Perioperative Care
1. A patient is having a conversation with a surgeon. Which perioperative phase should the nurse anticipate will begin once the patient has agreed to have surgery? a. Postoperative b. Preoperative c. Intraoperative d. Interoperative
1. ANS: B The preoperative phase begins when the patient agrees to have surgery. The postoperative phase begins when the patient is transferred from the operating room to the PACU. The intraoperative phase begins when the patient is transferred to the operating room. Interoperative is not a surgical phase.
4. The nurse provided preoperative teaching about pain management to a patient scheduled for surgery. Which postoperative activity by the patient indicates the effectiveness of teaching? a. Doing something enjoyable, such as relaxing and reading a book b. Requesting pain medication when no longer able to tolerate the pain c. Removing the postoperative dressing to see the surgical incision d. Refusing to wear antiembolism stockings while still on bed rest
1. Answer: a Distraction is a nonpharmacologic complimentary therapy technique that is used to assist with pain control. A delay in requesting pain medication makes it difficult to break the pain cycle and get the pain under control quickly. Removing the dressing increases the risk of infection and injury. Refusing to wear antiembolism stockings increases the risk of clot formation.
7. Which set of patient data assists the nurse in determining whether the nursing actions taken to prevent airway obstruction have been effective? a. Temperature 97.8° F, breathing regular and unlabored, no cough b. Intake equals output, denies pain or chest discomfort c. Oxygen saturation 91%, shortness of breath, R 26 d. Oxygen saturation 89%, breathing shallow and regular, R 24
1. Answer: a These findings indicate there is no respiratory distress. Intake and output values do not directly contribute to or affect evaluation of an airway obstruction. Decreased oxygen saturation, shortness of breath, and tachypnea can indicate the respiratory system has been compromised, which can cause an airway obstruction. Decreased oxygen saturation, shallow breathing, and tachypnea can indicate respiratory complications.
5. A 55-year-old male is scheduled to have a bowel resection for a diagnosis of colon cancer. He is very nervous about the surgery. How can the nurse help decrease his anxiety? a. Ask him if he is concerned the cancer has spread to other areas of his body. b. Talk to him to find out what is causing his anxiety. c. Question him to find out what the surgeon has told him about the surgery. d. Give him a preoperative medication to help him relax.
1. Answer: b It is important for the nurse to understand the source of the patient's anxiety. The nurse can then develop a plan to assist him. Asking whether he is concerned that the cancer has spread may increase his anxiety. Questioning him about the surgery does not help the nurse understand the source of his anxiety and may increase it. Giving medication does not help the patient deal with the problem. This may be appropriate after the nurse knows the source of his anxiety.
3. What is the role of the nurse in securing an informed consent for a surgical procedure? a. Ensuring that the patient signs the informed consent document b. Signing the consent form as a witness c. Ensuring that the patient does not refuse treatment d. Refusing to participate based on legal guidelines
1. Answer: b The nurse is acting as the witness. The physician has the primary responsibility of securing the signed consent form. The nurse serves as an advocate for the patient. It is unethical to force patients to have a treatment that they do not want. Legal guidelines allow nurses to witness the patient signing a consent form.
2. The postanesthesia care recovery unit (PACU) nurse is concerned about postoperative hemorrhage. Which clinical manifestation alerts the nurse to this problem? a. Incisional pain b. Elevated blood pressure c. Increased heart rate d. Bradypnea
1. Answer: c Increased heart rate is a clinical manifestation that occurs with hemorrhage. Incisional pain can be caused by the surgical procedure. When a person is hemorrhaging, the blood pressure decreases. With hemorrhage, tachycardia and tachypnea (not bradypnea) occur as the body tries to provide adequate tissue perfusion.
6. How does malnutrition compromise wound healing? a. There is increased stress on the wound. b. Blood supply to the wound is increased. c. It causes patients to be energized and overexert. d. It can increase the risk of infection.
1. Answer: d Malnutrition can increase the risk of infection, which can interfere with the formation of granulation tissue and new tissue growth, delaying wound healing. Malnutrition does not directly cause stress on the wound. Blood supply to the wound may be poor, not increased, which can lead to delayed wound healing. Malnourished patients do not feel energized. Poor nutrition contributes to malnourished cells, which leads to reduced energy.
