Perioperative Nursing Flashcards
Which test is the best resource for determining the preoperative status of a client’s liver function?
1. Serum electrolytes
2. Blood urea nitrogen (BUN), creatinine
3. Alanine aminotransferase (ALT), aspirate aminotransferase (AST), bilirubin
4. Serum albumin
- Answer: 3. Rationale: These tests are specific to liver function. Option 1 evaluates fluid and electrolyte status. Option 2 evaluates renal status; option 4 evaluates nutritional status. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 37-3.
A client who is having a mastectomy expresses sadness about losing her breast. Based on this information, the nurse would identify that the client is at risk for which nursing diagnosis?
1. Disturbed Body Image
2. Grieving
3. Fear
4. Ineffective Coping
- Answer: 2. Rationale: Grieving is the state in which an individual experiences reactions in response to an expected significant loss. The definition for option 1 is “confusion in mental picture of one’s self” and is often characterized by negative responses such as shame, embarrassment, guilt, or revulsion. Option 3, fear, is usually characterized by feelings of dread, fright, apprehension, or alarm. Ineffective coping, option 4, is usually characterized by verbalization of inability to cope or ask for help, inappropriate use of defense mechanisms, or inability to meet role expectations. Cognitive Level: Applying. Client Need: Psychological Integrity. Nursing Process: Diagnosis. Learning Outcome: 37-4.
Which statement by the client indicates that the preoperative teaching regarding gallbladder surgery has been effective?
1. “I cannot eat or drink anything after midnight.”
2. “I’m not going to cough after surgery because it might open my incision.”
3. “I might have a stroke if I stop taking my anticoagulant.”
4. “The nurse showed me how to contract and relax my calf muscles.”
- Answer: 4. Rationale: Option 1 is incorrect because of the ASA guidelines for preoperative fasting. Option 2 is incorrect because clients are taught how to cough and also how to splint their incision to prevent complications. Option 3 is incorrect because anticoagulants are discontinued a few days before surgery to avoid excessive bleeding postoperatively. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Evaluation. Learning Outcome: 37-6.
The nurse assesses a postoperative client who has a rapid, weak pulse; urine output of less than 30 mL/h; and decreased blood pressure. The client’s skin is cool and clammy. What complication should the nurse suspect?
1. Thrombophlebitis
2. Hypovolemic shock
3. Pneumonia
4. Wound dehiscence
- Answer: 2. Rationale: The symptoms describe decreased cardiac output and not any of the other listed complications. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 37-10.
The client is most likely to require the greatest amount of analgesia for pain during which period?
1. Immediately after surgery
2. 4 hours after surgery
3. 12 to 36 hours after surgery
4. 48 to 60 hours after surgery
- Answer: 3. Rationale: Options 1 and 2 are incorrect because the client is still recovering from the anesthesia used during surgery. Option 4 is incorrect because pain usually decreases after the second or third postoperative day. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 37-10.
- A postop client who had abdominal surgery is holding a pillow against his abdomen during deep-breathing and coughing exercises. What term does the nurse use to describe this technique? –––––––––––––––
- Answer: Splinting. Rationale: If the incision is painful when the client coughs, splinting the abdomen may reduce the pain. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 37-6.
A semiconscious client in the postanesthesia care unit (PACU) is experiencing dyspnea (difficulty breathing). Which action should the nurse perform first?
1. Place a pillow under the client’s head.
2. Remove the oropharyngeal airway. 3. Administer oxygen by mask.
4. Reposition the client to keep the tongue forward.
- Answer: 4. Rationale: The tongue can obstruct the airway in a semiconscious client. Repositioning in the side-lying position with the face slightly down will help prevent occlusion of the pharynx and also allow drainage of mucus out of the mouth. Option 1 is incorrect because a pillow under the head increases the risk of aspiration or airway obstruction. Because the problem is airway obstruction, actions to promote an open airway are most appropriate. The nurse would want to keep the airway in place (option 2). The problem is obstruction, not percentage of available oxygen (option 3). Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 37-9.
The client’s postoperative orders state “diet as tolerated.” The client has been NPO. The nurse will advance the client’s diet to clear liquids based on which assessment? Select all that apply.
1. Does not complain of nausea or vomiting
2. Pain level is maintained at a rating of 2–3 out of 10
3. States passing flatus 4. Ambulates with minimal assistance 5. Expresses feeling “hungry”
- Answer: 1 and 3. Rationale: Anesthetics, narcotics, fasting, and inactivity all inhibit peristalsis. Oral fluids and food are started after the return of peristalsis. The client may feel hungry but peristalsis may not be present. The other options are important but not related specifically to advancing the client’s diet. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Assessment. Learning Outcome: 37-9.
- The overall goal of nursing care during the intraoperative phase is the client’s ––––––––––––––––.
- Answer: Safety. Rationale: The client’s protective reflexes are compromised, especially with general anesthesia. Thus, the perioperative nurse needs to maintain the client’s safety during surgery. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcome: 37-5.
The nurse plans to remove the client’s sutures. Which action demonstrates appropriate standards of care? Select all that apply.
1. Use clean technique.
2. Grasp the suture at the knot with a pair of forceps.
3. Place the curved tip of the suture scissors under the suture as close to the skin as possible.
4. Pull the suture material that is visible beneath the skin during removal.
5. Remove alternate sutures first.
- Answer: 2, 3, and 5. Rationale: Option 1 is incorrect because sterile technique is used. The suture material that is visible is in contact with bacteria and must not be pulled beneath the skin during removal (option 4). Cognitive Level: Applying. Client Need: Physiological Integrity. Learning Outcome: 37-12e.
