A client had an open cholecystectomy (gall bladder removal) 36 hours
earlier, and the nurse's assessment this morning confirms that the
client has not yet had a bowel movement since prior to surgery. How
should the nurse best respond to this assessment
a)Increase the rate of the client's intravenous infusion.
b)Immediately administer a cleansing enema.
c)Contact the physician to come assess the client.
d)Monitor the client closely and promote fluid intake.
Monitor the client closely and promote fluid intake.
Bowel function does not typically return immediately after surgery, but it can be promoted by encouraging fluid and fiber intake as appropriate to the client and his or her surgery. A medical assessment is likely unnecessary at this early postoperative stage, and an enema would likely be premature. The nurse may not independently increase the client's IV infusion, and doing so would not necessarily promote a bowel movement.
The nurse is preparing a client for surgery and asks if the client
has an advance directive. The client asks “What is an advance
directive?” What is the nurse’s best response to this?
a)“We are not sure if you will wake up after surgery so the advance directive will let us know your wishes just in case.”
b)“An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so.”
c)“An advance directive is a living will. Some people already have one when they come to the hospital.”
d)“When you are going to have surgery, the hospital likes to have you fill out all paperwork needed beforehand.”
“An advance directive will communicate your wishes for health care postoperatively in case you are unable to do so.”
An advance directive allows the client to communicate instructions for health care postoperatively in case of an inability to do so. Although an advance directive is either a living will or a durable power of attorney for health care, and the hospital does like to determine if the client has these, these are not the best answers to the client’s question. The nurse would not want to explain to the client that he or she may not wake up after surgery
A nurse administers anticholinergics to a patient as a postoperative
medication. What condition does this medication help to
Anticholinergics, such as atropine and glycopyrrolate (Robinul), to decrease pulmonary and oral secretions and to prevent laryngospasm. Cardiovascular complications, nausea, and shock are not affected by anticholinergic medications.
A nurse is caring for an inpatient client scheduled to undergo a
surgery for the removal of a malignant tumor. What are the risk
factors that increase the likelihood of perioperative complications?
Select all that apply.
• Bleeding tendencies
• Low hemoglobin
Certain surgical risk factors, such as obesity, bleeding tendencies, low hemoglobin, smoking, diabetes, cardiopulmonary disease, drug and alcohol abuse, and diabetes, increase the likelihood of perioperative complications. Raised temperature and anxiety are causes for postponing or cancelling the surgery.
The nurse is preparing a client for a colonoscopy. The nurse is
familiar with the colonoscopy procedures at the hospital and is aware
that which type of anesthesia is commonly used for this
Moderate sedation/analgesia is also known as conscious sedation or procedural sedation. It is used for short-term and minimally invasive procedures such as endoscopy procedures (e.g., colonoscopy)
Which of these clients in the postanesthesia care unit (PACU)
requires the most immediate attention by the
a)a client reporting nausea who requests an antiemetic
b)a client with snoring respirations who arouses readily
c)a client reporting incisional pain rated 8/10 and no medication orders
d)a client who is pale and diaphoretic with a heart rate of 115 beats/minute
a client who is pale and diaphoretic with a heart rate of 115 beats/minute
All of these clients need attention but the one who is pale and diaphoretic with an elevated heart rate is the most unstable; this client needs further assessment to determine if there is a fluid volume deficit, which could be due to active bleeding or inadequate fluid replacement during surgery.
The nurse knows the term perioperative phase refers to care
given to the client:
a)immediately before an operative procedure.
b)before, during, and after the operative phase.
c)immediately after the operative phase.
d)from the start of surgery until its conclusion.
before, during, and after the operative phase.
Perioperative nursing includes three distinct phases: preoperative, intraoperative, and postoperative.
