TERM 3- MY NOTES ADULT NURSING CH.2 "SURGICAL CARE OF PATIENT" Flashcards
Surgery is defined as that branch of medicine concerned with diseases and trauma requiring operative procedures
A)true
B)false
A
________is defined as that branch of medicine concerned with diseases and trauma requiring operative procedures
Surgery
early surgeons had little knowledge of the principles of asepsis, and anesthetic techniques and that it were primitive and unsafe. Indeed, a surgeon’s success was based on speed during that time
A)true
B)false
A
Surgery is classified as elective, urgent, or emergency.
A)true
B)false
A
Elective surgery is not necessary to preserve life and may be performed at a time the patient chooses.
A)true
B)false
A
Elective surgery can be performed at anytime during a patient life
A)true
B)false
A
Urgent surgery is required to keep additional health problems from occurring.
A)true
B)false
A
Emergency surgery is performed immediately to save the individual’s life or preserve the function of a body part.
A)true
B)false
A
Surgery is performed for various purposes, including diagnostic, ablation, palliative, reconstructive, transplant, constructive, and cosmetic.
A)true
B)false
A
amputation or excision of any body part or removal of a growth or harmful substance is called
A)ablation
B) palliative
A
therapy to relieve or reduce uncomfortable symptoms without cure
A)palliative
B)ablation
A
CLASSIFICATION OF SURGICAL PROCEDURES
,
Involves extensive reconstruction or alteration in body parts; poses great risks to well-being (e.g., coronary artery bypass, colon resection, gastric resection)
A)major
B)minor
C)elective
A
Involves minimal alteration in body parts; often designed to correct deformities; involves minimal risks compared with those of major procedures (e.g. , cataract extraction, skin graft, tooth extraction)
A)major
B)minor
C)elective
B
Performed on basis of patient’s choice (e.g., bunionectomy, plastic surgery)
A)minor
B)major
C)elective
C
Necessary for patient’s health (e.g., excision of cancerous tumor, removal of gallbladder for stones, vascular repair for obstructed artery [e.g ., coronary artery bypass])
A)urgent
B)emergency
C)major
A
Must be done immediately to save life or preserve function of body part (e.g., removal of perforated appendix, repair of traumatic amputation, control of internal hemorrhaging)
A)emergency
B)urgent
C)elective
A
removal of perforated appendix, repair of traumatic amputation, control of internal hemorrhaging are all
A)emergency
B)false
A
coronary artery bypass, colon resection, gastric resection are all
A)major
B)minor
C)both a and b
A
cataract extraction, skin graft, tooth extraction are all
A)urgent
B)elective
C)minor
C
excision of cancerous tumor, removal of gallbladder for stones, vascular repair for obstructed artery [e.g ., coronary artery bypass]) are all
A)urgent
B)emergency
C)major
A
bunionectomy, plastic surgery are all
A)elective
B)minor
A
Excision or removal of diseased body part (e.g., amputation, removal of appendix, cholecystectomy)
A)Ablation
B)Palliative
A
Surgery for relief or reduction of intensity of disease symptoms; will not produce cure (e.g., colostomy, debridement of necrotic tissue)
A)Ablation
B)Palliative
B
PERIOPERATIVE NURSING
,
Perioperative nursing refers to the nurse’s role during the preoperative, intraoperative, and postoperative phases of a surgical experience
A)true
B)false
A
preoperative (before surgery) intraoperative (during surgery) postoperative (after surgery) A)true B) false
A
Perioperative nursing stresses the importance of providing continuity of care for the surgical patient using the nursing process.
A)true
B)false
A
In many hospitals, perioperative nurses assess a patient’s health status preoperatively, identify specific patient needs, teach and counsel, attend to the patient’s needs in the OR, and then follow the patient’s recovery.
A)true
B)false
A
The nurse’s major responsibility is safe, consistent, and effective nursing interventions during each phase of surgery.
A) true
B)false
A
SURGICAL TERMINOLOGY
,
Surgical joining of two ducts or blood vessels to allow flow from one to another; to bypass an area (e.g., Billroth I, joins stomach and duodenum)
A)Anastomosis
B)lysis
A
Destruction or dissolution of (e.g., lysis of adhesions, removal of adhesions)
A)orrhagy
B)lysis
B
Surgical repair of (e.g., herniorrhaphy, repair of a hernia)
A)orrhaphy
B)ostomy
A
Opening made to allow the passage of drainage (e.g., ileostomy, formation of an opening of the ileum onto the surface of the abdomen for passage of feces)
A)ostomy
B)otomy
A
Opening into (e.g., thoracotomy, surgical opening into the thoracic cavity)
A)otomy
B)ostomy
A
Fixation of (e.g., cecopexy, fixation or suspension of the cecum to correct its excessive mobility)
A)pexy
B)pasty
A
Plastic surgery (e.g., mammoplasty, reshaping of the breasts to reduce, lift, reconstruct)
A)pexy
B)pasty
B
Common Surgical Settings
,
Inpatient: Patient hospitalized for surgery
A)true
B)false
A
• One-day (same-day surgery): Patient admitted the day surgery is scheduled and dismissed the same day
A)true
B)false
A
• Outpatient: Patient, not hospitalized, admitted either to a short-stay unit or directly to the surgical suite (some-times referred to ambulatory surgery)
A)true
B)false
A
• Short-stay surgical center (“surgicenter’’): Independently owned agency; surgery performed when overnight hospitalization is not required {also called ambulatory surgical center or one-day surgery center)
A)true
B)false
A
• Short-stay unit: Department or floor where a patient’s stay does not exceed 24 hours (sometimes referred to as outpatient/observation unit)
A)true
B)false
A
• Mobile surgery units: Units that move from place to place; go to the patient instead of the patient traveling to the unit
A)true
B)false
A
DELEGATION CONSIDERATION IN PERIOPERATIVE NURSING
,
The skills of assessment that are part of preparing the patient for surgery require the critical thinking and knowledge application unique to a nurse. For these skills, delegation is inappropriate.
A)true
B)false
A
Assistive personnel (AP) may obtain vital signs and weight and height measurements. A)true B)false
A
AP can reinforce and assist patients in performing postoperative exercises.
A)true
B)false
A
AP may administer an enema or douche; obtain vital signs; apply antiembolic stockings; and assist patient in removing clothing, jewelry, and prostheses.
A)true
B)false
A
- Instruct AP in proper observations and precautions if the patient has an IV catheter in place
A)true
B)false
A
The skills of sterile gowning and gloving can be delegated to a surgical technologist or the nurse who has acquired the proper skills.
A)true
B)false
A
AP may obtain vital signs, apply nasal cannula or oxygen mask, and provide basic comfort and hygiene measures.
A)true
B)false
A
INFLUENCING FACTORS
,
By helping patients express their concerns, the nurse can offer support, reassurance, and information the best way to address fear of the unknown.
A)true
B)false
A
AGE
,
The young and the old do not tolerate major surgical treatment as well as those in other age-groups. Their altered metabolic needs may not respond to physiologic changes quickly. Specific concerns center on the body’s response to temperature changes, cardiovascular shifts, respiratory needs, and renal function.
A)true
B)false
A
To assist patients in returning to their optimal level of health, nursing assessments and appropriate interventions should be ongoing
A)true
B)false
A
PHYSICAL CONDITION
,
Healthy patients have smoother and faster recovery periods than patients who have coexisting health problems. Assess each body system to identify actual and potential problems, then select measures to prevent postsurgical complications
A)true
B)false
A
NUTRITIONAL FACTORS
,
The body uses carbohydrates, proteins, and fats to supply energy-producing glucose to its cells.
A)true
B)false
A
Carbohydrates and fats are the primary energy producers
A)true
B)false
A
protein is essential to build and repair body tissue.
A)true
B)false
A
Nutritional needs are affected by a patient’s age and physical requirements; patients who maintain a sound, nutritional diet tend to recover more quickly.
A)true
B)false
A
A complete diet history identifies the patient’s usual eating habits, nutritional patterns, and food preferences.
A)true
B)false
A
Dietary practices are influenced by a patient’s ethnic, cultural, religious, and socioeconomic background.
A)true
B)false
A
Surgery may decrease a patient’s appetite and alter metabolic functions, so observe the patient for signs of malnutrition.
A)true
B)false
A
Surgery can alter the patient regular nutritional diet so assess for malnutrition
A)true
B)false
A
If malnutrition is promptly identified, tube feedings, intravenous (IV) therapy, or parenteral hyperalimentation can be initiated
A)true
B)false
A
Life Span Considerations Older Adults Undergoing Surgery
,
Older adults undergoing surgery have higher morbidity and mortality rates than younger people.
A)true
B)false
A
Older patients tend to recover more slowly from surgery compared with younger patients.
A)true
B)false
A
Recovery is affected by the level of mental functioning, individual coping ability, and the availability of support systems.
A)true
B)false
A
Risks of aspiration, atelectasis, pneumonia, thrombus formation, infection, and altered tissue perfusion are increased in the older adult
A)true
B)false
A
Disorientation or toxic reactions can occur in the older adult after the administration of anesthetics, sedatives, or analgesics. These reactions are often present for days after administration of the medication.
A)true
B)false
A
When communicating with older adult patients, be aware of any auditory, visual, or cognitive impairment that may be present.
A)true
B)false
A
ABCDE Mnemonic Device to Ascertain Serious Illness or Trauma in the preoperative Patient
,
A
Allergy to medications, chemicals, and other environmental products such as latex. All allergies are reported to anesthesia and surgical personnel before the beginning of surgery. Place an allergy band on the patient’s arm immediately.
B
Bleeding tendencies or the use of medications that deter clotting, such as aspirin or products containing aspirin, heparin, or warfarin sodium. Herbal medications may also increase bleeding times or mask potential blood-related problems.
C
Cortisone or steroid use.
D
Diabetes mellitus, a condition that not only requires strict control of blood glucose levels but is also known to delay wound healing.
E
Emboli. Previous embolic events (such as lower leg blood clots) may recur because of prolonged immobility.
True
DM can delay wound healing
A)true
B)false
A
Patients whose immune systems are suppressed are at a much higher risk for development of postoperative infection and are less capable of fighting that infection.
A)true
B)false
A
PSYCHOSOCIAL NEEDS
,
Preoperative fear has been linked to postoperative behavior.
A)true
B)false
A
The preoperative anxiety level influences the amount of anesthesia required, the amount of postoperative pain medication needed, and the speed of recovery from surgery.
A)true
B)false
A
Determine each patient’s perceptions, emotions, behavior, and support systems that may help or hinder their progress through the surgical period.
A)true
B)false
A
Patiently and actively listening to the patient, the family, and significant others it invites confidence and helps reduce anxiety levels
A)true
B)false
A
ln addition to nursing and medical personnel, ministerial staff, social workers, or patient advocates can provide support for patients and families during this stressful time
A)true
B)false
A
SOCIOECONOMIC AND CULTURAL NEEDS
,
Even geographic location affects the way a patient responds to surgery.
A)true
B)false
A
A multicultural perspective helps nurses approach patients with respect and individually tailor care that promotes recovery
A)true
B)false
A
Common Fears Associated with Surgery
,
Fear of loss of control is associated primarily with anesthesia. The patient becomes almost totally dependent on the health care team during the surgical experience, even for basic needs such as breathing and life support-while under the influence of anesthesia.
A)true
B)false
A
• Fear of the unknown may result from uncertainty about the surgical outcome or a lack of knowledge regarding the surgical experience
A)true
B)false
A
Fear of the unknown can be fixed by the nurse giving postive attitude and knowledge of the whats going to happen
A)true
B)false
A
Fear of anesthesia may include fears of unpleasant induction of or emergence from anesthesia. The patient may fear waking up during the operation and feeling pain while under anesthesia.
A)true
B)false
A
This fear is often related to loss of control and fear of the unknown.
A)fear of anesthesia
B)fear of the unknown
A
• Fear of pain or inadequate postoperative analgesia is common. Reassure the patient and significant others that the pain will be controlled.
A)true
B)false
A
Fear of death is a legitimate fear. Even with the great strides in surgery and anesthesia, no anesthetic or operation is perfectly safe for all patients.
A)true
B)false
A
• Fear of separation from the usual support group may arise because the patient is separated from spouse, family, or significant others, as well as other support groups, and is cared for by strangers during this highly stressful period.
A)true
B)false
A
Fear of disruption of life patterns relates to surgery and recovery interfering in varying degrees with activities of daily living, social activities, work, and professional activities.
A)true
B) false
A
• Fear of change in body image and mutilation is not unusual. Surgery disrupts body integrity and threatens body image.
A) true
B)false
A
• Fear of detection of cancer produces a high anxiety level.
A)true
B)false
A
Patient Teaching Preoperative Care
,
Recovery room or postanesthesia care unit
- Place where the patient will awaken
-Frequent monitoring of vital signs
- Return to room when vital signs are stable
A)true
B)false
A
• Probable postoperative therapies
-Need for increased mobility as soon as possible
-Need to keep respiratory passages clear
A)true
B)false
A
MEDICATIONS
,
Polypharmacy (concurrent use of multiple medications) occurs in all age-groups but is more common with older adults
A)true
B)false
A
Large numbers of medications increase the chance of interactions.
A)true
B)false
A
The anesthesiologist, in collaboration with the patient’s physician and surgeon, determines whether these medications should be taken the day of surgery and postoperatively.
