ch. 14

Question 1

An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment?
a.
Change in behavior
b.
Daily white blood cell count
c.
Presence of fever and chills
d.
Tolerance of increasing activity

Answer 1

a.

Change in behavior

Older people have an age-related decrease in immune system functioning and may not show classic signs of infection such as increased white blood cell count, fever and chills, or obvious localized signs of infection. A change in behavior often signals an infection or onset of other illness in the older client.

ref. 221

Question 2

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team?
a.
Allergy to bee and wasp stings
b.
History of lactose intolerance
c.
No previous experience with surgery
d.
Use of multiple herbs and supplements

Answer 2

d.
Use of multiple herbs and supplements

Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered. Lack of experience with surgery may increase anxiety and may require higher teaching needs, but is not the priority over client safety.

ref. 228

Question 3

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care?
a.
Married young adult who is the primary caregiver for children
b.
Middle-aged client who is post knee replacement, needs physical therapy
c.
Older adult who lives at home despite some memory loss
d.
Young client who lives alone, has family and friends nearby

Answer 3

c.
Older adult who lives at home despite some memory loss

The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The client’s physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed. The other clients all have evidence of a support system and no known potential for serious safety issues.

ref. 221

Question 4

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?
a.
Assess the client for anxiety.
b.
Break the information into smaller bits.
c.
Give the client written information.
d.
Review the information again.

Answer 4

a.
Assess the client for anxiety.

Anxiety can interfere with learning and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious.

ref. 233

Question 5

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team?
a.
Creatinine: 1.2 mg/dL
b.
Hemoglobin: 14.8 mg/dL
c.
Potassium: 2.9 mEq/L
d.
Sodium: 134 mEq/L

Answer 5

c.
Potassium: 2.9 mEq/L

A potassium of 2.9 mEq/L is critically low and can affect cardiac and respiratory status. The nurse should communicate this laboratory value immediately. The creatinine is at the high end of normal, the hemoglobin is normal, and the sodium is only slightly low (normal low being 136 mEq/L), so these values do not need to be reported immediately.

ref. 223

Question 6

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best?
a.
Answer the questions and document that teaching was done.
b.
Do not have the client sign the consent and call the surgeon.
c.
Have the client sign the consent, then call the surgeon.
d.
Remind the client of what teaching the surgeon has done.

Answer 6

b.
Do not have the client sign the consent and call the surgeon.

In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the surgeon. The nurse should notify the surgeon to come back and answer the client’s questions before the client signs the consent form. The other actions are not appropriate.

ref. 226

Question 7

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best?
a.
Call the provider to request more analgesia.
b.
Demonstrate how to splint the incision.
c.
Have the client take shallower breaths.
d.
Tell the client a little pain is expected.

Answer 7

b.
Demonstrate how to splint the incision.

Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should know some pain is normal and expected after surgery, but that answer alone does not provide any interventions to help the client.

ref. 230

Question 8

A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate?
a.
“After you wash the surgical site, shave that area with your own razor.”
b.
“Be sure to wash the area where you will have surgery very thoroughly.”
c.
“Use a washcloth to wash the surgical site; do not take a full shower or bath.”
d.
“Wash the surgical site first, then shampoo and wash the rest of your body.”

Answer 8

b.
“Be sure to wash the area where you will have surgery very thoroughly.”

The entire proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap. Shaving, if absolutely necessary, should be done in the operative suite immediately before the operation begins, using sterile equipment. The client needs a full shower or bath (shower preferred). The client should wash the surgical site last; dirty water from shampooing will run over the cleansed site if the site is washed first.

ref. 228

Question 9

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met?
a.
Drainage from the surgical site is 30 mL less than yesterday.
b.
There is no redness, warmth, or drainage at the insertion site.
c.
The client reports adequate pain control with medications.
d.
Urine is clear yellow and urine output is greater than 40 mL/hr.

Answer 9

b.
There is no redness, warmth, or drainage at the insertion site.

The priority client problem related to a surgical drain is the potential for infection. An insertion site that is free of redness, warmth, and drainage indicates that goals for this client problem are being met. The other assessments are normal, but not related to the drain.

ref. 230

Question 10

A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)?
a.
Assess the client’s anxiety.
b.
Give the client a back rub.
c.
Remind the client to turn.
d.
Teach about postoperative care.

Answer 10

b.

Give the client a back rub.

A back rub reduces anxiety and can be delegated to the UAP. Once teaching has been done, the UAP can remind the client to turn, but this is not related to relieving anxiety. Assessing anxiety and teaching are not within the scope of practice for the UAP.

ref. 233

Question 11

A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client?
a.
Hydroxyzine (Atarax)
b.
Lorazepam (Ativan)
c.
Metoclopramide (Reglan)
d.
Morphine sulfate

Answer 11

c.
Metoclopramide (Reglan)

Reglan increases gastric emptying, an important issue for this client who was eating just prior to the operation. The other drugs are appropriate for any surgical client.

ref. 234

Question 12

A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best?
a.
Allow the client to walk to the bathroom.
b.
Delegate assisting the client to the nurse’s aide.
c.
Give the client a bedpan or urinal to use.
d.
Insert a urinary catheter now instead of waiting.

Answer 12

c.
Give the client a bedpan or urinal to use.

Although possibly uncomfortable or embarrassing for the client, the client should not be allowed out of bed after receiving sedation. The nurse should get the client a bedpan or urinal. The client may or may not need a urinary catheter.

ref. 234

Question 13

A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best?
a.
“A rapid heart rate requires more effort by the heart.”
b.
“Anesthesia has bad effects if the client is tachycardic.”
c.
“The client may have an undiagnosed heart condition.”
d.
“When the heart rate goes up, the blood pressure does too.”

Answer 13

a.
“A rapid heart rate requires more effort by the heart.”

Tachycardia increases the workload of the heart and requires more oxygen delivery to the myocardial tissues. This added strain is not needed on top of the physical and emotional stress of surgery. The other statements are not accurate.

ref. 219

Question 14

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best?
a.
Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met.
b.
Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy.
c.
Hold educational meetings with the nursing and surgical staff on infection prevention.
d.
Monitor staff on both units for consistent adherence to established hand hygiene practices.

Answer 14

a.
Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met.

The SCIP project contains core measures that are mandatory for all surgical clients and focuses on preventing infection, serious cardiac events, and venous thromboembolism. The managers should start by reviewing charts to see if the guidelines of this project were implemented. The other actions may be necessary too, but first the managers need to assess the situation.

ref. 216

Question 15

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best?
a.
Consult the surgeon about a postoperative dietitian referral.
b.
Document the findings thoroughly in the client’s chart.
c.
Encourage the client to eat more after recovering from surgery.
d.
Refer the client to Meals on Wheels after discharge.

Answer 15

a.
Consult the surgeon about a postoperative dietitian referral.

This client has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the surgeon about prescribing a consultation with a dietitian in the postoperative period. The nurse should document the findings but needs to do more. Encouraging the client to eat more may be helpful, but the client needs a professional nutritional assessment so that the appropriate diet and supplements can be ordered. The client may or may not need Meals on Wheels after discharge.

ref. 222

Question 16

A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best?
a.
Ask the client to describe current feelings.
b.
Determine if the client wants a chaplain.
c.
Reassure the client this surgery is common.
d.
Tell the client there is no need to be anxious.

Answer 16

a.
Ask the client to describe current feelings.

The nurse needs to conduct further assessment of the client’s anxiety. Asking open-ended questions about current feelings is an appropriate way to begin. The client may want a chaplain, but the nurse needs to do more for the client. Reassurance can be good, but false hope is not, and simply reassuring the client may not be helpful. Telling the client not to be anxious belittles the client’s feelings.

ref. 222

Question 17

A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client?
a.
Document giving the drug.
b.
Raise the siderails on the bed.
c.
Record the client’s vital signs.
d.
Teach relaxation techniques.

Answer 17

b.
Raise the siderails on the bed.

All actions are appropriate for a preoperative client. However, for client safety, the nurse should raise the siderails on the bed because hydroxyzine can make the client sleepy.

ref. 234

Question 18

A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate?
a.
Explain the rationale for giving the medicine now.
b.
Leave the room and come back in 15 minutes.
c.
Provide holistic client care and come back later.
d.
Tell the client you must start the medication now.

Answer 18

a.
Explain the rationale for giving the medicine now.

The preoperative antibiotic must be given within 60 minutes of the surgical start time to ensure the proper amount is in the tissues when the incision is made. The nurse should explain the rationale to the client for this timing. The other options do not take this timing into consideration and do not give the client the information needed to be cooperative.

ref. 234

Question 19

A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best?
a.
“All preoperative clients get this medication.”
b.
“It helps prevent ulcers from the stress of the surgery.”
c.
“Since you don’t have ulcers, I will have to ask.”
d.
“The physician prescribed this medication for you.”

Answer 19

b.
“It helps prevent ulcers from the stress of the surgery.”

Ulcer prophylaxis is common for clients undergoing long procedures or for whom high stress is likely. The nurse is not being truthful by saying all clients get this medication. If the nurse does not know the information, it is appropriate to find out, but this is a common medication for which the nurse should know the rationale prior to administering it. Simply stating that the physician prescribed the medication does not give the client any useful information.

ref. 234

Question 20

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.)
a.
Hemorrhage
b.
Infection
c.
Serious cardiac events
d.
Stroke
e.
Thromboembolism

Answer 20

b.
Infection
c.
Serious cardiac events

e.
Thromboembolism

The SCIP project includes core measures to prevent infection, serious cardiac events, and thromboembolic events such as deep vein thrombosis.

ref. 216

Question 21

A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.)
a.
Hemicolectomy: diagnostic
b.
Liver biopsy: diagnostic
c.
Mastectomy: restorative
d.
Spinal cord decompression: palliative
e.
Total shoulder replacement: restorative

Answer 21

b.
Liver biopsy: diagnostic

e.
Total shoulder replacement: restorative

A diagnostic procedure is used to determine cell type of cancer and to determine the cause of a problem. An example is a liver biopsy. A restorative procedure aims to improve functional ability. An example would be a total shoulder replacement or a spinal cord decompression (not palliative). A curative procedure either removes or repairs the causative problem. An example would be a mastectomy (not restorative) or a hemicolectomy (not diagnostic). A palliative procedure relieves symptoms but will not cure the disease. An example is an ileostomy. A cosmetic procedure is done to improve appearance. An example is rhinoplasty (a “nose job”).

ref. 218

Question 22

A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.)
a.
Metformin (Glucophage)
b.
Omega-3 fatty acids (Sea Omega 30)
c.
Phenytoin (Dilantin)
d.
Pilocarpine hydrochloride (Isopto Carpine)
e.
Warfarin (Coumadin)

Answer 22

a.
Metformin (Glucophage)
c.
Phenytoin (Dilantin)
d.
Pilocarpine hydrochloride (Isopto Carpine)
e.
Warfarin (Coumadin)

Although the client will be on NPO status before surgery, the nurse should check with the provider about allowing the client to take medications prescribed for diabetes, hypertension, cardiac disease, seizure disorders, depression, glaucoma, anticoagulation, or depression. Metformin is used to treat diabetes; phenytoin is for seizures; pilocarpine is for glaucoma, and warfarin is an anticoagulant. The omega-3 fatty acids can be held the day of surgery.ref. 228

Question 23

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.)
a.
Client with a humerus fracture
b.
Morbidly obese client
c.
Client who underwent a prolonged surgical procedure
d.
Client with severe heart failure
e.
Wheelchair-bound client

Answer 23

b.
Morbidly obese client
c.
Client who underwent a prolonged surgical procedure
d.
Client with severe heart failure
e.
Wheelchair-bound client

All surgical clients should be assessed for VTE risk. Those considered at higher risk include those who are obese; are over 40; have cancer; have decreased mobility, immobility, or a spinal cord injury; have a history of any thrombotic event, varicose veins, or edema; take oral contraceptives or smoke; have decreased cardiac output; have a hip fracture; or are having total hip or knee surgery. Prolonged surgical time increases risk due to mobility and positioning needs.ref. 231

Question 24

A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.)
a.
“A malnourished client will have fragile skin.”
b.
“Malnourished clients always have other problems.”
c.
“Many drugs are bound to protein in the body.”
d.
“Protein stores are needed for wound healing.”
e.
“Weakness and fatigue are common in malnutrition.”

Answer 24

a.
“A malnourished client will have fragile skin.”
c.
“Many drugs are bound to protein in the body.”
d.
“Protein stores are needed for wound healing.”
e.
“Weakness and fatigue are common in malnutrition.”

Malnutrition can lead to poorer surgical outcomes for several reasons, including fragile skin that might break down, altered pharmacokinetics, poorer wound healing, and weakness or fatigue that can interfere with recovery. Malnutrition can exist without other comorbidities.

ref. 222

Question 25

A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.)
a.
Decreased cardiac output
b.
Decreased oxygenation
c.
Frequent nocturia
d.
Mobility alterations
e.
Inability to adapt to changes

Answer 25

a.
Decreased cardiac output
b.
Decreased oxygenation
c.
Frequent nocturia
d.
Mobility alterations

Older adults have many age-related physiologic changes that put them at higher risk of falling and other complications after surgery. Some of these include decreased cardiac output, decreased oxygenation of tissues, nocturia, and mobility alterations. They also have a decreased ability to adapt to new surroundings, but that is not the same as being unable to adapt.ref. 220

Question 26

A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.)
a.
Allow the client to assume a position of comfort.
b.
Allow the client’s family to remain at the bedside.
c.
Give the client a warm, non-caffeinated drink.
d.
Provide warm blankets or cool washcloths as desired.
e.
Pull the curtains around the bed to provide privacy.

Answer 26

a.
Allow the client to assume a position of comfort.
b.
Allow the client’s family to remain at the bedside.
d.
Provide warm blankets or cool washcloths as desired.
e.
Pull the curtains around the bed to provide privacy.

There are many nonpharmacologic comfort measures the nurse can employ, such as allowing the client to remain in the position that is most comfortable, letting the family stay with the client, providing warmth or cooling measures as requested by the client, and providing privacy. The client in the preoperative holding area is NPO, so drinks should not be provided.ref. 233

Question 27

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.)
a.
Allow small sips of plain water.
b.
Check that consent is on the chart.
c.
Ensure the client has an armband on.
d.
Have the client help mark the surgical site.
e.
Allow the client to use the toilet before giving sedation.

Answer 27

b.
Check that consent is on the chart.
c.
Ensure the client has an armband on.
d.
Have the client help mark the surgical site.
e.
Allow the client to use the toilet before giving sedation.

Providing for client safety is a priority function of the preoperative nurse. Checking for appropriately completed consent, verifying the client’s identity, having the client assist in marking the surgical site if applicable, and allowing the client to use the toilet prior to sedating him or her are just some examples of important safety measures. The preoperative client should be NPO, so water should not be provided.

ref. 216