HESI Fundamentals -Perioperative Care Flashcards
Scenario
The 63-year-old Client arrives at the surgery center for her preoperative appointment. She is scheduled to undergo left hip replacement surgery in one week.
Preoperative screening
The nurse begins the preoperative assessment by taking the clients vital signs. The nurse reviews the clients medication’s. The client indicates that she has been taking two medication; hydrochlorothiazide a diuretic and warfarin an anticoagulant every day for more than a year
Which vital sign requires follow up by the nurse?
Blood pressure of 160/88 mmHg.
Rationale: this blood pressure is elevated and requires further action by the nurse
What nursing action is most important?
Explain the need to withhold the warfarin prior to surgery.
Rationale: anticoagulants increase the risk for bleeding during surgery in the postoperative period so the nurse must explain the need withhold the warfarin prior to surgery and instruct the client to contact the surgeon to determine how long before surgery the medication should be stopped
The nurse, then reviews the clients preoperative lab test results drawn earlier in the week
What serum lab value requires follow up by the nurse?
WBC of 14,000/UL
Rationale: the normal WBC count is 4000 to 10,000/uL an increase may indicate the onset of an infection, which may be a contraindication to surgery. The nurse should notify the surgeon of this abnormal lab value.
Preoperative teaching the nurse talks with the client about what to expect the day of surgery and during the immediate postoperative. The nurse provides instruction regarding cough and deep breathing exercises. The client performs a return demonstration by breathing in deeply through their mouth and exhaling forcefully and rapidly through pursed lips.
What action should the nurse implement?
Demonstrate the deep breathing and coughing technique again.
Rationale: the client has demonstrated incorrect technique when performing deep breathing exercises, the client should inhale through the nose and exhale slowly through the mouth without pursing the lips, the nurse should demonstrate the entire procedure again for best learning by the client.
When a nurse begins teaching about the benefits of early mobilization, following surgery, the client states “ oh, I know if I stay in bed very long I will get bed sores.”
How should the nurse respond?
“ bed sores are one of many problems that can occur from prolonged bedrest.”
Rationale: this response acknowledges the clients previous learning, and promotes further learning related to other complications of mobility, such as thrombus formation, constipation, and atelectasis
The nurse discusses postoperative pain management with a client and explains the use of a patient controlled analgesia (PCA) pump. The client expresses fear that they might accidentally overdose herself since they will be sleepy after surgery.
How should the nurse respond?
“The pump has a controlled device that prevents you from taking too much medicine.”
Rationale this response provides the client with the information needed to understand that she cannot overdose herself while she is sedated after surgery.
While discussing postoperative pain management strategies with a client, the nurse observes them begin to cry
What action should the nurse take?
Quietly sit with a client.
Rationale: offering one’s presence is a caring and therapeutic response.
After the client stops crying, she states “ my father, was in so much pain before he died: talking about pain brings back so many memories.”
How should the nurse respond?
“It sounds as if you went through a difficult time when your father died.”
Rationals: this open ended acknowledgment of the clients distress is therapeutic, and allows the opportunity for further discussion by the client if desired.
The next week the client arrives at the surgery center three hours before their scheduled surgery
Which question is most important for the nurse to ask the clients during the admission interview?
“Have you had anything to eat or drink since midnight?”
Rationale: ensuring that the client has remained NPO for the prescribed length of time before surgery is critical to prevent vomiting and aspiration during surgery.
After completing the admission interview, the nurse reviewed the client medical record and notes that the surgical consent form is filled out, but not signed by the client
What action should the nurse take?
Ask the client if she has received sufficient information to sign the consent form
Rationale: the nurse may witness the client signature if the nurses able to determine that the client has been sufficiently informed of the necessary information .
The nurse observes that the word “ yes” has been marked on the clients left hip hip and the word “ no” has been written on the right hip.
What action should the nurse implement?
Confirm that the left hip is the site of the search scheduled surgery
Rationale: the nurse should ensure that the markings on the hips are correct to help reduce the potential for error during surgery. When the surgical site involves a distinction between left and right sides of the body, marking the site is a required component of the joint commissions, universal protocol to prevent wrong site, wrong procedure, wrong person surgery.
The client transferred to a stretcher, and taken to the OR. The nurse assists the client off the stretcher and onto the OR table after general anesthesia, is induced the nurse positions the client for surgery
What nursing diagnosis has the highest priority at this time?
Risk for perioperative -positioning injury
Rationale: during surgery, the client may remain in one position for a prolonged. The nurse must ensure that the client is protected from injury secondary to inappropriate positioning.
Once the OR team has assembled in the room, the circulating nurse calls for a timeout.
What action should the nurse take during the time out?
Review the scheduled, procedure, site, and client
Rationale: a time out, the designated method for final verification before surgery begins, is a component of the joint commissions, universal protocol to prevent wrong site, wrong procedure, wrong person surgery.