MS - Perioperative Care COPY

Question 1

-lysis

Answer 1

Destruction of

E.g., electrolysis

Question 2

-ectomy

Answer 2

Excision or removal of

E.g., appendectomy

Question 3

-orrhaphy

Answer 3

Repair or suture of

E.g., herniorraphy

Question 4

-oscopy

Answer 4

Looking into

E.g., endoscopy

Question 5

-ostomy

Answer 5

Creation of opening into

E.g., colostomy

Question 6

-otomy

Answer 6

Cutting into or incision of

E.g., tracheotomy

Question 7

-plasty

Answer 7

Repair or reconstruction of

E.g., mammoplasty

Question 8

Three purposes of the preoperative interview

Answer 8

1. Obtain the patient’s health information
2. Provide and clarify information about the planned surgery, including anesthesia
3. Assess the patient’s emotional state and readiness for surgery, including his or her expectations about surgical outcomes

Question 9

Herbal products and surgery

Answer 9

• Astragalus and ginseng - increase blood pressure before and during surgery
• Garlic, vitamin E, ginkgo, fish oils - can increase bleeding
• Kava and valerian - cause excess sedation

In general, discontinue all herbal supplements 2 to 3 weeks before any surgical procedure

HELPFUL HERBS AND VITAMINS

• Ginger - useful for preventing nausea associated with anesthesia
• Arnica - useful in soft tissue healing
• Multivitamins can be taken until day before surgery. Taking them on day of surgery on empty stomach can contribute to nausea and vomiting after surgery

Question 10

Interaction of current medications and anasthetics

Answer 10

• Certain antidepressants can potentiate effect of opioids, agents that can be used for anesthesia
• Antihypertensive drugs may predispose patient to shock from combined effect of drug and vasodilator effect of some anesthetic agents
• Insulin or oral hypoglycemic agents may require dose or agent adjustments during perioperative period because of body metabolism, decreased oral intake, stress, and anesthesia
• Antiplatelet drugs (e.g. aspirin, clopidogrel) and NSAIDs inhibit platelet aggregation and may contribute to post-op bleeding
• Long-term anticoagulation therapy have options: (1) continue therapy, (2) withhold therapy for a time before/after surgery, or (3) withhold therapy and start subQ or IV heparin therapy during perioperative period

Question 11

Which procedures are done for curative purposes (select all that apply)?

a. Gastroscopy
b. Rhinoplasty
c. Tracheotomy
d. Hysterectomy
e. Herniorrhaphy

Answer 11

d, e (hysterectomy, herniorrhaphy)

Gastroscopy is for the purpose of diagnosis. Rhinoplasty is done for a cosmetic improvement. A tracheotomy is palliative.

Question 12

A patient is scheduled for a hemorrhoidectomy at an ambulatory day-surgery center. An advantage of performing surgery at an ambulatory center is a decreased need for

a. laboratory tests and perioperative medications.
b. preoperative and postoperative teaching by the nurse.
c. psychologic support to alleviate fears of pain and discomfort.
d. preoperative nursing assessment related to possible risks and complications.

Answer 12

a. laboratory tests and perioperative medications

Ambulatory surgery is usually less expensive and more convenient, generally involving fewer laboratory tests, fewer preoperative and postoperative medications, less psychologic stress, and less susceptibility to hospital-acquired infections. However, the nurse is still responsible for assessing, supporting, and teaching the patient who is undergoing surgery, regardless of where the surgery is performed.

Question 13

A patient who is being admitted to the surgical unit for a hysterectomy paces the floor, repeatedly saying, “I just want this over.” What should the nurse do to promote a positive surgical outcome for the patient?

a. Ask the patient what her specific concerns are about the surgery.
b. Reassure the patient that the surgery will be over soon and she will be fine.
c. Redirect the patient’s attention to the necessary preoperative preparations.
d. Tell the patient she should not be so anxious because she is having a common, safe surgery.

Answer 13

a. Ask the patient what her specific concerns are about the surgery.

Excessive anxiety and stress can affect surgical recovery and the nurse’s role in psychologically preparing the patient for surgery is to assess for potential stressors that could negatively affect surgery. Specific fears should be identified and addressed by the nurse by listening and by explaining planned postoperative care. Falsely reassuring the patient, ignoring her behavior, and telling her not to be anxious are not therapeutic.

