Deck 3 Module 17 Flashcards
A client is informed that a surgical procedure is to be scheduled in 2 weeks. Which teaching points should the nurse focus to prepare the client for the surgery? Select all that apply. A) Maintaining a patent airway B) Deep breathing and coughing C) Caring for the surgical incision D) Managing constipation E) Managing pain
B) Deep breathing and coughing
C) Caring for the surgical incision
D) Managing constipation
E) Managing pain
Rationale:
Maintaining a patent airway is a nursing action that is performed during the postoperative phase of surgical care. In the preoperative phase, when the client is alert and oriented, the nurse should focus teaching on deep breathing and coughing exercises, care of the surgical incision, managing constipation, and managing pain.
The nurse is discussing the various people whom the client will see when in the operating room suite. Which individuals should the nurse emphasize when discussing this aspect of the surgical process with the client? Select all that apply. A) Surgeon B) Postoperative nurse C) Circulating nurse D) Anesthesiologist E) Social worker
A) Surgeon
C) Circulating nurse
D) Anesthesiologist
Rationale:
The surgeon performs the procedure. The postoperative nurse will provide care to the client after the surgery is completed. The circulating nurse is a perioperative registered nurse who cares for the client during the surgical procedure. The anesthesiologist provides the anesthesia during the surgery and continually monitors the client’s physiologic status. The social worker will not be in attendance during the procedure but may become involved in the client’s care during the preoperative and postoperative phases.
The postoperative nurse is planning care for a client recovering from major thoracic surgery. Which nursing diagnoses should the nurse select to plan for this client’s immediate care needs?
Select all that apply.
A) Risk for Impaired Gas Exchange
B) Risk for Decreased Cardiac Output
C) Risk for Ineffective Airway Clearance
D) Risk for Imbalanced Nutrition: Less than Body Requirements
E) Risk for Imbalanced Fluid Volume
A) Risk for Impaired Gas Exchange
B) Risk for Decreased Cardiac Output
E) Risk for Imbalanced Fluid Volume
Rationale:
Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. The Risk for Ineffective Airway Clearance might be appropriate later as the client recovers from surgery. There is no Risk for Imbalanced Nutrition: Less than Body Requirements during the immediate postoperative phase.
The postoperative recovery room nurse determines that a client in the postoperative phase of care can be transitioned to Phase II of recovery. The client is able to take deep breaths and cough, is using oxygen to maintain a saturation of greater than 90%, is fully awake, has a systolic blood pressure that is 130 mmHg now but the preoperative systolic blood pressure was 100 mmHg, and is able to move all four extremities independently. Using the following scale, this client’s Aldrete score is ________.
The Aldrete score
Respiration
2 = Able to take deep breath and cough
1 = Dyspnea/shallow breathing
0 = Apnea
O2 Saturation
2 = Maintains > 92% on room air
1 = Needs O2 inhalation to maintain O2 saturation > 90%
0 = Saturation < 90% even with supplemental oxygen
Consciousness
2 = Fully awake
1 = Arousable on calling
0 = Not responding
Circulation
2 = BP+ 20 mmHg preop
1 = BP+ 20-50 mmHg preop
0 = BP+ 50 mmHg preop
Activity
2 = Able to move 4 extremities
1 = Able to move 2 extremities
0 = Able to move 0 extremities
Answer: 8
Rationale:
The Aldrete system is designed to assess a client’s transition from Phase I recovery to Phase II recovery, from discontinuation of anesthesia until return of protective reflexes and motor function. The criteria of respirations, oxygen saturation, consciousness, circulation, and activity are scored. The maximum score is 10. Clients who score > 8 are considered fit for transition to Phase II recovery.
The postoperative care nurse reviews the documentation from the intraoperative phase and determines that several areas are missing. Which areas did the nurse identify as being missing from the intraoperative documentation? Select all that apply. A) Pain assessment B) Start and stop times of anesthesia C) Medication review D) Antibiotic infusion times E) Start and stop times of the procedure
B) Start and stop times of anesthesia
D) Antibiotic infusion times
E) Start and stop times of the procedure
Rationale:
Intraoperative documentation is to include documentation about specific times, such as the start and stop times of anesthesia, antibiotic infusion times, and start and stop times of the procedure. The pain assessment and medication review are documented during both the preoperative and postoperative assessments.
The nurse is preparing a client for emergency surgery to repair liver and colon lacerations caused by a motor vehicle crash. Which information about this type of surgery will the nurse use to guide the client’s care?
Select all that apply.
A) An organ is going to be removed.
B) This is an emergency surgery.
C) The client will be hospitalized longer.
D) The client is at risk for blood loss.
E) The client is at risk for hypothermia.
B) This is an emergency surgery.
C) The client will be hospitalized longer.
D) The client is at risk for blood loss.
E) The client is at risk for hypothermia.
Rationale:
The suffix -ectomy indicates removal of an organ. The client is having surgery to repair lacerations. No organ is identified for removal. Emergency surgery is performed when a condition is life-threatening. Surgery to control internal hemorrhage from lacerations is an example of emergency surgery. An open procedure usually requires a longer hospital stay. Open procedures place the client at a higher risk for blood loss. If there is a large surgical opening, the client cannot be adequately covered and will be exposed to cold surgical suite air, and can develop hypothermia.
While receiving report from the operating room, the nurse learns that a client’s surgical wound for gallbladder removal is classified as III. What could have caused this wound classification?
Select all that apply.
A) The alimentary tract was not entered.
B) The wound is necrotic and infected.
C) Gallbladder contents spilled into the surgical site.
D) A break in sterility occurred during the surgery.
E) The alimentary, respiratory, genital, or urinary tract was entered.
