N410 Exam 2 Intraoperative NCLEX – Flashcards
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The nurse requests the client to sign a surgical informed consent form for an emergency appendectomy. Which statement by the client indicates further teaching is needed? 1."I will be glad when this is over so I can go home today." 2."I will not be able to eat or drink anything prior to my surgery." 3."I can practice relaxing by listening to my favorite music." 4."I will need to get up and walk as soon as possible."
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1 The client will be in the hospital for a few days. This is not a day-surgery procedure. The client needs more teaching.
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The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement? 1.Notify the surgeon about the client's request to wear the medal. 2.Tape the medal to the client and allow the client to wear the medal. 3.Request the family member take the medal prior to surgery. 4.Explain taking the medal to surgery is against the policy.
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2 The medal should be taped and the client should be allowed to wear themedal because meeting spiritual needs is essential to this client's care.
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The nurse must obtain surgical consent forms for the scheduled surgery. Which client would not be able to consent legally to surgery? 1.The 65-year-old client who cannot read or write. 2.The 30-year-old client who does not understand English. 3.The 16-year-old client who has a fractured ankle. 4.The 80-year-old client who is not oriented to the day.
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3 A 16-year-old client is not legally able togive permission for surgery unless the adolescent has been given an emancipated status by a judge. This information was not given in the stem.
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The nurse is preparing a client for surgery. Which intervention should the nurse implement first? 1.Check the permit for the spouse's signature. 2.Take and document intake and output. 3.Administer the "on call" sedative. 4.Complete the preoperative checklist.
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4 Completing the preoperative checklist has the highest priority to ensure all details are completed without omissions.
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The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply. 1.The client has loose, decayed teeth. 2.The client is experiencing anxiety. 3.The client smokes two (2) packs of cigarettes a day. 4.The client has had a chest x-ray which does not show infiltrates. 5.The client reports using herbs.
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1 Loose teeth or caries need to be re-ported to the anesthesiologist so he or she can make provisions to prevent breaking the teeth and causing the client to possibly aspirate pieces.
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Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? 1.Complete the preoperative checklist. 2.Assess the client's preoperative vital signs. 3.Teach the client about coughing and deep breathing. 4.Assist the client to remove clothing and jewelry.
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4 The UAP can remove clothing and jewelry.
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The nurse is assessing a client in the day surgery unit who states, "I am really afraid of having this surgery. I'm afraid of what they will find." Which statement would be the best therapeutic response by the nurse? 1."Don't worry about your surgery. It is safe." 2."Tell me why you're worried about your surgery." 3."Tell me about your fears of having this surgery." 4."I understand how you feel. Surgery is frightening."
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3 This statement focuses on the emotion which the client identified and is therapeutic.
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The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after three (3) tap water enemas. Which intervention should the nurse implement first? 1.Notify the surgeon of the client's status. 2.Continue giving enemas until clear. 3.Increase the client's IV fluid rate. 4.Obtain STAT serum electrolytes.
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1 The nurse should contact the surgeon because the client is at risk for fluid and electrolyte imbalance after three (3) enemas. Clients who are NPO, elderly clients, and pediatric clients are more likely to have these imbalances.
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The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select ALL that apply. 1.Perform passive range-of-motion exercises. 2.Discuss how to cough and deep breathe effectively. 3.Tell the client he can have a meal in the PACU. 4.Teach ways to manage postoperative pain. 5.Discuss events which occur in the post-anesthesia care unit.
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2, 4, 5 Coughing effectively aids in the removal of pooled secretions which can cause pneumonia. Deep-breathing exercises keep the alveoli inflated and prevent atelectasis. The client's postoperative pain should be kept within a tolerable range. These interventions help decrease the client's anxiety.
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The nurse is caring for a client scheduled for total hip replacement. Which behavior indicates the need for further preoperative teaching? 1.The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth. 2.The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves the feet in a circular motion. 3.The client uses the incentive spirometer and inhales slowly and deeply so the piston rises to the preset volume. 4.The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.
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4 The correct way to get out of bed postoperatively is to roll onto the side,grasp the side rail to maneuver to the side, and then push up with one hand while swinging the legs over the side. The client needs further teaching.
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The nurse is completing a preoperative assessment on a male client who states, "I am allergic to codeine." Which intervention should the nurse implement first? 1.Apply an allergy bracelet on the client's wrist. 2.Label the client's allergies on the front of the chart. 3.Ask the client what happens when he takes the codeine. 4.Document the allergy on the medication administration record.
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3 The nurse should first assess the events which occurred when the client took this medication because many clients think a side effect, such as nausea, is an allergic reaction.
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Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery? 1.Calcium 9.2 mg/dL. 2.Bleeding time 2 minutes. 3.Hemoglobin 15 g/dL. 4.Potassium 2.4 mEq/L.
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4 This potassium level is low and should be reported to the health-care provider because potassium is important for muscle function, including the cardiac muscle.
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Which activities are the circulating nurse's responsibilities in the operating room? 1.Monitor the position of the client, prepare the surgical site, and ensure the client's safety. 2.Give preoperative medication in the holding area and monitor the client's response to anesthesia. 3.Prepare sutures; set up the sterile field; and count all needles, sponges, and instruments. 4.Prepare the medications to be administered by the anesthesiologist and change the tubing for the anesthesia machine.
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1 The circulating nurse has many responsibilities in the OR, including coordinating the activities in the OR;keeping the OR clean; ensuring the safety of the client; and maintaining the humidity, lighting, and safety of the equipment.
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The circulating nurse observes the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement? 1.Place the sponge back where it was. 2.Tell the technician not to waste supplies. 3.Do nothing because this is the correct procedure. 4.Take the sponge out of the room immediately.
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3 The technician followed the correct procedure. Sponges are counted to maintain client safety, so all sponges must be kept together to repeat the count before the incision site is sutured. The sponge must be removed,not used, and placed in a designated area to be counted later.
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The circulating nurse and the scrub technician find a discrepancy in the sponge count. Which action should the circulating nurse take first? 1.Notify the client's surgeon. 2.Complete an occurrence report. 3.Contact the surgical manager. 4.Re-count all sponges.
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4 A re-count of sponges may lead to the discovery of the cause of the presumed error. Usually it is just a miscount or a result of a sponge being placed in a location other than the sterile field,such as the floor or a lower shelf.
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Which violation of surgical asepsis would require immediate intervention by the circulating nurse? 1.Surgical supplies were cleaned and sterilized prior to the case. 2.The circulating nurse is wearing a long-sleeved sterile gown. 3.Masks covering the mouth and nose are being worn by the surgical team. 4.The scrub nurse setting up the sterile field is wearing artificial nails.
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4 According to the Centers for Disease Control and Prevention (CDC),the Association of Operating Room Nurses (AORN), and the Association for Practitioners in Infection Control,artificial nails harbor microorganisms, which increase the risk for infection.
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The nurse identifies the nursing diagnosis "risk for injury related to positioning"for the client in the operating room. Which nursing intervention should the nurse implement? 1.Avoid using the cautery unit which does not have a biomedical tag on it. 2.Carefully pad the client's elbows before covering the client with a blanket. 3.Apply a warming pad on the OR table before placing the client on the table. 4.Check the chart for any prescription or over-the-counter medication use.
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2 Padding the elbows decreases pressure so nerve damage and pressure ulcers are prevented. This addresses the etiology of the nursing diagnosis.
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The circulating nurse is positioning clients for surgery. Which client has the greatest potential for nerve damage? 1.The 16-year-old client in the dorsal recumbent position having an appendectomy. 2.The 68-year-old client in the Trendelenburg position having a cholecystectomy. 3.The 45-year-old client in the reverse Trendelenburg position having a biopsy. 4.The 22-year-old client in the lateral position having a nephrectomy.
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2 The client's age, along with positioning with increased weight and pressure on the shoulders, puts this client at higher risk.
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Which situation demonstrates the circulating nurse acting as the client's advocate? 1.Plays the client's favorite audio book during surgery. 2.Keeps the family informed of the findings of the surgery. 3.Keeps the operating room door closed at all times. 4.Calls the client by the first name when the client is recovering.
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3 This would keep the client's dignity by maintaining privacy. With this action,the nurse is speaking for the client while the client cannot speak as a result of anesthesia; this is an example of client advocacy.
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The circulating nurse is planning the care for an intraoperative client. Which statement is the expected outcome? 1.The client has no injuries from the OR equipment. 2.The client has no postoperative infection. 3.The client has stable vital signs during surgery. 4.The client recovers from anesthesia.
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1 This expected outcome addresses the safety of the client while in the OR.
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Which nursing intervention has the highest priority when preparing the client for a surgical procedure? 1.Pad the client's elbows and knees. 2.Apply soft restraint straps to the extremities. 3.Prepare the client's incision site. 4.Document the temperature of the room.
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2 This action would prevent the client from falling off the table, which is the highest priority.
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The nursing manager is making assignments for the OR. Which case should the manager assign to the inexperienced nurse? 1.The client having open-heart surgery 2.The client having a biopsy of the breast. 3.The client having laser eye surgery. 4.The client having a laparoscopic knee repair.
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2 The case of a client having a biopsy of the breast would be a good case for an inexperienced nurse because it is simple.
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The circulating nurse assesses tachycardia and hypotension in the client. Which interventions should the nurse implement? 1.Prepare ice packs and mix dantrolene sodium. 2.Request the defibrillator be brought into the OR. 3.Draw a PTT and prepare a heparin drip. 4.Obtain finger stick blood glucose immediately.
