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Flashcards in Care of Surgical Patients Deck (47)
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1

The nurse is caring for a surgical patient, when the family member asks what perioperative nursing means. How should the nurse respond?
a. Perioperative nursing occurs in preadmission testing.
b. Perioperative nursing occurs primarily in the postanesthesia care unit.
c. Perioperative nursing includes activities before, during, and after surgery.
d. Perioperative nursing includes activities only during the surgical procedure.

c. Perioperative nursing incudes activities before, during, and after surgery.

Rationale:

Perioperative nursing care occurs before, during, and after surgery. Preadmission testing occurs before surgery and is considered preoperative. Nursing care provided during the surgical procedure is considered intraoperative, and in the postanesthesia care unit, it is considered postoperative. All of these are parts of the perioperative phase, but each individual phase does not explain the term completely.

2

The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patient’s laboratory tests and allergies and prepares the patient for surgery. In which perioperative nursing phase is the nurse working?
a. Perioperative
b. Preoperative
c. Intraoperative
d. Postoperative

b. Preoperative

Rationale:

Reviewing the patient’s laboratory tests and allergies is done before surgery in the preoperative phase. Perioperative means before, during, and after surgery. Intraoperative means during the surgical procedure in the operating suite; postoperative means after the surgery and could occur in the postanesthesia care unit, in the ambulatory surgical area, or on the hospital unit.

3

The nurse is caring for a patient in the postanesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. How will the nurse classify this procedure?
a. Major
b. Urgent
c. Elective
d. Emergency

d. Emergency

Rationale:

An emergency procedure must be done immediately to save a life or preserve the function of a body part. An example would be repair of a perforated appendix, repair of a traumatic amputation, or control of internal hemorrhaging. An urgent procedure is necessary for a patient’s health and often prevents additional problems from developing. An example would be excision of a cancerous tumor, removal of a gallbladder for stones, or vascular repair for an obstructed artery. An elective procedure is performed on the basis of the patient’s choice; it is not essential and is not always necessary for health. An example would be a bunionectomy, plastic surgery, or hernia reconstruction. A major procedure involves extensive reconstruction or alteration in body parts; it poses great risks to well-being. An example would be a coronary artery bypass or colon resection.

4

The nurse is caring for a patient in preadmission testing. The patient has been assigned a physical status classification by the American Society of Anesthesiologists of ASA III. Which assessment will support this classification?
a. Normal, healthy patient
b. Denial of any major illnesses or conditions
c. Poorly controlled hypertension with implanted pacemaker
d. Moribund patient not expected to survive without the operation

c. Poorly controlled hypertension with implanted pacemaker

Rationale:

An ASA III rating is a patient with a severe systemic disease, such as poorly controlled hypertension with an implanted pacemaker. ASA I is a normal healthy patient with no major illnesses or conditions. ASA II is a patient with mild systemic disease. ASA IV is a patient with severe systemic disease that is a constant threat to life. ASA V is a moribund patient who is not expected to survive without the operation and includes patients with ruptured abdominal/thoracic aneurysm or massive trauma.

5

The patient has presented to the ambulatory surgery center to have a colonoscopy. The patient is scheduled to receive moderate sedation (conscious sedation) during the procedure. How will the nurse interpret this information?
a. The procedure results in loss of sensation in an area of the body.
b. The procedure requires a depressed level of consciousness.
c. The procedure will be performed on an outpatient basis.
d. The procedure necessitates the patient to be immobile.

b. The procedure requires a depressed level of consciousness.

Rationale:

Moderate sedation (conscious sedation) is used routinely for procedures that do not require complete anesthesia but rather a depressed level of consciousness. Not all patients who are treated on an outpatient basis receive moderate sedation. Regional anesthesia such as local anesthesia provides loss of sensation in an area of the body. General anesthesia is used for patients who need to be immobile and to not remember the surgical procedure.

