Prep U: Unit 3 Ch. 14, 15, 16 MED/SURG
For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery?
7 Explanation: Aspirin should be stopped at least 7 to 10 days before surgery. The other time frames are incorrect. pg 406
What measurement should the nurse report to the physician in the immediate postoperative period?
A systolic blood pressure lower than 90 mm Hg Explanation: A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal.
A patient is scheduled for a reduction mammoplasty. What classification of surgery does the nurse understand that this is?
Optional Explanation: Cosmetic surgery, including reduction mammoplasties, is optional, as the decision to have the surgery rests with the patient.
A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize?
The edges of a sterile package, once opened, are considered unsterile. Explanation: To maintain surgical asepsis, the edges of a sterile package, once opened, are considered unsterile. When moving around a sterile field, individuals must maintain a distance of at least 1 foot from the sterile field. If a tear occurs in a sterile drape, it must be replaced. Only scrubbed personnel and sterile items may come in contact with sterile areas. Circulating nurses can only contact unsterile areas.
Hypothermia may occur as a result of
open body wounds. Explanation: Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids, inhalation of cold gases, open wounds or cavities, decreased muscle activity, advanced age, or particular pharmaceutical agents.
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?
<30 mL Explanation: If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL per hour are reported; if the patient is voiding, an output of less than 240 mL per 8-hour shift is reported.
The client vomits during the surgical procedure. The best action by the nurse is:
Suction the client to remove saliva and gastric secretions. Explanation: The nurse immediately suctions the client to prevent aspiration of vomitus.
Which of the following is an inappropriate nursing action by the surgical nurse?
Wearing sterile gloves over artificial nails Explanation: Artificial nails are prohibited in the clinical setting, because they can cause nosocomial infections.
Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency?
Adrenal Clients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids does not occur in the pituitary, thyroid, or parathyroid glands
A nursing measure for evisceration is to:
Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution. Explanation: If evisceration occurs, the nurse aseptically covers the abdominal contents with moist saline dressings to prevent drying of the bowel, notifies the surgical team immediately, and assesses the patient's vital signs including oxygen saturation. The patient remains in bed with knees bent to reduce abdominal muscle tension.
As a circulating nurse, what task are you solely responsible for?
Keeping records. Explanation: The circulating nurse wears OR attire but not a sterile gown. Responsibilities include obtaining and opening wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, receiving specimens for laboratory examination, and coordinating activities of other personnel, such as the pathologist and radiology technician. It is the responsibility of the scrub nurse to hand instruments to the surgeon and count sponges and needles. It is the responsibility of the surgeon to estimate blood loss.
The nurse is educating a community group about types of surgery. A member of the group asks the nurse to describe a type of surgery that is curative. What response by the nurse is true?
Tumor excision Explanation: An example of a curative surgical procedure is tumor excision. A biopsy, a face-lift, and the placement of a gastrostomy tube are not examples of curative surgical procedures.
A client with osteoarthritis receives a recommendation to have joint replacement surgery. For which type of surgery will the nurse plan teaching for this client?
Elective Explanation: Elective surgery means that the client should have the surgery even though failure to have the surgery is not catastrophic. Urgent surgery means that prompt attention is required within 24 to 30 hours. Required surgery means that the client needs to have surgery within a few weeks or months. Emergent surgery means that the client requires immediate attention for a life-threatening disorder without delay. pg 399
Which position is used for perineal surgical procedures?
Lithotomy Explanation: The lithotomy position is used for nearly all perineal, rectal, and vaginal surgeries. The Trendelenburg position is usually used for surgery on the lower abdomen and pelvis. The Sims or lateral position is used for renal surgery. The dorsal recumbent position is the usual position for surgical procedures.
The anesthesiologist is administering a stable and safe nondepolarizing muscle relaxant. What medication does the nurse anticipate will be administered?
Pavulon (pancuronium bromide) Explanation: Pancuronium (Pavulon) is a nondepolarizing muscle relaxant with a longer onset and duration. Succinylcholine (Anectine) and decamethonium (Syncurine) are depolarizing muscle relaxants. Vercuronium (Norcuron) is a nondepolarizing muscle relaxant that requires mixing.
A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member?
