Meds-Surg Perioperative Nursing Care

1. The client scheduled for knee replacement surgery today performed all of the following actions yesterday. Which action is most important for the nurse to report to the surgeon?

A. Took 50 mg of diphenhydramine (Benadryl) at bedtime

B. Smoked one pack of cigarettes instead of two

C. Drank two 12-ounce glasses of beer

D. Took two aspirins three times

ANS: D p. 247, Safe and Effective Care Environment
Rationale: The aspirin taken yesterday will significantly reduce blood clotting for surgery. The surgeon may decide to delay the surgery for at least a week to ensure that adequate numbers of platelets capable of activation are present. The reduction of cigarettes smoked from two packs to one is not significant; the client is a smoker. The beer (in this volume) and the 50 mg of diphenhydramine are not critical information.

Explanation

ANS: D p. 247, Safe and Effective Care Environment
Rationale: The aspirin taken yesterday will significantly reduce blood clotting for surgery. The surgeon may decide to delay the surgery for at least a week to ensure that adequate numbers of platelets capable of activation are present. The reduction of cigarettes smoked from two packs to one is not significant; the client is a smoker. The beer (in this volume) and the 50 mg of diphenhydramine are not critical information.

2. When changing the client's abdominal dressing on the second postoperative day, the nurse observes crusting on about half of the suture line and oozing of a small amount of serosanguineous drainage. What is the nurse's best action?

A. Loosen the sutures or staples in the area where crusts have formed.

B. Clean the suture line with sterile saline and apply new dressings.

C. Gently remove the crusts and culture the material beneath.

D. Apply pressure over the incision and notify the surgeon.

ANS: B p. 295, Physiological Integrity
Rationale: Serosanguineous drainage and a small amount of crusting are normal incision findings on the second postoperative day. The suture line needs to be cleaned and a new dressing applied. The other actions are inappropriate

Explanation

ANS: B p. 295, Physiological Integrity
Rationale: Serosanguineous drainage and a small amount of crusting are normal incision findings on the second postoperative day. The suture line needs to be cleaned and a new dressing applied. The other actions are inappropriate

3. The client brought to the holding area before surgery tells the nurse he has never had surgery before and is afraid of anything "medical." Which nursing action is most likely to reduce this client's anxiety?

A. Administering the preoperative medication as soon as possible.

B. Assuring the client that his scheduled surgery is routine and that nothing will go wrong.

C. Determining whether the client wants family members to be with him in the holding area.

D. Explaining to the client that this hospital’s surgical area is the most technologically advanced in the city.

ANS: C p. 266, Psychosocial Integrity
Rationale: Most anxious clients would feel some anxiety relief by having one or more familiar people waiting with them until the time of surgery. In addition, asking the client what he or she wants allows him to have more control over the situation. Telling the client about the advanced technology can imply to him that the procedure is dangerous. Stating that the procedure is routine and that nothing will go wrong does not address the client’s fears about his surgery and his lack of familiarity with “medical” routines.

Explanation

ANS: C p. 266, Psychosocial Integrity
Rationale: Most anxious clients would feel some anxiety relief by having one or more familiar people waiting with them until the time of surgery. In addition, asking the client what he or she wants allows him to have more control over the situation. Telling the client about the advanced technology can imply to him that the procedure is dangerous. Stating that the procedure is routine and that nothing will go wrong does not address the client’s fears about his surgery and his lack of familiarity with “medical” routines.

4. For which client preadmission testing laboratory result does the nurse take immediate action?

A. International normalized ratio 0.9

B. White blood cell count 8500/mm3

C. Serum potassium level 2.8 mEq/L

D. Serum sodium level 132 mEq/L

ANS: C p. 248, Safe and Effective Care Environment
Rationale: The serum potassium level is significantly low (hypokalemia) and must be corrected before surgery. This level increases the risk for toxicity if the client is taking digoxin, slows recovery from anesthesia, and increases cardiac irritability. Although the serum sodium and INR are also low, they are not low enough to cause any problems. The white blood cell count is normal.

Explanation

ANS: C p. 248, Safe and Effective Care Environment
Rationale: The serum potassium level is significantly low (hypokalemia) and must be corrected before surgery. This level increases the risk for toxicity if the client is taking digoxin, slows recovery from anesthesia, and increases cardiac irritability. Although the serum sodium and INR are also low, they are not low enough to cause any problems. The white blood cell count is normal.

