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Flashcards in MS - Perioperative Care (MS Success) Deck (25):
1

The nurse requests the client to sign a surgical informed consent form for an emergency appendectomy. Which statement by the client indicates further teaching is required?
1. "I will be glad when this is over so I can go home today."
2. "I will not be able to eat or drink anything prior to my surgery."
3. "I can practice relaxing by listening to my favorite music."
4. "I will need to get up and walk as soon as possible."

1. "I will be glad when this is over so I can go home today."

1. The client will be in the hospital for a few days. This is not a day-surgery procedure. The client needs more teaching.

2. Clients are NPO (nothing by mouth) prior to surgery to prevent aspiration during and after anesthesia. The client understands the teaching.

3. Listening to music and other relaxing techniques can be used to alleviate anxiety and pain. This statement indicates the client understands the teaching.

4. Clients are encouraged to get out of bed as soon as possible and progress until a return to daily activity is achieved. The client understands the teaching.

2

The day surgery nurse is caring for the client who had a laparoscopic cholescystectomy. Which task would be most appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
1. Empty and measure the client's T-tube drainage
2. Discontinue the client's intravenous fluid.
3. Assist the client who has been discharged to the car.
4. Check the client's bandages on the abdomen.

3. Assist the client who has been discharged to the car.

The UAP could escort the client to the car, because the client is stable.

3

The client with varicose veins is 8 hours postoperative vein ligation. Which priority intervention should the nurse implement?
1. Instruct the client to remain on strict bedrest.
2. Maintain pressure bandages on the affected leg.
3. Provide the client with a regular diet.
4. Administer the prophylactic intravenous antibiotic.

1. Instruct the client to remain on strict bedrest.

Because the saphenous vein is removed during vein ligation, standing and sitting are prohibited during the initial recovery period to prevent increased pressure in the lower extremities. The client is on strict bedrest for 24 hours, which is the priority intervention because standing could destroy the surgical procedure.

4

Which intervention should the nurse implement for the client who has had an abdominal perineal resection for cancer of the colon?
1. Provide meticulous skin care to stoma.
2. Assess the client's flank incision.
3. Irrigate the J-P drains every shift.
4. Position the client in high-Fowler's position.

1. Provide meticulous skin care to stoma.

Colostomy stomas are portions of the large intestines pulled through the abdominal wall through which feces exits the body. Feces can be irritating to the abdominal skin, so careful and thorough skin care is needed.

Assess the client's flank incision. -- There are midline and perineal incisions, not flank incisions.

Irrigate the J-P drains every shift. -- Jackson-Pratt (J-P) drains are emptied every shift, but they are not irrigated.

5

The client 3 hours postoperative left above-the-knee amputation (AKA) is complaining of pain in the left foot. Which intervention should the nurse implement first?
1. Do not administer pain medication because there is no left foot.
2. Assess the client to rule out any postoperative complications.
3. Check the client's medication administration record.
4. Medicate the client with an intravenous narcotic pain medication.

2. Assess the client to rule out any postoperative complications.

Phantom pain is caused by severing the peripheral nerves. The pain is real to the client, but pain could be expected or a complication so the nurse should first assess a client.

6

Which problem would be highest priority for the client who had an open cholecystectomy surgery?
1. Altered elimination: diarrhea
2. Alteration in skin integrity
3. Risk for infection
4. Risk for respiratory complications

4. Risk for respiratory complications

The surgical incision for an open cholecystectomy is just below the diaphragm, and the client has difficulty taking deep breaths due to pain. The client is at high risk for developing pneumonia. Remember Maslow's Hierarchy of Needs.

7

The client has an eviscerated abdominal wound. Which intervention should the nurse implement first?
1. Notify the client's surgeon immediately.
2. Assess the client's vital signs.
3. Prepare the client for emergency surgery.
4. Apply a sterile normal saline dressing.