6

The nurse is caring for a patient in the postanesthesia care unit who has undergone a left total knee arthroplasty. The anesthesia provider has indicated that the patient received a left femoral peripheral nerve block. Which assessment will be an expected finding for this patient?
a. Sensation decreased in the left leg
b. Patient report of pain in the left foot
c. Pulse decreased at the left posterior tibia
d. Left toes cool to touch and slightly cyanotic

a. Sensation decreased in the left leg

Rationale:

Induction of regional anesthesia results in loss of sensation in an area of the body—in this case, the left leg. The peripheral nerve block influences the portions of sensory pathways that are anesthetized in the targeted area of the body. Decreased pulse, toes cool to touch, and cyanosis are indications of decreased blood flow and are not expected findings. Reports of pain in the left foot may indicate that the block is not working or is subsiding and is not an expected finding in the immediate postoperative period.

7

The nurse is preparing a patient for surgery. Which goal is a priority for assessing the patient before surgery?
a. Plan for care after the procedure.
b. Establish a patient’s baseline of normal function.
c. Educate the patient and family about the procedure.
d. Gather appropriate equipment for the patient’s needs.

b. Establish a patient’s baseline of normal function.

Rationale:

The goal of the preoperative assessment is to identify a patient’s normal preoperative function and the presence of any risks to recognize, prevent, and minimize possible postoperative complications. Gathering appropriate equipment, planning care, and educating the patient and family are all important interventions that must be provided for the surgical patient; they are part of the nursing process but are not the priority reason/goal for completing an assessment of the surgical patient.

8

The nurse is completing a medication history for the surgical patient in preadmission testing. Which medication should the nurse instruct the patient to hold (discontinue) in preparation for surgery according to protocol?
a. Warfarin
b. Vitamin C
c. Prednisone
d. Acetaminophen

a. Warfarin

Rationale:

Medications such as warfarin or aspirin alter normal clotting factors and thus increase the risk of hemorrhaging. Discontinue at least 48 hours before surgery. Acetaminophen is a pain reliever that has no special implications for surgery. Vitamin C actually assists in wound healing and has no special implications for surgery. Prednisone is a corticosteroid, and dosages are often temporarily increased rather than held.

9

The nurse is prescreening a surgical patient in the preadmission testing unit. The medication history indicates that the patient is currently taking an anticoagulant. Which action should the nurse take when consulting with the health care provider?
a. Ask for a radiological examination of the chest.
b. Ask for an international normalized ratio (INR).
c. Ask for a blood urea nitrogen (BUN).
d. Ask for a serum sodium (Na).

b. Ask for an international normalized ratio (INR).

Rationale:

INR, PT (prothrombin time), APTT (activated partial thromboplastin time), and platelet counts reveal the clotting ability of the blood. Anticoagulants can be utilized for different conditions, but its action is to increase the time it takes for the blood to clot. This action can put the surgical patient at risk for bleeding tendencies. Typically, if at all possible, this medication is held several days before a surgical procedure to decrease this risk. Chest x-ray, BUN, and Na are diagnostic screening tools for surgery but are not specific to anticoagulants.

10

The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Which priority goal is the nurse trying to achieve?
a. Manage pain
b. Prevent atelectasis
c. Reduce healing time
d. Decrease thrombus formation

b. Prevent atelectasis

Rationale:

After surgery, patients may have reduced lung volume and may require greater effort to cough and deep breathe; inadequate lung expansion can lead to atelectasis and pneumonia. Purposely utilizing diaphragmatic breathing can decrease this risk. During general anesthesia, the lungs are not fully inflated during surgery and the cough reflex is suppressed, so mucus collects within airway passages. Diaphragmatic breathing does not manage pain; in some cases, if splinting and pain medications are not given, it can cause pain. Diaphragmatic breathing does not reduce healing time or decrease thrombus formation. Better, more effective interventions are available for these situations.