A)true
B)false
A
Remember to assess for allergies to drugs that may be given during any phase of the surgery
A)true
B)false
A
Also ask about non-drug allergies, including allergies to foods, chemicals, pollen, antiseptics used to prepare the skin for surgery, and latex rubber products.
A)true
B)false
A
Patients with a history of allergic responsiveness are more likely to have hypersensitivity reactions to anesthesia agents.
A)true
B)false
A
Cultural Considerations
The Surgical Patient
,
Use of the patient’s language helps put an anxious patient at ease. Use an interpreter when possible; learn some key phrases in foreign languages; and use references such as medical dictionaries, which usually have key phrases listed in an appendix.
A)true
B)false
A
• Because some Southeast Asians and Native Americans may avoid eye contact and consider it disrespectful, consider limiting eye contact when dealing with such patients.
A)true
B)false
A
Chinese-Americans may not ask for pain medication and may need teaching to help explain how comfort and relief from pain promote healing and a quicker recovery.
A)true
B)false
A
• Native Americans are often stoic when ill. Complaints of pain to the nurse may be in general terms such as, “I am uncomfortable.” Undertreatment of pain is common. The patient may lack basic trust.
A)true
B)false
A
stoic is a person who can endure pain and hardship without showing it
A)true
B)false
A
Among Arab-Americans, verbal consent often has more meaning than written consent because it is based on trust. Fully explain the need for written consent. The patient is expressive regarding pain; pain may cause intense fear. Prepare the patient for painful procedures, and develop a care plan to prevent pain
A)true
B)false
A
Among Arab-Americans, verbal conformation has more value then the written conformation
A)true
B)false
A
Blacks may be open to expression of pain but may avoid medication because of fear of addiction. For a terminal diagnosis, news is best expressed in a family care conference or by speaking with the patient’s religious representative.
A)true
B)false
A
Blacks may avoid medication because of fear of addiction.
A)true
B)false
A
For Vietnamese-American patients, having an interpreter (often a hired one) is important, depending on the sensitivity of the subject under discussion, because of modesty. A female family member is expected to be at the bedside to provide care and comfort. Men are the decision makers and support the family; therefore speaking with the male head of the family may be necessary
A)true
B)false
A
For Vietnamese-American patients,Men are the decision makers and support the family; therefore speaking with the male head of the family may be necessary
A)true
B)false
A
Russian-American patients often prefer an amiable nurse who has a friendly smile. Use open, inviting, nonverbal postures. A Russian-American patient is more willing to follow instruction if the nurse providing it is sincere, competent, and trustworthy. Russian-American families usually have a principal patriarch.
A)true
B)false
A
amiable means having a friendly and pleasant manner
A)true
B)false.
A
patriarch means the male is the head of the family
A)true
B)false
A
Preoperative Considerations for Commonly Ingested Herbs
,
Echinacea is used Treat cold symptoms
A)true
B)false
A
Garlic is used to Improved immunity, High blood pressure and cholesterol
A)true
B)false
A
Ginger is used for motion sickness, Cough, Menstrual cramps, Intestinal gas
A)true
B)false
A
St. John’s wort is used for Antidepressant, Antiviral properties and Antiinflammatory action
A)true
B)false
A
SURGICAL EFFECTS ON THE BODY SYSTEMS
,
CARDIOVASCULAR
Hypotension and cardiac dysrhythmias are the most common cardiovascular complications of the surgical patient. Early recognition and management before these complications become serious enough to diminish cardiac output depend on frequent assessment of the patient’s vital signs.
,
ENDOCRINE
-Liver disease alters metabolism and elimination of drugs administered during surgery and impairs wound healing because of alterations in protein metabolism.
-Diabetes increases susceptibility to infection and may impair wound healing from altered glucose metabolism and associated circulatory impairment. Fluctuating blood levels may cause central nervous system malfunction during anesthesia.
,
GASTROINTESTINAL
Preoperative and postoperative medication may be necessary to control gastric acidity. Risk of hemorrhage may increase due to intubation.
,
intubation means insertion of a tube into a body
A)true
B)false
A
IMMUNE
Disease slows the body’s ability to fight infection. Immunologic disorders increase risk of infection and delay wound healing after surgery. Hypothermia during surgery decreases immune function.
AIDS
MUSCULOSKELETAL
Osteoporosis and increased risk for fractures in the older adult places patient at increased risk for injury.
,
NEUROLOGIC
(Seizures) Check the therapeutic levels of patient’s medications. (Myasthenia gravis) Muscle relaxants may need to be excluded due to decreased ability to reverse their effects. (CVA) Impaired verbal communication, defective perception of the body, paralysis, and visual disturbances place patient at high risk for injury. (PVD) Patient has a decreased threshold for peripheral pain
,
RESPIRATORY
Lung motility is decreased and gas exchange slowed. Anesthetic agents reduce respiratory function, increasing risk for severe hypoventilation.
,
URINARY
Impaired kidney function decreases excretion of anesthesia and alters acid-base balance. Prostate enlargement may increase risk of urinary tract infection.
,
PREOPERATIVE PHASE
,
Before surgery, patients require a thorough health assessment. Acute or chronic diseases hinder the body’s ability to repair itself or adjust to surgical treatment.
A)true
B)false
,
Postoperative care is also adjusted, when possible, to prevent potential complications.
For example, a patient who smokes cigarettes may have impaired alveoli and reduced lung capacity. Mucus and anesthesia by-products may be trapped in the lung, causing atelectasis and pneumonia. After surgery, . breathing exercises and treatments for the smoker aid in lung expansion and decrease the risk of respiratory complications
A)true
B)false
A
PREOPERATIVE TEACHING
,
Patient teaching before surgery helps decrease the patient's stress associated with fear of the unknown. Preoperative information helps reduce (1) anxiety (2) the amount of anesthesia needed (3) postsurgical pain (4) corticosteroid production. A)true B)false
A
Decreasing postsurgical complications through preoperative teaching speeds wound healing.
A)true
B)false
A
For surgical procedures that have potential long-term effects, support groups can offer support preoperatively.
A)true
B)false
A
Ideally, preoperative teaching is provided 1 or 2 days before surgery, when anxiety is not as high.
A)true
B)false
A
Generally, instruct the patient about the surgical procedure, informed consent, the method of skin preparation, and the gastrointestinal (GI) cleanser to be used.
A)true
B)false
A
Clarify what the physician has explained. Review the time of the surgery and information about the recovery area (e.g., previously assigned units, intensive care, specialty units, or outpatient area).
A)true
B)false
A
Reinforce that vital signs, dressings, and tubes are assessed every 15 to 30 minutes until the patient is awake and stable.
A)true
B)false
A
PREOPERATIVE PREPARATION
,
For surgery in a short-stay or ambulatory setting, the workup normally occurs a few days in advance. If the patient is admitted to the hospital, testing may be conducted to assess for potential problems. Preparation frequently includes both in-hospital testing and evaluation of test results that were completed in the physician’s office.
A)true
B)false
A
Serum electrolytes are evaluated if extensive surgery is planned or the patient has associated problems. One essential electrolyte examined is potassium; if not enough potassium is available, dysrhythmias can occur during anesthesia and the patient’s recovery may be delayed by general muscle weakness
A)true
B)false
A
if not enough potassium is available, dysrhythmias can occur during anesthesia and the patient’s recovery may be delayed by general muscle weakness
A)true
B)false
A
Blood chemistry profile (lactate dehydrogenase, -y-glutamyltransferase, alkaline phosphatase, total bilirubin) and urine bilirubin levels are used to assess hepatic function.
A)true
B)false
A
informed consent (permission to perform a specific test or procedure) before the beginning of any procedure. A)true B)false
A
A witness only verifies that this is the person who signed the consent and that it was a voluntary consent.
A)true
B)false
A
Informed consent should not be obtained if the patient is disoriented, unconscious, mentally incompetent, or, in some agencies, under the influence of sedatives
A)true
B)false
A
If necessary, contact the physician and indicate that the patient does not understand the procedure.
A)true
B)false
A
In an emergency, the patient may not be able to give consent for surgery. Every effort is made to locate family members to assume this responsibility. Occasionally telephone permission may be obtained.
A)true
B)false
A
Hospitals have standard guidelines for obtaining verbal consent. If the patient’s life is in danger and family members cannot be located, the surgeon may legally perform surgery. If family members object to surgery that the physician believes is essential, a court order may be obtained for the procedure
A)true
B)false
A
Gastrointestinal Preparation
,
At midnight before surgery, the patient is usually placed on nothing by mouth (NPO) status; this ensures the GI tract is empty when the patient is anesthetized, thereby decreasing the chance of vomiting or aspirating emesis after surgery
A)true
B)false
A
Reinforce with both the patient and the family the importance of not ingesting foods or fluids. If the patient fails to comply with the NPO order, notify the physician
A)true
B)false
A
An order for NPO after midnight should apply to solid foods for patients scheduled for surgery in the morning. An early light breakfast is allowed for afternoon procedures. Clear liquid may be taken up to 3 hours before surgery.
A)GI preparation
B)false
A
Patients can have oral care while NPO, but caution them not to swallow fluids used. A wet cloth on the lips helps relieve dryness. If patients need to be hydrated or require special IV medications, the physician may order parenteral fluids or medication
A)true
B)false
A
Because anesthesia relaxes the bowel, a bowel cleanser may be ordered to evacuate fecal material and lessen postoperative GI problems (nausea and vomiting)
A)true
B)false
A
Go-LYTELY is contraindicated in patients with GI obstruction, gastric retention, bowel perforation, toxic colitis, or megacolon
A)true
B)false
A
Before bowel surgery, medication (neomycin, sulfonarnides, erythromycin) may be given over a period of days to detoxify and sterilize the GI tract.
A)true
B)false
A
Skin Preparation
,
The operative site must be shaved carefully to remove the hair without injuring the skin
A)true
B)false
A
surgeons generally order hair removal only if it might interfere with exposure, closure, or dressing of the surgical site.
A)true
B)false
A
Shaving the hair before surgery creates microscopic cuts that increase the risk of surgical site infection.
A)true
B)false
A
A lower rate of infection occurs with either no shave or use of electric clippers than with any other method
A)true
B)false
A
If shaving is used, it should be performed close to the actual time of the surgical procedure to decrease the time for growth of bacteria and lower the potential for infection
A)true
B)false
A
Once the patient is in the OR, scrub the skin thoroughly with a detergent solution and then apply an antiseptic solution to kill more adherent and deeper residing bacteria. The surgeon may place a transparent sterile drape directly over the skin before making an incision.
A)true
B)false
A
Special concerns for patients undergoing a surgical skin preparation are as follows:
• Small children may be easily frightened by this procedure, and it may need to be done in the OR.
• Older adults need a detailed explanation to relieve their anxiety.
• Older adults have less subcutaneous tissue, less skin elasticity, and more delicate skin tissue. Take extreme care when shaving the older adult.
• Older adults are usually more susceptible to infections.
True
Performing a Surgical Skin Preparation Nursing Action (Rationale)
,
Lather skin with antiseptic soap and warm water (Cleanses skin, softens hair, and reduces friction from razor.)
A)true
B)false
A
Hold razor at a 30- to 45-degree angle to skin. (Minimizes chances of cutting or nicking skin.)
a. Shave small areas while holding skin taut.
b. Use short, smooth strokes. (Prevents pulling skin.)
c. Shave hair in same direction it grows (see illustration). (Removes hair close to skin surface.)
True
Rinse razor frequently. (Removes accumulation of hair from razor and prevents contamination from dirty water.)
A)true
B)false
A
Latex Allergy Considerations
,
Focused assessment of risk factors helps identify patients with the nursing diagnosis of risk for latex allergy response
A)true
B)false
A
The type IV allergic reaction to latex is a cell-mediated response to the chemical irritants found in latex products
A)true
B)false
A
The true latex allergy is the type I allergic reaction, and it occurs shortly after exposure to the proteins in latex rubber. The type I reaction is an immunoglobulin E-mediated systemic reaction that occurs when latex proteins are touched, inhaled, or ingested.
A)true
B)false
A
Risk factors for latex allergy include the following:
• History of anaphylactic reaction of unknown etiology during a medical or surgical procedure
• Multiple surgical procedures (especially from infancy)
• Food allergies (specifically kiwi, bananas, avocados, chestnuts)
• A job with daily exposure to latex (health care, food handlers, tire manufacturers)
• History of reactions to latex (balloons, condoms, gloves)
• Allergy to poinsettia plants
• History of allergies and asthma
True
Identification of patients at risk is the first step in preventing a reaction.
A)true
B)false
A
Responding to a Patient’s Risk for Latex Allergy
,
LATEX-ALERT PATIENT (HIGH RISK FOR ALLERGIC RESPONSE)
• No premedications are required.
• No special pharmaceutical protocols are required.
• Use nonlatex gloves.
• Use latex-safe supplies.
• Keep a latex-safe supply cart available in patient’s area
True
LATEX-ALLERGY PATIENT (SUSPECTED OR KNOWN ALLERGIC RESPONSE)
- Administer prophylactic treatment with steroids and anti-histamines preoperatively.
- Prepare a latex-safe environment, include latex-safe supply cart and crash cart.
- Apply cloth barrier to patient’s arm under a blood pressure cuff.
- Use medications from glass ampules.
- Do not puncture rubber stoppers with needles.
- Wear synthetic gloves.
- Use latex-free syringes.
- Use latex-safe (polyvinyl chloride) intravenous (IV) tubing.
- Do not use latex preparation on IV bags.
