Prep U / (COMBINED) - Chapter 30: Perioperative Nursing
The preoperative nurse is teaching a client about deep-breathing exercises. The client asks, "Why do I need to learn about this?" Which response by the nurse is correct?
"After surgery, deep-breathing exercises help to remove anesthetic gases and mucus and improve oxygen supply to body tissues." Explanation: Deep-breathing exercises are intended to help prevent postoperative complications, such as low oxygen levels, accumulation of secretions, and atelectasis.
The nurse is taking a history on Kumar, who informs her that he has an allergy to adhesive tape. When the nurse asks Kumar to describe his reaction to the tape, he describes it as "blotchy and reddened." What type of allergic reaction is this?
Type IV Explanation: A type IV reaction is characterized by local inflammation, pruritus and erythema.
Which client in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse?
a 26-year-old client who is exhibiting a crowing sound Explanation: A client with a crowing sound is exhibiting stridor, which is an indication of an airway obstruction and can be a respiratory emergency. This client needs immediate attention. The client with disorientation needs to be frequently reoriented and observed for safety reasons but is not a priority over respiratory distress. The client who needs pain medication or the pediatric client requesting a parent are also not priority over a client in respiratory distress.
When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of:
a partial airway obstruction. Explanation: Loud, irregular respirations may indicate obstruction of the airway, possibly from emesis, accumulated secretions, or client positioning that allows the tongue to fall to the back of the throat.
Which client most likely requires special preoperative assessment and treatment as a result of the existing medication regimen?
a woman who takes daily anticoagulants to treat atrial fibrillation Explanation: Anticoagulants present a risk of hemorrhage. This risk supersedes that posed by thyroid supplements, ACE inhibitors, or most NSAIDs. Thyroid supplements assist with thyroid function. Angiotensin-converting enzyme (ACE) inhibitors help relax blood vessels and lower blood pressure. Nonsteroidal anti-inflammatory drugs (NSAIDs) are a drug class that reduce pain, decrease fever, prevent blood clots, and, in higher doses, decrease inflammation.
Surgery can lead to hypothermia. Which client is at greatest risk for hypothermia?
an older adult man with a fractured hip Explanation: The risk of hypothermia increases in the very young and the very old.
The nurse knows the term perioperative phase refers to care given to the client:
before, during, and after the operative phase. Explanation: Perioperative nursing includes three distinct phases: preoperative, intraoperative, and postoperative.
A client will be having a surgical procedure requiring general anesthesia. Which desired outcomes of general anesthesia does the nurse expect to observe? Select all that apply.
loss of consciousness analgesia relaxed skeletal muscles depressed reflexes Explanation: The desired actions of general anesthesia are loss of consciousness, analgesia, relaxed skeletal muscles, and depressed reflexes. An outcome of regional anesthesia is loss of sensation in a specific area. Altered mood with some degree of amnesia is an outcome of moderate sedation/analgesia.
In the postoperative phase of abdominal surgery, the client reports severe abdominal pain. In the second postoperative day, the client's bowel sounds are absent. What does the nurse suspect?
paralytic ileus Explanation: A potential complication after surgery is paralytic ileus, a condition in which there is decreased bowel functioning.
The nurse recognizes the value of leg exercises in the prevention of postoperative thrombophlebitis. When should the nurse teach the correct technique for leg exercises to a client?
prior to surgery Explanation: Though leg exercises are begun after surgery, such preventive measures should ideally be taught to the client during the preoperative period. In the postanesthesia care areas, the client has just arrived from the operating room where local or general anesthesia has been used. The client will be sedated but arousable and teaching would be inappropriate. Early signs of venous status is too late for leg exercises to begin, as the clot may have formed.
As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site?
procedural pause (time-out) Explanation: The procedural pause (time-out) must be done prior to any procedure to ensure client safety and to verify the client identity, staff roles, and procedure being performed.
A client is undergoing surgery for an appendectomy. This would be considered what type of surgery?
emergency surgery Explanation: An appendectomy is considered emergency or urgent surgery. Elective surgery can be scheduled in advance, and a delay has no ill effects. Palliative surgery is done to relieve or reduce the intensity of an illness. Diagnostic surgery is done to make or confirm a diagnosis.
