Quiz 1 (Ch. 1, 16, 17, 18) Flashcards
(219 cards)
0
Q
The Institute of medicine report ‘To Err Is Human’ highlighted the need to improve patient safety. Which national organization requires it’s accredited agencies to meet specific national patient safety goals?
A
The joint commission
1
Q
What is the purpose of the rapid response team?
A
Enable the nurse to recognize changes in patient status before an acute emergency
2
Q
In addition to being able to provide care with skill in techniques and procedures, one must medical surgical nurse also be prepared to utilize and caring for the patient?
A
- Teaching
- Patient advocacy
- Spiritual counseling and support
- Coordination of care
- Rehabilitation
3
Q
Which factors are likely to be causes of medical errors?
A
Lack of technical experience
Overload of info
Poor communication
Failure to follow accepted facility practices
4
Q
Which is the best way for the nurse to asses the patients learning after teaching?
A
Ask the patient to repeat the info back
5
Q
Which type of evidence is rated highest on a level of evidence scale?
A
Systematic review or meta analysis of all randomized controlled trials
6
Q
Which is the best use of information from electronic sources, such as websites or email, in retrieving data for the evidence-based practice process?
A
Evaluating the information for credibility and reliability before putting it into use
7
Q
Which action exemplifies the goal of case management in an acute care setting?
A
Making sure the patients dietary choices meet prescribed nutritional needs
8
Q
Which actions best demonstrate a collaborative nursing function?
A
- Requesting the assistance of another staff member to turn a patient
- Administering meds as prescribed by he health care provider
- Making a referral to the case manager to assist with discharge planning
- Ensuring clear communication with other health care providers
9
Q
Which occurrence does the joint commissions national patient safety goals designate as a high risk issue?
A
Administering medication that is not familiar to the nurse
10
Q
What is the joint commission?
A
The joint commission is a national organization that offers peer evaluation for accreditation every 3 years for all types of U.S. Health care agencies that meet their standards
11
Q
What do the national patient safety goals or NPSGs address?
A
They address high risk issues such as drug administration , fall reduction, pressure ulcer prevention, and communication among health care team members
12
Q
What are the 6 core competences for health care professionals?
A
Patient centered care, teamwork and collaboration, evidence-based practice, quality improvement, informatics, and safety.
13
Q
What are three essential ethical principles to consider when making clinical decisions?
A
- Self-determination
- Beneficence
- Justice
14
Q
On admission to the preoperative area, the client scheduled for a hip replacement tells the nurse that three autologous blood donations for the surgery have been made in the past three weeks. What is the nurses best action?
A
Call the laboratory to ensure that the blood is physically out the operating facility
Rationale: Many hospitals or surgical centers do not initially process autologous blood collections. Any donated blood must be in the facility where the surgery will take place before the client undergoes the planned surgical procedure.
15
Q
The client scheduled for knee replacement surgery today performed all the following actions yesterday. Which action is most important for the nurse report to the surgeon?
A
Took 2 aspirin three times
Rationale: The aspirin taken yesterday will significantly reduce blood clotting for surgery. The surgeon may decide to delay the surgery for at least a week to ensure that adequate numbers of platelets capable of activation are present.
16
Q
For which client preadmission testing laboratory result does the nurse take immediate action? A. International normalized ratio 0.9 B. White blood cell count 8500/mm3 C. Serum potassium level 2.8 mEq/L D. Serum sodium level 132 mEq/L
A
C.
Rationale: The serum potassium level is significantly low (hypokalemia) and must be corrected before surgery. This level increases the risk for toxicity if the client is taking digoxin, slows recovery from anesthesia, and increases cardiac irritability. Although the serum sodium and INR are also low, they are not low enough to cause any problems. The white blood cell count is normal.
17
Q
True or False
The terms outpatient and ambulatory refer to a patient who goes to the surgical center the day of the surgery and returns home the same day
A
True
18
Q
What is Atelecttasis
A
Atelectasis is the collapse of alveoli. Atelectasis reduces gas exchange and causes intolerance of anesthesia. It is also a common problem after general Anesthia.
19
Q
What are the limitations for autologous donations
A
Patients ca donate their own blood up to 5 weeks before their surgery if they are infection free ad have a hemoglobin level greater than 11 g.DL. The last donation cannot be made within 72 hours before surgery.
20
Q
How does nutritional status affect surgey
A
Surgery increases metabolic rate and depletes potassium, vitamin c, B vitamins, all of which are needed for wound healing and blood clotting. In malnourished patients decreased serum protein levels slow healing. Negative nitrogen balance may result from depleted protein stores. This problem increases risk for skin breakdown, delayed wound healing, dehiscence, dehydration, and sepsis.
21
Q
Hypokalemia and Surgery
A
Hypokalemia increases risk for toxicity if the patient is taking digoxin, slows recovery from anesthesia, and increases cardiac irritability.
22
Q
Hyperkalemia and Surgery
A
Hyperkalemia increases the risk for dysrhythmias, especially with use of anesthesia.
23
Q
What is the normal range for potassium
A
3.5-5.0 mEq L
24
What is the normal range for sodium
136-145 mEq L
25
What is the normal Range for chloride?
98-106 mEq/L
26
What is the normal white blood cell range?
5,000-10,000/ mm3
27
What is the normal range for hemoglobin?
Females: 12-16
Males: 14-18
28
Why is it important to be NPO before surgery ?
NPO status ensure that the stomach contains a limited volume of gastric secretions, which decreases the risk of aspiration.
NPO includes smoking
29
What are some procedures and exercises to prevent cardiovascular complications?
Anti embolism stocking
Pneumatic compression device
Leg exercises
Mobility
30
Which statement best describes the preoperative period?
- It ends at the time of transfer to the surgical suite
- It begins when the patient is scheduled for surgery
- It is a time during which the patient receives testing and education related to impending surgery
31
A female patient is having a biopsy of a nodule found in the right breast. Which classification identifies this surgery?
Diagnostic
32
A patient who can barely ambulated with a walker at home is having a left total knee replacement. What is the most appropriate category for this surgery?
Restorative
33
A colostomy is scheduled to be done on a patient who has severe Crohn's disease. What is the correct classification for this surgery?
Palliative
34
A male patient has a facial scar on his forehead from a third degree burn. What is the correct classification for this surgery?
Cosmetic
35
An appendectomy is being performed on a patient with appendicitis. What is the correct classification for this surgery?
Curative
36
A patient with an abdominal aortic aneurysm is having surgical repair. What is the correct classification for this surgery?
Emergent
37
A 76 yr old patient is having a bilateral cataract removal. What is the correct classification for this surgery?
Elective
38
A 47 yr old patient is having surgery to remove kidney stones. What is the correct classification for this surgery?
Urgent
39
The nurse screens a preoperative patient for conditions that may increase the risk for complications during the peri operative period. Which conditions are possible risk factors?
67 yrs old
Obesity
Pulmonary disease
40
Discharge planning is done for patients who had which types of surgery?
```
Minor
Urgent
Palliative
Curative
Emergent
```
41
The nurse has received a patient in the holding area who is scheduled for a left femoral popliteal bypass. What are the priority safety measures for this patient before surgery?
- The operative limb is marked by the surgeon
- The patient is positively identified by checking name and birth date
- The patient is asked to confirm the marked operative limb
42
Which common lab tests need to be ordered before surgery?