True
Respiratory Preparation
,
If a general anesthetic is administered, it is essential to ventilate the lungs postoperatively to prevent or treat atelectasis, improve lung expansion, improve oxygenation, and prevent postoperative pneumonia
A)true for respiratory preparation
B)false
A
Because the lungs do not expand fully during surgery, mucus and gases remain in the lungs until expelled. Pulmonary exercises can assist in expanding the lungs and removing these by-products.
A)true
B)false
A
In spirometry, referred to as incentive spirometry, the patient uses a device (spirometer) at the bedside at regular intervals to promote deep breathing.
A)true
B)false
A
To encourage patient use, place the spirometer in the bed or close by on the bedside stand. The usual rate of use is 8 to 10 breaths hourly during waking hours.
A)true
B)false
A
This type of incentive spirometer is inexpensive and measures inspiration. Encourage the patient to keep the colored balls floating as long as possible.
A)Flow-oriented inspiratory spirometer
B)Volume-oriented spirometer:
A
This form of incentive spirometer maintains a known volume of inspiration.Encourage the patient to breathe with normal inspired capacity
A)Flow-oriented inspiratory spirometer
B)Volume-oriented spirometer:
B
coughing increases intracranial pressure, it is usually contraindicated in cranial and spinal-related surgeries.
A)true
B)false
A
Coughing is also contraindicated for patients having cataract surgery
A)true
B)false
A
Patients frequently ambulate within a few hours of surgery to return cardiovascular and respiratory functions to normal more quickly.
A)true
B)false
A
Incentive Spirometry or Positive Expiratory Pressure Therapy and “Huff” Coughing
,
Nursing Action (Rationale}
,
Assess patient’s respiratory status and lungs sounds. Indications for spirometry are
(a) asymmetric chest wall movement,
(b) increased respiratory rate,
(c) increased production of sputum, and
(d) diminished lung expansion postoperatively.
(Alerts health care personnel to those patients at risk for respiration; complications during illness or after surgery.)
True
- Place prescribed incentive spirometer at the bedside. (Prepares equipment for procedure.)
A)true
B)false
A
- Place patient in semi-Fowler’s or full Fowler’s position. (Promotes optimal lung expansion for use of the incentive spirometer.
A)true
B)false
A
- Place tissues, emesis basin, and bedside trash bag within easy reach. (Enables sanitary disposal of respiratory secretions expectorated during procedure.)
A)true
B)false
A
Incentive spirometry
a. Instruct patient to completely cover mouth-piece with lips (use a noseclip if patient is unable to breathe through the mouthpiece) and to
(a) inhale slowly until maximum inspiration is reached,
(b) hold breath 2 or 3 seconds, and
(c) slowly exhale. (Promotes maximum inspiration.)
True
Store spirometer in an appropriate place, such as the bedside table, until next scheduled time. (Provides a convenient place for repeated use.)
A)true
B)false
A
PEP therapy and “huff” coughing
Instruct patient to assume semi-Fowler’s or high Fowler’s position, and place noseclip on patient’s nose. (Promotes optimum lung expansion and expectoration of
mucus.)
Instruct patient to place lips around mouth-piece and (1) take a full breath and exhale two or three times longer than inhalation and (b) repeat this pattern for 10 to 20 breaths. (Ensures that all breathing is done through the mouth and that the device is used properly.)
Remove device from mouth, and have patient take a slow, deep breath and hold for 3 seconds. (Promotes lung expansion before coughing.)
Instruct patient to exhale in quick, short, forced “huffs.” (“Huff” coughing, or forced expiratory technique, promotes bronchial hygiene by increasing expectoration of secretions.)
True
Patient Teaching Controlled Coughing Technique
,
The home health nurse may need to reinforce the importance of coughing one or two times an hour during waking hours for the patient at home
A)true
B)false
A
After brain, spinal, head, neck, or eye surgery, coughing is often contraindicated because of a potential increase in intracranial pressure.
A)true
B)false
A
Teaching Controlled Coughing
,
NURSING ACTION (rationale)
,
Assist patient to upright position. Place pillow between bed or chair and patient. (Facilitates deep breathing and optimum chest expansion.)
A)true
B)false
A
Cough two or three consecutive times without inhaling between coughs. (Consecutive coughs . remove mucus more effectively and completely than one forceful cough.)
A)true
B)false
A
Abdominal or thoracic incision can be splinted before coughing with hands, pillow, towel, or rolled bath blanket. (Surgical incision cuts through muscles, tissues, and nerve endings. Deep breathing and coughing place additional stress on suture Line and cause discomfort. Splinting incision provides firm support and reduces incisional pulling.)
A)true
B)false
A
Teaching Postoperative Breathing Techniques, Leg Exercises, and Turning NURSING ACTION (rationale)
,
Postoperative Breathing Techniques
,
Place pillow between patient and bed or chair. (Allows for fuller chest expansion. [Bed or chair itself . is too firm to provide expansion.])
A)true
B)false
A
Demonstrate taking slow, deep breaths. Avoid moving shoulders and chest while inhaling. Inhale through nose. (Prevents panting and hyperventilation. Moistens, filters, and warms inhaled air.)
A)true
B)false
A
Hold breath for a count of three, and slowly exhale through pursed lips. (Allows for gradual expulsion of air.)
A)true
B)false
A
Instruct patient to take 10 slow, deep breaths every 2 hours until ambulatory. (Helps prevent postoperative complications.)
A)true
B)false
A
Leg Exercises
,
Lifting one leg at a time and supporting joints, gently flex and extend leg 5 to 10 times. (Stimulates circulation and helps prevent . thrombi formation.)
A)true
B)false
A
Assess pulse, respiration, and blood pressure. (Aids in determining complications from exercise.)
A)true
B)false
A
Turning Exercises
,
Instruct patient to turn every 2 hours while awake. (Reduces risk of vascular and pulmonary complications.)
A)true
B)false
A
Surgeries for Which Coughing Is Contraindicated or Modified
,
- Intracranial: Coughing increases intracranial pressure (ICP), leading to cerebrospinal fluid leak.
- Eye: Coughing increases ICP, which then increases intra-ocular pressure, causing pressure on suture line.
- Ear: Mouth must be kept open if coughing occurs to prevent pressure backup through eustachian tube to middle ear, causing pressure on suture line.
- Nose: Mouth must be kept open if coughing occurs to prevent dislodgment of a clot with subsequent bleeding.
- Throat: Vigorous coughing may dislodge a clot with sub-sequent bleeding.
- Spinal: Coughing increases spinal canal pressure.
True
SURGICAL CARE OF THE PATIENT
,
Cardiovascular Considerations
,
Because blood stasis occurs when the patient lies flat, encourage him or her to do leg exercises to assist venous blood flow.
A)true
B)false
A
blood stasis occurs when the patient lies flat, so to prevent it, encourage the patient to do leg exercises to assist venous blood flow.
A)true
B)false
A
lf a thrombus is dislodged, it can travel as an embolus to the lungs, the heart, or the brain, where the vessel can be occluded.
A)true
B)false
A
Patient Teaching Use of Thromboembolic Deterrent Stockings and Sequential Compression Devices
,
- Teach patient appropriate care of the stockings. (Wash in warm water and mild soap, do not wring dry, and lay over flat surface to dry.)
- Instruct patient not to massage legs because of the risk of dislodging a thrombus.
- Teach patient the signs of possible complications. (If stockings or devices are too restrictive, edema and pain could result.)
True
Applying Thromboembolic Deterrent Stockings and Sequential Compression Devices
,
Nursing Action (Rationale)
,
Examine legs and assess risk for conditions. (Helps nurse determine presence of pigmentation around ankles, pitting edema, or peripheral cyanosis, which may indicate inadequate circulation.)
A)true
B)false
A
Assess patient for calf pain or positive Homans’ sign. (May indicate presence of thrombophlebitis or DVT.)
A)true
B)false
A
Thromboembolic Deterrent Stockings
,
Assist patient to supine position to apply stockings before patient rises. Patient should be recumbent for at least 30 mlnutes before application of the stocking. (Prevents veins from becoming distended or edema from occurring.)
A)true
B)false
A
Sequential Compression Devices
,
When the SCD is in place, make sure there are no wrinkles or creases in stockings
A)for SCD stocking
B)false
A
Vital Signs
,
Vital signs mirror the body’s response to anesthesia and surgery.
A)true
B)false
A
Genitourinary Considerations
,
After general anesthesia, the urinary bladder’s tone is decreased. Therefore you should know the patient’s normal bladder habits and identify when the bladder is full and distended.
A)true
B)false
A
Occasionally a urinary catheter is inserted to monitor urinary output. This procedure is normally reserved for patients undergoing urinary surgery or those who may have difficulty voiding.
A)true
B)false
A
The catheter is usually removed 1 or 2 days postoperatively to reduce the chance of bladder infection. Once it is removed, encourage the patient to drink 8 ounces of fluids per hour while awake unless contrainclicated.
A)true
B)false
A
Urinary retention and urinary tract infections are common postoperative complications.
A)true
B)false
A
Pain
,
Patients fear pain more than any other postsurgical complication. Emphasize to the patient that pain relief is an important part of care
A)true
B)false
A
non-pharmacologic analgesia which are imagery, biofeedback, .relaxation techniques
A)true
B)false
A
Postoperative pain is what the patient says it is, so it is important to reassure patients that addiction to analgesics rarely occurs in the time frame needed for comfort.
A)true
B)false
A
For the patient who is apprehensive tell the patient about intermittent injections, patient-controlled analgesia (PCA) and opioids injected into the epidural space (patient-controlled epidural) that they are safe and effective for postoperative pain management.
A)true
B)false
A
Preoperative Medication
,
Preoperative medication reduces the patient’s anxiety, decreases the amount of anesthetic needed, and reduces respiratory tract secretions
A)true
B)false
A
Barbiturates and tranquilizers (pheno-barbital and diazepam [Valium]) are sometimes given for sedation to reduce the amount of the anesthetic required.
A)true
B)false
A
Opioid analgesics (meperidine and morphine) may be administered by intermittent injection or PCA if the patient has pain before surgery; this also reduces the amount of anesthetic required. A)true B)false
A
Anticholinergics such as atropine reduce spasms of smooth muscles and decrease gastric, bronchial, and salivary secretions
A)true
B)false
A
The patient frequently becomes drowsy, notices a dry mouth, and experiences vertigo after receiving the preoperative medication
A)true
B)false
A
Institute safety measures, such as putting the bed in low position and raising side rails, and monitor the patient every 15 to 30 minutes until the patient leaves for surgery.
A)true
B)false
A
Surgery cancels all medications ordered before surgery, except for medications for long-term conditions, -such as phenytoin (Dilantin) for seizure control.
A)true
B)false
A
Anesthesia
,
___________means the absence of feelings (pain) (an, meaning “without,” plus esthesia, meaning “awareness of feeling”).
Anesthesia
Anesthesia is divided into three categories: general, regional, and local.
A)true
B)false
A
What category of anesthesia results in an immobile, quiet patient who does not recall the surgical procedure. The patient’s amnesia acts as protection from the unpleasant events.
General
General anesthesia is used for major surgery requiring extensive tissue manipulation.
A)true
B)false
A
An anesthesiologist gives general anesthetics by IV and inhalation routes through the four stages of anesthesia.
A)true
B)false
A
Stage I the patient is awake and the adrninistration of anesthetic agents begins. The stage is completed when the patient loses consciousness.
A)true
B)false
A
Stage II begins with the loss of consciousness and ends with the onset of regular breathing and loss of eyelid reflexes. This is referred to as the excitement or delirium phase because it is often accompanied by involuntary motor activity. The patient must not receive any auditory or physical stimulation during this period because it can stimulate a release of catecholarnines, which can raise heart rate and blood pressure
A)true
B)false
A
Stage III begins with the onset of regular breathing and ends if respirations cease.This stage is known as the operative or surgical phase.
A)true
B)false
A
Stage IV begins with the cessation of respirations and must be avoided, or it will necessitate the initiation of cardiopulmonary resuscitation and may lead to death. These stages were defined in the past when ether was used and may be less clear with newer anesthetic agents.
A)true
B)false
A
A more useful designation of stages includes the three phases of induction, maintenance, and emergence.
The induction phase includes the administration of agents and endotracheal intubation.
The maintenance phase includes positioning the patient, preparing the skin for incision, and performing the surgery. Appropriate levels of anesthesia are maintained during this phase.
During the emergence phase, anesthetics are decreased and the patient begins to awaken. Because of the short half-life of today’s medications, emergence often occurs in the OR.
True
intubation means insertion of a tube
A)true
B)false
A
To prevent aspiration and other respiratory complications, the anesthesiologist puts an endotracheal tube into the patient’s airway.
A)true
B)false
A
Endotracheal intubation is usually performed after administration of short-acting or, occasionally, long-acting muscle relaxants.
A)true
B)false
A
An anesthesia provider or OR nurse may assist with cricoid pressure during induction of general anesthesia and endotracheal cuff inflation during intubation.
A)true
B)false
A
Cricoid pressure reduces the risk of aspirating stomach contents by compressing the esophagus to prevent passive regurgitation. (This technique cannot, however, stop active vomiting.) Once initiated, pressure must be held constant until the cuff has been inflated or aspiration can happen rapidly.
A)true
B)false
A
greatest risks from general anesthesia are the side effects of anesthetic agents, including -cardiovascular depression -irritability -respiratory depression -liver and kidney damage. A)true B)false
A
Medications with Special Implications for the Surgical Patient
,
Effects during surgery (drugs)
,
Long term use of Anticonvulsants can alter metabolism of anesthetic agents.
