PERIOP NSG CARE (LEWIS MS)

135-157

The nurse is conducting a preoperative interview with a patient who is scheduled for an

elective hysterectomy and the patient tells the nurse, “I am afraid that I will die in surgery like

my mother did!” Which of the following responses by the nurse is most appropriate?

“Tell me more about what happened to your mother.”

A patient arrives at the ambulatory surgery centre for a scheduled outpatient surgery. Which of

the following information is of most concern to the nurse?

The patient is planning to drive home after surgery.

The nurse is admitting a female patient for an outpatient surgery procedure. Which of the

following information is most important to report to the anaesthesiologist before surgery?

The patient’s statement that her last menstrual period was 8 weeks previously

A patient who is scheduled for surgery in a week tells the nurse doing the preoperative

assessment about an allergy to bananas, kiwifruit, and latex products. Which of the following

actions is most important for the nurse to take?

Alert the surgery centre about the latex allergy.

According to the ASA Physical Status Classification System, which of the following

assessments is consistent with a rating of ASA III?

Persistent asthma, controlled with an inhaler and corticosteroids

The nurse is completing a preoperative assessment of a patient scheduled for a colon resection

and the patient tells the nurse about using St. John’s wort to prevent depression. Which of the

following information should the nurse alert the staff in the postanaesthesia recovery area

about?

Increased postanaesthesia waking time

On the day of surgery, the nurse is admitting a patient with a history of cigarette smoking.

Which of the following actions is most important at this time?

Auscultate for adventitious breath sounds.

A patient is seen at the health care provider’s office several weeks before hip surgery for

preoperative assessment. The patient reports use of Echinacea, ginseng, glucosamine, and

chondroitin. Which of the following actions should the nurse take?

Discuss the supplement use with the patient’s health care provider.

Before the administration of preoperative medications, the nurse is preparing to witness the

patient signing the operative consent form when the patient says, “I do not really understand

what the doctor said.” Which of the following actions is best for the nurse to take?

Notify the surgeon that the informed-consent process is not complete.

Which of the following topics is most important for the nurse to discuss preoperatively with a

patient who is scheduled for a colon resection?

Deep-breathing and coughing techniques

Ten minutes after the nurse administered the ordered preoperative opioid by intravenous (IV)

injection, the patient asks to get up to go to the bathroom to urinate. Which of the following

actions is best for the nurse to implement?

Offer a urinal or bedpan and position the patient in bed to promote voiding.

The nurse is providing preoperative teaching to an older-adult patient who has poor hearing

and vision. The partner answers most questions directed to the patient. Which of the following

actions should the nurse take when implementing patient teaching?

Provide additional time for the patient to understand preoperative instructions and

carry out procedures.

The nurse is caring for a patient with diabetes who is scheduled for a mastectomy at 1:00 PM

today and it is now 8:30 AM. The patient uses insulin to control blood glucose and has been

NPO since midnight. Which of the following actions should the nurse take?

Obtain a blood glucose measurement before any insulin administration.

The clinic nurse is reviewing the complete blood cell count (CBC) results for a patient who is

scheduled for surgery in a few days. The results are white blood cell count (WBC) 10.2 X

10^9/L; hemoglobin 150 g/L; hematocrit 45%; platelets 150 X 10^9/L. Which of the following

actions should the nurse take?

Send the CBC results to the surgery facility.

The nurse is preparing a patient the morning of surgery and the patient refuses to remove a

wedding ring, saying, “I have never taken it off since the day I was married.” Which of the

following actions should the nurse implement?

Tape the wedding ring securely to the patient’s finger.

The nurse is preparing to administer atropine to a patient before surgery. Which of the

following symptoms should the nurse teach the patient to expect?

Dry mouth

The nurse is obtaining the health history for a patient who is scheduled for outpatient knee

surgery. Which of the following statements by the patient is most important for the nurse to

report to the health care provider?

“I had a heart valve replacement last year.”

The nurse is interviewing a patient who is to have outpatient surgery using a general

anaesthetic. Which of the following information is most important to communicate to the

surgeon and anaesthesiologist before surgery?

The patient’s father died after receiving general anaesthesia for abdominal surgery.

The nurse is preparing a patient for surgery. Which of the following information about

medication use is most important for the nurse to communicate to the health care provider?

The patient takes garlic capsules daily but did not take any on the surgical day.

The nurse is preparing a patient for abdominal surgery who takes a diuretic and a -blocker

pill to control blood pressure. Which of the following patient information is most important

for the nurse to communicate to the health care provider before surgery?