5. The circulating nurse sees that a sponge is dropped onto the floor from the instrument table after the first surgical incision is opened. What is this nurse's best action?

A. Obtain an additional sterile sponge to replace the contaminated one and place it on the instrument table.

B. Place the sponge in the circulating area to include in the final count before incision closure.

C. Pick up the sponge and throw it out so no one slips on it.

D. Hand the sponge back to the scrub nurse.

ANS: B p. 270, Safe and Effective Care Environment
Rationale: An accurate count of all sponges initially prepared on the instrument table is matched to the count of sponges present before the incision can be closed. This sponge was counted before surgery and needs to be included in the final count. It cannot be thrown away before the final count is performed. The sponge is now contaminated and cannot not given back to the scrub nurse or surgeon. A replacement sponge should not be needed. Additional sponges are added to the instrument table only if requested and must be added to the initial count.

Explanation

ANS: B p. 270, Safe and Effective Care Environment
Rationale: An accurate count of all sponges initially prepared on the instrument table is matched to the count of sponges present before the incision can be closed. This sponge was counted before surgery and needs to be included in the final count. It cannot be thrown away before the final count is performed. The sponge is now contaminated and cannot not given back to the scrub nurse or surgeon. A replacement sponge should not be needed. Additional sponges are added to the instrument table only if requested and must be added to the initial count.

6. The client who had neck surgery to remove the entire thyroid gland is transferred to the medical-surgical unit after 4 hours in the PACU. The client reports difficulty swallowing. What is the nurse's priority action?

A. Assess the client’s respiratory status.

B. Inspect the client’s throat with a penlight.

C. Adjust the position of the drain in the incision.

D. Reassure the client that this is a normal and common problem after anesthesia.

ANS: A p. 292, Safe and Effective Care Environment
Rationale: Most clients have a sore throat for the first 12 to 24 hours after intubation during surgery, and this is made worse when the client tries to swallow. However, it is important for the nurse to differentiate soreness from true difficulty swallowing. Surgery in the neck area can cause swelling that reduces the lumen of the throat. This can cause respiratory impairment and swallowing difficulties. The most important action is to assess the airway and respiratory response to ensure that breathing impairment is not accompanying a swallowing problem.

Explanation

ANS: A p. 292, Safe and Effective Care Environment
Rationale: Most clients have a sore throat for the first 12 to 24 hours after intubation during surgery, and this is made worse when the client tries to swallow. However, it is important for the nurse to differentiate soreness from true difficulty swallowing. Surgery in the neck area can cause swelling that reduces the lumen of the throat. This can cause respiratory impairment and swallowing difficulties. The most important action is to assess the airway and respiratory response to ensure that breathing impairment is not accompanying a swallowing problem.

7. The client scheduled to have surgery today cannot read or write. The surgeon obtaining the consent wants to have the client's spouse sign the consent instead. What is the nurse's best action?

A. Nothing; a signed informed consent statement does not need to be obtained from this client.

B. Locate the spouse because the informed consent statement must be signed by the client’s closest relative.

C. Remind the surgeon that the client may sign the informed consent statement with an X in front of two witnesses.

D. Notify the administration because the court must appoint a legal guardian to represent the client’s best interests and give consent for all surgical procedures.

ANS: C p. 252, Safe and Effective Care Environment
Rationale: The lack of ability to read or write does not constitute incapacity to give legal consent. If the client meets all other legal and clinical aspects of competence for self-determination, he or she has the right to consent directly by using either his or her own signature or an X to demonstrate consent if the act is witnessed by two people.

Explanation

ANS: C p. 252, Safe and Effective Care Environment
Rationale: The lack of ability to read or write does not constitute incapacity to give legal consent. If the client meets all other legal and clinical aspects of competence for self-determination, he or she has the right to consent directly by using either his or her own signature or an X to demonstrate consent if the act is witnessed by two people.

8. The postanesthesia recovery unit nurse is receiving a hand-off report from the nurse anesthetist and the circulating nurse for an 82-year-old client who had a 2-hour open reduction of a fractured elbow. For which reported information about the client or surgery does the receiving nurse ask the reporting team for more details?