The nurse recognizes the value of leg exercises in the prevention of
postoperative thrombophlebitis. When should the nurse teach the
correct technique for leg exercises to a client?
a)prior to surgery
b)upon transfer from postanesthesia care unit (PACU) to the postoperative unit
c)when early signs of venous stasis are evident
d)in postanesthesia recovery
prior to surgery
Though leg exercises are begun after surgery, such preventative measures should ideally be taught to the client during the preoperative period
Which nursing action should the PACU nurse take to prevent
postoperative complications in clients?
a)Instruct the client to avoid coughing to prevent injury to the incision.
b)Encourage the client to breathe shallowly to prevent collapse of the alveoli.
c)Avoid turning the client in bed until the incision is no longer painful.
d)Assist the client to do leg exercises to increase venous return.
Assist the client to do leg exercises to increase venous return.
Leg exercises increase venous return in order to prevent the postoperative complication of clot formation in the lower extremities. Coughing, while splinting the incision, and deep breathing is encouraged to prevent respiratory complications such as pneumonia and atelectasis. Turning the client stimulates the circulatory and respiratory system, and prevents skin breakdown.
The procedural physician has initiated performance of a time-out in
the operating room before surgery. The student nurse asks the
operating room nurse why this is important. What is the operating room
nurse’s best response?
a)“The time-out checks to be sure that we have the right client and procedure.”
b)“The time-out allows us to make sure that the client has had adequate anesthesia.”
c)“We need to be sure the client has had the preoperative antibiotic.”
d)"We are checking the client’s baseline vital signs during time-out.”
“The time-out checks to be sure that we have the right client and procedure.”
The time-out is a safety measure performed before any surgical procedure and allows the operating room staff to determine they have the right client, procedure, and side (if appropriate). The client’s baseline vital signs should have already been performed. The anesthesia is managed by the anesthetist or anesthesiologist when the procedural physician is prepared for the beginning of the operation; however, this is not part of the time-out. The preoperative antibiotic should be administered within 60 minutes of the surgery but is also not part of the time-out.
A nurse is dressing the wound of a client who is admitted to the
outpatient surgical unit. What is a major advantage of outpatient
a)It allows less opportunity for family contact and support.
b)It interferes less with the client's daily routine.
c)It reduces the time for establishing a nurse–client rapport.
d)It requires intensive preoperative education in a short time.
It interferes less with the client's daily routine.
A major advantage of outpatient surgery is that it interferes less with the client's daily routine. It also allows more opportunity for family contact and support. Some disadvantages are that it reduces the time for establishing a nurse–client relationship and requires intensive preoperative education in a short time.
Which measure would the nurse implement for prevention of deep vein
thrombosis (DVT) in a postoperative client?
a)Place graduated compression stockings on the client.
b)Encourage the client to elevate the head of bed.
c)Educate the client about the use of incentive spirometer.
d)Elevate bilateral legs when client is lying in bed.
Place graduated compression stockings on the client.
Use of graduated compression stockings and/or pneumatic compression devices on the client will help with prevention of DVT, which is a risk for clients after surgery. Elevating the client’s legs will passively improve venous return but not prevent DVT if a client is not up and walking (to more actively promote the venous return). Elevating the head of the bed and using the incentive spirometer help prevent postoperative complications of atelectasis or pneumonia.
A female client age 54 years has been scheduled for a bunionectomy
(removal of bone tissue from the base of the great toe) which will be
conducted on an ambulatory basis. Which characteristic applies to this
type of surgery?
a)The client must be previously healthy with low surgical risks.
b)The client will be admitted the day of surgery and return home the same day.
c)The surgery is classified as urgent rather than elective.
d)The surgery will be conducted using moderate sedation rather than general anesthesia.
The client will be admitted the day of surgery and return home the same day.
Outpatient surgeries, also known as ambulatory surgeries, are conducted with admission and discharge on the same day. Such surgeries have become increasingly common in recent years, and some surgeries of increasing complexity and risk are conducted on an outpatient basis. General anesthesia is possible, and common. This approach is more common for elective surgeries than urgent surgeries
The nurse enters a postoperative client's room and finds that the
client is bleeding profusely from the surgical incision. What would be
the nurse's most appropriate initial
a)Apply pressure to the surgical site to decrease bleeding.
b)Determine the possible cause of the client's bleeding.
c)Notify the health care provider.
d)Assess the client's vital signs.
