PERIOP NSG CARE SAUNDERS

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 pa-

rameter most carefully during the next hour?

Urinary output of 20 mL/hr

The nurse is teaching a client about coughing and

deep-breathing techniques to prevent postoperative

complications. Which statement is most appropri-

ate 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.”

The nurse is creating a plan of care for a client sched-

uled for surgery. The nurse would include which ac-

tivity in the nursing care plan for the client on the

day of surgery?

Have the client void immediately before going

into surgery.

A client with a gastric ulcer is scheduled for sur-

gery. The client cannot sign the operative consent

form because of sedation from opioid analgesics

that have been administered. The nurse would take

which most appropriate action in the care of this

client?

Obtain a telephone consent from a family mem-

ber, following agency policy.

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?

“Can you share with me what you’ve been told

about your surgery?”

The nurse is conducting preoperative teaching with

a client about the use of an incentive spirometer.

The nurse needs to include which piece of informa-

tion in discussions with the client?

The best results are achieved when sitting up or

with the head of the bed elevated 45 to 90 de-

grees.

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 ace-

tylsalicylic acid. The nurse determines that the cli-

ent needs additional teaching if the client makes

which statement?

“I need to continue to take the aspirin until the

day of surgery.”

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 sur-

gical site?

Serous drainage

The nurse is monitoring the status of a postopera-

tive client in the immediate postoperative period.

The nurse would become most concerned with

which sign that could indicate an evolving compli-

cation?

Increasing restlessness

A client who has had abdominal surgery complains

of feeling as though “something gave way” in the

incisional site. The nurse removes the dressing and

notes the presence of a loop of bowel protruding

through the incision. Which interventions would

the nurse take? Select all that apply.

1. Contact the surgeon.

2. Instruct the client to remain quiet.

3. Prepare the client for wound closure.

4. Document the findings and actions taken.

5. Place a sterile saline dressing and ice packs over

the wound.

6. Place the client in a supine position without a

pillow under the head.

1,2,3,4

A client who has undergone preadmission testing

has had blood drawn for serum laboratory stud-

ies, including a complete blood count, coagula-

tion studies, and electrolytes and creatinine levels.

Which laboratory result would be reported to the

surgeon’s office by the nurse, knowing that it could

cause surgery to be postponed?

Hemoglobin, 8.0 g/dL (80 mmol/L)

The nurse receives a telephone call from the pos-

tanesthesia care unit, stating that a client is being

transferred to the surgical unit. The nurse plans to

take which action first on arrival of the client?

Assess the patency of the airway.

The nurse is reviewing a surgeon’s prescription sheet

for a preoperative client that states that the client

must be nothing by mouth (NPO) after midnight.

The nurse needs to call the surgeon to clarify that

which medication would be given to the client and

not withheld?

Prednisone