A)true
B)false
A
With prolonged use, corticosteroids cause adrenal atrophy, which reduces the body’s ability to withstand stress. Before and during surgery, dosage may be temporarily increased.
A)true
B)false
A
Diuretics can cause electrolyte imbalances after surgery
A)true
B)false
A
NSAIDs inhibit platelet aggregation and may prolong bleeding, increasing susceptibility to post-operative bleeding.
A)true
B)false
A
Induction of regional anesthesia results in loss of sensation in an area of the body.
A)true
B)false
A
Nerve block: Local anesthetic is injected into a nerve (e.g., brachial plexus in the arms), blocking the nerve supply to the operative site.
A)true
B)false
A
Spinal anesthesia: The anesthesiologist performs a lumbar puncture and introduces local anesthetic into the cerebrospinal fluid in the subarachnoid space. Spinal anesthesia is often used for lower abdominal pelvic, and lower extremity procedures; urologic procedures; or surgical obstetrics.
A)true
B)false
A
Epidural anesthesia blocks sensation in the vaginal and perineal areas and thus is often used for obstetric procedures.
A)true
B)false
A
IV regional anesthesia (Bier block): Local anesthetic is injected via an IV line into an extremity below the level of a tourniquet after blood has been withdrawn. The drug is allowed to infiltrate only tissues in the intended surgical area.However, the tourniquet may be inflated for only 2 hours or tissue damage will occur.
A)true
B)false
A
If the level of anesthesia rises, respiratory paralysis may develop, requiring resuscitation by the anesthesiologist.
A)true
B)false
A
Elevation of the upper body prevents respiratory paralysis.
A)true
B)false
A
The patient under regional anesthesia is awake throughout the surgery unless the physician orders a tranquilizer that promotes sleep and/or amnesia.
A)true
B)false
A
Local anesthesia involves loss of sensation at the desired site (e.g., growth on the skin or the cornea of the eye). The anesthetic agent (e.g., lidocaine) inhibits nerve conduction until the drug diffuses into the circulation. It may be injected or applied topically. The patient loses sensation of pain and touch, and control over motor and autonomic activities (e.g., bladder .emptying)
A)true
B)false
A
Local anesthesia involves loss of sensation at the desired site, The anesthetic agent (lidocaine) and it inhibits nerve conduction until the drug diffuses into the circulation. It may be injected or applied topically. The patient loses sensation of pain and touch, and control over motor and autonomic activities (e.g., bladder .emptying)
A)true
B)false
A
Conscious sedation is the administration of drugs that depress the central nervous system or provide analgesia to relieve anxiety or provide amnesia during surgical diagnostic procedures.
A)true
B)false
A
A patient under conscious sedation must independently retain a patent airway and airway reflexes and be able to respond appropriately to physical and verbal stimuli.
A)true
B)false
A
Advantages of conscious sedation include adequate sedation and reduction of fear and anxiety with minimal risk, amnesia, relief of pain and noxious stimuli, mood alteration, elevation of pain threshold, enhanced patient cooperation, stable vital signs, and rapid recovery.
A)true
B)false
A
In a patient who is anesthetized, however, normal defense mechanisms cannot guard against joint damage, muscle stretch, and strain, so be aware when positioning the patient
A)true
B)false
A
Preoperative Checklist
,
Any prosthesis (an artificial replacement for a missing part of the body), contact lenses, dentures, jewelry, and other valuables are removed and either given to family members or placed in a secure area A)true B)false
A
The patient should void before the preoperative medication is administered, or 1 hour before surgery is scheduled
A)true
B)false
A
Although most patients become drowsy after administration of a preoperative medication, a few either become hyperactive or demonstrate no side effects.
A)true
B)false
A
Remind the patient to remain in bed, and raise the side rails. Place the call light within reach and point it out to the patient.
A)true
B)false
A
Eliminating Wrong Site and Wrong Procedure Surgery
,
- Obtain a preoperative verification that guarantees all relevant documents and studies are available and that they meet the patient’s expectations.
- Mark the operative site with indelible ink, including marking left or right, multiple structures (e.g., toes), and levels of the spine.
- Just before the start of the procedure, all members of the surgical and procedure team have a time-out to verify they have the correct patient, procedure, site, and any implants.
True
Just before the start of the procedure, all members of the surgical and procedure team have a time-out to verify they have the correct patient, procedure, site, and any implants.
A)true
B)false
A
Transport to the Operating Room
,
The trip to surgery should be as smooth as possible so that the sedated patient does not experience nausea or dizziness
A)true
B)false
A
INTRAOPERATIVE PHASE
,
When the patient enters the OR, identify the patient both verbally and by the identification band and medical records.
A)true
B)false
A
Nursing interventions for intraoperative include warm, personal contact with the patient to humanize the OR’s often cold, aseptic, and highly technical environment.
A)true
B)false
A
Essential elements for monitoring and promoting patient safety are being aware of the potential for harm, recognizing body areas most susceptible to injury, strictly adhering to principles of positioning and asepsis, and monitoring sites for impairment or early signs of injury.
A)true
B)false
A
Use side rails and safety straps, even for the fully conscious patient; safety reminder devices may be necessary to protect the delirious, semi-comatose, or disoriented patient from injury.
A)true
B)false
A
HOLDING AREA
,
Use a large-bore IV catheter for optimal infusion of all fluids and possible blood products. Administer preoperative medications.
A)true
B)false
A
The temperature in the OR is usually cool, so offer the patient an extra blanket for warmth and relaxation.
A)true
B)false
A
In many hospitals the patient enters a surgical care unit called a preanesthesia care unit (or holding area) outside the OR, where the nurse completes the preoperative preparations.
A)true
B)false
A
The nurse or anesthesiologist inserts an IV catheter into the patient’s vein to establish a route for fluid replacement and IV medications
A)true
B)false
A
THE NURSE’S ROLE
,
In the intraoperative phase, the nurse assumes one of two roles during the surgical procedure: scrub nurse or circulating nurse
A)true
B)false
A
Everyone (nurses, physicians, anesthesia providers) in the OR must prevent contamination of sterile items and aid in maintaining aseptic conditions
A)true
B)false
A
The goal of surgical asepsis is to prevent or minimize postoperative wound infections. The patient is at risk for introduction of infecting organisms through catheters, drains, or the surgical wound.
A)true
B)false
A
Responsibilities of the Circulating Nurse and the Scrub Nurse
,
RESPONSIBiliTIES OF THE CIRCULATING NURSE
,
- Prepares operating room with necessary equipment and supplies and ensures that equipment is functional
- Arranges sterile and unsterile supplies; opens sterile supplies for scrub nurse
- Sends for patient at proper time
- Visits with patient preoperatively; explains role, identifies patient , verifies operative permit, and answers any questions
- Performs patient assessment
- Confirms patient assessment
- Checks medical record for completeness
- Assists in safe transfer of patient to operating room table
- Positions patient on operating room table in accordance with type of procedure and surgeon’s preference
- Places conductive pad on patient if electrocautery is to be used
- Counts sponges, needles, and instruments with scrub nurse before surgery
- Assists scrub nurse and surgeons by tying gowns
- May prepare patient’s skin
- Assists scrub nurse in arranging tables to create sterile field
- Maintains continuous astute observations during surgery to anticipate needs of patient, scrub nurse, surgeons, and anesthesiologist
- Provides supplies to scrub nurse as needed
- Observes sterile field closely for any breaks in aseptic technique, and reports accordingly
- Cares for surgical specimens according to institutional policy
- Documents operative record and nurse’s notes
- Counts sponges, needles, and instruments when closure of wound begins
- Transfers patient to gurney for transport to recovery area
- Accompanies patient to the recovery room and provides a report
True
RESPONSIBiliTIES OF THE SCRUB NURSE
,
- Performs surgical hand scrub
- Dons sterile gown and gloves aseptically
- Arranges sterile supplies and instruments in manner prescribed for procedure
- Checks instruments for proper functioning
- Counts sponges, needles, and instruments with circulating nurse
- Gowns and gloves surgeons as they enter operating room
- Assists with surgical draping of patient
- Maintains neat and orderly sterile field
- Corrects breaks in aseptic technique
- Observes progress of surgical procedure
- Hands surgeon instruments, sponges, and necessary supplies during procedure
- Identifies and handles surgical specimens correctly
- Maintains count of sponges, needles, and instruments so none will be misplaced or lost in wound
True
POSTOPERATIVE PHASE
,
IMMEDIATE POSTOPERATIVE PHASE
,
Immediate postoperative observation and interventions follow the ABCS of airway, breathing, consciousness, circulation, and systems
A)true
B)false
A
Assess vital signs every 15 minutes during the recovery period, and monitor respiratory and GI functions
A)post-op
B)false
A
Heat loss that occurs in the OR can continue in the PACU if the patient is not warmed sufficiently. Warm blankets are used, especially around the feet; adding warmth around the head is helpful.
A)true
B)false
A
Before discharge, their minimum temperature must be greater than 96.8° F (36° C). Warming requires the maintenance of temperature without overwarming and excessive vasodilation, which can cause fluid shifts and a decrease in blood pressure.
A)true
B)false
A
overwarming and excessive vasodilation can cause fluid shifts and a decrease in blood pressure.
A)true
B)false
A
Malignant hyperthemtia is a genetic disorder characterized by uncontrolled skeletal muscle contractions leading to potentially fatal hyperthermia. It occurs in patients predisposed to the disorder when they receive a combination of certain anesthetic agents. Unless the triggering event is stopped and the body is cooled, death results.
A)true
B)false
A
Interventions Associated with the ABCS of Immediate Recovery
,
Airway
- Maintain patency: keep head tilted up and back; may position on side with the face down and the neck slightly extended.
- Note presence or absence of gag or swallowing reflex; stay at bedside until gag reflex returns.
- Suction until awake and alert.
- Provide oxygen if necessary.
True
Breathing
- Evaluate depth, rate, sounds, rhythm, and chest movement.
- Assess color of mucous membranes.
- Place hand above patient’s nose to detect respirations if shallow.
- Initiate coughing and deep breathing exercises as soon as patient is able to respond.
- Chart time oxygen is discontinued. Monitor oxygen saturation levels (Sao2) by pulse oximetry checks
True
Consciousness
- Extubate patient (remove endotracheal tube from airway).
- Patient responds to commands.
- Patient verbalizes responses.
- Patient reacts to stimuli.
True
Circulation
- Monitor temperature, pulse, respirations, and blood pressure every 10 to 15 minutes; take axillary, tympanic, or rectal temperature if warranted.
- Assess rate, rhythm, and quality of pulse.
- Evaluate color and warmth of skin and color of nailbeds.
- Check peripheral pulses as indicated.
- Assess incision and dressing (monitor wound drainage output).
- Monitor intravenous lines: solution, rate, site.
- Cardiac monitors are usually in place for patients who had general anesthesia.
True
System review
- Assess neurologic functions, muscle strength, and response.
- Monitor drains, tubes, and color and amount of output.
- Check for pressure, type, and condition of dressings.
- Evaluate pain response; may need to give analgesic and monitor patient response.
- Observe for allergic reactions.
- Assess urinary output if Foley catheter is in place.
True
Temperature Assessment and Intervention
,
Cause:
HYPOTHERMIA
Within First 12 Hours Response to surgery, anesthesia, and body exposure
Assessment and intervention would be:
- Monitor temperature readings.
- Assess for warmth.
- Provide warm blankets.
- Do not expose for long periods.
- Assess orientation.
True
Cause:
HYPERTHERMIA
24-48 Hours
Dehydration,Decreased lung activity, Inflammatory response to surgery
Assessment and intervention would be:
- Monitor temperature readings.
- Monitor intravenous rate.
- Encourage fluids.
- Assess intake and output (1&0).
- Have patient turn, cough, and breathe deeply.
- Provide incentive spirometer.
- Assess lung sounds.
- Observe incision.
True
Cause:
After Day 2
Infection: respiratory, wound, urinary, or circulatory
Assessment and intervention would be:
- Monitor temperature readings.
- Assess lung sounds and expectoration of sputum.
- Evaluate incision and drainage.
- Monitor 1&0.
- Encourage fluids of 6-8 oz/hr unless contraindicated.
- Note urine color, odor, amount, and consistency, and patient’s complaints of burning on micturition.
- Perform leg exercises every 2 hours, and ambulate every 4 hours.
True
LATER POSTOPERATIVE PHASE
,
Unless otherwise indicated, monitor vital signs and make general assessments using the “times-four” factor. The times-four gauge is the maximal time that should elapse between assessments.
A)true
B)false
A
Although the patient may respond, the level of functioning is impaired. Keep the side rails up and the call light within reach. Until the patient is fully conscious, do not place a pillow under the head. Either position the patient on the side, depending on the type of surgery, or raise the head of the bed to a 45-degree angle.
A)post op
B)false
A
Positioning the head higher than the chest reduces the chance of the patient aspirating vomitus.
A)post op
B)false
A
Because nausea and vomiting are normal in the first 12 to 24 hours, keep an emesis basin at the bedside. If the patient vomits, measure the amount and carefully describe it in the documentation. Report any red or coffee-ground emesis immediately.
A)true, post op
B)false
A
A pulse that increases and becomes thready-coupled with a declining blood pressure, cool and clammy skin, reduced urinary output, and restlessness- may signal hypovolemic shock.
