as a precautionary measure before which procedure? a. Heel stick b. Venipuncture c. Arterial puncture d. Lumbar puncture

ANS: C The Allen test assesses the circulation of the radial, ulnar, or brachial arteries before arterial puncture. The Allen test is used before arterial punctures, not heel sticks, venipunctures, or lumbar punctures.

The emergency department nurse is cleaning multiple facial abrasions on a 9-year-old child whose mother is present. The child is crying and screaming loudly. What is the best nursing action? a. Ask the child to be quieter b. Have the child's mother give instructions about relaxation c. Tell the child it is okay to cry and scream d. Remove the mother from the room

ANS: C The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other emotion. The child needs to know it is all right to cry. There is no reason for the child to be quieter and feelings need to be able to be expressed. The mother should stay in the room to provide comfort to the child. DIF: Cognitive Level: Apply REF: p. 577 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Health Promotion and Maintenance

15. Which action by an inexperienced member of the surgical team requires rapid intervention by the charge nurse? a. Wearing street clothes into the nursing station b. Wearing a surgical mask into the holding room c. Walking into the hallway outside an operating room without the hair covered d. Putting on a surgical mask, cap, and scrubs before entering the operating room

ANS: C The corridors outside the OR are part of the semirestricted area where personnel must wear surgical attire and head coverings. Surgical masks may be worn in the holding room, although they are not necessary. Street clothes may be worn at the nursing station, which is part of the unrestricted area. Wearing a mask and scrubs is essential when going into the OR.

Which should the nurse consider when having consent forms signed for surgery and procedures on children? a. Only a parent or legal guardian can give consent. b. The person giving consent must be at least 18 years old. c. The risks and benefits of a procedure are part of the consent process. d. A mental age of 7 years or older is required for a consent to be considered "informed."

ANS: C The informed consent must include the nature of the procedure, benefits and risks, and alternatives to the procedure. In special circumstances, such as emancipated minors, the consent can be given by someone younger than 18 years without the parent or legal guardian. A mental age of 7 years is too young for consent to be informed. DIF: Cognitive Level: Understand REF: p. 575 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care

7. In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which action by the nurse is most helpful? a. Discuss the complications of immobility and poor cough effort. b. Teach the patient the purpose of respiratory care and ambulation. c. Administer ordered analgesic medications before these activities. d. Give the patient positive reinforcement for accomplishing these activities.

ANS: C The most essential nursing action in encouraging these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities.

7. The nurse from the general surgical unit is asked to bring the patients hearing aid to the surgical suite. The nurse will take the hearing aid to the a. clean core. b. scrub sink areas. c. nursing station or information desk. d. corridors of the operating room area.

ANS: C The nurse from the general unit would not be wearing surgical scrub attire or a head covering and would be restricted to the nursing station or information desk, which are unrestricted areas. The clean care, scrub sink area, and corridors are semirestricted areas that require staff members wear surgical scrub attire and head coverings.

The nurse plans to provide preoperative teaching to an alert older man who has hearing and vision deficits. His wife usually answers most questions that are directed to the patient. Which action should the nurse take when doing the teaching? a. Use printed materials for instruction so that the patient will have more time to review the material. b. Direct the teaching toward the wife because she is the obvious support and caregiver for the patient. c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. d. Ask the patient's wife to wait in the hall in order to focus preoperative teaching with the patient himself.

ANS: C The nurse should allow more time when doing preoperative teaching and preparation for older patients with sensory deficits. Because the patient has visual deficits, he will not be able to use written material for learning. The teaching should be directed toward both the patient and the wife because both will need to understand preoperative procedures and teaching

12. An alert 82-year-old who has poor hearing and vision is receiving preoperative teaching from the nurse. His wife answers most questions directed to the patient. Which action should the nurse take when doing the teaching? a. Use printed materials for instruction so that the patient will have more time to review the material. b. Direct the teaching toward the wife because she is the obvious support and caregiver for the patient. c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. d. Ask the patients wife to wait in the hall in order to focus preoperative teaching with the patient himself.

ANS: C The nurse should allow more time when doing preoperative teaching and preparation for older patients with sensory deficits. Because the patient has visual deficits, he will not be able to use written material for learning. The teaching should be directed toward both the patient and the wife because both will need to understand preoperative procedures and teaching.

3. After a new nurse has been oriented to the postanesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse a. places a patient in the Trendelenburg position when the blood pressure (BP) drops. b. assists a patient to the prone position when the patient is nauseated. c. turns an unconscious patient to the side when the patient arrives in the PACU. d. positions a newly admitted unconscious patient supine with the head elevated.

