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Here is Perioperative
SORRY IT WOULDNT LET ME POST AN ATTACHMENT SO HERE IT IS COPIED AND PASTED
Preoperative Screening
The nurse begins the preoperative assessment by taking Ms. Jackson's vital signs.
1.
Which vital sign requires follow-up by the nurse?
A) BP of 160/88.
CORRECT
This blood pressure is elevated and requires further action by the nurse.
B) Pulse of 68.
INCORRECT
This pulse rate is within normal limits for an adult client. No further action is needed.
C) Respirations of 14.
INCORRECT
This respiratory rate is within normal limits for an adult client. No further action is needed.
D) Temperature of 97.2° F.
INCORRECT
This temperature is within normal limits for an adult client.
Points Earned: 0.0/1.0
Correct Answer(s): A
The nurse reviews the medications taken by Ms. Jackson. Ms. Jackson states she has been taking two medications, hydrochlorothiazide (Hydrodiuril), a diuretic, and warfarin (Coumadin), an anticoagulant, every day for over a year.
2.
What nursing action is most important?
A) Observe the appearance of the client's oral mucosa.
INCORRECT
The nurse may observe the mucosa for signs of fluid volume deficit since the client is taking a diuretic, but since the client is receiving an established daily dose, this is not the most important preoperative intervention.
B) Assess the client for any signs of excessive bruising.
INCORRECT
The nurse may observe for signs of bruising since the client is taking an anticoagulant, but since the client is receiving an established daily dose, this is not the most important intervention preoperatively.
C) Review common side effects of each of the medications.
INCORRECT
Review of medication side effects is always a valuable intervention, but since the client has been receiving an established daily dose for over a year, this is not the most important intervention preoperatively.
D) Explain the need to hold the warfarin prior to surgery.
CORRECT
Anticoagulants increase the risk for bleeding during surgery and the postoperative period, so the nurse must explain the need to hold the warfarin prior to surgery and instruct the client to contact the surgeon to determine how long before surgery the medication should be stopped.
Points Earned: 1.0/1.0
Correct Answer(s): D
The nurse then reviews Ms. Jackson's preoperative lab test results, drawn earlier in the week.
3.
Which serum lab value requires follow-up by the nurse?
A) Sodium of 135 mEq/L.
INCORRECT
This value is within normal limits for an adult client, and requires no further follow-up action by the nurse.
B) WBC of 14,000/mm3.
CORRECT
The normal WBC count is 5,000 to 10,000/mm3. An increase may indicate the onset of an infection, which may be a contraindication to surgery. The nurse should notify the surgeon of this abnormal lab value.
C) Creatinine of 0.8 mg/dl.
INCORRECT
This value is within normal limits for an adult client, and requires no further follow-up action by the nurse.
D) Hemoglobin of 14 g/dl.
INCORRECT
This value is within normal limits for an adult client, and requires no further follow-up action by the nurse.
The nurse notifies the surgeon of Ms. Jackson's vital signs and lab values. The surgeon plans to evaluate Ms. Jackson later that day and will review the data at that time.
Points Earned: 1.0/1.0
Correct Answer(s): B
Preoperative Teaching
The nurse talks with Ms. Jackson about what to expect the day of surgery and during the immediate postoperative period. The nurse provides instructions regarding cough and deep breathing exercises. Ms. Jackson performs a return demonstration by breathing in through her mouth deeply and exhaling through pursed lips forcefully and rapidly.
4.
What action should the nurse implement?
A) Advise the client to avoid pursing her lips when exhaling.
INCORRECT
Another action promotes more effective use of the coughing and deep breathing technique.
B) Remind the client to cough after taking two to three breaths.
INCORRECT
Another action promotes more effective use of the coughing and deep breathing technique.
C) Demonstrate the deep breathing and coughing technique again.
CORRECT
Ms. Jackson has demonstrated incorrect technique. When performing deep breathing exercises, the client should inhale through the nose and exhale slowly through the mouth without pursing the lips. The nurse should demonstrate the entire procedure again for best learning by the client.
D) Document successful completion of the return demonstration.
INCORRECT
Ms. Jackson has not demonstrated the procedure correctly.
Points Earned: 1.0/1.0
Correct Answer(s): C
When the nurse begins teaching about the benefits of early mobilization following surgery, Ms. Jackson states, "Oh, I know if I stay in bed very long I will get bedsores."