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1 Unexplained tachycardia, hypotension,and elevated temperature are signs of malignant hyperthermia, which is treated with ice packs and dantrolene sodium.
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The nurse is planning the care of the surgical client having conscious sedation. Which intervention has highest priority? 1.Assess the client's respiratory status. 2.Monitor the client's urinary output. 3.Take a 12-lead ECG prior to injection. 4. Attempt to keep the client focused.
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1 Assessing the respiratory rate, rhythm,and depth is the most important action.
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The PACU nurse is receiving the client from the OR. Which intervention should the nurse implement first? 1.Assess the client's breath sounds. 2.Apply oxygen via nasal cannula. 3.Take the client's blood pressure. 4.Monitor the pulse oximeter reading.
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1 The airway should be assessed first. When caring for a client, the nurse should follow the ABCs: airway,breathing, and circulation.
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Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia? 1.Loss of sensation at the lumbar (L5) dermatome. 2.Absence of the client's posterior tibial pulse. 3.The client has a respiratory rate of eight (8). 4.The blood pressure is within 20% of client's baseline.
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3 If the effects of the spinal anesthesia move up rather than down the spinal cord, respirations can be depressed and even blocked.
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The surgical client's vital signs are T 98˚F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3) and the skin is pale and damp. Which intervention should the nurse implement first? 1.Call the surgeon and report the vital signs. 2.Start an IV of D5RL with 20 mEq KCl at 125 mL/hr. 3.Elevate the feet and lower the head. 4.Monitor the vital signs every 15 minutes.
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3 By lowering the head of the bed and raising the feet, the blood is shunted to the brain until volume-expanding fluids can be administered, which is the first intervention for a client who is hemorrhaging.
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The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication? 1.Alteration in comfort. 2.Risk for depressed respiratory pattern. 3.Potential for infection. 4.Fluid and electrolyte imbalance.
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2 A client with respiratory depression treated with Narcan can have another episode within 15 minutes after receiving the drug as a result of the short half-life of the medication.
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The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature, and complains of muscle stiffness. Which interventions should the nurse implement? Select all apply. 1.Give a back rub to the client to relieve stiffness. 2.Apply ice packs to the axillary and groin areas. 3.Prepare an ice slush for the client to drink. 4.Prepare to administer dantrolene, a smooth-muscle relaxant. 5. Reposition the client on a warming blanket.
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2, 4 Ice packs should be applied to the axillary and groin areas for a client experiencing malignant hyperthermia. Dantrolene is the drug of choice for treatment.
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Which data indicate to the nurse the client who is one (1) day postoperative right total hip replacement is progressing as expected? 1.Urine output was 160 mL in the past eight (8) hours. 2.Paralysis and parasthesia of the right leg. 3.T 99.0˚F, P 98, R 20, and BP 100/60. 4.Lungs are clear bilaterally in all lobes.
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4 Lung sounds which are clear bilaterally in all lobes indicate the client has adequate gas exchange, which prevents postoperative complications and indicates effective nursing care.
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The nurse and the unlicensed assistive personnel (UAP) are working on the surgical unit. Which task can the nurse delegate to the UAP? 1.Take routine vital signs on clients. 2.Check the Jackson Pratt insertion site. 3.Hang the client's next IV bag. 4.Ensure the client obtains pain relief.
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1 Taking the vital signs of the stable client may be delegated to the UAP.
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The charge nurse is making shift assignments. Which postoperative client should be assigned to the most experienced nurse? 1.The 4-year-old client who had a tonsillectomy and is able to swallow fluids. 2.The 74-year-old client with a repair of the left hip who is unable to ambulate. 3.The 24-year-old client who had an uncomplicated appendectomy the previous day. 4.The 80-year-old client with small bowel obstruction and congestive heart failure.
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4 An older client with a chronic disease would be a complicated case, requiring the care of a more experienced nurse.
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Which statement would be an expected outcome for the postoperative client who had general anesthesia? 1.The client will be able to sit in the chair for 30 minutes. 2.The client will have a pulse oximetry reading of 97% on room air. 3.The client will have a urine output of 30 mL per hour. 4.The client will be able to distinguish sharp from dull sensations.
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2 The anesthesia machine takes over the function of the lungs during surgery, so the expected outcome should directly reflect the client's respiratory status;the alveoli can collapse, causing atelectasis.
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The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first? 1.Apply anti-embolism hose to the client. 2.Attach the drain to 20 cm suction. 3.Assess the client's vital signs. 4.Listen to the report from the anesthesiologist.
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3 Assessing the client's status after transfer from the PACU should be the nurse's first intervention.
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Which problem should the nurse identify as priority for client who is one (1) day postoperative? 1.Potential for hemorrhaging. 2.Potential for injury. 3.Potential for fluid volume excess. 4.Potential for infection.
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1 All clients who undergo surgery are at risk for hemorrhaging, which is the priority problem.
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The unlicensed assistive personnel (UAP) reports the vital signs for a first-day postoperative client as T 100.8˚F, P 80, R 24, and BP 148/80. Which intervention would be most appropriate for the nurse to implement? 1.Administer the antibiotic earlier than scheduled. 2.Change the dressing over the wound. 3.Have the client turn, cough, and deep breathe every two (2) hours. 4.Encourage the client to ambulate in the hall.
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3 Having the client turn, cough, and deep breathe is the best intervention for the nurse to implement because, if a client has a fever within the first day,it is usually caused by a respiratory problem.
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Which client would the nurse identify as having the highest risk for developing postoperative complications? 1.The 67-year-old client who is obese, has diabetes, and takes insulin. 2.The 50-year-old client with arthritis taking non-steroidal anti-inflammatory drugs. 3.The 45-year-old client having abdominal surgery to remove the gallbladder. 4.The 60-year-old client with anemia who smokes one (1) pack of cigarettes per day.
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1 This client has comorbid conditions—advanced age, obesity, and diabetes— which put this client at a higher risk for postoperative complications.
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The nurse is completing the preoperative checklist on a client going to surgery. Which information should the nurse report to the surgeon? 1.The client understands the purpose of the surgery. 2.The client stopped taking aspirin three (3) weeks ago. 3.The client uses the oral supplements licorice and garlic. 4.The client has mild levels of preoperative anxiety.
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3 Licorice and garlic can interfere with coagulation; therefore, the surgeon should be notified.
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Which statement explains the nurse's responsibility when obtaining informed consent for the client undergoing a surgical procedure? 1.The nurse should provide detailed information about the procedure. 2.The nurse should inform the client of any legal consultation needed. 3.The nurse should write a list of the risks for postoperative complications. 4.The nurse should ensure the client is voluntarily giving consent.
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4 The nurse is responsible for ensuring the client voluntarily signs the surgical consent form giving permission for the surgery without coercion.
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Which client outcome would the nurse identify for the preoperative client? 1.The client's abnormal laboratory data will be reported to the anesthesiologist. 2.The client will not have any postoperative complications for the first 24 hours. 3.The client will demonstrate the use of a pillow to splint while deep breathing. 4.The client will complete an advance directive before having the surgery.
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3 This would be the expected outcome for the client during the preoperative phase. After the teaching has been completed,the client should be able to demonstrate how to splint with the pillow while deep breathing and coughing.
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Which problem would be appropriate for the nurse to identify for the preoperative client having an open reduction and internal fixation of the right ankle? 1.Alteration in skin integrity. 2.Knowledge deficit of postoperative care. 3.Alteration in gas exchange and pattern. 4.Alteration in urinary elimination.
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2 This would be an appropriate client problem for the preoperative client who is scheduled for ankle repair. Teaching is priority.
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The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a surgery unit. Which task would be most appropriate to delegate to the UAP? 1.Explain to the client how to cough and deep breathe. 2.Discuss preoperative plans with the client and family. 3.Determine the ability of the caregivers to provide postoperative care. 4.Assist the client to take a povidone-iodine (Betadine) shower.
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4 The UAP can assist a stable client to take a shower whether or not it is with Betadine.
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Which action by the client indicates to the nurse preoperative teaching has been effective? 1.The client demonstrates how to use the incentive spirometer device. 2.The client demonstrates the use of the patient-controlled analgesia pump. 3.The client can name two (2) anesthesia agents used during surgery. 4.The client ambulates down the hall to the nurse's station each hour.
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1 The teaching is effective if the client is able to demonstrate the use of the spirometer prior to surgery.
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Which intervention has priority for the nurse in the surgical holding area? 1.Verify the surgical checklist. 2.Prepare the client's surgical site. 3.Assist the client to the bathroom. 4.Restrain the client on the surgery table.
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1 The surgical checklist is assessed when the client arrives in the surgery department holding area where clients wait for a short time before entering the operating room.
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The client in the surgical holding area tells the nurse "I am so scared. I have never had surgery before." Which statement would be the nurse's most appropriate response? 1."Why are you afraid of the surgery?" 2."This is the best hospital in the city." 3."Does having surgery make you afraid?" 4."There is no reason to be afraid."
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3 This response is therapeutic and promotes communication of feelings.
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The unlicensed assistive personnel (UAP) can be overheard talking loudly to the scrub technologist discussing a problem which occurred during one (1) of the surgeries. Which intervention should the nurse in the surgical holding area with a female client implement? 1.Close the curtains around the client's stretcher. 2.Instruct the UAP and scrub tech to stop the discussion. 3.Tell the surgeon on the case what the nurse overheard. 4.Inform the client the discussion was not about her surgeon.
