The nurse is caring for a surgical patient, when the family member
asks what perioperative nursing means. How should the nurse
respond?
a. Perioperative nursing occurs in preadmission
testing.
b. Perioperative nursing occurs primarily in the
postanesthesia care unit.
c. Perioperative nursing includes
activities before, during, and after surgery.
d. Perioperative
nursing includes activities only during the surgical procedure.
c. Perioperative nursing includes activities before, during, and after surgery.
Perioperative nursing care occurs before, during, and after surgery. Preadmission testing occurs before surgery and is considered preoperative. Nursing care provided during the surgical procedure is considered intraoperative, and in the postanesthesia care unit, it is considered postoperative. All of these are parts of the perioperative phase, but each individual phase does not explain the term completely.
The nurse is caring for a patient who is scheduled to undergo a
surgical procedure. The nurse is completing an assessment and reviews
the patient’s laboratory tests and allergies and prepares the patient
for surgery. In which perioperative nursing phase is the nurse
working?
a. Perioperative
b. Preoperative
c.
Intraoperative
d. Postoperative
b. Preoperative
Reviewing the patient’s laboratory tests and allergies is done before surgery in the preoperative phase. Perioperative means before, during, and after surgery. Intraoperative means during the surgical procedure in the operating suite; postoperative means after the surgery and could occur in the postanesthesia care unit, in the ambulatory surgical area, or on the hospital unit.
The nurse is caring for a patient in the postanesthesia care unit.
The patient has developed profuse bleeding from the surgical site, and
the surgeon has determined the need to return to the operative area.
How will the nurse classify this procedure?
a. Major
b.
Urgent
c. Elective
d. Emergency
d. Emergency
An emergency procedure must be done immediately to save a life or preserve the function of a body part. An example would be repair of a perforated appendix, repair of a traumatic amputation, or control of internal hemorrhaging. An urgent procedure is necessary for a patient’s health and often prevents additional problems from developing. An example would be excision of a cancerous tumor, removal of a gallbladder for stones, or vascular repair for an obstructed artery. An elective procedure is performed on the basis of the patient’s choice; it is not essential and is not always necessary for health. An example would be a bunionectomy, plastic surgery, or hernia reconstruction. A major procedure involves extensive reconstruction or alteration in body parts; it poses great risks to well-being. An example would be a coronary artery bypass or colon resection.
The nurse is caring for a patient in preadmission testing. The
patient has been assigned a physical status classification by the
American Society of Anesthesiologists of ASA III. Which assessment
will support this classification?
a. Normal, healthy
patient
b. Denial of any major illnesses or conditions
c.
Poorly controlled hypertension with implanted pacemaker
d.
Moribund patient not expected to survive without the operation
c. Poorly controlled hypertension with implanted pacemaker
An ASA III rating is a patient with a severe systemic disease, such as poorly controlled hypertension with an implanted pacemaker. ASA I is a normal healthy patient with no major illnesses or conditions. ASA II is a patient with mild systemic disease. ASA V is a moribund patient who is not expected to survive without the operation and includes patients with ruptured abdominal/thoracic aneurysm or massive trauma.
The patient presented to the ambulatory surgery center to have a
colonoscopy is scheduled to receive moderate sedation (conscious
sedation) during the procedure. How will the nurse interpret this
information?
a. The procedure results in loss of sensation in an
area of the body.
b. The procedure requires a depressed level of
consciousness.
c. The procedure will be performed on an
outpatient basis.
d. The procedure necessitates the patient to be immobile.
b. The procedure requires a depressed level of consciousness.
Moderate sedation (conscious sedation) is used routinely for procedures that do not require complete anesthesia but rather a depressed level of consciousness. Not all patients who are treated on an outpatient basis receive moderate sedation. Regional anesthesia such as local anesthesia provides loss of sensation in an area of the body. General anesthesia is used for patients who need to be immobile and to not remember the surgical procedure.