C) Gallbladder contents spilled into the surgical site.
D) A break in sterility occurred during the surgery.
Rationale:
An incision is classified as III–contaminated wound if gross spillage occurred. This classification is also identified if a major break in sterile technique occurred. An incision is classified as I–clean if the alimentary, respiratory, genital, and urinary tract are not entered. An incision is classified as IV–dirty, infected if the wound is necrotic and infected. An incision is classified as II–clean contaminated if there are no signs of infection but the alimentary, respiratory, genital, or urinary tracts were entered.
The nurse is preparing an older adult client for surgery. Which topics should the nurse focus when preparing this client’s preoperative teaching?
Select all that apply.
A) Level of hearing
B) Including the family in the perioperative care plan
C) Teaching on deep breathing and coughing
D) Plans for discharge care
E) Actions to prevent pressure ulcers
A) Level of hearing
C) Teaching on deep breathing and coughing
D) Plans for discharge care
E) Actions to prevent pressure ulcers
Rationale:
Including the family as much as possible in perioperative care plan would be appropriate for a pediatric client. For the older client, make sure the client can hear the information to be presented or provide information through alternative means. Older adults are at greater risk for pneumonia and other postoperative complications and should have teaching related to deep breathing and coughing. The older client is going to need assistance once discharged and should have the necessary medical equipment such as walkers and raised toilet seats, assistance with transportation, or extended care. The older client is at risk for pressure ulcer formation because of poor nutritional status, diabetes, cardiovascular illness, or history of steroid use.
A prothrombin time (PT) test measures which of the following?
A) Time required for the client’s blood to clot
B) Time required for the client’s plasma to clot
C) Time required for platelets to effectively stop bleeding
D) Time required for a surgical procedure
B) Time required for the client’s plasma to clot
Rationale:
A prothrombin time (PT) test measures the time required for the client’s plasma to clot. A partial thromboplastin time (PTT) test measures the time required for the client’s blood to clot. A bleeding time test measures the time required for platelets to effectively stop bleeding. No diagnostic test measures the time required for a surgical procedure.
What drug may be used to treat nausea and vomiting associated with operative procedures? A) Metoclopramide B) Acetaminophen C) Midazolam D) Fentanyl
A) Metoclopramide
Rationale:
An antiemetic such as metoclopramide may be used to treat nausea and vomiting associated with operative procedures. A nonopioid analgesic such as acetaminophen provides temporary analgesia for mild to moderate pain. An anxiolytic such as midazolam is a relaxant. An opioid analgesic such as fentanyl controls moderate to severe pain but does not alter the pain threshold.
What is characteristic of assessment in perioperative care?
A) It is primarily a component of preoperative care.
B) It is used most often during the intraoperative process.
C) It primarily is involved in evaluating clients during postoperative care.
D) It is involved in every part of the perioperative process.
D) It is involved in every part of the perioperative process.
Rationale:
Assessment is the most significant concept during the perioperative process and encompasses most of the other concepts. In addition to monitoring the client’s vital signs and taking into account the spiritual, cultural, and emotional aspects of a client’s care, assessment may include a nurse’s communication with the healthcare and surgical team. Assessing what other team members gather from a nurse’s communication is vital to a client’s safety.
Which of the following statements best describes the vital signs the nurse collects during the preoperative phase?
A) They are the only vital signs collected during the perioperative period.
B) When later vital signs are taken, they are compared against the preoperative set.
C) Generally preoperative vital signs are only relevant during the intraoperative process.
D) These are not essential and may be omitted for emergency surgeries.
B) When later vital signs are taken, they are compared against the preoperative set.
Rationale:
Vital signs, including blood pressure, pulse, respiration, and oxygen saturation, should be taken throughout the perioperative period, with the baseline vital signs being obtained during the preoperative phase. Later vital signs will be compared against this baseline. Preoperative vital signs are not the only vital signs collected during the perioperative period, they are relevant through the perioperative period as a baseline, and they are important to record for any client.
How often should a client be monitored during the intraoperative phase? A) Every 5 minutes B) Every 30 minutes C) Constantly D) Occasionally
C) Constantly
Rationale:
Constant monitoring of both the surgical environment and the client is necessary to ensure client safety. Monitoring the client every 5 minutes, every 30 minutes, or just occasionally could miss an important change in the client’s status that could result in client harm or adverse complications.
A client with terminal cancer is undergoing surgery to partially remove a tumor that is pressing on a nerve and causing pain. This is classified as what type of surgery? A) Reconstructive B) Diagnostic C) Palliative D) Emergency
C) Palliative
Rationale:
Palliative surgery may be performed to alleviate pain or symptoms associated with a disease, and so this client’s surgery, because it involves partially removing a tumor causing severe pain, is most illustrative of palliative surgery. Reconstructive surgery is to restore lost or reduced appearance or function. A diagnostic procedure would be conducted to determine or confirm a diagnosis. Emergency surgery is to save life or limb.
Which of the following situations demands that all perioperative staff cover their bodies with lead shields?
A) The surgical team uses a bipolar handpiece to cauterize a client’s tissue.
B) The surgical team uses a class 3 laser to cut a client’s kidney stone.
C) The surgical team uses a pneumatic tourniquet to cut off circulation to a client’s hand.
D) The surgical team uses radiology to take intraoperative photos.
D) The surgical team uses radiology to take intraoperative photos.
Rationale:
When radiology is used, perioperative staff must make sure lead shields cover their bodies, including women’s ovaries and men’s testicles, because radiation can cause sterility. Staff should also wear a neck shield to protect the thyroid gland. The other procedures do not involve radiation and don’t require lead shields.
