PERIOPERATIVE TEST EXAM Questions WITH 100% CORRECT ANSWERS Latest Updates 2024.pdf, Exams of Nursing

Download PERIOPERATIVE TEST EXAM Questions WITH 100% CORRECT ANSWERS Latest Updates 2024.pdf and more Exams Nursing in PDF only on Docsity! PERIOPERATIVE TEST EXAM Questions WITH 100% CORRECT ANSWERS Latest Updates 2024 The nurse requests a client to sign the surgical consent form for an emergency appendectomy. Which statement by the client indicates that further teaching is needed? 1. "I will be glad when this is over so that I can go home." 2. "I will not be able to eat or drink anything prior to my surgery." 3. "I need to practice relaxing by listening to my favorite music." 4. "I will need to get up and walk as soon as possible." - ANS: 1 When recuperating from emergency surgery, the client will be in the hospital for a few days. This is not a day-surgery procedure. The client needs more teaching. 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 that the family member take the medal prior to surgery. 4. Explain that taking the medal to surgery is against the policy. - ANS: 2 The medal should be taped and the client should be allowed to wear the medal because meeting spiritual needs is essential to this client's care. The nurse must obtain surgical consent forms for the following clients who are scheduled for surgery. Which client would not be able to consent 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. - ANS: 3 A 16-year-old client is not legally able to give permission for surgery unless the adolescent is given an emancipated status by a judge. This information was not given in the stem. When 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. - ANS:4 Completing the preoperative checklist has the highest priority to ensure that all details are completed without omissions. When interviewing the surgical client in the holding area, which information should the nurse report to the health-care provider? Select all that apply. 1. The client has loose, decayed teeth. 2. The client is experiencing anxiety. 3. The client smokes 2 packs of cigarettes a day. client's anxiety. The client is scheduled for total hip replacement. Which behavior indicates to the nurse 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 takes three slow, deep, breaths and coughs forcefully after inhaling for the third time. 3. The client uses the incentive spirometer and inhales slowly and deeply so that 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. - ANS: 4 The correct way to get out of bed postoperatively is to roll onto the side, grasp the side rail to maneuver to the side, and then push up with one hand while swinging the legs over the side. The client needs further teaching. While completing the preoperative assessment, the male client tells the nurse that he is 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 drug. 4. Document the allergy on the medication administration record. - ANS: 3 The nurse should first assess the events that occurred when the client took this medication because many clients think that a side effect, such as nausea, is an allergic reaction. 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 gm/dL. 4. Potassium 2.4 mEq/L. - ANS: 4 This potassium level is low and should be reported to the health-care provider because potassium is important for muscle function, including the cardiac muscle. 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 be administered by the anesthesiologist and change the tubing for the anesthesia machine. - ANS: 1 The circulating nurse has many responsibilities in the OR, including coordinating the activities in the OR; keeping the OR clean; ensuring the safety of the client; and maintaining the humidity, lighting, and safety of the equipment. While working in the operating room 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. Take the sponge out of the room immediately. - ANS: 3 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 a desig- nated area to be counted later. While the circulating nurse compares the final sponge count with that of the scrub nurse, a discrepancy in the count is found. 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. - ANS: 4 A recount 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. Which violation of surgical asepsis would require immediate intervention by the circu- lating 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. - ANS: 4 According to the Centers for Disease Control (CDC), the American Operating Room Nurses Association (AORN), and the Association of Professionals in Infection Control, artificial nails harbor microorganisms, which increase the risk for infection. The nurse identifies the nursing diagnosis "risk for injury related to positioning" for the client in the operating room. Which nursing action should the nurse implement? 1. Avoid using the cautery unit that does not have a biomedical tag on it. 2. Carefully pad the client's elbows before covering the client with a blanket. 3. Apply a warming pad on the OR table before placing the client on the table. 4. Check the chart for any prescription or over-the-counter medication use. - ANS: 2 4. Obtain fingerstick blood glucose immediately. - ANS: 1 Unexplained tachycardia, hypotension, and elevated temperature are signs of malignant hyperthermia, which is treated with ice packs and Dantrolene sodium. When developing the plan of care for the surgical client having sedation, which intervention has highest priority for the nurse? 