Question 1

A patient returns from surgery with a nasogastric tube and intermittent gastric suction to provide abdominal decompression.Which of the following are correct nursing activities for managing the equipment and drainage? Select all that apply.

Accepted Answer

Nonsterile procedure gloves are to protect the nurse and other patients against microorganisms that might be present in body fluids; wearing them is in observance of standard precautions.For patients with an NG tube,frequent oral care,including water-soluble lubricant for dry lips,is important.Sterile gloves are not needed for irrigating the NG tube because the nasal passages,esophagus,and stomach are not sterile.Sterile normal saline and a sterile syringe are used for irrigation,however.Sterile water is not used; saline compensates for electrolytes lost through NG drainage.

Question 2

The nurse admits a patient to the postoperative unit following gastric bypass surgery for weight loss.Based on the patient's history,the nurse determines that the priority nursing diagnosis for this patient is:

Accepted Answer

This patient is at increased risk for infection because of a history of obesity and incision into the bowel to perform the surgery; therefore,this is an appropriate diagnosis. Delayed Surgical Recovery would apply only if complications arose or there was an indication the patient was not recovering appropriately; it does not apply as a risk diagnosis.While the patient's obesity may result in chronic pain due to stress on joints,it is not the priority.Also,there are no data in the scenario to indicate chronic pain.There is no indication of excess bleeding or fluid loss in the question,so Risk for Deficient Fluid Volume would not be appropriate.

Question 3

The nurse is caring for a patient who had abdominal surgery 3 days ago and will be discharged home later today.The nurse will know that teaching is effective if the patient does which of the following? Select all that apply.

Accepted Answer

The nurse would know that patient teaching was effective if the patient verbalizes signs and symptoms of infection,can perform the ordered dressing change,and completes the regimen of ordered antibiotics.Nurses cannot teach a patient to be free of pain.Pain is subjective.The nurse can teach the patient strategies to assist with pain,but they may not remove the pain completely.

Question 4

The nurse is caring for a patient who is wearing antiembolism compression stockings.The patient repeatedly complains of discomfort caused by the stockings.What actions will the nurse take to improve comfort? Select all that apply.

Accepted Answer

Discomfort can be caused by stockings that are too small,so it is important to make sure the stockings are correctly sized.Rolls and wrinkles can cause pressure sores and skin damage,so it would be important to make sure the stockings are on smoothly.Compression stockings are designed to provide different amounts of pressure in different areas,so it is important to make sure the stockings are on straight and the heel is in the right place.In addition,having the heel and toe incorrectly placed would contribute to wrinkles and discomfort.Stockings should be removed daily to wash the feet and legs,and then clean stockings should be reapplied.Some space should be left between the toes in the stockings and the patient's toe,so the toes of the stockings should not be molded over the toes.

Question 5

The postoperative patient is admitted to the postanesthesia care unit (PACU)with an oral airway in place,an indwelling urinary catheter,IV fluid infusing via two different sites,and a Jackson-Pratt drain pinned to the gown near the wound dressing.What is the nurse's priority action after the patient is moved to the bed?

Accepted Answer

Based on the fact that an oral airway remains in place,it can be concluded that the patient's sedation level is high.Guarding the airway by turning the patient's head to drain secretions or possible emesis is the highest priority action to be performed by the nurse.Although assessing for drainage on the dressing is an important activity,it is not the first thing the nurse will do.Vital signs should be obtained,but that is not the first priority.Ensuring proper drainage from the urinary catheter is important,but is not the first priority.The only immediately life-threatening risk for this patient would be a compromised airway.

Question 6

The postoperative patient returned to the surgical nursing unit at 1:30 p.m.The evening shift nurse receives the report and begins working at 3:30 p.m.How often will the evening shift nurse take this patient's vital signs?

Accepted Answer

Vital signs would have been taken every 15 minutes for the first hour (1:30 to 2:30),then every 30 minutes for the next 2 hours (2:30 to 4:30).It is now 3:30,so the nurse will take vital signs immediately,again at 4:00,and again at 4:30,at which time the nurse can begin to take hourly vital signs if the patient's vital signs are within acceptable and stable range.Vital signs would have been taken every 15 minutes for the first hour (1:30 to 2:30),then every 30 minutes for the next 2 hours (2:30 to 4:30); therefore,"immediately and every 30 minutes for the next 2 hours" is incorrect (on that schedule,the nurse would be taking VS at 3:30,4:00,4:30,5:00,and 5:30).It is too soon to begin hourly vital signs.At this time,the patient should be assessed more often than every hour.

Question 7

The perioperative nurse maintains the safety of the patient during surgery with which of the following goals? Select all that apply.

Accepted Answer

Preventing infection is an important safety requirement of nursing care of the perioperative patient.Making sure the right patient has the right procedure is an important nursing concern when caring for the perioperative patient.Mistakes in surgery can have devastating long-term consequences and the nurse needs to do everything possible to prevent errors.Although signed consent is necessary,it is not done to maintain safety but to make sure the patient is able to make an informed decision.Keeping the family informed is important for holistic care,but is not necessarily a safety intervention.

Question 8

The preoperative nurse is preparing a patient for surgery.Identify the interventions the nurse will perform.Select all that apply.