Surgeon Explanation: The registered nurse first assistant practices under the direct supervision of the surgeon. The circulating nurse works in collaboration with other members of the health care team to plan the best course of action for each patient. The scrub nurse assists the surgeon during the procedure as well as setting up sterile tables and preparing equipment. The anesthetist administers the anesthetic medications.
The patient is having a repair of a vaginal prolapse. What position does the nurse place the patient in?
Lithotomy position The lithotomy position is used for nearly all perineal, rectal, and vaginal surgical procedures (see Fig. 18-5C). The patient is positioned on the back with the legs and thighs flexed. The position is maintained by placing the feet in stirrups.
A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants?
Scrub nurse Explanation: The scrub nurse is sterile and assists the surgical team by handing instruments to the surgeon, preparing sutures, receiving specimens to be sent to the lab, and counting sponges and needles. The circulating nurse is not sterile and obtains and opens sterile equipment, adjusts lights, and keeps records. The first assistant is involved with the client's preoperative care. The certified registered nurse anesthetist assists in the client's anesthesia.
Which of the following positions would the nurse expect the client to be positioned on the operating table for renal surgery?
Sims position Explanation: The client undergoing renal surgery will be placed in the Sims position.
The nurse is caring for a client during an intraoperative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?
Temperature of 102.5°F (39°C) Explanation: Intraoperative hyperthermia can indicate a life-threatening condition called malignant hyperthermia. The circulating nurse closely monitors the client for signs of hyperthermia. The pulse rate, respiratory rate, and blood pressure did not indicate a significant concern.
A client scheduled for surgery asks why blood tests are being done to evaluate liver function. Which response will the nurse make?
"It is because the anesthesia you will receive is cleared through the liver." Explanation: The liver is one body organ that eliminates drugs and toxins and is important in the biotransformation of anesthetic compounds. Disorders of the liver may substantially affect how anesthetic agents are metabolized. Acute liver disease is associated with high surgical mortality. Careful assessment may include various liver function tests. Preoperative liver function tests may be routine but that does not explain the reason for the test to the client. Liver function tests are not done to determine prophylactic antibiotic therapy or to determine if the client had any alcohol before the surgery.
When developing a teaching plan for a patient scheduled for ambulatory surgery with epidural anesthesia, which of the following would the nurse include?
"You shouldn't experience a headache after this type of anesthesia." Explanation: With epidural anesthesia, a headache usually does not occur. If the dura mater is punctured during epidural anesthesia and the anesthetic travels toward the head, high spinal anesthesia can occur, producing severe hypotension and respiratory depression and arrest, but this is a complication and not a typical reaction. The anesthetic is introduced into the epidural space surrounding the dura mater of the spinal cord; this is in contrast to spinal anesthesia, which involves injection through the dura mater into the subarachnoid space surrounding the spinal cord. It blocks sensory, motor, and autonomic functions.
The client who had spinal anesthesia complains of a headache. Which of the following is an inappropriate action by the nurse?
Administer morphine sulfate. Explanation: The nurse implements interventions that increase cerebrospinal pressure, such as hydrating the client, keeping the head of the bed flat, and maintaining a quiet environment. A mild analgesic, such as acetaminophen, may be prescribed for the pain; morphine sulfate would be an inappropriate analgesic.
A patient is scheduled for a surgical procedure. For which surgical procedure should the nurse prepare an informed consent form for the surgeon to sign?
An open reduction of a fracture Explanation: Informed consent is necessary in the following circumstances: invasive procedures, such as a surgical incision (such as would be involved in an open reduction of a fracture), a biopsy, a cystoscopy, or paracentesis; procedures requiring sedation and/or anesthesia (see Chapter 18 for a discussion of anesthesia); a nonsurgical procedure, such as an arteriography, that carries more than a slight risk to the patient; and procedures involving radiation. Non-invasive procedures such as insertion of an intravenous or urethral catheter or irrigation of the external ear canal would not require informed consent. pg 401
Informed consent from the surgical client is essential in all of the following categories of surgery except:
Emergent surgery Explanation: In an emergency, a physician may perform surgery without a client's informed consent in order to save the client's life.
How would the operating room nurse place a patient in the Trendelenburg position?