A)true
B)false
A
A pulse that increases and becomes thready-coupled with a declining blood pressure, cool and clammy skin, reduced urinary output, and restlessness- may signal ____________
hypovolemic - shock.
Hypovolemic shock in the postoperative period is frequently caused by internal hemorrhage, a life-threatening emergency
A)true
B)false
A
Decreased blood pressure can also mean that the anesthetic is wearing off or that the patient is experiencing severe pain.
A)true
B)false
W
When a patient appears to be going into shock, take the following steps:
(1) administer oxygen or increase its rate of delivery
(2) raise the patient’s legs above the level of the heart
(3) increase the rate of IV fluids (unless contra-indicated because of fluid excretion problems),
(4) notify the anesthesia provider and the surgeon
(5) provide medications as ordered
(6) continue to assess the patient and response to interventions.
True
Possible Causes of Postoperative Shock
,
-Movement of patient from operating table to gurney • Patient (gurney) being jarred during transport • Reactions to drugs and anesthesia • Loss of blood and other body fluids • Cardiac dysrhythmias • Cardiac failure • Inadequate ventilation • Pain
True
Incision
,
Separation from 3 to 14 days postoperatively is usually associated with postoperative complications such as distention, vomiting, excessive coughing, dehydration, or infection.
A)wound dehiscence
B)false
A
Wound separation after 2 weeks is usually associated with metabolic factors, such as cachexia (ill health, malnutrition, and wasting as a result of chronic disease), hypoproteinemia, increased age, malignancy, radiation therapy, and obesity.
A)wound dehiscence
B)false
A
Both wound de-hiscence and evisceration require prompt attention. If the patient feels a sudden “give,” sutures may have broken. Contact the physician immediately. Cover the wound with a sterile towel moistened with sterile physiological saline (warm). Tension on the abdomen may be decreased by placing the patient in Fowler’s position with the knees slightly flexed.
A)true
B)false
A
Ventilation
,
Immediate postoperative hypoventilation can result from drugs (anesthetics, narcotics, tranquilizers, sedatives), incisional pain, obesity, chronic lung disease, or pressure on the diaphragm.
A)true
B)false
A
Inadequate ventilation leads to hypoxemia.
A)true
B)false
A
Abnormally low concentration of oxygen in the blood is called
A)hypoxemia
B)hyperxemia
A
Monitor arterial oxygenation saturation (Sao2), either by arterial blood gas measurements or by pulse oximetry
A)true
B)false
A
To ease the pressure on the incision, help the patient support the surgical site with a pillow, rolled bath blanket, or the heel of the hand.
A)true
B)false
A
Activity
,
Ambulation is usually contraindicated for patients with severe infection or thrombophlebitis.
A)true
B)false
A
Effects of Early Postoperative Ambulation
,
• Increased rate and depth of breathing
- Prevention of atelectasis and hypostatic pneumonia
- Increased mental alertness from increased oxygenation to brain
• Increased circulation
- Nutrients required for healing are more available to wound
- Prevention of thrombophlebitis
Positive effects of ambulation
Increased micturition (urinary elimination)
- Increased kidney function
- Prevention of urinary retention
• Increased metabolism
- Prevention of loss of muscle tone
- Restoration of nitrogen balance
Positive effects of ambulation
Increased peristalsis
- Promotion of expulsion of flatus
- Prevention of abdominal distention and gas pain
- Prevention of constipation
- Prevention of paralytic ileus
Positive effects of ambulation
Assessment
,
Cardiovascular status (orthostatic hypotension)
a. Assess pulse and respiratory rate and depth while patient is supine, then after sitting.
b. Observe skin color for pallor while patient is sitting.
c. Note complaints of vertigo while patient is sitting.
True
Nursing Interventions
,
Have patient sit on side of bed (legs dangling) to become accustomed to upright position before ambulating the first time.
A)true
B)false
A
Be certain that pulse has stabilized (returned to baseline) before patient attempts ambulation.
A)true
B)false
A
Use two people to assist in ambulating an unsteady patient receiving IV fluids
A)true
B)false
A
Clamp NG tube while patient ambulates, and
then reconnect.
A)true
B)false
A
The word ambulate means to move from place to place-to walk. Sitting in a chair is not ambulation.
A)true
B)false
A
GASTROINTESTINAL STATUS
,
Abdominal distention frequently occurs after surgery.
A)true
B)false
A
Because anesthesia and surgical manipulation slow peristalsis, it may take 3 or 4 days for bowel activity to return
A)true
B)false
A
Ask the patient if he or she is nauseated or hungry (a more accurate assessment of gastrointestinal activity than the presence of bowel sounds)
A)true
B)false
A
More accurate assessment of gI tract is seeing if the patient is nauseated or hungry
A)true
B)false
A
A paralytic ileus (a decrease in or absence of intestinal peristalsis that may occur after abdominal surgery, peritoneal trauma, severe metabolic disease, and other conditions) may also develop.
A)true
B)false
A
A _________(a decrease in or absence of intestinal peristalsis that may occur after abdominal surgery, peritoneal trauma, severe metabolic disease, and other conditions) may also develop.
paralytic ileus
Encouraging movement (turning every 2 hours, early ambulation) assists in restoring GI activity. A)true B)false
A
A rectal tube may be inserted, or the physician may order an “up and down” flush (Harris flush) to relieve pain from intestinal gas. A Harris flush is a mild colonic irrigation using 100 to 200 mL of enema solution.
A)true
B)false
A
For the patient who has difficulty with flatus, limiting iced beverages and offering warm liquids may help resolve the discomfort
A)true
B)false
A
Constipation is also a frequent problem after surgery.
A)true
B)false
A
If the patient does not pass feces within 2 or 3 days after resuming solid foods, a suppository or tap water enema may be ordered. Again, encourage ambulation to promote peristalsis
A)true
B)false
A
Singultus (hiccup) is an involuntary contraction of the diaphragm followed by rapid closure of the glottis.
A)true
B)false
A
Singultus results from irritation of the phrenic nerve. The condition is seen most often in men.
A)true
B)false
A
Abdominal distention usually is caused by gas in the intestinal tract, but may be related to internal bleeding. Evaluate the patient for signs of shock: vital signs, skin condition, and level of consciousness.
A)true
B)false
A
FLUIDS AND ELECTROLYTES
,
Fluid is lost during surgery through blood loss and increased insensible fluid loss through the lungs and skin. For at least the first 24 to 48 hours after surgery, the body retains fluids as part of the stress response to trauma and the effect of anesthesia
A)true
B)false
A
For at least the first 24 to 48 hours after surgery, the body retains fluids as part of the stress response due to trauma and the effect of anesthesia
A)true
B)false
A
Sodium and potassium depletion can occur after surgery as a result of the loss of blood or body fluids during surgery or the loss of GI secretion because of vomiting and NG tubes.
A)true
B)false
A
Potassium is also lost during catabolism (tissue breakdown), especially after severe trauma or crush injuries.
A)true
B)false
A
K can be lost due to serve trauma or crushing injuries
A)true
B)false
A
Loss of gastric secretions can result in chloride loss, producing metabolic alkalosis.
A)true
B)false
A
Electrolytes are often added to the IV solution in the form of potassium chloride (KCI).
A)true
B)false
A
potassium may irritate the vein when administered by an IV route. Advise the patient that a stinging sensation may occur.
A)true
B)false
A
Closely monitor fluid tolerance and electrolyte values during the postoperative period.
A)true
B)false
A
Until the patient is past the nausea and vomiting period and can tolerate oral fluids, maintain parenteral therapy.
A)true
B)false
A
parenteral means administered or occurring somewhere else in the body than the mouth in the GI tract
A)true
B)false
A
monitor the IV site for erythema, edema, heat, and pain. The IV solution may become infiltrated because of movement or inadvertent dislodgment of the needle when the patient ambulates; therefore it is necessary to assess the site every 1 to 2 hours or when the patient complains of discomfort
A)true
B)false
A
If the patient has difficulty drinking the amount of fluid recommended, offer fluids more frequently and without a straw. (A straw, although convenient, reduces the amount of fluids ingested.)
A)true
B)false
A
If nausea and vomiting persist, an antiemetic such as promethazine (Phenergan), benzquinamide (Emete-Con), or prochlorperazine (Compazine) -is usually ordered to be administered intravenously or rectally.
A)true
B)false
A
Preoperative nursing diagnosis
,
• Airway clearance, ineffective, related to:
- Diminished cough
- Increased pulmonary congestion
• Anxiety (specify level), related to:
- Knowledge deficit of impending surgery
- Threat of loss of body part
• Coping, compromised family, related to:
- Temporary role change of patient
- Impending severity of surgery
• Fear, related to:
- Impending surgery
- Anticipation of postoperative pain
• Knowledge, deficient regarding implications of surgery, related to:
- Lack of experience with surgery
- Information misinterpretation
• Nutrition, imbalanced: less than body requirements, related to:
-Preoperative malnourishment
• Nutrition, imbalanced: more than body requirements, related to:
-Excess intake of food
• Powerlessness, related to:
-Emergency nature of surgery
• Skin integrity, risk for impaired, related to:
- Preoperative radiation
- Immobilization during surgery
• Sleep deprivation, related to:
- Fear of surgery
- Preoperative hospital routines
True
Postoperative Nursing Diagnoses
,
Airway clearance, ineffective, related to:
- Diminished cough
- Retained secretions
- Prolonged sedation
• Body temperature, hypothermia, related to:
-Lowered metabolism
• Breathing pattern, ineffective, related to:
- lncisional pain
- Analgesia effects on ventilation
• Communication, impaired verbal, related to:
- Endotracheal tube placement
- Airway tube placement
• Coping, ineffective, related to:
- Constraints imposed by surgery
- Postoperative therapies
• Fluid volume, risk for deficient, related to:
- Wound drainage
- Inadequate fiuid intake
• Grieving, anticipatory, related to:
-Patient’s critical condition
True
DISCHARGE: PROVIDING GENERAL INFORMATION
,
Preparation for the patient’s discharge is an ongoing process throughout the surgical experience, beginning during the preoperative period
A)true
B)false
A
AMBULATORY SURGERY DISCHARGE
,
The patient leaving an ambulatory surgery setting must be able to provide a degree of self-care and must be mobile and alert
A)true
B)false
A
Vital Information for the Discharged Patient
,
- Care of wound site and any dressings
- Action and possible side effects of any medications; when and how to take them
- Activities allowed and prohibited; when various physical activities can be resumed safely (e.g., driving a car, return to work, sexual intercourse, leisure activities)
- Dietary restrictions or modifications
- Symptoms to be reported (e.g., development of incisional tenderness or increased drainage, discomfort in other parts of the body)
- Where and when to return for follow-up care
- Answers to any individual questions or concerns (allow time for questions)
True
Key Points
,
Informed consent should not be obtained if a patient is confused, unconscious, mentally incompetent, or under the influence of sedatives. Know agency policy.
A)true
B)false
A
Because a surgical patient’s condition may change rapidly during immediate postoperative recovery, monitor the patient’s status at least every 15 minutes.
A)true
B)false
A
NCLEX QUESTIONS
,
1. The patient has cancer of the larynx and is scheduled for a laryngectomy. This is an example of which type of surgery? 1. Minor 2. Elective 3. Emergency 4. Major
4
- The patient is being discharged, and the nurse is teaching her how to do daily dressing changes at home. The most important point to include in the teaching plan is:
- discussion of surgical asepsis.
- discussion of hand hygiene.
- instruction in sterilization.
- demonstration of gloving.
2
- To assist the patient in the prevention of postoperative pulmonary complications, preoperatively the nurse should:
- ask his physician to prescribe IPPB treatment.
- teach him to do leg exercises.
- teach him to use an incentive spirometer.
- tell him that if he does not cough, he may need to
be suctioned.
3
4. The patient underwent surgery for lysis of adhesions. He is transferred from the PACU to his own room on the surgical floor. During the immediate postoperative period on the surgical floor, measure blood pressure, pulse, and respirations every: 1. 15 minutes. 2. 5 minutes. 3. 20 minutes. 4. 30 minutes.
1
5. The nurse is assessing the bowel sounds of her patient who had a suprapubic prostatectomy 2 days ago. To determine that he does not have bowel sounds present, the nurse would need to auscultate each quadrant for: 1. 1 minute. 2. 3 minutes. 3. 1 0 minutes. 4. 15 minutes.
1
- The patient is recovering from a right lobectomy. The nurse is going to assist in splinting the patient’s incision so she can cough and breathe deeply. The most
therapeutic administration of an analgesic would be: - after the procedure so she can rest.
- 15 minutes before the procedure.
- 1 hour before the procedure.
- 30 minutes before the procedure.
4
A patient reports being allergic to penicillin. Which question would elicit the most useful information?
- When did the reaction occur?
- What infection did you have that required penicillin?
- What type of allergic reaction did you have?
- Did you notify your physician of the allergy?
3
- Which patient is at greatest risk for surgical and anesthetic complications?
- A 3-year-old patient scheduled for hernia repair
- An 80-year-old patient scheduled for exploratory laparotomy
- An 18-year-old patient scheduled for emergency
appendectomy - A 42-year-old patient scheduled for breast biopsy
2
- An alert 75-year-old patient is to undergo elective surgery. The operative permit must be signed in the presence of a witness by:
- the patient.
- the patient and the patient’s spouse.
- either the patient or the patient’s spouse.
- the patient and the surgeon.
1
- A nursing intervention to help a patient cope with fear of pain would be to:
- describe the degree of pain expected.
- explain the availability of pain medication.