Electrolyte levels
Clotting studies
Serum creatine
43
Which statement best describes a collaborative role of nurses and surgeon when obtaining informed consent?
The nurse may serve as a witness to the patient signature after the physician has a consent form signed before the preoperative sedation is given and before surgery is performed
44
The patient with diabetes is scheduled for surgery at oh 700. What are the actions, in order of priority, that the nurse perform preoperatively? In order...
Have nonlicensed personnel obtain the patients Accutech and vital signs
Modify the dose of insulin given based on the patient's blood glucose
Check if the patient has any jewelry on call security to secure valuable
Complete the preoperative checklist before 0700
45
To reduce the incidence of patients with a known history or risk of malignant hyperthermia, what best practices are put in place around the operating room?
- List of medications available for emergency treatment of MH
- Dedicated MH cart with treatment medications
- treatment before, during, and after surgery if the patient has a known history or risk
- additional nursing support on call if MH develops
- available MH hotline number
46
The patient has a malignant hyperthermia incident during surgery. To whom does the nurse report this incident?
North American malignant hypothermia registry
47
Who coordinates, overseas, and participates in the patient's nursing care while the patient is in the operating room?
Circulating nurse
48
Who assumes responsibility for the surgical procedure and any surgical judgments about the patient?
The surgeon
49
Who manages the patient's care will the patient is in this area and initiates documentation on the perioperative nursing record?
Holding area nurse
50
Who is educated in a particular type of surgery and responsible for intraoperative nursing care specific to patients needing that type of surgery?
Specialty nurse
51
Who sets up the sterile field, assist with the draping of the patient, and hands sterile supplies, sterile equipment, and instruments to the surgeon?
Scrub nurse
52
During surgery, what things do anesthesia personnel monitor, measure, and assess?
Intake and output, vital signs, cardiopulmonary function, level of anesthesia
53
Stage 1 of anesthesia
Close operating room doors and control traffic in and out of the room. Positioned patient securely with safety belts. Maintain minimum discussion in the operating room.
54
Stage 2 of anesthesia
Shield patient from excess noise and physical stimuli. Protect the patients extremities. Assist anesthesia personnel as needed. Stay with patient
55
Stage 3 of anesthesia
Assist anesthesia personnel with intubation of patient. Place the patient in position for surgery. Prep the patient skin and area of operative site
56
Stage 4 of anesthesia
Prepare for an assistant treatment of cardiovascular and or pulmonary arrest. Document in record
57
The acute, life-threatening complication of malignant hyperthermia results from the use of which agents?
Succinylcholine and inhalation agents
58
Which clinical features are found in an MH crisis?
```
Sinus tachycardia
Tightness and rigidity of the patients Jaw area
Lowering of the blood pressure
Skin mottling and cyanosis
Tachypnea
```
59
The surgical team understand that time is crucial in recognizing entreating and MH crisis once recognized. What is the treatment of choice?
Dantrolene sodium
60
The patient experiences MH immediately after induction of anesthesia. What interventions, and order of priority, does the nurse carry out?
1. Stop all inhalation anesthetic agents and succinylcholine
2. Administer IV dantrolene sodium 2-3 mg/KG
3. Assess ABGs and serum chemistries
4. Apply a cooling blanket over the torso
5. Monitor cardiac rhythm by electrocardiograph to assess for dysrhythmias
61
In which situations is regional anesthesia used instead of general anesthesia?
1. In patients who have had an adverse reaction to general anesthesia
2. In some cases with pain management after surgery is enhanced by regional anesthesia
3. In patients with serious medical problems
4. When the patient has a preference and a choice is possible
62
Halothane
Less irritating to respiratory tract than other inhalation agents
63
Nitrous oxide
Needs addition of other agents for longer procedures
64
Desflurane
May increase heart rate and lower BP during induction
65
Thiopental sodium
Can depress respiratory and cardiac functions
66
Ketamine HCL
Dissociative emergence reactions, can induce nausea and vomiting
67
Propofol
Short acting, patient becomes responsive quickly postoperatively
68
Fentanyl
Excellent postoperative analgesia and epidural anesthesia
69
Midazolam
Induces amnesia around the event
70
To avoid electrical safety problems during surgery, what does the nurse do?
Ensure proper placement of the grounding pads
71
Which medical condition increases a patients risk for surgical wound infection?
Diabetes mellitus
72
Topical Anesthesia
Agents applied directly to the area of skin or mucous membrane to be anesthetized. Onset is within 1 minute, duration up to 30.
73
Local infiltration
Injection of an anesthetic agent directly into the tissue around an incision, wound, or lesion. Blocks peripheral nerve function at its origin.
74
Nerve block
Injection of anesthetic agent into or around a nerve or group of nerves, resulting in block sensation and motor impulse transmission. Used to prevent pain during procedure or to identify the causes pain. A type of regional anesthesia
75
Spinal anesthesia
Also called intrathecal block, injection of anesthetic agent into the cerebrospinal fluid in he subarachnoid space. Used for lower abdominal and pelvic surgery.
76
Which patient would be a candidate for moderate sedation?
1. Endoscopy
2. Closed fracture reduction
3. Cardiac catheterization
4. Cardioversion
77
The patient is requesting moderate sedation for repair of a torn meniscus and has no medical contraindications. How does the nurse responder to the patient's request?
You can discuss your request for moderate sedation with your surgeon and anesthesiologist
78
Which medical condition influences whether a patient is to have moderate sedation for a laparoscopic cholecystectomy?
Chronic obstructive pulmonary disease
79
The client brought to the holding area before surgery tells the nurse he has never had surgery before and is afraid of anything “medical.” Which nursing action is most likely to reduce this client’s anxiety?
A. Administering the preoperative medication as soon as possible.
B. Assuring the client that his scheduled surgery is routine and that nothing will go wrong.
C. Determining whether the client wants family members to be with him in the holding area.
D. Explaining to the client that this hospital’s surgical area is the most technologically advanced in the city.
ANS: C
Rationale: Most anxious clients would feel some anxiety relief by having one or more familiar people waiting with them until the time of surgery. In addition, asking the client what he or she wants allows him to have more control over the situation. Telling the client about the advanced technology can imply to him that the procedure is dangerous. Stating that the procedure is routine and that nothing will go wrong does not address the client’s fears about his surgery and his lack of familiarity with “medical” routines.
80
The circulating nurse sees that a sponge is dropped onto the floor from the instrument table after the first surgical incision is opened. What is this nurse’s best action?
A. Obtain an additional sterile sponge to replace the contaminated one and place it on the instrument table.
B. Place the sponge in the circulating area to include in the final count before incision closure.
C. Pick up the sponge and throw it out so no one slips on it.
D. Hand the sponge back to the scrub nurse.
ANS: B
Rationale: An accurate count of all sponges initially prepared on the instrument table is matched to the count of sponges present before the incision can be closed. This sponge was counted before surgery and needs to be included in the final count. It cannot be thrown away before the final count is performed. The sponge is now contaminated and cannot not given back to the scrub nurse or surgeon. A replacement sponge should not be needed. Additional sponges are added to the instrument table only if requested and must be added to the initial count.
81
The client undergoing induction of anesthesia with succinylcholine, a depolarizing blocker agent, begins to experience generalized muscle twitching. What the circulating nurse’s best response?