ANS: C The patient should initially be positioned in the lateral recovery position to keep the airway open and avoid aspiration. The prone position is not usually used and would make it difficult to assess the patients respiratory effort and cardiovascular status. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness.

5. After orienting a new staff member to the scrub nurse role, the nurse preceptor will know that the teaching was effective if the new staff member a. documents all patient care accurately. b. labels all specimens to send to the lab. c. keeps both hands above the operating table level. d. takes the patient to the postanesthesia recovery area.

ANS: C The scrub nurse role includes maintaining asepsis in the operating field. The other actions would be appropriate to the circulating nurse role.

Frequent urine testing for specific gravity and glucose are required on a 6-month-old infant. Which is the most appropriate way to collect small amounts of urine for these tests? a. Apply a urine-collection bag to the perineal area. b. Tape a small medicine cup to the inside of the diaper. c. Aspirate urine from cotton balls inside the diaper with a syringe. d. Aspirate urine from a superabsorbent disposable diaper with a syringe.

ANS: C To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper. If diapers with absorbent material are used, place a small gauze dressing or cotton balls inside the diaper to collect the urine, and aspirate the urine with a syringe. For frequent urine sampling, the collection bag would be too irritating to the child's skin. It is not feasible to tape a small medicine cup to the inside of the diaper; the urine will spill from the cup. Diapers with superabsorbent gels absorb the urine, so there is nothing to aspirate.

A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen (Tylenol). What should the nurse explain about antipyretics? a. They may cause malignant hyperthermia b. They may cause febrile seizures c. They are of no value in treating hyperthermia d. They are of limited value in treating hyperthermia

ANS: C Unlike with fever, antipyretics are of no value in hyperthermia because the set point is already normal. Cooling measures are used instead. Malignant hyperthermia is a genetic myopathy that is triggered by anesthetic agents. Antipyretic agents do not have this effect. Antipyretics do not cause seizures and are of no value in hyperthermia. DIF: Cognitive Level: Apply REF: p. 589 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies

When caring for a preoperative patient on the day of surgery, which actions included in the plan of care can the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Teach incentive spirometer use. b. Explain preoperative routine care. c. Obtain and document baseline vital signs. d. Remove nail polish and apply pulse oximeter. e. Transport the patient by stretcher to the operating room.

ANS: C, D, E Obtaining vital signs, removing nail polish, pulse oximeter placement, and transport of the patient are routine skills that are appropriate to delegate. Teaching patients about the preoperative routine and incentive spirometer use require critical thinking and should be done by the registered nurse

1. When preparing the patient for surgery, which actions will the nurse include in the surgical time-out procedure (select all that apply)? a. Check for placement of IV lines. b. Have the surgeon identify the patient. c. Confirm the hospital chart identification (ID) number. d. Have the patient state name and date of birth. e. Ask the patient to state the surgical procedure. f. Verify the patient ID band number.

ANS: C, D, E, F These actions are included in surgical time out. IV line placement and identification of the patient by the surgeon are not included in the surgical time-out procedure.

A patient has received atropine before surgery and complains of dry mouth. Which action by the nurse is best? a. Check for skin tenting. b. Notify the health care provider. c. Ask the patient about any dizziness. d. Tell the patient dry mouth is an expected side effect.

ANS: D Anticholinergic medications decrease oral secretions, so the patient is taught that a dry mouth is an expected side effect. The dry mouth is not a symptom of dehydration in this case. Therefore there is no immediate need to check for skin tenting. The health care provider does not need to be notified about an expected side effect. Weakness, forgetfulness, and dizziness are side effects associated with other preoperative medications such as opioids and benzodiazepines

9. A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patients oxygen saturation is 99%, and recent lab results are all normal. Which action by the nurse is most appropriate? a. Insert an oral or nasal airway. b. Notify the anesthesia care provider. c. Orient the patient to time, place, and person. d. Be sure that the patients IV lines are secure.

ANS: D Because the patients assessment indicates physiologic stability, the most likely cause of the patients agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should ensure patient safety through interventions such as raising the bed rails and securing IV lines. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify the ACP. Insertion of an airway is not needed because the oxygen saturation is good. Orientation of the patient is needed but is not likely to be effective until the effects of anesthesia have resolved more completely.

9. A surgical patient received a volatile liquid as an inhalation anesthetic during surgery. Postoperatively the nurse should monitor the patient for a. tachypnea. b. myoclonia. c. hypertension. d. incisional pain.