Question 14

Many herbal products that are commonly taken cause surgical problems. Which herbs listed below should the nurse teach the patient to avoid before surgery to prevent an increase in bleeding for the surgical patient (select all that apply)?

a. Garlic
b. Fish oil
c. Valerian
d. Vitamin E
e. Astragalus
f. Ginkgo biloba

Answer 14

a, b, d, f (garlic, fish oil, vitamin E, ginkgo biloba)

Valerian may cause excess sedation. Astragalus may increase blood pressure before and during surgery.

Question 15

Priority decision: When the nurse asks a preoperative patient about allergies, the patient reports a history of seasonal environmental allergies and allergies to a variety of fruits. What should the nurse do next?

a. Note this information in the patient’s record as hay fever and food allergies.
b. Place an allergy alert wristband that identifies the specific allergies on the patient.
c. Ask the patient to describe the nature and severity of any allergic responses experienced from these agents.
d. Notify the anesthesia care provider (ACP) because the patient may have an increased risk for allergies to anesthetics.

Answer 15

c. Ask the patient to describe the nature and severity of any allergic responses experienced from these agents.

Risk factors for latex allergies include a history of hay fever and allergies to foods such as avocados, kiwi, bananas, potatoes, peaches, and apricots. When a patient identifies such allergies, the patient should be further questioned about exposure to latex and specific reactions to allergens. A history of any allergic responsiveness increases the risk for hypersensitivity reactions to drugs used during anesthesia but the hay fever and fruit allergies are specifically related to latex allergy. After identifying the allergic reaction, the anesthesia care provider (ACP) should be notified, the allergy alert wristband should be applied, and the note in the record will include the allergies and reactions as well as the nursing actions related to the allergies.

Question 16

During a preoperative review of systems, the patient reveals a history of renal disease. This finding suggests the need for which preoperative diagnostic tests?

a. ECG and chest x-ray
b. Serum glucose and CBC
c. ABGs and coagulation tests
d. BUN, serum creatinine, and electrolytes

Answer 16

d. BUN, serum creatinine, and electrolytes

BUN, serum creatinine, and electrolytes are used to assess renal function and should be evaluated before surgery. Other tests are often evaluated in the presence of diabetes, bleeding tendencies, and respiratory or heart disease.

Question 17

During a preoperative physical examination, the nurse is alerted to the possibility of compromised respiratory function during or after surgery in a patient with which problem?

a. Obesity
b. Dehydration
c. Enlarged liver
d. Decreased peripheral pulses

Answer 17

a. Obesity

Obesity, as well as spinal, chest, and airway deformities, may compromise respiratory function during and after surgery. Dehydration may require preoperative fluid therapy and an enlarged liver may indicate hepatic dysfunction that will increase perioperative risk related to glucose control, coagulation, and drug interactions. Weak peripheral pulses may reflect circulatory problems that could affect healing.

Question 18

What type of procedural information should be given to a patient in preparation for ambulatory surgery (select all that apply)?

a. How pain will be controlled
b. Any fluid and food restrictions
c. Characteristics of monitoring equipment
d. What odors and sensations may be experienced
e. Technique and practice of coughing and deep breathing, if appropriate

Answer 18

a, b, e (how pain will be controlled, any fluid and food restrictions, technique and practice of coughing and deep breathing if appropriate)

Procedural information includes what will or should be done for surgical preparation, including what to bring and what to wear to the surgery center, length and type of food and fluid restrictions, physical preparation required, pain control, need for coughing and deep breathing (if appropriate), and procedures done before and during surgery (such as vital signs, IV lines, and how anesthesia is administered). The other options are sensory and process information.

Question 19

The nurse asks a preoperative patient to sign a surgical consent form as specified by the surgeon and then signs the form after the patient does so. By this action, what is the nurse doing?

a. Witnessing the patient’s signature
b. Obtaining informed consent from the patient for the surgery
c. Verifying that the consent for surgery is truly voluntary and informed
d. Ensuring that the patient is mentally competent to sign the consent form

Answer 19

a. Witnessing the patient’s signature

The health care provider is ultimately responsible for obtaining informed consent. However, the nurse may be responsible for obtaining and witnessing the patient’s signature on the consent form. The nurse may be a patient advocate during the signing of the consent form, verifying that consent is voluntary and that the patient understands the implications of consent, but the primary legal action by the nurse is witnessing the patient’s signature.

