The nurse requests a client to sign the surgical consent form for an emergency appendectomy. Which statement by the client indicates that further teaching is needed? Show
1. "I will be glad when this is over so that I can go home." 2. "I will not be able to eat or drink anything prior to my surgery." 3. "I need to practice relaxing by listening to my favorite music." 4. "I will need to get up and walk as soon as possible."
ANS: 1 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 that the family member take the medal prior to surgery. 4. Explain that taking the medal to surgery is against the policy. ANS: 2 The nurse must obtain surgical consent forms for the following clients who are scheduled for surgery. Which client would not be able to consent to surgery? 1. The 65-year-old client who cannot read or ANS: 3 When preparing a client for surgery, which intervention should the nurse implement first? 1. Check the permit for the spouse's signature. ANS:4 When interviewing the surgical client in the holding area, which information should the nurse report to the health-care provider? Select all that apply. 1. The client has loose, decayed teeth. ANS: 1,2,3,5 1.Loose teeth or caries need to be reported to the health-care provider so he or she can make provisions to prevent breaking the teeth and causing the client to possibly aspirate pieces. 2. The nurse should report any client who is extremely anxious. 3. Smokers are at a higher risk for complica- tions from anesthesia. 5. Herbs—for example, St. John's wort, licorice, and ginkgo have serious interactions with anesthesia and with bodily functions such as coagulation. Which nursing task can the nurse delegate to the unlicensed nursing assistant (NA)? 1. Complete the preoperative checklist. ANS:
4 When completing the assessment for the client in the day surgery unit, the client 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." ANS: 3 The68-year-old client scheduled for intestinal surgery does not have clear fecal contents after three tap water enemas. Which intervention should the nurse implement first? 1. Notify the surgeon of the client's status. ANS: 1 The nurse is caring for a client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Perform range-of-motion exercises. ANS: 1,2,3,4,5 1. These exercises help prevent postoperative DVT The client is scheduled for total hip replacement. Which behavior indicates to the nurse 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 takes three slow, deep, breaths and coughs forcefully after inhaling for the third time. 3. The client uses the incentive spirometer and inhales slowly and deeply so that 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. ANS: 4 While completing the preoperative assessment, the male client tells the nurse that he is allergic to codeine. Which intervention should the nurse implement first? 1. Apply an allergy bracelet on the client's wrist. ANS: 3 Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery? 1. Calcium 9.2 mg/dL. ANS: 4 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 2. Give preoperative medication in the holding area and monitor the client's response 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 ANS: 1 While working in the operating room 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. ANS: 3 While the circulating nurse compares the final sponge count with that of the scrub nurse, a discrepancy in the count is found. Which action should the circulating nurse take first? 1. Notify the client's surgeon. ANS: 4 Which violation of surgical asepsis would require immediate intervention by the circu- lating 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. ANS: 4 The nurse identifies the nursing diagnosis "risk for injury related to positioning" for the client in the operating room. Which nursing action should the nurse implement? 1. Avoid using the cautery unit that 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. ANS: 2 When positioning the intraoperative client for surgery, which client should the nurse consider at the highest rank for irreparable 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. ANS: 2 Which situation demonstrates the circulating nurse acting as the client's advocate? 1. Plays the client's favorite audio book during ANS: 3 Which statement would be an expected outcome when the circulating nurse evaluates the goal of the intraoperative client? 1. The client has no injuries from the OR ANS: 1 Which nursing intervention has the highest priority when preparing the client for a surgical procedure? 1. Pad the client's elbows and knees. ANS: 2 When making assignments for nurses working in the OR, which case would the manager assign to the new nurse? 