Iggy Exam 1 Flashcards
A client is scheduled to have an ileostomy placed. How does the nurse document this type of surgery?
Diagnostic
Cosmetic
Curative
Palliative
Palliative
Colostomy surgery is categorized as palliative. Palliative surgery is performed to increase the quality of life (and often to reduce pain) while reducing stressors on the body. It is noncurative in nature.
Cosmetic surgery is performed primarily to alter or enhance personal appearance. Curative surgery is performed to resolve a health problem by repairing or removing the cause. Diagnostic surgery is performed to determine the origin and cause of a disorder or the cell type for cancer.
The nurse is providing preoperative care for a client who will have an arthroscopy of the left knee. As part of The Joint Commission National Patient Safety Goals (NPSG), what will the nurse do as the priority?
Ensure that the correct procedure is noted in the client’s health record.
Witness marking of the left knee site with the client awake and the surgeon present.
Communicate with the surgeon confirming the client will have a left knee arthroscopy.
Verify with the client that a left knee arthroscopy will be performed.
Witness marking of the left knee site with the client awake and the surgeon present.
The nurse will be required to mark the left knee site with the client awake and the surgeon present. The Joint Commission NSPG requires that the surgical site be marked by an independent licensed professional and should, when possible, involve the client. The surgeon is accountable and should be present.
The nurse will also ensure that the correct procedure is in the clients health record; verify with the client that the left knee arthroscopy will be performed, and communicate with the surgeon that the client is having a left knee arthroscopy. However, these are all done after the priority of witnessing the client awake and surgeon present to mark the left knee site.
As the nurse gives a client the informed consent form to sign, the client asks, “Now what exactly are they going to do to me?” What is the appropriate nursing action?
Have the client sign the form.
Contact the anesthesiologist.
Contact the surgeon.
Explain the procedure.
Contact the surgeon.
The nurse will contact the surgeon to convey the client’s question. The nurse is not responsible for explaining or providing detailed information about the surgical procedure. Rather, the nurse’s role is to clarify facts that have been presented by the health care provider and dispel myths that the client or family may have heard about the surgical experience.
The anesthesiologist is responsible for the anesthesia, not the surgical details. Although the nurse is only witnessing the signature, it is the nurse’s role to ensure that the facts are clarified before the consent form is signed. It is not appropriate to have the client sign the form until the surgeon has clarified the procedure with the client.
The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction from the nurse?
“I will have a bandage on my chest.”
“My family will not be able to see me right away.”
“I will wake up with a tube in my throat.”
“Pain medication will take away all of my pain.”
“Pain medication will take away all of my pain.”
The client’s statement that, “Pain medication will take away all of my pain,” indicates the need for further instruction. Pain medication will reduce pain, but will not take it away completely.
The client statement about waking up with a tube in the throat is accurate, because the client will be intubated. Following heart surgery, a dressing is placed on the chest. The client will not be able to see family immediately because he or she will go to recovery first.
An older client’s adult child tells the nurse that the client does not want life support. What does the nurse do first?
Call the legal department to draft the paperwork.
Thank the adult child for sharing the parent’s desires.
Talk to the client to be sure of their wishes.
Document the conversation in the electronic health record.
Talk to the client to be sure of their wishes.
The nurse would first talk to the client in order to determine the client’s wishes and state of mind. As long as the client is lucid, he or she can articulate his or her own wishes regarding life support or the absence of such.
Once the nurse has assessed that the client has certain end-of-life wishes, the nurse can confirm that the client wants these officially documented. If the client agrees, then the legal department can be contacted. Finally, the nurse can thank the adult child for sharing that the client has thoughts about life support, as this was the catalyst that allowed the nurse to further assess the client’s wishes. The nurse could not act on the adult child’s indications alone.
During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks?
“I quit smoking 10 years ago.”
“I had a heart attack 4 months ago.”
“I take a multivitamin daily.”
“I drink a glass of wine a night.”
“I had a heart attack 4 months ago.”
The statement by the client that he or she had a heart attack 4 months ago requires further investigation. Cardiac problems increase surgical risks, and the risk for a myocardial infarction during surgery is higher in clients who have heart problems.
The nurse will note that the client takes a multivitamin, but this is not of substantial risk. Moderate alcohol consumption is not considered high-risk behavior. A past history of smoking should be noted, but current or more recent smoking is of greater concern.
A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further nursing assessment?
Pain at the surgical site
Verbal stimuli needed to awaken
Sore throat upon swallowing
Snoring sounds when inhaling
Snoring sounds when inhaling
Snoring sounds when inhaling may indicate respiratory depression.
Postsurgical pain at the surgical site is normal. Requiring verbal stimuli to awaken and a sore throat on swallowing are normal postsedation assessment findings.
Which client does the nurse identify at greatest risk for slow wound healing?
A 47-year-old man with obesity and diabetes
A 58-year-old woman who smokes 2 packs of cigarettes daily
A 78-year-old man with controlled hypertension
A 21-year-old woman with an STI
A 47-year-old man with obesity and diabetes
Obesity and diabetes significantly place a client at greatest risk for slow wound healing.
The other clients may encounter slower wound healing, yet they are not at the highest risk like the client with obesity and diabetes.