The nurse is caring for a patient in the postanesthesia care unit who
has undergone a left total knee arthroplasty. The anesthesia provider
has indicated that the patient received regional anesthesia in the
form of a left femoral peripheral nerve block. Which assessment will
be an expected finding for this patient?
a. Sensation decreased
in the left leg
b. Patient report of pain in the left
foot
c. Pulse decreased at the left posterior tibia
d. Left
toes cool to touch and slightly cyanotic
a. Sensation decreased in the left leg
Induction of regional anesthesia results in loss of sensation in an area of the body—in this case, the left leg. The peripheral nerve block influences the portions of sensory pathways that are anesthetized in the targeted area of the body. Decreased pulse, toes cool to touch, and cyanosis are indications of decreased blood flow and are not expected findings. Reports of pain in the left foot may indicate that the block is not working or is subsiding and is not an expected finding in the immediate postoperative period.
Which nursing goal is a priority for assessing the patient before
surgery?
a. Plan for care after the procedure.
b. Establish
a patient’s baseline of normal function.
c. Educate the patient
and family about the procedure.
d. Gather appropriate equipment
for the patient’s needs.
b. Establish a patient’s baseline of normal function.
The goal of the preoperative assessment is to identify a patient’s normal preoperative function and the presence of any risks to recognize, prevent, and minimize possible postoperative complications. Gathering appropriate equipment, planning care, and educating the patient and family are all important interventions that must be provided for the surgical patient; they are part of the nursing process but are not the priority reason/goal for completing an assessment of the surgical patient.
The nurse is completing a medication history for the surgical patient
in preadmission testing. Which medication should the nurse instruct
the patient to hold (discontinue) in preparation for surgery according
to protocol?
a. Warfarin
b. Vitamin C
c.
Prednisone
d. Acetaminophen
a. Warfarin
Medications such as warfarin or aspirin alter normal clotting factors and thus increase the risk of hemorrhaging. Discontinue at least 48 hours before surgery. Acetaminophen is a pain reliever that has no special implications for surgery. Vitamin C actually assists in wound healing and has no special implications for surgery. Prednisone is a corticosteroid, and dosages are often temporarily increased rather than held.
The nurse is prescreening a surgical patient in the preadmission
testing unit. The medication history indicates that the patient is
currently taking an anticoagulant. Which action should the nurse
request when consulting with the health care provider?
a. A
radiological examination of the chest
b. An international
normalized ratio (INR)
c. A blood urea nitrogen (BUN)
d. A
serum sodium (Na)
b. An international normalized ratio (INR)
INR, PT (prothrombin time), APTT (activated partial thromboplastin time), and platelet counts reveal the clotting ability of the blood. Anticoagulants can be utilized for different conditions, but its action is to increase the time it takes for the blood to clot. This action can put the surgical patient at risk for bleeding tendencies. Typically, if at all possible, this medication is held several days before a surgical procedure to decrease this risk. Chest x-ray, BUN, and Na are diagnostic screening tools for surgery but are not specific to anticoagulants
The nurse is encouraging the postoperative patient to utilize
diaphragmatic breathing. Which priority goal is the nurse trying to
achieve?
a. Manage pain.
b. Prevent atelectasis.
c.
Reduce healing time.
d. Decrease thrombus formation.
b. Prevent atelectasis.
After surgery, patients may have reduced lung volume and may require greater effort to cough and deep breathe; inadequate lung expansion can lead to atelectasis and pneumonia. Purposely utilizing diaphragmatic breathing can decrease this risk. During general anesthesia, the lungs are not fully inflated during surgery and the cough reflex is suppressed, so mucus collects within airway passages. Diaphragmatic breathing does not manage pain; in some cases, if splinting and pain medications are not given, it can cause pain. Diaphragmatic breathing does not reduce healing time or decrease thrombus formation. Better, more effective interventions are available for these situations.
The nurse caring for a postoperative patient will encourage what
activity to prevent venous stasis and the formation of
thrombus?
a. Diaphragmatic breathing
b. Incentive
spirometry
c. Leg exercises
d. Coughing
c. Leg exercises
After general anesthesia, circulation slows, and when the rate of blood slows, a greater tendency for clot formation is noted. Immobilization results in decreased muscular contractions in the lower extremities; these promote venous stasis. Coughing, diaphragmatic breathing, and incentive spirometry are utilized to decrease atelectasis and pneumonia.