8. While conducting a preoperative health assessment, the nurse is informed about a patient's preexisting heart problem. What postoperative interventions should be included in the plan of care for this patient? a. Perform a systematic head-to-toe assessment every 4 hours. b. Monitor breath sounds and oxygen saturation. c. Administer pain medications as needed. d. Monitor the electrocardiogram (ECG), apical pulse, and capillary refill.
1. Answer: d Monitoring the patient's ECG, pulse, and capillary refill allows the nurse to assess the cardiovascular system. A head-to-toe assessment every 4 hours does not provide specific information for a focused assessment of the heart. Monitoring breath sounds and oxygenation saturation provides information about the respiratory system. Administering pain medication is necessary but does not give the nurse specific information about the heart.
1. The nurse is caring for a patient scheduled for a breast reduction to decrease pain in her back. How is this operation classified according to the degree of urgency? a. Urgent b. Emergency c. Emergent d. Elective
1. Answer: d The patient is choosing to have this procedure, and it is therefore elective surgery. Urgent surgery is performed when it is necessary for the patient's health. It is commonly performed within 24 hours of the diagnosis. Emergency surgery is performed immediately to preserve life, body parts, or function. Emergent surgery is the same as emergency surgery. It must be performed immediately to preserve life, body parts, or function.
9. A patient who recently had abdominal surgery complains of feeling as though their "wound is coming loose." Upon assessment, the nurse notes the presence of bowel loop protruding through the surgical incision. Which nursing intervention(s) should the nurse take? Select all that apply. a. Place the patient in semi-Fowler position. b. Contact the surgeon. c. Document findings and actions taken. d. Place dry sterile gauze over the bowel loop. e. Push the bowel loop back into the patient.
1. Answers: a, b, c Dehiscence and evisceration are medical emergencies. Once this occurs, the nurse should immediately place the patient in a position that puts the least amount of strain on the incision, such as the semi-Fowler position. Sterile gauze soaked in sterile saline is placed on the incision, and the surgeon is immediately notified. The nurse should never push the bowel loop back into the patient due to the risk of decreasing blood flow and oxygenation to that area of bowel.
10. When caring for a postoperative patient on a surgical unit, which nursing intervention(s) are included in the patient's plan of care to help reduce the risk of both pulmonary embolism (PE) and deep vein thrombosis? (Select all that apply.) a. Encourage oral hydration. b. Apply antiembolism stockings. c. Monitor laboratory values for clotting times. d. Encourage frequent ambulation. e. Instruct the patient to perform the Valsalva maneuver frequently.
1. Answers: b, d Nursing care to prevent clots from developing and preventing thrombus from becoming detached include use of antiembolism stockings, sequential compression devices, leg exercises, and ambulation to promote circulation. Encouraging oral hydration helps liquefy secretions and prevent pneumonia. Monitoring laboratory values should be done if a patient is receiving anticoagulants, but it does not help prevent clots. The patient should be instructed not to perform the Valsalva maneuver, because any activity that increases intrathoracic pressure increases the risk of an emboli traveling to the pulmonary artery.
2. Maintaining a safe environment is a major responsibility of which surgical team member? a. Circulating nurse b. Scrub nurse c. Surgeon d. Certified registered nurse anesthetist
2. ANS: A The circulating nurse observes the surgical procedure, coordinates the needs of the surgical team, and assists the team in maintaining a safe and comfortable environment. The scrub nurse is within the sterile field and passes instruments and other equipment needed to the surgeon during the surgical procedure. The surgeon performs the surgical procedure. The certified registered nurse anesthetist is a registered nurse who has been trained to deliver anesthesia.
3. A patient is scheduled for surgery. Which should the nurse include in the preoperative teaching? a. Side effects of postoperative pain medication b. The importance of stopping smoking before the surgery c. The different types of wound drainage d. Advice to call the doctor for severe pain after discharge
3. ANS: B A patient should stop smoking once he/she has made the decision to have surgery. Smoking can increase the risk for respiratory complications. At this time the nurse may not know what will be ordered for postoperative pain management. The patient should be given information to help him/her understand signs of infection. Giving information on all the types of drainage is unnecessary. Discharge instructions would be given prior to discharge.