Question 20

When the nurse prepares to administer a preoperative medication to a patient, the patient tells the nurse that she does not really understand what the surgeon plans to do.
a. What action should be taken by the nurse?

b. What criterion of informed consent has not been met in this situation?

Answer 20

a. The nurse should notify the health care provider because the patient needs further explanation of the planned surgery.
b. Sufficient comprehension

Question 21

A patient scheduled for hip replacement surgery in the early afternoon is NPO but receives and ingests a breakfast tray with clear liquids on the morning of the surgery. What response does the nurse expect when the anesthesia care provider is notified?

a. Surgery will be done as scheduled.
b. Surgery will be rescheduled for the following day.
c. Surgery will be postponed for 8 hours after the fluid intake.
d. A nasogastric tube will be inserted to remove the fluids from the stomach.

Answer 21

a. Surgery will be done as scheduled.

The preoperative fasting recommendations of the American Society of Anesthesiology indicate that clear liquids may be taken up to 2 hours before surgery for healthy patients undergoing elective procedures. There is evidence that longer fasting is not necessary.

Question 22

What is the rationale for using preoperative checklists on the day of surgery?

a. The patient is correctly identified.
b. All preoperative orders and procedures have been carried out and records are complete.
c. Patients’ families have been informed as to where they can accompany and wait for patients.
d. Preoperative medications are the last procedure before the patient is transported to the operating room.

Answer 22

b. All preoperative orders and procedures have been carried out and records are complete.

Preoperative checklists are a tool to ensure that many preparations and precautions performed before surgery have been completed and documented. Patient identification, instructions to the family, and administration of preoperative medications are often documented on the checklist, which ensures that no details are omitted.

Question 23

A common reason that a nurse may need extra time when preparing older adults for surgery is their

a. ineffective coping.
b. limited adaptation to stress.
c. diminished vision and hearing.
d. need to include caregivers in activities.

Answer 23

c. diminished vision and hearing

One of the major reasons that older adults need increased time preoperatively is the presence of impaired vision and hearing that slows understanding of preoperative instructions and preparation for surgery. Thought processes and cognitive abilities may also be impaired in some older adults. The older adult’s decreased adaptation to stress because of physiologic changes may increase surgical risks and overwhelming surgery-related losses may result in ineffective coping that is not directly related to time needed for preoperative preparation. The involvement of caregivers in preoperative preparation. The involvement of caregivers in preoperative activities may be appropriate for patients of all ages.

Question 24

The nurse is reviewing laboratory results for a preoperative patient. Which test result should be brought to the attention of the surgeon immediately?

a. Serum K+ of 3.8 mEq/L
b. Hemoglobin of 15 g/dL
c. Blood glucose of 100 mg/dL
d. White blood cell (WBC) count of 18,000/uL

Answer 24

d. White blood cell (WBC) count of 18,000/uL

This finding may indicate an infection. The surgeon will probably postpone the surgery until the cause of the elevated WBC count has been found.

Question 25

The nurse is preparing a patient for transport to the operating room. The patient is scheduled for a right knee arthroscopy. What actions should the nurse take at this time (select all that apply)?

a. Ensure that the patient has voided.
b. Verify that the informed consent is signed.
c. Complete preoperative nursing documentation.
d. Verify that the right knee is marked with indelible marker.
e. Ensure that the H&P, diagnostic reports, and vital signs are on the chart.

Answer 25

a, b, c, d, e, (all options)

All of these are actions that are needed to ensure the patient is ready for surgery. In addition, the nurse should verify that the identification band and allergy band (if applicable) are on; the patient is not wearing any cosmetics; nail polish has been removed; valuables have been removed and secured; and prosthetics, such as eyeglasses, have been removed and secured.

Question 26

An overweight patient (BMI 28.1 kg/m2) is scheduled for a laparoscopic cholecystectomy at an outpatient surgery setting. The nurse knows that

a. surgery will involve multiple small incisions.
b. this setting is not appropriate for this procedure.
c. surgery will involve removing a portion of the liver.
d. the patient will need special preparations because of obesity.

