An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment?
a. Change in behavior
b. Daily white blood cell count
c. Presence of fever and chills
d. Tolerance of
ANS: A
Older people have an age-related decrease in immune system functioning and may not show classic signs of infection such as increased white blood cell count, fever and chills, or obvious localized signs of infection. A change in behavior often signa
A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team?
a. Allergy to bee and wasp stings
b. History of lactose intolerance
c. No previous experience with surgery
ANS: D
Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client
A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care?
a. Married young adult who is the prim
ANS: C
The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The client's physical abilities may be limited by chronic illness. This client has several safety
A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?
a. Assess the client for anxiety.
b. B
ANS: A
Anxiety can interfere with learning and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxiou
A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team?
a. Creatinine: 1.2 mg/dL
b. Hemoglobin: 14.8 mg/dL
c. Potassium: 2.9 mEq/L
d. Sodium: 13
ANS: C
A potassium of 2.9 mEq/L is critically low and can affect cardiac and respiratory status. The nurse should communicate this laboratory value immediately. The creatinine is at the high end of normal, the hemoglobin is normal, and the sodium is only
An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best?
a. Answer the questions and document that teaching
ANS: B
In order to give informed consent, the client needs sufficient information. Questions about potential complications should be answered by the surgeon. The nurse should notify the surgeon to come back and answer the client's questions before the cli
A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best?
a. Call the provider to request more analgesia.
b. Demonstrate how to splint the incision.
c. Have
ANS: B
Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should kno
A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate?
a. "After you wash the surgical site, shave that area with your own razor."
b. "Be sure to wash the area
ANS: B
The entire proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap. Shaving, if absolutely necessary, should be done in the operative suite immediately before the operation begins, using sterile equipment. Th
A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met?
a. Drainage from the surgical site is 30 mL less than yesterday.
b. There is no redness,
ANS: B
The priority client problem related to a surgical drain is the potential for infection. An insertion site that is free of redness, warmth, and drainage indicates that goals for this client problem are being met. The other assessments are normal, bu
A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)?
a. Assess the client's anxiety.
b. Give the client a back rub.
c. Remind the client to turn.
d. Teach about postoperative c
ANS: B
A back rub reduces anxiety and can be delegated to the UAP. Once teaching has been done, the UAP can remind the client to turn, but this is not related to relieving anxiety. Assessing anxiety and teaching are not within the scope of practice for th
A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client?
a. Hydroxy
ANS: C
Reglan increases gastric emptying, an important issue for this client who was eating just prior to the operation. The other drugs are appropriate for any surgical client.
A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best?
a. Allow the client to walk to the bathroom.
b. Delegate assisting the client to the nurse's aide.
c. Give the client a bedpan or u
ANS: C
Although possibly uncomfortable or embarrassing for the client, the client should not be allowed out of bed after receiving sedation. The nurse should get the client a bedpan or urinal. The client may or may not need a urinary catheter.
A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was
ANS: A
Tachycardia increases the workload of the heart and requires more oxygen delivery to the myocardial tissues. This added strain is not needed on top of the physical and emotional stress of surgery. The other statements are not accurate.
The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best?
a. Audit charts to see if the Surgical Care Improvement Project (SC
ANS: A
The SCIP project contains core measures that are mandatory for all surgical clients and focuses on preventing infection, serious cardiac events, and venous thromboembolism. The managers should start by reviewing charts to see if the guidelines of t
A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best?
a. Consult the surgeon about a postoperative dietitian referral.
b. Document the findings t
ANS: A
This client has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the surgeon about prescribing a consultation with a dietitian in the postoperative period. The nurse should document the findings but needs to d
A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best?
a. Ask the client to describe current feelings.
b. Determine if the client wants a chaplain.
c. Reassure the client
ANS: A
The nurse needs to conduct further assessment of the client's anxiety. Asking open-ended questions about current feelings is an appropriate way to begin. The client may want a chaplain, but the nurse needs to do more for the client. Reassurance can
A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client?
a. Document giving the drug.
b. Raise the siderails on the bed.
c. Record the client's vital signs.
d. Teach relaxat
ANS: B
All actions are appropriate for a preoperative client. However, for client safety, the nurse should raise the siderails on the bed because hydroxyzine can make the client sleepy.
A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most app
ANS: A
The preoperative antibiotic must be given within 60 minutes of the surgical start time to ensure the proper amount is in the tissues when the incision is made. The nurse should explain the rationale to the client for this timing. The other options
A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best?
a. "All preoperative clients get this medication."
b. "I
ANS: B
Ulcer prophylaxis is common for clients undergoing long procedures or for whom high stress is likely. The nurse is not being truthful by saying all clients get this medication. If the nurse does not know the information, it is appropriate to find o
A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.)
a. Hemorrhage
b. Infection
c. Ser
ANS: B, C, E
The SCIP project includes core measures to prevent infection, serious cardiac events, and thromboembolic events such as deep vein thrombosis.
A nursing instructor is teaching students about different surgical procedures and their classifications. Which examples does the instructor include? (Select all that apply.)
a. Hemicolectomy: diagnostic
b. Liver biopsy: diagnostic
c. Mastectomy: restorati
ANS: B, E
A diagnostic procedure is used to determine cell type of cancer and to determine the cause of a problem. An example is a liver biopsy. A restorative procedure aims to improve functional ability. An example would be a total shoulder replacement o
A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.)
a. Metformin (Glucophage)
b. Omega-3 fatty acids (Sea Omega
ANS: A, C, D, E
Although the client will be on NPO status before surgery, the nurse should check with the provider about allowing the client to take medications prescribed for diabetes, hypertension, cardiac disease, seizure disorders, depression, glaucom
A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.)
a. Client with a humerus fracture
b. Morbidly obese client
ANS: B, C, D, E
All surgical clients should be assessed for VTE risk. Those considered at higher risk include those who are obese; are over 40; have cancer; have decreased mobility, immobility, or a spinal cord injury; have a history of any thrombotic eve
A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.)
a. "A malnourished client will have
ANS: A, C, D, E
Malnutrition can lead to poorer surgical outcomes for several reasons, including fragile skin that might break down, altered pharmacokinetics, poorer wound healing, and weakness or fatigue that can interfere with recovery. Malnutrition can
A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.)
a. Decreased cardiac output
b. Decreased oxygenation
c. Frequent nocturia
d. Mobility alteratio
ANS: A, B, C, D
Older adults have many age-related physiologic changes that put them at higher risk of falling and other complications after surgery. Some of these include decreased cardiac output, decreased oxygenation of tissues, nocturia, and mobility
A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.)
a. Allow the client to assume a position of comfort.
b.
ANS: A, B, D, E
There are many nonpharmacologic comfort measures the nurse can employ, such as allowing the client to remain in the position that is most comfortable, letting the family stay with the client, providing warmth or cooling measures as request
A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.)
a. Allow small sips of plain water.
b. Check that consent is on the chart.
c. Ensure the client has an armband on.
d. Have the clie
ANS: B, C, D, E
Providing for client safety is a priority function of the preoperative nurse. Checking for appropriately completed consent, verifying the client's identity, having the client assist in marking the surgical site if applicable, and allowing
The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best?
a. Call maintenance for repair.
b. Check the machine before using.
c. Get another piece of equipment.
d. Notify the charge nurse
ANS: C
The circulating nurse is responsible for client safety. If an electrical cord is frayed, the risk of fire or sparking increases. The nurse should obtain a replacement. The nurse should also tag the original equipment for repair as per agency policy
The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority?
a. Allergies noted and allergy band on
b. Con
ANS: B
All MIS procedures have the potential for becoming open procedures depending on findings and complications. The client's consent should include this possibility. The nurse should report this finding to the surgeon prior to surgery taking place. Hav
A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to "break scrub" when going to the console and sitting down. What action by the nurse is best?