Serum potassium 3.3 mmol/L

The nurse is analyzing a patient’s preoperative blood studies. Which of the following blood

studies should the nurse review to assess for anemia and infection in a patient with no known

health problems? (Select all that apply.)

a. Red blood cell count

b. White blood cell count

c. Serum potassium

d. Hematocrit

e. Prothrombin (INR) time

a,b,d

The nurse is providing preoperative teaching to a patient who is scheduled for surgery in 3

days. Which of the following information should the nurse include when addressing

preoperative sensory information? (Select all that apply.)

a. Warming blankets are available as the operating room is often cold.

b. Lighting in the operating room is low that may cause the patient to have blurred

vision.

c. The operating room bed is narrow and a safety strap is used to secure the patient to

the bed.

d. Not to be alarmed by the quiet environment as there is no conversation in the

operating room.

e. Machines may be making “ticking and pinging noises” that can be heard.

a,c,e

The perioperative nurse is encouraging a family member to remain with a patient in the

preoperative holding area until the patient is taken into the operating room. Which of the

following reasons is the primary reason for this encouragement?

Help relieve the stress of surgery for the patient and family member.

Which of the following descriptions best define the role of the nurse anaesthetist as a member

of the surgical team?

Is able to administer anaesthetics.

Which of the following outcome measures is best for the operating room (OR) nurse manager

to use in determining the effectiveness of the physical environment and traffic control

measures in the operating room?

Low incidence of perioperative infection

Which of the following actions should the scrub nurse use to maintain aseptic technique

during surgery?

Change gloves after touching the thigh of a surgeon’s sterile gown.

After orienting a new staff member to the scrub nurse role, the nurse preceptor will know that

the teaching was effective if the new staff member implements which of the following

actions?

Keeps both hands above the operating table level.

The perioperative nurse is assessing a patient in the preoperative holding area. Which of the

following findings would indicate a need for special protection techniques during surgery?

A history of spinal and hip arthritis

The nurse from the general surgical unit is asked to bring the patient’s hearing aid to the

surgical suite. The nurse will take the hearing aid to which one of the following areas?

Nursing station or communication centre

The nurse is caring for a preoperative adult patient who is scheduled for a routine surgery and

is in the holding area. The patient asks the nurse, “Will the doctor put me to sleep with a mask

over my face?” Which of the following responses is most appropriate?

“A drug will be given to you through your IV line, which will cause you to go to

sleep almost immediately.”

A surgical patient received a volatile liquid as an inhalation anaesthetic during surgery. Which

of the following symptoms should the nurse monitor for in the immediate postoperative

period?

Incisional pain

The nurse is caring for a patient before surgery who has a question about the preoperative

medication. Which of the following people will the nurse communicate this information to?

Anaesthesiologist

The nurse is preparing a patient with a dislocated shoulder for a closed, manual reduction of

the dislocation with procedural sedation. Which of the following medications should the nurse

anticipate administering for this procedure?

IV midazolam

Which of the following actions should the nurse include in the plan of care immediately after

surgery for a patient who received ketamine as an anaesthetic agent?

Provide a quiet environment in the postanaesthesia care unit.

A patient’s family history reveals that the patient may be at risk for malignant hyperthermia

(MH) during anaesthesia. Which of the following information should the nurse include when

providing preoperative patient teaching?

Anaesthesia can be administered with minimal risks with the use of appropriate

precautions and medications.

A patient in surgery receives a neuro-muscular blocking agent as an adjunct to general

anaesthesia. At completion of the surgery, it is most important that the nurse monitor the

patient for which of the following adverse effects?

Weak chest-wall movement

Which of the following actions by a member of the surgical team requires rapid intervention

by the charge nurse?

Walking into the hallway outside an operating room without the hair covered

Which of the following nursing actions should the preoperative nurse perform to prepare a

patient for cranial surgery that requires hair removal?

Use a depilatory agent to remove hair from the surgical area.

The nurse is positioning a patient in the operating room for a transurethral resection of the

prostate. Which of the following patient positions should the nurse place this patient in?