- inform the patient of the frequency of pain medication.
- divert the patient when talking about pain.
.
2
- A patient tells the nurse that “blowing into this tube thing [incentive spirometer] is a waste of time.” The nurse explains that the specific purpose of the therapy is to:
- directly remove excess secretions from the lungs.
- increase pulmonary circulation.
- promote lung expansion.
- stimulate the cough reflex.
3
- When preparing a patient for surgery, the nurse should:
- provide sips of water for a dry mouth.
- remove the patient’s makeup and nail polish.
- remove the patient’s gown before transport to the OR.
- leave all of the patient’s jewelry on.
2
- A patient who is being prepped for surgery asks the nurse to explain the purpose of the preoperative medications he has been given. The nurse should inform the
patient that these particular medications: - reduce preoperative fear.
- promote gastric emptying.
- reduce body secretions.
- facilitate the induction of anesthesia
4
- A patient who receives general or regional anesthesia in an ambulatory surgery center:
- will remain in the unit longer than a hospitalized
patient. - is allowed to ambulate as soon as being admitted to
the recovery area. - must be near the level of preoperative functioning before dismissal.
- is immediately given liberal amounts of fluid to promote excretion of the anesthesia.
3
- After abdominal surgery, a patient is suspected of having internal bleeding. Which finding is most indicative of this complication?
- Increased blood pressure
- lncisional pain
- Abdominal distention
- Increased urinary output
3
- An obese patient is at risk for poor wound healing postoperatively because:
- ventilatory capacity is reduced.
- fatty tissue has a poor blood supply.
- the risk for dehiscence is increased.
- resuming normal physical activity is delayed.
2
- The nurse should ask each patient preoperatively for the name and dosage of all prescription and over-the counter medications (including herbal remedies) taken
before surgery because they: - may cause allergies to develop.
- are automatically ordered postoperatively.
- may create a greater risk for complications or interact with anesthetic agents.
- should be taken the morning of surgery with sips of
water.
3
- A patient who smokes two packs of cigarettes per day is most at risk postoperatively for:
- infection.
- pneumonia.
- hypotension.
- cardiac dysrhythmias.
2
- Family members should be included when the nurse teaches the patient preoperative exercises so that they can:
- supervise the patient at home.
- coach the patient postoperatively.
- practice with the patient while waiting for transport
to the OR. - relieve the nurse by getting the patient to exercise every 2 hours.
2
- When deep breathing and coughing, the patient should be sitting because this position:
- facilitates expansion of the thorax.
- is more comfortable.
- increases the patient’s view of the room and is more
relaxing. - helps the patient to splint with a pillow.
1
21 . The nurse is checking a patient 2 hours after he returns from surgery. Which assessment finding requires immediate attention?
1. The nasogastric tube drained 50 ml of tea-colored
urine.
2. The patient’s skin is pale, cool, and dry.
3. The Foley catheter drained 30 ml of urine during the past 2 hours.
4. The patient is drowsy, but responds promptly to
voices.
3
- A postoperative abdominal surgery patient complains that he “felt something give way” in his incision. On assessing the wound, the nurse notes a large amount of
serosanguineous drainage and that wound edges are not approximated. Intestines are protruding from the wound. The nurse immediately: - encourages the patient to turn, cough, and deep
breathe while splinting the opening. - covers the protruding internal organs with sterile gauze moistened with normal saline.
- paints the open wound with an antimicrobial solution to prevent infection.
- reinserts the organs and applies a pressure dressing to prevent further organ protrusion.
2
On admission of a patient to the PACU from surgery, the nurse places the highest priority on assessing the:
- patient’s level of consciousness.
- condition of the surgical site.
- adequacy of airway and breathing.
- fluid and electrolyte balance.
3
- The patient arrives on the unit after undergoing extensive abdominal surgery. He is awake and alert. He refuses to be repositioned in bed. What should the nurse assess first to determine the reason for the patient’s refusal?
- Consciousness
- Maturation
- Knowledge related to complications of immobility
- Pain
4
- The nurse is admitting a patient into the room on the surgical unit after abdominal surgery. There is a 1.5-cmdiameter spot of serosanguineous drainage on the dressing. What should the nurse do at this time?
- Notify the physician of bleeding from the wound.
- Note the amount of drainage and continue to monitor.
- Remove the dressing to check for bleeding from the
suture line. - Apply gentle pressure to the site for 5 minutes.
2
POWER POINT NOTES
,
Elective is the patient choice like plastic surgery
A)true
B)false
A
Urgent surgery is necessary for patient health like gallstones and excision of tumor
A)true
B)false
A
Diagnostic confirms the diagnosis like exploratory laparotomy
A)true
B)false
A
Excision or removal of a diseased body part or removal of a harmful substance like amputation and cholecyectomy
A)ablation
B)excision
A
Restores function or appearance to the traumatized or malfunction tissue
A)reconstructive
B)constructive
A
Replaces malfunctioning organs or structures is called an
A)transplant
B)construction
A
Restores function lost or reduced as result of congenital anomalies for example like repair of a cleft lip
A)reconstructive
B)constructive
B
Factors influencing patient outcomes include (select all that apply)
A)age
B)physical condition
C)nutritional
A B C
Routes of nonsocomial infection include bladder due to catheter, Respiratory due being immobile, cardiovascular due to blood stasis and causing embolus and skin due integrity of the skin not being met.
A)true
B)false
A
GI PREP, have the patient NPO after midnight (6-8 hours) and been given an vowel cleanser
A)true
B)false
A
SKIN PREP, removal of hair,assess skin impairment and then scrub with antiseptic solution
A)true
B)false
A
A patient who does not ambulate can develop blood clots which can then lead to pulmonary embolism
A)true
B)false
A
Asses heart, lung, liver etc for older patients who are taking medications
A)true
B)false
A
Extubate is removing of a tube
A) true
B)false
A
Atelectasis is collapse of lung tissue
A)true
B)false
A
Cachexia means malnutrition
A)true
B)false
A
Catabolism mean tissue breakdown
A)true
B)false
A
Pneumothorax means collapse of lung
A)true
B)false
A
The doctor would state risk and beneficence before having the patient sign an informed consent
A)true
B)false
A
Pneumonia is infection of the lung caused by inactivity or by not coughing or deep breathing
A)true
B)false
A
Incentive spiromerty helps prevent or treat atelectasis, improve lung expansion and improve oxygenation
A)true
B)false
A
Nurse only witness the informed consent
A)true
B)false
A
Pre op patient
A-allergies B-bleeding C-cortisone/steroids D-diabetes E-emboli/DVT
True
What prevents thrombus,embolus and infact
A)leg exercises
B)TED STOCKINGS
C)SCD
A B C
Scrub nurse and circulating nurse are intraoperative
A)true
B)false
A
An infact is a localized necrosis of tissue resulting in obstruction of blood supply
A)true
B)false
A
Anesthesia is the absence of feeling (pain)
A)true
B)false
A
Nontraditional analgesia are select all that apply
A)imagery
B)biofeedback
C)relaxation
A B C
Traditional analgesia are select all that apply A)intermittent injections B)PCA DEVICE C)epidural D)oral analgesics
A B C D
PERIOPERATIVE involved periods of surrounding surgery; which include preoperative, intraoperative and postoperative
A)true
B)false
A
WBC. Normal lab is 5,000-10,000
A)true
B)false
A
Normal hemoglobin lab value is for male 14-18 and for female 12-16 g/dl
A)true
B)false
A
HCT normal lab value is for male .42-.52 and for females .37-.47
A)true
B)false
A
Normal lab value for sodium is 136-145 mEq/L
A)true
B)false
A
Normal lab value for potassium is 3.5-5 mEq/L
A)true
B)false
A
WBC lab value of 14,000 the nurse should report to the doctor
A)true
B)false
A normal value is 5,000-10,000
The nurse should verify that the patient has stop taking Coumadin before surgery because of the increase risk of bleeding that the medication causes
A)true
B)false
A
Valium and versed reduces anxiety
A)true
B)false
A
Valium, meperidine and morphine decreases anesthetic needed
A)true
B)false
A
Anticholinergic-atropine reduces respiratory tract secretions
A)true
B)false
A
Infection in the bone does not heal quickly and usually last for life
A)true
B)false
A
What class of medication atropine belongs to
Anticholinergic
General anesthesia includes analgesia, amnesia, muscle relaxation and unconsciousness occur and the routes invole inhalation, oral, rectal and parental.
A)true
B)false
A
Regional anesthesia renders only a specific region of the body insensitive to pain and the routes are nerve block, spinal and epidural anesthesia
A)true
B)false
A
Local anesthesia includes topical application or infiltration into tissues of anesthetic agent that disrupts sensations at the level of the nerve endings and action the immediate area of application
A)true
B)false
A
A patient that has a purulent drainage from the wound the nurse would report a lab valve of WBC
A)true
B)false
A
You can not infuse lactated ringer solution with blood
A)true
B)false
A
Always use normal saline when infusing blood
A)true
B)false
A
Highest priority the nurse should address is risk of preoperative position injury due to the patient might chocking or aspirating vomit
A)true
B)false
A
During a TIME OUT the nurse should partial ate in the review of the scheduled procedure
A)true
B)false
A
Conscious sections is the administration of drugs to depress the CNS provides an analgesia effect
A)true
B)false
A
Patient bleeding to much the nurse would report the lab valve of hemoglobin and hematocrit
A)true
B)false
A
PACU-position patient on the side for all patient coming out of the unit, to prevent aspiration and Vomitting
A)true
B)false
A
Notify the doctor if IV is not infusing
A)true
B)false
A
You can not discontinue saline that you do not have an order to
A)true
B)false
A
It is normal for a client to have hypoactive bowel sounds after surgery so the nurses should document the finding
A)true
B)false
A
Elements of Pre-Op teaching
- surgical event
- knowledge of the surgery
- NPO
- treatment
- Labs
- pre-op meds
- pain management
- recovery
- informed consent
- allergies
True
When the patient returns from surgery the first thing the nurse would check is breathing and vital signs
A)true
B)false
A
PACU- vital signs checked every 15 mins
A)true
B)false
A
An incision dressing the nurse should reinforce for the first 24hrs
A)true
B)false
A
What can cause the patient to experience hypoventilation(select all that apply) A)drugs B)incisional pain C)obesity D)chronic lung disease E)pressure on the diaphragm
A B C D E
Prevention of atelectasis and pneumonia is at the nurse should have the client:(select all that apply)
A)turn, cough, and deep breathe every 2hrs
B)take analgesics as order
C)early mobility
D)frequent positioning changing
A B C D
Pulmonary embolism s/s the patient might experience is sudden chest pain, dyspena, tachycardia, cyanosis, diaphoresis and hypotension. So which of e following intervention should the nurse perform:(select all that apply)
A)HOB UP TO 45 degrees
B)give O2
C)notify physcian
A B C
Assessment of pain, objective data would be, restlessness, moaning, grimacing, diaphoresis, vitals changing, pallor and guarding the area of pain
A)true
B)false
A
URINARY FUNCTION
- assess every 2hrs for distention
- report no ursine output after 8hrs
- accurate intake and output of urine is 30ml an hour minimum
True
Measures to promote urination would include the following (select all that apply) A)running warm water B)hands in warm water C)ambulate to bathroom D)males stand to void
A B C D
Venous stasis is a normal flow of blood through the vessels that is slowed
A)true
B)false
A
To assess for venous stasis the nurse would palpate the pedal pluses and note the skin color and temperature, assess for edema, aching, cramping in the calf and homans’ sign
A)true
B)false
A
Prevention of venous stasis is leg exercises every 2hrs, TED stockings and SCD
A)true
B)false
A
Effects of early post-op ambulation is increased circulation,increased in rate and depth of breathing, increased urination, metabolism and peristalsis.
A)true
B)false
A
GI status post-op
-3-4 days for bowel activity to return
True
Potential problems related to post-op GI status
Is a condition called paralytic ileus
A)true
B)false
A
A decrease or absence of peristalsis is called
A)paralytic ileus
B)hypoactive
A
Involuntary contraction of the diaphragm followed by rapid closure of the glottis, also irritation of the phrenic nerve and the cause could be abdominal distention or internal bleeding
A)singlultus (hiccup)
B)hyperactivation
A
STUDY GUIDE PART 1
,
Arthritis medications
- NSAID
- corticosteroid
- supplements
- analgesics
True
You can not just stop taking steroids, you have to slowly stop taking them
A)true
B)false
A
Pre-op check list:ensures that all nursing interventions are completed by the day of sureger
A)true
B)false
A
High risk considerations for surgery:age, mental status, nutritional status and health
A)true
B)false
A
Meds like aspirin should be discontinued, because can cause excessive bleeding
A)true
B)false
A
Steroids should be tapered(reduced) over time before surgery
A)true
B)false
A
Latex sensitivity: apply a cloth barrier to the patient arm before applying the BP cuff
A)true
B)false
A
Blood thinner meds should be discontinued before surgery
A)true
B)false
A
Prioritizing early post-op interventions: airway, breathing, level of consciousness, circulation and system review
A)true
B)false
A
UAP can be delegated to task like vital signs, enema and height and weight
A)true
B)false
A
Role of the PACU NURSE
- airway
- observe the order of assessment; airway, breathing, consciousness, circulation and system review(ABCCS)
- bleeding
- pain
- Emerson’s: monitor color, consistency and amount
True
Types of anesthesia
,
General anesthesia : includes the administration of agents and endotracheal intubation
A)true
B)false
A
Regional anesthesia : results in loss in an area of the body
A)true
B)false
A
Epidural anesthesia : anesthetic agent is injected into the epidural space outside the dura matter
A)true
B)false
A
Spinal anesthesia : a lumber puncture is performed and local anesthesia is injected into the subarachnoid space. Postoperatively the patient is nursed flat for several hours and fluids are replaces to treat spinal headaches
A)true
B)false
A
Conscious sedation : administration of drugs that depress the CNS or provide analgesia to relive anxiety or provide amnesia. There is depressed level of consciousness
A)true
B)false
A
STUDY GUIDE PART 1 contd..