A. Call the anesthesia provider’s attention to this response.
B. Ensure the client is secured to the table.
C. Cover the client with a warm blanket.
D. Document this expected response.
ANS: D
Rationale: Depolarizing blocker agents depolarize the motor end plates of nerves innervating skeletal muscles, causing a brief period of fasciculations or muscle twitching. This response is considered normal.
82
A very anxious patient, a 48-year-old attorney, has entered the preoperative holding area about 60 minutes before her scheduled procedure. Before the OR nurse can interview her, the patient is medicated with 2 mg midazolam (Versed). The OR schedule lists that she is scheduled to have a left breast lumpectomy as treatment for breast cancer. When you ask her what procedure she is having, her response is “I am going to have a lumpectomy of the RIGHT breast.” Upon further review, you determine that the surgeon wrote, “operative consent for lumpectomy of the right breast.” However, when you check the informed consent, the consent states lumpectomy, left breast, and the patient signature is present, as is the witness signature.
1. How should you proceed with the discrepancies surrounding the operative procedure among the patient, operative consent, and OR schedule?
The anesthesia care provider, the surgeon, and nursing management should be notified immediately. Re-verify with the patient the correct site, side, and operative procedure according to facility policy.
2. Can the patient sign a new consent after she has been medicated with midazolam? Why or why not?
This will depend on the policy of the facility, the emergent or nonemergent nature of the surgical procedure, and the half-life of the preoperative medication. The team may wish to consult with the facility attorney to determine the best course of action.
3. How could this have happened?
Because of the nature of the surgical procedure, the patient may have been anxious when asked to sign the surgical consent and did not realize that it was incorrect. Changes in personnel and inadequate transfer of patient care information may have contributed to the error.
4. How can this occurrence be prevented in the future?
The anesthesia care provider should verify the correct patient, site, side, and operative procedure before any preoperative medication is administered.
83
The patient is a 50-year-old thin woman (115 lb) who will be placed in the prone position during surgery.
1. What general safety considerations should be taken for a patient in the prone position?
Maintain the patient’s cervical neck alignment; protect the patient’s forehead, eyes, ears, and chin; use chest rolls to allow chest movement and decrease abdominal pressure; position the patient’s toes to hang over the end of the bed or to be raised off the bed with padding under the shins.
2. What areas on this patient are most likely to be injured as a result of poor positioning or inadequate padding?
Ocular injuries can occur due to direct pressure on the patient’s eyes. Brachial plexus damage can occur if the patient’s arms are positioned above the head. Ideally, the arms should be by the patient’s side or on padded arm boards at less than a 90-degree angle. Torsion or pressure can occur if the breasts and male genitalia are incorrectly positioned. Other pressure point areas of concern are the knees, elbows, shins, and iliac crests.
84
```
For which client preadmission testing laboratory result does the nurse take immediate action?
A. International normalized ratio 0.9
B. White blood cell count 8500/mm3
C. Serum potassium level 2.8 mEq/L
D. Serum sodium level 132 mEq/L
```
ANS: C
Rationale: The serum potassium level is significantly low (hypokalemia) and must be corrected before surgery. This level increases the risk for toxicity if the client is taking digoxin, slows recovery from anesthesia, and increases cardiac irritability. Although the serum sodium and INR are also low, they are not low enough to cause any problems. The white blood cell count is normal.
85
The client scheduled to have surgery today cannot read or write. The surgeon obtaining the consent wants to have the client’s spouse sign the consent instead. What is the nurse’s best action?
A. Nothing; a signed informed consent statement does not need to be obtained from this client.
B. Locate the spouse because the informed consent statement must be signed by the client’s closest relative.
C. Remind the surgeon that the client may sign the informed consent statement with an X in front of two witnesses.
D. Notify the administration because the court must appoint a legal guardian to represent the client’s best interests and give consent for all surgical procedures.
ANS: C
Rationale: The lack of ability to read or write does not constitute incapacity to give legal consent. If the client meets all other legal and clinical aspects of competence for self-determination, he or she has the right to consent directly by using either his or her own signature or an X to demonstrate consent if the act is witnessed by two people.
86
The client is NPO for surgery scheduled to occur in 4 hours. It is now 9 AM, and the client’s regularly prescribed oral drugs (digoxin 0.125 mg, docusate [Colace] 300 mg, and ferrous fumarate [Feostat] 325 mg) are due to be administered. The physician will not be available until the time of surgery. What is the nurse’s best action?
A. Administer digoxin with minimal water and hold the other drugs.
B. Administer all medications parenterally.
C. Administer all medications orally.
D. Hold all medications.
ANS: A
Rationale: Regularly scheduled cardiac medications should be administered on schedule. If taken with only a few small sips of water at least 2 hours before surgery, the amount of water should not increase the risk of intraoperative or postoperative aspiration. However, not administering this drug could result in cardiac complications during surgery.
87
The patient is a 70-year-old woman scheduled to have knee surgery. She has signed her consent form for a right total knee replacement. After confirming the identity of the patient and the correct site, side, and procedure, you inform her that the surgeon will be marking the operative site. The patient states that she wants her grandchild to mark the site because she promised him the chance to draw on grandma’s leg.
1. How would you respond to the patient’s request?
Acknowledge the patient’s request and inform her of the necessity of marking the surgical site according to facility policy and procedure and that it is in the best interest of patient safety. Explain the need to have the surgeon who is performing the surgery mark the site because there will be a final confirmation by all members of the team in the OR, including the surgeon, before the surgery begins.
2. How can you include the grandchild in the process in order not to disregard the patient’s request?
If possible, allow the grandchild to observe the surgeon marking the site. If supplies are available, provide paper and crayons and encourage the grandchild to draw a picture of how the surgeon marked the site.
88
You are about to send the patient, described earlier in the Decision-Making Challenge on p. 259, to the surgical suite. A partner of the operating surgeon, who has not met the patient, proceeds to implement the time-out, which provides a final assessment that includes that the correct patient, site, side, and procedure are identified. The patient is concerned, stating she thought that the surgeon would be here for this part.
1. As the patient advocate, how would you proceed with the time-out?
Pause the time-out, calm the patient, and inform the partner that it is the policy of the facility that the operating surgeon be present in the OR during the time-out. If needed, page the surgeon.
2. Which measures should the facility have in place to promote best practices for this process?
The facility should dictate:
a. Policy and procedure for implementing the Universal Protocol.
b. How the OR nurse should communicate the event to the leadership team.
c. The quality improvement process to evaluate the quality of patient care related to the Universal Protocol and the formulation of plans for corrective action.
3. What steps can be taken to prevent such an occurrence in the future?
The leadership team should:
a. Provide a copy of the policy and procedure to the medical director or chief of surgery so that the physicians are aware of the process.
b. Stress the importance of following The Joint Commission Universal Protocol and how it impacts facility accreditation.
c. Encourage a dialogue about the importance of correctly implementing the time-out with the anesthesia department, surgeons, and all surgical staff.
d. Schedule periodic educational sessions for all staff.
89
The postanesthesia recovery unit nurse is receiving a hand-off report from the nurse anesthetist and the circulating nurse for an 82-year-old client who had a 2-hour open reduction of a fractured elbow. For which reported information about the client or surgery does the receiving nurse ask the reporting team for more details?