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2 The UAP and scrub tech are violating HIPAA and should be told to stop the conversation immediately.
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The nurse is completing the preoperative checklist. Which laboratory value should be reported to the health care provider immediately? 1.Hemoglobin 13.1 g/dL. 2.Glucose 60 mg/dL. 3.White blood cells 6.0 (×10^3)/mm^3. 4.Potassium 3.8 mEq/L.
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2 This glucose level indicates hypoglycemia, which requires medical intervention.
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Which problem is appropriate for the nurse to identify for a client in the intraoperative phase of surgery? 1.Alteration in comfort. 2.Disuse syndrome. 3.Risk for injury. 4.Altered gas exchange.
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3 This problem would be appropriate for the intraoperative phase. The circulating nurse would strap and carefully padareas to prevent damage to tissues and nerves.
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The client is in the lithotomy position during surgery. Which nursing intervention should be implemented to decrease a complication from the positioning? 1.Increase the intravenous fluids. 2.Lower one leg at a time. 3.Raise the foot of the stretcher. 4.Administer epinephrine, a vasopressor.
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2 The lithotomy position has both legs elevated and placed in stirrups. The legs should be lowered one leg at a time to prevent hypotension from the shift of the blood.
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The circulating nurse observes the surgeon tossing a bloody gauze sponge onto thesterile field. Which action should the circulating nurse implement first? 1.Include the sponge in the sponge count. 2.Obtain a new sterile instrument pack. 3.Tell the surgical technologist about the sponge. 4.Throw the sponge in the sterile trashcan.
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3 The circulating nurse should inform the surgical technologist of any break in sterile technique or field. This is the first intervention because the field is now contaminated.
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The circulating nurse notes a discrepancy in the needle count. What intervention should the nurse implement first? 1.Inform the other members of the surgical team about the problem. 2.Assume the original count was wrong and change the record. 3.Call the radiology department to perform a portable x-ray. 4.Complete an occurrence report and notify the risk manager.
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1 If the needle count does not correlate,the surgical technologist and the other surgical team members should be informed. After repeating the count,a search for the missing needle should be conducted.
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The client in the surgery holding area identifies the left arm as the correct surgical site, but the operative permit designates surgery to be performed on the right arm. Which interventions should the nurse implement? Select all that apply. 1.Review the client's chart. 2.Notify the surgeon. 3.Immediately call a "time-out." 4.Correct the surgical permit. 5.Request the client mark the left arm.
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1, 2, 3, 5 When the client in the holding area states the surgery site differs from the scheduled surgery, the nurse should identify the client and review the client's chart. If there is a discrepancy, the nurse should notify the surgeon to explain the situation and resolve the issue. The Joint Commission surgical standards state a "time-out" period is called and everything stops until the discrepancy is resolved. Clients are encouraged to mark the correct side or site with indelible ink.
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The nurse received a male client from the post-anesthesia care unit. Which assessment data would warrant immediate intervention? 1.The client's vital signs are T 97˚F, P 108, R 24, and BP 80/40. 2.The client is sleepy but opens the eyes to his name. 3.The client is complaining of pain at a "5" on a 1-to-10 pain scale. 4.The client has 20 mL of urine in the urinary drainage bag.
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1 These are symptoms of hypovolemic shock and require immediate intervention
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The client received naloxone (Narcan), an opioid antagonist, in the post-anesthesiacare unit. Which nursing intervention should the nurse include in the care plan? 1.Measure the client's intake and output hourly. 2.Administer sleep medications at night. 3.Encourage the client to verbalize feelings. 4.Monitor respirations every 15 to 30 minutes.
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4 Narcan is given to reverse respiratory depression from opioid analgesic medications and has a short half-life. The client may experience a rebound respiratory depression in 15 to 20 minutes, so this nursing intervention of monitoring respirations every 15 to 30 minutes is appropriate.
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Which nursing task would be most appropriate to delegate to the unlicensed assistive personnel (UAP) on a postoperative unit? 1.Change the dressing over the surgical site. 2.Teach the client how to perform incentive spirometry. 3.Empty and record the amount of drainage in the JP drain. 4.Auscultate the bowel sounds in all four (4) quadrants
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3 Emptying the drainage devices and recording the amounts on the bedside intake and output forms can be delegated.
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Which client assessment data are priority for the post-anesthesia care nurse? 1.Bowel sounds. 2.Vital signs. 3.IV fluid rate. 4.Surgical site.
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2 The post-anesthesia care unit nurse should follow the ABCs format described by the American Heart Association. "A" is for airway, "B" is for breathing, and "C" is for circulation. Vital signs assess for hemodynamic stability; this is priority in the PACU.
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The male client in the day surgery unit complains of difficulty urinating postoperatively. Which intervention should the nurse implement? 1.Insert an indwelling catheter. 2.Increase the intravenous fluid rate. 3.Assist the client to stand to void. 4.Encourage the client to increase fluids.
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3 Helping the male client to stand can offer the assistance needed to void. The safety of the client should been sured.
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The postoperative client complains of hearing a "popping sound" and feeling"something opening" when ambulating in the room. Which intervention should the nurse implement first? 1.Notify the surgeon the client has had an evisceration. 2.Contact the surgery department to prepare for emergency surgery. 3.Assess the operative site and cover the site with a moistened dressing. 4.Explain this is a common feeling and tell the client to continue with activity.
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3 The nurse should assess the surgical site and, if the site has eviscerated,cover the opening with a sterile dressing moistened with sterile 0.9% saline. This will prevent the tissues from becoming dry and infected.
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The nurse received a report the elderly postoperative client became confused duringthe previous shift. Which client problem would the nurse include in the plan of care? 1.Risk for injury. 2.Altered comfort level. 3.Impaired circulation. 4.Impaired skin integrity
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1 Anytime the nurse has a client who is disoriented, the nurse must initiate fall fall/safety precautions.
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The client one (1) day postoperative develops an elevated temperature. Whichintervention would have priority for the client? 1.Encourage the client to deep breathe and cough every hour. 2.Encourage the client to drink 200 mL of water every shift. 3.Monitor the client's wound for drainage every eight (8) hours. 4.Assess the urine output for color and clarity every four (4) hours.
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1 When a postoperative client develops a fever within the first 24 hours, the cause is usually in the respiratory system. The client should increase deep breathing and coughing to assist the client to expand the lungs and decrease pulmonary complications.
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Which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective? 1."I will take my temperature each week and report any elevation." 2."I will not need any pain medication when I go home." 3."I will take all of my antibiotics until they are gone." 4."I will not take a shower until my three (3)-month checkup."
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3 This statement about taking all the antibiotics ordered indicates the teaching is effective.
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The client diagnosed with appendicitis has undergone an appendectomy. At two (2)hours postoperative, the nurse takes the vital signs and notes T 102.6˚F, P 132, R 26,and BP 92/46. Which interventions should the nurse implement? List in order of priority. 1.Increase the IV rate. 2.Notify the health-care provider. 3.Elevate the foot of the bed. 4.Check the abdominal dressing. 5.Determine if the IV antibiotics have been administered.
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1, 3, 4, 5, 2 The nurse should increase the IV rate to maintain the circulatory system function until further orders can be obtained. The foot of the bed should be elevated to help treat shock, the symptoms of which include elevated pulse and decreased blood pressure. Those signs and an elevated temperature indicate an infection may be present and the client could be developing septicemia. The dressing should be assessed to determine if bleeding is occurring. The nurse should administer any IV antibiotics ordered after addressing hypovolemia. The nurse will need this information when reporting to the healthcare provider. The health-care provider should be notified when the nurse has the needed information.
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An overweight patient (BMI 28.1 kg/m^2) is scheduled for a laparoscopic cholecystectomy at an outpatient surgery setting. The nurse knows that: 1. surgery will involve multiple small incisions. 2. this setting is not appropriate for this procedure. 3. surgery will involve removing a portion of the liver. 4. the patient will need special preparation because of obesity.
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1 Many operative procedures are performed as ambulatory surgery (i.e., same-day or outpatient surgery). Obesity is not a contraindication to surgery in the outpatient setting. This patient is not classified as obese on the bases of BMI. The case implied that a laparoscopic technique will be used that involves several small incisions and meets the requirement of a minimally invasive technique.
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The patient tells the nurse in the preoperative setting that she has noticed she has a reaction when wearing rubber gloves. What is the most appropriate intervention? 1. Notify the surgeon so the case can be cancelled. 2. Ask additional questions to assess for possible latex allergy. 3. Notify the OR staff immediately so that latex-free supplies can be used. 4. No intervention is needed because the patient's rubber sensitivity has no bearing on surgery.
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2 The nurse should ask additional screening questions to determine the patient's risk for a latex allergy. Latex precaution protocols should be used for patients identified as having a positive latex allergy test result or a history of signs and symptoms related to latex exposure. Many health care facilities have created latex-free product carts that can be used for patients with latex allergies.
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A 59-year old man is scheduled for a herniorrhaphy in 2 days. During the preoperative evaluation he reports that he takes ginkgo daily. What is the priority intervention? 1. Inform the surgeon, since the procedure may need to be rescheduled. 2. Notify the anesthesia care provider, since this herb interferes with anesthetics. 3. Ask the patient if he has noticed any side effects from taking this herbal supplement. 4. Tell the patient to continue to take the herbal supplement up to the day before surgery.
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1 Ginkgo can increase bleeding during and after surgery. The surgeon should determine how long it should be discontinued before surgery.