,
Caring for a patient with ICP(intracranial pressure)-nurse in the supine position and avoid coughing
A)true
B)false
A
Incentive spirometry have patient in the fowlers position
A)true
B)false
A
Monitoring for internal bleeding: vitals, restlessness, and level of consciousness
A)true
B)false
A
STUDY GUIDE PART 2
,
The restoration of function to a lacerated arm is considered constructive surgery
A)true
B)false
B
Closure of an arterial septal defect in the heart is constructive surgery
A)true
B)false
A
Internal fixation of the right fibula is a reconstructive surgery
A)true
B)false
A
An ablative surgery is a removal of a diseased body part
A)true
B)false
A
Removal of a mole that has an abnormal appearance is a reconstructive surgery
A)true
B)false
B
Elective surgery is the patient choice for example liposuction
A)true
B)false
A
Emergency surgery must be done immediately for example an appendenectomy
A)true
B)false
A
Urgent surgery is nesscessary for patient health for example tonsillectomy
A)true
B)false
A
Preoperative check list is completed by staff in the holding area of the surgical department
A)true
B)false
B
The primary purpose of preoperative checklist is to ensure that preoperative meds are administered on time
A)true
B)false
B
The preoperative checklist is completed by a licensed nurse
A)true
B)false
A
The preoperative checklist provides a means of documenting the disposition of the patient jewelry
A)true
B)false
A
The Joint Commission requires surgical facilities to use a standardized preoperative checklist
A)true
B)false
B
Name the formal requirement that a patient provide informed consent before havinga specific test or surgery
A)patient bill of rights
B)false
A
What is established by the patient signing the consent form
A)competence and agreement to the stated procedure
B)loyalty
A
Four elements required to be included in the information provided to the patient before a procedure is
- Clarity
- explanation of risks
- explanation of benefits, consequences
- treatment alternatives
True
the patient is in the induction stage of anesthesia, which of the following activities will most likely be taking place?
A)endotracheal intubation
B)skin prep
A
during the pre-op teaching session, a patient voices concerns about waking up during surgery. what response by the nurse is indicated?
A)emergence from anesthesia is a rare complication of surgery
B)we have meds for that
A
the patient is scheduled to undergo a urologic procedure in the surgical site. the patient will be conscious during the procedure. which of the following types of anesthesia will most likely be used?
A)spinal
B)local
A
the patient is scheduled to undergo the removal of a benign cyst from his hand in the physicians office. the nurse is aware that the physician will most likely use which of the following types of anesthesia
A)local
B)regional
A local because it infiltrated between the tissue and is applied on topical
the nurse in preparing to assist the physician who is performing a procedure using conscious sedation. which activity will be included in the nurse’s responsibilities during the procedure?
A)monitoring I&O
B)assessment of vital signs
B
the nurse is preparing an in-service for nursing staff on the unit. when discussing conscious sedation, which of the following statements should be included in the presentation?
A)there must be close access to thee resuscitation equipment
B)the recovery of procedure that is to risky
A
skills of the nurse assisting with a conscious sedation procedure include:(select all that apply)
A)knowledge of normal and abnormal vital signs
B)ability to initiate resuscitative actions
C)knowledge of pharmacologic principles related to anesthetic
A B C
when developing the plan of care for an arab American undergoing surgery, what cultural consideration may be of concern?
A)the need for a written consent for surgery
B)the often submissive role of a woman
A
pre-op teaching is done 1-2 days before surgery
A)true
B)false
A
in which of the following condition is use of GoLYTELY contraindicated?(select all that apply)
A)patients experiencing gastric retention
B)patients having history of bowel perforation
C)patients having had a hysterectomy
A B C
before surgery of the bowel, neomycin, sulfonamides, or erythromycin may be given to?
A)detoxify and sterilize the GI tract
B)hypootension
A
side effects for a patient taking long standing antihypertensive drugs would be
A)hypotension
B)tachycardia
A
ibuprofen is associated with increased bleeding and will have to be avoided and discontinued before surgery
A)true
B)false
A
which of the following nursing Dx will of the highest priority during the immediate post-op period
A)potential for ineffective airway clearance
B)anxiety
A
The following statements are true regarding medications and surgery
- review of the patient current medication regimen is essential to promote a safe surgical outcome
- a seriously ill patient may receive as many as 20 medications in a preoperative setting at one time
- the patient chart should be “flagged” to alert all health providers to the patient’s allergy status
True
Pre-op information helps lessen anxiety, reduce the amount of anesthesia required, decrease post-op pain and reduce corticosteroid production
A)true
B)false
A
To help prevent respiratory complications post-op,the nurse should
A)assist the patient to ambulate within a few hours of surgery, unless contraindicated
B)assist the patient to deep breathe and cough in all surgeries
A
assist the patient to deep breathe and cough in all surgeries to prevent respiratory complications, this statement is
A)true
B)false
B false because intracranial pressure surges can be damaged by coughing
Induction phase of general anesthesia is administration of anesthetic agents and endotracheal intubation
A)true
B)false
A
Maintence phase of general anesthesia includes positioning the patient, preparing of the skin for incision and the surgical procedure itself
A)true
B)false
A
During the emergence phase of general anesthesia, anesthetic are decreased and the patien begins to awaken. Because of short half life of today’s anesthic agents emergence may occur in the operating room
A)true
B)false
A
Stage IV of the general anesthesia begins with the cessation of respirations and must be avoided, or it will necessitate the initiation of cardiopulmonary resuscitation and may lead to death
A)true
B)false
A
A routine type of sedation that might be used for a surgical procedure that does not require complete anesthesia but rather a depressed level of consciousness is called
A) Local anesthesia
B) Conscious sedation
B
The usual interval at which nursing assessments including vital signs are monitored in the postoperative phase is every
A) 15 minutes times four, Every 30 minutes times four, Every hour times four, Every four hours times four
B)false
A
Without an adequate blood supply, an infarct (localized area of necrosis) can occur.
A)true
B)false
A
Consider the following points when applying anti-embolism stockings.
• Postoperative patients with abdominal or tho-racic incisions will not be able to bend and pull on their own stockings.
• Stockings may be difficult to fit and maintain in obese or very thin patients.
• Stockings may be difficult to apply for elderly patients; the nurse or family members will need to assist.
True
Inhalation anesthesia is used For minor surgical procedures
A)true
B)false
A
Nerve block anesthetic is used for foot and orthopedic surgery
A)true
B)false
A
Local anesthesia is used for minor surgical procedures
A)true
B)false
A
Intravenous anesthesia is used for rapid induction and shorter duration surgery
A)true
B)false
A
Spinal anesthesia is use for surgery involving the lower half of the body
A)true
B)false
A
The nurse assessing a patient scheduled for an open cholecystectomy the next morning discovers that the patient is allergic to clams. How might this information affect the upcoming surgery?
A)The anesthesiologist may need to change the type of anesthesia used.
B)The physician may need to alter the type of skin preparation used.
C)The physician may need to change the antibiotic to be used postoperatively.
D)The physician will need to closely monitor the patient’s thyroid levels.
B
Skin preparations containing povidone-iodine should not be used on patients with known or suspected allergies to shellfish (e.g., clams, oysters, lobster, crabs).
A)true
B)false
A
The patient’s shellfish allergy has no effect on antibiotics or anesthesia used.
A) True
B)false
A
The nurse is reviewing his patient's preoperative laboratory values. Which value requires immediate attention? A)Prothrombin time 80 seconds B)Hematocrit 38 mL/dL C) Hemoglobin 14 g/dL D)White blood cell count 6000/mm3
A
Normal prothrombin time is 11 to 20 seconds. Prolonged prothrombin time increases the risk of hemorrhage.
A)true
B)false
A
Your patient tells you that he is an active Jehovah’s Witness. You are aware that your patient’s spiritual beliefs may prohibit him from which action?
A)The use of antibiotic and antiviral medications
B)Consuming pork in any form, including medication derived from pork sources (such as insulin)
C)Eating shellfish
D)The use of plasma
D
A member of the Jehovah’s Witness faith might not consent to treatment with blood or blood products.
A)true
B)false
A
Jehovah’s Witnesses will most likely take antibiotics and antivirals, use pork or pork products, and eat shellfish.
A)true
B)false
A
The nurse is performing a preoperative assessment on a 78-year-old patient. What should the nurse keep in mind regarding surgery with an elderly patient?
A)Elderly patients experience more anxiety before surgery than younger patients.
B)Decreased cardiac output is a normal physiologic function of aging.
C)Renal function increases with age.
D)Pain tolerance will be decreased.
B
Cardiac output normally decreases as a person ages.
A) true
B)false
A
Anxiety may be high in a patient of any age.
A) true
B)false
A
Renal function begins to decrease after age 60.
A) true
B)false
A
Pain tolerance is individualized, regardless of age.
A) true
B)false
A
IV fluids during the surgical experience are most often used to prevent dehydration and maintain electrolyte balance
A)true
B)false
A
The patient asks the nurse what the major benefit is for having an autologous blood transfusion during surgery, if needed. What is the nurse’s best response?
A)“Patients usually need less blood than if receiving blood from another donor.”
B) “This type of transfusion will cause antibodies to develop against the blood.”
C) “It is less likely you will acquire a virus such as hepatitis B.”
D)“You are less prone to having circulatory overload with this type of transfusion.”
C
Autologous blood transfusion (the patient’s own blood) prevents contraction of blood-borne pathogens from donated blood products
A)true
B)false
A
The LPN/LVN is preparing a 50-year-old woman for surgery. The nurse plans to prepare the patient to have which test(s)? (Select all that apply.) A)Echocardiogram B)Electrocardiogram C)Chest x-ray D)Blood glucose
B C D
Echocardiogram is not a common preoperative test.
A)true
B)false
A
An 85-year-old patient who is to have surgery says to the LPN/LVN, “I’ve had so many tests, even liver tests, in preparation for this surgery. I had surgery many years ago and didn’t need to have all these tests.” What should the nurse consider when responding to this patient?
A) Patients often forget unpleasant experiences.
B) All patients have more tests now than they did years ago, regardless of their age.
C) The tests are necessary to be sure that the major systems have not become impaired by the aging process.
D) Because the tests are necessary, the patient should not be concerned about the cost.
C
The aging process affects several body systems, so the elderly patient is likely to have more preoperative testing to determine the operative risk for the patient and to prepare for prevention of postoperative complications.
A)true
B)false
A
Corticosteroids may delay wound healing whether taken systemically or topically. Corticosteroids may need to be tapered prior to surgery; however, this is done only if ordered by the physician, and it is important for the patient not to abruptly stop taking them.
A)true
B)false
A
The nurse caring for a diabetic patient postoperatively is aware that the patient is at risk for complications. What factor places the diabetic patient at risk?
A)The patient cannot consume the prescribed diet for several days.
B)Healing of the diabetic patient’s wound rarely takes place.
C) The blood glucose levels of the diabetic patient fluctuate greatly with surgery.
D) The patient usually cannot give his or her own insulin injections for a while postoperatively.
C
The blood glucose level frequently fluctuates with any stressor on the diabetic patient’s body, such as with surgery.
A)true
B)false
A
A patient who is scheduled for surgery the following morning awakens at 11:15 P.M., after receiving a sedative for sleep at 9:00 P.M., and cannot get back to sleep. Which nursing action ismost appropriate?
A)Offer him a cup of coffee.
B) Tell him to try deep breathing exercises to go back to sleep.
C) Give him a back rub, listen to him for a while, and then suggest he try to sleep.
D) Contact the physician requesting an order for a second dose of the sedative and suggest that the patient empty his bladder.
C
A back rub and talking with the patient may put the patient at ease and allow the sedative to be effective
A)true
B)false
A
When caring for a patient during the preoperative period, which action should the LPN/LVN take first?
A) Have the patient empty his bladder.
B)Raise the side rails and tell the patient not to get out of bed.
C)Remove the patient’s dentures and place them in a labeled cup.
D)Give the preoperative medication to the patient.
A
The patient should empty his bladder before administration of preoperative medications. .
A)true
B)false
A
The side rails should be raised after preoperative medication has been administered.
A)true
B)false
A
Dentures may or may not be required to be removed; if removal is required, dentures can be removed at any time prior to surgery.
A)true
B)false
A
The nurse is preparing to administer preoperative medication to an elderly patient. What should the nurse keep in mind?
A)An increased amount of sedative is usually necessary for elderly patients.
B)There is no need for an antacid to be administered to an elderly patient.
C)The elderly patient may require more medication to decrease secretions and mucus production.
D) A reduced dose of narcotic is often necessary for the elderly patient.
D
The elderly patient is more likely to have impaired renal, hepatic, respiratory, and cardiac functions; therefore, lower doses of preoperative medications may be necessary for the elderly patient to metabolize more effectively
A)true
B)false
A
The student nurse is scheduled to observe a surgery. The student identifies which action as belonging to the role of the circulating nurse?
