final exam: chapter 31 (perioperative nursing care)

Question 1

nursing pt safety goals include (1) __ surgery is done (2) __ operative site (3) __ before surgery to make sure a mistake is not made

Answer 1

correct; mark; time out

Question 2

surgery classification based on urgency includes: (1) __ (2) __ and (3) __

Answer 2

elective - pre planned; urgent - w/in short time period; emergency - now

Question 3

surgery classification based on risk is divided into __ and __

Answer 3

major - any urgency (remove/repair body part, restore, function, improve or maintain health); minor - primarily elective (teeth extraction, arthroscopy, etc.)

Question 4

surgery classification based on purpose includes: __ (daprtc)

Answer 4

diagnostic | ablative | palliative | reconstructive | transplantation | constructive

Question 5

informed consent is NOT legal if pt is (1)__ (2)__ (3)__ or (4)__

Answer 5

confused; sedated; mentally incompetent; minor

Question 6

advanced directives can either be given through __ or __

Answer 6

living will; durable power of attorney for health care

Question 7

outpt/same day surgery is conducted in __ care settings

Answer 7

ambulatory

Question 8

outpt/same day surgery __ length of hospital stay & __ costs

Answer 8

reduces; cuts

Question 9

outpt/same day surgery pts receive __ sedation

Answer 9

moderate

Question 10

older adults, chronically ill pts, and ppl who do not have support at home may require __ teaching or home health care

Answer 10

additional

Question 11

are these all of the outcomes for the surgical pt?
- receive respectful and culturally and age-appropriate care
- be free from injury and adverse effects
- be free from infection and DVT
- maintain fluid and electrolyte balance; skin integrity, normal temperature
- have pain managed
- demonstrate understanding of physiologic and psychological responses to surgery
- participate in rehabilitation process

Answer 11

yes

Question 12

pre-op nursing care includes:
acip

Answer 12

assessment | client teaching | informed consent | prep for or

Question 13

hlth hx & physical assessment, identifying risk factors & allergies, identifying meds, determining teaching & psychosocial needs, and determining post-surgical support & referral needs are part of the __ part of pre-op care

Answer 13

assessment

Question 14

deep breathing
coughing
incentive spirometry
leg exercises
turning in bed
early ambulation

are all part of __

Answer 14

client teaching

Question 15

surgery can cause absence of peristalsis for __ to __ hours

Answer 15

24; 48

Question 16

standard npo is

Answer 16

8 hours

Question 17

can be on clear liquid diet up to __ hours before surgery

Answer 17

2

Question 18

respiratory status includes airway __ and __ for immediate pacu nursing care

Answer 18

patency; oxygenation

Question 19

the endotracheal tube/airway __ (is/is not) removed until gag reflex returns

Answer 19

is not

Question 20

some interventions to take are: (1) assess every __ to __ mins (2) admin humidified O2, __, and suctioning

Answer 20

10; 15; deep breaths

Question 21

compare cardiovascular to __

Answer 21

pre-op baseline

Question 22

typical post-op orders include:

Answer 22

• vs frequency
• IVF – type and rate
• meds
• need to be reordered post-op
• diet and po status (may be NPO)
• activity level
• positioning considerations
• I & O
• labs
• special orders (e.g. dressings, drains, therapy)

Question 23

typical post-op orders include:

Answer 23

• vs frequency
• IVF – type and rate
• meds
• need to be reordered post-op
• diet and po status (may be NPO)
• activity level
• positioning considerations
• I & O
• labs
• special orders (e.g. dressings, drains, therapy)

Question 24

__: restlessness, anxiety, hypotension, tachycardia, cool extremities, decrease urine output

Answer 24

shock

Question 25

hemorrhage and shock: you must __ the surgeon and medical team, __ airway, pt in __ position w legs __, __ line, administer __ and __, monitor __, __, __ and __

Answer 25

notify; establish; flat; elevated; iv; oxygen; meds; vs; labs; abgs; urine output

Question 26

you find a pt’s calf to be red, swollen, warm, and hypertrophied. they complain of pain. what cv complication is this?

Answer 26

thrombophlebitis

Question 27

what must you not do if the pt has thrombophlebitis?

Answer 27

massage legs (don’t want clot to move)

Question 28

what is the first priority for a thrombophlebitis?

Answer 28

prevent dislodgement

Question 29

a pt experiences dyspnea, chest pain, is coughing, exhibits cyanosis, and has increased rr, hr and anxiety. what is your first priority?

Answer 29

stabilize cv & resp function
this is a pulmonary embolism (life threatening)

Question 30

a pt has pneumonia, what must you do first?

Answer 30

treat the infection

Question 31

a pt has atelectasis, what must you do first?

Answer 31

oxygenation & expand involved lung tissues

Question 32

activity restrictions | diet restrictions | follow-up appt | meds | pain management | and transportation are all things needed to be discussed for __

Answer 32

discharge