Lithotomy

The nurse is preparing a patient for surgery. Which of the following actions should the nurse

include in the surgical time-out procedure? (Select all that apply.)

a. Check for placement of IV lines.

b. Have the surgeon identify the patient.

c. Confirm the hospital chart identification (ID) number.

d. Have the patient state name and date of birth.

e. Ask the patient to state the surgical procedure.

f. Verify the patient ID band number.

c,d,e,f

The nurse is completing an inventory of medications on the unit. Which of the following

anaesthesia medications should the nurse expect to observe under refrigeration? (Select all

that apply.)

a. Atracurium

b. Pancuronium

c. Rocuronium

d. Neostigmine bromide

e. Succinylcholine

a,e

The nurse is caring for a patient who is recovering from anaesthesia in the postanaesthesia

care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty

minutes after admission, the blood pressure is 112/60, with a pulse of 72 and warm, dry skin.

Which of the following actions is the most appropriate for the nurse to implement at this time?

Continue to take vital signs every 15 minutes.

The nurse is caring for a patient who is recovering from anaesthesia in the postanaesthesia

care unit (PACU), and the vital signs are blood pressure 118/72, pulse 76, respirations 12, and

SpO2 91%. The patient is sleepy but awakens easily. Which of the following actions should

the nurse take at this time?

Encourage the patient to take deep breaths.

After a new nurse has been oriented to the postanaesthesia care unit (PACU), the charge nurse

will evaluate that the orientation has been successful when the new nurse does which of the

following actions?

Turns an unconscious patient to the side when the patient arrives in the PACU.

The nurse is preparing an older-adult patient for discharge from the ambulatory surgical unit

following left eye surgery. The patient tells the nurse, “I do not know if I can take care of

myself with this patch over my eye.” Which of the following actions is the most appropriate

for the nurse to implement?

Discuss the specific concerns regarding self-care.

After removal of the nasogastric (NG) tube on the second postoperative day, the patient is

placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas

pains. Which of the following actions should the nurse take?

Assist the patient to ambulate.

The nurse is caring for a patient following gallbladder surgery, and the patient’s T-tube is

draining dark green fluid. Which of the following actions should the nurse take?

Document the colour and amount of drainage.

In intervening to promote ambulation, coughing, deep breathing, and turning by a

postoperative patient on the first postoperative day, which of the following actions by the

nurse is most helpful?

Administer ordered analgesic medications before these activities.

The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway

clearance in a postoperative patient have been successful when which of the following goals

has been met?

Patient’s breath sounds are clear to auscultation.

The nurse is caring for a patient who has begun to awaken after 30 minutes in the

postanaesthesia care unit (PACU), who is restless and shouting at the nurse. The patient’s

oxygen saturation is 99%, and recent laboratory results are all normal. Which of the following

actions by the nurse is most appropriate?

Be sure that the patient’s IV lines are secure.

The nurse is caring for an older adult in the postanaesthesia unit. Which of the following age-

related considerations may impact postoperative recovery?

Decreased ability to cough

The nurse is caring for a patient who is being transferred from the postanaesthesia care unit

(PACU) to the clinical surgical unit. Which of the following actions should the nurse

implement first on the clinical surgical unit?

Take the patient’s vital signs.

The nurse is caring for an older-adult patient who had a surgical repair of a hip fracture 2 days

previously and has restrictions on ambulation. Based on this information, which of the

following collaborative problems is priority for the patient?

Potential complication: venous thrombo-embolism

The nurse is caring for a patient who is just waking up after having a general anaesthetic and

the patient is agitated and confused. Which of the following actions should the nurse take

first?

Check the O2 saturation.

The nurse is caring for a postoperative patient who has not voided for 7 hours after return to

the postsurgical unit. Which of the following actions should the nurse take first?

Assess for bladder distension.

The nurse is caring for a patient with abdominal surgery and on the first postoperative day, the

nurse notices new bright-red drainage about 6 cm in diameter on the dressing. Which of the

following actions should the nurse implement first?

Take the patient’s vital signs.

The nurse is caring for a patient and during the second postoperative day after abdominal

surgery, the nurse obtains an oral temperature of 38.2C (100.8F). Which of the following

actions should the nurse take first?

Have the patient use the incentive spirometer.

The nurse is caring for an unconscious patient who was transferred to the postanaesthesia care

unit (PACU) 10 minutes previously and has an oxygen saturation of 88%. Which of the

following actions should the nurse take first?

Perform the jaw-thrust manoeuvre or insert an oral airway.

The nurse is caring for a patient who had abdominal surgery two days previously. Which of

the following information about the patient is most important to communicate to the health

care provider?

The right calf is swollen, warm, and painful.

The nurse is caring for a patient in the postoperative period who is on bed rest. Which of the

following actions should the nurse implement?

Implement active ROM exercise every 1–2 hours.