Apply pressure to the surgical site to decrease bleeding.
It is essential that the nurse be prepared to address life-threatening needs of the client. Excessive bleeding is a life-threatening issue. Determining the cause of the client's bleeding, assessing the vital signs, and notifying the health care provider are important, but the life-threatening issue must be addressed first.
Which client most likely requires special
preoperative assessment and treatment as a result of the existing
a)a man who takes an angiotensin-converting enzyme (ACE) inhibitor because he has hypertension
b)a man who regularly treats his rheumatoid arthritis with over-the-counter nonsteriodal anti-inflammatory drugs (NSAIDs)
c)a woman who takes daily thyroid supplements to treat her longstanding hypothyroidism
d)a woman who takes daily anticoagulants to treat atrial fibrillation
a woman who takes daily anticoagulants to treat atrial fibrillation
Anticoagulants present a risk of hemorrhage. This risk supersedes that posed by thyroid supplements, ACE inhibitors, or most NSAIDs.
Which client would a nurse monitor most closely for postoperative
a)a 75-year-old client with a history of hypertension who had a colonoscopy
b)an 8-year-old client with no medical problems who had a tonsillectomy
c)a 55-year-old client with a history of asthma who had a colon resection
d)a 31-year-old client with no medical problems who had an appendectomy
a 55-year-old client with a history of asthma who had a colon resection
All of these clients have a potential for respiratory complications, which can occur with chest or abdominal surgery, preexisting cardiovascular or respiratory disease, and in older adults or obese clients. The client who has had abdominal surgery and has preexisting respiratory disease would be at the greatest risk for observation of any respiratory complications (due to having two factors instead of only one). The pediatric client having a tonsillectomy would need to be observed for any airway problems but would not be a greater risk than the client with two risk factors.
What information must be provided to a patient to obtain informed
consent? (Select all that apply.)
a)Explanation of the risks involved and how often they occur
b)A description of the procedure or treatment, along with potential alternative therapies
c)Customary insurance coverage for the Procedure
d)The underlying disease process and its natural course
e)Explanation that a signed consent form is binding and cannot be withdrawn
f)The name and qualifications of the nurse providing perioperative care
• A description of the procedure or treatment, along with potential
• The underlying disease process and its natural course
• Explanation of the risks involved and how often they occur
The informed consent provides a description of the procedure or treatment (its name, site and side if applicable), along with potential alternative therapies; the underlying disease process and its natural course; the name and qualifications of the person performing the procedure or treatment; explanation of the common risks involved, including risk for damage, disfigurement, or death, and how often they occur; explanation that the patient has the right to refuse treatment and that consent can be withdrawn; and explanation of expected outcome, recovery, and rehabilitation plan and course.
A nurse is applying a pneumatic compression device to a client. What
is the purpose of a pneumatic compression device?
a)enables the client to void
b)pumps liquid diet to the client
c)promotes circulation of venous blood
d)reduces swelling and pain
promotes circulation of venous blood
A pneumatic compression device promotes the circulation of venous blood and relocation of excess fluid into the lymphatic vessels. The device does not pump a liquid diet to the client, help the client to void, or reduce swelling and pain.
A nurse is discussing a surgical procedure with a client who needs to
sign his informed consent. Which of these tasks is part of the nursing
a)explaining to the client about potential risks of having the surgery
b)witnessing the client signature with their consent for surgery
c)describing how the client will benefit from the surgical procedure
d)determining for the client what other treatment options exist
witnessing the client signature with their consent for surgery
The nursing role with informed consent is to witness the client signature on the form. The procedural physician is responsible for explaining the procedure, any alternative treatment, and the risks and benefits of having the surgery. The nurse may clarify information, but if in-depth explanation is needed, the procedural physician should be notified
The nurse recognizes that palliative surgery is performed for what
a)to remove a part of the body that is diseased
b)to lessen the intensity of an illness
c)to make or confirm a diagnosis
d)to restore function to tissue that is traumatized
to lessen the intensity of an illness
Palliative surgery is performed to help lessen the intensity of an illness; it is not meant to be curative but will help improve the client’s quality of life. A diagnostic surgery makes or confirms a diagnosis such as with a biopsy to check for cancer. A removal of a body part that is diseased is ablative surgery, such as an appendectomy. Restoring function to traumatized tissue is reconstructive surgery, such as with plastic surgery
Which statement, if made by an adolescent preparing for abdominal
surgery, would indicate to the nurse that the client requires
a)“I can have a hamburger and French fries as soon as I wake up.”