The nurse caring for a preoperative patient teaches the principles
and demonstrates leg exercises for the patient. The patient is unable
to perform leg exercises correctly. What is the nurse’s best next
step?
a. Encourage the patient to practice at a later
date.
b. Assess for the presence of anxiety, pain, or
fatigue.
c. Ask the patient why exercises are not being
done.
d. Evaluate the educational methods used to educate the patient.
b. Assess for the presence of anxiety, pain, or fatigue.
If the patient is unable to perform leg exercises, the nurse should look for circumstances that may be impacting the patient’s ability to learn. In this case, the patient can be anticipating the upcoming surgery and may be experiencing anxiety. The patient may also be in pain or may be fatigued; both of these can affect the ability to learn. Evaluation of educational methods may be needed, but in this case, principles and demonstrations are being utilized. Asking anyone ―why can cause defensiveness and may not help in attaining the answer. The nurse is aware that the patient is unable to do the exercises. Moving forward without ascertaining that learning has occurred will not help the patient in meeting goals.
Which nursing assessment will indicate the patient is performing
diaphragmatic breathing correctly?
a. Hands placed on the border
of the rib cage with fingers extended will touch as the chest wall
contracts.
b. Hands placed on the chest wall with fingers
extended will separate as the chest wall contracts.
c. The
patient will feel upward movement of the diaphragm during
inspiration.
d. The patient will feel downward movement of the
diaphragm during expiration.
a. Hands placed on the border of the rib cage with fingers extended will touch as the chest wall contracts
The nurse is caring for a postoperative patient with an abdominal
incision. When the nurse provides a pillow to use during coughing,
which activity is the nurse promoting?
a. Pain relief
b.
Splinting
c. Distraction
d. Anxiety reduction
b. Splinting
Deep breathing and coughing exercises place additional stress on the suture line and cause discomfort. Splinting incision with hands and a pillow provides firm support and reduces incisional pull. Providing a pillow during coughing does not provide distraction or reduce anxiety. Providing a pillow does not provide pain relief. Coughing can increase anxiety because it can cause pain. Analgesics provide pain relief.
The nurse is encouraging a reluctant postoperative patient to deep
breathe and cough. Which explanation can the nurse provide that may
encourage the patient to comply?
a. ―If you don’t deep breathe
and cough, you will get pneumonia.
b. ―You will need to cough
only a few times during this shift.
c. ―Let’s try clearing the
throat because that will work just as well.
d. ―Deep breathing
and coughing will clear your lungs of the anesthesia
d. ―Deep breathing and coughing will clear your lungs of the anesthesia
The nurse and the nursing assistive personnel are assisting a
postoperative patient to turn in bed. To assist in minimizing
discomfort, which instruction should the nurse provide to the
patient?
a. ―Close your eyes and think about something
pleasant.
b. ―Hold your breath and count to three.
c. ―Grab
my shoulders with your hands.
d. ―Use your hand to support your incision
d. ―Use your hand to support your incision
Instruct the patient to place the right hand over the incisional area to splint it, providing support and minimizing pulling during turning. Closing one’s eyes, holding one’s breath, and holding the nurse’s shoulders do not help support the incision during a turn.
The nurse is preparing to assist the patient in using the incentive
spirometer. Which nursing intervention should the nurse provide
first?
a. Perform hand hygiene.
b. Explain use of the
mouthpiece.
c. Instruct the patient to inhale slowly.
d.
Place in the reverse Trendelenburg’s position.
a. Perform hand hygiene
Performing hand hygiene reduces microorganisms and should be
performed first. Placing the patient in the correct position such as
high Fowler’s for the typical postoperative patient or reverse
Trendelenburg’s for the bariatric patient would be the next step in
the process.
Demonstration of use of the mouthpiece followed by
the instruction to inhale slowly would be the last step in this scenario.