11

The nurse is caring for a postoperative patient on the medical-surgical floor. Which activity will the nurse encourage to prevent venous stasis and the formation of thrombus?
a. Diaphragmatic breathing
b. Incentive spirometry
c. Leg exercises
d. Coughing

c. Leg exercises

Rationale:

After general anesthesia, circulation slows, and when the rate of blood slows, a greater tendency for clot formation is noted. Immobilization results in decreased muscular contractions in the lower extremities; these promote venous stasis. Coughing, diaphragmatic breathing, and incentive spirometry are utilized to decrease atelectasis and pneumonia.

12

The nurse is caring for a preoperative patient. The nurse teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurse’s best next step?
a. Encourage the patient to practice at a later date.
b. Assess for the presence of anxiety, pain, or fatigue.
c. Ask the patient why exercises are not being done.
d. Evaluate the educational methods used to educate the patient.

b. Assess for the presence of anxiety, pain, or fatigue.

Rationale:

If the patient is unable to perform leg exercises, the nurse should look for circumstances that may be impacting the patient’s ability to learn. In this case, the patient can be anticipating the upcoming surgery and may be experiencing anxiety. The patient may also be in pain or may be fatigued; both of these can affect the ability to learn. Evaluation of educational methods may be needed, but in this case, principles and demonstrations are being utilized. Asking anyone “why” can cause defensiveness and may not help in attaining the answer. The nurse is aware that the patient is unable to do the exercises. Moving forward without ascertaining that learning has occurred will not help the patient in meeting goals.

13

Which nursing assessment will indicate the patient is performing diaphragmatic breathing correctly?
a. Hands placed on the border of the rib cage with fingers extended will touch as the chest wall contracts.
b. Hands placed on the chest wall with fingers extended will separate as the chest wall contracts.
c. The patient will feel upward movement of the diaphragm during inspiration.
d. The patient will feel downward movement of the diaphragm during expiration.

a. Hands placed on the border of the rib cage with fingers extended will touch as the chest wall contracts.

Rationale:

Positioning the hands along the borders of the rib cage allows the patient to feel movement of the chest and abdomen as the diaphragm descends and the lungs expand. As the patient takes a deep breath and slowly exhales, the middle fingers will touch while the chest wall contracts. The fingers will separate as the chest wall expands. The patient will feel normal downward movement of the diaphragm during inspiration and normal upward movement during expiration.

14

The nurse is caring for a postoperative patient with an abdominal incision. The nurse provides a pillow to use during coughing. Which activity is the nurse promoting?
a. Pain relief
b. Splinting
c. Distraction
d. Anxiety reduction

b. Splinting

Rationale:

Deep breathing and coughing exercises place additional stress on the suture line and cause discomfort. Splinting incisions with hands and a pillow provides firm support and reduces incisional pull. Providing a pillow during coughing does not provide distraction or reduce anxiety. Providing a pillow does not provide pain relief. Coughing can increase anxiety because it can cause pain. Analgesics provide pain relief.

15

The nurse is encouraging a reluctant postoperative patient to deep breathe and cough. Which explanation can the nurse provide that may encourage the patient to comply?
a. “If you don’t deep breathe and cough, you will get pneumonia.”
b. “You will need to cough only a few times during this shift.”
c. “Let’s try clearing the throat because that will work just as well.”
d. “Deep breathing and coughing will clear out the anesthesia.”

d. “Deep breathing and coughing will clear out the anesthesia.”

Rationale:

Deep breathing and coughing expel retained anesthetic gases and facilitate a patient’s return to consciousness. Although it is correct that a patient may experience atelectasis and pneumonia if deep breathing and coughing are not performed, the way this is worded sounds threatening and could be communicated in a more therapeutic manner. Deep breathing and coughing are encouraged every 2 hours while the patient is awake. Just clearing the throat does not remove mucus from deeper airways.

16

The nurse and the nursing assistive personnel are assisting a postoperative patient to turn in bed. To assist in minimizing discomfort, which instruction should the nurse provide to the patient?
a. “Close your eyes and think about something pleasant.”
b. “Hold your breath and count to three.”
c. “Grab my shoulders with your hands.”
d. “Place your hand over your incision.”

d. “Place your hand over your incision.”

