Questions and Answers Rated A

Perioperative Nursing Care NCLEX Questions and Answers Rated A

The nurse has just reassessed the condition of a post-operative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?

• Urinary output of 20 mL/hr
• Temperature of 37.6 C (99.6 F)
• Blood pressure of 100/70 mmHg
• Serous drainage on the surgical dressing ✔✔1. Urinary output of 20 mL/hr

Urine output should be maintained at a minimum of 30 mL/hr for an adult. An output of less than 30 Ml for 2 consecutive hours should be reported to the surgeon. A temperature higher than 37.7 C (100 F) or lower than 36.1 C (97 F) and a falling systolic blood pressure, lower than 90 mm HG, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

The nurse is teaching a client about coughing and deep breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques?

• "Use of an incentive spirometer will help prevent pneumonia."
• "Close monitoring of your oxygen saturation will detect hypoxemia."
• "Administration of intravenous fluids will prevent or treat fluid imbalance."
• "Early ambulation and administration of blood thinners will prevent pulmonary embolism."

✔✔1. "Use of an incentive spirometer will help prevent pneumonia."

Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps prevent pneumonia and atelectasis.

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?

• Avoid oral hygiene and rinsing with mouthwash
• Verify that the client has not eaten for the last 24 hours
• Have the client void immediately before going into surgery
• Report immediately any slight increase in blood pressure or pulse ✔✔3. Have the client void

immediately before going into surgery

The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6-8 hours (or longer if prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?

• Obtain a court order for the surgery
• Have the charge nurse sign the informed consent immediately
• Send the client to surgery without the consent form being signed
• Obtain a telephone consent from a family member, following agency policy ✔✔4. Obtain a

telephone consent from a family member, following agency policy

Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by

• persons who hear the family member's oral consent. The 2 witnesses then sign the consent with

the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a surgeon is permitted legally to perform surgery without consent, but the data in the question do not indicate an emergency.

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

• "If it's any help, everyone is nervous before surgery."
• "I will be happy to explain the entire surgical procedure to you."
• "Can you share with me what you've been told about your surgery?"
• "Let me tell you about the care you'll receive after surgery and the amount of pain you can

anticipate." ✔✔3. "Can you share with me what you've been told about your surgery?"

Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the entire surgical procedure may increase the client's anxiety. Option 4 avoids the client's anxiety and is focused on postoperative care.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

• Inhale as rapidly as possible
• Keep a loose seal between the lips and the mouthpiece

• After maximum inspiration, hold the breath for 15 seconds and exhale
• The best results are achieved when sitting up or with the head of the bead elevated 45 to 90

degrees ✔✔4. The best results are achieved when sitting up or with the head of the bead elevated 45 to 90 degrees

For optimal lung expansion with the incentive spirometer, the client should assume the semi- Fowler's or high-Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement?

• "Aspirin can cause bleeding after surgery."
• "Aspirin can cause my ability to clot blood to be abnormal."
• "I need to continue to take the aspirin until the day of surgery."
• "I need to check with my doctor about the need to stop the aspirin before the scheduled surgery."

✔✔3. "I need to continue to take the aspirin until the day of surgery."

Antiplatelets alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter platelet aggregation and should be discontinued at least 48 hours before surgery. However, the client should always check with his or her surgeon regarding when to stop taking the aspirin when a surgical procedure is scheduled. Options 1, 2, and 4 are accurate client statements.

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

• Red, hard skin
• Serous drainage