HESI Perioperative Care

Question 1

Scenario

Answer 1

The 63-year-old Client arrives at the surgery center for her preoperative appointment. She is scheduled to undergo left hip replacement surgery in one week.

Question 2

Preoperative screening

Answer 2

The nurse begins the preoperative assessment by taking the clients vital signs. The nurse reviews the clients medication’s. The client indicates that she has been taking two medication; hydrochlorothiazide a diuretic and warfarin an anticoagulant every day for more than a year

Question 3

Which vital sign requires follow up by the nurse?

Answer 3

Blood pressure of 160/88 mmHg.

Rationale: this blood pressure is elevated and requires further action by the nurse

Question 4

What nursing action is most important?

Answer 4

Explain the need to withhold the warfarin prior to surgery.
Rationale: anticoagulants increase the risk for bleeding during surgery in the postoperative period so the nurse must explain the need withhold the warfarin prior to surgery and instruct the client to contact the surgeon to determine how long before surgery the medication should be stopped

Question 5

The nurse, then reviews the clients preoperative lab test results drawn earlier in the week
What serum lab value requires follow up by the nurse?

Answer 5

WBC of 14,000/UL
Rationale: the normal WBC count is 4000 to 10,000/uL an increase may indicate the onset of an infection, which may be a contraindication to surgery. The nurse should notify the surgeon of this abnormal lab value.

Question 6

Preoperative teaching the nurse talks with the client about what to expect the day of surgery and during the immediate postoperative. The nurse provides instruction regarding cough and deep breathing exercises. The client performs a return demonstration by breathing in deeply through their mouth and exhaling forcefully and rapidly through pursed lips.
What action should the nurse implement?

Answer 6

Demonstrate the deep breathing and coughing technique again.
Rationale: the client has demonstrated incorrect technique when performing deep breathing exercises, the client should inhale through the nose and exhale slowly through the mouth without pursing the lips, the nurse should demonstrate the entire procedure again for best learning by the client.

Question 7

When a nurse begins teaching about the benefits of early mobilization, following surgery, the client states “ oh, I know if I stay in bed very long I will get bed sores.”
How should the nurse respond?

Answer 7

“ bed sores are one of many problems that can occur from prolonged bedrest.”
Rationale: this response acknowledges the clients previous learning, and promotes further learning related to other complications of mobility, such as thrombus formation, constipation, and atelectasis

Question 8

The nurse discusses postoperative pain management with a client and explains the use of a patient controlled analgesia (PCA) pump. The client expresses fear that they might accidentally overdose herself since they will be sleepy after surgery.

How should the nurse respond?

Answer 8

“The pump has a controlled device that prevents you from taking too much medicine.”
Rationale this response provides the client with the information needed to understand that she cannot overdose herself while she is sedated after surgery.

Question 9

While discussing postoperative pain management strategies with a client, the nurse observes them begin to cry

What action should the nurse take?

Answer 9

Quietly sit with a client.
Rationale: offering one’s presence is a caring and therapeutic response.

Question 10

After the client stops crying, she states “ my father, was in so much pain before he died: talking about pain brings back so many memories.”

How should the nurse respond?

Answer 10

“It sounds as if you went through a difficult time when your father died.”
Rationals: this open ended acknowledgment of the clients distress is therapeutic, and allows the opportunity for further discussion by the client if desired.

Question 11

The next week the client arrives at the surgery center three hours before their scheduled surgery

Which question is most important for the nurse to ask the clients during the admission interview?

Answer 11

“Have you had anything to eat or drink since midnight?”
Rationale: ensuring that the client has remained NPO for the prescribed length of time before surgery is critical to prevent vomiting and aspiration during surgery.

Question 12

After completing the admission interview, the nurse reviewed the client medical record and notes that the surgical consent form is filled out, but not signed by the client

What action should the nurse take?

Answer 12

Ask the client if she has received sufficient information to sign the consent form
Rationale: the nurse may witness the client signature if the nurses able to determine that the client has been sufficiently informed of the necessary information .

Question 13

The nurse observes that the word “ yes” has been marked on the clients left hip hip and the word “ no” has been written on the right hip.

What action should the nurse implement?

Answer 13

Confirm that the left hip is the site of the search scheduled surgery
Rationale: the nurse should ensure that the markings on the hips are correct to help reduce the potential for error during surgery. When the surgical site involves a distinction between left and right sides of the body, marking the site is a required component of the joint commissions, universal protocol to prevent wrong site, wrong procedure, wrong person surgery.

Question 14

The client transferred to a stretcher, and taken to the OR. The nurse assists the client off the stretcher and onto the OR table after general anesthesia, is induced the nurse positions the client for surgery

What nursing diagnosis has the highest priority at this time?

Answer 14

Risk for perioperative -positioning injury
Rationale: during surgery, the client may remain in one position for a prolonged. The nurse must ensure that the client is protected from injury secondary to inappropriate positioning.

Question 15

Once the OR team has assembled in the room, the circulating nurse calls for a timeout.
What action should the nurse take during the time out?

Answer 15

Review the scheduled, procedure, site, and client
Rationale: a time out, the designated method for final verification before surgery begins, is a component of the joint commissions, universal protocol to prevent wrong site, wrong procedure, wrong person surgery.

Question 16

The surgery is successfully completed without complications. Following surgery, the client is admitted to the post anesthesia care unit. The operative report indicates that the client has a left hip replacement under general anesthesia. The initial nursing assessment reveals that the client is not responding to verbal stimuli. Their vital signs are T 97.6°F (36.4° C), P 88, R 14, and BP 130/70.

What action should the nurse implement first?

Answer 16

Position the client on her side.
Rationale: during the immediate anesthesia. The unconscious client should be positioned on the side to maintain an open airway and promote drainage of secretions.