The nurse is preparing a client for surgery and asks if the client has an advance directive. The client asks "What is an advance directive?" What is the nurse's best response to this?
"An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so." Explanation: An advance directive allows the client to communicate instructions for health care postoperatively in case of an inability to do so. Although an advance directive is either a living will or a durable power of attorney for health care, and the hospital does like to determine if the client has them, these are not the best answers to the client's question. The nurse would not want to explain to the client that he or she may not wake up after surgery.
A client who is scheduled to undergo coronary bypass surgery in a week asks the nurse whether he should discontinue taking his cholesterol medicine ahead of the surgery. Which should be the nurse's response?
"I will need to check with your health care provider about that." Explanation: The client may be permitted to take certain medications before surgery. The health care provider, not the nurse, should provide guidance about which medications should be taken and which ones should be held.
An older adult client underwent a hip replacement and now states to the nurse, "My parents are coming to visit me today. I need to mow the lawn and run errands." The client is trying to get out of the bed. What does the nurse identify is occurring with this client?
Delirium Explanation: Delirium refers to acute confusion that is reversible. It is common in the acute postoperative period.
The graduate nurse will be orienting to the role of circulator in perioperative services. What statements made by the nurse requires further education regarding the role of the circulator? Select all that apply.
Explanation: The circulating nurse ensures that the client's rights are protected and coordinates client care in the operating room. The circulating nurse and the scrub person are responsible for accounting for all sponges and instruments at the close of surgery.
A 9-month-old baby is scheduled for heart surgery. When preparing this client for surgery, the nurse should consider which surgical risk associated with infants?
Impaired thermoregulation Explanation: Infants have difficulty maintaining stable body temperature during surgery because the shivering reflex is not well developed, making hypothermia or hyperthermia more likely. They are not at an increased risk for prolonged wound healing, infection or shock.
A client is scheduled for hip replacement surgery this morning but admits to the nurse that he had a small piece of toast and some water after waking up. What is the nurse's most appropriate response?
Inform the anesthesiologist or surgeon of this fact. Explanation: The surgeon or anesthesiologist must be informed if a client has not adhered to preoperative fasting instructions, since this constitutes a risk for aspiration. There is no benefit to assessing the client's abdomen. Unilaterally postponing the surgery would be beyond the nurse's scope.
The healthy adult client is given an opioid prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first?
Notify the physician of the oversight. Explanation: Do not administer any medications that might alter judgment or perception before the client signs the consent form because many drugs commonly administered as preoperative medications, such as opioids or barbiturates, can alter cognitive abilities and invalidate informed consent.
A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which characteristic applies to this type of surgery?
The client will be admitted the day of surgery and return home the same day. Explanation: Outpatient surgeries, also known as ambulatory surgeries, are conducted with admission and discharge on the same day. Such surgeries have become increasingly common in recent years, and some surgeries of increasing complexity and risk are conducted on an outpatient basis. General anesthesia is possible and common. This approach is more common for elective surgeries than urgent surgeries.
The nurse is caring for a postoperative client. During the past hour, there is 20 mL of dark, concentrated amber urine. Which actions should the nurse choose? Select all that apply.
The nurse should determine what may be causing the low urine output, and starting with the indwelling catheter, the nurse should check for kinks in the catheter that may be obstructing the flow. The nurse would not average the urine output because each hour the minimum amount of urine the kidneys should produce is at least 30 mL/hr, if the kidneys are adequately perfused with adequate blood flow and fluid volume. Assessing skin turgor for tenting and mucous membranes for dryness will help the nurse to determine if the client is dehydrated, which could lead to a low urine output. Assessing vital signs and comparing them to the baseline will also help the nurse to examine for clues of hypovolemia (low volume), including hypotension, tachycardia, and elevation in body temperature. When the nurse examines intake, it should be close to the output. The nurse should also examine the operative report for estimated blood loss, which helps the nurse to recognize if the client may be hypovolemic from blood loss.
A client is in the preoperative area and states, "I am not sure about having surgery." What is the nurse's best response?