Answer 26

a. surgery will involve multiple small incisions.

Rationale: Many operative procedures are performed as ambulatory surgery (i.e., same-day or outpatient surgery). Obesity is not a contraindication to surgery in the outpatient setting. This patient is not classified as obese on the basis of the BMI. The case implied that a laparoscopic technique will be used that involves several small incisions and meets the requirement of a minimally invasive technique.

Question 27

The patient tells the nurse in the preoperative setting that she has noticed she has a reaction when wearing rubber gloves. What is the most appropriate intervention?

a. Notify the surgeon so the case can be cancelled.
b. Ask additional questions to assess for a possible latex allergy.
c. Notify the OR staff immediately so that latex-free supplies can be used.
d. No intervention is needed because the patient’s rubber sensitivity has no bearing on surgery.

Answer 27

b. Ask additional questions to assess for a possible latex allergy

Rationale: The nurse should ask additional screening questions to determine the patient’s risk for a latex allergy. Latex precaution protocols should be used for patients identified as having a positive latex allergy test result or a history of signs and symptoms related to latex exposure. Many health care facilities have created latex-free product carts that can be used for patients with latex allergies.

Question 28

A 59-year-old man is scheduled for a herniorrhaphy in 2 days. During the preoperative evaluation he reports that he takes ginkgo daily. What is the priority intervention?

a. Inform the surgeon, since the procedure may need to be rescheduled.
b. Notify the anesthesia care provider, since this herb interferes with anesthetics.
c. Ask the patient if he has noticed any side effects from taking this herbal supplement.
d. Tell the patient to continue to take the herbal supplement up to the day before surgery.

Answer 28

a. Inform the surgeon, since the procedure may need to be rescheduled

Rationale: Ginkgo can increase bleeding during and after surgery. The surgeon should determine how long it should be discontinued before surgery.

Question 29

A 17-year-old patient with a leg fracture is scheduled for surgery. She reports that she is living with a friend and is an emancipated minor. She has a statement from the court for verification. Which intervention is most appropriate?

a. Witness the permit after consent is obtained by the surgeon.
b. Call a parent or legal guardian to sign the permit, since the patient is under 18.
c. Obtain verbal consent, since written consent is not necessary for emancipated minors.
d. Investigate your state’s nurse practice act related to emancipated minors and informed consent.

Answer 29

a. Witness the permit after consent is obtained by the surgeon.

Rationale: An emancipated minor may sign his or her own permit. The nurse should be available to witness the signature, but no further action is required.

Question 30

A break in sterile technique occurs during surgery when the scrub nurse touches

a. the mask with sterile gloved hands
b. sterile gloved hands to the gown at chest level.
c. the drape at the incision site with sterile gloved hands.
d. the lower arm to the instruments on the instrument tray.

Answer 30

a. the mask with sterile gloved hands

Question 31

During surgery, a patient has a nursing diagnosis of risk for perioperative positioning injury. What is a common risk factor for this nursing diagnosis?

a. Skin lesions
b. Break in sterile technique
c. Musculoskeletal deformities
d. Electrical or mechanical equipment failure

Answer 31

c. Musculoskeletal deformities

Question 32

At the end of the surgical procedure, the perioperative nurse evaluates the patient’s response to the nursing care delivered during the perioperative period. What reflects a positive outcome related to the patient’s physical status?

a. The patient’s right to privacy is maintained
b. The patient’s care is consistent with the perioperative plan of care.
c. The patient receives consistent and comparable care regardless of setting.
d. The patient’s respiratory function is consistent with or improved from baseline levels established preoperatively.

Answer 32

d. The patient’s respiratory function is consistent with or improved from baseline levels established preoperatively.