1. Assess the client's respiratory status. 2. Monitor the client's urinary output. 3. Take a 12-lead ECG prior to injection. 4. Attempt to keep the client focused. - ANS: 1 Assessing the respiratory rate, rhythm, and depth is the most important action. When receiving the client from the OR, which intervention should the PACU nurse implement first? 1. Assess the client's breath sounds. 2. Apply oxygen via nasal cannula. 3. Take the client's blood pressure. 4. Monitor the pulse oximeter reading. - ANS: 1 The airway should be assessed first. When caring for a client, the nurse should follow the ABCs: airway, breathing, and circulation. Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia? 1. Loss of sensation on the lumbar (L5) dermatome. 2. Absence of the client's posterior tibial pulse. 3. The client has a respiratory rate of eight (8). 4. The blood pressure is within 20% of client's baseline. - ANS: 3 If the effects of the spinal anesthesia move up rather than down the spinal cord, respirations can be depressed and even blocked. After transferring the client from the PACU to the surgical unit, the client's vital signs are T 98F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3). The client's skin is pale and damp. Which intervention should the nurse implement first? 1. Call the surgeon and report the vital signs. 2. Start an IV of D5RL with 20 mEq KCl at 125 mL/hour. 3. Elevate the feet and lower the head. 4. Monitor the vital signs every 15 minutes. - ANS: 3 By lowering the head of the bed and raising the feet, the blood is shunted to the brain until volume-expanding fluids can be administered, which is the first intervention for a client who is hemorrhaging. The nurse receives a report that the postoperative client received Narcan, an opioid antagonist, in PACU. Which client problem should the nurse add to the plan of care? 1. Alteration in comfort. 2. Risk for depressed respiratory pattern. 3. Potential for infection. 4. Fluid and electrolyte imbalance. - ANS: 2 Aclientwithrespiratorydepressiontreated with Narcan can have another episode within 15 minutes after receiving the drug as a result of the short half-life of the medication. The 26-year-old male client in the PACU has a heart rate of 110, has a rising temper- ature, and complains of muscle stiffness. Which interventions should the nurse imple- ment? Select all apply. 1. Give a back rub to the client to relieve stiffness. 2. Apply ice packs to axillary and groin areas. 3. Prepare a nice slush for the client to drink. 4. Prepare to administer Dantrolene, a smooth-muscle relaxant. 5. Reposition the client on a warming blanket. - ANS: 2,3,4 2. Ice packs should be applied to the axillary and groin areas for a client experiencing malignant hyperthermia. 3. The client would be NPO to prepare for intubation, but an ice slush would be used to irrigate the bladder and stomach per nasogastric tube. 4. Dantrolene is the drug of choice for treatment. Which data indicate the nursing care has been effective for the client who is one (1) day postoperative surgery? 1. Urine output was 160 mL in the past eight (8) hours. 2. Bowel sounds occur four (4) times per minute. 3. T 99.0F, P 98, R 20, and BP 100/60. 4. Lungs are clear bilaterally in all lobes. - ANS: 4 Lung sounds that are clear bilaterally in all lobes indicate the client has adequate gas exchange, which prevents postoperative complications and indicates effective nursing care. When working on the surgical floor, which task can the nurse delegate to the unli- censed nursing assistant (NA)? 1. Take vital signs every four (4) hours. 2. Check the Jackson-Pratt insertion site. 3. Hang the client's next IV bag. 4. Ensure that the client gets pain relief. - ANS: 1 Taking the vital signs of the stable client may be delegated to the NA. The charge nurse is making the shift assignments. Which postoperative client would be the most appropriate assignment to the graduate nurse? 1. The four (4)-year-old client who had a tonsillectomy and is swallowing frequently. 2. The 74-year-old client with a repair of the left hip who is unable to ambulate. 3. A 24-year-old client who had an uncomplicated appendectomy the previous day. 4. An 80-year-old client with small bowel obstruction and congestive heart failure. - ANS: 3 1. Administer pain medication as soon as the time frame allows. 2. Use nonpharmacological methods to replace medications. 3. Use cryotherapy after heat therapy because it works faster. 4. Instruct family members to administer medication with the PCA. - ANS: 1 Pain medications should be administered at the frequency ordered by the HCP, not just when the client requests them, especially for acute pain. Which situation is an example of the nurse fulfilling the role of client advocate? 1. The nurse brings the client pain medication when it is due. 2. The nurse collaborates with other disciplines during the care conference. 3. The nurse contacts the health-care provider when pain relief is not obtained. 4. The nurse teaches the client to ask for medication before the pain gets to a "5." - ANS: 3 When the nurse contacts the HCP about unrelieved pain, the nurse is speaking when the client cannot, which is the definition of a client advocate. Which statement would be an expected outcome for a client experiencing acute pain? 1. The client will have decreased use of medication. 