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A 17-year old patient with a leg fracture is scheduled for surgery. She reports that she is living with a friend and is an emancipated minor. She has a statement from the court for verification. Which intervention is the most appropriate? 1. Witness the permit after consent is obtained by the surgeon. 2. Call a parent or legal guardian to sign the permit, since the patient is under 18. 3. Obtain verbal consent, since written consent is not necessary for emancipated minors. 4. Investigate your state's nurse practice act related to emancipated minors and informed consent.
answer
1 An emancipated minor may sign his or her own permit. The nurse should be available to witness the signature, but no further action is required.
question
A priority nursing intervention to assist a preoperative patient coping with fear of postoperative pain would be to: 1. inform the patient that pain medication will be available. 2. teach the patient to use guided imagery to help manage pain. 3. describe the type of pain expected with the patient's particular surgery. 4. explain the pain management plan, including the use of pain rating scale.
answer
4 If a patient has a fear of pain and discomfort after surgery, the nurse should reassure the patient that a pain management plan will be in place. The nurse should teach the patient to ask for medication after surgery when pain is present and assure him or her that taking these medications will not contribute to an addiction. The nurse should instruct the patient on the use of some form of pain rating scale (e.g., 0 to 10, FACES) and to request pain medication before the pain becomes severe.
question
A patient is scheduled for surgery requiring general anesthesia at an ambulatory surgical center. The nurse asks him when he ate last. He replies that he had a light breakfast a couple of hours before coming to the surgery center. What should the nurse do first? 1.Tell the patient to come back tomorrow, since he ate a meal. 2. Proceed with the preoperative checklist, including site identification. 3. Notify the anesthesia care provider when and what the patient last ate. 4. Have the patient void before administering any preoperative medication.
answer
3 The nothing-by-mouth (NPO) protocol of each surgical facility should be followed. Restriction on fluids and food is designed to minimize the potential risk of postoperative nausea and vomiting. If a patient has not followed the NPO instructions, surgery may be delayed or canceled. The nurse should notify the anesthesia care provider immediately.
question
A patient who normally takes 40 units of glargine insulin (long acting) at bedtime asks the nurse what to do about her dose the night before surgery. The best response would be to have her: 1. skip her insulin altogether the night before surgery. 2. take her usual dose at bedtime and eat a light breakfast in the morning. 3. eat a moderate meal before bedtime and then take half her usual insulin dose. 4. get instructions from her surgeon or health care provider on any insulin adjustments.
answer
4 Insulin is not usually omitted completely. The patient should obtain instructions from her health care provider or surgeon about any dosage adjustments that she should make the day before and the morning of surgery (if applicable).
question
Preoperative considerations for older adults include (select all that apply) 1. only using large-print educational materials. 2. speaking louder for patients with hearing aids. 3. recognizing that sensory deficits may be present. 4. providing warm blankets to prevent hypothermia. 5. teaching important information early in the morning.
answer
3, 4 Many older adults have sensory deficits. Preoperative and operating rooms are cool; warm blankets should be provided as needed.
question
Proper attire for the semirestricted area of the surgery department is: 1. street clothing. 2. surgical attire and head cover. 3. surgical attire, head cover, and mask. 4. street clothing with addition of shoe covers.
answer
2 The semi-restricted area includes the surroundings support areas and corridors. Only authorized staff members are allowed access to the semi-restricted areas. All staff in the semi-restricted area must wear surgical attire and cover all head and facial hair.
question
Activities that the nurse might perform in the role of a scrub nurse during surgery include (select all that apply): 1. checking electrical equipment. 2. preparing the instrument table. 3. passing instruments to the surgeon and assistants. 4. coordinating activities occurring in the operating room. 5. maintaining accurate counts of sponges, needles, and instruments.
answer
2, 3, 5 Maintaining accurate counts of sponges, needles, and instruments is a shared responsibility of the scrub nurse and circulating nurse. (Note: It is listed as an activity for both in table 19-1).
question
The nurse is caring for a patient undergoing surgery for a knee replacement. What is critical to the patient's safety during the procedure (select all that apply)? 1. Universal protocol is followed. 2. The ACP is an anesthesiologist. 3. The patient has adequate health insurance 4. the circulating nurse is a registered nurse. 5. The patient's allergies are conveyed to the surgical team.
answer
1, 5 Intraoperative nursing care includes determining the patient's allergy status in response to food, drugs, and latex. Preventing use of the wrong site, wrong procedure, and wrong surgery has become known as the UNIVERSAL PROTOCOL. The Universal Protocol is part of a global patient safety initiative.
question
The nurse's primary responsibility for the care of the patient under going surgery is: 1. developing an individualized plan of nursing care for the patient. 2. carrying out specific tasks related to surgical policies and procedures 3. ensuring that the patient has been assessed for safe administration of anesthesia 4. performing a preoperative history and physical assessment to identify patient needs.
answer
1 A primary role of the nurse is to assess the patient to develop an individual plan of care.
question
When scrubbing at the scrub sink, the nurse should: 1. scrub from the elbows to hands. 2. scrub without mechanical friction. 3. scrub for a minimum of 10 minutes. 4. hold the hands higher than the elbows.
answer
4 To perform a surgical scrub, the fingers and hands should be scrubbed first, progressing to the forearms and elbows. The hands should be held away from surgical attire and higher than the elbows at all times to prevent contamination from clothing or from detergent suds and water draining from the unclean area above the elbows to the clean and previously scrubbed areas of hands and fingers.
question
When positioning a patient in preparation for surgery, the nurse understands that injury to the patient is most likely to occur as a result of: 1. incorrect musculoskeletal alignment. 2. loss of perception of pain or pressure. 3. pooling of blood in peripheral vessels. 4. disregarding the patient's need for modesty
answer
1 Whatever position is required for the procedure, great care is taken to prevent injury to the patient. Because anesthesia blocks the sensory nerve impulses, the patient does nto feel pain or discomfort or sense stress placed on the nerves, muscles, bones, and skin. Improper positioning can result in muscle strain, joint damage, pressure ulcers, nerve damage, and other untoward effects.
question
Intravenous induction for general anesthesia is the method of choice for most patients because: 1. the patient is not intubated. 2. the agents are nonexplosive. 3. induction is rapid and pleasant. 4. emergence is longer but with fewer complications.
answer
3 Routine general anesthesia is usually established with an intravenous (IV) induction agent, which may be hypnotic, anxiolytic, or dissociative agent. When used during the initial period of anesthesia, these agents induce a pleasant sleep with a rapid onset of action that patients find desirable.
question
When a patient is admitted to the PACU, what are the priority interventions the nurse performs? 1. Assess the surgical site, noting presence and character of drainage. 2. Assess the amount of urine output and the presence of bladder distention. 3. Assess for airway patency and quality of respirations, and obtain vital signs. 4. Review results of intraoperative laboratory values and medications received.
answer
3 Assessment in the postanesthesia care unit (PACU) begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Identificaiton of inadequate oxygenation and ventilation or respiratory compromise necessitates prompt intervention.
question
A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to "throw up." A priority nursing intervention would be to: 1. increase the rate of the IV fluids. 2. obtain vital signs, including O2 saturation. 3. position patient in lateral recovery position 4. administer antiemetic medication as ordered.
answer
3 If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs.
question
After admission of the postoperative patient to the clinical unit, which assessment data require the most immediate attention? 1. Oxygen saturation of 85% 2. Respiratory rate of 13/min 3. Temperature of 100.4 F (38 C) 4. Blood pressure of 90/60 mm Hg
answer
1 During the initial assessment, identify signs of inadequate oxygenation and ventilation. Pulse oximetry monitoring is initiated because if provides a noninvasive means of assessing the adequacy of oxygenation. Pulse oximetry may indicate low oxygen saturation (<90% to 92%) with respiratory compromise. This necessitates prompt intervention.
question
A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to: 1. perform a straight catheterization to measure the amount of urine in the bladder. 2. notify the physician and anticipate obtaining blood work to evaluate renal function. 3. continue to monitor the patient because this is a normal finding during this time period. 4. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound.
answer
4 Because of the possibility of infection associated with catheterization, the nurse should first try to validate that the bladder is full. The nurse should consider fluid intake during and after surgery and should determine bladder fullness by percussion, by palpation, or by a portable bladder ultrasound study to assess the volume of urine in the bladder and avoid unnecessary catheterization.
question
Discharge criteria for the phase II patient include (select all that apply): 1. no nausea or vomiting. 2. ability to drive self home. 3. no respiratory depression. 4. written discharge instructions understood. 5. opioid pain medication given 45 mins ago.
answer
3, 4, 5 Phase II discharge criteria that must be met include the following: all PACU discharge criteria (phase I) met; no intravenous opioid drugs administered for the past 30 minutes; patient's ability to void (if appropriate with regard to surgical procedure or orders); patient's ability to ambulate if it is not contraindicated; presence of a responsible adult to accompany or drive patient home; and written discharge instructions given and understood.
question
Which procedures are done for the curative purposes (select all that apply)? 1. Gastroscopy 2. Rhinoplasty 3. Tracheotomy 4. Hysterectomy 5. Herniorrhaphy
answer
4, 5 Gastroscopy is for the purpose of diagnosis. Rhinoplasty is done for a cosmetic improvement. A tracheotomy is palliative.