4. Apply a sterile normal saline dressing.

Evisceration is a life-threatening condition in which the abdominal contents have protruded through the abdominal incision. The nurse must protect the bowel from the environment by placing a sterile normal saline dressing on it. The saline prevents the intestines from drying out and becoming necrotic.

8

The client who has undergone a craniotomy for a brain tumor has an intake of 1,400 mL and a urinary output of 3,800 mL for a 12-hour shift. Which intervention should the nurse implement first?
1. Document the findings in the chart as normal.
2. Increase the client's intravenous rate.
3. Monitor the client's sodium level.
4. Prepare to administer vasopressin, an antidiuretic hormone.

4. Prepare to administer vasopressin, an antidiuretic hormone.

Diabetes insipidus is a complication of a craniotomy and is exhibited by a large amount of dilute urine. The treatment is administering the antidiuretic hormone, vasopressin.

9

The client diagnosed with L3-L4 disc degeneration has undergone an laminectomy. Which intervention should the nurse implement?
1. Position the client in the prone position.
2. Assess the client's respiratory status.
3. Turn the client using the log-rolling method.
4. Monitor the client's pelvic traction.

3. Turn the client using the log-rolling method.

The nurse should turn the client as a "log" to prevent undue strain on the surgical site. Two or three staff members should turn the client in one movement.

10

Which diagnosis should the nurse identify as priority for the client who is 1 day postoperative open-heart surgery?
1. Alteration in comfort related to incisional pain.
2. Altered respiratory status related to mechanical ventilation.
3. Fluid and electrolyte imbalance related to increased blood loss.
4. High risk for complications related to knowledge deficit of postoperative care.

2. Altered respiratory status related to mechanical ventilation.

The client is on a mechanical ventilator which is an altered way of breathing; airway is priority according to Maslow's Hierarchy of Needs.

11

The nurse in the holding area of the surgery department is interviewing a client who requests to keep his religious medal on during surgery. Which intervention should the nurse implement?
1. Notify the surgeon about the client's request to wear the medal.
2. Tape the medal to the client and allow the client to wear the medal.
3. Request the family member take the medal prior to surgery.
4. Explain taking the medal to surgery is against the policy.

2. Tape the medal to the client and allow the client to wear the medal.

12

The nurse must obtain surgical consent forms for the scheduled surgery. Which client would not be able to consent legally to surgery?
1. The 65-year-old client who cannot read or write.
2. The 30-year-old client who does not understand English.
3. The 16-year-old client who has a fractured ankle.
4. The 80-year-old client who is not oriented to the day.

3. The 16-year-old client who has a fractured ankle.

13

The nurse is preparing a client for surgery. Which intervention should the nurse implement first?
1. Check the permit for the spouse's signature.
2. Take and document intake and output.
3. Administer the "on call" sedative.
4. Complete the preoperative checklist.

4. Complete the preoperative checklist.

14

The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply.
1. The client has loose, decayed teeth.
2. The client is experiencing anxiety.
3. The client smokes two (2) packs of cigarettes a day.
4. The client has had a chest x-ray which does not show infiltrates.
5. The client reports using herbs.

1. The client has loose, decayed teeth.
3. The client smokes two (2) packs of cigarettes a day.
5. The client reports using herbs.

15

Which task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
1. Complete the preoperative checklist.
2. Assess the client's preoperative vital signs.
3. Teach the client about coughing and deep breathing.
4. Assist the client to remove clothing and jewelry.

4. Assist the client to remove clothing and jewelry.

The UAP can remove clothing and jewelry.

16

The nurse is assessing a client in the day surgery unit who states, "I am really afraid of having this surgery. I'm afraid of what they will find." Which statement would be the best therapeutic response by the nurse?
1. "Don't worry about your surgery. It is safe."
2. "Tell me why you're worried about your surgery."
3. "Tell me about your fears of having this surgery."
4. "I understand how you feel. Surgery is frightening."