2. The client will participate in self-care activities. 3. The client will use relaxation techniques. 4. The client will repeat instructions about medications. - ANS: 2 Clients experiencing acute pain will not be involved in self-care because of their reluctance to move, which increases the pain; therefore, participation indicates the client's pain is tolerable. Which intervention has the highest priority when administering pain medication to a client experiencing acute pain? 1. Monitor the client's vital signs. 2. Verify the time of the last dose. 3. Check for the client's allergies. 4. Discuss the pain with the client. - ANS: 3 The face scale is the best way to assess pain for a four (4)-year-old child. Which intervention should the nurse delegate to the unlicensed nursing assistant when caring for the client experiencing acute pain? 1. Take the pain medication to the room. 2. Apply an ice pack to the site of pain. 3. Check on the client 30 minutes after he or she takes the pain medication. 4. Observe the patient's ability to use the PCA. - ANS: 2 This task does not require teaching, evaluating, or nursing judgment and therefore could be delegated. When administering an opioid narcotic, which interventions should the nurse imple- ment to provide for client safety? Select all that apply. 1. Compare the hospital number on the MAR to the client's bracelet. 2. Have a witness verify the wasted portion of the narcotic. 3. Assess the client's vital signs prior to administration. 4. Determine if the client has any allergies to medications. 5. Clarify all orders with the health-care provider. - ANS: 1,3,4 1.This procedure ensures client safety by preventing medication from being given to the wrong client. 3. This intervention would prevent giving a narcotic to a client who is unstable or compromised. 4. Determining allergies addresses client safety. Which intervention would be the best way for the nurse to assess a four (4)-year-old client for acute pain? 1. Use words that a four (4)-year-old child can remember. 2. Explain the 0-10 pain scale to the child's parent. 3. Have the child point to the face that describes the pain. 4. Administer the medication every four (4) hours. - ANS: 3 The face scale is the best way to assess pain for a four (4)-year-old child. before. b. The patient is planning to drive home after surgery. c. The patient's insurance does not cover outpatient surgery. d. The patient had a glass of water a few hours before arriving. - ANS: B After outpatient surgery, the patient should not drive home and will need assistance with transportation and home care. The patient's experience with outpatient surgery is assessed, but it does not have as much application to the patient's physiologic safety. The patient's insurance coverage is important to establish, but this is not usually the nurse's role or a priority in nursing care. Having clear liquids a few hours before surgery does not usually increase risk for aspiration. A 36-year-old woman is admitted for an outpatient surgery. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery? a. The patient's lack of knowledge about postoperative pain control measures b. The patient's statement that her last menstrual period was 8 weeks previously c. The patient's history of a postoperative infection following a prior cholecystectomy d. The patient's concern that she will be unable to care for her children postoperatively - ANS: B This statement suggests that the patient may be pregnant, and pregnancy testing is needed before administration of anesthetic agents. Although the other data also may be communicated with the surgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery. A patient who is scheduled for surgery in a week tells the nurse doing the preoperative assessment about an allergy to bananas, kiwifruit, and latex products. Which action is most important for the nurse to take? a. Notify the dietitian about the food allergies. b. Alert the surgery center about the latex allergy. c. Reassure the patient that all allergies are noted on the medical record. d. Ask whether the patient uses antihistamines to reduce allergic reactions. - ANS: B When a patient is allergic to latex, special nonlatex materials are used during surgical procedures and the staff will need to know about the allergy in advance to obtain appropriate nonlatex materials and have them available on the surgical date. The other actions also may be appropriate, but prevention of allergic reaction (either contact dermatitis or anaphylaxis) during surgery is the most important action. Any patient guilt about having a therapeutic abortion may be identified when the nurse assesses the functional health pattern of _____________. a. value-belief. b. cognitive-perceptual. c. sexuality-reproductive. d. coping-stress tolerance. - ANS: A The value-belief pattern includes information about conflicts between a patient's values and proposed medical care. In the cognitive-perceptual pattern, the nurse will ask questions about pain and sensory intactness. The sexuality-reproductive pattern includes data about the impact of the surgery on the patient's sexuality. The coping-stress tolerance pattern assessment will elicit information about how the patient feels about the surgery. During the preoperative assessment of a patient scheduled for a colon resection, the patient tells the nurse about using St. John's wort to prevent depression. The nurse should alert the staff in the postanesthesia recovery area that the patient may a. experience increased pain. b. have hypertensive episodes. c. take longer to recover from the anesthesia. d. have more postoperative bleeding than expected. - ANS: C St. John's wort may prolong the effects of anesthetic agents and increase the time to waken completely after surgery. It is not associated with increased bleeding risk, hypertension, or increased pain. On the day of surgery, the nurse is admitting a patient with a history of cigarette smoking. Which action is most important at this time? Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for a colon resection? a. Care for the surgical incision b. Medications used during surgery c. Deep breathing and coughing techniques d. Oral antibiotic therapy after discharge home - ANS: C Preoperative teaching, demonstration, and redemonstration of deep breathing and coughing are needed on patients having abdominal surgery to prevent postoperative atelectasis. Incisional care and the importance of completing antibiotics are better discussed after surgery, when the patient will be more likely to retain this information. The patient does not usually need information about medications that are used intraoperatively. Ten minutes after receiving the ordered preoperative opioid by intravenous (IV) injection, the patient asks to get up to go to the bathroom to urinate. The most appropriate action by the nurse is to a. assist the patient to the bathroom and stay with the patient to prevent falls. b. offer a urinal or bedpan and position the patient in bed to promote voiding. c. allow the patient up to the bathroom because the onset of the medication takes more than 10 minutes. d. ask the patient to wait because catheterization is performed at the beginning of the surgical procedure. - ANS: B The patient will be at risk for a fall after receiving the opioid, so the best nursing action is to have the patient use a bedpan or urinal. Having the patient get up either with assistance or independently increases the risk for a fall. The patient will be uncomfortable and risk involuntary incontinence if the bladder is full during transport to the operating room. An alert 82-year-old who has poor hearing and vision is receiving preoperative teaching from the nurse. His wife answers most questions directed to the patient. Which action should the nurse take when doing the teaching? a. Use printed materials for instruction so that the patient will have more time to review the material. b. Direct the teaching toward the wife because she is the obvious support and caregiver for the patient. c. Provide additional time for the patient to understand preoperative instructions and carry out procedures. d. Ask the patient's wife to wait in the hall in order to focus preoperative teaching with the patient himself. - ANS: C The nurse should allow more time when doing preoperative teaching and preparation for older patients with sensory deficits. Because the patient has visual deficits, he will not be able to use written material for learning. The teaching should be directed toward both the patient and the wife because both will need to understand preoperative procedures and teaching. A diabetic patient who uses insulin to control blood glucose has been NPO since midnight before having a mastectomy. The nurse will anticipate the need to a. withhold the usual scheduled insulin dose because the patient is NPO. b. obtain a blood glucose measurement before any insulin administration. c. give the patient the usual insulin dose because stress will increase the blood glucose. d. administer a lower dose of insulin because there will be no oral intake before surgery. - ANS: B Preoperative insulin administration is individualized to the patient, and the current blood glucose will provide the most reliable information about insulin needs. It is not possible to predict whether the patient will require no insulin, a lower dose, or a higher dose without blood glucose monitoring. The clinic nurse reviews the complete blood cell count (CBC) results for a patient who is scheduled for surgery in a few days. The results are white blood cell count (WBC) 10.2 ⋅ 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 ⋅ 103/µL. Which action should the nurse take? a. Send the CBC results to the surgery facility. b. Call the surgeon and anesthesiologist immediately. c. Ask the patient about any symptoms of a anesthetic, which info is most important to communicate to the surgeon and anesthesiologist before surgery? a. The patient drinks 3 or 4 cups of coffee every morning before going to work. b. The patient takes a baby aspirin daily but stopped taking aspirin 10 days ago. c. The patient drank 4 ounces of apple juice 3 hours before coming to the hospital. d. The patient's father died after receiving general anesthesia for abdominal surgery. - ANS: D The information about the patient's father suggests that there may be a family history of malignant hyperthermia and that precautions may need to be taken to prevent this complication. Current research indicates that having clear liquids 3 hours before surgery does not increase the risk for aspiration in most patients. Patients are instructed to discontinue aspirin 1 to 2 weeks before surgery. The patient should be offered caffeinated beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not have preoperative implications. Which information about medication use in a preoperative patient is most important to communicate to the health care provider? a. The patient uses acetaminophen (Tylenol) occasionally for aches and pains. b. The patient takes garlic capsules daily but did not take any on the surgical day. c. The patient has a history of cocaine use but quit using the drug over 10 years ago. d. The patient took a sedative medication the previous night to assist in falling asleep. - ANS: B Chronic use of garlic may predispose to intraoperative and postoperative bleeding. The use of a sedative the previous night, occasional acetaminophen use, and a distant history of cocaine use will not usually affect the surgical outcome. A 24-year-old who takes a diuretic and a β-blocker to control blood pressure is scheduled for abdominal surgery. Which patient information is most important to communicate to the health care provider before surgery? a. Pulse rate 59 b. Hematocrit 35% c. Blood pressure 142/78 d. Serum potassium 3.3 mEq/L - ANS: D The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of patient anxiety. The heart rate would be expected in a patient taking a β-blocker. The hematocrit is in the low normal range but does not require any intervention before surgery. The perioperative nurse encourages a family member or a friend to remain with a patient in the preoperative holding area until the patient is taken into the operating room primarily to a. ensure the proper identification of the patient before surgery. b. protect the patient from cross-contamination with other patients. c. assist the perioperative nurse to obtain a complete patient history. d. help relieve the stress of separation for the patient and significant others. - ANS: D The presence of a family member or friend reduces the stress associated with the preoperative period. Although the family may give information about the patient's name and history, this information is obtained and confirmed by the nurse in other ways. Nursing staff, rather than family members, are responsible for prevention of cross-contamination. Which description best defines the role of the nurse anesthetist as a member of the surgical team? a. Functions independently in the administration of anesthetics b. Has the same credentials and responsibilities as an anesthesiologist c. Is responsible for intraoperative administration of anesthetics ordered by the anesthesiologist d. Requires supervision by the anesthesiologist or surgeon while administering anesthesia to a patient - ANS: A The certified registered nurse anesthetist (CRNA) is independently responsible for all aspects of the administration of anesthetic agents. Although the responsibilities of a CRNA and an The patient with arthritis may require special positioning to avoid injury and postoperative discomfort. Preoperative anxiety and having a sip of water 2 to 3 hours before surgery are not unusual for the preoperative patient. An allergy to cats and dogs will not impact the care needed during the intraoperative phase. The nurse from the general surgical unit is asked to bring the patient's hearing aid to the surgical suite. The nurse will take the hearing aid to the a. clean core. b. scrub sink areas. c. nursing station or information desk. d. corridors of the operating room area. - ANS: C The nurse from the general unit would not be wearing surgical scrub attire or a head covering and would be restricted to the nursing station or information desk, which are unrestricted areas. The clean care, scrub sink area, and corridors are semirestricted areas that require staff members wear surgical scrub attire and head coverings. A preoperative patient in the holding area asks the nurse, "Will the doctor put me to sleep with a mask over my face?" The most appropriate response by the nurse is, a. "A drug will be given to you through your IV line, which will cause you to go to sleep almost immediately." b. "Only your surgeon can tell you for sure what method of anesthesia will be used. Should I ask your surgeon?" c. "General anesthesia is now given by injecting medication into your veins, so you will not need a mask over your face." d. "Masks are not used anymore for anesthesia. A tube will be inserted into your throat to deliver a gas that will put you to sleep." - ANS: A The first step in general anesthesia is the injection of an intravenous (IV) induction agent, which rapidly induces sleep. The anesthesiologist (not the surgeon) determines the method of anesthesia used. Masks may still be used for inhalation, although many patients are intubated. Total IV anesthesia may be used for some patients but inhalation anesthetics also are commonly used. A surgical patient received a volatile liquid as an inhalation anesthetic during surgery. Postoperatively the nurse should monitor the patient for a. tachypnea. b. myoclonia. c. hypertension. d. incisional pain. - ANS: D Because volatile liquid inhalation agents are rapidly metabolized, postoperative pain occurs soon after surgery. Hypertension and tachypnea are not associated with general anesthetics. Myoclonia may occur with nonbarbiturate hypnotics but not with the inhaled inhalation agents. When the nurse caring for a patient before surgery has a question about a sedative medication to be given before sending the patient to the