"Can you tell me what your feelings are about the surgery?" Explanation: The client who is unsure about surgery needs their feelings explored to determine why the client doubts the decision. After exploring these feelings, the nurse can then contact the procedural physician and make this person aware of the client's concerns. Asking the client why the client wouldn't want the surgery is phrased negatively and implies a judgment by the nurse on the client's feelings; likewise, the client wouldn't be told to have the surgery done without allowing the client to express feelings.
Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction?
"I can have a hamburger and French fries as soon as I wake up." Explanation: Oral fluid and food may be withheld until intestinal motility resumes.
The nurse is preparing a client for a total hip arthroplasty and is obtaining data preoperatively. Which statement made by the client is most important for the nurse to immediately report to the health care provider?
"I've been taking ibuprofen for my hip pain twice a day." Explanation: The nurse should immediately report the use of ibuprofen twice daily for the hip pain since this medication can cause the complication of postoperative bleeding. The history of hip pain and the inability to perform activities that were previously enjoyed are not relevant in determining complications. The intake of food or fluids is relevant, but the amount of time the client has been NPO is acceptable and reduces the risk of complications from anesthesia.
A nurse is caring for a client in the same-day surgery unit. The client asks the nurse, "Do I really need to be put to sleep for this surgery?" Which would be the nurse's best response?
"Tell me what you are most worried about." Explanation: As the client's advocate, the nurse should first assess what the client is most worried about and then provide emotional support. The nurse would not offer false hope, reassurance, nor pass the client off to another team member. Asking if the client had surgery before would not reveal the concerns with this surgery.
The nurse is providing education about deep-breathing exercises to a postoperative client whose surgery took place earlier today. Which instruction should the nurse provide?
"Try to do your exercises every 1 to 2 hours." Explanation: Instruct the client that deep-breathing exercises should be performed every 1 to 2 hours for the first 24 hours after surgery.
The circulating nurse calls for a time-out prior to the surgical procedure and the surgeon states, "I don't have time for this. I have another case to follow and need to get busy." What is the best response by the circulator?
"We all have the same goal and that is the safety of the client, so let's do the time-out." Explanation: Final verification just prior to beginning the procedure is referred to as the time-out. The time-out occurs immediately before starting the surgical procedure and is initiated by a designated member of the team. The surgeon, the anesthesia provider, the circulating nurse, the operating room technician, and any other active participants conduct the time-out assessment and ensure that there are no questions or concerns. During the time-out, all members of the surgical team must agree on the identity of the patient, the correct surgical site, and the procedure that will be performed. The completion of the time-out is documented appropriately.
The nurse needs to evaluate the effectiveness of a preoperative teaching session with a client scheduled for abdominal surgery. Which client statement indicates the need for further clarification?
"While my pneumatic compression device is on, I don't need to do leg exercises." Explanation: Compression stockings and pneumatic compression devices help to decrease the formation of thrombus by helping to promote venous return to the heart. The nurse needs to clarify that the pneumatic compression device does not replace leg exercises because the exercises help keep the joints flexible and help strengthen muscles while the client is in bed. The client is correct that splinting the incision when coughing is important. The client should sit up in bed when using the incentive spirometer, taking deep breaths and coughing. The client should take deep breaths and cough at least every 2 hours while awake to help expand lungs, loosen secretions, and help prevent atelectasis and pneumonia.
The nurse is caring for a client after breast augmentation. Before performing a bowel assessment, what education will the nurse provide the client?
"You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or opioids. By listening for bowel sounds, I can check for a return of peristalsis." Explanation: A postoperative client can typically have decreased or absent peristalsis because of bowel manipulation and/or administration of anesthetic agents or opioids. Auscultation of bowel sounds will help determine a return of peristalsis. Palpating the abdomen would not help with determining peristalsis return; the nurse may feel distention and firmness of the abdomen with decreased peristalsis, but this is not accurate in determining return of peristalsis. The symphysis pubis would be assessed to determine bladder fullness, not peristalsis. Giving the client sips of water would not help determine or promote the return of peristalsis; this also could be a safety issue if the client has decreased peristalsis due to emesis and subsequent potential aspiration.