b)“I might be sick to my stomach and throw up after surgery.”
c)“When I can eat again, the best meal would be steak and orange juice.”
d)“The better I eat before surgery, the more likely I will heal.”
“I can have a hamburger and French fries as soon as I wake up.”
Oral fluid and food may be withheld until intestinal motility resumes.
A nurse teaches deep breathing exercises to a client scheduled for
surgery. In which perioperative phase would this action
d)Postanesthesia care unit (PACU)
Exercises and physical activities occurring in the preoperative phase include deep-breathing exercises, coughing, incentive spirometry, turning, leg exercises, and pneumatic compression stockings.
A client is in the preoperative area and states, "I am not sure
about having surgery." What is the nurse’s best
a)“I will tell the surgeon you changed your mind.”
b)“You really need to have this surgery done.”
c)“Why wouldn't you want the surgery so you can feel better?”
d)“Can you tell me what your feelings are about the surgery?”
“Can you tell me what your feelings are about the surgery?”
The client who is unsure about surgery needs their feelings explored to determine why the client doubts the decision. After exploring these feelings, the nurse can then contact the procedural physician and make this person aware of the client’s concerns. Asking the client why the client wouldn't want the surgery is phrased negatively and implies a judgment by the nurse on the client’s feelings; likewise, the client wouldn't be told to have the surgery done without allowing the client to express feelings.
A client has arrived to the postanesthesia care unit (PACU) and is
drowsy with a respiratory rate of 12 breaths per minute. What would be
an accurate interpretation by the nurse?
a)The client needs to have the neurological status fully evaluated.
b)This is an expected finding in the immediate postoperative period.
c)The procedural physician should be notified immediately of client findings.
d)The client should be returned to the operating room for further evaluation.
This is an expected finding in the immediate postoperative period.
Having drowsiness and a respiratory rate of 12 breaths/minute are normal findings in the immediate postoperative period. The client needs to be monitored to ensure that there is no deterioration in respiratory status, and the client awakens readily. As the anesthetics wear off, the client should return to a normal level of consciousness. The nurse would not need to notify the procedural physician or return the client to the operating room because this is not an emergent situation.
In the postoperative phase of abdominal surgery, the client reports
severe abdominal pain. In the second postoperative day, the client's
bowel sounds are absent. What does the nurse suspect?
A potential complication after surgery is paralytic ileus, a condition in which there is decreased bowel functioning.
As a circulating nurse caring for a 45-year-old man undergoing left
knee arthroscopic exploratory surgery, which task ensures that the
team is on the same page and will perform the procedure on the right
client and at the right site?
a)Procedural pause (time-out)
d)Operative site marking
Procedural pause (time-out)
The procedural pause (time-out) must be done prior to any procedure to ensure client safety and to verify the client identity, staff roles, and procedure being performed.
A client has been taking aspirin since his heart attack in 1997. The
client is at risk
Current medication use, especially use of medications that can affect coagulation status (warfarin, nonsteroidal anti-inflammatory drugs, aspirin) is important and should be reported to the surgeon.