Rationale:

Instruct the patient to place the right hand over the incisional area to splint it, providing support and minimizing pulling during turning. Closing one’s eyes, holding one’s breath, and holding the nurse’s shoulders do not help support the incision during a turn.

17

The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide first?
a. Perform hand hygiene.
b. Explain use of the mouthpiece.
c. Instruct the patient to inhale slowly.
d. Place in the reverse Trendelenburg position.

a. Perform hand hygiene.

Rationale:

Performing hand hygiene reduces microorganisms and should be performed first. Placing the patient in the correct position such as high Fowler’s for the typical postoperative patient or reverse Trendelenburg for the bariatric patient would be the next step in the process. Demonstration of use of the mouthpiece followed by the instruction to inhale slowly would be the last step in this scenario.

18

The nurse and the nursing assistive personnel (NAP) are caring for a group of postoperative patients who need turning, coughing, deep breathing, incentive spirometer, and leg exercises. Which task will the nurse assign to the NAP?
a. Teach postoperative exercises.
b. Do nothing associated with postoperative exercises.
c. Document in the medical record when exercises are completed.
d. Inform the nurse if the patient is unwilling to perform exercises.

d. Inform the nurse if the patient is unwilling to perform exercises.


Rationale:

The nurse can delegate to the NAP to encourage patients to practice postoperative exercises regularly after instruction and to inform the nurse if the patient is unwilling to perform these exercises. The skills of demonstrating and teaching postoperative exercises and documenting are not within the scope of practice for the nursing assistant. Doing nothing is not appropriate.

19

The nurse is providing preoperative teaching for the ambulatory surgery patient who will be having a cyst removed from the right arm. Which will be the best explanation for diet progression after surgery?
a. “Start with clear liquids, soup, and crackers. Advance to a normal diet as tolerated.”
b. “Stay with ice chips for several hours. After that, you can have whatever you want.”
c. “Stay on clear liquids for 24 hours. Then you can progress to a normal diet.”
d. “Start with clear liquids for 2 hours and then full liquids for 2 hours. Then progress to a normal diet.”

a. “Start with clear liquids, soup, and crackers. Advance to a normal diet as tolerated.”

Rationale:

Patients usually receive a normal diet the first evening after surgery unless they have undergone surgery on GI structures. Implement diet intake while judging the patient’s response. For example, provide clear liquids such as water, apple juice, broth, or tea after nausea subsides. If the patient tolerates liquids without nausea, advance the diet as ordered. There is no need to stay on ice chips for several hours or clear liquids for 24 hours after this procedure. Putting a time frame on the progression is too prescriptive. Progression should be adjusted for the patient’s needs.

20

The nurse explains the pain relief measures available after surgery during preoperative teaching for a surgical patient. Which comment from the patient indicates the need for additional education on this topic?
a. “I will be asked to rate my pain on a pain scale.”
b. “I will have minimal pain because of the anesthesia.”
c. “I will take the pain medication as the provider prescribes it.”
d. “I will take my pain medications before doing postoperative exercises.”

b. “I will have minimal pain because of the anesthesia.”

Rationale:

Anesthesia will be provided during the procedure itself, and the patient should not experience pain during the procedure; however, this will not minimize the pain after surgery. Pain management is utilized after the postoperative phase. Inform the patient of interventions available for pain relief, including medication, relaxation, and distraction. The patient needs to know and understand how to take the medications that the health care provider will prescribe postoperatively. During the stay in the facility, the level of pain is frequently assessed by the nurses. Coordinating pain medication with postoperative exercises helps to minimize discomfort and allows the exercises to be more effective.

21

The nurse is making a preoperative education appointment with a patient. The patient asks if a family member should come to the appointment. Which is the best response by the nurse?
a. “There is no need for an additional person at the appointment.”
b. “Your family can come and wait with you in the waiting room.”
c. “We recommend including family members at this appointment.”
d. “It is required that you have a family member at this appointment.”

c. “We recommend including family members at this appointment.”