question
A patient is scheduled for a hemorrhoidectomy at an ambulatory day-surgery center. An advantage of performing surgery at an ambulatory center is a decreased need for: 1. lab tests and perioperative medications 2. preoperative and postoperative teaching by the nurse 3. psychologic support to alleviate fears of pain and discomfort 4. preoperative nursing assessment related to possible risks and complications
answer
1 ambulatory surgery is usually less expensive and more convenient, generally involving fewer laboratory tests, fewer preoperative and postoperative medications, less psychologic stress, and less susceptibility to hospital acquired infections. Howerver, the nurse is still responsible for assessing, supporting, and teaching the patient who is undergoing surgery, regardless of where the surgery is performed.
question
A patient who is being admitted to the surgical unit for a hysterectomy paces the floor, repeatedly saying "I just want this over." What should the nurse do to promote a positive surgical outcome for the patient? 1. Ask the patient what her specific concerns are about the surgery. 2. Reassure the patient that the surgery will be over soon and she will be fine. 3. Redirect the patient's attention to the necessary preoperative preparations. 4. Tell the patient she should not be so anxious because she is having a common, safe surgery.
answer
1 Excessive anxiety and stress can affect surgical recovery and the nurse's role in psychologically preparing the patient for surgery is to assess for potential stressors that could negatively affect surgery. Specific fears should be identified and addressed by the nurse listening and by explaining planned postoperative care.
question
Many herbal products that are commonly taken cause surgical problems. Which herbs listed below should the nurse teach the patient to avoid before surgery to prevent an increase in bleeding for the surgical patient (select all that apply)? 1. garlic 2. fish oil 3. valerian 4. vitamin E 5. astragalus 6. ginkgo biloba
answer
1, 2, 4, 6 Valerian may cause excess sedation. Astragalus may increase blood pressure before and during surgery.
question
When the nurse asks a preoperative patient about allergies, the patient reports a history of seasoned environmental allergies and allergies to a variety of fruits. What should the nurse do next? 1. Note this information in the patient's record as hay fever and food allergies. 2. Place an allergy alert wristband that identifies the specific allergies on the patient 3. Ask the patient to describe the nature and severity of any allergic responses experienced from these agents. 4. Notify the anesthesia care provider (ACP) because the patient may have an increased risk for allergies to anesthetics.
answer
3 Risk factors for latex allergies include a history of hay fever and allergies to foods such as avocados, kiwi, bananas, potatoes, peaches, and apricots. When a patient identifies such allergies, the patient should be further questioned about exposure to latex and specific reactions to allergens.
question
During a preoperative review of systems, the patient reveals a history of renal disease. This finding suggests the need for which preoperative diagnostic tests? 1. ECG and chest x-ray 2. Serum glucose and CBC 3. ABGs and coagulation tests 4. BUN, serum creatinine, and electrolytes
answer
4 BUN, serum creatinine, and electrolytes are used to assess renal function and should be evaluated before surgery. Other tests are often evaluated in the presence of diabetes, bleeding tendencies, and respiratory or heart disease.
question
During a preoperative physical examination, the nurse is alerted to the possibility of compromised respiratory function during or after surgery in a patient with which problem? 1. obesity 2. dehydration 3. enlarged liver 4. decreased peripheral pulses
answer
1 Obesity, as well as spinal, chest, and airway deformities, may compromise respiratory function during and after surgery.
question
What type of procedural information should be given to a patient in preparation for ambulatory surgery (select all that apply)? 1. how pain will be controlled 2. any fluid and food restrictions 3. characteristics of monitoring equipment 4. what odors and sensations may be experienced 5. technique and practice of coughing and deep breathing, if appropriate
answer
1, 2, 5 Procedural information includes what will or should be done for surgical preparation, including what to bring and what to wear to the surgery center, length and type of food and fluid restriction, physical preparation required, pain control, need for coughing and deep breathing, and procedures done before and during surgery (such as vital signs, IV lines, and hwo anesthesia is administered). The other options are sensory and process information (SEE TABLE 18-6).
question
The nurse asks a preoperative patient to sign a surgical consent form as specified by the surgeon and then signs the form after the patient does so. By this action, what is the nurse doing? 1. witnessing the patient's signature 2. obtaining informed consent from the patient for the surgery 3. verifying that the consent for surgery is truly voluntary and informed 4. ensuring that the patient is mentally competent to sign the consent form
answer
1 The health care provider is ultimately responsible for obtaining informed consent. However, the nurse may be responsible for obtaining and witnessing the patient's signature on the consent form.The nurse may be a patient advocate during the signing of the consent form, verifying that consent is voluntary and that the patient understands the implications of consent, but the primary legal actoin by the nurse is witnessing the patient's signature.
question
A patient scheduled for hip replacement surgery in the early afternoon is NPO but receives and ingests a breakfast tray with clear liquids on the morning of surgery. What response does the nurse expect when the anesthesia care provider is notified? 1. surgery will be done as scheduled 2. surgery will be rescheduled for the following day 3. surgery will be postponed for 8 hours after the fluid intake 4. a nasogastric tube will be inserted to remove the fluids from the stomach
answer
1 The preoperative fasting recommendations of the American Society of Anesthesiology indicate that clear liquids may be taken up to 2 hours before surgery for healthy patients undergoing elective procedures. There is evidence that longer fasting is not necessary.
question
What is the rationale for using preoperative checklists on the day of surgery? 1. the patient is correctly identified 2. all preoperative orders and procedures have been carried out and records are complete 3. patients' families have been informed as to where they can accompany and wait for patients 4. preoperative medications are the last procedure before the patient is transported to the operating room
answer
2 Preoperative checklists are a tool used to ensure that the many preparations and precautions performed before surgery have been completed and documented. Patient identification, instructions to the family, and administration of preoperative medications are often documented on the checklist, which ensures that no details are omitted.
question
A common reason that a nurse may need extra time when preparing older adults for surgery is their: 1. ineffective coping 2. limited adaptation to stress 3. diminished vision and hearing 4. need to include caregivers in activities
answer
3 One of the major reasons that older adults need increased time preoperatively is the presence of impaired vision and hearing that slows understanding of preoperative instructions and preparation for surgery.
question
The nurse is reviewing the laboratory results for a preoperative patient. Which test result should be brought to the attention of the surgeon immediately? 1. serum K+ of 3.8 mEq/L 2. hemoglobin of 15 g/dL 3. blood glucose of 100 mg/dL 4. white blood cell count of 18,500 /uL
answer
4 Finding this may indicate infection. The surgeon will probably postpone the surgery until the cause of the elevated WBC count has been found.
question
The nurse is preparing a patient for transport to the operating room. The patient is scheduled for a right knee arthroscopy. What actions should the nurse take at this time (select all that apply)? 1. ensure that the patient has voided 2. verify that the informed consent is signed 3. complete preoperative nursing documentation 4. verify that the right knee is marked with indelible marker 5. ensure that the H&P, diagnostic reports, and vital signs are on the chart.
answer
1, 2, 3, 4, 5 All of these are actions that are needed to ensure that the patient is ready for surgery.
question
The nurse is providing preoperative teaching to the following patients. To which patient should the nurse plan to teach coughing and deep breathing exercises? 1. A 20-year-old man who is scheduled for a tonsillectomy 2. A 40-year-old woman who is scheduled for an open cholecystectomy 3. A 30-year-old woman who is scheduled for a transsphenoidal hypophysectomy 4. A 50-year-old man who is scheduled for an evacuation of a subdural hematoma
answer
2 Patients with abdominal surgeries should be taught how to cough and deep breathe to prevent pulmonary complications such as atelectasis and pneumonia. Coughing and deep breathing is contraindicated in cranial surgeries (e.g., subdural hematoma evacuation or trans-sphenoidal hypophysectomy) and tonsillectomies.
question
A 58-year-old man with a recent diagnosis of prostate cancer is scheduled for a radical prostatectomy. Before signing the consent, the patient tells the nurse, "I am not sure if this surgery is safe." Which response by the nurse is the most appropriate? 1. "Tell me what you know about your surgery and the risks involved." 2. "Any surgery has risks, but we will be here to take good care of you." 3. "You seem anxious. Once you sign the consent, I can give you a sedative." 4. "You do not need to be concerned. Your surgeon has not had any complaints."
answer
1 The health care provider performing the surgery is responsible for obtaining the patient's consent. The nurse may witness the patient's signature on the consent form. As a patient advocate, the nurse should verify that the patient understands the surgery and the risks involved. If the nurse determines that the patient is unclear about operative plans, the nurse should contact the health care provider about the patient's need for more information. The other options provide false reassurance or do not respond to the patient's concern.
question
The nurse is assigned to provide preoperative teaching to a 54-year-old man who is scheduled for coronary artery bypass surgery. The patient speaks only Spanish but the nurse only speaks English. What is the best method for the nurse to teach the patient how to use an incentive spirometer? 1. Give the patient a pamphlet written in Spanish with directions on the use of the incentive spirometer. 2. Ask another Spanish-speaking patient in the preoperative area to translate as the nurse describes the procedure. 3. Have the hospital translator available while the nurse demonstrates the procedure and the patient returns the demonstration. 4. Notify the postoperative unit to have a Spanish-speaking nurse provide education on the incentive spirometer after surgery.
answer
3 If the patient does not speak English, it is essential that the services of a competent translator be obtained. Hospitals are required to provide translators for common languages other than English. Demonstration and return demonstration is the most effective teaching method for use of equipment such as the incentive spirometer and should be done in the preoperative period if possible.
