Question 1

A client recovering from surgery is experiencing severe nausea and vomiting.Which action should the nurse take to assist this client?

Accepted Answer

Providing ice cubes for the client to suck can help with nausea and vomiting by providing a cooling sensation and keeping the client hydrated. Warm fluids and high-fat foods can worsen nausea, and lying down after eating can increase the risk of aspiration.

Question 2

The nurse is admitting a client from the post-anesthesia care unit (PACU).When should the nurse assess this client?

Accepted Answer

The nurse should assess the client on arrival to the care area, as they are being admitted from the PACU and may require immediate intervention or medication administration. After this initial assessment, the nurse can establish a plan for ongoing assessments based on the client's condition and the facility's policies. The other options may not provide adequate monitoring for a recently post-operative client.

Question 3

What is the focus of nursing care during the intraoperative phase?

Accepted Answer

During the intraoperative phase, the primary focus of nursing care is to ensure patient safety during the surgery.

Question 4

A patient scheduled for surgery does not have a signed consent form on the chart.The healthcare provider directs the nurse to have the client sign the consent before reviewing the type of surgery.What should the nurse do?

Accepted Answer

It is important for the patient to fully understand the nature and risks of the surgery before signing the consent form. Therefore, the nurse should inform the surgeon that the consent form will be provided after the surgery is discussed with the patient.

Question 5

The preoperative phase encompasses which period of time?

Accepted Answer

The preoperative phase refers to the period from the decision to proceed with surgical intervention until the patient is transferred into the operating suite. This phase includes all preparations for surgery, such as preoperative assessments and patient education.

Question 6

The intraoperative nurse prepares a client on the operative table.What will the nurse use to guide the position in which to place the client for the surgery?

Accepted Answer

The airway is a critical consideration when positioning a client for surgery to ensure that it remains open and accessible throughout the procedure.

Question 7

The nurse learns that a patient having surgery the next day takes an anticoagulant,a multivitamin,and vitamin E 1,500 IU.The anticoagulant was stopped 4 days ago as instructed; however,the patient continues to take the multivitamin and vitamin E.Why should the nurse contact the surgeon?

Accepted Answer

Vitamin E at high doses, such as 1,500 IU, can act as a blood thinner and increase the risk of bleeding, especially in a patient who was on anticoagulants. This could be a concern during surgery, hence the need to contact the surgeon.

Question 8

The family of a patient recovering from surgery asks the nurse why the patient is in the post-anesthesia care unit (PACU).How should the nurse respond to the family?

Accepted Answer

The post-anesthesia care unit (PACU) is where patients recover from the effects of anesthesia after surgery. Once they are stable, they will be transferred to the postsurgical unit for further care.

Question 9

What is the focus of nursing activities during the preoperative phase?

Accepted Answer

The focus of nursing activities during the preoperative phase is to prepare the patient mentally and physically for surgery. This includes assessing their readiness for surgery, explaining the procedure and what to expect, obtaining informed consent, ensuring they have fasted appropriately, administering preoperative medications as ordered, and preparing the surgical site. Admitting the patient to the surgical suite, setting up the sterile field, and performing the primary surgical scrub are responsibilities of the surgical team.

Question 10

The nurse notes that a client had a 500-mL blood loss during a surgical procedure.Which nursing diagnosis should the nurse identify as appropriate for the client?

Accepted Answer

The client had a significant blood loss during a surgical procedure, which puts them at risk for deficient fluid volume. The loss of 500 mL of blood puts the client at risk for hypovolemia, which can lead to decreased blood pressure, tachycardia, and decreased organ perfusion. Monitoring for symptoms of deficient fluid volume such as decreased urine output, dry mucous membranes, and skin turgor, and administering IV fluids as ordered are important nursing interventions for this diagnosis. The other options may not be as relevant in this scenario, as they do not directly address the potential consequences of the blood loss.

Question 11

A client is going to be in surgery for at least 6 hours.What should the nurse do to protect the client's skin during the surgery?