a. Call a "time-out" to discuss ster
ANS: B
During a robotic operative procedure, the surgeon inserts the articulating arms into the client, then "breaks scrub" to sit at the viewing console to perform the operation. The nurse should document the time the robotic portion of the procedure beg
The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate?
a. As
ANS: C
The surgical gown is considered sterile from the chest to the level of the surgical field. By placing the hands down by the hips, the surgeon has broken sterile field. The circulating nurse informs the surgeon of this breach. Changing only the glov
A client is in stage 2 of general anesthesia. What action by the nurse is most important?
a. Keeping the room quiet and calm
b. Being prepared to suction the airway
c. Positioning the client correctly
d. Warming the client with blankets
ANS: B
During stage 2 of general anesthesia (excitement, delirium), the client can vomit and aspirate. The nurse must be ready to react to this potential occurrence by being prepared to suction the client's airway. Keeping the room quiet and calm does hel
A client is having surgery. The circulating nurse notes the client's oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best?
a. Assess the client's end-tidal carbon dioxide level.
b. Document the findings in the cli
ANS: A
Malignant hyperthermia is a rare but serious reaction to anesthesia. The triad of early signs include decreased oxygen saturation, tachycardia, and elevated end-tidal carbon dioxide (CO2) level. The nurse should quickly check the end-tidal CO2 and
A nurse is monitoring a client after moderate sedation. The nurse documents the client's Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best?
a. Assess the client's gag reflex.
b. Begin providing discharge instructions.
c. Document fi
ANS: C
An RSS score of 3 means the client is able to respond quickly, but only to commands. The client has not had enough time to fully arouse. The nurse should document the findings and continue to monitor per agency policy. If the client had an oral end
A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate?
a. Facilitate marking the site with the client and surgeon.
b. Have
ANS: A
The Joint Commission now recommends that both the client and the surgeon mark the operative site together in order to prevent wrong-site surgery. The nurse should facilitate this process.
A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important?
a. Assist with administering muscle relaxants to the client.
b. Place the client on a cardiac monitor and pulse oximeter.
c.
ANS: B
Intravenous anesthetic agents have the potential to cause respiratory and circulatory depression. The nurse should ensure the client is on a cardiac monitor and pulse oximeter. Muscle relaxants are not indicated for this client at this time. Intrav
A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client?
a. Allow the client to keep hearing aids in until anesthesia begins.
b. Pad the table as appropriate for the surgical pr
ANS: A
Many older clients have sensory loss. To help prevent disorientation, facilities often allow older clients to keep their eyeglasses on and hearing aids in until the start of anesthesia. The other actions are appropriate for all operative clients.
A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best?
a. Administer anxiolytics.
b. Give the client warm blankets.
c. Introduce the surgical staff.
d. Re
ANS: D
The nurse can provide emotional support by remaining with the client until anesthesia has been provided. An extremely anxious client may need anxiolytics, but not all clients require this for emotional support. Physical comfort and introductions ca
A client in the operating room has developed malignant hyperthermia. The client's potassium is 6.5 mEq/L. What action by the nurse takes priority?
a. Administer 10 units of regular insulin.
b. Administer nifedipine (Procardia).
c. Assess urine for myoglob
ANS: A
For hyperkalemia in a client with malignant hyperthermia, the nurse administers 10 units of regular insulin in 50 mL of 50% dextrose. This will force potassium back into the cells rapidly. Nifedipine is a calcium channel blocker used to treat hyper
A student nurse observing in the operating room notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? (Select all that apply.)
a. Dressing the surgical wound
b. Grafting new or synthetic skin
c. Reatt
ANS: A, D, E
The CRNFA can perform tasks under the direction of the surgeon such as suturing and dressing surgical wounds, cutting away tissue, suctioning the wound to improve visibility, and holding retractors. Reattaching severed nerves and performing g
The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.)
a. Ensuring the client's safety
b. Accounting for all sharps
c. Documenting all care given
d.
ANS: A, E
The circulating nurse has several functions, including maintaining client safety and privacy, monitoring traffic in and out of the operating room, assessing fluid losses, reporting findings to the surgeon and anesthesia provider, anticipating ne
The circulating nurse reviews the day's schedule and notes clients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which clients does this include? (Select all that apply.)
a. A 75-year-old client scheduled for an
ANS: A, B, C, E
People at higher risk for anesthetic overdose or other anesthesia-related complications include people with a slowed metabolism (older adults generally have slower metabolism than younger adults), those with kidney or liver impairments, an
A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.)
a. Assessing distal circulation to the operative arm after positioning
ANS: A, C
After regional anesthesia is administered, the client loses all sensation distally. The nurse ensures client safety by assessing distal circulation and padding the shoulder and arm appropriately. Although awake, the client will not be able to re
What actions by the circulating nurse are important to promote client comfort? (Select all that apply.)
a. Correct positioning
b. Introducing one's self
c. Providing warmth
d. Remaining present
e. Removing hearing aids
ANS: A, B, C, D
The circulating nurse can do many things to promote client comfort, including positioning the client correctly and comfortably, introducing herself or himself to the client, keeping the client warm, and remaining present with the client. R
Math Time: A client has developed malignant hyperthermia. The client weighs 136 pounds. What is the safe dose range for one dose of dantrolene sodium (Dantrium)? The dose of dantrolene is 2 to 3 mg/kg. (Enter your answer using whole numbers, separated by
ANS:
124-186 mg
The dose of dantrolene is 2 to 3 mg/kg. The client weighs 62 kg, so the safe dose range is 124 to 186 mg.
A client has arrived in the postoperative unit. What action by the circulating nurse takes priority?
a. Assessing fluid and blood output
b. Checking the surgical dressings
c. Ensuring the client is warm
d. Participating in hand-off report
ANS: D
Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The postoperative nurse and circulating nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can
The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first?
a. Client with a blood pressure of 100/50 mm Hg
b. Client with a pulse of 118 beats/min
c. Client with a respirat
ANS: C
The respiratory rate is the most critical vital sign for any client who has undergone general anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low and indicates respiratory depression. The nurse should
A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate?
a. Assess other indicators of oxygenation.
b. Call the Rapid Response Team.
c. Notify the anesthesia provider.
d. P
ANS: A
If a postoperative client's oxygen saturation (SaO2) drops below 95% (or the client's baseline), the nurse should notify the anesthesia provider. If the SaO2 drops by 10% or more, the nurse should call the Rapid Response Team. Since this is approxi
Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best?
a. "Let me call the surgeon to s
ANS: D
According to the Surgical Care Improvement Project (SCIP), any prophylactic measures to prevent thromboembolic events during surgery are continued for 24 hours afterward. The nurse should explain this to the client. Calling the surgeon is not warra
A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the client's bed. The client's blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best?
a. Call the Rapid Response Team.
b. Increase
ANS: C
A client who had epidural or spinal anesthesia may become hypotensive when the head of the bed is raised. If this occurs, the nurse should lower the head of the bed to its original position. The Rapid Response Team is not needed, nor is an increase
A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important?
a. Allow the client to rest.
b. Auscultate lung sounds.
c. Document the episode.
d. Encourage the client to eat dry toast.
ANS: B
Vomiting after surgery has several complications, including aspiration. The nurse should listen to the client's lung sounds. The client should be allowed to rest after an assessment. Documenting is important, but the nurse needs to be able to docum
A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority?
a. Airway
b. Bleeding
c. Breathing
d. Cardiac rhythm
ANS: A
Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of the circulation assessment, as is cardiac rhythm.
A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer?
a. Flumazenil (Romazicon) 0.2 to 1 mg
b. Flumazenil (Romazicon) 2 to 10 mg
c. Naloxo
ANS: A
Flumazenil is a benzodiazepine antagonist and would be the correct drug to use in this situation. The correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist.
A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort?
a. Assess the client's pain on a 0-to-10 scale.
b. Assist the client into a pos
ANS: B
Several nonpharmacologic comfort measures can help postoperative clients with their pain, including distraction, music, massage, guided imagery, and positioning. The nurse should help this client into a position of comfort considering the surgical
A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?
a. "Be sure you keep all your postoperative appointments."
b. "Call your su
ANS: D
All options are appropriate for the client being discharged after surgery. However, for this client who is changing a dressing and managing a drain, infection control is the priority. The nurse should instruct the client to wash hands often, includ
An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states "She needs to get back to her old self!" What response by the nurse is best?
a. "Everyone co
ANS: D
Due to age-related changes, it may take longer for an older adult to metabolize anesthetic agents and pain medications, making it appear that they are taking too long to wake up and return to their normal baseline cognitive status. The nurse should
A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?
a. Assess the client's blood press
ANS: B
Prior to assessing or treating the drainage from the wound, the nurse performs hand hygiene and dons gloves to protect both the client and nurse from infection.
A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. Wh
ANS: D
After ensuring the client's physiologic status is stable, these manifestations should lead the nurse to assess the client's psychosocial status. Anxiety especially can be demonstrated with elevations in vital signs. Cognitive and nutrition status a
A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN?
a. Cleaning around the drain per agency protocol
b. Placing a new sterile gauze un
ANS: C
The safety pin that prevents the drain from slipping back into the client's body should be pinned to the client's gown, not the bedding. Pinning it to the sheets will cause it to pull out when the client turns. The other actions are appropriate.
A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.)
a. All phases require the client to be in the hospital.
b. Phase I care may last for several days in some clients.
c. Phase I requ
ANS: B, D, E
There are three phases of postoperative care. Phase I is the most intense, with clients coming right from surgery until they are completely awake and hemodynamically stable. This may take hours or days and can occur in the intensive care unit
A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.)
a. Blood glucose: 120 mg/dL
b. Hemoglobin: 7.8 mg/dL
c. pH:
ANS: B, C, D
Fluid and electrolyte balance are assessed carefully in the postoperative client because many imbalances can occur. The low hemoglobin may be from blood loss in surgery. The higher pH level indicates alkalosis, possibly from losses through th
A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the client's plan of care to minimize the poten
ANS: A, B, C, E
Older clients may have difficulty adjusting to the stress of the hospital environment and illness or surgery. Techniques that are helpful include allowing liberal visitation, assisting the client to use successful coping techniques, and ke
A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.)
a. "Check all over-the-counter medications for acetaminoph
ANS: A, B, C, E
Percocet is a common opioid analgesic that contains acetaminophen. The client should be taught to check all over-the-counter medications for acetaminophen and to not take more than the prescribed amount of Percocet, as the maximum daily do
A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.)
a. Apply stimulation to the contralateral leg.
b. Assess the client's willingness to try m
ANS: A, B, C, D
There are many nonpharmacologic comfort measures for pain, including applying stimulation to the opposite leg, providing opportunities for meditation, elevation of the leg, applying ice, and reducing noxious stimuli in the environment. Par
A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.)
a. Administering antibiotics for 72 hours
b. Disposing of dressings properly
ANS: B, D, E
Interventions necessary to prevent surgical wound infection include proper disposal of soiled dressings, performing proper hand hygiene, and removing wet dressings as they can be a source of infection. Prophylactic antibiotics are given to cl
Math Time: A postoperative client has the following orders:
IV lactated Ringer's 125 mL/hr
NG tube to low continuous suction
Replace NG output every 4 hours with normal saline over 4 hours
Morphine sulfate 2 mg IV push every hour as needed for pain
NPO
Up
ANS:
175 mL/hr
200 mL of NG output � 4 hours = 50 mL/hr.
125 mL/hr + 50 mL/hr = 175 mL/hr.