Session 6 Quizlet - Perioperative nursing

What measurement should the nurse report to the physician in the immediate postoperative period?

systolic blood pressure lower than 90 mm Hg

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."

The scrub nurse is responsible for:

Preparing the sterile instruments for the surgical procedure

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.

Which nursing statement would best ease a client's anxiety before an emergency operative procedure?

"Let me explain to you what will happen next."

A client asks the nurse how an inhalant general anesthetic is expelled by the body. What is the best response by the nurse?

"The lungs primarily eliminate the anesthesia." When inhalant anesthetic administration is discontinued, the vapor or gas is eliminated through the lungs.

A patient has reported to the preadmission clinic in anticipation of her scheduled hysterectomy and oophorectomy. The patient states that her health care provider has explained the parameters for fasting prior to her surgery but tells the nurse that she does not entirely understand why she cannot eat or drink before surgery. What explanation should the nurse provide to this patient?

"You're asked to refrain from eating and drinking so there's less of a chance that you'll inhale food or fluids into your lungs.

A client who is scheduled for knee surgery is anxious about the procedure, saying, "You hear stories on the news all the time about doctors working on the wrong body part. What if that happens to me?" What is the nurse's best response? Select all that apply.

-"The client can be involved in marking the knee, the site for the surgery." -"The surgical team performs a 'time-out' prior to surgery to conduct a final verification." -"The client will be involved in the verification process prior to surgery."

The nurse recognizes adequate hourly urine output for a client with an indwelling urinary catheter as at least

0.5 mL/kg/h

A nurse who has provided care in perioperative settings for many years has seen first-hand the trend toward increasing numbers of surgical procedures being performed in ambulatory surgical centers and on an outpatient basis. What factors have contributed most significantly to this trend?

Advances in anesthesia and in the technology surrounding surgical techniques

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.

Many medications are available to control nausea and vomiting without oversedating the patient. At what point should a nurse normally administer antiemetics to a surgical patient?

At the patient's first report of nausea

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?

Central venous pressure

The nurse is evaluating the client's understanding of diet teaching aimed at promoting wound healing following surgery. The nurse would conclude teaching was ineffective if the client selects which of the following?

Cheeseburger, french fries, coleslaw, and ice cream

Which is the least important issue concerning safety for the perioperative team before proceeding to the operating room?

Client's ambulatory aids It is imperative that the entire perioperative team participates in verifying the client's identity, the correct surgical procedure, and the appropriate surgical site before preceding to the OR. The client's ambulatory aids are not an important safety concern before proceeding to the OR.

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.

A client scheduled for surgery follows a vegan eating plan. For which potential postoperative complication will the nurse plan care for this client?

Delayed wound healing 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.

A nurse asks a client who had abdominal surgery 1 day ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?

Encourage the client to ambulate as soon as possible after surgery. The nurse should encourage the client to ambulate as soon as possible after surgery. Ambulating stimulates peristalsis, which helps the bowels to move. It isn't appropriate to apply heat to a surgical wound. Moreover, heat application can't be initiated without a health care provider's order. A tap water enema is typically administered as a last resort after other methods fail. A health care provider's order is needed with a tap water enema as well. Notifying the health care provider isn't necessary at this point because the client is exhibiting bowel function by passing flatus.

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?

Evisceration Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

First intention

Which would be included as a responsibility of the scrub nurse?

Handing instruments to the surgeon and assistants

Which stage of anesthesia is referred to as surgical anesthesia?

III Stage III may be maintained for hours with proper administration of the anesthetic. Stage I is beginning anesthesia, where the client breathes in the anesthetic mixture and experiences warmth, dizziness, and a feeling of detachment. Stage II is the excitement stage, which may be characterized by struggling, singing, laughing, or crying. Stage IV is a state of medullary depression and is reached when too much anesthesia has been administered.

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?

Ineffective thermoregulation Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.

A nurse is caring for a patient following surgery under a spinal anesthetic. What interventions can the nurse implement to prevent a spinal headache?

Keep the patient lying flat.

A client is undergoing a perineal surgical procedure. The nurse should place the client in which position?

Lithotomy 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.

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.

A client scheduled for surgery has a blood pressure of 186/90 mm Hg. After documenting this in the medical record, which action will the nurse take?