Question 17

While assessing the client, the nurse observes that the surgical dressing is in placed on the left hip, with no visible drainage.
How should the nurse document this finding?

Answer 17

Left hip dressing, clean, dry, and intact.
Rationale: is documentation is concise, but thorough providing a clear picture of the assessment data

Question 18

When the client arrives on the unit, the nurse notes that their IV is wide open review of the clients postoperative prescriptions indicates that sodium chloride 0.9% is to infuse at 75 ML/hour, alternating with lactated ringer solution at 75 ML/hour. An infusion pump is not immediately available so the nurse knows that the infusion tubing has a drop factor of 15 drops/ML and reset the IV.
At what rate in the drop/min should the IV and fuse?

Answer 18

19
Rationale: 75, ML/60 minutes x 15gtts/1 ML equals 18.75, which rounds up to 19.

Question 19

Well, the nurse begins to assist a client. Another nurse finds an infusion pump and prepares a prescribed “ now” dose of an intravenous antibiotic. The prescription is for 2 g of cefazolin which arrives from the pharmacy diluted in 50 mL of sodium chloride 9% and is now to be administered over 30 minutes.

At what rate in milliliters/HR should the infusion pump be set?

Answer 19

100
Rationale: 50 mL/30 minutes = X milliliters/60 minutes. 30X =50×60 = 100 mL/hour.

Question 20

The nurse continues the postoperative assessment.
What action should the nurse take to assess atelectasis?

Answer 20

Osculate the client breathing sounds.
Rationale: atelectasis is a condition in which the collapse. Absent breathing sounds along with changes and breathing patterns are expected findings when atelectasis occurs

Question 21

The nurse determines that the client bowel sounds are hypoactive.

What action should the nurse implement and response to this finding?

Answer 21

Document this assessment, finding in the chart
Rationale: hypoactive bowel sounds are expected finding general anesthesia, so the nurse should document this finding in the chart and continue to monitor the patient

Question 22

During the postoperative assessment, the nurse observes the client surgical site. The left hip dressing has a moderate amount of sanguinous drainage.

What actions should the nurse implement?

Answer 22

1.Observe the linens under the hip.
Rationale: gravity pulls drainage down, so then inspect the area below the surgical site for additional drainage

2. Mark the amount of drainage on the dressing.
   Rationale: marking the amount of drainage on the dressing, will allow for later comparison

Question 23

The nurse observes that the Hemovac drain is full of sanguinous drainage

What action should the nurse implement first?

Answer 23

Empty the drain and measure the amount of drainage.
Rationale: the nurse should first empty the drain and measure the drainage, then compress the drain to reestablish suction. Documentation of the findings and notification of the surgeon can then be done

Question 24

The nurse notifies the surgeon of the wound drainage

What lab data is important for the nurse to report to the surgeon?

Answer 24

Hemoglobin and hematocrit
Rationale: the nurses reporting the amount of surgical drainage to the surgeon due to a concern for excessive blood loss. The surgeon needs to know information related to blood volume provided by the hemoglobin and hematocrit levels.

Question 25

 based on the lab provided by the nurse that HCP prescribes a transfusion of two units of packed red blood cells as soon as possible. Once the first unit of ordered, the blood cells is ready, the nurse obtains the blood from the blood bank. When the nurse enters the clients room to begin the transfusion. The UAP is giving the client a partial bath.

What action should the nurse take?

Answer 25

Hang the transfusion of packed cells, while the UAP continues to complete the client. Personal care.
Rationale: transfusion of the blood is a higher priority than personal care. If necessary, the remainder of the care can be delayed.

Question 26

The client is currently receiving lactated ringers solution IV at a rate of 75 mL/hour.
Transfusing the 250 ML unit of PRBCs what action should the nurse implement?

Answer 26

Stop the IV solution and transfuse the packed cells at 125 ML/hour via tubing connected to a bag of sailing solution.
Rationale red blood cells are only compatible with normal sailing. The blood should be connected to a bag of saline solution using special white tubing and administered within one and a half to two hours if possible, but no longer than four hours. (250 ML transfused at 125 ML/hour = two hours.)

Question 27

The nurse is assisting the client to the bedside commode on the second postoperative day. The client states “I have never had to depend on anyone before. I like to take care of myself. I feel so helpless.”

In response to these remarks, the nurse plans care for the client based on the identification vacation of what nursing diagnosis?

Answer 27

Situational, low self-esteem.
Rationale: the clients remarks, regarding feelings of helplessness relates to her sense of how she perceives herself in her present ability to care for herself.

Question 28

The nurse teaches the client safe, transfer techniques and consult with the physical therapist to begin ambulation activities as soon as possible possible.
What is the rationale for the inclusion of these actions in the clients plan of care

Answer 28

Increase mobility will promote and improved sense of control.
Rationale: increased mobility, should result, increased independence and an improved sense of control, which will reduce the clients feelings of helplessness

Question 29

After the client ambulates with physical therapist, the nurse prepares to change the surgical dressing. While obtaining supplies, the nurse reviews the sterile procedure to be followed.
At what step in the procedure should the nurse don sterile gloves?

Answer 29

Before cleansing the clients hip incision.
Rationale: when, using surgical as sepsis for wound care of the sterile gloves, should be done prior to cleaning the wound and applying the new sterile dressing. Period.

Question 30

Well cleansing the incision, the nurse, observes that the staples are intact, but a 2 cm gap has opened as the bottom of the incision

How should the nurse document this finding?

Answer 30

Small area of dehiscence at inferior portion of incision
Rationale: and unintentional opening in a surgical wound prior to healing, is referred to as dehiscence.