TBRQ Ch: 50 - Patient Care Flashcards
Obesity places patients at an increased surgical risk because of which of the following factors? (Select all that apply.)
- Risk for bleeding is increased.
- Ventilatory capacity is reduced.
- Fatty tissue has a poor blood supply.
- Metabolic demands are increased.
- Physical mobility is often impaired.
Answer: 2, 3, 5.
A decreased blood supply in adipose tissue slows the delivery of essential nutrients, antibodies, and enzymes needed for wound healing. A decreased ventilatory capacity allows for alveolar collapse, which can lead to pneumonia. Patients who are obese often have difficulty resuming normal physical activity after surgery because of the pain and fatigue caused by surgery in addition to preexisting impaired physical mobility.
The primary reason that you need to include family members when you teach a patient preoperative exercises is so they can:
- Coach and encourage the patient after surgery.
- Demonstrate to the patient at home.
- Relieve the nurse by getting the patient to do the exercises every 2 hours.
- Practice with the patient while he or she is waiting to be taken to the operating room.
Answer: 1.
Patients may need support from family to be motivated to return to their previous state of health. The family may also have better retention of preoperative teaching and will be with the patient and able to help him or her in recovery.
In the postanesthesia care unit (PACU) a nurse notes that a patient is having difficulty breathing and suspects an upper-airway obstruction. The nurse’s priority intervention at this time is:
- Suction the pharynx and bronchial tree.
- Give oxygen through a mask at 4 L/min.
- Ask the patient to use an incentive spirometer.
- Position the patient on one side with the face down and the neck slightly extended so the tongue falls forward.
Answer: 4.
Weak pharyngeal/laryngeal muscle tone from anesthetics can occur. Positional change helps to move the tongue forward to open the airway. The immediate intervention should be to open the airway. Suctioning the bronchial tree or providing oxygen does not alleviate an upper-airway obstruction.
Because an older adult is at increased risk for respiratory complications after surgery, the nurse needs to:
- Withhold pain medications and ambulate the patient every 2 hours.
- Monitor fluid and electrolyte status every shift and vital signs with temperature every 4 hours.
- Orient the patient to the surrounding environment frequently and ambulate him or her every 2 hours.
- Encourage the patient to turn, deep breathe, and cough frequently and ensure adequate pain control.
Answer: 4.
Adequate pain control is important to allow participation in postoperative exercises such as turning, deep coughing, and deep breathing to prevent respiratory complications.
You are caring for a patient after surgery who had a liver resection. His prothrombin time (PT) is greater than normal. He has low blood pressure; tachycardia; thready pulse; and cool, clammy, pale skin, and he is restless. You assess his surgical wound, and the dressing is saturated with blood. Which immediate interventions do you perform? (Select all that apply.)
- Notify the surgeon.
- Maintain intravenous (IV) fluid infusion and prepare to give volume replacement.
- Monitor the patient’s vital signs every 15 minutes or more frequently until his condition stabilizes.
- Wean oxygen therapy.
- Provide comfort through bathing.
Answer: 1, 2, 3.
A common early complication of surgery is bleeding. It is important to continue oxygen therapy and notify the surgeon. Signs of bleeding include hypotension; tachycardia; and cool, clammy, pale skin. Signs of bleeding may be visible, or the bleeding may be internal. Be prepared to administer fluid or blood as needed and frequently monitor vital signs to assess the patient’s status.
You are a nurse in the postanesthesia care unit (PACU), and you note that your patient has a heart rate of 130 beats/min and a respiratory rate of 32 breaths/min; you also assess jaw muscle rigidity and rigidity of limbs, abdomen, and chest. What do you suspect, and which intervention is indicated?
1. Infection: Notify surgeon and anticipate administration of antibiotics.
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2. Pneumonia: Listen to breath sounds, notify surgeon, and anticipate order for chest radiography.
3. Hypertension: Check blood pressure, notify surgeon, and anticipate administration of antihypertensives.
4. Malignant hyperthermia: Notify surgeon/anesthesia provider immediately, prepare to administer dantrolene sodium (Dantrium), and monitor vital signs frequently.