Notify the health care provider of the blood pressure.

What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site?

Obtain the attention of all members of the surgical team. The second verification of the surgical procedure and surgical site should be done at one time and include all members of the surgical team. The marked surgical site is confirmed with all members of the surgical team, not just the surgeon or client. Complications, allergies, and anticipated problems are also discussed among the entire surgical team.

An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults?

Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients.

The nurse is preparing an older adult for a surgical procedure. Which action will the nurse take to protect the client from injury during the operative period?

Protect bony prominences with extra padding.

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.

A client vomits postoperatively. What is the most important nursing intervention?

Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs. When a client vomits, the nurse should turn the client's head to the side to prevent aspiration; the vomitus is collected in the emesis basin. Measuring the vomitus is not helpful to the client. Offering fluids is not advised with vomiting. Supporting the wound is important, but not a priority with vomiting.

A patient who is currently undergoing surgery has vomited a small amount of emesis. How should the OR nurses best respond to this intraoperative event?

Turn the patient on his or her side and perform oral suctioning.

The nurse is caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock?

Weak and rapid pulse rate Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretion

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for?

Wound dehiscence

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 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 nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

first intention.

The nurse expects informed consent to be obtained for insertion of:

A gastrostomy tube Informed consent is required for invasive procedures that require sedation and are associated with more than usual risk to the client.

A nurse is planning preoperative teaching for an older client. Which structural or functional changes in the older adult impact the surgical experience? Select all that apply.

-Increased fatty tissue prolongs elimination of anesthesia. -Decreased ability to compensate for hypoxia increases the risk of an embolism. -Loss of collagen increases the risk of skin complications. -Reduced tactile sensitivity can lead to assessment and communication problems.

A nurse is caring for a bariatric client prior to a surgical procedure. What surgical complications would the nurse monitor the bariatric client for postoperatively? Select all that apply.

-cardiovascular complications -pulmonary complications Like age, obesity increases the risk and severity of complications associated with surgery. The cardiovascular system is at risk for complications with obese surgical clients because of hypertension and diabetes complications. The client tends to have shallow respirations when supine, increasing the risk of hypoventilation and postoperative pulmonary complications. The acquired physical characteristics-a short, thick neck; large tongue; recessed chin; and redundant pharyngeal tissue, associated with increased oxygen demand and decreased pulmonary reserves-impede intubation. Obesity should not cause postoperative complications with the gastrointestinal system, renal system, or nervous system.

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 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.

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 78-year-old client is undergoing surgery to repair a right hip fracture. What nursing action is appropriate during the intraoperative phase?

Appropriately position the client using adequate padding and support

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

What medication should the nurse prepare to administer in the event the client has malignant hyperthermia?

Dantrolene sodium 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.

What action by the nurse best encompasses the preoperative phase?

Educating clients on signs and symptoms of infection Educating clients on preventing or recognizing complications begins in the preoperative phase. Applying SCDs and frequently monitoring vital signs happen after the preoperative phase. Only electric clippers should be used to remove hair.

A client is being prepared in the operating room for a surgical procedure. Which assessment parameter(s) will the surgical nurse use to monitor the client's status when receiving general anesthesia? Select all that apply.

HR Pupil response BP RR

Which stage of surgical anesthesia is also known as excitement?

II Stage II is the excitement stage, which is characterized by struggling, shouting, and laughing. Stage II is often avoided if the anesthetic is administered smoothly and quickly. Stage I is the beginning of anesthesia, during which the client breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia, which is achieved by continued administration of anesthetic vapor and gas. Stage IV is medullary depression, in which the client is unconscious and lies quietly on the table.

A postoperative client with an open abdominal wound is currently taking corticosteroids. The physician orders a culture of the abdominal wound even though no signs or symptoms of infection are seen. What action by the nurse is appropriate?

Obtain the wound culture specimen. Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. The culture should be obtained even though the client is not demonstrating traditional signs and symptoms of infection. The order should not be discontinued or held until purulent drainage is noted because the infection could worsen and the client could develop sepsis. An antibiotic cleaning agent should not be used before obtaining the specimen because it will alter the growth of the organisms.

The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?

Ondansetron (Zofran) is used to treat nausea and vomiting.

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?