question
Lorazepam (Ativan) 1 mg IV is ordered for a 45-year-old male patient before a scheduled surgery. Which of the following is the most appropriate action for the nurse to take before the administration of this medication? 1. Ask the patient about an allergy to iodine or shellfish. 2. Encourage or assist the patient to the bathroom to void. 3. Explain that the medication is used to prevent postoperative nausea. 4. Check the laboratory results for the most recent serum potassium level.
answer
2 The nurse should instruct the patient to void before administering preoperative medications that may interfere with balance and increase the fall risk when ambulating to the bathroom. Lorazepam is a benzodiazepine that may be used for sedation and amnesia before surgery. Lorazepam does not affect serum potassium, is not contraindicated in patients with allergies to iodine or shellfish, and is not indicated to prevent or treat nausea.
question
The nurse in an ambulatory surgery center has administered the following preoperative medications to a 42-year-old female patient scheduled for general surgery: diazepam (Valium), cefazolin (Ancef), and famotidine (Pepcid). What mode of transportation to the operating room (OR) would be the most appropriate for the nurse to arrange for this patient? 1.Seated in a wheelchair accompanied by a responsible family member 2. Ambulatory and accompanied by a hospital escort and a family member 3. Stretcher with side rails up and accompanied by OR transportation personnel 4. Ambulatory accompanied by an OR staff member or transportation personnel
answer
3 The patient has received a sedative (diazepam) and should be transported either by stretcher (with side rails raised) or wheelchair and accompanied by either OR staff, OR transport personnel, or the nurse.
question
Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. What is the most appropriate action for the nurse to take? 1. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. 2. Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done. 3. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes. 4. Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room.
answer
1 The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance. The other options would not be safe for the patient.
question
What is the primary reason for accurately recording the patient's current medications during a preoperative assessment? 1. Some medications may alter the patient's perceptions about surgery. 2. Many anesthetics alter renal and hepatic function, causing toxicity of other drugs. 3. Some medications may interact with anesthetics, altering the potency and effect of the drugs. 4. Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery.
answer
3 Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that they have been communicated to the anesthesia care provider. Routine medications may or may not be prescribed for use the day of surgery.
question
While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that 1. she must be NPO after breakfast. 2. she needs to be NPO after midnight. 3. she can drink clear liquids up to 2 hours before surgery. 4. she can drink clear liquids up until she is moved to the OR.
answer
3 Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidence-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.
question
The nurse is admitting a patient to the same-day surgery unit. The patient tells the nurse that he was so nervous he had to take kava last evening to help him sleep. Which nursing action would be most appropriate? 1. Tell the patient that using kava to help sleep is often helpful. 2. Inform the anesthesiologist of the patient's recent use of kava. 3. Tell the patient that the kava should continue to help him relax before surgery. 4. Inform the patient about the dangers of taking herbal medicines without consulting his health care provider.
answer
2 Kava may prolong the effects of certain anesthetics. Thus the anesthesiologist needs to be informed of recent ingestion of this herbal supplement. Patients should not take anything before surgery without the health care provider's knowledge.
question
Which preoperative patient has the greatest risk of bleeding as a result of his or her medication? 1. A woman who takes metoprolol (Lopressor) for the treatment of hypertension 2. A man whose type 1 diabetes is controlled with insulin injections four times daily 3. A man who is taking clopidogrel (Plavix) after the placement of a coronary artery stent 4. A man who recently started taking finasteride (Proscar) for the treatment of benign prostatic hyperplasia
answer
3 Any drug that inhibits platelet aggregation, such as clopidogrel (Plavix), represents a bleeding risk. Insulin, metoprolol (Lopressor), and finasteride (Proscar) are less likely to contribute to a risk for bleeding.
question
A 70-year-old woman has been admitted prior to having surgery for a bilateral mastectomy and breast reconstruction. What should the nurse include in the patient's preoperative teaching (select all that apply)? 1. Information about various options for reconstructive surgery 2. Information about the risks and benefits of her particular surgery 3. Information about risk factors for breast cancer and the role of screening 4. Information about where in the hospital she will be taken postoperatively 5. Information about performing postoperative deep-breathing and coughing exercises
answer
4, 5 During preoperative teaching, it is important to introduce the role of deep-breathing and coughing exercises and to inform the patient about the different locations involved in her hospital stay. The specific risks and benefits of her surgery and reconstruction options should be addressed by her surgeon. Teaching about breast cancer screening would be inappropriate, and likely insensitive, at this point in her disease trajectory.
question
The patient is having a mole removed that has changed appearance. What does the nurse teach the patient about the rationale for this surgical procedure? 1. It is to prevent malignancy. 2. It is to alleviate symptoms. 3. It is to cure the malignancy. 4. It is to provide cosmetic improvement.
answer
1 Removing a mole that is changing is to prevent as well as diagnose malignancy. There are no symptoms to alleviate mentioned or cosmetic problems for this patient.
question
This will be the patient's first surgical experience and the patient states, "I am nervous about this." The vital signs show BP 158/88, HR 96, RR 24. In the assessment, the nurse finds that the lungs are clear, bowel tones are evident, peripheral pulses are strong, and the patient is fidgeting nervously. The patient took alprazolam (Xanax) at bedtime last night and takes acetaminophen (Tylenol) for tension headaches. Related to this assessment information, what should the nurse do before the patient goes to surgery? 1. Review the surgery with the patient. 2. Notify the anesthesia care provider (ACP). 3. Administer another dose of alprazolam (Xanax). 4. Tell the patient that everything will be okay with the surgery.
answer
2 In determining the psychologic status of the patient, the nurse notes the patient's anxiety, which is supported by the elevated BP and heart rate and fidgeting. The nurse should notify the anesthesia care provider (ACP) after assessing the cause of the anxiety or fear the patient is experiencing. The patient may only need to talk about the surgery related to the situation, concerns with the unknown or body image, or past experiences to relieve the anxiety, but the nurse cannot assume that lack of knowledge is the cause of the anxiety. Medication administration will be prescribed by the ACP if needed, but medications can also be administered during surgery. Reassuring the patient is not taking the patient's needs into account.
question
A 75-year-old patient is being prepared for surgery. What assessment data needs to be included for this patient (select all that apply)? 1. Fluid balance history 2. Attitude about surgery 3. Foods the patient dislikes 4. Current mobility problems 5. Current cognitive function 6. Patient's opinion about the surgeon
answer
1, 4, 5 Preoperative fluid balance history is especially critical for older adults as they have reduced adaptive capacity that puts them at greater risk for over- and under-hydration. Mobility problems must be assessed to assist with intraoperative and postoperative positioning and ambulation. Preoperative assessment of the older person's baseline cognition function is especially crucial for intraoperative and postoperative evaluation as they are more prone to adverse outcomes during and after surgery from the stressors of the surgery, dehydration, hypothermia, and anesthesia. Attitude about surgery and opinion or faith in the surgeon is important for all patients. Foods the patient dislikes are not important unless the patient is allergic to them, but this is no more important for older patients than it is for all patients.
question
When reviewing the preoperative forms, the nurse notices that the informed consent form is not present or signed. What is the best action for the nurse to take? 1. Have the patient sign the consent form. 2. Have the family sign the form for the patient. 3. Call the surgeon to obtain consent for surgery. 4. Teach the patient about the surgery and get verbal permission.
answer
3 The informed consent for the surgery must be obtained by the physician. The nurse can witness the signature on the consent form and verify that the patient (or caregiver if patient is a minor, unconscious, or mentally incompetent to sign) understands the informed consent. Verbal consents are not enough. The state's nurse practice act and agency policies must be followed.
question
As the nurse is preparing a patient for outpatient surgery, the patient wants to give his hearing aid to his wife so it will not be lost during surgery. Which action by the nurse should be taken in this situation? 1. Give the hearing aid to the wife as he wishes. 2. Tape the hearing aid to his ear to prevent loss. 3. Encourage the patient to wear it for the surgery. 4. Tell the surgery nurse that he has his hearing aid out.
answer
3 Although jewelry is removed before surgery, hearing aids should be left in place to allow the patient to better follow instructions given in the surgical suite and the postanesthesia care unit (PACU), as well as the dismissal instructions that will be given before he returns home for recovery.
question
It is 6:00 AM. The anesthesiologist prescribes preoperative medications for a patient who is scheduled for surgery at 7:30 AM: cefazolin (Ancef) IV to be infused 30 minutes before surgery; midazolam (Versed) before surgery and scopolamine patch (Transderm Scop) behind the ear. Which medication should the nurse administer first? 1. Cefazolin (Ancef) 2. Fentanyl (Sulimaze) 3. Midazolam (Versed) 4. Scopolamine (Transderm Scop)
answer
4 The scopolamine patch (Transderm Scop) will be administered first to allow enough time for the serum level to become therapeutic. The cefazolin (Ancef) will be given at 7:00 AM to allow infusion 30 minutes before surgery. Fentanyl (Sulimaze) is a narcotic and was not ordered preoperatively. The midazolam (Versed), a short-acting benzodiazepine, is used as a sedative.
question
An alert male patient needs a tracheostomy because he has been intubated for 7 days with an endotracheal tube and cannot be weaned from the ventilator. The patient does not want the tracheostomy, but his family insists that the surgery be performed. What is the best action for the nurse to take? 1. Advocate for the patient's rights. 2. Try to change the patient's mind. 3. Call surgery to cancel the procedure. 4. Tell the family they cannot interfere.
answer
1 The nurse must act as the patient's advocate and assist the patient with fulfilling his wishes. However, as the patient's advocate the nurse must be sure he knows the risks and benefits of refusing a tracheostomy. Trying to change the patient's mind is unethical because it is contrary to acting as an advocate. As long as the patient is lucid, he retains the right of self-determination. Canceling the procedure is not indicated until discussion with the patient and surgeon has occurred. Telling the family they cannot interfere can aggravate or escalate the situation.