The nurse and the nursing assistive personnel (NAP) are caring for a
group of postoperative patients who need turning, coughing, deep
breathing, incentive spirometer, and leg exercises. Which task will
the nurse assign to the NAP?
a. Teaching postoperative
exercises
b. Doing nothing associated with postoperative
exercises
c. Documenting in the medical record when exercises are
completed
d. Informing the nurse if the patient is unwilling to
perform exercises
d. Informing the nurse if the patient is unwilling to perform exercises
The nurse can delegate to the NAP to encourage patients to practice postoperative exercises regularly after instruction and to inform the nurse if the patient is unwilling to perform these exercises. The skills of demonstrating and teaching postoperative exercises and documenting are not within the scope of practice for the nursing assistant. Doing nothing is not appropriate.
The nurse is providing preoperative teaching for the ambulatory
surgery patient who will be having a cyst removed from the right arm.
Which will be the best explanation for diet progression after
surgery?
a. ―Start with clear liquids, soup, and crackers.
Advance to a normal diet as tolerated.
b. ―Stay with ice chips
for several hours. After that, you can have whatever you want.
c.
―Stay on clear liquids for 24 hours. Then you can progress to a normal
diet.
d. ―Start with clear liquids for 2 hours and then full
liquids for 2 hours. Then progress to a normal diet
a. ―Start with clear liquids, soup, and crackers. Advance to a normal diet as tolerated
Patients usually receive a normal diet the first evening after surgery unless they have undergone surgery on GI structures. Implement diet intake while judging the patient’s response. For example, provide clear liquids such as water, apple juice, broth, or tea after nausea subsides. If the patient tolerates liquids without nausea, advance the diet as ordered. There is no need to stay on ice chips for several hours or clear liquids for 24 hours after this procedure. Putting a time frame on the progression is too prescriptive. Progression should be adjusted for the patient’s needs
The nurse explains the pain-relief measures available after surgery
during preoperative teaching for a surgical patient. Which comment
from the patient indicates the need for additional education on this
topic?
a. ―I will be asked to rate my pain on a pain
scale.
b. ―I will have minimal pain because of the
anesthesia.
c. ―I will take the pain medication as the provider
prescribes it.
d. ―I will take my pain medications before doing
postoperative exercises
b. ―I will have minimal pain because of the anesthesia.
Anesthesia will be provided during the procedure itself, and the patient should not experience pain during the procedure; however, this will not minimize the pain after surgery. Pain management is utilized after the postoperative phase. Inform the patient of interventions available for pain relief, including medication, relaxation, and distraction. The patient needs to know and understand how to take the medications that the health care provider will prescribe postoperatively. During the stay in the facility, the level of pain is frequently assessed by the nurses. Coordinating pain medication with postoperative exercises helps to minimize discomfort and allows the exercises to be more effective
The nurse is making a preoperative education appointment with a
patient. The patient asks if a family member should come to the
appointment. Which is the best response by the nurse?
a. ―There
is no need for an additional person at the appointment.
b. ―Your
family can come and wait with you in the waiting room.
c. ―We
recommend including family members at this appointment.
d. ―It is
required that you have a family member at this appointment
c. ―We recommend including family members at this appointment.
Including family members in perioperative education is advisable. Often a family member is a coach for postoperative exercises when the patient returns from surgery. If anxious relatives do not understand routine postoperative events, it is likely that their anxiety will heighten the patient’s fears and concerns. Preoperative preparation of family members before surgery helps to minimize anxiety and misunderstanding. An additional person is needed at the appointment if at all possible, and he or she needs to be involved in the process, not just waiting in the waiting room; however, it is certainly not a requirement for actually completing the surgery that someone comes to this appointment
The nurse is reviewing the surgical consent with the patient during
preoperative education and finds the patient does not understand what
procedure will be performed. What is the nurse’s best next
step?
a. Notify the health care provider about the patient’s
question.
b. Explain the procedure that will be
completed.
c. Continue with preoperative education.
d. Ask
the patient to sign the form
a. Notify the health care provider about the patient’s question.
Surgery cannot be legally or ethically performed until the patient fully understands the need for a procedure and all the implications. It is the surgeon’s responsibility to explain the procedure, associated risks, benefits, alternatives, and possible complications. It is important for the nurse to pause with preoperative education to notify the health care provider of the patient’s questions. It is not within the nurse’s scope to explain the procedure. The nurse can certainly reinforce what the health care provider has explained, but the information needs to come from the health care provider. It is not prudent to ask a patient to sign a form for a procedure that he/she does not understand.