5.
How should the nurse respond?
A) "Getting a bedsore is very serious. Sometimes people die from infected bedsores."
INCORRECT
This response may frighten the client.
B) "The nurses will make sure you do not stay in bed long enough to get bedsores."
INCORRECT
This response provides false reassurance and does not emphasize the client's responsibility in mobilization.
C) "Bedsores are one of many problems that can occur from prolonged bedrest."
CORRECT
This response acknowledges the client's previous learning and promotes further learning related to other complications of immobility such as thrombus formation, constipation, and atelectasis.
D) "Those are now called pressure ulcers because they are caused by pressure."
INCORRECT
This response is less helpful in teaching the client than another response.
Points Earned: 1.0/1.0
Correct Answer(s): C
The nurse discusses postoperative pain management with Ms. Jackson and explains the use of a patient-controlled analgesia (PCA) pump. Ms. Jackson expresses fear that she might accidentally overdose herself, since she will be sleepy after surgery.
6.
How should the nurse respond?
A) "You will only use the PCA pump for the first 24 hours after surgery."
INCORRECT
While this is probably true, it is not the correct explanation regarding the risk for overdose.
B) "The surgeon will prescribe the dose of medication that is correct for you."
INCORRECT
While this is true, it is not the correct explanation regarding the risk for overdose.
C) "I will tell the surgeon that you prefer that the nurses administer your pain medicine."
INCORRECT
The client needs additional information before making a decision regarding the use of the PCA pump.
D) "The pump has a control device that prevents you from taking too much medicine."
CORRECT
This response provides the client with the information needed to understand that she cannot overdose herself while she is sedated after surgery.
Points Earned: 1.0/1.0
Correct Answer(s): D
Therapeutic Communication
While discussing postoperative pain management strategies with Ms. Jackson, the nurse observes that Ms. Jackson begins to cry.
7.
What action should the nurse take?
A) Quietly sit with the client.
CORRECT
Offering one's presence is a caring and therapeutic response.
B) Offer reassurance about the surgery.
INCORRECT
Since the nurse does not know why the client is crying, this is not the best response.
C) Calmly continue the preoperative instructions.
INCORRECT
This is not the most therapeutic response to the client's tears.
D) Leave the room until the client has composed herself.
INCORRECT
Unless the client requests to be left alone, this is not the most therapeutic response to the client's tears.
Points Earned: 1.0/1.0
Correct Answer(s): A
After Ms. Jackson stops crying, she states, "My father was in so much pain before he died. Talking about pain brings back so many memories."
8.
How should the nurse respond?
A) "We do not need to talk about pain control today if it makes you sad."
INCORRECT
Postoperative pain management needs to be addressed during preoperative teaching.
B) "Perhaps you need to see a counselor to help you resolve your grief."
INCORRECT
The client's expression of sadness does not indicate the need for counseling.
C) "It sounds as if you went through a difficult time when your father died."
CORRECT
This open-ended acknowledgment of the client's distress is therapeutic and allows the opportunity for further discussion by the client if desired.
D) "You need to focus on your own needs now and not on past memories."
INCORRECT
Offering advice and attempting to change the subject are not therapeutic responses.
Points Earned: 1.0/1.0
Correct Answer(s): C
Ms. Jackson shares her experiences related to her father's death with the nurse and expresses appreciation for the nurse's caring attitude. Ms. Jackson leaves after the preoperative teaching is completed, with plans to meet with the surgeon that afternoon and return to the surgery center the morning of surgery.
Surgical Preparation
The next week, Ms. Jackson arrives at the surgery center 3 hours before her scheduled surgery.
9.
Which question is most important for the nurse to ask Ms. Jackson during the admission interview?
A) "Have you had anything to eat or drink since midnight?"
CORRECT
Ensuring that the client has remained NPO for the prescribed length of time before surgery is critical to prevent vomiting and aspiration during surgery.
B) "Are any of your family members or friends here with you?"
INCORRECT
Determining if persons are waiting for the client is important but of less priority than another action.
C) "Do you understand you will be admitted to the hospital following surgery?"
INCORRECT
This is an important question but is of less priority than another question.