1. The client having open-heart surgery. ANS: 2 While working in the operating room, the nurse notices that the client has tachycar- dia and hypotension. Which interventions should the nurse anticipate? 1. Prepare ice packs and mix dantrolene sodium. ANS: 1 When developing the plan of care for the surgical client having sedation, which intervention has highest priority for the nurse? 1. Assess the client's respiratory status. ANS: 1 When receiving the client from the OR, which intervention should the PACU nurse implement first? 1. Assess the client's breath sounds. ANS: 1 Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia? ANS: 3 After transferring the client from the PACU to the surgical unit, the client's vital signs are T 98F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3). The client's skin is pale and damp. Which intervention should the nurse implement first? 1. Call the surgeon and report the vital signs. ANS: 3 The nurse receives a report that the postoperative client received Narcan, an opioid antagonist, in PACU. Which client problem should the nurse add to the plan of care? 1. Alteration in comfort. ANS: 2 The 26-year-old male client in the PACU has a heart rate of 110, has a rising temper- ature, and complains of muscle stiffness. Which interventions should the nurse imple- ment? Select all apply. 1. Give a back rub to the client to relieve
stiffness. ANS: 2,3,4 2. Ice packs should be applied to the axillary and groin areas for a client experiencing malignant hyperthermia. 3. The client would be NPO to prepare for intubation, but an ice slush would be used to irrigate the bladder and stomach per nasogastric tube. 4. Dantrolene is the drug of choice for treatment. Which data indicate the nursing care has been effective for the client who is one (1) day postoperative surgery? 1. Urine output was 160 mL in the past eight (8) hours. ANS: 4 When working on the surgical floor, which task can the nurse delegate to the unli- censed nursing assistant (NA)? 1. Take vital signs every four (4) hours. ANS: 1 The charge nurse is making the shift assignments. Which postoperative client would be the most appropriate assignment to the graduate nurse? 1. The four (4)-year-old client who had a tonsillectomy and is swallowing frequently. 2. The 74-year-old client with a repair of the left hip who is unable to ambulate. 3. A 24-year-old client who had an uncomplicated appendectomy the previous day. 4. An 80-year-old client with small bowel obstruction and congestive heart failure. ANS: 3 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. ANS: 2 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. ANS: 3 Which client problem would be priority for client who is one (1) day postoperative? 1. Potential for hemorrhaging. ANS: 1 The unlicensed nursing assistant reports the vital signs for a first-day postoperative client of T 100.8F, P 80, R 24, and B/P 148/80. Which intervention would be most appropriate for the nurse to implement? 1. Administer the antibiotic earlier than scheduled. ANS: 3 The client is complaining of left shoulder pain. Which response would be best for the nurse to assess the pain? 1. Request that the client describe the pain. ANS: 1 When preparing the plan of care for the client in acute pain as a result of surgery, the nurse should include which intervention? 1. Administer pain medication as soon as the time frame ANS: 1 Which situation is an example of the nurse fulfilling the role of client advocate? 1. The nurse brings the client pain medication when it is ANS:
3 Which statement would be an expected outcome for a client experiencing acute pain? 1. The client will have decreased use of medication. ANS: 2 Which intervention has the highest priority when administering pain medication to a client experiencing acute pain? 1. Monitor the client's vital signs. ANS: 3 Which intervention should the nurse delegate to the unlicensed nursing assistant when caring for the client experiencing acute pain? 1. Take the pain medication to the room. ANS: 2 When administering an opioid narcotic, which interventions should the nurse imple- ment to provide for client safety? Select all that apply. 1. Compare the hospital number on the
MAR to the client's ANS: 1,3,4 1.This procedure ensures client safety by preventing medication from being given to the wrong client. 3. This intervention would prevent giving a narcotic to a client who is unstable or compromised. 4. Determining allergies addresses client safety. Which intervention would be the best way for the nurse to assess a four (4)-year-old client for acute pain? 1. Use words that a four (4)-year-old child can remember. ANS: 3 Which nursing intervention would be priority for the client experiencing acute pain? 1. Assess verbal and nonverbal behavior.