Question 33

Phases of postanesthesia care

Answer 33

Phase I:

• Care during immediate postanesthesia period
• Upon admission to PACU, ACP gives complete postanesthesia admission report
• ECG and more intense monitoring (e.g., arterial BP monitoring, mechanical ventilation)
• Goal: Prepare patient to transfer to Phase II or inpatient unit

Phase II:

• Ambulatory surgery patients
• Goal: Prepare for transfer to extended observation, home, or extended care facility

Extended Observation:

• Extended care or observation unit
• Goal: Prepare patient for self-care

Question 34

What does progression of patients through various phases of care in a postanesthesia care unit (PACU) primarily depend on?

a. Condition of patient
b. Type of anesthesia used
c. Preference of surgeon
d. Type of surgical procedure

Answer 34

a. Condition of patient

Although some surgical procedures and drug administration require more intensive postanesthesia care, how fast and through which levels of care patients are moved depend on the condition of the patient. A physiologically unstable outpatient may stay an extended time in Phase I, whereas a patient requiring hospitalization but who is stable and recovering may well be transferred quickly to an impatient unit.

Question 35

Priority decision: Upon admission of a patient to the PACU, the nurse’s priority assessment is

a. vital signs.
b. surgical site.
c. respiratory adequacy.
d. level of consciousness.

Answer 35

c. respiratory adequacy

Physiologic status of the patient is always prioritized with regard to airway, breathing, and circulation, and respiratory adequacy is the first assessment priority of the patient on admission to the PACU from the operating room. Following assessment of respiratory function, cardiovascular, neurologic, and renal function should be assessed as well as the surgical site.

Question 36

How is the initial information given to the PACU nurses about the surgical patient?

a. A copy of the written operative report
b. A verbal report from the circulating nurse
c. A verbal report from the anesthesia care provider (ACP)
d. An explanation of the surgical from the surgeon

Answer 36

c. A verbal report from the anesthesia care provider (ACP)

The admission of the patient to the PACU is a joint effort between the ACP, who is responsible for supervising the postanesthesia recovery of the patient, and the PACU nurse, who provides care during anesthesia recovery. The ACP gives a verbal report that presents the details of the surgical and anesthetic course, preoperative conditions influencing the surgical and anesthetic outcome, and PACU treatment plans to ensure patent safety and continuity of care.

Question 37

To prevent agitation during the patient’s recovery during anesthesia, when should the nurse begin orientation explanations?

a. When the patient is awake
b. When the patient first arrives in the PACU
c. When the patient becomes agitated or frightened
d. When the patient can be aroused and recognizes where he or she is

Answer 37

b. When the patient first arrives in the PACU

Even before patients awaken from anesthesia, their sense of hearing returns and all activities should be explained by the nurse from the time of admission to the PACU to assist in orientation and decrease confusion.

Question 38

What is included in the routine assessment of the patient’s cardiovascular function on admission to the PACU?

a. Monitoring arterial blood gases
b. Electrocardiographic (ECG) monitoring
c. Determining fluid and electrolyte status
d. Direct arterial blood pressure monitoring

Answer 38

b. Electrocardiographic (ECG) monitoring

ECG monitoring is performed on patients to assess initial cardiovascular problems during anesthesia recovery. Fluid and electrolyte status is an indication of renal function and determinations of arterial blood gases and direct arterial blood pressure monitoring are used only in special cardiovascular or respiratory problems.

Question 39

With what are the postoperative respiratory complications of atelectasis and aspirations of gastric contents associated?

a. Hypoxemia
b. Hypercapnia
c. Hypoventilation
d. Airway obstruction

Answer 39

a. Hypoxemia

Hypoxemia occurs with atelectasis and aspiration as well as pulmonary edema, pulmonary embolism, and broncospasm. Hypercapnia is caused by decreased removal of CO2 from the respiratory system that could occur with airway obstruction or hypoventilation. Hypoventilation may occur with depression of central respiratory drive, poor respiratory muscle tone due to disease or anesthesia, mechanical restriction, or pain. Airway obstruction could occur with the tongue blocking the airway, restrained thick secretions, laryngospasm, or laryngeal edema.

Question 40

To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, what will the nurse do?

a. Encourage deep breathing
b. Elevate the head of the bed
c. Administer oxygen per mask
d. Position the patient in a side-lying position

Answer 40

d. Position the patient in a side-lying position

An unconscious or semiconscious patient should be placed in a lateral position to protect the airway from obstruction by the tongue. Deep breathing and elevation of the head of the bed are implemented to facilitate gas exchange when the patient is responsive. Oxygen administration is often used but the patient must first have a patent airway.