4. A patient scheduled for surgery takes several medications. Which medication indicates that the patient's surgical risk is increased? a. Acetaminophen b. Insulin c. Thyroid medication d. Vitamin C
4. ANS: B Insulin is taken for an elevated glucose level. This person has diabetes, which increases the surgical risk. Acetaminophen does not increase the risk. Aspirin, steroids, and herbal medications increase surgical risk. Thyroid medication does not increase surgical risk. Vitamin C is needed for normal growth and development. It is also required for the growth and repair of tissues in all parts of the body.
5. The nurse is teaching a patient about being discharged after an elective surgery. The procedure is being performed at an ambulatory surgical center. What information should the nurse include about transportation? a. You will be able to drive home. b. You will need someone to drive you home. c. You can drive home if someone is in the car with you. d. If you are lightheaded or dizzy, you will not be able to drive home.
5. ANS: B Patients undergoing surgery in an ambulatory center will need someone to drive them home because of the effects of anesthesia, pain medication, and the surgery itself. Patients are instructed not to drive home. A patient cannot drive home with or without feeling lightheaded or dizzy. Patients should not drive even if someone is in the car with them.
6. The nurse is teaching a patient about regional anesthesia. Which statement is accurate about this type of anesthesia? a. Patients will be awake but disoriented during the surgery. b. Patients are awake with loss of sensation in an area of the body. c. Patients will be asleep but may feel some pressure during the surgery. d. Patients are asleep and won't be able to remember the surgery.
6. ANS: B Regional anesthesia allows for the patient to remain awake. The patient will not feel any sensations during the surgery. The patient will not be disoriented. Many patients may be asked to follow instructions during the surgery. The patient will remain awake and he/she should not feel any pressure. The patient should have full memory of the surgical experience.
An unidentified client from the emergency department requires immediate surgery, but he is not conscious and no one is with him. What must the nurse, who is verifying the informed consent, do? a. Ensure written consultation of two noninvolved physicians. b. Read the surgeon's consult to determine whether the client's condition is life-threatening. c. Sign the operative permit. d. Withhold surgery until the next of kin is notified.
ANS: A In a life-threatening situation in which every effort has been made to contact the person with medical power of attorney, consent is desired but not essential. In place of written or oral consent, written consultation by at least two physicians who are not associated with the case may be requested by the health care provider.It is not within the nurse's role to make a judgment about the client's life-threatening status based on the surgeon's consult. Signing documents on the client's behalf is not legal. Withholding surgery is not in this client's best interests.
Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? a. Creatinine, 1.9 mg/dL (168 mcmol/L) b. Fasting glucose, 80 mg/dL (4.4 mmol/L) c. Potassium, 3.9 mEq/L (3.9 mmol/L) d. Sodium, 140 mEq/L (140 mmol/L)
ANS: A The nurse will immediately report a creatinine of 1.9 mg/dL (168 mcmol/L) to the anesthesiologist. A creatinine of 1.9 mg/dL (168 mcmol/L) is outside the normal range and may indicate renal problems.A fasting glucose of 80 mg/dL (4.4 mmol/L), a potassium level of 3.9 mEq/L (3.9 mmol/L), and sodium level of 140 mEq/L (140 mmol/L) are normal laboratory values.
Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area? a. Provide preoperative teaching to a client who needs insertion of a tunneled central venous catheter. b. Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. c. Obtain the medical history from a client who is scheduled for a total hip replacement. d. Assess the client who is being admitted for an elective laparoscopic cholecystectomy.
ANS: B Insertion of a catheter is the best task within the scope of skills approved for the LPN/LVN.Preoperative teaching and physical assessment of a preoperative client are under the scope of the RN. History information would be completed by the RN on the unit.
As the nurse obtains informed consent, the client asks, "Now what exactly are they going to do to me?" What is the nurse's response? a. Contact the anesthesiologist. b. Contact the surgeon. c. Explain the procedure. d. Have the client sign the form.
ANS: B The nurse will contact the surgeon to convey the client's question. The nurse is not responsible for explaining or providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the health care provider and dispel myths that the client or family may have heard about the surgical experience.The anesthesiologist is responsible for the anesthesia, not the surgical details. Although the nurse is only witnessing the signature, it is the nurse's role to ensure that the facts are clarified before the consent form is signed.