D) "Did you bring any valuables with you that need to be stored during surgery?"
INCORRECT
This is an important question but is of less priority than another question.
Points Earned: 1.0/1.0
Correct Answer(s): A
After completing the admission interview, the nurse reviews Ms. Jackson's medical record and notes that the surgical consent form is filled out but is not signed by the client.
10.
What action should the nurse take?
A) Ask Ms. Jackson if she has received sufficient information to sign the consent form.
CORRECT
The nurse may witness the client's signature if the nurse is able to determine that the client has been sufficiently informed of the necessary information.
B) Call the operating room and notify the staff that the surgery needs to be cancelled.
INCORRECT
Other actions should be taken before canceling the surgery.
C) Notify the surgeon of the need to come to the client's room so the consent can be signed.
INCORRECT
Another action should be taken before contacting the surgeon.
D) Inform a family member of the need to serve as a witness to the client's signature.
INCORRECT
A family member should not serve as the witness to the client's signature.
Points Earned: 1.0/1.0
Correct Answer(s): A
The nurse observes that the word, "Yes" has been marked on Ms. Jackson's left hip, and the word, "No" has been written on her right hip.
11.
What action should the nurse implement?
A) Use an antimicrobial agent to cleanse the operative site.
INCORRECT
The markings should not be removed at this time. Any needed operative site skin preparation is typically performed in the operative suite.
B) Take a photograph of the markings to place in the chart.
INCORRECT
This action is not necessary.
C) Confirm that the left hip is the site of the scheduled surgery.
CORRECT
The nurse should ensure that the markings on the hips are correct, to help reduce the potential for error during surgery. When the surgical site involves a distinction between left and right sides of the body, marking the site is a required component of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) universal protocol to prevent wrong site, wrong procedure, wrong person surgery.
D) Reassure the client that the surgeon will not make a mistake.
INCORRECT
Another action is more effective in promoting client safety. Additionally, this action may be false reassurance.
Ms. Jackson is prepared for surgery, and states she feels calm and states, "I am ready to get it over with."
Points Earned: 1.0/1.0
Correct Answer(s): C
Intraoperative Care
Ms. Jackson is transferred to a stretcher and taken to the operating room (OR). The nurse assists Ms. Jackson off the stretcher and onto the OR table. After general anesthesia is induced, the nurse positions Ms. Jackson for surgery.
12.
Which nursing diagnosis has the highest priority at this time?
A) Ineffective protection.
INCORRECT
This diagnosis relates to the body's inability to protect itself during surgery due to the effects of medications and anesthesia.
B) Ineffective tissue perfusion.
INCORRECT
This diagnosis is related to insufficient blood supply to the tissues, which may occur during surgery if, for example, a tourniquet is left in place too long.
C) Risk for perioperative-positioning injury.
CORRECT
During surgery the client may remain in one position for a prolonged period of time. The nurse must ensure that the client is protected from injury secondary to inappropriate positioning.
D) Risk for imbalanced body temperature.
INCORRECT
This diagnosis is related to the effects of anesthesia.
Points Earned: 0.0/1.0
Correct Answer(s): C
Once the OR team has assembled in the room, the circulating nurse calls for a time out.
13.
What action should the nurse take during the time out?
A) Ensure that sufficient surgical supplies are available.
INCORRECT
This is not the purpose of the time out period.
B) Check that all surgical personnel are properly attired.
INCORRECT
This is not the purpose of the time out period.
C) Review the scheduled procedure, site, and client.
CORRECT
A time out, the designated method for final verification before surgery begins, is a component of the JCAHO universal protocol to prevent wrong site, wrong procedure, wrong person surgery.
D) Confirm that informed consent has been obtained.
INCORRECT
This is not the purpose of the time out period.
The surgery is successfully completed without complications.
Points Earned: 1.0/1.0
Correct Answer(s): C
Immediate Postoperative Care
Following surgery, Ms. Jackson is admitted to the Post Anesthesia Care Unit. The operative report indicates that Ms. Jackson had a left hip replacement under general anesthesia. The initial nursing assessment reveals that Ms. Jackson is not responding to verbal stimuli. Her vital signs are T 97.6° F, P 88, R 14, and BP 130/70.
14.
What action should the nurse implement first?
A) Position the client on her side.