ANS: 1 While conducting an interview with a 75-year-old client admitted with acute pain, which question would have priority when assisting with pain management? 1. "Have you ever had difficulty getting your pain controlled?" ANS: 1 At the end of the shift, the nurse clears the PCA and discovers that the client has used only a small amount of medication. Which intervention should the nurse implement? 1. Determine why
the client is not using the PCA. ANS: 1 During the preoperative interview, a patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which response by the nurse is most appropriate? a. "Tell me more about what happened to your ANS: A The patient's statement may indicate an unusually high anxiety level or a family history of problems such as malignant hyperthermia, which will require precautions during surgery. The other statements also may address the patient's concerns, but further assessment is needed first. A patient arrives at the ambulatory surgery center for a scheduled outpatient surgery. Which information is of most concern to the nurse? a. The patient has not had outpatient surgery ANS: B After outpatient surgery, the patient should not drive home and will need assistance with transportation and home care. The patient's experience with outpatient surgery is assessed, but it does not have as much application to the patient's physiologic safety. The patient's insurance coverage is important to establish, but this is not usually the nurse's role or a priority in nursing care. Having clear liquids a few hours before surgery does not usually increase risk for aspiration. A 36-year-old woman is admitted for an outpatient surgery. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery? a. The patient's lack of knowledge about ANS: B This statement suggests that the patient may be pregnant, and pregnancy testing is needed before administration of anesthetic agents. Although the other data also may be communicated with the surgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery. A patient who is scheduled for surgery in a week tells the nurse doing the preoperative assessment about an allergy to bananas, kiwifruit, and latex products. Which action is most important for the nurse to take? a. Notify the dietitian about the food allergies. ANS: B When a patient is allergic to latex, special nonlatex materials are used during surgical procedures and the staff will need to know about the allergy in advance to obtain appropriate nonlatex materials and have them available on the surgical date. The other actions also may be appropriate, but prevention of allergic reaction (either contact dermatitis or anaphylaxis) during surgery is the most important action. Any patient guilt about having a therapeutic abortion may be identified when the nurse assesses the functional health pattern of _____________. a. value-belief. ANS: A The value-belief pattern includes information about conflicts between a patient's values and proposed medical care. In the cognitive-perceptual pattern, the nurse will ask questions about pain and sensory intactness. The sexuality-reproductive pattern includes data about the impact of the surgery on the patient's sexuality. The coping-stress tolerance pattern assessment will elicit information about how the patient feels about the surgery. During the preoperative assessment of a patient scheduled for a colon resection, the patient tells the nurse about using St. John's wort to prevent depression. The nurse should alert the staff in the postanesthesia recovery area that the patient may a. experience increased pain. ANS: C St. John's wort may prolong the effects of anesthetic agents and increase the time to waken completely after surgery. It is not associated with increased bleeding risk, hypertension, or increased pain. On the day of surgery, the nurse is admitting a patient with a history of cigarette smoking. Which action is most important at this time? a. Auscultate for adventitious breath sounds. ANS: A Abnormal breath sounds may indicate the presence of an acute respiratory infection or chronic lung disease that will affect the choice of anesthesia and/or proceeding with the scheduled surgery. The other nursing actions also are appropriate but will not affect the immediate surgical procedure as much as the presence of abnormal breath sounds. A patient is seen at the health care provider's office several weeks before hip surgery for preoperative assessment. The patient reports use of echinacea, saw palmetto, and glucosamine/chondroitin. The nurse should a. ascertain that there will be no interactions ANS: B The nurse should discuss the medication use with the patient's health care provider because saw palmetto is used to decrease prostatic hyperplasia, and the patient may need to continue taking the medication or a prescription medication to prevent urinary retention. The nurse should not advise the patient to stop the supplements or to continue them without consulting with the health care provider. Determining the interactions between the supplements and anesthetics is not within the nurse's scope of practice. Before the administration of preoperative medications, the nurse is preparing to witness the patient signing the operative consent form when the patient says, "I do not really understand what the doctor said." Which action is best for the nurse to take? a. Provide an explanation of the planned ANS: B The surgeon is responsible for explaining the surgery to the patient, and the nurse should wait until the surgeon has clarified the surgery before having the patient sign the consent form. The nurse should communicate directly with the surgeon about the consent form rather than asking other staff to pass on the message. It is not within the nurse's legal scope of practice to explain the surgical procedure. No preoperative medications should be administered until the patient signs the consent form. Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for a colon resection? a. Care for the surgical incision ANS: C Preoperative teaching, demonstration, and redemonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. The patient does not usually need information about medications that are used intraoperatively. Ten minutes after receiving the ordered preoperative opioid by intravenous (IV) injection, the patient asks to get up to go to the bathroom to urinate. The most appropriate action by the nurse is to a. assist the patient to the bathroom and stay ANS: B The patient will be at risk for a fall after receiving the opioid, so the best nursing action is to have the patient use a bedpan or urinal. Having the patient get up either with assistance or independently increases the risk for a fall. The patient will be uncomfortable and risk involuntary incontinence if the bladder is full during transport to the operating room.
An alert 82-year-old who has poor hearing and vision is receiving preoperative teaching from the nurse. His wife answers most questions directed to the patient. Which action should the nurse take when doing the teaching? a. Use printed materials for instruction so that the patient will have more time to review the material. b. Direct the teaching toward the wife because she is the obvious support and caregiver for the patient. c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. d. Ask the patient's wife to wait in the hall in order to focus preoperative teaching with the patient himself. ANS: C The nurse should allow more time when doing preoperative teaching and preparation for older patients with sensory deficits. Because the patient has visual deficits, he will not be able to use written material for learning. The teaching should be directed toward both the patient and the wife because both will need to understand preoperative procedures and teaching. A diabetic patient who uses insulin to control blood glucose has been NPO since midnight before having a mastectomy. The nurse will anticipate the need to a. withhold the usual scheduled insulin dose ANS: B Preoperative insulin administration is individualized to the patient, and the current blood glucose will provide the most reliable information about insulin needs. It is not possible to predict whether the patient will require no insulin, a lower dose, or a higher dose without blood glucose monitoring. The clinic nurse reviews the complete blood cell count (CBC) results for a patient who is scheduled for surgery in a few days. The results are white blood cell count (WBC) 10.2 ⋅ 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 ⋅ 103/µL. Which action should the nurse take? a. Send the CBC results to the surgery facility. ANS: A The nurse should be sure that the CBC results, which are normal, are available at the surgical facility to avoid delay of the procedure. With normal results, there is no need to notify the surgeon or anesthesiologist, discuss blood transfusion, or ask about recent infection. As the nurse prepares a patient the morning of surgery, the patient refuses to remove a wedding ring, saying, "I have never taken it off since the day I was married." The nurse should a. have the patient sign a release and leave the ANS: B The ring can be taped to the patient's finger and noted on the preoperative checklist. There is no need for a release form or to discuss liability with the patient. Wearing the ring is obviously important to the patient, so the nurse should tape the ring in place rather than have a family member keep the ring for the patient. A patient is to receive atropine before surgery. The nurse teaches the patient to expect a.
dizziness. ANS: C Anticholinergic medications decrease oral secretions, so the patient is taught that a dry mouth is an expected side effect. Weakness, forgetfulness, and dizziness are side effects associated with other preoperative medications such as opioids and benzodiazepines. The nurse is obtaining the health history for a patient who is scheduled for outpatient knee surgery. Which statement by the patient is most important to report to the health care provider? a. "I had a heart valve replacement last year." ANS: A A patient with a history of valve replacement is at risk for endocarditis associated with invasive procedures and may need antibiotic prophylaxis. A current respiratory infection may affect whether the patient should have surgery, but a history of pneumonia is not a reason to postpone surgery. The patient's knee pain is the likely reason for the surgery. A family history of breast cancer does not have any implications for the current surgery. When the nurse interviews a patient who is to have outpatient surgery using a general anesthetic, which info is most important to communicate to the surgeon and anesthesiologist before surgery? a. The patient drinks 3 or 4 cups of coffee every morning before going to work. b. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. c. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital. d. The patient's father died after receiving general anesthesia for abdominal surgery. ANS: D The information about the patient's father suggests that there may be a family history of malignant hyperthermia and that precautions may need to be taken to prevent this complication. Current research indicates that having clear liquids 3 hours before surgery does not increase the risk for aspiration in most patients. Patients are instructed to discontinue aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative implications. Which information about medication use in a preoperative patient is most important to communicate to the health care provider? a. The patient uses acetaminophen (Tylenol) occasionally for aches and pains. b. The patient takes garlic capsules daily but did not take any on the surgical day. c. The patient has a history of cocaine use but quit using the drug over 10 years ago. d. The patient took a sedative medication the previous night to assist in falling asleep. ANS: B Chronic use of garlic may predispose to intraoperative and postoperative bleeding. The use of a sedative the previous night, occasional acetaminophen use, and a distant history of cocaine use will not usually affect the surgical outcome. A 24-year-old who takes a diuretic and a β-blocker to control blood pressure is scheduled for abdominal surgery. Which patient information is most important to communicate to the health care provider before surgery? a. Pulse rate 59 ANS: D The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of patient anxiety. The heart rate would be expected in a patient taking a β-blocker. The hematocrit is in the low normal range but does not require any intervention before surgery. The perioperative nurse encourages a family member or a friend to remain with a patient in the preoperative holding area until the patient is taken into the operating room primarily to a. ensure the proper identification of the patient before surgery. b. protect the patient from cross-contamination with other patients. c. assist the perioperative nurse to obtain a complete patient history. d. help relieve the stress of separation for the patient and significant others. ANS: D The presence of a family member or friend reduces the stress associated with the preoperative period. Although the family may give information about the patient's name and history, this information is obtained and confirmed by the nurse in other ways. Nursing staff, rather than family members, are responsible for prevention of cross-contamination. Which description best defines the role of the nurse anesthetist as a member of the surgical team? a. Functions independently in the administration of anesthetics b. Has the same credentials and responsibilities as an anesthesiologist c. Is responsible for intraoperative administration of anesthetics ordered by the anesthesiologist d. Requires supervision by the anesthesiologist or surgeon while administering anesthesia to a patient ANS: A The certified registered nurse anesthetist (CRNA) is independently responsible for all aspects of the administration of anesthetic agents. Although the responsibilities of a CRNA and an anesthesiologist have some overlap, the credentialing and roles are different. No supervision by a health care provider is necessary during anesthetic administration by a CRNA. The CRNA assesses the patient and makes the choice of anesthetic agent. Which outcome measure will be best for the operating room (OR) nurse manager to use in determining the effectiveness of the physical environment and traffic control measures in the operating room? a. Smooth functioning of the OR team ANS: D The primary focus when setting up the OR is the prevention of cross-contamination and transmission of infection to the patient. Patient privacy, efficient completion of procedures, and smooth functioning of the OR team also are important, but the priority is protection of the patient from infection. Which action will the scrub nurse use to maintain aseptic technique during surgery? a. Use waterproof shoe covers. ANS: D The sleeves of a sterile surgical gown are considered sterile only to 2 inches above the elbows, so touching the surgeon's upper arm would contaminate the nurse's gloves. Shoe covers are not sterile. Personal protective equipment is designed to protect caregivers, not the patient, and is not part of aseptic technique. Staff members such as the circulating nurse do not have to perform a surgical scrub before entering the OR. After orienting a new staff member to the scrub nurse role, the nurse preceptor will know that the teaching was effective if the new staff member a. documents all patient care accurately. ANS: C The scrub nurse role includes maintaining asepsis in the operating field. The other actions would be appropriate to the circulating nurse role. Data that were obtained during the perioperative nurse's assessment of a patient in the preoperative holding area that would indicate a need for special protection techniques during surgery include a. a stated allergy to cats and dogs. ANS: B The patient with arthritis may require special positioning to avoid injury and postoperative discomfort. Preoperative anxiety and having a sip of water 2 to 3 hours before surgery are not unusual for the preoperative patient. An allergy to cats and dogs will not impact the care needed during the intraoperative phase. The nurse from the general surgical unit is asked to bring the patient's hearing aid to the surgical suite. The nurse will take the hearing aid to the a. clean core.
ANS: C The nurse from the general unit would not be wearing surgical scrub attire or a head covering and would be restricted to the nursing station or information desk, which are unrestricted areas. The clean care, scrub sink area, and corridors are semirestricted areas that require staff members wear surgical scrub attire and head coverings. A preoperative patient in the holding area asks the nurse, "Will the doctor put me to sleep with a mask over my face?" The most appropriate response by the nurse is, a. "A drug will be given to you through your IV line, which will cause you to go to sleep almost immediately." b. "Only your surgeon can tell you for sure what method of anesthesia will be used. Should I ask your surgeon?" c. "General anesthesia is now given by injecting medication into your veins, so you will not need a mask over your face." d. "Masks are not used anymore for anesthesia. A tube will be inserted into your throat to deliver a gas that will put you to sleep." ANS: A The first step in general anesthesia is the injection of an intravenous (IV) induction agent, which rapidly induces sleep. The anesthesiologist (not the surgeon) determines the method of anesthesia used. Masks may still be used for inhalation, although many patients are intubated. Total IV anesthesia may be used for some patients but inhalation anesthetics also are commonly used. A surgical patient received a volatile liquid as an inhalation anesthetic during surgery. Postoperatively the nurse should monitor the patient for a. tachypnea. ANS: D Because volatile liquid inhalation agents are rapidly metabolized, postoperative pain occurs soon after surgery. Hypertension and tachypnea are not associated with general anesthetics. Myoclonia may occur with nonbarbiturate hypnotics but not with the inhaled inhalation agents. When the nurse caring for a patient before surgery has a question about a sedative medication to be given before sending the patient to the surgical suite, the nurse will communicate with the a. surgeon. ANS: B The anesthesiologist is responsible for prescribing preoperative medications. The RNFA and surgeon are responsible for the surgery, but not for the preoperative sedation. The circulating nurse does not have authority to make a change in any medication. A patient with a dislocated shoulder is prepared for a closed, manual reduction of the dislocation with monitored anesthesia care (MAC). The nurse anticipates the administration of a. IV midazolam (Versed). ANS: A IV sedatives such as the benzodiazipines are administered for MAC. Inhaled, epidural, and topical agents are not included in MAC. Which action will the nurse include in the plan of care immediately after surgery for a patient who received ketamine (Ketalar) as an anesthetic agent? a. Administer larger doses of analgesic agents. ANS: C Hallucinations are an adverse effect associated with the dissociative anesthetics such as ketamine, so the postoperative environment should be kept quiet to decrease the risk of hallucinations. Since ketamine causes profound analgesia lasting into the postoperative period, larger doses of analgesics are not needed. Ketamine causes an increase in heart rate. Benzodiazepine use with ketamine may be used to decrease the incidence of hallucinations and nightmares. A patient's family history reveals that the patient may be at risk for malignant hyperthermia (MH) during anesthesia. The nurse explains to the patient that a. anesthesia can be administered with minimal risks with the use of appropriate precautions and medications. b. as long as succinylcholine (Anectine) is not administered as a muscle relaxant, the reaction should not occur. c. surgery must be performed under local anesthetic to prevent development of a sudden, extreme increase in body temperature. d. surgery will be delayed until the patient is genetically tested to determine whether he or she is susceptible to malignant hyperthermia ANS: A General anesthesia can be administered to patients with MH as long as precautions to avoid MH are taken and preparations are made to treat MH if it does occur. Other factors besides succinylcholine administration are associated with MH. Predictions about whether MH will occur based on family history are inconsistent, and it may not be possible to delay surgery. A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. At completion of the surgery, it is most important that the nurse monitor the patient for a. nausea. ANS: D The most serious adverse effect of the neuromuscular blocking agents is weakness of the respiratory muscles leading to postoperative hypoxemia. Nausea and confusion are possible adverse effects of these drugs, but they are as great a concern as respiratory depression. Because these medications decrease muscle contraction, laryngospasm and bronchospasm are not concerns. Which action by an inexperienced member of the surgical team requires rapid intervention by the charge nurse? a. Wearing street clothes into the nursing station ANS: C The corridors outside the OR are part of the semirestricted area where personnel must wear surgical attire and head coverings. Surgical masks may be worn in the holding room, although they are not necessary. Street clothes may be worn at the nursing station, which is part of the unrestricted area. Wearing a mask and scrubs is essential when going into the OR. Which nursing action should the operating room (OR) nurse manager delegate to the registered nurse first assistant (RNFA)? a. Make surgical incisions and suture incisions as needed. ANS: A The role of the RNFA includes skills such as making and suturing incisions and maintaining hemostasis. The other actions should be delegated to other staff members such as the circulating nurse, scrub nurse, or surgical technician. Which of these actions included in the perioperative patient plan of