During preoperative assessment for a 7:30 AM (0730) surgery, the
nurse finds the patient drank a cup of coffee this morning. The nurse
reports this information to the anesthesia provider. Which action does
the nurse anticipate next?
a. A delay in or cancellation of
surgery
b. Questions regarding components of the coffee
c.
Additional questions about why the patient had coffee
d.
Instructions to determine what education was provided in the
preoperative visit
a. A delay in or cancellation of surgery
The recommendations before nonemergent procedures requiring general and regional anesthesia or sedation/analgesia include fasting from intake of clear liquids for 2 or more hours. A delay in or cancellation of surgery will be in order for this case. Questions regarding components of the coffee, asking why, and evaluating the preoperative education may all be items to be addressed, especially from a performance improvement perspective, but at this time in caring for this patient, a delay or cancellation is in order to prevent aspiration.
The nurse has administered a preoperative medication to the patient
going to surgery. Which action will the nurse take next?
a.
Notify the operating suite that the medication has been given.
b.
Instruct the patient to call for help to go to the restroom.
c.
Waste any unused medication according to policy.
d. Ask the
patient to sign the consent for surgery
b. Instruct the patient to call for help to go to the restroom.
Once a preoperative medication has been administered, instruct the patient to call for help when getting out of bed to prevent falls. For patient safety, explain the purpose of a preoperative medication and its effects. Notifying the operating suite that the medication has been given may be part of a facilities procedure but is not the best next step. It is important to have the patient sign consents before the patient has received medication that may make him/her drowsy. Wasting unused medication according to policy is important but is not the best next step.
The nurse has completed a preoperative assessment for a patient going
to surgery and gathers assessment data. Which will be the most
important next step for the nurse to take?
a. Notify the
operating suite that the patient has a latex allergy.
b. Document
that the patient had a bath at home this morning.
c. Administer
the ordered preoperative intravenous antibiotic.
d. Ask the
nursing assistive personnel to obtain vital signs.
a. Notify the operating suite that the patient has a latex allergy.
The most important step is notifying the operating suite of the patient’s latex allergy. Many products that contain latex are used in the operating suite and the post-anesthesia care unit (PACU). When preparing for a patient with this allergy, special considerations are required from preparation of the room to the types of tubes, gloves, drapes, and instruments utilized. Obtaining vital signs, documenting, and administering medications are all part of the process and should be done—with the latex allergy in mind. However, making sure that the patient has a safe environment is the first step.
The nurse is preparing a patient for a surgical procedure on the
right great toe. Which action will be most important to include in
this patient’s preparation?
a. Place the patient in a clean
surgical gown.
b. Ask the patient to remove all hairpins and
cosmetics.
c. Ascertain that the surgical site has been correctly
marked.
d. Determine where the family will be located during the procedure
c. Ascertain that the surgical site has been correctly marked.
Because errors have occurred in the past with patients undergoing the wrong surgery on the wrong site, the universal protocol guidelines have been implemented and are used with all invasive procedures. Part of this protocol includes marking the operative site with indelible ink. Knowing where the family is during a procedure, placing the patient in a clean gown, and asking the patient to remove all hairpins and cosmetics are important but are not most important in this list of items.
The circulating nurse is caring for a patient intraoperatively. Which
primary role of the circulating nurse will be implemented?
a.
Suturing the surgical incision in the OR suite
b. Managing
patient care activities in the OR suite
c. Assisting with
applying sterile drapes in the OR suite
d. Handing sterile
instruments and supplies to the surgeon in the OR suite
b. Managing patient care activities in the OR suite
The nurse is caring for a patient in the preoperative holding area of
an ambulatory surgery center. Which nursing action will be most
appropriate for this area?
a. Counting the sterile surgical
instruments
b. Emptying the urinary drainage bag
c. Checking
the surgical dressing
d. Appling a warm blanket
d. Appling a warm blanket
The temperature in the preoperative holding area and in adjacent operating suites is usually cold. Offer the patient an extra warm blanket. Counts are taken by the circulating and scrub nurses in the operating room. Emptying a urinary drainage bag and checking the surgical dressing occur in the post-anesthesia care unit, not in the holding area.