CORRECT
During the immediate postanesthesia period, the unconscious client should be positioned on the side to maintain an open airway and promote drainage of secretions.
B) Observe the surgical dressing.
INCORRECT
Another action should be taken first.
C) Place the call bell within reach.
INCORRECT
Another action should be taken first.
D) Remove the oral airway.
INCORRECT
Other actions should be implemented before the oral airway is removed.
Points Earned: 1.0/1.0
Correct Answer(s): A
While assessing Ms. Jackson, the nurse observes that the surgical dressing is in place on the left hip, with no visible drainage.
15.
How should the nurse document this finding?
A) No problems with dressing on left hip.
INCORRECT
This documentation does not provide a clear picture of the assessed data.
B) Left hip dressing clean, dry, and intact.
CORRECT
This documentation is concise but thorough, providing a clear picture of the assessed data.
C) Dressing present over left hip incision.
INCORRECT
This documentation does not include sufficient data.
D) Incision well-approximated with no drainage.
INCORRECT
This documentation is inaccurate, since the nurse did not observe the incision.
Ms. Jackson is discharged from the PACU to the acute care unit two hours later. She is responding to verbal stimuli and has stable vital signs.
Points Earned: 1.0/1.0
Correct Answer(s): B
Pharmacologic Calculations
When Ms. Jackson arrives on the unit, the nurse notes that her IV is wide open. Review of Ms. Jackson's postoperative prescriptions indicates that 0.9% Normal Saline is to infuse at 75 ml/hour, alternating with Lactated Ringer's solution at 75 ml/hour. An infusion pump is not immediately available, so the nurse notes that the infusion tubing has a drop factor of 10 drops/ml and resets the IV.
16.
At what rate should the IV infuse?
A) 8 drops per minute.
INCORRECT
Recalculate!
B) 10 drops per minute.
INCORRECT
Recalculate!
C) 13 drops per minute.
CORRECT
75 ml/60 minutes × 10 gtts/1 ml = 12.5, which rounds up to 13 drops per minute.
D) 21 drops per minute.
INCORRECT
Recalculate!
Points Earned: 1.0/1.0
Correct Answer(s): C
While the nurse begins to assess the client, another nurse finds an infusion pump and prepares a prescribed "now" dose of an intravenous antibiotic. The prescription is for 2 grams of cefazolin (Ancef), which arrives from the pharmacy diluted in 100 ml of normal saline and is to be administered over 30 minutes.
17.
At what rate should the infusion pump be set?
A) 20 ml/hour.
INCORRECT
Recalculate!
B) 50 ml/hour.
INCORRECT
Recalculate!
C) 100 ml/hour.
INCORRECT
Recalculate!
D) 200 ml/hour.
CORRECT
100 ml/30 minutes = X ml/60 minutes. 30X = 100 × 60 = 200 ml/hour.
Points Earned: 1.0/1.0
Correct Answer(s): D
Postoperative Assessment
The nurse continues the postoperative assessment.
18.
To assess for atelectasis, what action should the nurse take?
A) Auscultate the client's breath sounds.
CORRECT
Atelectasis is a condition in which the alveoli collapse. Dull or absent breath sounds, along with changes in breathing patterns, are expected findings when atelectasis occurs.
B) Observe the appearance of the sputum.
INCORRECT
Clients with atelectasis do not typically exhibit changes in the sputum, and may not have a productive cough. Changes in the color, consistency, or amount of sputum are common in clients with pneumonia.
C) Determine the client's temperature.
INCORRECT
A change in temperature is not a typical finding when atelectasis occurs.
D) Measure the client's blood pressure.
INCORRECT
A change in blood pressure is not a typical finding when atelectasis occurs.
Points Earned: 1.0/1.0
Correct Answer(s): A
The nurse determines that Ms. Jackson's bowel sounds are hypoactive.
19.
What action should the nurse implement in response to this finding?
A) Document the assessment finding in the chart.
CORRECT
Hypoactive bowel sounds are an expected finding following general anesthesia, so the nurse should document this finding in the chart and continue to monitor the client.
B) Notify the surgeon of the assessment finding.
INCORRECT
It is not necessary to notify the surgeon of this finding.
C) Review the client's serum electrolyte values.
INCORRECT
This action is not needed in response to the assessment finding.