A. The client is Jewish.
B. The estimated blood loss is 150 mL.
C. The client reported an allergy to codeine.
D. The total intraoperative urine output is 25 mL.
ANS: D
Rationale: The total intraoperative urine output is very low. Information regarding the client’s total intake, kidney function, and fluid status is needed.
90
A postoperative client’s arterial blood gas (ABG) values are pH 7.36, HCO3 21 mEq/L, PaCO2 35 mm Hg, PaO2 98 mm Hg. What is the nurse’s priority action?
A. Compare these values with the client’s preoperative ABG values.
B. Assess the airway and notify the physician.
C. Document the values as the only action.
D. Increase the oxygen flow rate.
ANS: C
Rationale: All of these ABG results are within the normal range and indicate adequacy of ventilation, gas exchange, and kidney function. Documentation is the only action that needs to be taken.
91
The client who had neck surgery to remove the entire thyroid gland is transferred to the medical-surgical unit after 4 hours in the PACU. The client reports difficulty swallowing. What is the nurse’s priority action?
A. Assess the client’s respiratory status.
B. Inspect the client’s throat with a penlight.
C. Adjust the position of the drain in the incision.
D. Reassure the client that this is a normal and common problem after anesthesia.
ANS: A
Rationale: Most clients have a sore throat for the first 12 to 24 hours after intubation during surgery, and this is made worse when the client tries to swallow. However, it is important for the nurse to differentiate soreness from true difficulty swallowing. Surgery in the neck area can cause swelling that reduces the lumen of the throat. This can cause respiratory impairment and swallowing difficulties. The most important action is to assess the airway and respiratory response to ensure that breathing impairment is not accompanying a swallowing problem.
92
When changing the client’s abdominal dressing on the second postoperative day, the nurse observes crusting on about half of the suture line and oozing of a small amount of serosanguineous drainage. What is the nurse’s best action?
A. Loosen the sutures or staples in the area where crusts have formed.
B. Clean the suture line with sterile saline and apply new dressings.
C. Gently remove the crusts and culture the material beneath.
D. Apply pressure over the incision and notify the surgeon.
ANS: B
Rationale: Serosanguineous drainage and a small amount of crusting are normal incision findings on the second postoperative day. The suture line needs to be cleaned and a new dressing applied. The other actions are inappropriate.
93
A 55-year-old female patient with a history of smoking and obesity is returned to the surgical unit after a 3-hour abdominal procedure. She has a nasogastric tube with orders for intermittent suction, a Foley catheter draining clear amber urine, an IV of 0.9% saline at 100 mL/hr, and an abdominal dressing that is dry and intact. Her vital signs are as follows: HR = 65 beats/min; BP = 138/80 mm Hg; R = 20; and T = 98.9° F. After the patient has been moved to the bed, she reports dull pain in her right calf. She is wearing thigh-high antiembolism stockings.
1. What additional assessment data should you obtain?
Compare the affected leg with the other limb, check peripheral pulses, assess the color and appearance of the skin, assess for the presence of warmth and swelling, and palpate for induration along the blood vessel.
2. Should the surgeon be notified? Why or why not?
Yes, the surgeon should be notified because these symptoms may be indicative of deep vein thrombosis.
3. If the physician diagnoses the patient with possible deep vein thrombosis, which tests and treatments should you anticipate for this patient?
Venous duplex ultrasonography, anticoagulation therapy (i.e., unfractionated heparin), baseline prothrombin time (PT), activated partial thromboplastin time (APPT or aPTT), international normalized ratio (INR), complete blood count, creatinine; bed rest, and elevation of the affected extremity
94
Who is the most likely person to administer blood products and an operating suite?
Circulating nurse
95
If a sterile gauze falls to the ground and hit the front of the surgeons down on the way down, what's the nurse do for proper infection control?
Picks the gauze up without touching the surgeon
96
During surgery, who is most responsible for monitoring for possible breaks and sterile technique?
Circulating nurse
97
The client has undergone an eight hour surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which finding?
Diminished peripheral pulses in the lower extremities
98
The nurse anesthetist notices that the surgical client has an unexpected rise in the end-tidal carbon dioxide level, with a decrease in oxygen saturation and sinus tachycardia. What is the nurses first action?
Immediately stop all inhalation anesthetic agents and succinylcholine
99
When does the intraoperative period begin?
The intraoperative period begins when the patient enters the surgical suite and ends at the time of transfer to the post anesthesia recovery area
100
What is an endoscope?
An endoscope is a tube that allows viewing and manipulation of internal body areas. These instruments may be rigid, semirigid, or flexible.
101
What is insufflation?
It is injecting gas or air into the cavity before the surgery to separate organs and improve visualization. This injection is known as insufflation and may contribute to complications and patient discomfort
102
What does the word anesthesia mean?
Negative sensation
103
What is anesthesia?
Anesthesia is an induced state of partial or total loss of sensation, occurring with or without loss of consciousness
104
What is malignant hyperthermia?
Malignant hypothermia is an acute, life-threatening complication of certain drugs used for general anesthesia. The reaction begins in skeletal muscle exposed to specific agents, causing increased calcium levels in muscle cells and increased muscle metabolism. Serum calcium and potassium levels are increased, as is the metabolic rate, leading to acidosis, cardiac dysrhythmias, and a high body temperature.
105
What is myoglobinuria?
The presence of muscle proteins in the urine
106
What do you do if your patient develops malignant hyperthermia?
- stop all inhalation anesthetic agents and succinylcholine
- administer dantrolene sodium
- administer 100% oxygen
- use active cooling techniques
107
What is unrecognized hypoventilation?
Unrecognized hypo ventilation occurs as an anesthesia induced complication. Failure to exchange gases adequately can lead to cardiac arrest, permanent brain damage and death.
108
What is the nurses role in the delivery of regional anesthesia?
- assisting the anesthesia provider
- observing for breaks in the sterile technique
- providing emotional support
- offering information and reassurance
- positions patient comfortably
109
When does the postoperative period begin?
Completion of surgery and transfer of the patient to either the post anesthesia care unit, or intensive care unit mark the beginning of the postoperative period.
110
True or false
The joint commissions national patient safety goals require that the anesthesia provider and circulating nurse give PACU nurse a verbal hand off report to communicate he patients conditions and care needs
True
111
How often are vital signs taken after surgery?
Once the patient is discharged from the PACU, vital signs are often measured every 15 minutes for four times, every 30 minutes for four times, every hour for four times, and then every 4 hours for 24 to 48
112
True or false
A respiratory rate of less than 10 breaths per minute may indicate anesthetic or opioid analgesic induced respiratory depression
True
113
When should you report BP changes?
Report blood pressure changes that are 25% higher or lower than values obtained by surgery
114
What solutions are used for fluid replacement in the PACU?
Isotonic solutions such as lactated ringers 0.9% sodium chloride (normal saline), and 5% dextrose win lactated ringers are used for IV fluid replacement
115
What % of patients experience GI upset after surgery.
30% experience nausea and vomitting
116
When does a surgical wound heal?
Around 2 weeks time ( not completely healed for 2 years till the scar is strengthened)
117
What is dehiscence?
Wound dehiscence is a partial or complete separation of the outer wound layers, sometimes described as splitting open of the wound
118
What is evisceration?
