Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 017 (edited file)—"Perioperative Nursing Care" 10/14/08, Page 1 of 9, 7 Figure(s), 0 Table(s), 4 Box

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17: Perioperative Nursing Care
PRACTICE QUESTIONS
1. A nurse is reviewing the laboratory results of a client scheduled for surgery. Which of these laboratory results would indicate to the nurse that the surgery might be postponed? 1. Sodium, 140 mEq/L 2. Hemoglobin, 9.2 g/dL 3. Platelets, 200,000/mm3 4. Serum creatinine, 0.9 mg/dL Answer: 2 Rationale: Routine screening tests include a complete blood cell count, serum electrolyte analysis, coagulation studies, and serum creatinine tests. The complete blood count includes the hemoglobin analysis. All these values are within normal range, except the hemoglobin. If a client has a low hemoglobin level, the surgery may be postponed. Test-Taking Strategy: Use the process of elimination. Recalling the normal values for serum sodium, hemoglobin, platelets, and creatinine will direct you to option 2. This is the only abnormal value. Review these normal laboratory values if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, p. 490. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1606. 2. A nurse is assisting in developing a plan of care for a client scheduled for surgery. The nurse would include which of the following activities in the nursing care plan for the client on the day of surgery? 1. Have the client void immediately before surgery. 2. Report immediately any slight increase in blood pressure or pulse. 3. Verify that the client has not eaten for the last 24 hours. 4. Avoid oral hygiene and rinsing with mouthwash. Answer: 1 Rationale: The nurse would assist the client to void immediately before surgery so that the bladder will be empty. A slight increase in blood pressure and pulse is common during the preoperative period and is generally the result of anxiety. The client usually has a restriction of food and fluids for 8 hours prior to surgery instead of 24 hours. Oral hygiene is allowed, but the client should not swallow any water. Test-Taking Strategy: Use the process of elimination and read each option carefully. Eliminate option 2 because of the words "immediately" and "slight." Eliminate option 3, knowing that the client should be NPO for 8 hours prior to surgery. There is no useful reason for option 4; in fact, oral hygiene may make the client feel more comfortable. Review general preoperative care if you had difficulty with this question.

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Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005), Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 1606, 1609. 3. Emergency surgery is scheduled for a client with a bowel obstruction. The licensed practical nurse (LPN) tells the registered nurse (RN) that he or she is unable to obtain informed consent from the client because the client has received narcotic analgesics and is very sedated. The LPN understands that which of the following is the appropriate action? 1. Performing the surgery without an informed consent 2. Calling the family and telling them that they must come to the hospital immediately to sign the informed consent 3. Obtaining a telephone consent from the family member and ensuring that the oral consent is witnessed by two persons 4. Having the client sign the consent form because this is an emergency situation Answer: 3 Rationale: Every effort must be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member’s oral consent. The two witnesses then sign the consent and document the name of the family member, noting that an oral consent was obtained. In emergencies, the client may be unable to sign and family members may not be available. In this type of a situation, the physician is legally permitted to perform surgery without consent. Consent is not informed if it is obtained from the client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. Test-Taking Strategy: Use the process of elimination. Note the key word, appropriate. Eliminate options 1 and 4 first because they are inappropriate. From the remaining options, select option 3 because it is legally acceptable to obtain telephone permission from a family member if two persons witness it. Review the issues related to informed consent if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 212. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 416. 4. A nurse is caring for a client scheduled for surgery. The client is concerned about the surgical procedure. To alleviate the client’s fears and misconceptions about surgery, the nurse should: 1. Provide explanations about the procedures involved in the planned surgery. 2. Explain all nursing care and possible discomfort that may result. 3. Tell the client that preoperative fear is normal. 4. Ask the client to discuss information known about the planned surgery.

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Answer: 4 Rationale: Explanations should begin with the information that the client knows. Option 3 is a block to communication. Options 1 and 2 may produce additional anxiety in the client. Test-Taking Strategy: Use the process of elimination. Remember always to focus on the client’s feelings first. This will direct you to option 4. Additionally, option 4 is the only option that addresses data collection, the first step of the nursing process. Review the psychosocial aspects related to the preoperative client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Caring Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1604. 5. A nurse is reinforcing instructions to a client regarding the use of the incentive spirometer. Which of the following client’s statements indicate that the client does not clearly understand the procedure? 1. “My lips should cover the mouthpiece completely.” 2. “I should inhale slowly to maintain a constant flow through the unit.” 3. “After maximum inspiration, I should hold my breath for 2 to 3 seconds, and then exhale slowly.” 4. “I can use the incentive spirometer in any position to achieve optimal lung expansion.” Answer: 4 Rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler’s or high-Fowler’s position. The mouthpiece should be covered completely while the client inhales slowly, with a constant flow through the unit. The client’s breath should be held for 2 to 3 seconds before exhaling slowly. Test-Taking Strategy: Use the process of elimination and note the key words, does not clearly understand. Remember that, for optimal lung expansion, the head should be elevated to decrease the pressure of the internal organs on the diaphragm and to increase the expansion of the diaphragm. If you had difficulty with this question, review the correct procedure related to the use of an incentive spirometer. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1614. 6. A nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (ASA, aspirin). The nurse reports the information to the physician and anticipates that the physician will prescribe which of the following? 1. Continue to take the aspirin as prescribed. 2. Decrease the dose of the aspirin to half of what is normally taken.