Question 41

Priority decision: To promote effective coughing, deep breathing, and ambulation in the postoperative patient, what is most important for the nurse to do?

a. Teach the patient controlled breathing
b. Explain the rationale for these activities
c. Provide adequate and regular pain medication
d. Use an incentive spirometer to motivate the patient

Answer 41

c. Provide adequate and regular pain medication

Incisional pain is often the greatest deterrent to patient participation in effective ventilation and ambulation and adequate and regular analgesic medications should be provide to encourage these activities. Controlled breathing may help the patient to manage pain but does not promote coughing and deep breathing. Explanations and use of an incentive spirometer help to gain patient participation but are more effective if pain is controlled.

Question 42

While assessing a patient in the PACU, the nurse finds that the patient’s blood pressure is below the preoperative baseline. The nurse determines that the patient has residual vasodilating effects of anesthesia when what is assessed?

a. A urinary output of >30 mL/hr
b. An oxygen saturation of 88%
c. A normal pulse with warm, dry, pink skin
d. A narrowing pulse pressure with normal pulse

Answer 42

c. A normal pulse with warm, dry, pink skin

Hypotension with normal pulse and skin assessment is typical of residual vasodilating effects of anesthesia and requires continued observation. An oxygen saturation of 88% indicates hypoxemia, whereas a narrowing pulse pressure accompanies hypoperfusion. A urinary output >30 mL/hr is desirable and indicates normal renal function.

Question 43

Priority decision: A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess for first in the patient?

a. Hypoxemia
b. Neurologic injury
c. Distended bladder
d. Cardiac dysrhythmias

Answer 43

a. Hypoxemia

The most common cause of emergence delirium is hypoxemia and initial assessment should evaluate respiratory function. When hypoxemia is ruled out, other causes, such as a distended bladder, pain, and fluid and electrolyte disturbances, should be considered. Delayed awakening may result from neurologic injury and cardiac dysrhythmias most often result from specific respiratory, electrolyte, or cardiac problems.

Question 44

The PACU nurse applies warm blankets to a postoperative patient who is shivering and has a body temperature of 96.0F (35.6C). What treatment also may be used to treat the patient?

a. Oxygen
b. Vasodilating drugs
c. Antidysrhythmic drugs
d. Analgesics or sedatives

Answer 44

a. Oxygen

During hypothermia, oxygen demand is increased and metabolic processes slow down. Oxygen therapy is used to treat the increased demand for oxygen. Antidysrhythmics and vasodilating drugs would only be used if the hypothermia caused symptomatic cardiac dysrhythmias and vasoconstriction. Sedatives and analgesics are not indicated for hypothermia.

Question 45

Which patient is ready for discharge from Phase I PACU care to the clinical unit?

a. Arouses easily, pulse is 112 bpm, respiratory rate is 24, dressing is saturated, SaO2 is 88%
b. Difficult to arouse, pulse is 52, respiratory rate is 22, dressing is dry and intact, SaO2 is 91%
c. Awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92%
d. Arouses, blood pressure (BP) higher than preoperative preoperatve and respiratory rate is 10, no excess bleeding, SaO2 is 90%

Answer 45

c. Awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92%

On initial assessment in PACU, the airway, breathing, and circulation (ABC) status is assessed using a standardized tool that usually includes consciousness, respiration, oxygen saturation, circulation, and activity. Increased or decreased respiratory rate, hypertension, and an SaO2 below 90% indicate inadequate oxygenation that will be treated or managed in the PACU before discharging the patient to the next phase.

Question 46

For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation found to be an appropriate intervention (select all that apply)?

a. Impaired skin integrity related to incision
b. Impaired mobility related to decreased muscle strength
c. Risk for aspiration related to decreased muscle strength
d. Ineffective airway clearance related to decreased respiratory excursion
e. Constipation related to decreased physical activity and impaired gastrointestinal (GI) motility
f. Venous thromboembolism related to dehydration, immobility, vascular manipulation, or injury

Answer 46

b, d, e, f (impaired mobility related to decreased muscle strength; ineffective airway clearance related to decreased respiratory excursion; constipation related to decreased physical activity and impaired gastrointestinal (GI) motility; venous thromboembolism related to dehydration, immobility, vascular manipulation, or injury)

These problems are improved with ambulation. Other collaborative problems could be potential complications: urinary retention, atelectasis, and pneumonia.

Question 47

A patient who had major surgery is experiencing emotional stress as well as physiologic stress from the effects of surgery. What can this stress cause?

a. Diuresis
b. Hyperkalemia
c. Fluid retention
d. Impaired blood coagulation

Answer 47

c. Fluid retention

The stress response causes fluid retention during the first 1 to 3 days postoperatively and fluid overload is possible during this time. Fluid retention results from secretion and release of antidiuretic hormone (ADH) and adrenocorticotropic hormone (ACTH) by the pituitary and activation of the renin-angiotensin-aldosterone system (RAAS). ACTH stimulates the adrenal cortex to secrete cortisol and aldosterone. The RAAS increases aldosterone release, which also increases fluid retention. Aldosterone causes renal potassium loss with possible hypokalemia and blood coagulation is enhanced by cortisol.

Question 48

In addition to ambulation, which nursing intervention could be implemented to prevent or treat the postoperative complication of syncope?

a. Monitor vital signs after ambulation
b. Do not allow the patient to eat before ambulation
c. Slowly progress to ambulation with slow changes in position
d. Have the patient deep breathe and cough before getting out of bed

Answer 48

c. Slowly progress to ambulation with slow changes in position

Slow progression to ambulation by slowly changing the patient’s position will help prevent syncope. Monitoring vital signs after walking will not prevent or treat syncope. Monitor the patient’s pulse and blood pressure (BP) before, during, and after position changes. Elevate the patient’s head, then slowly have the patient dangle, then stand by the bed to help determine if the patient is safe for walking. Eating will not have an effect on syncope. Deep breathing and coughing will not decrease syncope, although it will prevent respiratory complications.

Question 49

Which tubes drain gastric contents (select all that apply)?

a. T-tube
b. Hemovac
c. Nasogastric tube
d. Indwelling catheter
e. Gastrointestinal tube

Answer 49

c, e (nasogastric tube, gastrointestinal tube)

The nasogastric tube and gastrointestinal tube drain gastric contents. The T-tube drains bile, the Hemovac drains blood from a surgical site, and the indwelling catheter drains urine from the bladder.

Question 50

Which drainage is drained with a Hemovac?

a. Bile
b. Urine
c. Gastric contents
d. Wound drainage

Answer 50

d. Wound drainage

Bile is drained by a T-tube, urine is drained by an indwelling urinary catheter, and gastric contents are drained by a nasogastric tube or a gastrointestinal tube.

Question 51

Priority decision: The nurse notices drainage on the surgical dressing when the patient is transferred from the PACU to the clinical unit. In what order of priority should the nurse do the following actions? Number the options with 1 for the first action and 5 for the last action.
____ a. Reinforce the surgical dressing.
____ b. Change the dressing and assess the wound as ordered.
____ c. Notify the surgeon of excessive drainage type and amount.
____ d. Recall the report from PACU for the number and type of drains in use.
____ e. Note and record the type, amount, and color and odor of the drainage.

Answer 51

1: d. Recall the report from PACU for the number and type of drains in use.
2: a. Reinforce the surgical dressing.
3: e. Note and record the type, amount, and color and odor of the drainage.
4: c. Notify the surgeon of excessive drainage type and amount.
5: b. Change the dressing and assess the wound as ordered.

The nurse must be aware of the drains, if used, and the type of surgery to help predict the expected drainage. Dressings over surgical sites are initially removed by the surgeon unless otherwise specified and should not be changed, although reinforcing the dressing is appropriate. Some drainage is expected for most surgical wounds and the drainage should be evaluated and recorded to establish a baseline for continuing assessment. The surgeon should be notified of excessive drainage. Dressings will then be changed as ordered with assessment for infection being done as well.

Question 52

Thirty-six hours postoperatively a patient has a temperature of 100F (37.8C). What is the most likely cause of this temperature elevation?

a. Dehydration
b. Wound infection
c. Lung congestion and atelectasis
d. Normal surgical stress response

Answer 52

d. Normal surgical stress response

During the first 24 to 48 postoperative hours, temperature elevations to 100.4F (38C) are a result of the inflammatory response to surgical stress. Dehydration and lung congestion or atelectasis in the first 2 days will cause a temperature elevation above 100.4F (38C). Wound infections usually do not become evident until 3 to 5 days postoperatively and manifest with temperatures above 100F (37.8C).