Accepted Answer

Padding bony prominences is a direct measure to protect the client's skin during prolonged surgery by reducing pressure and preventing skin breakdown and pressure ulcers. Repositioning the client every 2 hours and massaging the lower extremities are not feasible during surgery due to the nature of surgical procedures and the need for sterility. Sequential compression devices are used to prevent deep vein thrombosis, not specifically for skin protection.

Question 12

Which is the most appropriate nursing goal for a 2-year-old who is to have a tonsillectomy?

Accepted Answer

At 2 years old, a child is likely to experience separation anxiety, especially in a hospital setting. Minimizing this anxiety is a key goal for a child of this age undergoing surgery.

Question 13

Which type of surgery will a patient have if the purpose is removal of tissue to relieve pain?

Accepted Answer

Palliative surgery is performed to relieve symptoms or pain without curing the disease, often used in the context of serious illnesses to improve the patient's quality of life.

Question 14

A patient wearing knee-high antiembolism stockings is to have a sequential compression device (SCD)applied while on the postoperative unit.When applying the SCD,what should the nurse do?

Accepted Answer

The SCD can be applied over the knee-high antiembolism stockings to provide additional protection against deep vein thrombosis. It is not necessary to remove the stockings or replace them with thigh-high stockings. It is not necessary to notify the surgeon about the antiembolism stockings unless there are specific concerns related to the patient's condition or treatment plan.

Question 15

A 2-year-old child is scheduled for a tonsillectomy.What should the nurse do when planning this client's plan of care?

Accepted Answer

Including the parents or caregivers in the plan of care is essential, especially for a 2-year-old child. The parents/caregivers can provide valuable information about the child's health status, preferences, and any special needs. They can also help in providing emotional support to the child, which is crucial during the recovery phase. The other options are not appropriate as explaining the procedure to the child may cause undue anxiety and stress, telling the child that she can have her favorite foods may contradict the instructions given by the healthcare provider, and preparing the child for discharge as soon as she is alert might not be the best decision considering the child's age and the need for observation post-surgery.

Question 16

The nurse has a prescription to give a series of medications on an "on call" basis.When should the nurse expect to provide these medications?

Accepted Answer

The prescription for "on call" medications means that the nurse should be prepared to give these medications when they are needed, which will be at the discretion of the OR staff. The nurse should be available and ready to provide these medications whenever they are requested by the staff.

Question 17

The patient tells the nurse,"I'm so nervous.I want to be knocked out for the surgery so that I don't know what is going on." When the nurse communicates with the surgeon and anesthetist,which type of surgery should the nurse report that the patient desires?

Accepted Answer

The patient desires to be "knocked out" and not know what is going on, which indicates the desire for general anesthesia. Conscious sedation would allow the patient to be aware of what is going on and local or regional anesthesia would only numb a specific area and not provide the desired level of unconsciousness.

Question 18

A patient has chronic confusion secondary to dementia and is unable to sign an informed consent for surgery.What should be done in this situation?

Accepted Answer

In this situation, a family member or legally authorized representative should be asked to sign the informed consent on behalf of the patient. It is important to ensure that the person signing the consent understands the risks and benefits of the procedure and is authorized to make decisions on behalf of the patient. A healthcare provider cannot sign the informed consent for the patient, as it would not be a true informed consent.

Question 19

A patient scheduled for hip surgery takes an anticoagulant,a multivitamin,and vitamin E 1,500 IU every day.The patient stopped taking the anticoagulant 4 days ago as instructed by the surgeon,but has continued to take the multivitamin and vitamin E.Which is a potential problem for this patient?

Accepted Answer

The patient's continued use of vitamin E, which is known to increase bleeding risk, can potentially lead to bleeding complications during or after surgery. It is important to always inform healthcare providers about all supplements and medications being taken, as they can have adverse effects on surgery and recovery.

Question 20

The nurse notes that a client's surgical wound is healing slowly.What should the nurse suggest to improve this client's tissue integrity?

Accepted Answer

Increasing protein intake is important for tissue repair and healing. It provides the body with the necessary amino acids to build and repair tissues. Encouraging bedrest or providing high-fat foods would not necessarily improve tissue integrity. Reminding the client to avoid taking a multivitamin may not be relevant unless the client has a specific vitamin deficiency that is contributing to the slow healing.

Quiz 40: Perioperative Nursing