A)Preparing the sterile tray where the instruments are kept.
B)Arranging the sterile supply table.
C) Observing for breaks in sterile technique.
D)Handing sterile materials to the surgeon.
C
The circulating nurse is responsible for the overall coordination of the actions and environment of the operating room, including observing for breaks in sterile technique and bringing these breaks to the attention of the surgical team.
A)true
B)false
A
The scrub person or the surgical technician is primarily responsible for preparing, arranging, and handing sterile supplies to the surgeon.
A)true
B)false
A
The student nurse is discussing various anesthetic agents used for induction of anesthesia. The student nurse needs further instruction after he or she inaccurately identifies which as an inhalation agent? A)Ethyl ether B)Halothane C) Thiopental sodium D)Nitrous oxide
C
Thiopental sodium is an injectable anesthetic agent.
A)true
B)false
A
Ethel ether, halothane, and nitrous oxide are all inhaled anesthetic agents.
A)true
B)false
A
A patient has just received a regional anesthetic for a surgical procedure. The nurse is most concerned with which reaction occurring in the patient? A) Anaphylactic shock B)Oversedation C)Aspiration of vomitus D) Convulsive seizures
A
The patient is most likely to suffer from an anaphylactic reaction to a regional or local anesthetic.
A)true
B)false
A
Oversedation, aspiration of vomitus, and convulsive seizures are more likely to occur with general anesthesia.
A)true
B)false
A
General anesthesia uses an inhalant gas that renders the patient unconscious
A)true
B)false
A
To heal property cells need oxygen, anemia decreases the amount of oxygen that the blood stream can deliver to the cells therefore makes a patient poor surgical candidate
A)true
B)false
A
Complications of NG suction, especially if prolonged, include dehydration, hypokalemia, hyponatremia, and metabolic alkalosis.
A)true
B)false
A
A patient is admitted to the unit 3 days after undergoing bowel resection. He suddenly develops chest pain and shortness of breath. Assessment reveals tachypnea, severe tachycardia, anxiety, cyanosis, and blood pressure (BP) 160/40. The first nursing action should be to:
A) Apply oxygen (O2) at 2 L/min by mask.
B)Begin cardiopulmonary resuscitation (CPR).
C) Place him in high Fowler’s position.
D)Administer a prescribed sedative
C
A postoperative patient with chest pain, shortness of breath, tachypnea, tachycardia, anxiety, and cyanosis may have developed a pulmonary embolus. High Fowler’s position will facilitate breathing. O2 should be applied by mask at approximately 10 L/min in this situation
A)true
B)false
A
A patient with a radical mastectomy can be helped to accept and cope with her diagnosis and subsequent body changes by a member of a support group that has had similar experiences.
A)true
B)false
A
The nurse is performing a postoperative assessment of an elderly patient who has had a total hip replacement. Although he has not requested medication for pain, the nurse suspects the patient's discomfort is severe and prepares to administer pain medication. Which sign supports the nurse's assessment of acute postoperative pain? (Select all that apply.) A)Increased blood pressure B)Inability to concentrate C)Dilated pupils D)Decreased heart rate E)Restlessness
A B C D
For minor surgical procedures on an outpatient basis, the nurse must be sure the gag reflex has returned before administering oral fluids in order to prevent aspiration.
A)true
B)false
A
When a patient has had spinal anesthesia, it is necessary to include which of these measures in the patient’s care?
A) Keep the patient in the Sims’ position.
B) Put the patient’s legs through range of motion every 2 hours.
C) Encourage the patient to drink fluids, including caffeinated beverages.
D)Dim the lights in the patient’s room.
C
Fluids and caffeine are encouraged because they raise the vascular pressure at the spinal puncture site and help to seal the insertion site of the spinal needle.
A)true
B)false
A
During the immediate postoperative period, the surgical dressing is assessed as often as the vital signs are measured in order to detect any excessive bleeding from the surgical wound or other complications.
A)true
B)false
A
The surgeon has put a drain with a Jackson-Pratt suction device into the patient's wound. What is a priority action in the care of the patient with this drain? A)Empty the drainage every hour. B)Reinforce the dressing every 4 hours. C) Keep the suction bulb compressed. D) Report bloody drainage.
C
The suction bulb must be compressed after emptying the device and reset whenever necessary, in order for suction to occur. It is not usually necessary to drain the device every hour or reinforce the dressing every 4 hours. Bloody drainage in the drainage device is expected.
To ensure adequate urinary elimination needs, the nurse must verify that the patient voids within 4 to 8 hours following surgery.
A)true
B)false
A
A postoperative patient has been given a medication for postoperative pain that is ordered every 4 hours, PRN. Three hours later, the patient complains of pain and discomfort. What is the nurse’s best action?
A) Assess the patient to determine the source of pain.
B) Administer pain-relieving medication that has been prescribed.
C)Notify the anesthesiologist and request an analgesic.
D)Notify the surgeon and ask to have the dosage or type of pain medication adjusted.
A
It is important to not assume that the patient is experiencing incisional pain rather than another type of pain. Determining the source of pain will aid in guiding appropriate interventions to be implemented.
If a patient say that they are in pain always assess what the pain is before giving medication that is order every 4 hours if the patient has pain on the third hour
A)true
B)false
A
This is the second time the patient, who had surgery yesterday, will be permitted to get out of bed. What is the best nursing action?
A) Ask the patient if he feels strong enough to get up by himself this time.
B) Remain with the patient and assist him.
C)Ask the patient’s family to observe him when he gets up and call you if there is a problem.
D)Tell the patient to put on his call light if he experiences any difficulty while getting up.
B
Since this is only the second time this patient has ambulated, it is important for the nurse to remain with the patient to assist as necessary and assess his response to activity. Remaining with the patient is also important for maintaining the patient’s safety.
The nurse is caring for a patient who develops symptoms of shock. The nurse places the patient in a supine position with the lower extremities elevated. In what condition would the nurse avoid this position as treatment? A) The patient is hemorrhaging. B) The patient is in cardiogenic shock. C)The patient is semiconscious. D)The patient is comatose.
B
The patient in cardiogenic shock is placed in Fowler s position to lower the diaphragm and increase oxygenation as long as the patient does not become too hypotensive.
A)true
B)false
A
The nurse should assess for signs and symptoms of cardiac or pulmonary complications in any patient who complains of chest pain unless he or she has had chest surgery and is specifically complaining of incisional pain.
A)true
B)false
A
Which of these factors aid in wound healing?
A)Maintaining the affected area in a position higher than the heart
B) Increasing the intake of vitamin B
C) Splinting the incision
D)Forceful exhalation of breaths
C
Splinting the incision during activity and coughing and deep breathing are necessary for prevention of dehiscence and/or evisceration. Nutrients that should be increased to promote wound healing include protein, vitamin C, zinc, copper, and iron.
A)true
B)false
A
The LPN/LVN observes the postoperative patient for signs of pneumonia. Which signs are most indicative of pneumonia? A) Dyspnea B)Pallor C)Decreased sputum production D)Throat pain
A
Symptoms of pneumonia include fever, malaise, increased sputum, purulent sputum, cough, flushed skin, dyspnea, pain on inspiration, and abnormal breath sounds.
A)true
B)false
A
Distention, abdominal pain, and lack of bowel sounds upon auscultation are evident when paralytic ileus has occurred.
A)true
B)false
A
It is essential that the nurse ensures the patient understands all discharge instructions in order to prevent or promptly treat postoperative complications.
A)true
B)false
A
The number one priority of care for the patient in the post anesthesia care unit is safety, And that means keeping an open functioning airway
A)true
B)false
A
Name four specific interventions to prevent constipation in a post-operative patient who is receiving narcotic analgesic for pain
- Increase fluids to at least 2500 mL a day unless contraindicated
- Ambulate frequently
- Increase fiber in diet
- Administer ordered stool softener
True
Factors that would indicate a wound infection:
- Increased pain at wounds site
- purulent discharge from wound
- Increased white blood cells and blood
- Redness around the wound
- Increased soreness around the wound
- Increase temperature
- Increased swelling around the wound
True
The new nurse understands the job description of the unlicensed assistive personnel (UAP) by making which statement? (Select all that apply.)
A)“The UAP may assist the nurse with direct patient care.”
B)“The UAP is able to do whatever the nurse delegates to them.”
C)“The UAP may perform care without direct supervision.”
D)“The UAP is trained and certified to perform certain nursing tasks.”
A D
The LPN/LVN may be limited from assuming primary care responsibility for which patient?
A) A patient who is in labor.
B)A patient who is 2 days postoperative for an appendectomy.
C) A patient who has a central line venous access device.
D)A patient who has bipolar disorder.
C
Extra information
,
Ventilation part two
,
Listen is for wheezing or crowing songs from patients who have undergone head or neck surgery, this response occurs when Edema places pressure over the trachea, resulting in respiratory insufficiency.
A)true
B)false
A
The patient feels chest pain or has a fever, productive cough, or dyspnea atelectasis or pneumonia may be developing
A)true
B)false
A
Sudden chest pain along with dyspena, tachycardia, cyanosis, diaphoresis, and hypotension is a sign of pulmonary embolism
Raise the head of the bed to decrease dyspena and immediately report signs and symptoms.
A)true
B)false
A
Volume oriented spirometers assist patient and deep breathing. Patients are encouraged to take tenebrous every hour while awake
A)true
B)false
A
Do not leave patients unattended going postural drainage, since they may experience respiratory distress
A)true
B)false
A
Pain part two
,
Objective pain factors are signs that the body is responding to pain, these include vital sign changes ( blood-pressure lowers into immediate postoperative period and elevate and response to pain after about 12 hours and pulse increases), Restlessness, diaphoresis, and pallor
A)true
B)false
A
Each patient interprets pain differently and has a personal pain tolerance level
A)true
B)false
,
Patients experiencing chronic pain may have more difficulty obtaining relief than individuals with acute episodes
A)true
B)false
A
TENS units applies electrical impulses to the nerve endings and blocks transmission of pain signals to the brain
A)true
B)false
A
Monitor the PCA system every 3 to 4 hours
A)true
B)false
A
Postoperative comfort measures for pain
,
Decrease external stimuli by darkening the room and closed the drapes
Reduce interruptions
Eliminating odors
Nursing interventions;
- Have the patient practice deep breathing and relaxation techniques
- Provide a rest periods, provide back rubs.
- Engage patient in conversation,ask about concerns and fears
- Encourage activities
- reposition and support with pillows, Bed rolls
- Check tube placement,
- offer warm fluids if indicated
- Reduce room clutter, provide restful environment
True
Venous stasis
,
Venous stasis (a disorder which the normal flow of fluid through a vessel of the body is slow or halted) Is the underlining call of thrombus formation A)true B)false
A
Performing leg exercises every two hours and using intermittent pneumatic compression devices and compression stockings aid the circulatory system and help prevent deep vein thrombosis
A)true
B)false
A
Teach the patient not to cross legs when in bed and encourage setting up as another means of preventing venous stasis. Do not use a Knee gatch
A)true
B)false
A
Surgical patients are at the greatest risk of developing life-threatening deep vein thrombosis and pulmonary embolism
A)true
B)false
A
Not only does surgery injure blood vessels, but anesthesia and inactivity also causes venous stasis
A)true
B)false
A
Surgery however is not the only risk factor. For venous stasis.Others include pregnancy ,myocardial infarction ,heart failure ,stroke ,cancer ,sepsis and immobility
A)true
B)false
A
The most effective method of preventing deep vein thrombosis is with low-dose subcutaneous heparin therapy.
A)true
B)false
A
Heparin is an anticoagulant but is contraindicated in trauma and general surgery patients
A)true
B)false
A
Antiembolism stockings and ambulation are also useful preventive measures of venous stasis
A)true
B)false
A
SCD, the pressure cause automatically inflate to 40 and MmHG or the prescribed setting and deflate in cycles, with inflation lasting about 12 seconds and deflation lasting about 48 seconds. This system is contraindicated for patients with acute thrombophlebitis or deep vein thrombosis
A)true
B)false
A
Do not disconnect the device for more than 30 minutes. If the patient has diagnostic examination that require leaving the nursing unit for longer than 30 minutes, the compression pump, the cuffs or sleeves, and instruction on operations should travel with the patient.
A)true
B)false
A
The treatment continues for 72 hours post operatively or until the patient is ambulating well. Remove the cuffs once a day to assess skin integrity and provide skin care
A)for SCD
B)false
A
Patient taking anticoagulant is at greatest risk for surgery
A)true
B)false
A
First signs and symptoms of hemorrhage will be restlessness
A)true
B)false
A
Give pain medication regularly before pain gets severe
A)true
B)false
A
PCA device that would not be included in the nursing intervention is that
A)not administering analgesics to the patient
B)false
A
Increased restlessness can be a major concern, Instead Hypoactive bowel sounds in postoperative patients
A)true
B)false
A
Informed consent is done when the nurse obtains the patient signature and The only signature on the informed consent is the patient
A)true
B)false
A
Side effects of anesthesia is delayed consciousness
A)true
B)false
A
Transfer to a sub acute unit from the hospital is because financial restriction of insurance limit time spent in an acute care setting
A)true
B)false
A
Any long procedure or surgery make sure the patient voids Before anything else for example medication or taking the patient to the OR
A)true
B)false
A
Prednisone (deltasone) is a steroid
A)true
B)false
A
Procnlorperazine (compazine) is a antiemetic
A)true
B)false
A
Most post op patients are going to vomit
A)true
B)false
A