Rationale:

Including family members in perioperative education is advisable. Often a family member is a coach for postoperative exercises when the patient returns from surgery. If anxious relatives do not understand routine postoperative events, it is likely that their anxiety will heighten the patient’s fears and concerns. Preoperative preparation of family members before surgery helps to minimize anxiety and misunderstanding. An additional person is needed at the appointment if at all possible, and he or she needs to be involved in the process, not just waiting in the waiting room; however, it is certainly not a requirement for actually completing the surgery that someone comes to this appointment.

22

The nurse is reviewing the surgical consent with the patient during preoperative education and finds the patient does not understand what procedure will be completed. What is the nurse’s best next step?
a. Notify the health care provider about the patient’s question.
b. Explain the procedure that will be completed.
c. Continue with preoperative education.
d. Ask the patient to sign the form.

a. Notify the health care provider about the patient’s question.

Rationale:

Surgery cannot be legally or ethically performed until the patient fully understands the need for a procedure and all the implications. It is the surgeon’s responsibility to explain the procedure, associated risks, benefits, alternatives, and possible complications. It is important for the nurse to pause with preoperative education to notify the health care provider of the patient’s questions. It is not within the nurse’s scope to explain the procedure. The nurse can certainly reinforce what the health care provider has explained, but the information needs to come from the health care provider. It is not prudent to ask a patient to sign a form for a procedure that he/she does not understand.

23

During preoperative assessment for a 7:30 AM (0730) surgery, the nurse finds the patient drank a cup of coffee this morning. The nurse reports this information to the anesthesia provider. Which action does the nurse anticipate next?
a. A delay in or cancellation of surgery
b. Questions regarding components of the coffee
c. Additional questions about why the patient had coffee
d. Instructions to determine what education was provided in the preoperative visit

a. A delay in or cancellation of surgery

Rationale:

The recommendations before nonemergent procedures requiring general and regional anesthesia or sedation/analgesia include fasting from intake of clear liquids for 2 or more hours. A delay in or cancellation of surgery will be in order for this case. Questions regarding components of the coffee, asking why, and evaluating the preoperative education may all be items to be addressed, especially from a performance improvement perspective, but at this time in caring for this patient, a delay or cancellation is in order to prevent aspiration.

24

The nurse has administered a preoperative medication to the patient going to surgery. Which action will the nurse take next?
a. Notify the operating suite that the medication has been given.
b. Instruct the patient to call for help to go to the restroom.
c. Waste any unused medication according to policy.
d. Ask the patient to sign the consent for surgery.

b. Instruct the patient to call for help to go to the restroom.

Rationale:

Once a preoperative medication has been administered, instruct the patient to call for help when getting out of bed to prevent falls. For patient safety, explain the purpose of a preoperative medication and its effects. Notifying the operating suite that the medication has been given may be part of a facilities procedure but is not the best next step. It is important to have the patient sign consents before the patient has received medication that may make him/her drowsy. Wasting unused medication according to policy is important but is not the best next step.


25

The nurse has completed a preoperative assessment for a patient going to surgery and gathers assessment data. Which will be the most important next step for the nurse to take?
a. Notify the operating suite that the patient has a latex allergy.
b. Document that the patient had a bath at home this morning.
c. Administer the ordered preoperative intravenous antibiotic.
d. Ask the nursing assistive personnel to obtain vital signs.

a. Notify the operating suite that the patient has a latex allergy.

Rationale:

The most important step is notifying the operating suite of the patient’s latex allergy. Many products that contain latex are used in the operating suite and the postanesthesia care unit (PACU). When preparing for a patient with this allergy, special considerations are required from preparation of the room to the types of tubes, gloves, drapes, and instruments utilized. Obtaining vital signs, documenting, and administering medications are all part of the process and should be done—with the latex allergy in mind. However, making sure that the patient has a safe environment is the first step.