Wound evisceration is the total separation of all wound layers and protrusion of internal organs. Usually occurs between 5-10 days after surgery
119
Who starts the pain assessment ?
PACU nurse
120
When are sutures removed?
Skin sutures or staples are usually removed 5-10 days after surgery
121
Penrose drain vs. Jackson Pratt and hemovac drains
Penrose drain is placed into the external aspect of the incision and drains into the dressing and skin around incision
Jackson Pratt and hemovac drains are two self contained drainage systems that drain wounds directly through a tube via gravity and vacuum
122
What are the most common drugs given by he PCA method?
Morphine and hydromorphone
123
What technique do you use during dressing changes?
Aseptic technique
124
Which description best illustrates the beginning of the postoperative period?
Completion of the surgical procedure and transfer of patient to the post anesthesia care unit or PACU or intensive care unit
125
What is the primary purpose of the PACU?
Ongoing critical evaluation and stabilization of the patient
126
A patient develops respiratory distress after having a left total hip replacement. The patient develops labored breathing and a pulse oximetry reading is 83% on 2 L nasal cannula. Which intervention is appropriate for unlicensed personnel to perform?
Take vitals signs
127
Which signs and symptoms are considered postoperative complications?
Pulmonary embolism
Hypothermia
Wound evisceration
128
If a patient experiences wound dehiscence, which description illustrates what is happening with the wound?
A partial or complete separation of outer layers is present at incision site
129
A patient who is 2 days postop for abdominal surgery says I coughed and heard something pop. The nurses immediate assessment reveals an opened Incision with a portion of large intestine protruding. Which statements apply to this clinical situation?
This is an emergency situation
The wound must be kept moist with normal saline soaked sterile dressing
Incision eviseration has occurred
130
In the PACU, the nurse assesses that a patient is bleeding profusely from an abdominal incision. What actions in order of priority, does the nurse perform?
1. The nurse applies pressure to the dressing
2. Unlicensed as stove personnel are asked to get additional dressing supplies
3. The surgeon is paged
4. A complete blood count is ordered
131
What are respiratory related assessments?
1. Symmetrical chest wall expansion
2. Use of accessory muscles
3. Exhalation felt from nose and mouth
4. Sternal retraction
5. Vesicular crackles
6. Snoring
132
What are cardiovascular related assessments?
1. Absent dorsalis pedis pulsations
2. Negative Homans sign
3. Decreased blood pressure
4. Faint heart sounds
5. Simultaneous apical and radial pulsations
133
What are fluid electrolyte balance assessments?
1. Foley catheter to facilitate drainage
2. IV infusion of dextrose 5% ringers lactate
3. Decreased blood pressure
4. Dry mucous membranes
5. Vomiting
6. Tenting
7. Faint heart sounds
8. Vesicular crackles
134
What are neurological related assessment?
1. States name when asked
2. Pupils contract equally
3. Hands grip equal
135
What are renal/neurological related assessments?
1. Foley catheter to facilitate drainage
| 2. Dullness over symphis pubis
136
What are gastrointestinal related assessments?
1. Rounded firm abdomen
2. Vomiting
3. Nasogastric tube in place
4. Absent bowel sounds
137
What are integumentary related assessments?
1. Large amounts of drainage
2. Wound edges approx
3. Evisceration
4. Tenting
5. Wound dressing dry
6. Dehiscence
138
The client is admitted for surgery. Although not physically distressed the client appears apprehensive and withdrawn. What is the nurses best action?
Orient the client to the unit environment
139
What principle must a nurse consider when caring for a client with a closed wound drainage system?
Fluids flow from an area of higher pressure to one of lower pressure
140
A client has extensive, prolonged surgery. Which electrolyte levels of the nurse monitor most closely?
Potassium, release of adrenocortical steroids by the stress of surgery causes renal retention of sodium and excretion of potassium
141
A CBC, urinalysis, and x-ray examination of the chest are ordered for a client before surgery. The client asked why these tests are done. Which is the best reply by the nurse?
They are done to identify other health risks that may increase the risk involved with surgery
142
Immediately after receiving spinal anesthesia a client develops hypertension. To what physiologic change does the nurse attribute the decreased blood pressure?
Dilation of blood vessel, paralysis of the sympathetic vasomotor nerves after administration of a spinal anesthetic results in dilation of blood vessels, which causes a subsequent decrease in blood pressure
143
General anesthetics
1. Neuromuscular blocking agents: inhibit transmission of nerve impulses by binding with cholinergic receptor sites, antagonizing action of acetylcholine
2. Available in parenteral ( IV, IM ) and inhalation preparations
Examples: halothane, nitrous oxide, succinylcholine , ketamine
144
Local anesthetics
1. Block nerve impulse conduction and sensory, motor, and autonomic nerve cells by decreasing nerve membrane permeability to sodium ion influx, use for pain control without loss of consciousness
2. Used for obstetrics, dental, and minor surgical procedures
3. Available in topical, spinal, regional, and nerve block preparation
Examples: lidocaine, procaine, Novocain
145
Sedative/hypnotics
1. Used for short-term treatment of clients with situational anxiety and insomnia
2. Available in oral, parenteral ( IV, IM ) and rectal preparations
Examples: benzodiazepines, barbiturates, non-barbiturates
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Providing immediate care in the PACU
1. Maintain airway and respiration
- position onside with next slightly extended to prevent aspiration and accumulation of mucus secretions
- suction artificial airway and oral cavity is needed to remove secretions
- administer oxygen as needed
- keep artificial airway in place until gag reflects returns
147
A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions?
Frequent changes in position
This minimizes pooling of respiratory secretions and maximizes chest expansion, which aids in the removal of secretions. This helps maintain the airway and is an independent nursing function
148
What is the priority nursing intervention for a client during the immediate postoperative period?
Maintaining a patent airway
~Maintenance of a patent airway is always the priority because airway obstruction impedes breathing and may result in death
149
A nurse in the postanesthisa care unit (PACU) observes that after an abdominal cholecystectomy a client has serosainguineous drainage on the abdominal dressing. What is the next nursing action?
Reinforce the dressing
~ The nurse should anticipate drainage and reinforce the surgical dressing as needed
150
Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of ileus?
Impaired neural functioning
~ Paralytic ileus occurs when neurologic impulses are diminished as a result of anesthesia, infection, or surgery
151
A client experiences abdominal distention following surgery. Which nursing actions are appropriate?
Encouraging ambulation & auscultating bowel sounds
~Ambulation will stimulate peristalsis, increasing passage of flatus and decreasing distention
152
A nurse is applying a dressing to a clients surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated?
Capillary
~When a sterile surface becomes wet, microorganisms from the unsterile surface below the sterile field will be drawn up, contaminating the sterile field. The absorption of fluids by gauze results from the adhesion of water to the gauze threads, the surface tension of water causes contraction of the fiber, pulling fluid up the threads
153
A nurse is preparing to change a clients dressing. What is the reason for using surgical asepsis during the procedure?
Keeps the area free of microorganisms
~Surgical asepsis means that practices are employed to keep a defined site or objects free of all microorganisms
154
When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low fowlers position with the knees slightly bent and encourages the client to lie still. What is the next nursing action?
Cover the wound with a sterile towel moistened with normal saline
155
While caring for a client with a portable wound drainage system, a nurse observes that the collection container is half full and empties it. What is the next nursing intervention?