D) Administer a laxative prescribed for PRN use.
INCORRECT
The administration of a laxative is not warranted at this time.
Points Earned: 0.0/1.0
Correct Answer(s): A
Postoperative Wound Management
During the postoperative assessment, the nurse observes Ms. Jackson's surgical site. The left hip dressing has a moderate amount of sanguineous drainage.
20.
What action should the nurse implement?
A) Apply pressure to the site.
INCORRECT
Pressure does not need to be applied to a surgical wound with a moderate amount of drainage.
B) Elevate the leg on a pillow.
INCORRECT
Elevating the leg will not reduce drainage at the hip and may be contraindicated due to the type of surgery.
C) Observe the linens under the hip.
CORRECT
Gravity pulls drainage down, so the nurse should inspect the area below the surgical site for additional drainage. The nurse may also mark the amount of drainage on the dressing for later comparison.
D) Use sterile technique to replace the dressing.
INCORRECT
The initial postoperative dressing is typically left in place to reduce the risk of infection in the immediate postoperative period.
Points Earned: 0.0/1.0
Correct Answer(s): C
The nurse observes that the Hemovac drain is full of sanguineous drainage.
21.
What action should the nurse implement first?
A) Compress the drain and re-establish suction.
INCORRECT
This action should be performed after another action is taken.
B) Empty the drain and measure the amount.
CORRECT
The nurse should first empty the drain and measure the drainage, then compress the drain to re-establish suction. Documentation of the findings and notification of the surgeon can then be done.
C) Page the surgeon to report the finding.
INCORRECT
Another action should be taken before notifying the surgeon.
D) Document the appearance of the drainage.
INCORRECT
Another action should be taken before this documentation is done.
Points Earned: 0.0/1.0
Correct Answer(s): B
Blood Transfusion
The nurse notifies the surgeon of the wound drainage.
22.
What lab data is important for the nurse to report to the surgeon?
A) White blood cell count.
INCORRECT
The WBC provides information related to infection and inflammation and is not the data the surgeon needs at this time.
B) Hemoglobin and hematocrit.
CORRECT
The nurse is reporting the amount of surgical drainage to the surgeon due to a concern for excessive blood loss. The surgeon needs to know information related to blood volume, provided by the hemoglobin and hematocrit levels.
C) Culture and sensitivity.
INCORRECT
The culture and sensitivity provides information about infecting organisms and is not the data the surgeon needs at this time.
D) Type and cross match.
INCORRECT
A type and cross match is used by the blood bank to ensure that a blood transfusion is correctly matched to a client.
Points Earned: 1.0/1.0
Correct Answer(s): B
Based on the lab data provided by the nurse, the healthcare provider prescribes the transfusion of two units of packed red blood cells as soon as possible. Once the first unit of packed red blood cells is ready, the nurse obtains the blood from the blood bank. When the nurse enters Ms. Jackson's room to begin the transfusion, the UAP is giving Ms. Jackson a partial bath.
23.
What action should the nurse take?
A) Place the unit of blood in the medication refrigerator until the client's personal care is completed.
INCORRECT
The temperature of the medication refrigerator is not sufficiently controlled to be safe for blood storage.
B) Hang the transfusion of packed cells while the UAP continues to complete the client's personal care.
CORRECT
Transfusion of the blood is a higher priority than personal care. If necessary, the remainder of the care can be delayed.
C) Lock the unit of blood in the computerized medication cart and assist the UAP in completing the personal care.
INCORRECT
Blood cannot be stored at room temperature.
D) Return the blood to the blood bank and send the UAP to obtain the blood when the personal care is completed.
INCORRECT
This time consuming action will delay the transfusion of the blood.
Points Earned: 1.0/1.0
Correct Answer(s): B
Ms. Jackson is currently receiving Lactated Ringer's solution IV at a rate of 75 ml/hour.
24.
In transfusing the 250 ml unit of packed red blood cells, what action should the nurse implement?
A) Stop the IV solution and transfuse the packed cells at 125 ml/hour via tubing connected to a bag of saline solution.
CORRECT
Packed red blood cells are only compatible with normal saline. The blood should be connected to a bag of saline solution using special Y-tubing and administered within 1½ to 2 hours, if possible, but no longer than 4 hours (250 ml transfused at 125 ml/hour = 2 hours).