Pink to red and soft, bleeding easily In second-intention healing, necrotic material gradually disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue.

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse?

Position the client in the side-lying position

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing the dressing or applying pressure if bleeding is frank The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply will not help manage and minimize hemorrhage and shock. Monitoring vital signs every 15 minutes is an appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to determine the extent and progression of the problem.

A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention?

Report early calf pain.

A scrub nurse is diagnosed with a skin infection to the right forearm. What is the priority action by the nurse?

Report the infection to an immediate supervisor.

Nursing assessment findings reveal that the client is afraid of dying during the surgical procedure. Which surgical team member would be most helpful in addressing the client's concern?

Surgeon It is the surgeon's responsibility to explain the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts in obtaining informed consent from the client.

A 55-year-old patient arrives at the operating room. The nurse is reviewing the medical record and notes that the patient has a history of osteoporosis in her lower back and hips. The patient is scheduled to receive epidural anesthesia. Which of the following nursing diagnoses would be a priority for this patient?

Risk for perioperative positioning injury related to operative position Although any of the nursing diagnoses might apply for this patient, the priority would be risk for perioperative positioning injury related to the patient's history of osteoporosis. The bone loss associated with this condition necessitates careful manipulation and positioning during surgery.

A client is scheduled for a spinal fusion to treat spinal stenosis. For which reason might the nurse anticipate surgery being delayed because of the risk for postoperative complications?

Smoking

Which clinical manifestation is often the earliest sign of malignant hyperthermia?

Tachycardia (heart rate >150 beats per minute) 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 postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client?

The client can be discharged from the PACU.

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. 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.

A client is having a surgical procedure that requires the client to be in the prone position. What is an expected client outcome?

The client remains free of perioperative positioning injury. The potential for transient discomfort or permanent injury is present because many surgical positions are awkward. Hyperextending joints, compressing arteries, or pressing on nerves and bony prominences usually results in discomfort simply because the position must be sustained for a long period of time.

A nurse on a postsurgical unit is providing care for 20-year-old man who had an open appendectomy performed earlier this morning. Which of the following assessment findings should prompt the nurse to contact the patient's surgeon?

The patient has put out 35 mL of urine in the 7 hours since admission. If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/hour are reported; if the patient is voiding, an output of less than 240 mL per 8-hour shift is reported. Nausea, infiltrated IVs, and lack of social support are problems that can be independently addressed by the nurse.

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

Use diaphragmatic breathing 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 client is being prepared for a surgical procedure. The circulating nurse is specifically responsible for which piece of the surgical timeout?

Verification of the timeout

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing?

Wound infection

A client is preparing for a surgical procedure is taking corticosteroids for Crohn's disease. What is most important for the nurse to monitor during the operative experience with the client?

adrenal insufficiency Clients who have received corticosteroids are at risk for adrenal insufficiency. They are not at greater risk for obstruction, infection, or hypoglycemia during the operative experience.

During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 103°F. The nurse should prepare to administer:

dantrolene sodium (Dantrium) The client is exhibiting clinical manifestations of malignant hyperthermia. Dantrolene sodium, a skeletal muscle relaxant, is administered.

The nurse recognizes the client has reached stage III of general anesthesia when the client:

lies quietly on the table Understanding the stages of anesthesia is necessary for nurses because of the emotional support that the client may need. Stage III or surgical anesthesia is reached when the patient is unconscious and lies quietly on the table. The pupils are small but constrict when exposed to light. Respirations are regular, the pulse rate and volume are normal, and the skin is pink or slightly flushed. Clients in stage I of anesthesia may have a ringing, roaring, or buzzing in the ears and, although still conscious, may sense an inability to move the extremities easily. These sensations can result in agitation. Stage II of anesthesia is characterized variously by struggling, shouting, talking, singing, laughing, or crying, and is often avoided if IV anesthetic agents are given smoothly and quickly. Stage IV is reached if too much anesthesia is given. Respirations become shallow, the pulse is weak and thready, and the pupils become widely dilated and no longer constrict when exposed to light. Cyanosis develops and, without prompt intervention, death rapidly follows. If this stage develops, the anesthetic agent is discontinued immediately and respiratory and circulatory support is initiated to prevent death.

Hypothermia may occur as a result of

open body wounds.

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