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Chapter 37: Perioperative Nursing Care
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative Practice, 2nd Edition
MULTIPLE CHOICE
1.The nurse is caring for a patient who is about to have surgery. Which intervention will be included in the patient’s care to meet the goals for risk for perioperative positioning injury related to immobilization during surgical procedure?a.Use adequate assistance to move patient onto the OR table.b.Watch for early signs of hypovolemia caused by patient’s NPO status since midnight.c.Use therapeutic touch and guided imagery to allay patient’s fears of surgery.d.Pad all bony prominences and avoid hyperextension of extremities.
ANS:D
Risk for perioperative positioning injury is addressed by ensuring that the patient’s skin and bony prominences are well padded during the surgery. In addition, hyperextension of extremities may lead to joint damage, so this should be avoided as well. The other interventions are appropriate for perioperative care but do not relate directly to the Nursing diagnosis of positioning injury potential.DIF:Applying OBJ:37.7 TOP:Planning MSC:NCLEX Client Needs Category: Reduction of Risk Potential: Potential for Complications from Surgical ProceduresNOT:Concepts: Safety 2.The nurse is caring for a male patient who is having open heart surgery. The patient’s chest is covered with thick hair, so the surgical technician begins to shave the patient’s skin near the operative site. Which action by the technician requires intervention by the nurse to correct the technique?a.A straight safety razor and antibiotic foam is used.b.Disposable electric trimmers are used to trim the hair.c.Antibacterial soap is used prior to hair removal.d.Only the hair directly around the surgical site is removed.
ANS:A
Disposable electric trimmers should be used to remove excess hair from operative sites.Antibacterial soap is commonly used to clean the skin before surgical procedures. Only the hair around the surgical site is removed. A straight safety razor would never be used because small nicks in the skin can occur, increasing infection risk.DIF:RememberingOBJ:37.3 TOP:Implementation MSC:NCLEX Client Needs Category: Safety and Infection Control: Safe Use of Equipment NOT:Concepts: Infection 3.The nurse is caring for a patient who has just been brought to the postoperative unit following major surgery and notes that the patient has many tubes and monitors in place. Which will the nurse assess first?a.The patient’s intravenous lines b.The patient’s urinary catheter This study source was downloaded by 100000869267694 from CourseHero.com on 10-24-2023 08:35:56 GMT -05:00
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c.The patient’s nasogastric tube d.The patient’s endotracheal tube
ANS:D
Airway maintenance and protection is the highest priority for this patient, so the nurse should assess the endotracheal tube first to ensure that it is patent and positioned correctly. The other tubes may be assessed afterward.DIF:Applying OBJ:37.5 TOP:Assessment MSC:NCLEX Client Needs Category: Management of Care: Establishing Priorities NOT:Concepts: Clinical Judgment 4.The nurse is caring for a patient who has a family history of reactions to general anesthesia.Which medication will the nurse anesthetist have ready as a precautionary measure before the patient’s surgery is started?a.Protamine sulfate b.Dantrolene sodium (Dantrium) c.Activated charcoal with sorbitol d.Folinic acid (Leucovorin)
ANS:B
Malignant hyperthermia is a dangerous anesthesia reaction caused by a genetic defect that may be passed down via family history. Knowing this, the anesthesiologist would have dantrolene ready as a precaution because it is a mainstay of treatment for malignant hyperthermia. The other medications are not related.DIF:Applying OBJ:37.4 TOP:Implementation MSC:NCLEX Client Needs Category: Reduction of Risk Potential: Potential for Complications from Surgical ProceduresNOT:Concepts: Clinical Judgment 5.Which action by the nurse best demonstrates accountability in the operating room?a.Applying warm blankets when the patient reports feeling chilly b.Holding the patient’s hand to allay anxiety before anesthesia is administered c.Double-checking that the surgical site is clearly marked and visible after draping d.Using calming speech with a reassuring tone of voice when speaking with the patient
ANS:C
Accountability is accomplished by ensuring that proper precautions are taken to prevent errors from happening. The nurse can prevent wrong-site surgery by making sure that the surgical site is clearly marked and visible after the draping is completed. The surgeon could inadvertently operate on the incorrect site if the markings are covered by the surgical drapes.The other actions of the nurse are appropriate but do not demonstrate accountability and error prevention.DIF:Applying OBJ:37.3 TOP:Implementation MSC:NCLEX Client Needs Category: Safety and Infection Control: Error Prevention NOT:Concepts: Safety 6.The nurse is caring for a patient who will be having surgery. The patient has just signed the consent form for the operation. What does the patient’s signature indicate?a.The patient agrees with the doctor’s diagnosis. This study source was downloaded by 100000869267694 from CourseHero.com on 10-24-2023 08:35:56 GMT -05:00
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b.The patient gives permission for the surgery to be performed.c.The patient has agreed to pay for any costs not covered by insurance.d.The patient has been told of all the available treatment options.