Accepted Answer

Before being transported to the operating suite,the patient must remove all artificial body parts,such as dentures,artificial limbs,or contact lenses.Wigs,eyeglasses,makeup,and jewelry must also be removed.The nurse will also inform the patient's relatives where they may wait during the surgery.The surgical suite will be prepared by the surgical team.It is not necessary to have a living will prior to surgery.However,the nurse will ask the patient whether there is one when obtaining the nursing history.

Question 9

The nurse is caring for a patient with a Salem sump double lumen nasogastric (NG)tube to suction.The patient complains of nausea and has mild abdominal distention.What is the nurse's priority action?

Accepted Answer

The first action should be to check placement of the NG tube because it may have migrated out of the stomach into either the esophagus or the duodenum.The patient with a nasogastric tube should not require an antiemetic because the stomach should be emptied by suction; therefore,this is not the priority action.The nasogastric tube should not be replaced unless other actions are ineffective and the tube is no longer functioning properly.Irrigating the tube would be the second action to take,but placement must be checked before taking this step.

Question 10

The nurse admits a patient who is scheduled for surgery tomorrow morning.The nursing admission assessment indicates that the patient is mildly anxious about the procedure,does not drink alcohol or smoke,is married with two children,and is allergic to kiwi,avocados,and penicillin.The nurse identifies the priority nursing diagnosis for this patient as:

Accepted Answer

Risk for Latex Allergy Response is appropriate for patients who are allergic to bananas,avocados,kiwi,chestnuts,or poinsettia plants.This patient has two of these allergies,so this is a priority diagnosis.The patient is only mildly anxious,and there are no defining characteristics of Fear; therefore Fear would not be an appropriate diagnosis.Although the patient does have mild Anxiety,this is not the priority diagnosis for this patient.There is no indication that this patient will have,or currently has,Ineffective Airway Clearance.

Question 11

A patient had a colon resection for removal of a cancerous tumor.Postoperatively,on the surgical floor which of the following activities would the nurse perform for the purpose of decreasing the risk of postoperative complications? Select all that apply.

Accepted Answer

The nurse assists the patient to turn,breathe deeply,and cough every 2 hours to decrease the risk of postoperative atelectasis or pneumonia.The nurse assesses the wound drainage to monitor for signs of bleeding,infection,or wound complications.Vital signs are monitored to detect the potential for infection or hemorrhage,not to prevent them.The nurse may teach the patient about cancerous tumors; however,this intervention will not decrease the risk of postoperative complications.

Question 12

Identify the desired effects of general anesthesia.Select all that apply.

Accepted Answer

General anesthesia is used to control pain (analgesia),relax muscles,and promote amnesia.Anesthesia is not used for the purpose of obtaining a reduction in risk potential; however,surgical risk is influenced by the type of anesthesia used.

Question 13

Which of the following describes the Perioperative Nursing Data Set? Select all that apply.

Accepted Answer

The Perioperative Nursing Data Set (PNDS)is a standardized vocabulary specifically designed to describe the care of perioperative clients.The current edition was updated to include 20 new interventions,10 new outcomes (plus refining 10 existing outcomes for clarity),a new emphasis on the perioperative clinical workflow,recoding the PNDS to clearly express the perioperative plan of care (i.e.,assessment,diagnosis,implementation,evaluation,outcome),and replacing the PNDS nursing diagnosis codes with their original NANDA International nursing diagnosis codes.It was the first specialty language recognized by the ANA and is updated periodically to sustain validity and usefulness in the perioperative workplace.

Question 14

Surgeries are commonly classified by which of the following? Select all that apply.

Accepted Answer

Surgeries can be classified by body systems,purpose,level of urgency,and degree of seriousness (acuity).The length of surgery and organ involved are not used for classifying surgeries.

Question 15

In the emergency department (ED),the patient is diagnosed with a dislocated humerus.What type of anesthesia would the nurse anticipate will be used to repair the dislocation in the ED?

Accepted Answer

Conscious sedation would relax the muscles and can be administered with an analgesic to allow repair of the dislocation with rapid return to consciousness following the procedure.General anesthesia produces rapid unconsciousness and loss of sensation,but also depresses the patient's central nervous system (CNS)and relaxes the musculature.It produces more extensive effects than would be required for a procedure that will be performed in a few minutes.It also involves more risks than are justified in this case.An epidural anesthetic would not reduce pain or induce muscle relaxation as high up as the shoulder-if it did,it would also paralyze the muscles involved in breathing.A local anesthetic would not adequately relax muscles or anesthetize the shoulder joint.

Question 16

Which of the following members of the operative team use sterile technique during the surgical procedure? Select all that apply.

Accepted Answer

The anesthetist is a member of the clean team and remains outside the sterile field.Members of the sterile team include the surgeon,the scrub nurse,and the registered first nurse assistant.

Question 17

The intraoperative nurse observes the anesthesiologist administer general anesthesia,insert the endotracheal tube,and take control of the airway.The nurse understands that the next important nursing intervention for this patient is to:

Accepted Answer

The circulating nurse will position the patient to maintain the patient's airway,to allow vital signs to be monitored,to maintain the patient's comfort and safety,and to make the operative site accessible.The site is usually prepared after the patient is positioned because some sites are not visible until after positioning.The surgical site is not normally shaved,but if it is required it is usually done in preoperative holding.Only after the patient is positioned can the bony prominences be padded.

Quiz 39: Perioperative Care