26

The nurse is preparing a patient for a surgical procedure on the right great toe. Which action will be most important to include in this patient’s preparation?
a. Place the patient in a clean surgical gown.
b. Ask the patient to remove all hairpins and cosmetics.
c. Ascertain that the surgical site has been correctly marked.
d. Determine where the family will be located during the procedure.

c. Ascertain that the surgical site has been correctly marked.

Rationale:

Because errors have occurred in the past with patients undergoing the wrong surgery on the wrong site, the universal protocol guidelines have been implemented and are used with all invasive procedures. Part of this protocol includes marking the operative site with indelible ink. Knowing where the family is during a procedure, placing the patient in a clean gown, and asking the patient to remove all hairpins and cosmetics are important but are not most important in this list of items.

27

The circulating nurse is caring for a patient intraoperatively. Which primary role of the circulating nurse will be implemented?
a. Suturing the surgical incision in the OR suite
b. Managing patient care activities in the OR suite
c. Assisting with applying sterile drapes in the OR suite
d. Handing sterile instruments and supplies to the surgeon in the OR suite

b. Managing patient care activities in the OR suite

Rationale:

The circulating nurse is an RN who remains unscrubbed and uses the nursing process in the management of patient care activities in the OR suite. The circulating nurse also manages patient positioning, antimicrobial skin preparation, medications, implants, placement and function of intermittent pneumatic compression (IPC) devices, specimens, warming devices and surgical counts of instruments, and dressings. The RN first assistant collaborates with the surgeon by handling and cutting tissue, using instruments and medical devices, providing exposure of the surgical area and hemostasis, and suturing. The scrub nurse, who can be a registered nurse, a licensed practical nurse, or a surgical technologist, maintains the sterile field, assists with applying the sterile drapes, and hands sterile instruments and supplies to the surgeon.

28

The nurse is caring for a patient in the preoperative holding area of an ambulatory surgery center. Which nursing action will be most appropriate for this area?
a. Count the sterile surgical instruments.
b. Empty the urinary drainage bag.
c. Check the surgical dressing.
d. Apply a warm blanket.

d. Apply a warm blanket.

Rationale:

The temperature in the preoperative holding area and in adjacent operating suites is usually cold. Offer the patient an extra warm blanket. Counts are taken by the circulating and scrub nurses in the operating room. Emptying a urinary drainage bag and checking the surgical dressing occur in the postanesthesia care unit, not in the holding area.

29

The nurse is caring for a patient in the operating suite. Which outcome will be most appropriate for this patient at the end of the intraoperative phase?
a. The patient will be free of burns at the grounding pad.
b. The patient will be free of nausea and vomiting.
c. The patient will be free of infection.
d. The patient will be free of pain.

a. The patient will be free of burns at the grounding pad.

Rationale:

A primary focus of intraoperative care is to prevent injury and complications related to anesthesia, surgery, positioning, and equipment use, including use of the electrical cautery grounding pad for the prevention of burns. The perioperative nurse is an advocate for the patient during surgery and protects the patient’s dignity and rights at all times. Signs and symptoms of infection do not have the time to present during the intraoperative phase. During the intraoperative phase, the patient is anesthetized and unconscious and typically has an endotracheal tube that prevents conversation. Nausea, vomiting, and pain typically begin in the postoperative phase of the experience.

30

The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which action will the nurse take to minimize skin breakdown?
a. Encouraging the patient to bathe before surgery
b. Securing attachments to the operating table with foam padding
c. Periodically adjusting the patient during the surgical procedure
d. Measuring the time a patient is in one position during surgery

b. Securing attachments to the operating table with foam padding

Rationale:

Although it may be necessary to place a patient in an unusual position, try to maintain correct alignment and protect the patient from pressure, abrasion, and other injuries. Special mattresses, use of foam padding, and attachments to the operating suite table provide protection for the extremities and bony prominences. Bathing before surgery helps to decrease the number of microbes on the skin. Periodically adjusting the patient during the surgical procedure is impractical and can present a safety issue with regard to maintaining sterility of the field and maintaining an airway. Measuring the time the patient is in one position may help with monitoring the situation but does not prevent skin breakdown.