Question 1

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?

Accepted Answer

The priority client problem related to a surgical drain is the potential for infection.An insertion site that is free of redness,warmth,and drainage indicates that goals for this client problem are being met.The other assessments are normal,but not related to the drain.

Question 2

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

Accepted Answer

All actions are appropriate for a preoperative client.However,for client safety,the nurse should raise the siderails on the bed because hydroxyzine can make the client sleepy.

Question 3

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?

Accepted Answer

Splinting an incision provides extra support during coughing and activity and helps decrease pain.If the client is otherwise comfortable,no more analgesia is required.Shallow breathing can lead to atelectasis and pneumonia.The client should know some pain is normal and expected after surgery,but that answer alone does not provide any interventions to help the client.

Question 4

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?

Accepted Answer

In order to give informed consent,the client needs sufficient information.Questions about potential complications should be answered by the surgeon.The nurse should notify the surgeon to come back and answer the client's questions before the client signs the consent form.The other actions are not appropriate.

Question 5

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?

Accepted Answer

The SCIP project contains core measures that are mandatory for all surgical clients and focuses on preventing infection,serious cardiac events,and venous thromboembolism.The managers should start by reviewing charts to see if the guidelines of this project were implemented.The other actions may be necessary too,but first the managers need to assess the situation.

Question 6

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?

Accepted Answer

Tachycardia increases the workload of the heart and requires more oxygen delivery to the myocardial tissues.This added strain is not needed on top of the physical and emotional stress of surgery.The other statements are not accurate.

Question 7

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

Accepted Answer

A back rub reduces anxiety and can be delegated to the UAP.Once teaching has been done,the UAP can remind the client to turn,but this is not related to relieving anxiety.Assessing anxiety and teaching are not within the scope of practice for the UAP.

Question 8

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

Accepted Answer

The entire proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap.Shaving,if absolutely necessary,should be done in the operative suite immediately before the operation begins,using sterile equipment.The client needs a full shower or bath (shower preferred).The client should wash the surgical site last; dirty water from shampooing will run over the cleansed site if the site is washed first.

Question 9

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?

Accepted Answer

Ulcer prophylaxis is common for clients undergoing long procedures or for whom high stress is likely.The nurse is not being truthful by saying all clients get this medication.If the nurse does not know the information,it is appropriate to find out,but this is a common medication for which the nurse should know the rationale prior to administering it.Simply stating that the physician prescribed the medication does not give the client any useful information.

Question 10

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.)

Accepted Answer

The SCIP project includes core measures to prevent infection,serious cardiac events,and thromboembolic events such as deep vein thrombosis.

Question 11

An older client is hospitalized after an operation.When assessing the client for postoperative infection,the nurse places priority on which assessment?

Accepted Answer

Older people have an age-related decrease in immune system functioning and may not show classic signs of infection such as increased white blood cell count,fever and chills,or obvious localized signs of infection.A change in behavior often signals an infection or onset of other illness in the older client.

Question 12

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?

Accepted Answer

The preoperative antibiotic must be given within 60 minutes of the surgical start time to ensure the proper amount is in the tissues when the incision is made.The nurse should explain the rationale to the client for this timing.The other options do not take this timing into consideration and do not give the client the information needed to be cooperative.

Question 13

A clinic nurse is teaching a client prior to surgery.The client does not seem to comprehend the teaching,forgets a lot of what is said,and asks the same questions again and again.What action by the nurse is best?

Accepted Answer

Anxiety can interfere with learning and cooperation.The nurse should assess the client for anxiety.The other actions are appropriate too,and can be included in the teaching plan,but effective teaching cannot occur if the client is highly anxious.

Question 14

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow.Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care?

Accepted Answer

The older adult has the most potentially complex discharge needs.With memory loss,the client may not be able to follow the prescribed home regimen.The client's physical abilities may be limited by chronic illness.This client has several safety needs that should be assessed.The other clients all have evidence of a support system and no known potential for serious safety issues.

Question 15

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

Accepted Answer

Although possibly uncomfortable or embarrassing for the client,the client should not be allowed out of bed after receiving sedation.The nurse should get the client a bedpan or urinal.The client may or may not need a urinary catheter.

Question 16

A preoperative nurse is assessing a client prior to surgery.Which information would be most important for the nurse to relay to the surgical team?

Accepted Answer

Some herbs and supplements can interact with medications,so this information needs to be reported as the priority.An allergy to bee and wasp stings should not affect the client during surgery.Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered.Lack of experience with surgery may increase anxiety and may require higher teaching needs,but is not the priority over client safety.

Question 17

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?

Accepted Answer

This client has signs of malnutrition,which can impact recovery from surgery.The nurse should consult the surgeon about prescribing a consultation with a dietitian in the postoperative period.The nurse should document the findings but needs to do more.Encouraging the client to eat more may be helpful,but the client needs a professional nutritional assessment so that the appropriate diet and supplements can be ordered.The client may or may not need Meals on Wheels after discharge.

Question 18

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

Accepted Answer

A potassium of 2.9 mEq/L is critically low and can affect cardiac and respiratory status.The nurse should communicate this laboratory value immediately.The creatinine is at the high end of normal,the hemoglobin is normal,and the sodium is only slightly low (normal low being 136 mEq/L),so these values do not need to be reported immediately.

Question 19

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 as a priority for this client?

Accepted Answer

Reglan increases gastric emptying,an important issue for this client who was eating just prior to the operation.The other drugs are appropriate for any surgical client.

Question 20

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?

Accepted Answer

The nurse needs to conduct further assessment of the client's anxiety.Asking open-ended questions about current feelings is an appropriate way to begin.The client may want a chaplain,but the nurse needs to do more for the client.Reassurance can be good,but false hope is not,and simply reassuring the client may not be helpful.Telling the client not to be anxious belittles the client's feelings.

Quiz 14: Care of Preoperative Patients