question
The nurse is doing a preoperative assessment on a male patient who has type 2 diabetes mellitus, weighs 146 kg, and is 5 feet 8 inches tall. Which patient assessment is a priority related to anesthesia? 1. Has hemoglobin A1C of 8.5% 2. Has several seasonal allergies 3. Has body mass index of 48.8 kg/m2 4. Has history of postoperative vomiting
answer
3 The patient's body mass index is the priority because it indicates the patient is severely obese. The patient's size may impair the anesthesiologist's ability to ventilate and medicate the patient properly, as well as the surgery room staff's ability to position the patient safely. The other factors are not the priority.
question
While the perioperative nurse is transporting a 34-year-old female patient to the operating room for general surgery, the patient states, "I am a Jehovah's Witness and I am worried about blood transfusions." What would be the best response by the nurse to this patient's statement? 1."I will make sure that you do not receive a blood transfusion during this surgery." 2. "Would you like to sign the consent form just in case you need blood during surgery?" 3. "Do you have someone I can contact in an emergency if you need a blood transfusion?" 4. "Tell me what you would like done if it is determined that you need blood replacement during surgery."
answer
4 The perioperative nurse should identify what the patient's concern is related to a blood transfusion. In addition, the nurse should clarify whether the patient wants a blood transfusion. The Jehovah's Witness community member may refuse blood transfusions, but each patient should be consulted to determine an individualized plan related to receiving or refusing blood transfusions.
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The perioperative nurse is supervising the surgical technologist before the arrival of the patient in the operating room for an exploratory laparotomy. Which action, if taken by the surgical technologist, would require the nurse to intervene? 1. The surgical technologist holds hands away from the body and above the elbows at all times. 2. The surgical technologist scrubs the fingers and hands first followed by the forearms and elbows. 3. After a surgical scrub, the surgical technologist puts on a sterile gown and a pair of sterile gloves. 4. Once wearing a sterile gown and gloves, the surgical technologist is able to organize the equipment on the sterile field.
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3 Once a surgical hand scrub is completed, the surgical technologist should put on a sterile surgical gown and two pairs of gloves to prevent the transmission of microorganisms. Surgical hand antisepsis is completed by scrubbing fingers and hands first followed by progression to forearms and elbows. The hands should be held away from surgical attire and higher than the elbows at all times to prevent contamination. After performing a surgical hand scrub and applying a sterile gown and two pairs of sterile gloves, the person may manipulate and organize all sterile items for use during the procedure.
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The surgical team in the operating room performs a surgical time-out just before starting hip replacement surgery for a 62-year-old woman. Which action would be part of the surgical time-out? 1. Assess the patient's vital signs and oxygen saturation level. 2. Check the chart for a signed consent form for the procedure. 3. Determine if the patient has any questions about the procedure. 4. Have the patient verify the procedure and the location of the surgery.
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4 During a surgical time-out, the surgery team will stop all activities right before the procedure to verify the patient identification, surgical procedure, and surgical site. Proper identification will be accomplished by asking the patient to state name, birth date, and operative procedure and location. In addition, the surgical team will compare the hospital ID number with the patient's own ID band and chart.
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The nurse administered midazolam (Versed) to a 58-year-old male patient during a colonoscopy. What nursing action is appropriate if the patient's respiratory rate changes from 14 breaths/minute to 3 breaths/minute? 1. Give a dose of naloxone (Narcan). 2. Administer flumazenil (Romazicon). 3. Initiate oxygen at 4 L/min per nasal cannula. 4. Reposition the patient with the head of bed up.
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2 Midazolam is a benzodiazepine administered during monitored anesthesia care to patients having procedures such as a colonoscopy. The nurse should monitor the level of consciousness and assess for respiratory depression, hypotension, and tachycardia. To reverse severe benzodiazepine-induced respiratory depression, the nurse would administer flumazenil. Naloxone would reverse opioid-induced respiratory depression. Oxygen should be initiated based on pulse oximetry but at a higher concentration than what is provided with a nasal cannula at 4 L/min. The patient with severe respiratory depression should receive 100% oxygen with a non-rebreather mask. Repositioning the patient will not reverse the effects of sedation and may interfere with the procedure in progress.
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The perioperative nurse is reviewing the chart of a 48-year-old male patient who is being admitted into the operating room for a laminectomy. What information obtained from the chart review should be immediately discussed with the anesthesiologist? 1. The patient's grandmother developed hypothermia during a craniotomy. 2. The patient's mother developed contact dermatitis related to a latex allergy. 3. The patient's brother developed nausea after surgery with general anesthesia. 4. The patient's father developed an elevated temperature during a recent surgery.
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4 Malignant hyperthermia (MH) is an autosomal dominant disorder characterized by hyperthermia with rigidity of skeletal muscles that can result in death. It may occur if an affected individual is exposed to certain general anesthetic agents. To prevent MH, it is important for the nurse to obtain a careful family history. The patient known or suspected to be at risk for MH can be anesthetized with minimal risks if appropriate precautions are taken.
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The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates what manifestation? 1. Hypocapnia 2. Muscle rigidity 3. Decreased body temperature 4. Confusion upon arousal from anesthesia
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2 Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles from altered control of intracellular calcium occurring as a result of exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercapnia, and ventricular dysrhythmias may also be seen with this disorder.
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Before admitting a patient to the operating room, which forms or results must the nurse make sure are in the chart of all patients (select all that apply)? 1. Electrocardiogram 2. Signed consent form 3. Functional status evaluation 4. Renal and liver function tests 5. A history and physical report
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2, 5 The National Patient Safety Goals (NPSG) require documentation of a history and physical, signed consent form, and nursing and preanesthesia assessment in the chart of a patient going for surgery. The physical examination explains in detail the overall status of the patient before surgery for the surgeon and other members of the surgical team.
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Which intraoperative nursing responsibilities should be performed by the scrub nurse (select all that apply)? 1. Documenting intraoperative care 2. Keeping track of irrigation solutions for monitoring of blood loss 3. Passing instruments and supplies to the surgeon by anticipating his or her needs 4. Coordinating the flow and activities of members of the surgical team in the surgical suite 5. Performing the count of sponges, needles, and instruments used during the surgical procedure
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2, 3, 5 Both the scrub nurse and circulating nurse will participate in the counting of surgical sponges, needles, and instruments, whereas passing instruments to the surgeon and other sterile activities are the exclusive responsibility of the scrub nurse. The circulating nurse takes primary responsibility for the coordination of the surgical suite and documentation.
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What event in the surgical suite represents a violation of aseptic technique? 1. A glove contacts the leg of the table that supports the sterile field. 2. The cuff of the scrub nurse's sterile gown contacts the sterile field. 3. The sterile field was established at 0650, and the current time is 0900. 4. Bacteria are present in the nares and upper respiratory passages of the nurse.
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1 Tables are sterile only at tabletop level. Areas below this are considered contaminated. The sterile gown below the point 2 inches above the elbow is considered sterile. The passage of time in and of itself does not necessarily render a field contaminated. Bacteria are inevitable in the respiratory passages of team members, but they present a threat to sterility only if they are not confined by attire.
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The perioperative nurse would recognize the need to monitor the patient for hallucinations and agitation when which anesthetic agent is administered? 1. Nitrous oxide 2. Ketamine (Ketalar) 3. Thiopental (Pentothal) 4. Halothane (Fluothane)
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2 A disadvantage of ketamine (Ketalar) is the associated risk of agitation, hallucinations, and nightmares. These unwanted effects are not associated with the use of thiopental (Pentothal), halothane (Fluothane), or nitrous oxide.
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A 71-year-old male patient who is currently undergoing coronary artery bypass graft (CABG) surgery has just experienced intraoperative vomiting. The nurse should consequently anticipate the use of which drug? 1. Midazolam (Versed) 2. Fentanyl (Sublimaze) 3. Meperidine (Demerol) 4. Ondansetron (Zofran)
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4 Ondansetron (Zofran) is an antiemetic, whereas midazolam (Versed) is a benzodiazepine, and fentanyl (Sublimaze) and meperidine (Demerol) are opioid analgesics.
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A surgical patient's premedication regimen includes midazolam (Versed). What are the most likely desired effects of this medication? 1. Monitored anesthesia care and amnesia 2. Potentiates volatile agents to speed induction 3. Analgesia and prevention of intraoperative vomiting 4. Relaxation of skeletal muscles and facilitation of endotracheal intubation
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1 Midazolam is a benzodiazepine that is widely used for its ability to induce amnesia and provide moderate sedation (conscious sedation). Nitrous oxide is a gaseous agent that potentiates volatile agents to speed induction and reduce total dosage and side effects. Antiemetics prevent intraoperative vomiting. Neuromuscular blocking agents facilitate endotracheal intubation.
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The new nursing student is confused about where the patient's family (who are wearing street clothes) can be with the patient in the surgical suite. Which explanation should the perioperative nurse give to the student nurse? 1. The family is not allowed to talk to the nurse at the nursing station. 2. The family can be with the patient in the preoperative holding area. 3. The family cannot be with the patient until the postanesthesia care unit. 4. The family is only allowed in the conference room for preoperative teaching.
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2 The perioperative nurse should explain to the student nurse that the family can be in the preoperative holding area before the patient goes to surgery, but this includes talking to the nurse at the nursing station. They are also taken to the conference room for preoperative and postoperative meetings with staff, including teaching.