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3. Discontinue the aspirin immediately. 4. Discontinue the aspirin 48 hours before the scheduled surgery. Answer: 4 Rationale: Anticoagulants alter normal clotting factors and increase the risk of hemorrhage. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. Test-Taking Strategy: Use the process of elimination. Remembering that aspirin has properties that can alter normal clotting factors and that it should be discontinued at least 48 hours before surgery will assist in directing you to option 4. Review the medications that affect the preoperative client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1602. 7. A nurse preparing a client for surgery reviews the client’s medication record. The client is to be NPO after midnight. Which of the following medications, if noted on the client’s record, would the nurse question? 1. Cyclobenzaprine (Flexeril) 2. Fentanyl (Duragesic) 3. Allopurinol (Zyloprim) 4. Prednisone (Deltasone) Answer: 4 Rationale: Prednisone is a corticosteroid that can cause adrenal atrophy, which reduces the body’s ability to withstand stress. Before and during surgery, dosages may be temporarily increased. Cyclobenzaprine is a skeletal muscle relaxant. Fentanyl is an opioid analgesic. Allopurinol is an antigout medication. Test-Taking Strategy: Use the process of elimination and knowledge regarding the medications that may have special implications for the surgical client to answer this question. Review these medications if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1602. 8. A nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client’s blood pressure (BP) is 100/60 mm Hg, pulse is 90 beats per minute, and respiration rate is 20 breaths per minute. Based on these findings, which of the following nursing actions should be performed? 1. Cover the client with a warm blanket. 2. Shake gently to arouse.

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3. Continue to monitor the vital signs. 4. Call the surgeon immediately. Answer: 3 Rationale: A slightly lower than normal BP and an increased pulse rate are common after surgery. Warm blankets are applied to maintain the client’s body temperature. Level of consciousness can be determined by checking the client’s response to light touch and verbal stimuli, rather than by shaking the client. There is no reason to contact the surgeon. Test-Taking Strategy: Focus on the data in the question. Noting that the vital signs are within normal limits will direct you to option 3. Review expected postoperative findings if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 1631-1632. 9. A client arrives to the surgical nursing unit after surgery. The initial nursing action is to check the: 1. Dressing for bleeding 2. Tubes or drains for patency 3. Patency of the airway 4. Vital signs to compare with preoperative measurements Answer: 3 Rationale: If the airway is not patent, immediate measures must be taken for the survival of the client. After checking the client’s airway, the nurse would next check the client’s vital signs and then check the dressing and tubes and drains. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation. Airway patency is the first action to be taken. Options 1, 2, and 4 are all nursing actions that should be performed after a patent airway has been established. Review care to the postoperative client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1632. 10. A nurse is monitoring an adult client for postoperative complications. Which of the following would be most indicative of a potential postoperative complication that requires further observation? 1. Urinary output of 20 mL/hour 2. Temperature of 37.6° C (99.6° F) 3. Serous drainage on the surgical dressing 4. Blood pressure of 100/70 mm Hg

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Answer: 1 Rationale: Urine output is maintained at a minimum of at least 30 mL/hour for an adult. An output of less than 30 mL/hour for each of two consecutive hours should be reported to the physician. A temperature above 37.7° C (100° F) or below 36.1° C (97° F) and a falling systolic blood pressure under 90 mm Hg are to be reported. The client’s preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal. Test-Taking Strategy: Knowledge of the normal ranges for temperature, blood pressure, urinary output, and wound drainage is necessary to determine the correct option. Through the process of elimination, you can determine that the urinary output is the only observation that is not within the normal range. Review expected postoperative findings if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 1637-1640. 11. A nurse monitors the postoperative client frequently for the presence of secretions in the lungs, knowing that accumulated secretions can lead to: 1. Pulmonary edema 2. Pneumonia 3. Fluid imbalance 4. Carbon dioxide retention Answer: 2 Rationale: The most common postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and crackles. Pulmonary edema usually results from left-sided heart failure and can be caused by medications, fluid overload, and smoke inhalation. Carbon dioxide retention results from the inability to exhale carbon dioxide in conditions such as chronic obstructive pulmonary disease. Fluid imbalance can be a deficit or excess related to fluid loss or overload. Test-Taking Strategy: Use the process of elimination and note the key words, presence of secretions in the lungs. Focusing on the issue of the question, the postoperative client, will direct you to option 2. Options 1, 3, and 4 most commonly occur with other conditions. Review postoperative complications if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1636. 12. A nurse is caring for a postoperative client who has a drain inserted into the surgical wound. Which of the following nursing actions would be inappropriate in the care of the drain?