On his back with his head lowered so that the plane of his body meets the horizontal on an angle Explanation: The Trendelenburg position usually is used for surgery on the lower abdomen and pelvis to obtain good exposure by displacing the intestines into the upper abdomen. In this position, the head and body are lowered. The patient is supported in position by padded shoulder braces (see Fig. 18-5B), bean bags, and foam padding.
A client is to receive general anesthesia with sevoflurane. What does the nurse anticipate would be given with the inhaled anesthesia?
oxygen Explanation: Sevoflurane is an inhalation anesthetic always combined with oxygen to decrease the risk of coughing and laryngospasm. It would not be combined with alfentanil, rocuronium, or lidocaine. Alfentanil and rocuronium are intravenous anesthetics. Lidocaine is a local anesthetic.
After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements?
"I'll be sleepy but able to respond to your questions." Explanation: With moderate sedation, the patient can maintain a patent airway (i.e., doesn't need a tube to help breathing), retain protective airway reflexes, and respond to verbal and physical stimuli. The patient is not unconscious with moderate sedation. Local anesthesia involves anesthetizing or numbing the area of the surgery.
Which nursing statement would best ease a client's anxiety before an emergency operative procedure?
"Let me explain to you what will happen next." Explanation: Many clients feel fearful of knowing little about the operative procedure and what to expect. This fear causes anxiety and can lead to a poorer response to surgery and surgical complications. Explanations of what the client is to expect can help to decrease anxiety. False reassurance of being fine does not diminish anxiety. Deep breathing and relaxation techniques can be helpful to the client, but addressing the source of the anxiety is more beneficial. Keeping the family informed helps the family and is not client focused.
You are the nurse working in an ambulatory surgery center. A teenage son of your clients ask you why so many people have surgery. What would be your best reply?
"Many people have diagnostic or short therapeutic surgical procedures." Explanation: Many diagnostic or short therapeutic surgical procedures—such as bone marrow biopsy, endoscopy, or cardiac catheterization—are now performed in outpatient settings and ambulatory surgical centers. Options B, C, and D seem to minimize the teenager's question.
The policies and procedures on a preoperative unit are being amended to bring them closer into alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most directly addresses the priorities of the SCIP?
Actions aimed at preventing surgical site infections Explanation: SCIP identifies performance measures aimed at preventing surgical complications, including venous thromboembolism (VTE) and surgical site infections (SSI). It does not explicitly address family participation, interdisciplinary collaboration, or CAM.
The nurse in the postanesthesia care unit (PACU) is preparing to receive a client from the operating room. The nurse knows that which information would need to be communicated? Allergies Surgical procedure Estimated blood loss Vital signs before surgery Medical comorbidities Anesthetic agents used
Allergies Surgical Procedure Estimated Blood Loss Medical Comorbidities Anesthetic Agents Used The nurse who admits the client to the PACU reviews essential information with the anesthesiologist or CRNA and the circulating nurse. Oxygen is applied, monitoring equipment is attached, and an immediate physiologic assessment is conducted. Information provided to the nurse in the PACU includes the client's allergies, the surgical procedure, estimated blood loss, the last set of vital signs, medical comorbidities, and the anesthetic agents used. The nurse knows that the last set of vitals would be necessary for continuity of care.
A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take?
Allow the client to wear the ring and cover it with tape. Explanation: Most facilities will allow a client to wear a wedding band during a surgical procedure. The nurse must secure the ring with tape. Although it is appropriate to discuss the risk for infection, the client has already refused to remove the ring. The surgery should not be canceled and the ring should not be removed without permission.
What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities?
Coordinating the surgical team The person in the scrub role, either a nurse or a surgical technician, provides sterile instruments and supplies to the surgeon during the procedure by anticipating the surgical needs as the surgical case progresses. The circulating nurse coordinates the care of the patient in the OR. Care provided by the circulating nurse includes planning for and assisting with patient positioning, preparing the patient's skin for surgery, managing surgical specimens, anticipating the needs of the surgical team, and documenting intraoperative events.
The nurse is teaching the client about usual side effects associated with spinal anesthesia. Which of the following should the nurse include when teaching?
Headache Explanation: Headache is a common effect following spinal anesthesia.