surgical suite, the nurse will communicate with the a. surgeon. b. anesthesiologist. c. circulating nurse. d. registered nurse first assistant (RNFA). - ANS: B The anesthesiologist is responsible for prescribing preoperative medications. The RNFA and surgeon are responsible for the surgery, but not for the preoperative sedation. The circulating nurse does not have authority to make a change in any medication. A patient with a dislocated shoulder is prepared for a closed, manual reduction of the dislocation with monitored anesthesia care (MAC). The nurse anticipates the administration of a. IV midazolam (Versed). b. inhaled desflurane (Suprane). c. epidural lidocaine (Xylocaine). d. eutectic mixture of local anesthetics (EMLA). - ANS: A IV sedatives such as the benzodiazipines are administered for MAC. Inhaled, epidural, and topical agents are not included in MAC. Which action will the nurse include in the plan of care immediately after surgery for a patient who received ketamine (Ketalar) as an anesthetic agent? a. Administer larger doses of analgesic agents. b. Monitor for severe slowing of the heart rate. The corridors outside the OR are part of the semirestricted area where personnel must wear surgical attire and head coverings. Surgical masks may be worn in the holding room, although they are not necessary. Street clothes may be worn at the nursing station, which is part of the unrestricted area. Wearing a mask and scrubs is essential when going into the OR. Which nursing action should the operating room (OR) nurse manager delegate to the registered nurse first assistant (RNFA)? a. Make surgical incisions and suture incisions as needed. b. Coordinate transfer of the patient to the operating table. c. Provide postoperative teaching about coughing to the patient. d. Set up instrument tables at the beginning of the surgical procedure. - ANS: A The role of the RNFA includes skills such as making and suturing incisions and maintaining hemostasis. The other actions should be delegated to other staff members such as the circulating nurse, scrub nurse, or surgical technician. Which of these actions included in the perioperative patient plan of care can the perioperative nurse delegate to a surgical technologist? a. Complete the patient's admission assessment. b. Pass sterile instruments and supplies to the surgeon. c. Teach the patient about what to expect in the operating room (OR). d. Give the postoperative report to the postanesthesia care unit (PACU) nurse. - ANS: B The education and certification for a surgical technologist includes the scrub and circulating functions in the OR. Patient teaching, communication with other departments about a patient's condition, and the admission assessment require RN level education and scope of practice. When preparing the patient for surgery, which actions will the nurse include in the surgical time-out procedure (select all that apply)? a. Check for placement of IV lines. b. Have the surgeon identify the patient. c. Confirm the hospital chart identification (ID) number. d. Have the patient state name and DOB e. Ask the patient to state the surgical procedure. f. Verify the patient ID band number. - ANS: C, D, E, F These actions are included in surgical time out. IV line placement and identification of the patient by the surgeon are not included in the surgical time-out procedure. A 42-year-old patient is recovering from anesthesia in the postanesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure falls to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at this time is to a. increase the rate of the IV fluid replacement. b. continue to take vital signs every 15 minutes. c. administer oxygen therapy at 100% per mask. d. notify the anesthesia care provider (ACP) immediately. - ANS: B A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration. During recovery from anesthesia in the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take at this time? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient from the PACU. d. Increase the rate of the postoperative IV fluids. - ANS: B The patient's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable BP and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU is not appropriate. a. Place the patient on bed rest. b. Notify the patient's surgeon. c. Document the color and amount of drainage. d. Irrigate the T-tube with sterile normal saline. - ANS: C A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary. In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which action by the nurse is most helpful? a. Discuss the complications of immobility and poor cough effort. b. Teach the patient the purpose of respiratory care and ambulation. c. Administer ordered analgesic medications before these activities. d. Give the patient positive reinforcement for accomplishing these activities. - ANS: C The most essential nursing action in encouraging these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities. The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when the a. patient drinks 2 to 3 L of fluid in 24 hours. b. patient uses the spirometer 10 qh c. patient's breath sounds are clear to auscultation. d. patient's temperature is less than 100.4° F orally. - ANS: C One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or wheezes, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems. A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 99%, and recent lab results are all normal. Which action by the nurse is most appropriate? a. Insert an oral or nasal airway. b. Notify the anesthesia care provider. c. Orient the patient to time, place, and person. d. Be sure that the patient's IV lines are secure. - ANS: D Because the patient's assessment indicates physiologic stability, the most likely cause of the patient's agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should ensure patient safety through interventions such as raising the bed rails and securing IV lines. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify the ACP. Insertion of an airway is not needed because the oxygen saturation is good. Orientation of the patient is needed but is not likely to be effective until the effects of anesthesia have resolved more completely. Which action should the postanesthesia care unit (PACU) nurse delegate to nursing assistive personnel (NAP) who help with the transfer of a patient to the surgical unit? a. Help with the transfer of the patient onto a stretcher. b. Give a verbal report to the surgical unit charge nurse. c. Document the appearance of the patient's incision in the chart. d. Ensure that the receiving nurse understands the postoperative orders. - ANS: A The scope of practice for nursing assistants includes repositioning and moving patients under the supervision of an RN. Providing report to another RN, assessing and documenting the wound appearance, and clarifying physician orders with another RN require RN level education and scope of practice. When a patient is transferred from the postanesthesia care unit (PACU) to the clinical surgical unit, the first action by the nurse on the surgical unit should be to While caring for a patient with abdominal surgery the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this finding, the nurse should first a. reinforce the dressing. b. take the patient's vital signs. c. recheck the dressing in 1 hour for increased drainage. d. notify the patient's surgeon of a potential hemorrhage. - ANS: B New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing. When caring for a patient during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 100.8° F. Which action should the nurse take first? a. Have the patient use the incentive spirometer. b. Assess the surgical incision for redness and swelling. c. Administer the ordered PRN acetaminophen (Tylenol). d. Notify the patient's health care provider about the fever. - ANS: A A temperature of 100.8° F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because evidence of wound infection does not usually occur before the third postoperative day, assessment of the incision is not likely to be useful. The nurse notes that the oxygen saturation is 88% in an unconscious patient who was transferred to the postanesthesia care unit (PACU) 10 minutes previously. Which action should the nurse take first? a. Elevate the patient's head. b. Suction the patient's mouth. c. Increase the oxygen flow rate. d. Perform the jaw-thrust maneuver. - ANS: D In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient's head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake. While caring for a patient who had abdominal surgery on the second postoperative day, which information about the patient is most important to communicate to the health care provider? a. The right calf is swollen, warm, and painful. b. The patient's temperature is 100.3° F c. The 24-hour oral intake is 600 ml greater than the total output. d. The patient complains of abdominal pain at level 6 (0-10 scale). - ANS: A The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require health care provider orders for diagnostic tests and anticoagulants. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3° F on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities. A patient complains of dizziness when ambulating in the room on the first postoperative day. In what order will the nurse accomplish the following activities? ____________________ a. Take the patient's blood pressure (BP). b. Have the patient sit down in a chair. c. Give the patient something to drink. d. Notify the patient's health care provider. - ANS: B, A, C, D The first priority for the patient with syncope is to prevent a fall, so the patient should be assisted to a chair. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the fluid intake will help prevent orthostatic dizziness. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no urgent need to notify the health care provider. A. Insist the patient remove the ring for safety purposes. B. Explain that the hospital will not be responsible for the ring. C. Tape the ring securely to the finger and document this on the preoperative checklist. D. Note the presence of the ring in the nurse's notes of the chart and on the preoperative checklist. - ANS: C. It is customary policy to tape a patient's wedding band to the finger and make a notation on the preoperative checklist that the ring is taped in place. While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that A She must be NPO after breakfast. B She needs to be NPO after midnight. I C She can drink clear liquids up to 2 hours before surgery. D She can drink clear liquids up until she is moved to the OR. - ANS: C. Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidence-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.