The nurse is caring for a patient in the operating suite. Which
outcome will be most appropriate for this patient at the end of the
intraoperative phase?
a. The patient will be free of burns at the
grounding pad.
b. The patient will be free of nausea and
vomiting.
c. The patient will be free of infection.
d. The
patient will be free of pain.
a. The patient will be free of burns at the grounding pad.
A primary focus of intraoperative care is to prevent injury and complications related to anesthesia, surgery, positioning, and equipment use, including use of the electrical cautery grounding pad for the prevention of burns. The perioperative nurse is an advocate for the patient during surgery and protects the patient’s dignity and rights at all times. Signs and symptoms of infection do not have the time to present during the intraoperative phase. During the intraoperative phase, the patient is anesthetized and unconscious and typically has an endotracheal tube that prevents conversation. Nausea, vomiting, and pain typically begin in the postoperative phase of the experience.
The nurse is concerned about the skin integrity of the patient in the
intraoperative phase of surgery. Which action will the nurse take to
minimize skin breakdown?
a. Encouraging the patient to bathe
before surgery
b. Securing attachments to the operating table
with foam padding
c. Periodically adjusting the patient during
the surgical procedure
d. Measuring the time, a patient is in one
position during surgery
b. Securing attachments to the operating table with foam padding
Although it may be necessary to place a patient in an unusual position, try to maintain correct alignment and protect the patient from pressure, abrasion, and other injuries. Special mattresses, use of foam padding, and attachments to the operating suite table provide protection for the extremities and bony prominences. Bathing before surgery helps to decrease the number of microbes on the skin. Periodically adjusting the patient during the surgical procedure is impractical and can present a safety issue with regard to maintaining sterility of the field and maintaining an airway. Measuring the time, the patient is in one position may help with monitoring the situation but does not prevent skin breakdown.
The nurse is assessing a postoperative patient with a history of
obstructive sleep apnea for airway obstruction. Which assessment
finding will best alert the nurse to this complication?
a. Drop
in pulse oximetry readings
b. Moaning with reports of
pain
c. Shallow respirations
d. Disorientation
a. Drop in pulse oximetry readings
One of the greatest concerns after general anesthesia is airway obstruction, especially in patients with obstructive sleep apnea. A drop-in oxygen saturation by pulse oximetry is a sign of airway obstruction in patients with obstructive sleep apnea. Weak pharyngeal/laryngeal muscle tone from anesthetics; secretions in the pharynx, bronchial tree, or trachea; and laryngeal or subglottic edema also contribute to airway obstruction. In the postanesthetic patient, the tongue is a major cause of airway obstruction. Shallow respirations are indicative of respiratory depression. Moaning and reports of pain are common in all surgical patients and are an expected event. Disorientation is common when first awakening from anesthesia but can be a sign of hypoxia
The nurse is caring for a patient in the operating suite who is
experiencing hypercarbia, tachypnea, tachycardia, premature
ventricular contractions, and muscle rigidity. Which condition does
the nurse suspect the patient is experiencing?
a. Malignant
hyperthermia
b. Fluid imbalance
c. Hemorrhage
d. Hypoxia
a. Malignant hyperthermia
A life-threatening, rare complication of anesthesia is malignant hyperthermia. Malignant hyperthermia causes hypercarbia, tachycardia, tachypnea, premature ventricular contractions, unstable blood pressure, cyanosis, skin mottling, and muscular rigidity. It often occurs during anesthesia induction. Hypoxia would manifest with decreased oxygen saturation as one of its signs and symptoms. Fluid imbalance would be assessed with intake and output and can manifest with tachycardia and blood pressure fluctuations but does not have muscle rigidity. Hemorrhage can manifest with tachycardia and decreased blood pressure, along with a thready pulse. Usually some sign or symptom of blood loss is noted (e.g., drains, incision, orifice, and abdomen)
The nurse is caring for a postoperative patient who has had a
minimally invasive carpel tunnel repair. The patient has a temperature
of 97 F and is shivering. Which reason will the nurse most likely
consider as the primary cause when planning care?
a. Anesthesia
lowers metabolism.
b. Surgical suites have air currents.
c.
The patient is dressed only in a gown.
d. The large open body
cavity contributed to heat loss
a. Anesthesia lowers metabolism.
The operating suite and recovery room environments are extremely cool. The patient’s anesthetically depressed level of body function results in lowering of metabolism and a fall in body temperature. Although the patient is dressed in a gown and there are air currents in the operating room, these are not the primary reasons for the low temperature. Also, the patient in this type of case does not have a large open body cavity to contribute to heat loss
The nurse is monitoring a patient in the post-anesthesia care unit
(PACU) for postoperative fluid and electrolyte imbalance. Which action
will be most appropriate for the nurse to take?
a. Encourage
copious amounts of water.
b. Start an additional intravenous (IV)
line.
c. Measure and record all intake and output.
d. Weigh
the patient and compare with preoperative weight.
c. Measure and record all intake and output.
Accurate recording of intake and output assesses renal and circulatory function. Measure and record all sources of intake and output. Encouraging copious amounts of water in a postoperative patient might encourage nausea and vomiting. In the PACU, it is impractical to weigh the patient while waking from surgery, but in the days afterward, it is a good assessment parameter for fluid imbalance. Starting an additional IV is not necessary and is not important at this juncture.
The nurse is caring for a patient in the post-anesthesia care unit.
The patient asks for a bedpan and states to the nurse, ―I feel like I
need to go to the bathroom, but I can’t. Which nursing intervention
will be most appropriate initially?
a. Assess the patient for
bladder distention.
b. Encourage the patient to wait a minute and
try again.
c. Inform the patient that everyone feels this way
after surgery.
d. Call the health care provider to obtain an
order for catheterization
a. Assess the patient for bladder distention.
The post-anesthesia care unit (PACU) nurse transports the inpatient
surgical patient to the medical-surgical floor. Before leaving the
floor, the medical-surgical nurse obtains a complete set of vital
signs. What is the rationale for this nursing action?
a. This is
done to complete the first action in a head-to-toe assessment.
b.
This is done to compare and monitor for vital sign variation during
transport.
c. This is done to ensure that the medical-surgical
nurse checks on the postoperative patient.
d. This is done to
follow hospital policy and procedure for care of the surgical patient.
b. This is done to compare and monitor for vital sign variation during transport.
Before the PACU nurse leaves the acute care area, the staff nurse assuming care for the patient takes a complete set of vital signs to compare with PACU findings. Minor vital sign variations normally occur after transporting the patient. The PACU nurse reviews the patient’s information with the medical-surgical nurse, including the surgical and PACU course, physician orders, and the patient’s condition. While vital signs may or may not be the first action in a head-to-toe assessment, this is not the rationale for this situation. While following policy or ascertaining that the floor nurse checks on the patient are good reasons for safe care, they are not the best rationale for obtaining vital signs.
The nurse is caring for a patient who will undergo a removal of a
lung lobe. Which level of care will the patient require immediately
post procedure?
a. Acute care—medical-surgical unit
b. Acute
care—intensive care unit
c. Ambulatory surgery
d. Ambulatory
surgery—extended stay
b. Acute care—intensive care unit
Patients undergoing extensive surgery and requiring anesthesia of long duration recover slowly. If a patient is undergoing major surgery such as a procedure on the lung, a stay in the hospital and specifically in the intensive care unit is required to monitor for potential risks to well-being. This patient would require more care than can be provided on a medical-surgical unit. It is not appropriate for this type of patient to go home after the procedure or to stay in an extended stay area of an ambulatory surgery area because of the complexity and associated risks.
The nurse is caring for a group of patients. Which patient will the
nurse see first?
a. A patient who had cataract surgery is
coughing.
b. A patient who had vascular repair of the right leg
is not doing right leg exercises.
c. A patient after knee surgery
is wearing intermittent pneumatic compression devices and receiving
heparin.
d. A patient after surgery has vital signs taken every
15 minutes twice, every 30 minutes twice, hourly for 2 hours then
every 4 hours.
a. A patient who had cataract surgery is coughing.
For patients who have had eye, intracranial, or spinal surgery, coughing may be contraindicated because of the potential increase in intraocular or intracranial pressure. The nurse will need to see this patient first to control the cough and intraocular pressure. All the rest are normal postoperative patients. Leg exercise should not be performed on the operative leg with vascular surgery. A patient after knee surgery should receive heparin and be wearing intermittent pneumatic compression devices; while the nurse will check on the patient, it does not have to be first. Monitoring vital signs after surgery is required and this is the standard schedule.
The nurse demonstrates postoperative exercises for a patient. In
which order will the nurse instruct the patient to perform the
exercises?
1. Turning
2. Breathing
3. Coughing
4.
Leg exercises
a. 4, 1, 2, 3
b. 1, 2, 3, 4
c. 2, 3, 4,
1
d. 3, 1, 4, 2
a. 4, 1, 2, 3
The nurse is participating in a ―time-out. In which activities will
the nurse be involved? (Select all that apply.)
a. Verify the
correct site.
b. Verify the correct patient.
c. Verify the
correct procedure.
d. Perform ―time-out after surgery.
e.
Perform the actual marking of the operative site.
a. Verify the correct site.
b. Verify the correct
patient.
c. Verify the correct procedure.
The nurse is using a forced air warmer for a surgical patient
preoperatively. Which goals is the nurse trying to achieve? (Select
all that apply.)
a. Induce shivering.
b. Reduce blood
loss.
c. Induce pressure ulcers.
d. Reduce cardiac
arrests.
e. Reduce surgical site infection
b. Reduce blood loss.
d. Reduce cardiac arrests.
e. Reduce
surgical site infection
The nurse is caring for a postoperative patient with an incision.
Which actions will the nurse take to decrease wound infections?
(Select all that apply.)
a. Maintain normoglycemia.
b. Use a
straight razor to remove hair.
c. Provide bath and linen change
daily.
d. Perform first dressing change 2 days
postoperatively.
e. Perform hand hygiene before and after contact
with the patient.
f. Administer antibiotics within 60 minutes
before surgical incision.
a. Maintain normoglycemia.
e. Perform hand hygiene before and
after contact with the patient.
The nurse is preparing for a patient who will be going to surgery.
The nurse screens for risk factors that can increase a person’s risks
in surgery. What risk factors are included in the nurse’s screening?
(Select all that apply.)
a. Age
b. Race
c.
Obesity
d. Nutrition
e. Pregnancy
f. Ambulatory surgery
a. Age
c. Obesity
d. Nutrition
e. Pregnancy
The nurse is providing preoperative education and reviews with the
patient what it will be like to be in the surgical environment. Which
points should the nurse include in the teaching session? (Select all
that apply.)
a. The operative suite will be very dark.
b.
The family is not allowed in the operating suite.
c. The
operating table or bed will be comfortable and soft.
d. The
nurses will be there to assist you through this process.
e. The
surgical staff will be dressed in special clothing with hats and masks.
b. The family is not allowed in the operating suite.
d. The
nurses will be there to assist you through this process.
e. The
surgical staff will be dressed in special clothing with hats and masks.
The operating room nurse is providing a hand-off report to the
post-anesthesia care unit (PACU) nurse. Which components will the
operating room nurse include? (Select all that apply.)
a. IV
fluids
b. Vital signs
c. Insurance data
d. Family
location
e. Anesthesia provided
f. Estimated blood loss
a. IV fluids
b. Vital signs
e. Anesthesia provided
f.
Estimated blood loss
The nurse is caring for a group of postoperative patients on the
surgical unit. Which patient assessments indicate the nurse needs to
follow up? (Select all that apply.)
a. Patient with abdominal
surgery has patent airway.
b. Patient with knee surgery has
approximated incision.
c. Patient with femoral artery surgery has
strong pedal pulse.
d. Patient with lung surgery has 20 mL/hr of
urine output via catheter.
e. Patient with bladder surgery has
bloody urine within the first 12 hours.
f. Patient with appendix
surgery has thready pulse and blood pressure is 90/60.
d. Patient with lung surgery has 20 mL/hr of urine output via
catheter.
f. Patient with appendix surgery has thready pulse and
blood pressure is 90/60.