Question 1

The nurse is caring for a male patient who will soon have open heart surgery. The patient's chest is covered with thick hair so the surgical technician comes in to shave the patient's skin near the operative site. Which action by the technician requires intervention by the nurse to correct the technique?

Accepted Answer

Disposable electric trimmers should be used to remove excess hair from operative
sites. Antibacterial soap is commonly used to clean the skin before surgical procedures. Only the hair around the surgical site is removed. A straight razor should never be used because small nicks in the skin can occur, increasing infection risk.

Question 2

After general anesthesia is administered, the patient is carefully placed in the prone position. What is the primary consideration of the nursing staff as the patient is positioned?

Accepted Answer

Ensuring that the patient's respiratory status is not compromised is the priority of all staff during repositioning after general anesthesia has been administered. Positioning and protection of eyes is important but less than protection of the endotracheal tube patency.

Question 3

The nurse is walking a postoperative patient in the hallway when she notices a large red stain of fresh blood on the patient's gown over the abdominal incision. The patient states, "I felt something just ripped open." What is the priority action of the nurse?

Accepted Answer

The large red blood stain over the incision and feeling of ripping open most likely indicates that the patient's wound has dehisced or eviscerated. The nurse should immediately lower the patient to the floor to reduce tension on the wound. Patient modesty and privacy should be maintained, so the incision should be assessed once the patient is transported back to his room. Checking the patient's vital signs and pulse oximetry can be performed once the patient has been lowered to the floor.

Question 4

Which action by the nurse best demonstrates accountability in the operating room?

Accepted Answer

Accountability is accomplished by ensuring that proper precautions are taken to prevent errors from happening. The nurse can prevent wrong-site surgery by making sure that the surgical site is clearly marked and visible after the draping is completed. The surgeon could inadvertently operate on the incorrect site if the markings are covered by the surgical drapes. The other actions of the nurse are appropriate but do not demonstrate accountability and error prevention.

Question 5

The nurse is caring for a patient who is headed to the operating room for abdominal surgery. Which goal is appropriate for the nursing diagnosis risk for Perioperative positioning injury?

Accepted Answer

Numbness and tingling of extremities may be indicative of injury following improper positioning for surgery. The other goals do not relate to positioning injury but relate to nursing diagnoses of Fluid balance and Nausea.

Question 6

The nurse is caring for a patient who is recovering from chest surgery. Which action by the patient indicates that additional teaching is needed about how to use the ordered incentive spirometer correctly?

Accepted Answer

The patient must take in a deep breath while holding the spirometer to the mouth so that the device can indicate how much air is being inhaled into the lungs. The patient should use the spirometer at least 10 times every hour while awake, seal the lips closely around the mouthpiece, and rest for a few seconds between breaths.

Question 7

The nurse is caring for a postoperative patient who is very sleepy following general anesthesia and administration of pain medication. The nurse notes that the patient is making snoring sounds and his pulse oximetry has dropped to 88%. What is the best action of the nurse?

Accepted Answer

The snoring sounds made by the patient and low oximetry levels indicate that the patient's airway is partially occluded due to the effects of anesthesia and pain medication. An oral airway should be inserted and oxygen administered to maintain the airway and oxygenation. Reintubation should be performed if the oral airway alone does not maintain the airway and improve oxygenation. Removing the pillow from the head of the patient's bed or elevating the head of the patient's bed will not be sufficient to open the patient's airway.

Question 8

The nurse is caring for a patient with advanced colon cancer. The patient is to have surgery to relieve a bowel obstruction that has been causing unrelenting vomiting and abdominal pain. What type of surgery will this patient undergo?

Accepted Answer

Palliative surgery is performed to alleviate distressing symptoms such as unrelenting pain, nausea, and vomiting. Palliative surgery will not attempt to cure the underlying disease process but will make the patient more comfortable.

Question 9

The nurse is caring for a postoperative patient who has a history of COPD. What is the priority nursing diagnosis for this patient?

Accepted Answer

Ineffective airway clearance is the priority diagnosis for the COPD patient undergoing surgery because the patient is at high risk for bronchoconstriction, increased mucus, and ineffective cough, which may easily become worse after the patient has received general anesthesia. The other nursing diagnoses are applicable to the patient but are not as high priority.

Question 10

The nurse is obtaining preoperative information for a patient who will be having emergency surgery shortly for a ruptured appendix. Which information is crucial for the nurse to assess? (Select all that apply.)

Accepted Answer

Priority assessment must be completed prior to emergency surgery, including use of medications, alcohol, tobacco, or recreational drugs because these may interact with anesthesia medications. Allergies must be identified to prevent reactions in the operating room. Special precautions may be taken if the patient is pregnant, so this must also be determined preoperatively. Asking the patient about vaccinations or insurance coverage is not a priority prior to surgery.