The nurse positions the client in the lithotomy position in preparation for
Perineal surgery Explanation: The client undergoing perineal surgery will be placed in the lithotomy position.
The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to:
Respond verbally during the procedure Explanation: Clients can respond to verbal and physical stimuli and maintain an oral airway and protective reflexes during moderate sedation.
Which of the following techniques least exhibits surgical asepsis?
Suctioning the nasopharyngeal cavity of a client Explanation: To maintain surgical asepsis, only sterile items should touch sterile items. Basic guidelines ensuring that all materials in contact with the surgical wound or used within the sterile field are sterile and maintaining at least a 1-foot distance from the sterile field. Surgical gowns are considered sterile in front from the chest to the level of the sterile field, and sleeves are considered sterile from 2 inches above the elbow to the stockinette cuff; therefore, sterile gloved hands should be kept above the sterile field to prevent contamination. Nasopharyngeal suction is an aerosol-generating procedure.
A nurse evaluates the potential effects of a client's medication therapies before surgery. Which drug classification may cause respiratory depression from an associated electrolyte imbalance during anesthesia?
diuretics Explanation: Diuretics during anesthesia may cause excessive respiratory depression resulting from an associated electrolyte imbalance. Corticosteroids, insulin, and anticoagulants are not known to cause respiratory depression during anesthesia.
A client is scheduled to have surgery to address a cleft palate. What type of surgery would the nurse be preparing this client for?
reconstructive Explanation: Clients have surgery for many different reasons. Reconstructive surgery is intended to repair or reconstruct physical deformities and abnormalities caused by traumatic injuries, birth defects, developmental abnormalities, or disease. Corrective surgery usually involves fixing a problem. Diagnostic surgery is the removal and study of tissue to make a diagnosis. Prophylactic surgery is the removal of tissue that does not yet contain cancer cells but has a high probability of becoming cancerous in the future.
A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective?
"I will support my incision with my hands when I cough and do my deep breathing exercises." Explanation: Splinting of the incision provides support to the incision and helps to control pain, so this client statement is correct. Clients should take pain medication routinely and frequently after surgery. Pain medications for postoperative clients are given orally at home. Pain is a subjective feeling, so comparison is difficult.
A nurse is teaching a client about pain management after surgery. Which client statement indicates the teaching was effective?
"I will support my incision with my hands when I cough and do my deep breathing exercises." Explanation: Splinting of the incision provides support to the incision and helps to control pain, so this client statement is correct. Clients should take pain medication routinely and frequently after surgery. Pain medications for postoperative clients are given orally at home. Pain is a subjective feeling, so comparison is difficult. pg408
A client has been transported to the operating room for emergent surgery. Which statement by the nurse best supports the need for emergent surgery?
"The client was unresponsive, had a distended abdomen, and had unstable vital signs after a motor vehicle accident." Explanation: Emergency surgery means that the client requires immediate attention and the disorder may be life threatening. A client with unstable vital signs and a distended abdomen after a motor vehicle accident requires immediate attention. A client with left abdominal pain may not need surgery. Epigastric pain with vomiting for 1 day is usually not an indication for emergent surgery. Lacerations to the face require sutures, not emergent surgery. A thyroidectomy to treat hyperthyroidism is a required surgery, not an emergent one.
The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed?
"The nurse will explain the details of the surgery before I sign a consent." Explanation: Further instruction would be needed to clarify that the physician, not the nurse, explains the details of the surgery and obtains voluntary consent for the procedure. It is correct that preoperative instructions must be followed prior to surgery for the safety of the client, medical records are present for review prior to surgery, and the physician speaks with the family following the procedure and provides instructions for discharge.
A client is undergoing a lumbar puncture. The nurse educates the client about surgical positioning. Which statement by the nurse is appropriate?
"You will be lying on your side with your knees to your chest." Explanation: For the lumbar puncture procedure, the client usually lies on the side in a knees-to-chest position. A position flat on the table, face down does not open the vertebral spaces to allow access for the lumbar puncture. Having the client lie on their back does not allow access to the surgical site.
The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room?
7 Explanation: Many hospitals use a scoring system (e.g., Aldrete score) to determine the patient's general condition and readiness for transfer from the PACU (Aldrete & Wright, 1992). Throughout the recovery period, the patient's physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. This evaluation guide allows an objective assessment of the patient's condition in the PACU. The patient is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The Aldrete score is usually between 7 and 10 before discharge from the PACU.