3. "Tell me about your fears of having this surgery."

17

The 68-year-old client scheduled for intestinal surgery does not have clear fecal contents after three (3) tap water enemas. Which intervention should the nurse implement first?
1. Notify the surgeon of the client's status.
2. Continue giving enemas until clear.
3. Increase the client's IV fluid rate.
4. Obtain STAT serum electrolytes.

1. Notify the surgeon of the client's status.

18

The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select all that apply.
1. Perform passive range-of-motion exercises.
2. Discuss how to cough and deep breathe effectively.
3. Tell the client he can have a meal in the PACU.
4. Teach ways to manage postoperative pain.
5. Discuss events which occur in the post-anesthesia care unit.

2. Discuss how to cough and deep breathe effectively.

19

The nurse is caring for a client scheduled for total hip replacement. Which behavior indicates the need for further preoperative teaching?
1. The client uses the diaphragm and abdominal muscles to inhale through the nose and exhale through the mouth.
2. The client demonstrates dorsiflexion of the feet, flexing of the toes, and moves the feet in a circular motion.
3. The client uses the incentive spirometer and inhales slowly and deeply so the piston rises to the preset volume.
4. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.

4. The client gets out of bed by lifting straight upright from the waist and then swings both legs along the side of the bed.

20

The nurse is completing a preoperative assessment on a male client who states, "I am allergic to codeine." Which intervention should the nurse implement first?
1. Apply an allergy bracelet on the client's wrist.
2. Label the client's allergies on the front of the chart.
3. Ask the client what happens when he takes the codeine.
4. Document the allergy on the medication administration record.

3. Ask the client what happens when he takes the codeine.

21

Which laboratory result would require immediate intervention by the nurse for the client scheduled for surgery?
1. Calcium 9.2 mg/dL.
2. Bleeding time 2 minutes.
3. Hemoglobin 15 g/dL.
4. Potassium 2.4 mEq/L.

4. Potassium 2.4 mEq/L.

22

Which activities are the circulating nurse's responsibilities in the operating room?
1. Monitor the position of the client, prepare the surgical site, and ensure the client's safety.
2. Give preoperative medication in the holding area and monitor the client's response to anesthesia.
3. Prepare sutures; set up the sterile field; and count all needles, sponges, and instruments.
4. Prepare the medications to administered by the anesthesiologist and change the tubing for the anesthesia machine.

1. Monitor the position of the client, prepare the surgical site, and ensure the client's safety.

23

The circulating nurse observes the surgical scrub technician remove a sponge from the edge of the sterile field with a clamp and place the sponge and clamp in a designated area. Which action should the nurse implement?
1. Place the sponge back where it was.
2. Tell the technician not to waste supplies.
3. Do nothing because this is the correct procedure.
4. Re-count all sponges.

3. Do nothing because this is the correct procedure.

The technician followed the correct procedure. Sponges are counted to maintain client safety, so all sponges must be kept together to repeat the count before the incision site is sutured. The sponge must be removed, not used, and placed in the designated area to be counted later.

24

Which violation of surgical asepsis would require immediate intervention by the circulating nurse?
1. Surgical supplies were cleaned and sterilized prior to the case.
2. The circulating nurse is wearing a long-sleeved sterile gown.
3. Masks covering the mouth and nose are being worn by the surgical team.
4. The scrub nurse setting up the sterile field is wearing artificial nails.

4. The scrub nurse setting up the sterile field is wearing artificial nails.

25

The circulating nurse and the scrub technician find a discrepancy in the sponge count. Which action should the circulating nurse take first?
1. Notify the client's surgeon.
2. Complete an occurrence report.
3. Contact the surgical manager.
4. Re-count all sponges.

4. Re-count all sponges.

A re-count of sponges may lead to the discovery of the cause of the presumed error. Usually it is just a miscount or a result of a sponge being placed in a location other than the sterile field, such as the floor or a lower shelf.