ANS: D Because volatile liquid inhalation agents are rapidly metabolized, postoperative pain occurs soon after surgery. Hypertension and tachypnea are not associated with general anesthetics. Myoclonia may occur with nonbarbiturate hypnotics but not with the inhaled inhalation agents.

The nurse must do a heel stick on an ill neonate to obtain a blood sample. What action is recommended to facilitate blood flow? a. Apply cool, moist compresses. b. Apply a tourniquet to the ankle. c. Elevate the foot for 5 minutes. d. Wrap the foot in a warm washcloth.

ANS: D Before the blood sample is taken, the heel is heated with warm moist compresses for 5 to 10 minutes to dilate the blood vessels in the area. Cooling causes vasoconstriction, making blood collection more difficult. A tourniquet is used to constrict superficial veins. It will have an insignificant effect on capillaries. Elevating the foot will decrease the blood in the foot available for collection.

The nurse obtains a health history from a patient who is scheduled for elective hip surgery in 1 week. The patient reports use of garlic and ginkgo biloba. Which action by the nurse is most appropriate? a. Ascertain that there will be no interactions with anesthetic agents. b. Teach the patient that these products may be continued preoperatively. c. Advise the patient to stop the use of all herbs and supplements at this time. d. Discuss the herb and supplement use with the patient's health care provider.

ANS: D Both garlic and ginkgo biloba increase a patient's risk for bleeding. The nurse should discuss the herb and supplement use with the patient's health care provider. The nurse should not advise the patient to stop the supplements or to continue them without consulting with the health care provider. Determining the interactions between the supplements and anesthetics is not within the nurse's scope of practice

The nurse is doing a pre-hospitalization orientation for a 7-year-old child who is scheduled for cardiac surgery. As part of the preparation, the nurse explains that she will not be able to talk because of an endotracheal tube but that she will be able to talk when it is removed. This explanation is: a. unnecessary. b. the surgeon's responsibility. c. too stressful for a young child. d. an appropriate part of the child's preparation.

ANS: D Explanation is a necessary part of preoperative preparation. If the child wakes and is not prepared for the inability to speak, she will be even more anxious. This is a necessary component for preparation for surgery that will help reduce the anxiety associated with surgery. It is a joint responsibility of nursing, medical staff, and child life personnel.

17. The nurse notes that the oxygen saturation is 88% in an unconscious patient who was transferred to the postanesthesia care unit (PACU) 10 minutes previously. Which action should the nurse take first? a. Elevate the patients head. b. Suction the patients mouth. c. Increase the oxygen flow rate. d. Perform the jaw-thrust maneuver.

ANS: D In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patients head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake.

It is important to make certain that sensory connectors and oximeters are compatible. What can incompatible wiring cause? a. Hyperthermia b. Electrocution c. Pressure necrosis d. Burns under sensors

ANS: D It is important to make certain that sensor connectors and oximeters are compatible. Wiring that is incompatible can generate considerable heat at the tip of the sensor, causing second- and third-degree burns under the sensor. Incompatibility would cause a local irritation or burn. A low voltage is used, which should not present risk of electrocution. Pressure necrosis can occur from the sensor being attached too tightly, but this is not a problem of incompatibility.

As the nurse prepares a patient the morning of surgery, the patient refuses to remove a wedding ring, saying, "I have never taken it off since the day I was married." Which response by the nurse is best? a. Have the patient sign a release and leave the ring on. b. Tape the wedding ring securely to the patient's finger. c. Tell the patient that the hospital is not liable for loss of the ring. d. Suggest that the patient give the ring to a family member to keep.

ANS: D Jewelry is not allowed to be worn by the patient, especially if electrocautery will be used. There is no need for a release form or to discuss liability with the patient

How should the nurse administer a gavage feeding to a school-age child? a. Lubricate the tip of the feeding tube with Vaseline to facilitate passage. b. Check the placement of the tube by inserting 20 ml of sterile water. c. Administer feedings over 5 to 10 minutes. d. Position the patient on the right side after administering feeding.

ANS: D Position the child with the head elevated about 30 degrees and on the right side or abdomen for at least 1 hour. This is in the same manner as after any infant feeding to minimize the possibility of regurgitation and aspiration. Insert a tube that has been lubricated with sterile water or water-soluble lubricant. With a syringe, inject a small amount of air into the tube, while simultaneously listening with a stethoscope over the stomach area. Feedings should be administered via gravity flow and take from 15 to 30 minutes to complete.

What is an appropriate intervention to encourage food and fluid intake in a hospitalized child? a. Force the child to eat and drink to combat caloric losses. b. Discourage participation in non-eating activities until caloric intake is sufficient. c. Administer large quantities of flavored fluids at frequent intervals and during meals. d. Give high-quality foods and snacks whenever the child expresses hunger.