Which surgical client does the nurse in the preoperative setting anticipate having the greatest potential for surgical complications?
72-year-old client with a history of renal failure and chronic bronchitis Explanation: The client who is elderly with renal and lung disease has the most risk factors preoperatively for surgery. This client will have concerns over administration of anesthesia and medication, with the kidneys being able to clear these from the body, as well as with the lungs and potential postoperative complications of atelectasis and pneumonia. Clients who are young, have chronic disease, or are obese have risk factors as well, but not as many as the elderly client with both renal and pulmonary disease.
The nurse is caring for several post-operative clients and is planning their care. Which surgical client will likely resume activities of daily living most quickly?
A client who has just had a laparoscopic cholecystectomy Explanation: Clients who have surgery using a laparoscope are able to return to previous activity levels much sooner than clients who have not. The other clients have not undergone laparoscopic procedures.
A nurse is teaching a client about the rationale for fasting from food and fluids prior to surgery. What condition does this measure attempt to avoid?
Aspiration Explanation: Food and fluid are restricted before surgery to ensure that the stomach contains a minimal amount of gastric secretions. This restriction is important to reduce the risk of aspiration.
A client has presented to the outpatient surgical center for a scheduled procedure. Which action should the nurse perform prior to the procedure?
Assess the client's allergy status. Explanation: The nurse should assess or confirm the client's allergy status prior to surgery. An advance directive may be in place, but one would not be created on the day of surgery if it were not already established. Analgesia is not normally given preoperatively. Leg exercises should be taught and modeled preoperatively, but they do not need to be performed during this phase.
The acute care nurse is preparing a client for surgery. Which action is essential to complete before transferring the client to surgery?
Assure that diagnostic testing has been completed and results are available. Explanation: All prescribed diagnostic tests should be performed, and results made available before the client goes to surgery. Unless otherwise indicated, no special positioning is required preoperatively. Graduated compression stockings, if prescribed, should remain in place. The surgeon, not the nurse, is responsible for marking the skin.
A nurse is interacting with a client in the outpatient surgical unit intraoperatively. What is the nurse's priority responsibility?
Client safety Explanation: Client safety is the most important nurse responsibility during the intraoperative phase. Safety concerns include equipment, electrical, chemical, radiation, surgical verification, client transport and positioning, and continuous asepsis. Postoperative protocol education is done preoperatively. Establishing a nurse-client rapport and providing emotional support are important, but they are not the most important nursing responsibility during the intraoperative phase.
A nurse is creating a leg exercise regimen for client who is recovering from surgery. Which factors should the nurse consider when recommending leg exercises to this client? Select all that apply.
Client's individual needs Client's physical condition Health care provider preference Facility protocol Explanation: Leg exercises increase venous return through flexion and contraction of the quadriceps and gastrocnemius muscles. It is important to individualize leg exercises to client needs, physical condition, health care provider preference, and facility protocol. Current popularity of the exercise and the cardiovascular intensity of the exercise are not factors to consider.
The nurse is providing care for a client who is postoperative day zero following abdominal surgery. Which image demonstrates the correct action the nurse will instruct the postoperative client to take to engage in deep breathing and coughing exercises during the postoperative period?
Explanation: Because deep breathing and coughing is often painful, the nurse should teach the client how to splint the incision (i.e., support the incision with a pillow or folded bath blanket). The client cannot cough effectively when supine or in a low Fowler position. The orthopneic position is used to facilitate respiratory expansion for clients who are short of breath. Grasping the side rails in a high-Fowler position is likely to put traction on the incision.
The nurse is performing a preoperative assessment of a client who has been scheduled for a reduction mammoplasty (breast reduction). The client states, "I'm starting to wonder if I made the right decision in going ahead with this." What should the nurse do next?
Explore the client's feelings and inform the surgeon. Explanation: The nurse should discuss this and notify the care provider. Clients should not undergo surgery until they are sure that surgery is what they want. Informed consent documents do not bind the client to an earlier decision. It would be inappropriate to try to convince the client to go through with the surgery if she is questioning her decision.