care can the perioperative nurse delegate to a surgical technologist? a. Complete the patient's admission ANS: B The education and certification for a surgical technologist includes the scrub and circulating functions in the OR. Patient teaching, communication with other departments about a patient's condition, and the admission assessment require RN level education and scope of practice. When preparing the patient for surgery, which actions will the nurse include in the surgical time-out procedure (select all that apply)? a. Check for placement of IV lines. ANS: C, D, E, F These actions are included in surgical time out. IV line placement and identification of the patient by the surgeon are not included in the surgical time-out procedure. A 42-year-old patient is recovering from anesthesia in the postanesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure falls to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at this time is to a. increase the rate of the IV fluid replacement. ANS: B A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration. During recovery from anesthesia in the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take at this time? a. Place the patient in a side-lying position. ANS: B The patient's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable BP and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU is not appropriate. After a new nurse has been oriented to the postanesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse a. places a patient in the Trendelenburg position when the blood pressure (BP) drops. b. assists a patient to the prone position when the patient is nauseated. c. turns an unconscious patient to the side when the patient arrives in the PACU. d. positions a newly admitted unconscious patient supine with the head elevated. ANS: C The patient should initially be positioned in the lateral "recovery" position to keep the airway open and avoid aspiration. The prone position is not usually used and would make it difficult to assess the patient's respiratory effort and cardiovascular status. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness. A 75-year-old is to be discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I do not know if I can take care of myself with this patch over my eye." The most appropriate nursing action is to a. refer the patient for home health care ANS: B The nurse's initial action should be to assess exactly the patient's concerns about self-care. Referral to home health care and assessment of the patient's support system may be appropriate actions but will be based on further assessment of the patient's concerns. Written instructions should be given to the patient, but these are unlikely to address the patient's stated concern about self-care. After removal of the nasogastric (NG) tube on the second postoperative day, the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. Which action should the nurse take? a. Reinsert the NG tube. ANS: C Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient's discomfort. If distention persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains. Following gallbladder surgery, a patient's T-tube is draining dark green fluid. Which action should the nurse take? a. Place the patient on bed rest. ANS: C A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary. In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which action by the nurse is most helpful? a. Discuss the complications of immobility and ANS: C The most essential nursing action in encouraging these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities. The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when the a. patient drinks 2 to 3 L of fluid in 24 hours. ANS: C One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or wheezes, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems. A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 99%, and recent lab results are all normal. Which action by the nurse is most appropriate? a. Insert an oral or nasal airway. ANS: D Because the patient's assessment indicates physiologic stability, the most likely cause of the patient's agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should ensure patient safety through interventions such as raising the bed rails and securing IV lines. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify the ACP. Insertion of an airway is not needed because the oxygen saturation is good. Orientation of the patient is needed but is not likely to be effective until the effects of anesthesia have resolved more completely. Which action should the postanesthesia care unit (PACU) nurse delegate to nursing assistive personnel (NAP) who help with the transfer of a patient to the surgical unit? a. Help with the transfer of the patient onto a ANS: A The scope of practice for nursing assistants includes repositioning and moving patients under the supervision of an RN. Providing report to another RN, assessing and documenting the wound appearance, and clarifying physician orders with another RN require RN level education and scope of practice. When a patient is transferred from the postanesthesia care unit (PACU) to the clinical surgical unit, the first action by the nurse on the surgical unit should be to a. assess the patient's pain. ANS: B Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer. An 83-year-old who had a surgical repair of a hip fracture 2 days previously has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for the patient as a. potential complication: hypovolemic shock. ANS: B The patient is older and relatively immobile, two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient. A patient who is just waking up after having a general anesthetic is agitated and confused. Which action should the nurse take first? a. Check the O2 saturation. ANS: A Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action. A postoperative patient has not voided for 7 hours after return to the postsurgical unit. Which action should the nurse take first? a. Notify the surgeon. ANS: B The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Catheterization should only be done after other measures have been tried without success because of the risk for urinary tract infection. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful. While caring for a patient with abdominal surgery the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this finding, the nurse should first a. reinforce the dressing. ANS: B New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing. When caring for a patient during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 100.8° F. Which action should the nurse take first? a. Have the patient use the incentive ANS: A A temperature of 100.8° F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because evidence of wound infection does not usually occur before the third postoperative day, assessment of the incision is not likely to be useful. The nurse notes that the oxygen saturation is 88% in an unconscious patient who was transferred to the postanesthesia care unit (PACU) 10 minutes previously. Which action should the nurse take first? a. Elevate the patient's head. ANS: D In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient's head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake. While caring for a patient who had abdominal surgery on the second postoperative day, which information about the patient is most important to communicate to the health care provider? a. The right calf is swollen, warm, and painful. ANS: A The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require health care provider orders for diagnostic tests and anticoagulants. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3° F on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities. A patient complains of dizziness when ambulating in the room on the first postoperative day. In what order will the nurse accomplish the following activities? ____________________ a. Take the patient's blood pressure
(BP). ANS: B, A, C, D The first priority for the patient with syncope is to prevent a fall, so the patient should be assisted to a chair. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the fluid intake will help prevent orthostatic dizziness. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no urgent need to notify the health care provider. A patient's blood pressure in the PACU has dropped from an admission blood pressure of 138/84 to 100/58 with a pulse change of 68 to 94. SpO2 is 98% on 3L of oxygen. In which order should the nurse take these actions? a. Raise the IV infusion rate. ANS: A, C, B, D The first nursing action should be to increase the IV infusion rate. Since the most common cause of hypotension is volume loss, the IV rate should be increased. The next action should be to increase the oxygen flow rate to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient should be assessed for vasodilation caused by rewarming. Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. Which of the following is the most appropriate action for the nurse to take? A. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. B. Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done. C. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes. D. Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room. ANS: A 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. Which of the following is the primary reason for accurately recording the patient's current medications during a preoperative assessment? A. Some medications may alter the patient's perceptions about surgery. B. Many anesthetics alter renal and hepatic function, causing toxicity of other drugs. C. Some medications may interact with anesthetics, altering the potency and effect of the drugs. D. Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery. ANS: A. 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. As the nurse is preparing a patient for surgery, the patient refuses to remove a wedding ring. Which of the following is the most appropriate action by the nurse? A. Insist the patient remove the ring for safety ANS: C. It is customary policy to tape a patient's wedding band to the finger and make a notation on the preoperative checklist that the ring is taped in place. 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 A She must be NPO after breakfast. ANS: C. 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. Which nursing intervention has the highest priority when preparing the client for surgical intervention?Nursing Responsibilities
Safety is the highest priority.
Which priority intervention should the nurse in the preoperative waiting area implement?The key nursing intervention during the preoperative period is patient and family education. Take every opportunity during the patient assessment and preparation for surgery, to provide information that will increase the patient's familiarity with the procedure, which will decrease anxiety.
How do you prepare a patient for a surgical procedure?Preparing for Surgery. Stop drinking and eating for a certain period of time before the time of surgery.. Bathe or clean, and possibly shave the area to be operated on.. Undergo various blood tests, X-rays, electrocardiograms, or other procedures necessary for surgery.. What would be your role as a nurse in preparing the patient for surgery?Working with patients prior to surgery to complete paperwork, and help answer questions or calm fears about surgery. Monitoring a patient's condition during and after surgery. Selecting and passing instruments and supplies to the surgeon during operation (sometimes referred to as a scrub nurse)
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