A patient with renal failure is scheduled for a surgical procedure. When would surgery be contraindicated for this patient due to laboratory results?
A blood urea nitrogen level of 42 mg/dL Explanation: The kidneys are involved in excreting anesthetic medications and their metabolites; therefore, surgery is contraindicated if a patient has acute nephritis, acute renal insufficiency with oliguria or anuria, or other acute renal problems (see Chapter 54). A blood urea nitrogen level of 42 mg/dL (significantly elevated) is an indicator of renal failure. The other levels are normal.
The nurse recognizes that which of the following clients is at the lowest risk for perioperative complications?
A client who has a history of arthritis Explanation: A history of arthritis does not increase the risk for complications during the perioperative period.
The nurse expects informed consent to be obtained for insertion of:
A gastrostomy tube Explanation: Informed consent is required for invasive procedures that require sedation and are associated with more than usual risk to the client.
A client is scheduled for a surgical procedure. When planning the client's care, the nurse should consider that which of the following conditions will increase the client's risk of complications after surgery?
A history of diabetes Explanation: As a chronic condition that affects many body systems, diabetes is a risk factor for surgical complications. The client's blood glucose level and insulin requirements need to be closely monitored before and after surgery. Being sensitive to aspirin does not pose a risk for the client in surgery. Osteoarthritis is not a systemic condition and does not place the client at risk during surgery. Chronic low back pain is not a systemic condition that places the client at risk during surgery; however, it can be exacerbated by positioning on the operating room table. Reference:
A client undergoing coronary artery bypass surgery is subjected to intentional hypothermia. The client is ready for rewarming procedures. Which action by the nurse is appropriate?
Apply a warm air blanket, gradually increasing body temperature. Explanation: A warm air blanket can be used to treat hypothermia. The body temperature should be increased gradually. A sudden increase in body temperature could cause complications. The OR temperature should not exceed 26.6°C to prevent pathogen growth. Only dry materials should be placed on the client because wet materials promote heat loss. IV fluids should be warmed to body temperature, not room temperature.
A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?
Assess for signs and symptoms of fluid volume deficit. Explanation: The client's 24-hour intake is 1800 mL (75 x 24). The client's 24-hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Because the output is significantly higher than the intake, the client is at risk for fluid volume deficit. The nurse should not discontinue the nasogastric suctioning without a physician's order. The findings should be documented and reassessed, but the nurse needs to take more action to prevent complication. Edema is usually associated with fluid volume excess.
A client scheduled for surgery follows a vegan eating plan. For which potential postoperative complication will the nurse plan care for this client?
Blood clots The client following a vegan eating plan is at risk for a low protein intake. The reduced protein can lead to impaired or delayed wound healing and cause decreased skin and wound strength. A low protein intake does not cause blood clots, stasis pneumonia, or hypoactive bowel sounds.
The nurse is caring for a client who has just arrived for surgery. Which assessment finding indicates to the nurse that the client may be experiencing dehydration because of taking nothing by mouth after midnight for the surgery?
Blood pressure 80/50 mm Hg Explanation: Assessment of a client's hydration status is essential preoperatively. The client's NPO (nothing by mouth or nil per os) status should be confirmed preoperatively. Preoperative fasting helps prevent the risk of aspiration but it also induces stress on the body, including the loss of glycogen stores, and the body sacrifices lean muscle to meet the energy needs of the surgery. This may lead to dehydration, which may be exhibited day of surgery by low blood pressure. A urine output of 60 mL/hr is within normal limits. A pulse of 88 beats per minute is within normal limits. A respiratory rate of 20 breaths per minute is within normal limits. pg 402
A patient is in the operating room for surgery. Which individual would be responsible for ensuring that procedure and site verification occurs and is documented?
Circulating nurse Explanation: The circulating nurse is responsible for ensuring that the second verification of the surgical procedure and site takes place and is documented. Each member of the surgical team verifies the patient's name, procedure, and surgical site using objective documentation and data before beginning the surgery.