Compress the container before closing the port
~ A portable drainage system (jackson pratt, hemovac) is compressed before closing the port to reestablish the negative pressure necessary for suction
156
A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. What mediation does the nurse anticipate will be prescribed for this patient?
Absorbic acid (vitamin c)
~Vitamin C plays a major role in wound healing. It is necessary for the maintenance and formation of collagen, the major protein of most connective tissue
157
A client reports severe pain 2 days after surgery. Which initial action should the nurse take after assessing the character of pain?
Obtain the vital signs
~Immediately before administration of an analgesic, an assessment of vital signs is necessary to determine whether any contraindications to the medications exist
158
After abdominal surgery a client reports pain. What action should the nurse take first?
Determine the characteristic of pain
159
A client is extubated in the PACU after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress?
Restlessness
~Inadequate oxygenation of the brain may produce restlessness or behavioral changes. Your pulse increases with cerebral hypoxia and your pupils dilate
160
In the immediate postoperative period after a gastrectomy, the clients nasogastric tube is draining a light red liquid. For how long should the nurse expect this type of drainage?
10~12
~It takes about 10~12 hours for coagulation to occur so anything sooner or later than that is abnormal
161
A postoperative patient is diagnosed as having atelectasis. Which nursing assessment supports this diagnoses?
Diminshed breath sounds on auscultation
~Atelectasis refers to the collapse of alveoli, so breath sounds over the area are diminished. Crackles are associated with fluid in the alveoli, which occurs with heart failure and pulmonary edema
162
On which concern should the nurse focus on when caring for a client after abdominal surgery?
Identifying signs of bleeding
163
After an abdominal cholecystectomy, a client has a T tube attached to a collection device. On the day of surgery, at 10:30 pm, 300 ml bile is emptied from the collection bag. At 6:30 am the next day the bag contains 60 ml of bile. What does the nurse consider in response to this info?
Mechanical problems may have developed with the T tube
~ This amount of drainage is inadequate, 1000 ml of bile is expected in 24 hours via surgically implanted tube.
164
You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given the diagnoses of activity intolerance. Which action should you delegate to the UAP?
Encouraging, monitoring, and recording nutritional intake
165
What is the difference between urgent and emergent surgery ?
Urgent : requires prompt intervention
Emergent: requires IMMEDIATE intervention
166
Cardiovascular problems may cause as many as ______ of surgery related deaths
30%
167
How often should coughing and splinting be performed?
Coughing and splinting may be performed along with deep breathing every 1 to 2 hours after surgery
168
Who sets up the sterile table and drapes the patient?
Scrub nurses
169
True or false
| Scrub attire is clean but not sterile
True
170
How does malignant hyperthermia begin?
The reaction begins in skeletal muscle exposed to specific agents, causing increased calcium levels in muscle cells and increase muscle metabolism. Serum calcium and potassium levels are increased, as is the metabolic rate, leading to acidosis, cardiac dysrhythmias, and a high body temperature
171
What is the most sensitive indication of malignant hyperthermia?
The most sensitive indication is an unexpected rise in the end-tidal carbon dioxide level with a decrease in oxygen saturation. Another early indication is sinus tachycardia.
172
What is a late sign of malignant hyperthermia ?
Extremely elevated body temp, as high as 111.2
173
What is given to patients who suddenly develop unexplained bradycardia?
Epinephrine
174
True or false
| Cardiac arrest may occur as a result of spinal anesthesia
True
175
Which statement best describe the preoperative period?
1. It ends at the time of transfer to the surgical suite
2. It begins when the patient is scheduled for surgery
3. Is a time during which the patient receives testing and education related to impending surgery
176
The colostomies scheduled to be done on a patient with severe Crohn's disease. What is the correct classification for the surgery?
Palliative
177
The nurse has a patient in the holding area who scheduled for left tomorrow popliteal bypass. What are the priority safety measures for this patient before surgery?
1. The operative limb is marked by the surgeon
2. The patient is positively identified by checking the name and date of birth
3. The patient is asked to confirm the marked limb
178
In the preoperative setting, the nurse functions as a patient advocate when which factors are assessed in the discharge planning process
1. Support systems
2. Self care capabilities
3. Home environment
180
Which statement is true regarding the patient who has given consent for a surgical procedure
Info necessary to understand the nature of and reason fort eh surgery has been provided
181
1. How does palliative surgery differ from any other type of surgery?
A. The main purpose is cosmetic in nature rather than functional repair or comfort.
B. There are fewer risks associated with palliative surgery than with any other type of surgery.
C. The outcomes of palliative surgery cannot be ensured to produce the desired effect or restoration of functional ability.
D. Palliative surgery is performed to provide temporary relief of distressing symptoms rather than to cure a problem or condition.
ANS: D
The purpose of palliative surgery is to improve the client's quality of life by reducing or eliminating distressing symptoms. It does not cure a health problem and, often, does not prolong life. Although the exact outcomes of palliative surgery cannot be ensured, neither can the outcomes of any other type of surgery.
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2. The client tells the nurse during the preoperative history that he is a three-pack a day cigarette smoker. This information alerts the nurse to which potential complication during the intraoperative and postoperative periods?
A. A decreased tolerance to pain
B. A decreased clotting ability
C. An increased risk for atelectasis and hypoxia
D. An increased risk for excessive scar tissue formation
ANS: C
Smoking increases the level of circulating carboxyhemoglobin, which decreases oxygen delivery to the tissues. In addition, cigarette smoking damages the cilia of mucous membranes, decreasing transport of secretions and increasing the risk of pulmonary infection and atelectasis.
183
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3. The client receiving preoperative medication tells the nurse that all of the following medications (drugs or herbs) were ingested yesterday. Which one should the nurse report to the surgical team?
A. Acetaminophen (Tylenol)
B. Vitamin C
C. Motherwort
D. Diphenhydramine (Benadryl)
```
ANS: C
Motherwort interferes with coagulation, increasing the client's risk for bleeding during and after the surgical proceduere
184
. When the nurse brings the preoperative medication to the client about to have abdominal surgery, she tells the nurse that she does not need the injection because she had a good night's sleep last night. What is the nurse's best first action?
A. Tell the client that her surgeon has ordered the medication; therefore, she should go ahead and take the medication because the surgeon knows what is best.
B. Tell the client that the preoperative medication is ordered to reduce the risk of some problems during surgery rather than to ensure adequate rest.
C. Appropriately discard the preoperative medication and notify the surgeon.
D. Document the client's statement and notify the charge nurse.
ANS: B
The preoperative medication is prescribed to prevent a vagal response during intubation and surgery, reduce the amount of anesthetic needed during induction, and reduce anxiety.
185
5. The client who is scheduled to have surgery cannot read or write. The surgeon obtaining the consent wants to have the client's spouse sign the consent instead. What is the nurse's best action?
A. Nothing; a signed informed consent statement does not need to be obtained from this client.
B. Locate the spouse, because the informed consent statement must be signed by the client's closest relative.
C. Inform the surgeon that the client may sign the informed consent statement with an X in front of two witnesses.
D. Notify the administration because the court must appoint a legal guardian to represent the client's best interests and give consent for all surgical procedures.