A. The client is Jewish.

B. The estimated blood loss is 150 mL.

C. The client reported an allergy to codeine.

D. The total intraoperative urine output is 25 mL.

ANS: D p. 285, Safe and Effective Care Environment
Rationale: The total intraoperative urine output is very low. Information regarding the client’s total intake, kidney function, and fluid status is needed.

Explanation

ANS: D p. 285, Safe and Effective Care Environment
Rationale: The total intraoperative urine output is very low. Information regarding the client’s total intake, kidney function, and fluid status is needed.

9. The client is NPO for surgery scheduled to occur in 4 hours. It is now 9 am, and the client's regularly prescribed oral drugs (digoxin 0.125 mg, docusate [Colace] 300 mg, and ferrous fumarate [Feostat] 325 mg) are due to be administered. The physician will not be available until the time of surgery. What is the nurse's best action?

A. Administer digoxin with minimal water and hold the other drugs.

B. Administer all medications parenterally.

C. Administer all medications orally.

D. Hold all medications.

ANS: A p. 254, Safe and Effective Care Environment
Rationale: Regularly scheduled cardiac medications should be administered on schedule. If taken with only a few small sips of water at least 2 hours before surgery, the amount of water should not increase the risk of intraoperative or postoperative aspiration. However, not administering this drug could result in cardiac complications during surgery.

Explanation

ANS: A p. 254, Safe and Effective Care Environment
Rationale: Regularly scheduled cardiac medications should be administered on schedule. If taken with only a few small sips of water at least 2 hours before surgery, the amount of water should not increase the risk of intraoperative or postoperative aspiration. However, not administering this drug could result in cardiac complications during surgery.

10. On admission to the preoperative area, the client scheduled for a hip replacement tells the nurse that three autologous blood donations for this surgery have been made in the past 3 weeks. What is the nurse's best action?

A. Check the client’s international normalized ratio (INR).

B. Call the laboratory to ensure that the blood is physically at the operating facility.

C. Ensure that the client has given consent to receive blood if a transfusion is necessary.

D. Inform the client that an autologous transfusion does not eliminate the risk for development of bloodborne diseases.

ANS: B p. 246, Physiological Integrity
Rationale: Many hospitals or surgical centers do not initially process autologous blood collections. Any donated blood must be in the facility where the surgery will take place before the client undergoes the planned surgical procedure. p. 246, Physiological Integrity

Explanation

ANS: B p. 246, Physiological Integrity
Rationale: Many hospitals or surgical centers do not initially process autologous blood collections. Any donated blood must be in the facility where the surgery will take place before the client undergoes the planned surgical procedure. p. 246, Physiological Integrity

11. A postoperative client's arterial blood gas (ABG) values are pH 7.36, HCO₃ 21 mEq/L, Paco₂ 35 mm Hg, Pao₂ 98 mm Hg. What is the nurse's priority action?

A. Compare these values with the client’s preoperative ABG values.

B. Assess the airway and notify the physician.

C. Document the values as the only action.

D. Increase the oxygen flow rate.

ANS: C
p. 289, Physiological IntegrityRationale: All of these ABG results are within the normal range and indicate adequacy of ventilation, gas exchange, and kidney function. Documentation is the only action that needs to be taken.

Explanation

ANS: C
p. 289, Physiological IntegrityRationale: All of these ABG results are within the normal range and indicate adequacy of ventilation, gas exchange, and kidney function. Documentation is the only action that needs to be taken.

12. The client undergoing induction of anesthesia with succinylcholine, a depolarizing blocker agent, begins to experience generalized muscle twitching. What the circulating nurse's best response?

A. Call the anesthesia provider’s attention to this response.

B. Ensure the client is secured to the table.

C. Cover the client with a warm blanket.

D. Document this expected response.

ANS: D p. 275, Physiological Integrity
Rationale: Depolarizing blocker agents depolarize the motor end plates of nerves innervating skeletal muscles, causing a brief period of fasciculations or muscle twitching. This response is considered normal.

Explanation

ANS: D p. 275, Physiological Integrity
Rationale: Depolarizing blocker agents depolarize the motor end plates of nerves innervating skeletal muscles, causing a brief period of fasciculations or muscle twitching. This response is considered normal.

Meds-surg Perioperative Nursing care