A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team?

Potassium: 2.9 mEq/L

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best?

Do not have the client sign the consent and call the surgeon.

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best?

Demonstrate how to splint the incision.

A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate?

Be sure to wash the area where you will have surgery very thoroughly.

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met?

There is no redness, warmth, or drainage at the insertion site.

A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)?

Give the client a back rub.

A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer

Metoclopramide (Reglan)

A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best?

Give the client a bedpan or urinal to use.

A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best?

A rapid heart rate requires more effort by the heart.

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best?

Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met.

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best?

Consult the surgeon about a postoperative dietitian referral.

A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best?

Ask the client to describe current feelings.

A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client?

Raise the siderails on the bed.

A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate?

Explain the rationale for giving the medicine now.

A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best?

It helps prevent ulcers from the stress of the surgery.

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.)

Infection

Serious cardiac events

Thromboembolism

A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.)

Liver biopsy: diagnostic

Total shoulder replacement: restorative

A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.)

Metformin (Glucophage)

Phenytoin (Dilantin)
Pilocarpine hydrochloride (Isopto Carpine)

Warfarin (Coumadin)

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.)

Morbidly obese client

Client who underwent a prolonged surgical procedure

Client with severe heart failure

Wheelchair-bound client

A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.)

A malnourished client will have fragile skin.

Many drugs are bound to protein in the body.
Protein stores are needed for wound healing.
Weakness and fatigue are common in malnutrition.

A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.)

Decreased cardiac output
Decreased oxygenation

Frequent nocturia

A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.)

Allow the client to assume a position of comfort.
Allow the clients family to remain at the bedside.

Provide warm blankets or cool washcloths as desired.

Pull the curtains around the bed to provide privacy.

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.)

Check that consent is on the chart.

Ensure the client has an armband on.
Have the client help mark the surgical site. Allow the client to use the toilet before giving sedation.

The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best?

Get another piece of equipment.

The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority?

Consent for MIS procedure only

A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to break scrub when going to the console and sitting down. What action by the nurse is best?

Document the time the robotic portion of the procedure begins.

The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate?

Inform the surgeon that the sterile field has been broken.

A client is in stage 2 of general anesthesia. What action by the nurse is most important?

Being prepared to suction the airway

A client is having surgery. The circulating nurse notes the clients oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best?

Assess the clients end-tidal carbon dioxide level.

A nurse is monitoring a client after moderate sedation. The nurse documents the clients Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best?

Document findings and continue to monitor.

A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate?

Facilitate marking the site with the client and surgeon.

A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important

Place the client on a cardiac monitor and pulse oximeter.

A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client?

Allow the client to keep hearing aids in until anesthesia begins.

A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best?

Remain with the client.

A client in the operating room has developed malignant hyperthermia. The clients potassium is 6.5 mEq/L. What action by the nurse takes priority?

Administer 10 units of regular insulin.

A student nurse observing in the operating room notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? (Select all that apply.)

Dressing the surgical wound

Suctioning the surgical site

Suturing the surgical wound

The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.)

Ensuring the clients safety

Monitoring traffic in the room

The circulating nurse reviews the days schedule and notes clients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which clients does this include? (Select all that apply.)

75-year-old client scheduled for an elective procedure
Client who drinks a 6-pack of beer each day
Client with a serum creatinine of 3.8 mg/dL

Young male client with a RYR1 gene mutation

A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.)

Assessing distal circulation to the operative arm after positioning

Padding the clients shoulder and arm on the operating table

What actions by the circulating nurse are important to promote client comfort? (Select all that apply.)

Correct positioning
introducing ones self
Providing warmth

Remaining present

A client has arrived in the postoperative unit. What action by the circulating nurse takes priority?

Participating in hand-off report

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first?

Client with a respiratory rate of 6 breaths/min

A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate?

Assess other indicators of oxygenation.

Ten hours after surgery, a postoperative client reports that the anti-embolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best?

To prevent blood clots you need them a few more hours.

A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the clients bed. The clients blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best?

Lower the head of the bed.

A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important?

Auscultate lung sounds.

A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority?

Airway

A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer?

Flumazenil (Romazicon) 0.2 to 1 mg

A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort?

Assist the client into a position of comfort.

A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?

Wash your hands before touching the drain or dressing.

An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states She needs to get back to her old self! What response by the nurse is best?

Sometimes older people take longer to wake up.

A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?

Perform hand hygiene and apply gloves.

A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What should the nurse assess next?

Psychosocial status

A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN?

Securing the drains safety pin to the sheets

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.)

Phase I care may last for several days in some clients.

Phase II ends when the client is stable and awake.
Vital signs may be taken only once a day in phase III.

A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogagastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.)

Hemoglobin: 7.8 mg/dL

pH: 7.68
Potassium: 2.9 mEq/L

A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the clients plan of care to minimize the potential for this occurring? (Select all that apply.)

Allow family and friends to visit as the client desires.

Ask the client about coping techniques frequently used.
Instruct the nursing assistant to ensure the client is bathed.

Provide the client with uninterrupted periods of sleep.

A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.)

Check all over-the-counter medications for acetaminophen.
Do not take more pills each day than you are prescribed.

Eat a diet that is high in fiber and drink lots of water.

You shouldnt drive while you are taking this medication.

A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.)

Apply stimulation to the contralateral leg.
Assess the clients willingness to try meditation.

Elevate the clients operative leg and apply ice.
Reduce the noise level in the clients environment.

A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.)

Disposing of dressings properly

Performing proper hand hygiene
Removing and replacing wet dressings