Question 11

The nurse is caring for a patient who requires emergency surgery for injuries sustained in a motor vehicle accident. The patient was on his way back to work after having lunch with colleagues when the accident happened. What is the highest priority nursing diagnosis for this patient?

Accepted Answer

Risk for aspiration is the highest priority because the patient has not been NPO and his stomach is filled with food after lunching with his colleagues. The patient may easily aspirate stomach contents into the airway when general anesthesia is administered, so precautions must be taken to prevent this from happening. The other nursing diagnoses certainly apply but are not as important as risk for aspiration.

Question 12

The nurse is caring for a patient who is about to have surgery. Which intervention will be included in the patient's care to meet the goals for Risk for perioperative positioning injury r/t immobilization during surgical procedure?

Accepted Answer

Risk for perioperative positioning injury is addressed by ensuring that the patient's skin and bony prominences are well padded during the surgery. In addition, hyperextension of extremities may lead to joint damage, so this should be avoided as well. The other interventions are appropriate for perioperative care but do not relate directly to the nursing diagnosis of positioning injury potential.

Question 13

The nurse is caring for a preoperative patient who has just received sedation prior to general anesthesia in the OR. What is the priority action of the nurse?

Accepted Answer

Safety of the preoperative patient is a priority after sedation has been administered. Raising the side rails of the stretcher will help prevent the patient from falling. Turning off the lights is nice but is not a priority. Marking the surgical site and signing the consent form must be performed prior to administration of sedation.

Question 14

The nurse is caring for a patient who will be having surgery. The patient has just signed the consent form for the operation. What does the patient's signature indicate?

Accepted Answer

The patient's signature on the consent form indicates that the patient gives permission for the surgery to be performed. It does not indicate that the patient agrees with the physician's diagnosis, agrees to pay for costs not covered by insurance, or has been informed of all the possible treatment options.

Question 15

The nurse is assigned to care for several patients on the surgical unit. Which patient need will the nurse address first?

Accepted Answer

Urinary retention is common after removal of urinary catheters and must be addressed promptly. The nurse should address the patient with urinary retention first because it is the highest priority. The other patients may wait until later.

Question 16

The nurse is caring for a postoperative patient on his first day after surgery. The nurse informs the patient that the plan is to sit in the chair and ambulate in the hallway. The patient states that he is in pain and he has no intention of getting out of bed. What is the nurse's best response?

Accepted Answer

The nurse should teach the patient why it is important to ambulate after surgery to prevent postoperative deep vein thrombosis (DVT) formation. Simply telling the patient that the physician ordered ambulation is not sufficient. Allowing the patient to stay in bed will increase the risk of DVT.

Question 17

The nurse is caring for a patient who has a family history of reactions to general anesthesia. Which medication will the anesthesiologist have ready as a precautionary measure before the patient's surgery is started?

Accepted Answer

Malignant hyperthermia is a dangerous anesthesia reaction caused by a genetic defect that may be passed down via family history. Knowing this, the anesthesiologist should have Dantrium ready as a precaution because it is a mainstay of treatment for malignant hyperthermia.

Question 18

The nurse will be caring for a patient who has just arrived on the medical-surgical unit following surgical repair of his fractured right ankle. Which is the priority action of the nurse when the patient arrives on the unit?

Accepted Answer

Checking pulse oximetry and vital signs is the priority action when the patient first arrives on the medical-surgical unit from the postoperative area. The other actions can wait until the vital signs have been obtained.

Question 19

The nurse is caring for a patient who has just been brought to the postoperative unit following major surgery. The patient has many tubes and monitors in place. Which will the nurse assess first?

Accepted Answer

Airway maintenance and protection is the highest priority for this patient, so the nurse should assess the endotracheal tube first to ensure that it is patent and positioned correctly. The other tubes may be assessed afterward.

Question 20

The nurse is caring for a postoperative patient who is recovering from abdominal surgery. The nurse notes that the patient's breath sounds are clear but diminished, shallow, and slightly labored. The patient's pulse oximetry is 96% on room air. What is the priority action of the nurse?

Accepted Answer

The assessment findings indicate that the patient most likely has atelectasis, so the nurse should ensure that the patient is using the incentive spirometer 10 times every hour to facilitate expansion and reinflation of alveoli. Administering prescribed pain medication is not the priority and may further suppress the patient's respiratory drive. The patient's pulse oximetry is 96% on room air so supplemental oxygen is not needed. A chest x-ray may be ordered if the patient's condition worsens or does not improve with regular spirometer use.

Quiz 37: Perioperative Nursing Care