Answer: 4.
Malignant hyperthermia is a life-threatening complication of general anesthesia. It is a severe hypermetabolic condition that causes rigidity of skeletal muscles caused by an increase in intracellular calcium ion concentration and leads to hypercarbia, tachypnea, and tachycardia. An elevated temperature is a late sign, and an increase in the respiratory rate to eliminate carbon dioxide is one of the first signs. Dantrolene sodium (Dantrium) is a skeletal muscle relaxant used to treat this complication.
After a patient has been given preoperative sedatives, which safety precaution do you take?
- Reinforce to patient to remain in bed or on the stretcher
- Raise the side rails and keep the bed or stretcher in the high position
- Determine if patient has any allergies to latex
- Obtain informed consent immediately after sedative administration
Answer: 1.
It is important for patient safety to inform patients who have been given sedatives of the importance of remaining in bed after preoperative sedatives are administered. It is inappropriate to have a bed or stretcher in the high position because of the increased fall risk and potential for injury. Obtain informed consent and assess allergies before sedative administration.
The operating room (OR) and postanesthesia care unit (PACU) are high-risk environments for patients with a latex allergy. Which safety measures do nurses in these areas implement to prevent a latex reaction? (Select all that apply.)
- Screen patients about food allergies known to have cross-reactivity to latex.
- Have a latex allergy cart available at all times.
- Communicate with the operating room (OR) team as soon as 24 to 48 hours in advance of the surgery when a patient with latex sensitivity is identified.
- Schedule the patient with a latex allergy for the last operative case of the day.
- Plan for the patient to be admitted to a private room after surgery.
Answer: 1, 2, 3.
Identifying patients with potential cross-reactivity is important since they may be unaware of their latex sensitivity. Having all necessary equipment easily accessible to staff ensures that all items are available when needed. It is important for the operative team to be aware of the case so they can plan appropriate safeguards; scheduling the latex-sensitive patient for the first case means that latex dust from the previous day was removed overnight before the latex-sensitive patient’s operation.
A nurse is recovering a patient who received conscious sedation for cosmetic surgery. Which of the following is an advantage that conscious sedation has over general anesthesia? (Select all that apply.)
- Loss of sensation at the surgical site
- Reduction of fear and anxiety
- Amnesia about procedure
- Monitoring in phase I recovery
- Close monitoring for airway patency
Answer: 2, 3.
Conscious sedation offers adequate sedation, reduction of fear and anxiety, amnesia, and relief of pain while maintaining airway patency and ventilation independently along with stable vital signs and rapid recovery. Loss of sensation at the surgical site is an effect of local anesthesia. These patients usually only go through phase II recovery.
You are assigned to care for the following patients on your surgical unit. On the basis of the information provided, which patient do you need to see first?
- A 75-year-old following hip replacement surgery who is complaining of moderate pain in the surgical site, with a heart rate of 92
- A 57-year-old following hip replacement 6 hours earlier who is receiving intravenous patient-controlled analgesia (PCA) with a history of obstructive sleep apnea (OSA) (The pulse oximeter has been alarming and reading 85%.)
- A 36-year-old following bladder neck suspension who is 30 minutes late to receive her postoperative dose of antibiotic
- A 48-year-old following total knee replacement who needs help repositioning in bed
Answer: 2.
The patient with OSA has a risk of airway obstruction, which takes immediate precedence. She is symptomatic of oxygen desaturation.
Hand-off communications that occur between the postanesthesia care unit (PACU) nurse and the nurse on the postoperative nursing unit need to be done when a patient returns to the nursing unit. Which are appropriate components of a safe and effective hand-off? (Select all that apply.)
- Vital signs, type of anesthesia provided, blood loss, and level of consciousness
- Uninterrupted time to review the recent pertinent events and ask questions
- Verification of the patient using one identifier and the type of surgery performed
- Review of pertinent events occurring in the operating room (OR) while at the nurses’ station
- Location of patient’s family members
Answer: 1, 2, 5.
A standardized approach or tool for hand-off communication helps providers provide accurate information about the care received in the operating room and the PACU before coming to the postoperative nursing unit. Proper identification of the patient requires using a standard of two identifiers and explaining the surgery performed and information about the type of anesthesia provided, blood loss, and level of consciousness. Allowing appropriate time for questions and communication free of distraction improves the quality of the hand-off. It must occur at the patient’s bedside. Informing the nurse of the family’s location ensures prompt notification.
A nurse is working in the preoperative holding area and is assigned to care for a patient who is having a prosthetic aortic valve placed. The nurse inserts an intravenous (IV) line and obtains vital signs. The patient has a temperature of 39° C (102° F), heart rate of 120, blood pressure (BP) of 84/50, and an elevated white blood cell (WBC) count. The nurse immediately notifies the surgeon of the patient’s vital signs because:
- He or she needs to get the patient into the operating room (OR) quickly to start the surgery because of the low BP.
- The surgery may need to be delayed to recheck the patient’s WBC count and investigate the source of fever before surgery.
- The nurse anticipates the need for a fluid bolus to increase the patient’s BP.
- The nurse anticipates an order for a sedative to help calm the patient and decrease the heart rate.
Answer: 2.
The patient has a fever, elevated WBC count, tachycardia, and hypotension, which are all signs of a potential infection. It may be necessary to delay the surgery until the source of the fever is treated.
A nurse is preparing to provide a patient with instructions for how to perform incentive spirometry. The patient will likely have incisional pain after returning from an elective colon resection. Which of the following steps for incentive spirometry is the patient likely to have the most difficulty performing? (Select all that apply.)
- Assuming semi-Fowler’s or high-Fowler’s position
- Setting the incentive spirometer device scale at the volume level to be attained
- Placing the mouthpiece of the incentive spirometer so lips completely cover the mouthpiece
- Inhaling slowly while maintaining constant flow through unit until it reaches goal volume
- Breathing normally for a short period between each of the 10 breaths on incentive spirometry
- Ending with two coughs after the end of 10 incentive spirometry breaths hourly
Answer: 1, 4, 6.
The patient will likely have pain after surgery, making it difficult to change positions and sit upright, take a full deep breath, and be able to cough. Splinting and administration of analgesics before the use of spirometry can increase the patient’s ability to perform the exercise.
A patient is admitted through the emergency department following a motorcycle crash with multiple orthopedic injuries. He goes to surgery for repair of fractures. He is postoperative day 3 from an open-reduction internal fixation of bilateral femur fractures and external fixator to his unstable pelvic fracture. Interventions that are necessary for prevention of venous thromboembolism in this patient include: (Select all that apply.)
- Intermittent pneumatic compression stockings.
- Vitamin K therapy.
- Passive range-of-motion exercises every 4 hours.
- Subcutaneous heparin or enoxaparin (Lovenox).
- Continuous heparin drip with a goal of an international normalized ratio (INR) 5 times higher than baseline.
Answer: 1, 4.
Combination therapy with mechanical and pharmacological prophylaxis is recommended for high-risk patients. Vitamin K therapy creates a higher risk for clotting, and aPTT levels are drawn to evaluate the effectiveness of heparin therapy. Therapeutic levels are typically 1.5-2.5 times the normal aPTT level.
You are caring for a 65-year-old patient 2 days after surgery and helping him ambulate down the hallway. The surgeon ordered exercise as tolerated. Your assessment indicates that the patient’s heart rate at baseline is 88. After walking approximately 30 yards down the hallway, his heart rate is 110. What is your next action?
- Stop exercise immediately and have him sit in a nearby chair.
- Ask him how he feels; determine if there is any discomfort or shortness of breath; and, if not, continue exercise.
- Tell him that he needs to walk further to reach a heart rate of 120.
- Have him walk slower; he has reached his maximum.
Answer: 2.
The patient’s maximum heart rate with exercise should be 220 − 65 = 155. He is still in a safe range. An assessment of how the patient feels is good practice. The patient can safely continue to walk.