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Which National Patient Safety Goal (NPSG) requirement is enacted immediately before surgery with a surgical time-out? 1. Prevention of infection 2. Improved staff communication 3. Identify patients at risk for suicide. 4. Patient, surgical procedure, and site are checked.
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4 During the surgical time-out the Universal Protocol is used to verify the patient's identity, surgical procedure, and site to prevent mistakes in surgery. Prevention of infection is to be done at all times. Improved staff communication relates to getting important test results to the right staff on time. Identifying patient's safety risks for suicide is not usually vital before surgery and does not occur during the time-out.
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A patient having an open reduction internal fixation (ORIF) of a left lower leg fracture will receive regional anesthesia during the procedure. As the patient is prepared in the operating room, what should the nurse implement to maintain patient safety during surgery that is directly related to the type of anesthesia being used? 1. Apply grounding pad to unaffected leg. 2. Assess peripheral pulses and skin color. 3. Verify the last oral intake before surgery. 4. Ensure a smooth surface under the patient.
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4 Regional anesthesia decreases sensation to the anesthetized area without impairing level of consciousness, which means the affected leg will be without sensation while the anesthetic is effective. A double tourniquet on the affected leg is used to restrict blood flow. This increases the patient's risk of impaired skin integrity because the patient does not have sensation and cannot identify discomfort or foreign objects and will not be moving during surgery. The nurse's role includes positioning the patient for correct alignment, exposure of the surgical site, and preventing injury. The other options will be occurring but are not directly related to the regional anesthesia.
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A 78-year-old patient is having surgery. What risk areas will the nurse need to be especially aware of for this patient during surgery? 1. Sterility 2. Paralysis 3. Urine output 4. Skin integrity
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4 Skin of older adults has lost elasticity and is at increased risk for injury from tape, electrodes, warming or cooling blankets, and dressings. Pooling cleansing solution may create skin burns or abrasions. The nurse is responsible for monitoring patient safety and adjusting patient position as necessary to prevent pressure or misalignment. Sterility and urine output would be monitored for all patients. Paralysis would not be unusual during some types of surgery but would have an impact on any patient's skin integrity.
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The patient is going to have a colonoscopy. Which type of anesthesia should the nurse expect to be used? 1. Local anesthesia 2. Moderate sedation 3. General anesthesia 4. Monitored anesthesia care (MAC)
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4 The nurse should expect monitored anesthesia care (MAC) to be used for the patient having a colonoscopy because it can match the sedation level to the patient needs and procedural requirements. Local anesthesia would not be used because the area affected by a colonoscopy is larger than loss of sensation could be provided for with topical, intracutaneous, or subcutaneous application. Moderate sedation is used for procedures performed outside the OR, and the patient remains responsive. General anesthesia is not needed for a colonoscopy, and it requires advanced airway management.
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In which surgical area will the patient's skin be prepped for surgery, and what clothing will the person doing the prepping be wearing? 1. Surgical suite wearing a lab coat 2. Preoperative holding area wearing street clothes 3. Postanesthesia care unit (PACU) wearing scrubs 4. Operating room wearing surgical attire and masks
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4 Surgical attire includes pants and shirts (or scrubs), a cap or hood, masks, and protective eyewear. All surgical attire is worn when the patient's skin is being prepped in the operating room to avoid contamination of the site. The surgical suite includes all unrestricted, semirestricted, and restricted areas of the controlled surgical environment. A lab coat is usually worn by the staff over their scrubs when they leave the surgical area. The staff will not wear street clothes in the preoperative holding area, although the family may. The holding area and PACU will not include prepping the patient for surgery.
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A 67-year-old male patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression? 1. Increased respiratory rate 2. Decreased oxygen saturation 3. Increased carbon dioxide pressure 4. Frequent premature ventricular contractions (PVCs)
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3 Transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a sensitive indicator of respiratory depression. Increased CO2 pressures would indicate respiratory depression. Clinical manifestations of inadequate oxygenation include increased respiratory rate, dysrhythmias (e.g., premature ventricular contractions), and decreased oxygen saturation.
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The nurse is caring for a 54-year-old unconscious female patient who has just been admitted to the postanesthesia care unit after abdominal hysterectomy. How should the nurse position the patient? 1. Left lateral position with head supported on a pillow 2. Prone position with a pillow supporting the abdomen 3. Supine position with head of bed elevated 30 degrees 4. Semi-Fowler's position with the head turned to the right
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1 The unconscious patient should be placed in the lateral "recovery" position to keep the airway open and reduce the risk of aspiration. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated to maximize expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.
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Which patient would be at highest risk for hypothermia after surgery? 1. A 42-year-old patient who had a laparoscopic appendectomy 2. A 38-year-old patient who had a lumpectomy for breast cancer 3. A 20-year-old patient with an open reduction of a fractured radius 4. A 75-year-old patient with repair of a femoral neck fracture after a fall
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4 Patients at highest risk for hypothermia are those who are older, debilitated, or intoxicated. Also, long surgical procedures and prolonged anesthetic administration place the patient at increased risk for hypothermia.
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The nurse is providing discharge teaching to a 51-year-old female patient who has had a laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the patient, indicates an understanding of the discharge instructions? 1. "I will have someone stay with me for 24 hours in case I feel dizzy." 2. "I should wait for the pain to be severe before taking the medication." 3. "Because I did not have general anesthesia, I will be able to drive home." 4. "It is expected after this surgery to have a temperature up to 102.4o F."
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1 The nurse must assess understanding of discharge instructions and the ability of the patient and caregiver to provide for home care needs. The patient must be accompanied by a responsible adult caregiver. The patient may not drive after receiving anesthetics or sedatives. The patient should understand how to manage pain, and pain medication should be taken before the pain becomes severe. The patient should understand symptoms to be reported, such as a fever.
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The nurse cares for a 72-year-old Native American male patient 2 days after a thoracotomy for tumor resection. What would be the most appropriate action if the patient does not report any pain? 1. Contact the health care provider. 2. Identify possible reasons for denial of pain. 3. Administer the prescribed pain medication. 4. Assess the renal and liver function test results.
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2 Encourage the older adult to report pain, especially those who are reluctant to discuss pain or deny pain when it is likely present, such as after surgery. Older patients may be hesitant to request pain medication, believe pain is an inevitable consequence of surgery, and may not understand how to use patient-controlled machines. Some cultures discourage the expression of pain. The nurse should encourage the use of analgesics, explaining to the patient that untreated pain has a negative effect on recovery. Assessment of pain and administration of medications are within the scope of practice of a nurse. An older patient may have decreased renal and liver function that may lead to drug toxicity. However, this would not be a reason for denial of pain. Administration of pain medication must be based on the patient assessment.
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Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately postoperative? 1. Supine 2. Lateral 3. Semi-Fowler's 4. High-Fowler's
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2 Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated.
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The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? 1. Assess the patient's pain. 2. Assess the patient's vital signs. 3. Check the rate of the IV infusion. 4. Check the physician's postoperative orders.
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2 The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence.
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When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first? 1. Recheck in 1 hour for increased drainage. 2. Notify the surgeon of a potential hemorrhage. 3. Assess the patient's blood pressure and heart rate. 4. Remove the dressing and assess the surgical incision.
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3 The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.
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In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes? 1. Administering adequate analgesics to promote relief or control of pain 2. Asking the patient to demonstrate the postoperative exercises every 1 hour 3. Giving the patient positive feedback when the activities are performed correctly 4. Warning the patient about possible complications if the activities are not performed
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1 Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.
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Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing? 1. Atelectasis 2. Bronchospasm 3. Hypoventilation 4. Pulmonary embolism
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1 The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.
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In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)? 1. Monitor the patient's pain. 2. Do the admission vital signs. 3. Assist the patient to take deep breaths and cough. 4. Change the dressing when there is excess drainage.
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3 The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The LPN or RN will monitor and treat the patient's pain and change the dressings.
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The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient? 1. Blood administration 2. Restoring circulating volume 3. An ECG to check circulatory status 4. Return to surgery to check for internal bleeding
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2 The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, or there is a past history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient's level of consciousness changes or the abdomen becomes firm and distended.
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The patient donated a kidney, and early ambulation is included in her plan of care. But the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? 1. "Early walking keeps your legs limber and strong." 2. "Early ambulation will help you be ready to go home." 3. "Early ambulation will help you get rid of your syncope and pain." 4. "Early walking is the best way to prevent postoperative complications."
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4 The best rationale is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and VTE, speeds wound healing, and increases vital capacity and maintains normal respiratory function. These things help the patient be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management should always occur before walking.
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An older patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this new patient? 1. Check his chart for intraoperative complications. 2. Check which medications were used for anesthesia. 3. Check the effectiveness of the analgesics he has received. 4. Check his preoperative assessment for previous delirium or dementia.
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4 If the patient's ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed as these can all contribute to delirium.
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The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)? 1. Vital signs baseline or stable 2. Minimal nausea and vomiting 3. Wants to go to the bathroom at home 4. Responsible adult taking patient home 5. Comfortable after IV opioid 15 minutes ago
answer
1, 2, 4 Ambulatory surgery discharge criteria includes meeting Phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria includes a responsible adult driving patient, no IV opioid drugs for last 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.
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A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? 1. Manage patient pain. 2. Control the bleeding. 3. Maintain fluid balance. 4. Manage oxygenation status.
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4 The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.