The OR personnel responsible for maintaining the safety of the client and the surgical environment is the:
Circulating nurse Explanation: The circulating nurse is responsible for maintaining the safety of the client and the surgical environment.
What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities?
Coordinating the surgical team Explanation: The person in the scrub role, either a nurse or a surgical technician, provides sterile instruments and supplies to the surgeon during the procedure by anticipating the surgical needs as the surgical case progresses. The circulating nurse coordinates the care of the patient in the OR. Care provided by the circulating nurse includes planning for and assisting with patient positioning, preparing the patient's skin for surgery, managing surgical specimens, anticipating the needs of the surgical team, and documenting intraoperative events.
What medication should the nurse prepare to administer in the event the client has malignant hyperthermia?
Dantrolene sodium Explanation: Anesthesia and surgery should be postponed. However, if end-tidal carbon dioxide (CO2) monitoring and dantrolene sodium (Dantrium) are available and the anesthesiologist is experienced in managing malignant hyperthermia, the surgery may continue using a different anesthetic agent.
A patient who has undergone surgery and received spinal anesthesia is reporting a headache. Which of the following would be most appropriate?
Encourage increased fluid intake. Explanation: Headache may be an after-effect of spinal anesthesia. To aid in relieving the headache, the nurse would maintain a quiet environment and keep the patient flat and well-hydrated. There is no need to notify the anesthesiologist because this report is not unexpected.
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?
First intention Explanation: When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing.
A patient with uncontrolled diabetes is scheduled for a surgical procedure. What chief life-threatening hazard should the nurse monitor for?
Hypoglycemia Explanation: The patient with diabetes who is undergoing surgery is at risk for both hypoglycemia and hyperglycemia. Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or excessive administration of insulin. Hyperglycemia, which can increase the risk of surgical wound infection, may result from the stress of surgery, which can trigger increased levels of catecholamine. Other risks are acidosis and glucosuria, but hypoglycemia is a bigger risk. Dehydration is a lesser risk for a patient with diabetes than is hypoglycemia.
An obese client is undergoing abdominal surgery. During the procedure a surgical resident states, "The amount of fat we have to cut through is disgusting." What is the best response by the nurse?
Inform the resident that all communication needs to remain professional. Explanation: The nurse must advocate for the client, especially when the client cannot speak for themselves. By informing the resident that all communication needs to be professional, the nurse is addressing the comment at that moment in time, advocating for the client. Ignoring the comment is not appropriate. The nurse may need to address the concerns of unprofessional communication with the attending surgeon or the charge nurse if the behavior continues. The best action is to address the behavior when it happens.
A student nurse is scheduled to observe a surgical procedure. The nurse provides the student nurse with education on the dress policy and provides all attire needed to enter a restricted surgical zone. Which observation by the nurse requires immediate intervention?
Mask is placed over nose and extends to bottom lip. Explanation: The mask should fit tightly, covering the nose and mouth. The mask should extend down past the chin. The mask may not effectively cover the mouth if extended only to the bottom lip. The hair, scrub top, drawstring, and shoe covering are all appropriate and do not require intervention.
The nurse notes that the consent form for surgery needs to be signed; however, the client just received preoperative medication. Which action will the nurse take?
Notify the health care provider that the consent form has not been signed. Explanation: Informed consent is the client's autonomous decision about whether to undergo a surgical procedure. Voluntary and written informed consent from the client is necessary before nonemergent surgery can be performed to protect the client from unsanctioned surgery and protect the health care provider from claims of an unauthorized operation or battery. Because of this, the health care provider should be notified that the consent form has not been signed. The consent form needs to be signed before administering psychoactive premedication because consent is not valid if it is obtained while the client is under the influence of medications that can affect judgment and decision-making capacity. A family member is not responsible for approving the client's surgery. Verbal agreement to a surgical procedure is not legal or appropriate.
An OR nurse needs to assist a patient to the Trendelenburg position. Which of the following is the correct position?
On his back, with his head lowered, so that the plane of his body meets the horizontal on an angle Explanation: The Trendelenburg position usually is used for surgery on the lower abdomen and pelvis to obtain good exposure by displacing the intestines into the upper abdomen. In this position, the head and body are lowered. The patient is held in position by padded shoulder braces.
A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?