The nurse educates a client about what to expect after abdominal surgery. How will the nurse explain the progression of a client's diet in the postoperative period?
Food and liquids will be held in the immediate postoperative period. Explanation: Intestinal manipulation, pain medications, and anesthetic agents may result in a decrease in intestinal motility. The client may experience nausea and vomiting. Therefore, after surgery, fluids and food are often withheld until gastric motility returns. A diet with sufficient amounts of protein and vitamins A and C (not vitamin B) helps to rebuild tissues and promotes wound healing. A soft diet with adequate (not high) carbohydrates for energy is started after the client has demonstrated tolerance to liquids well. Clients are not able to eat anything they want following surgery; the diet is usually progressed from NPO, to clear then full liquids, a soft diet, and finally a regular diet.
A nurse is monitoring a client post cardiac surgery. What action would help to prevent cardiovascular complications for this client?
Implement leg exercises and turn the client in bed every 2 hours. Explanation: Ambulation and leg exercises increase circulation, which prevents cardiovascular complications. The nurse should provide covers, forced warm air, or other warming devices/techniques as necessary to prevent shivering and hypothermia caused by the surgical procedure, the procedure's length, anesthetic agents, a cool environment, the client's age, or the use of cool irrigating/infusion fluids. Pillows placed under the knees can cause venous pooling, leading to thrombophlebitis.
The preoperative nurse has prepared a client for surgery and has been notified that the operating room staff is ready for the client. The client states, "My bladder feels full. I need to go to the bathroom!" Which action by the nurse is appropriate?
Inform the operating room staff and assist the client to the bathroom. Explanation: Clients should empty the bowel and bladder before surgery. A urinary catheter is not indicated. The remaining statements are untrue.
The nurse is supervising a nursing student who is providing postoperative education to a client with an abdominal incision. The nurse sees the student coaching the client to perform coughing exercises, as pictured above. What is the nurse's best action?
Instruct the student to provide the client with a pillow or folded blanket to hug. Explanation: Because coughing is often painful, the student should teach the client how to splint the incision (i.e., support the incision with a pillow or folded bath blanket). It is not normally necessary to physically support the client, and it may be unsafe for the client to dangle. The client should not be in a supine or in a low Fowler's position, but the client does not necessarily need to be fully upright.
The nurse cares for a client following surgery to repair an abdominal aortic aneurysm. Which nursing intervention assists with healing and maintaining client comfort?
Maintaining a calm environment Explanation: The nurse should plan for adequate periods of rest and sleep and maintain a quiet, restful environment. Nursing interventions that can help promote rest include maintaining a calm environment and limiting interruptions to the client's sleep (including frequent family visits). Providing solid food and keeping the client recumbent will not assist with healing and maintaining client comfort and may be contraindicated.
A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding?
Monitor the client closely and promote fluid intake. Explanation: Bowel function does not typically return immediately after surgery, but it can be promoted by encouraging fluid and fiber intake as appropriate to the client and his or her surgery. A medical assessment is likely unnecessary at this early postoperative stage, and an enema would likely be premature. The nurse may not independently increase the client's IV infusion, and doing so would not necessarily promote a bowel movement.
A perioperative nurse is assessing a client scheduled for surgery. The client mentions that he takes aspirin on a daily basis since having a heart attack several years ago. In addition to ensuring the surgeon is aware, what is the nurse's most appropriate action?
Monitor the client closely for signs of hemorrhage Explanation: Current medication use, especially use of medications that can affect coagulation status (warfarin, nonsteroidal anti-inflammatory drugs, aspirin), is important and should be reported to the surgeon. It is common for anticoagulants to be withheld prior to surgery. The client does not face an increased risk for DVT and assesment of knowledge is secondary to physical safety.
Which nursing action will best promote pain management for a client in the postoperative phase?
Performing relaxation techniques Explanation: Performing relaxation techniques is the best nursing action to promote pain management for a client in the postoperative phase.
Which measure would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client?
Place graduated compression stockings on the client. Explanation: Use of graduated compression stockings and/or pneumatic compression devices on the client will help with prevention of DVT, which is a risk for clients after surgery. Elevating the client's legs will passively improve venous return but not prevent DVT if a client is not up and walking (to more actively promote the venous return). Elevating the head of the bed and using the incentive spirometer help prevent postoperative complications of atelectasis or pneumonia. Early ambulation is beneficial, but it is not necessary for the client to ambulate every hour.
The nurse is caring for a client postoperatively. The vital signs are blood pressure 88/50 mm Hg, heart rate 110 beats/min, respiratory rate 24 breaths/min. The client stated the pain in the abdomen will not stop. The abdominal dressing is saturated with fresh blood. Along with notifying the surgeon, what is the nurse's priority in this situation?
Place in supine position. Explanation: The client is hemorrhaging from the abdominal incision and has symptoms of shock: hypotension, tachycardia, increased respirations. The nurse's priority is to place the client in supine position to help increase the blood pressure by increasing the blood return to the heart. The supine position will also decrease intra-abdominal pressure and help take pressure off the incision. The nurse can quickly assess urine output, which may be decreased due to hypovolemia from the blood loss and subsequent shock. The nurse can reinforce the abdominal dressing to absorb drainage. The nurse should not remove the dressing because this would lead to removal of the clot formation and increase bleeding. Because the client is hypotensive, the nurse would need to reassess blood pressure before administering certain prescribed opioid analgesics since the med could lower the blood pressure more. The nurse would stay with the client until the client is stable.
The recovery nurse is caring for a surgical client who entered the PACU 30 minutes ago. The client's blood pressure is dropping steadily while the client's heart rate has doubled since admission. What is the nurse's best action?
Prepare interventions aimed at resolving shock Explanation: Decreasing blood pressure and an increased pulse rate in the postoperative client are significant because they may signify hemorrhage or shock. Neither of these changes are anticipated. Naloxone is used to treat opioid toxicity, which is unlikely in the postoperative period and which would be accompanied by decreased heart rate. The client should indeed monitor the client, but this action is not sufficient, given the client's worsening status.
The nurse is teaching the client who recently experienced abdominal surgery to deep breathe and cough effectively. What observable action serves to best minimize pain that may result from the intervention?
Providing support to abdominal and accessory respiratory muscles Explanation: Coughing and deep breathing uses abdominal and accessory respiratory muscles, which may have been cut during surgery. Splinting, in this case with a pillow, supports the incision and surrounding tissues and reduces pain during coughing and deep breathing exercises. While providing emotional support is appropriate, doing so will not affect physiological pain resulting from the intervention. Exhaling with lips pursed increases resistance in the airways, which helps them stay open during exhalation. Supporting the head and shoulders adds to the client's comfort, but doing so does not address the primary source of pain produced by therapeutic coughing and deep breathing.
The nurse is caring for a confused older adult client who requires surgery for a broken hip. What steps does the nurse take to determine if the client has a durable power of attorney for health care and how to contact that person?
Review the medical chart for a copy of a durable power of attorney for health care or permission for disclosure contact. Explanation: The client cannot give consent due to confusion. In most cases, the durable power of attorney for health care document is discussed and obtained during the admission process. The nurse should act as a client advocate by seeking someone with durable power of attorney to sign the informed consent form. It is the surgeon's responsibility to explain the surgical procedure and obtain the appropriate signature on the consent form; however, the nurse still acts as the client advocate to locate the designated person. A living will specifies the types of medical treatment the client wants should the client become unable to speak in a terminal or permanently unconscious medical condition, but it does not address matters related to client confusion. Telling visitors about the need for surgery may violate client confidentiality. If the nurse identifies who they have permission to disclose medical information to, they can ask that person about a durable power of attorney for health care.
Which methods would the nurse anesthetist use when administering regional anesthesia to surgical clients? Select all that apply.
Spinal block Nerve block Epidural block Explanation: Regional anesthesia occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. Regional anesthesia includes spinal blocks, nerve blocks, and epidural blocks. Inhalation and intravenous administration of anesthesia are associated with general anesthesia. Anesthesia is not administered via the oral route.
The nurse is caring for a client who had a procedure under moderate sedation at the ambulatory surgical center. Which assessment finding indicates to the nurse that the client may be ready for discharge to home?
The client is alert and oriented with a blood pressure 118/70 mm Hg and respirations 18 breaths/minute, is able to ambulate, is not nauseated or vomiting, pain is controlled with medication, and has no excessive bleeding and drainage is as expected. Explanation: Stable vital signs, being alert and oriented, ability to ambulate, minimal nausea and vomiting, adequate pain control, and no excessive bleeding or drainage may indicate that the client is ready for discharge to home. The ability to void is a criterion after a spinal anesthesia or after pelvic surgery. Dizziness or inadequate pain control indicate that the client still needs to be monitored before discharge. Elevated blood pressure should be monitored and the client should not be discharged until stable.
A nurse is instructing a client in how to perform leg exercises following surgery. The client asks the nurse, "Why do I have to do these exercises?" Which is the health reason the nurse should mention?
To increase venous return of blood to the heart Explanation: During surgery, venous blood return from the legs slows. In addition, some client positions used during surgery decrease venous return. Thrombophlebitis, deep vein thrombosis, and the risk for emboli are potential complications from circulatory stasis in the legs. Leg exercises increase venous return through flexion and contraction of the quadriceps and gastrocnemius muscles. Although leg exercises may also strengthen the leg muscles, improve the efficiency of the heart, and increase flexibility, the health reason to perform them following surgery is to increase venous return of blood to the heart.
The nurse is providing care for a pre-surgical client who will be providing informed consent. What is the nurse's most appropriate action in this process?
Witnessing the signed informed consent document Explanation: The nurse may witness the signed informed consent document. The health care provider will explain what takes place during the procedure, and provide benefits and risks. the nurse should avoid being the intermediary between the client; the nurse should arrange for direct communication between the client and the surgeon to address any questions.
Instruct the student to provide the client with a pillow or folded blanket to hug. Explanation: Because coughing is often painful, the student should teach the client how to splint the incision (i.e., support the incision with a pillow or folded bath blanket). It is not normally necessary to physically support the client, and it may be unsafe for the client to dangle. The client should not be in a supine or in a low Fowler's position, but the client does not necessarily need to be fully upright.
before, during, and after the operative phase. Explanation: Perioperative nursing includes three distinct phases: preoperative, intraoperative, and postoperative.
A nurse teaches deep breathing exercises to a client scheduled for surgery. In which perioperative phase would this action occur?
preoperative Explanation: Exercises and physical activities occurring in the preoperative phase include deep breathing exercises, coughing, incentive spirometry, turning, leg exercises, and pneumatic compression stockings. The intraoperative phase is when the client is in the operating room. In the postoperative area and postanesthesia care unit areas, clients are monitored and deep breathing exercises begin.
The nurse has been waiting until after the administration of a toddler's anesthesia before removing the child's clothing and applying monitoring equipment. Doing these actions after the administration of anesthesia will:
prevent anxiety. Explanation: Relaxation can be enhanced by removing the child's clothing, applying the grounding pad, and applying monitoring devices after the child is anesthetized. This action has no effect on vital signs, thermoregulation, or blood loss.
When preparing a client who has diabetes mellitus for surgery, the nurse should be aware of what surgical risk associated with this disease?
slow wound healing Explanation: Due to impaired circulation and high glucose levels, the client with diabetes is at an increased risk for slow wound healing. The surgical risk of fluid and electrolyte imbalances is often associated with clients who have kidney and liver disease. The risk of respiratory depression from surgery increases for clients with existing respiratory disorders. Altered metabolism may occur as a result of surgery for clients with kidney and liver diseases.
A nurse from the ambulatory surgical center is preparing discharge instructions for a client who has had pelvic surgery. Which criterion would the client need to demonstrate to ensure that she is ready for discharge?
void normally Explanation: Before discharge from an ambulatory surgical unit, the client should be able to void normally after a pelvic surgery. It is natural for the client to experience pain after surgery; however, the client should also have the comfort level to control it. The client may not be in a position to eliminate nausea and vomiting completely before discharge, but should suffer minimally from them. The client may have some bleeding or drainage, which should not be excessive at the time of discharge from an ambulatory surgical unit.