B) Infuse the Lactated Ringer's solution through the IV tubing concurrently with the blood at a combined rate of 75 ml/hour.
INCORRECT
This is an unsafe rate and method of transfusion.
C) Flush the IV tubing with a 5 ml bolus of normal saline before and after the transfusion, and transfuse the blood within 1 hour.
INCORRECT
This is an unsafe method of transfusion.
D) Replace the Lactated Ringer's solution with the unit of packed red blood cells and administer through the tubing at 75 ml/hour.
INCORRECT
This is an unsafe method of transfusion.
The two units of packed red blood cells are transfused without complication. The drainage begins to decrease and Ms. Jackson's hemoglobin and hematocrit remain stable.
Points Earned: 0.0/1.0
Correct Answer(s): A
Nursing Plan of Care
The nurse is assisting Ms. Jackson to the bedside commode on the second postoperative day. Ms. Jackson states, "I have never had to depend on anyone before. I like to take care of myself. I feel so helpless."
25.
In response to these remarks, the nurse plans care for Ms. Jackson based on the identification of which nursing diagnosis?
A) Disturbed body image.
INCORRECT
Body image refers to our understanding of our physical body.
B) Altered self-concept.
CORRECT
The client's remarks regarding feelings of helplessness relate to her sense of how she perceives herself; her self-concept.
C) Anticipatory grieving.
INCORRECT
The client is not expressing feelings of grief.
D) Impaired physical mobility.
INCORRECT
This is an appropriate diagnosis for Ms. Jackson, but it is not the best diagnosis based on the client's remarks.
Points Earned: 1.0/1.0
Correct Answer(s): B
The nurse teaches Ms. Jackson safe transfer techniques and consults with the physical therapist to begin ambulation activities as soon as possible.
26.
What is the rationale for the inclusion of these actions in Ms. Jackson's plan of care?
A) Frequent activity will distract the client from her concerns.
INCORRECT
While this may be true, it is not the best rationale for the inclusion of these interventions in the plan of care.
B) Maintaining a safe environment reduces client depression.
INCORRECT
While this may be true, it is not the best rationale for the inclusion of these interventions in the plan of care.
C) The client should depend on the therapist rather than the nurse.
INCORRECT
This is not a valid rationale for the inclusion of these interventions in the plan of care.
D) Increased mobility will promote an improved sense of control.
CORRECT
Increasing mobility should result in increased independence and an improved sense of control, which will reduce the client's feelings of helplessness.
Points Earned: 1.0/1.0
Correct Answer(s): D
Dressing Change
After Ms. Jackson ambulates with the physical therapist, the nurse prepares to change the surgical dressing. While obtaining supplies, the nurse reviews the sterile procedure to be followed.
27.
At what step in the procedure should the nurse don sterile gloves?
A) Prior to removing the dressing on the client's hip.
INCORRECT
Removing the old dressing will result in contamination of the sterile gloves.
B) Before opening the new sterile dressing package.
INCORRECT
Opening the dressing package will result in contamination of the sterile gloves.
C) Before cleansing the client's hip incision.
CORRECT
When using surgical asepsis for wound care, the sterile gloves should be donned prior to cleaning the wound and applying the new sterile dressing.
D) After cleansing the client's hip incision.
INCORRECT
This is not the best time to apply sterile gloves.
Points Earned: 1.0/1.0
Correct Answer(s): C
While cleansing the incision, the nurse observes that the staples are intact, but a 2 cm gap has opened at the bottom of the incision.
28.
How should the nurse document this finding?
A) Bottom edges of incision approximated.
INCORRECT
The upper edges are well approximated, or closed; the bottom edge is not.
B) Small area of dehiscence at bottom of incision.
CORRECT
An unintentional opening in a surgical wound prior to healing is referred to as dehiscence.
C) Evisceration of incision noted at bottom edge.
INCORRECT
Evisceration refers to the protrusion of internal tissues through an open wound.
D) Wound healing via secondary intention.
INCORRECT
This is not correct documentation.
Points Earned: 0.0/1.0
Correct Answer(s): B
Case Outcome
Ms. Jackson's surgical wound continues to heal slowly and she is discharged from the inpatient surgery center. She continues to receive physical therapy until she is once again completely independent.
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