ANS: C
The lack of ability to read or write does not constitute incapacity to give legal consent. If the client meets all other legal and clinical aspects of competence, he or she may use an X to demonstrate consent if the act is witnessed by two persons.
186
6. Twenty minutes after the client has received a preoperative injection of atropine and midazolam (Versed), the client tells the nurse that he must be allergic to the medication because his mouth is dry and his heart seems to be beating faster than normal. What is the nurse's best first action?
A. Document the findings as the only action.
B. Check the client's pulse and blood pressure.
C. Prepare to administer epinephrine and diphenhydramine (Benadryl).
D. Explain to the client that these symptoms are normal responses to the medication.
ANS: B
Although these are the expected physiologic responses to the preoperative medication, any time the client states that he or she can feel a change in normal cardiac function, the system should be assessed. If the client's pulse and blood pressure are within normal limits, the nurse should
187
7. Which nursing action or statement is most likely to reduce anxiety in a client being brought to the surgical suite?
A. Asking the client if he or she has talked with the hospital chaplain
B. Asking the client what specific surgery he or she is having done today
C. Asking the client if he or she wants family members to be with them in the holding area
D. Explaining to the client that the surgical area is the most technologically advanced in the city
ANS: C
Most anxious clients would feel some relief by having one or more familiar persons waiting with them until surgery begins. In addition, asking the client what he or she wants allows the client to have more control over the situation. Asking the client if he or she has visited with the hospital chaplain and telling the client about the advanced technology can imply to the client that the procedure is dangerous. Although the client must be asked what procedure he or she is having (to ascertain that the client does know what is to be done), this question may make the client worry about the competency of the staff.
188
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8. All of the members of the surgical team must perform a "surgical scrub" except which of the following?
A. Anesthetist/anesthesiologist
B. Surgical technologist
C. Scrub nurse
D. Surgeon
```
ANS: A
The anesthetist or anesthesiologist does not enter the sterile field. Caps, masks, scrub clothing, and scrub jackets are worn to prevent shedding of microorganisms, but sterile gloves and surgical scrubbing are not needed.
189
9. In the operating room, the client tells the circulating nurse that he is going to have the cataract in his left eye removed. The nurse notes that the consent form indicates that surgery is to be performed on the right eye. What is the nurse's best first action?
A. Assume that the client is a little confused because he is older and has received midazolam intramuscularly.
B. Check to see if the client has received any preoperative medications.
C. Notify the surgeon and anesthesiologist.
D. Ask the client his name.
ANS: D
Ensuring proper identification of the client is a responsibility of all members of the surgical team. Especially in a specialty surgical setting, where many people undergo the same type of surgery each day, such as cataract removal, it is possible that the client and the record do not match. The nurse identifies the client and the client's consent form before the physicians are notified.
190
10. The anesthetized client with an open abdomen suddenly develops malignant hyperthermia. What intervention should the nurse be prepared to initiate or assist with?
A. Discontinue mechanical ventilation.
B. Administer intravenous potassium chloride.
C. Administer intravenous calcium chloride.
D. Administer intravenous dantrolene (Dantrium).
ANS: D
Dantrolene is a skeletal muscle relaxant and can help lower body temperature by reducing metabolic heat production by the muscles. Clients become hyperkalemic and hypercalcemic; therefore, neither of these electrolytes should be administered. The client's gas exchange is severely compromised. If the client is not already receiving mechanical ventilation, it is initiated.``
191
11. What is the priority nursing diagnosis for the client under general anesthesia during surgery?
A. Acute Pain related to surgical procedure
B. Risk for Infection related to surgical wound
C. Risk for Impaired Skin Integrity related to prolonged static position
D. Disturbed Body Image related to presence of surgical wound or scar
ANS: C
| The problem that nursing is most responsible for with this client is ensuring maintenance of skin integrity
192
12. The client who has received ketamine hydrochloride during a surgical procedure has all of the following manifestations and behaviors. Which one alerts the nurse to a dissociative reaction?
A. Hypoventilation and decreased oxygen saturation
B. Presence of hives on the skin around the IV site
C. Crying because the pain at the surgical site has increased
D. Pulling out the IV because he sees bugs in the solution bag
ANS: D
Ketamine hydrochloride induces dissociative reactions such as hallucinations, distorted images, and irrational behavior during emergence from the anesthesia.
193
3. Who is responsible for accompanying the surgical client to the postanesthesia recovery area after surgery and for giving a report of the client's intraoperative experience to the PACU nurse?
A. The surgeon and scrub nurse
B. The surgeon and circulating nurse
C. The anesthesiologist and scrub nurse
D. The anesthesiologist and circulating nurse
```
ANS: D
The anesthesiologist (or certified registered nurse anesthetist) and the circulating nurse are responsible for accompanying the client to the postoperative recovery area and giving a report of the client's intraoperative experience.
```
194
14. The client is admitted to the postanesthesia care unit (PACU) after surgery that took place with the client in the lithotomy position. Which change in assessment findings alerts the nurse to a possible complication of this surgical position?
A. The electrocardiogram (ECG) shows tall, peaked T waves and wide QRS complexes.
B. The client only arouses in response to light shaking.
C. The pulse pressure has increased from 28 to 40 mm Hg.
D. The dorsalis pedis pulses are not palpable bilaterally.
ANS: D
| The lithotomy position can compromise the client's peripheral circulation in the lower extremities.
195
15. Which client is at greatest risk for respiratory complications after surgery under general anesthesia?
A. 65-year-old woman taking a calcium channel blocker for hypertension
B. 55-year-old man with chronic allergic rhinitis
C. 45-year-old woman with diabetes mellitus type 1
D. 35-year-old man who smokes two packs of cigarettes daily
ANS: D
Cigarette smoking greatly increases the risk for pulmonary problems following general anesthesia because the cilia of the mucous membranes may be absent or hypoactive, the lining of the airways may be hypertrophied, and the alveoli may be less compliant. Age and gender are not significant in this case.
196
16. Two hours after abdominal surgery, the nurse auscultates the client's abdomen. No bowel sounds are present. What is the nurse's best first action?
A. Position the client on the right side with the bed flat.
B. Check the dressing and apply an abdominal binder.
C. Palpate the bladder and measure abdominal girth.
D. Document the finding as the only action.
ANS D
Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that should be documented. No intervention specific to this finding is needed at this time.
197
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17. Calculate the actual amount of nasogastric (NG) tube drainage during an 8-hour shift (3 PM to 11 PM) from the client who has a drainage container with 200 mL marked at 3 PM and 840 mL at 11 PM, and who received NG irrigations (flushings) of 60 mL three times during the 8-hour shift.
A. 840 mL
B. 660 mL
C. 460 mL
D. 420 mL
```
ANS: C
The initial volume of 200 mL is subtracted from the 840 mL, leaving 640 mL. The irrigation fluid is not drainage and also must be subtracted (60 3 = 180 mL). The total drainage from this client's NG tube during the 8-hour shift was 460 mL (640 180 = 460 mL).
198
8. The client who is 24 hours postoperative from abdominal surgery has light brown fluid with small particles that look like coffee grounds in the NG tube drainage. What is the nurse's best action?
A. Notify the physician.
B. Irrigate the tube with normal saline.
C. Clamp the tube and advance it 1 to 2 inches.
D. Document the finding as the only action.
ANS: A
| This type of drainage indicates possible gastrointestinal bleeding and should be explored further as soon as possible.