ANS: D Small, frequent meals and nutritious snacks should be provided for the child. Favorite foods such as peanut butter and jelly sandwiches, fruit yogurt, cheese, pizza, and macaroni and cheese should be available. Forcing a child to eat only meets with rebellion and reinforces the behavior as a control mechanism. Large quantities of fluid may decrease the child's hunger and further inhibit food intake. DIF: Cognitive Level: Apply REF: p. 588 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort

The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a patient who is scheduled for surgery in a few days. The results are white blood cell (WBC) count 10.2 ´ 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 ´ 103/µL. Which action should the nurse take? a. Call the surgeon and anesthesiologist immediately. b. Ask the patient about any symptoms of a recent infection. c. Discuss the possibility of blood transfusion with the patient. d. Send the patient to the holding area when the operating room calls.

ANS: D The CBC count results are normal. With normal results, the patient can go to the holding area when the operating room is ready for the patient. There is no need to notify the surgeon or anesthesiologist, discuss blood transfusion, or ask about recent infection

The nurse approaches a group of school-age patients to administer medication to Sam Hart. What should the nurse do to identify the correct child? a. Ask the group, "Who is Sam Hart?" b. Call out to the group, "Sam Hart?" c. Ask each child, "What's your name?" d. Check the patient's identification name band

ANS: D The child must be correctly identified before the administration of any medication. Children are not totally reliable in giving correct names on request; the identification bracelet should always be checked. Asking children or the group for names is not an acceptable way to identify a child. Older children may exchange places, give an erroneous name, or choose not to respond to their name as a joke.

The nurse interviews a patient scheduled to undergo general anesthesia for a hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery? a. The patient drinks 3 or 4 cups of coffee every morning before going to work. b. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. c. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital. d. The patient's father died after receiving general anesthesia for abdominal surgery.

ANS: D The information about the patient's father suggests that there may be a family history of malignant hyperthermia and that precautions may need to be taken to prevent this complication. Current research indicates that having clear liquids 3 hours before surgery does not increase the risk for aspiration in most patients. Patients are instructed to discontinue aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative implications

18. When the nurse interviews a patient who is to have outpatient surgery using a general anesthetic, which information is most important to communicate to the surgeon and anesthesiologist before surgery? a. The patient drinks 3 or 4 cups of coffee every morning before going to work. b. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. c. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital. d. The patients father died after receiving general anesthesia for abdominal surgery.

ANS: D The information about the patients father suggests that there may be a family history of malignant hyperthermia and that precautions may need to be taken to prevent this complication. Current research indicates that having clear liquids 3 hours before surgery does not increase the risk for aspiration in most patients. Patients are instructed to discontinue aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative implications.

A patient who takes a diuretic and a b-blocker to control blood pressure is scheduled for breast reconstruction surgery. Which patient information is most important to communicate to the health care provider before surgery? a. Hematocrit 36% b. Blood pressure 144/82 c. Pulse rate 58 beats/minute d. Serum potassium 3.2 mEq/L

ANS: D The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of anxiety. The lower heart rate would be expected in a patient taking a b-blocker. The hematocrit is in the low normal range but does not require any intervention before surgery

20. A 24-year-old who takes a diuretic and a -blocker to control blood pressure is scheduled for abdominal surgery. Which patient information is most important to communicate to the health care provider before surgery? a. Pulse rate 59 b. Hematocrit 35% c. Blood pressure 142/78 d. Serum potassium 3.3 mEq/L

ANS: D The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of patient anxiety. The heart rate would be expectedin a patient taking a -blocker. The hematocrit is in the low normal range but does not require any intervention before surgery.

A mother calls the outpatient clinic requesting information on appropriate dosing for over-the-counter medications for her 13-month-old who has symptoms of an upper respiratory tract infection and fever. The box of acetaminophen says to give 120 mg q4h when needed. At his 12-month visit, the nurse practitioner prescribed 150 mg. What is the nurse's best response? a. "The doses are close enough; it doesn't really matter which one is given." b. "It is not appropriate to use dosages based on age because children have a wide range of weights at different ages." c. "From your description, medications are not necessary. They should be avoided in children at this age." d. "The nurse practitioner ordered the drug based on weight, which is a more accurate way of determining a therapeutic dose."

ANS: D The method most often used to determine children's dosage is based on a specific dose per kilogram of body weight. The mother should be given correct information. For a therapeutic effect, the dosage should be based on weight, not age. Acetaminophen can be used to relieve discomfort in children at this age group.