Oxygen saturation (SaO2) of 85% Explanation: Normal SaO2 is 95% to 100%. Oxygen saturation of 85% indicates inadequate oxygenation, which may be a consequence of the moderate sedation. Appropriate nursing actions include rousing the client, if necessary, assisting the client with coughing and deep breathing, and evaluating the need for additional oxygen. A heart rate of 84 beats/minute is within normal limits. Colonoscopy doesn't affect cough and gag reflexes, although these reflexes may be slightly decreased from the administration of sedation. These findings don't require immediate intervention. Blood-tinged stools are a normal finding after colonoscopy, especially if the client had a biopsy.
A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?
Oxygen saturation (SaO2) of 85% Explanation: Normal SaO2 is 95% to 100%. Oxygen saturation of 85% indicates inadequate oxygenation, which may be a consequence of the moderate sedation. Appropriate nursing actions include rousing the client, if necessary, assisting the client with coughing and deep breathing, and evaluating the need for additional oxygen. A heart rate of 84 beats/minute is within normal limits. Colonoscopy doesn't affect cough and gag reflexes, although these reflexes may be slightly decreased from the administration of sedation. These findings don't require immediate intervention. Blood-tinged stools are a normal finding after colonoscopy, especially if the client had a biopsy.
What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?
Pneumonia Older clients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Delirium, pneumonia, decline in functional ability, exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and falls are all threats to recovery in the older adult.
When is the ideal time to discuss preoperative teaching
Preadmission visit Explanation: The ideal timing for preoperative teaching is not on the day of surgery but during the preadmission visit, when diagnostic tests are performed. Teaching should be done long before the patient enters the preop area. Preoperative teaching should not be done when the patient is sedated.
The scrub nurse is responsible for:
Preparing the sterile instruments for the surgical procedure Explanation: The scrub nurse is responsible for preparing the sterile instruments for the surgical procedure.
What complication is the nurse aware of that is associated with deep venous thrombosis?
Pulmonary embolism Explanation: Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010).
A nurse is witnessing a client sign the consent form for surgery. After signing the consent form, the client starts asking questions regarding the risks and benefits of a surgical procedure. What action by the nurse is most appropriate?
Request that the surgeon come and answer the questions. Explanation: It is the physician's responsibility to provide information pertaining to risks and benefits of surgery. It is not the responsibility of the nurse or nurse manager to discuss risks and benefits. The consent form should not be placed in the medical record until all of the client's questions are answered fully.
A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications?
Splint the incision site using a pillow during deep breathing and coughing exercises. Explanation: Splinting the incision site will help decrease pain and support the incision. This will increase compliance with the deep breathing and coughing exercises that assist in preventing respiratory complications. Pain medication should be taken regularly, not only before deep breathing and coughing exercises. Deep breathing and coughing exercises should be done at least every 2 hours, more frequently if possible. While some clients will find the exercises relaxing, most clients find it painful to complete them.
The client vomits during the surgical procedure. The best action by the nurse is:
Suction the client to remove saliva and gastric secretions. Explanation: The nurse immediately suctions the client to prevent aspiration of vomitus.
A nurse is working as a registered nurse first assistant as defined by the state's nurse practice act. This nurse practices under the direct supervision of which surgical team member?
Surgeon Explanation: The registered nurse first assistant practices under the direct supervision of the surgeon. The circulating nurse works in collaboration with other members of the health care team to plan the best course of action for each patient. The scrub nurse assists the surgeon during the procedure as well as setting up sterile tables and preparing equipment. The anesthetist administers the anesthetic medications.
Which clinical manifestation is often the earliest sign of malignant hyperthermia?
Tachycardia (heart rate >150 beats per minute) Explanation: Tachycardia is often the earliest sign of malignant hyperthermia. Hypotension is a later sign of malignant hyperthermia. The rise in temperature is actually a late sign that develops quickly. Scant urinary output is a later sign of malignant hyperthermia.
A nurse is teaching a client about diaphragmatic breathing. What client action indicates that further teaching is needed?
The client exhales forcefully with a short expiration. Explanation: Diaphragmatic breathing should be performed gently and fully. Placing the hands on the lower chest to feel the rise and fall with breathing, performing diaphragmatic breathing in a semi-Fowler's position, and breathing deeply through the nose and mouth are all aspects of diaphragmatic breathing. pg 409
A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition?