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1. Maintain aseptic technique when emptying. 2. Observe for bright red bloody drainage. 3. Check the drain for patency. 4. Secure the drain by curling or folding it and taping it firmly to body. Answer: 4 Rationale: Aseptic technique must be used when emptying the drainage container or changing the dressing to avoid contamination of the wound. Usually, drainage from the wound is pale, red, and watery. Active bleeding will be bright red in color. The drain should be checked for patency to provide an exit for the fluid or blood to promote healing. The nurse needs to ensure that drainage flows freely and that there are no kinks in the drains. Curling or folding the drain prevents the flow of the drainage. Test-Taking Strategy: Use the process of elimination and note the key word, inappropriate. Remember that the nurse needs to ensure that drainage flows freely from a drain. Review care of the surgical client with a drain if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, pp. 1640-1641. 13. A nurse checks the client’s surgical incision for signs of infection. Which of the following would be indicative of a potential infection? 1. The presence of serous drainage 2. Temperature of 98.8° F (37.1° C) 3. Client complains of feeling cold 4. The presence of purulent drainage Answer: 4 Rationale: Signs and symptoms of a wound infection include warm, red, and tender skin around the incision. The client may have fever and chills. Purulent material may exit from drains or from separated wound edges. It may be caused by poor aseptic technique and a contaminated wound before surgical exploration. It appears 3 to 6 days after surgery. Serous drainage is not indicative of a wound infection. A temperature of 98.8° F is not an abnormal finding in a postoperative client. Complaining of feeling cold is not indicative of an infection, although chills along with a fever are signs of an infection. Test-Taking Strategy: Use the process of elimination. Noting the word “purulent” in option 4 will direct you to this option. Review the signs of a wound infection if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed). St. Louis: Mosby, p. 414. Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1640.

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14. A nurse is checking a client’s surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which of the following is the initial action? 1. Clean the wound using aseptic technique, and apply a sterile dry dressing. 2. Apply a sterile dressing soaked with normal saline to the wound. 3. Leave the incision open to the air to assist in drying the drainage. 4. Cover the wound with a Betadine-soaked dressing. Answer: 2 Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. It usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and to avoid coughing or straining. The client should be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The physician needs to be notified. Test-Taking Strategy: Use the process of elimination. Eliminate option 3 first because this action would expose the open wound and underlying tissues to infection. Eliminate options 1 and 4 next. A dry dressing and a dressing soaked with Betadine will irritate the exposed body tissues. Review emergency care when dehiscence or evisceration occurs if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed). St. Louis: Mosby, pp. 419-420. 15. A nurse monitors a postoperative client for signs of complications. Which of the following would the nurse determine to be indicative of a sign of a potential complication? 1. Faint bowel sounds heard in all four quadrants 2. A negative Homan’s sign 3. A blood pressure of 120/70 mm Hg with a pulse of 90 beats per minute 4. Increasing restlessness Answer: 4 Rationale: Increasing restlessness noted in a client is a sign that requires continuous and close monitoring, because it could be a potential indication of a complication such as hemorrhage or shock. Faint bowel sounds heard in all four quadrants is a normal occurrence. A negative Homan’s sign is also normal. A positive Homan’s sign, however, may be indicative of thrombophlebitis. A blood pressure of 120/70 mm Hg with a pulse of 90 beats per minute is a relatively normal sign. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 2, and 3 because these are normal expected findings. Review the normal expected postoperative findings if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity

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Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 1636. <AQ>16. A client who had abdominal surgery complains of feeling as though “something gave way” in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Select all nursing interventions that the nurse would take. ____Place the client in a supine position without a pillow under the head. ____Instruct the client to remain quiet. ____Place a sterile saline dressing and ice packs over the wound. ____Contact the registered nurse. ____Prepare the client for wound closure. Answers: Instruct the client to remain quiet. Contact the surgeon. Prepare the client for wound closure. Rationale: Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the surgeon is notified immediately. The client is placed in a low-Fowler’s position, kept quiet, and instructed not to cough. Protruding organs are covered with a warm, sterile saline dressing. The treatment for evisceration is immediate wound closure under local or general anesthesia. Test-Taking Strategy: Focus on the information in the question to determine that the client is experiencing wound evisceration. Visualizing this occurrence will assist in determining that the client would not be placed supine and that ice packs would not be placed on the incision. Review this surgical complication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills References: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed) St. Louis: Mosby, pp. 419-420. Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medical-surgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 452.

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