The nurse reviews a routine discharge teaching plan on postoperative care with a client. Which client statement indicates that teaching about wound care has been effective?
“The wound will completely heal in about 2 months.”
“I should remove the dressing if the wound is draining.”
“I may need to restrict my activities for several months.”
“Some bleeding from the incision is normal for several weeks.”
“I may need to restrict my activities for several months.”
To protect the integrity of the wound, activities may need to be restricted.
The wound is usually open to air for healing, but draining wounds need to be covered. Bleeding and serosanguineous drainage are not normal after 5 days. The length of time it takes for a wound to heal varies, which can be up to 2 years.
A client with opioid depression has received naloxone. Vitals signs are currently recorded as BP 110/70, P 70, R 16, and T 98.9° F. Which additional treatment does the nurse anticipate will be needed?
Restraints due to naloxone causing agitation
Activation of the Rapid Response Team
Supplemental pain medication
External pacing to regular heartbeat
Supplemental pain medication
Supplemental pain medication will be anticipated, as the reversal of the opioid via naloxone reduces the analgesic effect also.
The vital signs do not warrant the Rapid Response Team’s activation, external pacing, or restraints.
The nurse assesses a client’s wound 24 hours postoperatively. Which finding causes the nurse to contact the surgeon?
Sanguineous drainage at the suture site
Crusting along the incision line
Serosanguineous drainage on the dressing
Redness and swelling around the incision
Redness and swelling around the incision
The nurse’s concern is redness and swelling around the incision. This needs to be reported to the surgeon because these signs could indicate an infection.
Crusting along the incision line, sanguineous drainage, and serosanguineous drainage are normal.
Which action does the nurse implement for a client with wound evisceration?
Irrigate the wound with warm, sterile saline.
Cover the wound with a sterile, warm, moist dressing.
Replace tissue protruding into the opening.
Apply direct pressure to the wound.
Cover the wound with a sterile, warm, moist dressing.
Covering the wound with a sterile, warm, moist dressing protects the organs until the surgeon can repair the wound. Evisceration occurs when a wound opens up and body organs are exposed.
Applying direct pressure to a wound traumatizes the organs. Irrigating the wound is not necessary. Replacing protruding tissue could induce infection.
Which electrolyte laboratory result for a presurgical client will the nurse report to the anesthesiologist? (Select all that apply.)
White blood cell count 14,000 mm3
Potassium, 3.9 mEq/L (3.9 mmol/L)
Creatinine, 1.9 mg/dL (168 mcmol/L)
Fasting glucose, 80 mg/dL (4.4 mmol/L)
Sodium, 140 mEq/L (140 mmol/L)
White blood cell count 14,000 mm3
Creatinine, 1.9 mg/dL (168 mcmol/L)
The nurse will report a creatinine of 1.9 mg/dL (168 mcmol/L) and a white blood cell count of 14,000 mm3 to the anesthesiologist. These values are outside of the expected normal ranges and may indicate renal problems (creatinine) and infection (white blood cell count).
A fasting glucose of 80 mg/dL (4.4 mmol/L), a potassium level of 3.9 mEq/L (3.9 mmol/L), and sodium level of 140 mEq/L (140 mmol/L) are normal laboratory values.
The nurse completes the preoperative checklist for a client scheduled for general surgery. Which factor does the nurse identify that places the client at high risk for the planned procedure? (Select all that apply.)
Select all that apply.
Ten pounds (4.5 kg) over ideal body weight
Takes saw palmetto for benign prostatic hyperplasia (BPH)
Anesthesia complications experienced by partner
Currently prescribed methylprednisolone therapy
Age 59 years
History of diabetes mellitus
Takes saw palmetto for benign prostatic hyperplasia (BPH)
Currently prescribed methylprednisolone therapy
History of diabetes mellitus
The client’s risk factors include diabetes mellitus, being on methylprednisolone therapy, and taking an herbal preparation (saw palmetto). Diabetes contributes to an increased risk for surgery or postsurgical complications. Methylprednisolone use can decrease the body’s ability to fight infection. Any type of herbal preparation has the potential to interfere with anesthesia or recovery.
Older adults are at greater risk for surgical procedures, but this client is not an older adult. Family medical history and problems with anesthetics may indicate possible reactions to anesthesia, but not anesthesia complications experienced by a partner. Obesity increases the risk for poor wound healing, but being 10 lb (4.5 kg) overweight does not categorize this client as obese.
The nurse is instructing a client about the postoperative use of antiembolism stockings. Which statement by the client indicates the need for further teaching? (Select all that apply.)
Select all that apply.
“I will take off my stockings one to three times a day for 30 minutes.”
“It is up to me to determine how long I wear the stockings at each interval.”
“My stockings are loose so they do not hurt my legs.”
“These stockings help promote blood flow.”
“I feel like these stockings are compressing my legs just a bit.”
“It is up to me to determine how long I wear the stockings at each interval.”
“My stockings are loose so they do not hurt my legs.”
Stockings that are too loose are ineffective. Stockings that are too tight will impede blood flow. The client should wear the stockings as prescribed; not at their own discretion.
Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. Antiembolism stockings may be used during and after surgery to promote venous return. Antiembolism stockings should fit properly by providing gentle compression to achieve the desired result.