199
9. The nurse empties 80 mL of sanguineous drainage from the Jackson-Pratt drain in the client's hip after hip surgery. What other actions regarding the drain should the nurse take?
A. Flush the tubing with urokinase to ensure patency.
B. Compress and close the drain to ensure suction.
C. Advance the tubing ½ inch from the insertion site.
D. Clamp the drain for 2 hours and release the clamp for 2 hours.
ANS: B
The Jackson-Pratt drain removes fluid from the wound through closed suction. The drain must be compressed and closed to create suction as it slowly re-expands.
200
20. The client is postoperative from surgery performed to determine whether a growth in her colon is cancerous. She asks the nurse what the pathology report shows. The pathology report indicates that the growth is benign. What is the nurse's best response?
A. "Congratulations! The growth was not cancerous."
B. "You will have to wait for your doctor to tell you the results."
C. "You shouldn't worry. Most tumors of this sort are benign."
D. "I will call your doctor to let her know you are awake and are concerned about the results."
ANS: D
Unless there are specific orders to tell the client the pathology results, the surgeon is the person to explain them to the client.
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Which principal nursing actions best support a focus on client safety? Select all that apply.
Client restraints
Handwashing
Preoperative checklists
Respect for others
Five rights of drug administration
```
Handwashing, preoperative checklist, five rights of drug admin
202
A nursing student has been assigned to the hospital's Rapid Response Team (RRT). Which statement by the student indicates a correct understanding of the RRT member's purpose?
"I will be caring for clients in the hospital."
"I will be riding along in the hospital's ambulance."
"I will be admitting clients to the hospital."
"I will be observing code 'blue' resuscitations."
"I will be caring for clients in the hospital."
203
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A nurse supports the client and family in deciding on a "Do Not Resuscitate" order. Which ethical principle that guides nursing clinical decision making is demonstrated in this situation?
Beneficence
Justice
Legality
Self-determination
```
Self-determination refers to the idea that clients are autonomous individuals capable of making informed decisions about their care. When the client is not capable of self-determination, the nurse is ethically obligated to protect the client as an advocate in the professional scope of practice.
204
A 78-year-old Mexican American client is admitted to the hospital for hypertension. His wife passed away 6 months ago, and his only child still lives in Mexico. Which intervention does the nurse use in dealing with this client following his admission?
Assess the client for his use of folk medicine.
Call the client's child and explain why his father needs him.
Present all information on hypertension to the client in one teaching session.
Provide a pamphlet on hypertension for initial education.
Assess the client for his use of folk medicine.
205
Bedside computers are an example of informatics used in health care primarily for which purpose?
Documenting interdisciplinary care
Enhancing collaboration and coordination of care
Offering clients access to e-mail and the Internet
Retrieving data for the evidence-based practice
Documenting interdisciplinary care
206
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A nurse is asked to collaborate with others to implement an interdisciplinary (ID) plan of care for a client. Which health care team members are essential for the client's daily care regimen? Select all that apply.
Anesthesiologist
Case Manager
Health Care Provider
Occupational therapist
```
Case Manager
| Health Care Provider
207
Which of these hospital staff members will the nurse manager assign to coordinate the discharge of a client who will need community-based rehabilitation services after a traumatic injury?
The nurse who is responsible for the client's case management
The physical therapist who developed the client's exercise program
The physician who is assigned as the client's medical resident
The unit-based RN who has cared for the client during the hospital stay
The physical therapist who developed the client's exercise program
Which of these hospital staff members will the nurse manager assign to coordinate the discharge of a client who will need community-based rehabilitation services after a traumatic injury?
The nurse who is responsible for the client's case management
The physical therapist who developed the client's exercise program
The physician who is assigned as the client's medical resident
The unit-based RN who has cared for the client during the hospital stay
208
```
A nurse educator is instructing newly hired registered nurses about patient-centered care. Which competency categories are included in this content? Select all that apply.
Attitudes
Environments
Judgments
Knowledge
Skills
Values
```
Attitudes, knowledge , skills
209
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In going through the preoperative checklist, the nurse notices that the client's armband does not match the handwritten name on the informed consent, but it matches the stamped name. What does the nurse do first?
Calls admissions
Cancels the surgery
Contacts the surgeon
Talks to the operating team
```
Talks to the operating team
210
```
Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist?
Creatinine, 1.9 mg/dL
Fasting glucose, 80 mg/dL
Potassium, 3.9 mEq/L
Sodium, 140 mEq/L
```
Creatinine, 1.9 mg/dL
211
The nurse is instructing the client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching?
"I will take off my stockings one to three times a day for 30 minutes."
"My stockings are too loose."
"These stockings will prevent blood clots."
"These stockings help promote blood flow."
"These stockings will prevent blood clots
212
Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area?
Provide preoperative teaching to a client who needs insertion of a tunneled central venous catheter.
Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer.
Obtain the medical history from a client who is scheduled for a total hip replacement.
Assess the client who is being admitted for an elective laparoscopic cholecystectomy.
Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer.
213
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Who is the most likely person to administer blood products in an operating suite?
Circulating nurse
Holding area nurse
Scrub nurse
Specialty nurse
```
Circulating nurse
214
The charge nurse for a hospital operating room is making client assignments for the day. Which client is most appropriate to assign to the least-experienced circulating nurse?
A 20-year-old client who has a ruptured appendix and is having an emergency appendectomy
A 28-year-old client with a fractured femur who is having an open reduction and internal fixation
A 45-year-old client with coronary artery disease who is having coronary artery bypass grafting
A 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed
A 52-year-old client with stage I breast cancer who is having a tunneled central venous catheter placed
215
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In conducting a postoperative assessment of the client, what is most important for the nurse to examine first?
Breathing pattern
Level of consciousness
Oxygen saturation
Surgical site
```
Breathing pattern
216
How does the nurse position the client with postoperative respiratory depression?
Flat in bed, with the head in alignment with the body
Prone, with the head of the bed flat
Side-lying, with the head in a neutral position
Supine in bed, with the neck flexed
Side-lying, with the head in a neutral position
217
.
Which of these RNs who have been floated to the postanesthesia care unit (PACU) for the day should the charge nurse assign to care for an 18-year-old diabetic client who has just arrived from the operating room (OR) after having laparoscopic abdominal surgery?
An RN who usually works on the inpatient pediatric unit
An RN who provides education to diabetic clients in a clinic
An RN who has 5 years of experience in the delivery room
An RN who ordinarily works as a scrub nurse in the OR
An RN who has 5 years of experience in the delivery room
218
After gastric surgery, a client arrives in the postanesthesia care unit (PACU). Which of these nursing actions is most appropriate for the RN to delegate to an experienced nursing assistant?
Monitor respiratory rate and airway patency.
Irrigate the nasogastric tube with saline.
Position the client on the left side.
Assess the client's pain level.
Position the client on the left side.
219
The RN has just received reports about all of these clients on the inpatient surgical unit. Which client would the nurse care for first?
A 43-year-old client who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing
A 46-year-old client who had a thoracotomy 5 days ago and needs discharge teaching before going home
A 48-year-old client who had bladder surgery earlier in the day and is complaining of pain when coughing
A 49-year-old client who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4° F (38° C)
A 43-year-old client who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing
