Chpt. 1 PREOP PATIENT ASSESSMENT & DIAGNOSIS

Question 1

What are the 6 steps (in order) of the nursing process?

Answer 1

1. Assessment (assess the patient)
2. Diagnosis (identify nursing diagnosis per the patient’s needs)
3. Outcome identification (per the diagnosis)
4. Planning (plan patient care)
5. Implementation (implement required care)
6. Evaluation (evaluate outcome of patient care)

Question 2

_________is the collection and analysis of relevant health data about the patient

Answer 2

ASSESSMENT

Question 3

_________was created to prevent wrong-person, wrong-procedure, and wrong-site surgery in hospitals and outpatient settings

Answer 3

THE UNIVERSAL PROTOCOL

Question 4

The steps of the universal protocol include____

Answer 4

1. preoperative/preprocedure verification process, 2.marking the operative/procedure site, and
2. a timeout (final verification)

Question 5

When is the time out performed?

Answer 5

Immediately before starting the procedure.

Question 6

The patient assessment includes

Answer 6

1. conducting an assessment
2. performing the physical examination,
3. completing the medical record review (eg, assessing laboratory and diagnostic test values), and performing the medication reconciliation process.

Question 7

The process of preprocedure verification includes

Answer 7

• confirming the patient’s identity,
  • verifying the scheduled surgical procedure,
  • site marking, and
  • performing the time out (eg, regional blocks, line placement, before incision)

Question 8

TRUE OR FALSE?

The patient and family should be actively
engaged during the assessment phase.

Answer 8

TRUE!

because they are an excellent source of health care
information

Question 9

When performing the preoperative assessment, the nurse gathers data from a variety of sources. These
sources include, but are not limited to______

Answer 9

• the patient;
• the medical record, including the physician’s physical examination (H& P);
• the surgeon, anesthesia professional, and other health care personnel; and
• the perioperative nurse’s knowledge of the
planned surgical procedure.

Question 10

The nurse must
endeavor to establish a trusting relationship with
the patient and his or her family members. WHY?

Answer 10

so that

open communication can occur

Question 11

TRUE OR FALSE?
Actively involving the patient in the preoperative assessment makes information collection easier, and
it can also decrease the patient’s anxiety by allowing him or her to have a say in the plan of care.

Answer 11

TRUE

Question 12

Regardless of the method of data collection used, the focus of the preoperative assessment is on the
following key elements:

Answer 12

-obtaining the patient’s current diagnosis and physical and psychosocial status;
• obtaining the patient’s medical history, to include previous illnesses and surgical procedures; and
• validating patient’s understanding of the procedure.

Question 13

Additional information the nurse should obtain during the assessment includes______

Answer 13

1. NPO status;
2. nutritional status (eg, body mass index [BMI]);
3. loose teeth, dentures, or caps;
4. eyeglasses or contact lenses;
5. hearing aids;
6. unexplained family death while under anesthesia;
7. adverse response to previous surgeries or anesthesia;
8. travel to countries with infectious disease outbreaks

Question 14

During the physical assessment, the perioperative nurse must also identify physical factors that will
need to be taken into consideration during intraoperative planning: (which include)

Answer 14

-Does the patient have any joint immobility (eg, is hip or shoulder immobility pertinent when assessing for procedure-specific patient positioning)?
• What is the condition of the patient’s skin? Are there any current areas of breakdown?
• What are the patient’s heart rate and rhythm

Question 15

TRUE OR FALSE?

Additionally, the nurse must ask the patient about body piercings which will need to be removed for
patient safety and current implants, because
intraoperative positioning or electrosurgical unit
dispersive pad placement may be hindered by the
presence of artificial joints and the patient may not
require an additional preoperative antibiotic.

Answer 15

FALSE!

Additionally, the nurse must ask the patient about body piercings which will need to be removed for
patient safety and current implants, because
intraoperative positioning or electrosurgical unit
dispersive pad placement may be hindered by the
presence of artificial joints and the patient MAY
require an additional preoperative antibiotic.

Question 16

a signed_____________ that may include some or all of the following: surgical, anesthesia,
blood products, photography, special laboratory testing, presence of additional people in the OR;

Answer 16

a signed INFORMED CONSENT that may include some or all of the following: surgical, anesthesia,
blood products, photography, special laboratory testing, presence of additional people in the OR;

Question 17

If the H&P is done by another doctor other than the one doing the procedure. What needs to be done before the new surgeon can proceed with the procedure?

Answer 17

a current history and physical examination performed by the admitting physician or his or her
delegate; however, if this person is different from the person performing the procedure, there may
be an additional note by the surgeon;

Question 18

When checking the medical records, what important Items need to be looked at?

Answer 18

• a signed INFORMED CONSENT that may include some or all of the following: surgical, anesthesia,
blood products, photography, special laboratory testing, presence of additional people in the OR;
• a current HISTORY & PHYSICAL examination performed by the admitting physician or his or her
delegate; however, if this person is different from the person performing the procedure, there may
be an additional note by the surgeon;
EXAM TIP
Information gathered during the assessment
facilitates prioritization of care and may reveal
information that should be shared with other
health care disciplines participating in the care
of the patient.
-Preoperative Patient Assessment and Diagnosis
• a preanesthesia assessment;
• baseline admission vital signs;
• laboratory results;
• radiographic reports; and
• height and weight in kilograms because
most emergency medications are administered based on weight.
-ADVANCE DIRECTIVES

Question 19

a document designed to
control certain future health care decisions
only when a person becomes unable to
make decisions and choices on his or
her own

Answer 19

LIVING WILL

Question 20

a legal
document in which a person names
someone to be his or her proxy (ie, agent)
to make all health care decisions if the
person becomes unable to do so

Answer 20

DURABLE POWER OF ATTORNEY

Question 21

_____written
physician orders instructing health care
providers not to perform cardiopulmonary
resuscitation

Answer 21

DNR ORDER

Question 22

_____the provision
of only comfort measures for the actively
dying patient

Answer 22

ALLOW NATURAL DEATH (AND)

Question 23

physician orders for

life-sustaining treatment

Answer 23

POLST

Question 24

a federal law that requires most health
care institutions to provide information on
advance directives at the time of admission

Answer 24

PSDA—the Patient Self-Determination

Act

Question 25

_____is the process of
comparing the medications that a patient is using
at home currently with the medications that are
ordered for him or her by the surgeon or the surgeon’s delegate (eg, perioperative nurse practitioner, the
surgeon’s physician’s assistant).

Answer 25

MEDICATION RECONCILIATION

Question 26

Per the Universal

Protocol, there are three components of verification: Which are _________

Answer 26

Per the Universal
Protocol, there are three components of verification:
1. preprocedure verification,
2.appropriate site marking,
and the
3. surgical time out prior to the start of the procedure.

Question 27

Proper identification requires the use of how many identifiers?

Answer 27

Proper identification requires the use of two identifiers.2
Most organizations use a minimum of the
patient’s name and date of birth as these identifiers. In an ideal situation, this simply requires the
perioperative nurse to introduce himself or herself to the patient and ask the patient to state his or
her name and date of birth

Question 28

How do you properly identify a patient who cannot properly identify him/herself due to age, or AMS?

Answer 28

This task becomes more difficult when the patient is unable to answer
the questions. This inability could be a result of young age, serious illness, or incapacitated mental
status, among other medical reasons. In this situation, the perioperative nurse can identify the patient with the help of a parent, legal guardian, or
legal representative2 or by matching the patient’s
name, date of birth, and medical record number
on the chart with the information on the patient’s
identification band.

Question 29

TRUE OR FALSE?

According to the WHO’s surgical safety
checklist, the perioperative nurse must first
properly identify the patient before beginning
any care

Answer 29

TRUE