The nurse has entered the room of a client who is postoperative day 1
and finds the client grimacing and guarding her incision. The client
refuses the nurse's offer of p.r.n. analgesia and, on discussion,
states that this refusal is motivated by his fear of becoming addicted
to pain medications. How should the nurse respond to the client's
a)"The hospital has excellent resources for dealing with any addiction that might result from the medications you take to control your pain."
b)"Actually, people who are not addicted to drugs before their surgery never develop a tolerance or addiction during their recovery."
c)"You should remind yourself that treating your pain is important now, and that dealing with any resulting dependency can come later."
d)"Research has shown that there is very little risk of clients becoming addicted to painkillers after they have surgery."
"Research has shown that there is very little risk of clients becoming addicted to painkillers after they have surgery."
There is little danger of addiction to pain medications used in the postoperative management of pain.
A 51-year-old woman with a diagnosis of breast cancer has been
scheduled for a unilateral mastectomy during which biopsies of her
axillary lymph nodes will be taken. Which categorizations of surgical
procedures are represented in this client's case? Select all that apply.
Curative surgery involves the removal of a diseased body part (e.g., breast tissue). Diagnostic surgery, such as biopsy of a lymph node, involves the removal of tissue for determining a diagnosis or the extent of disease involvement. This client is not receiving constructive, reconstructive, or palliative surgery at this time.
A nurse from the ambulatory surgical center is preparing discharge
instructions for a client who has had pelvic surgery. Which criterion
would the client need to demonstrate to ensure that she is ready for
a)Verbalize absence of pain
b)Exhibit no bleeding
d)Eat without nausea
Before discharge from an ambulatory surgical unit, the client should be able to void normally after a pelvic surgery. It is natural for the client to experience pain after surgery; however, the client should also have the comfort level to control it. The client may not be in a position to eliminate nausea and vomiting completely before discharge, but should suffer minimally from them. The client may have some bleeding or drainage, which should not be excessive at the time of discharge from an ambulatory surgical unit.
A nurse is reinforcing wound edges and applying a blinder to the
separated incisions of a client after a surgery. Which postoperative
complication has the client developed?
The nurse is taking care of a client with dehiscence. Hypoxemia develops when there is inadequate oxygenation of blood. Evisceration occurs when there is protrusion of abdominal organs through a separated wound. A client has shock when there is inadequate blood flow.
Which nursing action will best promote pain management for a client
in the postoperative phase?
a)Dimming the lights
b)Breathing into a paper bag
c)Providing food and medication
d)Performing relaxation techniques
The nurse is providing education for a postoperative client regarding
pain management. Which teaching point should the nurse
a)“If your pain is not relieved, ask your nurse to order a different medication.”
b)“You will receive pain medication by injection as long as you are n.p.o.”
c)“Be sure to ask for your p.r.n. medication when the pain becomes severe.”
d)“All postoperative pain control methods will be given by injection.”
Which surgical client does the nurse in the preoperative setting
anticipate having the greatest potential for surgical
a)50-year-old overweight client with controlled hypertension
b)6-month-old client who has just been introduced to solid food
c)40-year-old client with type 2 diabetes mellitus and a history of anxiety
d)76-year-old client with a history of renal failure and chronic bronchitis
A nurse is preparing an obese male client for gastric banding
surgery. What would the nurse be least likely to include in the
client's preoperative education plan?
a)appropriate procedure to care for the surgical site
b)techniques for effective deep breathing and turning
c)information about medications that will control nausea and pain
d)information about bowel preparation and skin preparation
A 2-year-old toddler just underwent a tonsillectomy and adenoidectomy
surgery. The postanesthesia care unit (PACU) nurse is checking on him.
What is the best course of action regarding the developmental care of
a)Give the child a new teddy bear.
b)Administer acetaminophen before the child wakes.
c)Allow the parents into the PACU before the child wakes.
d)Extubate the child as soon as possible.
A client is undergoing surgery for an appendectomy. This would be
considered what type of surgery?
A client in the immediate postoperative period begins to report
nausea and ultimately begins vomiting. The nausea and vomiting are
most likely related to:
a)movement of bowels during surgery.
b)inactivity and emotional upset.
c)severe pain at the operative site.
d)the effects of anesthetic agents.