1. Which assessment data finding for a client scheduled for total knee replacement surgery is most important for the nurse to communicate to the surgeon and the anesthesia provider before the procedure? Select all that apply. a. The oxygen saturation is 97%. b. The serum potassium level is 3.0 mEq/L (3.0 mmol/L). c. The client took a total of 1300 mg of aspirin yesterday. d. The client requests to talk with a registered dietitian about weight loss. e. The client took a regularly scheduled antihypertensive drug with a sip of water 2 hours ago. f. After receiving the preoperative medications, the client tells the nurse that he lied on the assessment form and that he really is a current smoker.
ANS: B, C, F This is a low potassium value (3.0 mEq/L) which should be communicated to the surgeon and anesthesia provider prior to surgery. Taking aspirin prior to surgery can increase the risk for bleeding. This should be communicated to the surgeon and anesthesia provider prior to surgery. The client's smoking status can change important assessment information collected by the surgeon and anesthesia provider; therefore, this should be immediately communicated. The oxygen saturation level is normal, and it is acceptable that the regularly scheduled antihypertensive was taken with a sip of water 2 hours ago.
1. A client is scheduled for surgery at noon. The surgeon is delayed and the surgery is now scheduled for 3:00 PM. How will the nurse plan to administer the preoperative prophylactic antibiotic? a. Give at noon as originally prescribed. b. Cancel orders; preoperative prophylactic antibiotics are given optionally. c. Adjust the administration time to be given within one hour prior to surgery. d. Hold the preoperative antibiotic so it can be administered immediately following surgery.
ANS: C According to the Surgical Care Improvement Project (SCIP) guidelines, prophylactic antibiotics should be given within one hour before the surgical incision.
The nurse is instructing a client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? a. "I will take off my stockings one to three times a day for 30 minutes." b. "My stockings are too loose." c. "It's better if they are too tight rather than too loose." d. "These stockings help promote blood flow."
ANS: C Antiembolism stockings should fit properly to achieve the desired result. Stockings that are too tight will impede blood flow.Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. Stockings that are too loose are ineffective. Antiembolism stockings may be used during and after surgery to promote venous return.
At 8:00 a.m., the registered nurse is admitting a client scheduled for sinus surgery to the outpatient surgery department. Which information given by the client is of most immediate concern to the nurse? a. An allergy to iodine and shellfish b. Being nauseated after a previous surgery c. Having a small glass of juice at 7:00 a.m. d. Expressing anxiety about the surgery
ANS: C Clients need to be NPO for a sufficient length of time before surgery to prevent aspiration of fluid into the lungs. Intake of food or fluids may delay the start time of the surgery, so the nurse must notify the surgeon and anesthesiologist for possible rescheduling.The nurse would confirm that all allergies are charted, and that the client has the correct allergy band identification. Many clients experience nausea after surgery; the nurse would document this in the client's information as well. The nurse would talk with the client and explore the anxiety; this is a normal feeling before surgery.
1. What client teaching will the nurse provide regarding postoperative leg exercises, to minimize the risk for development of deep vein thrombosis after surgery? a. Only perform each exercise one time to prevent overuse. b. Begin exercises by sitting at a 90-degree angle on the side of the bed. c. Point toes of one foot toward bottom of bed, then point toes of same leg toward their face. Repeat several times, then switch legs. d. Bend knee, and push heel of foot into the bed until the calf and thigh muscles contract. Repeat several times, then switch legs.
ANS: C Exercises should be repeated several times for each leg. Clients should begin by lying in the bed in a 45-degree angle. Pointing toes, as described, promotes circulation. Clients should push the ball of the foot into the bed until the calf and thigh muscles contract.
The nurse completes the preoperative checklist on a client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure? a. Age 59 years b. General anesthesia complications experienced by the client's brother c. Diet-controlled diabetes mellitus d. Ten pounds (4.5 kg) over the client's ideal body weight
ANS: C The client's greatest risk factor is diabetes mellitus. Diabetes contributes an increased risk for surgery or postsurgical complications.Older adults are at greater risk for surgical procedures, but this client is not classified as an older adult. Family medical history and problems with anesthetics may indicate possible reactions to anesthesia, but this is not the best answer. Obesity increases the risk for poor wound healing, but being 10 pounds (4.5 kg) overweight does not categorize this client as obese.
A preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best physical outcomes? a. Instruct the client to quit smoking. b. Teach about the dangers of tobacco. c. Teach the importance of incentive spirometry. d. Tell the client that smoking increases postoperative complications.
ANS: C The nurse would first teach the importance of incentive spirometry. Incentive spirometry is good for lung hygiene and it encourages deep breathing.The nurse can suggest quitting or advice about the dangers of tobacco, but it is not therapeutic to instruct it at this time. Telling the client that smoking causes increased complications is not helpful or therapeutic just prior to surgery.
During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? a. "I am taking vitamins." b. "I drink a glass of wine a night." c. "I had a heart attack 4 months ago." d. "I quit smoking 10 years ago."
ANS: C The statement by the client that he or she had a heart attack 4 months ago requires further investigation. Cardiac problems increase surgical risks, and the risk for a myocardial infarction during surgery is higher in clients who have heart problems.The type of vitamins the client takes should be assessed, but this is not the highest risk. Moderate alcohol consumption is not considered high-risk behavior. A past history of smoking should be noted, but current or more recent smoking is of greater concern.
A client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. This preoperative procedure is done to a. decrease expected blood loss during surgery. b. eliminate any risk of infection. c. ensure that the bowel is sterile. d. reduce the number of intestinal bacteria.
ANS: D Bowel or intestinal preparations are performed to empty the bowel to minimize the leaking of bowel contents, prevent injury to the colon, and reduce the number of intestinal bacteria.Decreasing expected blood loss and sterilizing the bowel are not the goals of a bowel preparation. While the bowel prep may reduce the number of intestinal bacteria, it will not completely eliminate the risk of infection.
Colostomy surgery is categorized as what type of surgery? a. Cosmetic b. Curative c. Diagnostic d. Palliative
ANS: D Colostomy surgery is categorized as palliative. Palliative surgery is performed to relieve symptoms of a disease process, but does not cure the disease.Cosmetic surgery is performed primarily to alter or enhance personal appearance. Curative surgery is performed to resolve a health problem by repairing or removing the cause. Diagnostic surgery is performed to determine the origin and cause of a disorder or the cell type for cancer.
A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order does the nurse accomplish first? a. Use electric clippers to cut hair at the surgical site. b. Start an infusion of lactated Ringer's solution at 75 mL/hr. c. Administer one-half of the client's usual lispro insulin dose. d. Draw blood for glucose, electrolyte, and complete blood count values.
ANS: D The blood sample needs to be drawn and sent to the laboratory first to confirm that results are within normal limits. If blood work is abnormal, the surgery may be rescheduled.Removal of hair can be accomplished in the operating room directly before the start of surgery. The IV infusion can be accomplished after the laboratory orders have been completed. The nurse should check blood glucose with the laboratory orders before administration of lispro.
The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction? a. "I will wake up with a tube in my throat." b. "I will have a bandage on my chest." c. "My family will not be able to see me right away." d. "Pain medication will take away my pain."
ANS: D The client's statement that, "Pain medication will take away my pain," indicates the need for further instruction. Pain medication will reduce pain, but will not take it away completely.The client statement about waking up with a tube in the throat is accurate, because the client will be intubated. Following heart surgery, a dressing is placed on the chest. The client will not be able to see family immediately because he or she will go to recovery first.
The nurse is providing preoperative care for a client who will have an arthroscopy of the left knee. As part of the Joint Commission National Patient Safety Goals (NPSG), what will the nurse be required to do? a. Ensure that the correct procedure is noted in the client's history. b. Remind the surgeon that the client will have a left knee arthroscopy. c. Verify with the client that a left knee arthroscopy will be performed. d. Mark the left knee site with the client awake and the surgeon present.
ANS: D The nurse will be required to mark the left knee site with the client awake and the surgeon present. The Joint Commission NSPG requires that the surgical site be marked by an independent licensed professional and should, when possible, involve the client. The surgeon is accountable and should be present.The EMR should identify the correct procedure, but is not a specific JCAHO requirement. The nurse will verify the procedure with the client when possible, but this is not a requirement. Communication with the surgeon is ideal, but is not specifically required.
An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? a. Call the legal department to draft the paperwork. b. Document this in the chart. c. Thank the person and do nothing else. d. Talk to the client.
ANS: D The nurse would first talk to the client in order to determine the client's wishes and state of mind.The nurse should not call the legal department or document in the client's chart before speaking with the client. Doing nothing is not appropriate.
The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. A pulse of 86 beats per minute 3. Blood pressure of 110/70 mm Hg 4. Hypoactive bowel sounds in all 4 quadrants
Answer: 1 Rationale: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats per minute is within normal limits. Hypoactive bowel sounds heard in all 4 quadrants are a normal occurrence in the immediate postoperative period.
The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? 1. "Use of an incentive spirometer will help prevent pneumonia." 2. "Close monitoring of your oxygen saturation will detect hypoxemia." 3. "Administration of intravenous fluids will prevent or treat fluid imbalance." 4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."
Answer: 1 Rationale: Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps prevent pneumonia and atelectasis. Hypoxemia is an inadequate concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help detect hypoxemia, monitoring is not directly related to coughing and deep-breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to 1 or more lobes of the lung; this is usually due to clot formation. Early ambulation and administration of blood thinners helps prevent this complication; however, it is not related to coughing and deep-breathing techniques.
The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine 4. Conjugated estrogen
Answer: 1 Rationale: Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily and may be given parenterally rather than orally. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. These last 3 medications may be withheld before surgery without undue effects on the client.
A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Hemoglobin, 8.0 g/dL (80 mmol/L) 2. Sodium, 145 mEq/L (145 mmol/L) 3. Serum creatinine, 0.8 mg/dL (70.6 mcmol/L) 4. Platelets, 210,000 cells/mm3 (210 × 109/L)
Answer: 1 Rationale: Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All of these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.
The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway. 2. Check tubes or drains for patency. 3. Check the dressing to assess for bleeding. 4. Assess the vital signs to compare with preoperative measurements.
Answer: 1 Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.
The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 mL/hr 2. Temperature of 37.6° C (99.6° F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing
Answer: 1 Rationale: Urine output should be maintained at a minimum of 30 mL/hr for an adult. An output of less than 30 mL for 2 consecutive hours should be reported to the surgeon. A temperature higher than 37.7° C (100° F) or lower than 36.1° C (97° F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply. 1. Contact the surgeon. 2. Instruct the client to remain quiet. 3. Prepare the client for wound closure. 4. Document the findings and actions taken. 5. Place a sterile saline dressing and ice packs over the wound. 6. Place the client in a supine position without a pillow under the head.
Answer: 1, 2, 3, 4 Rationale: Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low-Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.
The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin
Answer: 2 Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.
The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? 1. "Aspirin can cause bleeding after surgery." 2. "Aspirin can cause my ability to clot blood to be abnormal." 3. "I need to continue to take the aspirin until the day of surgery." 4. "I need to check with my doctor about the need to stop the aspirin before the scheduled surgery."
Answer: 3 Rationale: Antiplatelets alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter platelet aggregation and should be discontinued at least 48 hours before surgery. However, the client should always check with his or her surgeon regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client statements.
A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "If it's any help, everyone is nervous before surgery." 2. "I will be happy to explain the entire surgical procedure to you." 3. "Can you share with me what you've been told about your surgery?" 4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."
Answer: 3 Rationale: Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the entire surgical procedure may increase the client's anxiety. Option 4 avoids the client's anxiety and is focused on postoperative care.
The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash. 2. Verify that the client has not eaten for the last 24 hours. 3. Have the client void immediately before going into surgery. 4. Report immediately any slight increase in blood pressure or pulse.
Answer: 3 Rationale: The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours (or longer as prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.
A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? 1. Obtain a court order for the surgery. 2. Have the charge nurse sign the informed consent immediately. 3. Send the client to surgery without the consent form being signed. 4. Obtain a telephone consent from a family member, following agency policy.
Answer: 4 Rationale: Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by 2 persons who hear the family member's oral consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a surgeon is permitted legally to perform surgery without consent, but the data in the question do not indicate an emergency. Options 1, 2, and 3 are not appropriate in this situation. Also, agency policies regarding informed consent should always be followed.
The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? 1. Inhale as rapidly as possible. 2. Keep a loose seal between the lips and the mouthpiece. 3. After maximum inspiration, hold the breath for 15 seconds and exhale. 4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.
Answer: 4 Rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.