ANS:B
The patient’s signature on the consent form indicates that the patient gives permission for the surgery to be performed. It does not indicate that the patient agrees with the physician’s diagnosis, agrees to pay for costs not covered by insurance, or has been informed of all the possible treatment options.DIF:RememberingOBJ:37.3
TOP:Communication and Documentation
MSC:NCLEX Client Needs Category: Management of Care: Informed Consent NOT:Concepts: Health Care Law 7.The nurse is caring for a postoperative patient who is very sleepy following general anesthesia and administration of pain medication. The nurse notes that the patient is making snoring sounds and his pulse oximetry has dropped to 88%. What is the best action of the nurse?a.Assess the airway and administer oxygen.b.Call for anesthesia to immediately reintubate the patient.c.Remove the pillow from behind the patient’s head.d.Elevate the head of the patient’s bed.
ANS:A
The snoring sounds made by the patient and low oximetry levels indicate that the patient’s airway is partially occluded because of anesthesia and pain medication. Patency of the airway should be assessed and oxygen administered to maintain the airway and oxygenation.Reintubation should be performed if the oral airway alone does not maintain the airway and improve oxygenation. Removing the pillow from the head of the patient’s bed or elevating the head of the patient’s bed will not be sufficient to open the patient’s airway.DIF:Applying OBJ:37.8 TOP:Implementation MSC:NCLEX Client Needs Category: Reduction of Risk Potential: Changes & Abnormalities in Vital SignsNOT: Concepts: Gas Exchange 8.The nurse is caring for a postoperative patient on his first day after surgery. The nurse informs the patient that the plan is to sit in the chair and ambulate in the hallway. The patient states that he is in pain and has no intention of getting out of bed. What is the nurse’s best response?a.“It’s important to move around so you don’t get a blood clot in your leg.” b.“Your doctor ordered that you are to get out of bed at least twice every day.” c.“I understand. You can rest in bed until tomorrow when the pain is better.” d.“I will call the doctor and let him know that you do not want to get up.”
ANS:A
The nurse should teach the patient why it is important to ambulate after surgery. Early ambulation helps to prevent many complications postoperatively, including constipation, deep vein thrombosis, atelectasis, pneumonia, and urinary stasis. Many patients who experience abdominal distention and gas pain obtain some relief from ambulating. Simply telling the patient that the physician ordered ambulation is not sufficient. Allowing the patient to stay in bed will increase the risk of DVT.DIF:UnderstandingOBJ:37.8 TOP:Teaching/Learning This study source was downloaded by 100000869267694 from CourseHero.com on 10-24-2023 08:35:56 GMT -05:00
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MSC:NCLEX Client Needs Category: Reduction of Risk Potential: Potential for Complications from Surgical ProceduresNOT:Concepts: Patient Education 9.The nurse is walking a postoperative patient in the hallway when she notices a large red stain of fresh blood on the patient’s gown over the abdominal incision. The patient states, “I felt something just ripped open.” What is the priority action of the nurse?a.Lift up the patient’s gown and assess the incision.b.Assist the patient to the floor and call for assistance.c.Return the patient to bed and irrigate the wound with sterile saline.d.Check the patient’s vital signs and pulse oximetry.
ANS:B
The large red blood stain over the incision and feeling of ripping open most likely indicates that the patient’s wound has dehisced or eviscerated. The nurse should immediately lower the patient to the floor to reduce tension on the wound. Patient modesty and privacy should be maintained, so the incision should be assessed once the patient is transported back to his room. Checking the patient’s vital signs and pulse oximetry can be performed once the patient has been lowered to the floor.DIF:Applying OBJ:37.4 TOP:Implementation MSC:NCLEX Client Needs Category: Physiological Adaptation: Medical Emergencies NOT:Concepts: Safety 10.The nurse is caring for a patient with advanced colon cancer. The patient is to have surgery to relieve a bowel obstruction that has been causing unrelenting vomiting and abdominal pain.What type of surgery will this patient undergo?a.Palliative b.Reconstructive c.Diagnostic d.Ablative
ANS:A
Palliative surgery is performed to alleviate distressing symptoms such as unrelenting pain, nausea, and vomiting. Palliative surgery will not attempt to cure the underlying disease process but will make the patient more comfortable. Reconstructive surgery restores function or appearance of traumatized tissue. A diagnostic surgical procedure establishes or confirms a diagnosis. Ablative surgery removes diseased tissue.DIF:Applying OBJ:37.2 TOP:Planning MSC:NCLEX Client Needs Category: Management of Care: Establishing Priorities NOT:Concepts: Palliation 11.After general anesthesia is administered, the patient is carefully placed in the prone position.What is the primary consideration of the nursing staff as the patient is positioned?a.Making sure that the patient’s endotracheal tube does not become kinked b.Ensuring that the patient’s head is positioned to prevent cervical nerve injury c.Carefully taping the patient’s eyes shut to avoid corneal abrasions d.Padding the operating table carefully and keeping linens free of wrinkles ANS:A This study source was downloaded by 100000869267694 from CourseHero.com on 10-24-2023 08:35:56 GMT -05:00
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