Question 53

The health care provider has ordered IV morphine q2-4hr PRN for a patient following major abdominal surgery. When should the nurse plan to administer the morphine?

a. Before all planned painful activities
b. Every 2 to 4 hours during the first 48 hours
c. Every 4 hours as the patient requests the medication
d. After assessing the nature and intensity of the patient’s pain

Answer 53

d. After assessing the nature and intensity of the patient’s pain

Before administering all analgesic medications, the nurse should first assess the nature and intensity of the patient’s pain to determine if the pain is expected, prior doses of the medication have been effective, and any undesirable side effects are occurring. The administration of PRN analgesic medication is based on the nursing assessment. If possible, pain medication should be in effect during painful activities, but activities may be scheduled around medication administration.

Question 54

What should be included in the instructions given to the postoperative patient before discharge?

a. Need for follow-up care with home care nurses
b. Directions for maintaining routine postoperative diet
c. Written information about self-care during recuperation
d. Need to restrict all activity until surgical healing is complete

Answer 54

c. Written information about self-care during recuperation

All postoperative patients need discharge instructions regarding what to expect and what self-care can be assumed during recovery. Diet, activities, follow-up care, symptoms to report, and instructions about medications are individualized to the patient.

Question 55

When a patient is admitted to the PACU, what are the priority interventions the nurse performs?

a. Assess the surgical site, noting presence and character of drainage.
b. Assess the amount of urine output and presence of bladder distention.
c. Assess for airway patency and quality of respirations, and obtain vital signs.
d. Review results of intraoperative laboratory values and medications received.

Answer 55

c. Assess for airway patency and quality of respirations, and obtain vital signs

Rationale: Assessment in the postanesthesia care unit (PACU) begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Identification of inadequate oxygenation and ventilation or respiratory compromise necessitates prompt intervention.

Question 56

A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to “throw up.” A priority nursing intervention would be to

a. increase the rate of the IV fluids.
b. obtain vital signs, including O2 saturation.
c. position patient in lateral recovery position.
d. administer antiemetic medication as ordered.

Answer 56

c. position patient in lateral recovery position

If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs.

Question 57

After admission of the postoperative patient to the clinical unit, which assessment data requires the most immediate attention?

a. Oxygen saturation of 85%
b. Respiratory rate of 13/min
c. Temperature of 100.4F (38C)
d. Blood pressure of 90/60 mmHg

Answer 57

a. Oxygen saturation of 85%

During the initial assessment, identify signs of inadequate oxygenation and ventilation. Pulse oximetry monitoring is initiated because it provides a noninvasive means of assessing the adequacy of oxygenation. Pulse oximetry may indicate low oxygen saturation (

Question 58

A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to

a. perform a straight catheterization to measure the amount of urine in the bladder.
b. notify the physician and anticipate obtaining blood work to evaluate renal function.
c. continue to monitor the patient because this is a normal finding during this time period.
d. evaluate the patient’s fluid volume status since surgery and obtain a bladder ultrasound.

Answer 58

d. evaluate the patient’s fluid volume status since surgery and obtain a bladder ultrasound

Because of the possibility of infection associated with catheterization, the nurse should first try to validate that the bladder is full. The nurse should consider fluid intake during and after surgery and should determine bladder fullness by percussion, by palpation, or by a portable bladder ultrasound study to assess the volume of urine in the bladder and avoid unnecessary catheterization.

Question 59

Discharge criteria for the Phase II patient include (select all that apply)

a. no nausea or vomiting.
b. ability to drive self home.
c. no respiratory depression.
d. written discharge instructions understood.
e. opioid pain medication given 45 minutes ago.

Answer 59

c, d, e (no respiratory depression, written discharge instructions understood, opioid pain medication given 45 minutes ago)

Phase II discharge criteria that must be met include the following: all PACU discharge criteria (Phase I) met; no intravenous opioid drugs administered for the past 30 minutes; patient’s ability to void (if appropriate with regard to surgical procedure or orders); patient’s ability to ambulate if it is not contraindicated; presence of a responsible adult to accompany or drive patient home; and written discharge instructions given and understood.