14. A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. At completion of the surgery, it is most important that the nurse monitor the patient for a. nausea. b. confusion. c. bronchospasm. d. weak chest-wall movement.

ANS: D The most serious adverse effect of the neuromuscular blocking agents is weakness of the respiratory muscles leading to postoperative hypoxemia. Nausea and confusion are possible adverse effects of these drugs, but they are as great a concern as respiratory depression. Because these medications decrease muscle contraction, laryngospasm and bronchospasm are not concerns.

An 8-month-old infant is restrained to prevent interference with the IV infusion. How should the nurse appropriately care for this child? a. Remove the restraints once a day to allow movement. b. Keep the restraints on constantly. c. Keep the restraints secure so the infant remains supine. d. Remove restraints whenever possible.

ANS: D The nurse should remove the restraints whenever possible. When parents or staff are present, the restraints can be removed and the IV site protected. Restraints must be checked and documented every 1 to 2 hours. They should be removed for range of motion on a periodic basis. The child should not be securely restrained in the supine position because of risks of aspiration.

What should the nurse do when caring for a child with an intravenous infusion? a. Use a macrodropper to facilitate reaching the prescribed flow rate. b. Avoid restraining the child to prevent undue emotional stress. c. Change the insertion site every 24 hours. d. Observe the insertion site frequently for signs of infiltration.

ANS: D The nursing responsibility for IV therapy is to calculate the amount to be infused in a given length of time; set the infusion rate; and monitor the apparatus frequently (at least every 1 to 2 hours) to make certain that the desired rate is maintained, the integrity of the system remains intact, the site remains intact (free of redness, edema, infiltration, or irritation), and the infusion does not stop. A minidropper (60 drops/ml) is the recommended IV tubing in pediatrics. The IV site should be protected. This may require soft restraints on the child. Insertion sites do not need to be changed every 24 hours unless a problem is found with the site. This exposes the child to significant trauma.

Which is the preferred site for intramuscular injections in infants? a. Deltoid b. Dorsogluteal c. Rectus femoris d. Vastus lateralis

ANS: D The preferred site for infants is the vastus lateralis. The deltoid and dorsogluteal sites are used for older children and adults. The rectus femoris is not a recommended site.

1. The perioperative nurse encourages a family member or a friend to remain with a patient in the preoperative holding area until the patient is taken into the operating room primarily to a. ensure the proper identification of the patient before surgery. b. protect the patient from cross-contamination with other patients. c. assist the perioperative nurse to obtain a complete patient history. d. help relieve the stress of separation for the patient and significant others.

ANS: D The presence of a family member or friend reduces the stress associated with the preoperative period. Although the family may give information about the patients name and history, this information is obtained and confirmed by the nurse in other ways. Nursing staff, rather than family members, are responsible for prevention of cross-contamination.

3. Which outcome measure will be best for the operating room (OR) nurse manager to use in determining the effectiveness of the physical environment and traffic control measures in the operating room? a. Smooth functioning of the OR team b. Effective protection of patient privacy c. Rapid completion of surgical procedure d. Low incidence of perioperative infection

ANS: D The primary focus when setting up the OR is the prevention of cross-contamination and transmission of infection to the patient. Patient privacy, efficient completion of procedures, and smooth functioning of the OR team also are important, but the priority is protection of the patient from infection.

4. Which action will the scrub nurse use to maintain aseptic technique during surgery? a. Use waterproof shoe covers. b. Wear personal protective equipment. c. Insist that all operating room (OR) staff perform a surgical scrub. d. Change gloves after touching the upper arm of the surgeons gown.

ANS: D The sleeves of a sterile surgical gown are considered sterile only to 2 inches above the elbows, so touching the surgeons upper arm would contaminate the nurses gloves. Shoe covers are not sterile. Personal protective equipment is designed to protect caregivers, not the patient, and is not part of aseptic technique. Staff members such as the circulating nurse do not have to perform a surgical scrub before entering the OR.

Intraoperative Care

Intraoperative Care

NSG 502 Exam 2 Perioperative Care Harding Chapters 17, 18 & 19 (emphasis on 19)

NSG 502 Exam 2 Perioperative Care Harding Chapters 17, 18 & 19 (emphasis on 19)

NSG 502 Exam 2 Perioperative Care_Pediatrics Hockenberry Chapter 20 ("Surgical Procedures")

NSG 502 Exam 2 Perioperative Care_Pediatrics Hockenberry Chapter 20 ("Surgical Procedures")

Postoperative

Postoperative

Preoperative Care

Preoperative Care