The client is displaying early signs of shock. Explanation: The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated. Medication or anesthesia reactions may cause client symptoms similar to these; however, these causes are not as likely as early shock.
The nurse should determine that a client is coughing effectively after surgery if the nurse observes which of the following activities?
The client takes a deep abdominal breath and then "huff" or "hack" coughs three or four times. Explanation: Taking a deep abdominal breath and then "huff" coughing is the most effective manner of coughing. This technique helps facilitate removal of secretions and conserves energy for the client. The client should breathe slowly but not hold her breath. Short, panting breaths and then coughing from the throat do not promote expectoration of sputum from the lungs. Coughing forcefully can cause alveoli to collapse; "huff" coughing prevents this. pg 408
A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize?
The edges of a sterile package, once opened, are considered unsterile. Explanation: To maintain surgical asepsis, the edges of a sterile package, once opened, are considered unsterile. When moving around a sterile field, individuals must maintain a distance of at least 1 foot from the sterile field. If a tear occurs in a sterile drape, it must be replaced. Only scrubbed personnel and sterile items may come in contact with sterile areas. Circulating nurses can only contact unsterile areas.
When does the nurse understand the patient is knowledgeable about the impending surgical procedure?
The patient participates willingly in the preoperative preparation. Explanation: The nurse knows that the patient understands the surgical intervention when the patient participates in preoperative preparation. The other answers pertain to the patient experiencing decreased fear or anxiety, not knowledge about the procedure.
When a client with a history of chronic alcoholism is admitted to the hospital for surgery, the nurse anticipates that the client may show signs of alcohol withdrawal delirium during which time period?
Up to 72 hours after alcohol withdrawal Explanation: Alcohol withdrawal delirium is associated with a significant mortality rate when it occurs postoperatively. Onset of symptoms depends on when alcohol was last consumed. Twenty-four hours is too short a time frame to consider alcohol withdrawal delirium as no longer a threat to a chronic alcoholic.
Following diagnostic testing, a patient requires a cholecystectomy. This surgical procedure would be categorized as which of the following?
Urgent Explanation: Acute gallbladder infection would be categorized as an urgent surgery. Emergent surgeries include severe bleeding, bladder or intestinal obstruction, and a fractured skull. Required surgeries include thyroid disorders and cataracts. Elective surgeries include repair of scars, simple hernia, and vaginal repair.
A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?
Use diaphragmatic breathing. Explanation: In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.
A 17-year-old client is having same-day surgery. Solely during the intraoperative phase of perioperative care, the nurse:
continuously monitors the sedated client. Explanation: Intraoperative care includes the entire surgical procedure. During sedation, the nurse continuously evaluates the client. Assessment of heart rate, respiratory rate, BP, oxygen saturation, and level of consciousness occurs during all phases of perioperative care. Obtaining consent would occur during the preoperative phase of perioperative care. During the postoperative phase the nurse would assess how the client is recovering from anesthesia. pg 397
A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client?
experiences pain within tolerable limits. Explanation: Because pain can contribute to postoperative delirium, adequate pain control without oversedation is essential. Nursing assessment of mental status and of all physiologic factors influencing mental status helps the nurse plan for care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult client.
A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:
first intention. Explanation: Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.
The nurse understands that the purpose of the "time out" is to:
maintain the safety of the client. Explanation: Verification of the identification of the client, procedure, and operative site are essential to maintain the safety of the client.
The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which laboratory value would be of greatest concern to the nurse?
potassium 6.2 mEq/L Explanation: Hyperkalemia places the client at risk for surgical complications. The sodium level, calcium level, and white blood cell count are within normal limits.
A nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which post-surgical risk factor would decrease if the surgical client maintained strict blood glycemic control?
wound healing Explanation: In caring for a postoperative client, the nurse is correct to correlate hyperglycemia with an increased risk of surgical incision infections and delayed wound healing. Strict control of glycemic blood levels at the therapeutic range of 80-110 mg/dL would reduce this risk factor. There is no direct correlation between blood glucose levels and nutrient deficiencies, respiratory complications, or liver dysfunction.
