PREOP ASSESSMENT 1
A patient scheduled for abdominal surgery tells the nurse, “I take a blood thinner every day, but I stopped it yesterday because I thought I was supposed to.” What is the nurse’s priority action?
What is clarify the medication history and immediately notify the surgical/anesthesia team?
A patient is being transported to the operating room. The nurse notices that the consent form is signed, but the patient says, “I'm still not sure what operation I'm having.” What should the nurse do?
What is stop the transfer/procedure process and notify the appropriate provider so the patient can receive clarification?
During the surgical procedure, the circulating nurse notices that a sterile instrument has fallen below the level of the sterile field. What should the nurse recognize?
What is the instrument is contaminated and must not be returned to the sterile field?
A patient arrives in the PACU after general anesthesia. The patient is drowsy but responds to verbal stimulation. What assessment has the highest priority?
What is airway and respiratory status?
A patient refuses to cough because of incisional pain. Two days later, the patient develops decreased breath sounds and difficulty taking deep breaths. What complication is the nurse concerned about?
What is atelectasis?
During the preoperative assessment, a patient reports a previous reaction to anesthesia that caused severe difficulty breathing. What should the nurse do first?
What is obtain details about the previous reaction and ensure the anesthesia team is aware?
A patient who has been fasting for surgery says, “I am extremely thirsty. I'm just going to drink some water.” What is the nurse's best response?
What is explain the reason for the prescribed fasting and reinforce that the patient should not take anything orally unless specifically instructed?
Before incision, the surgical team pauses to confirm the patient's identity, procedure, and surgical site. What is the primary purpose of this action?
What is preventing wrong-patient, wrong-procedure, and wrong-site events?
A postoperative patient has an oxygen saturation of 88%, is difficult to arouse, and has shallow respirations. What is the nurse's priority action?
What is immediately assess and support the airway and breathing and provide oxygen as indicated?
A postoperative patient develops unilateral calf swelling, warmth, and tenderness. What is the nurse's priority concern?
What is deep vein thrombosis (DVT)?
A patient scheduled for surgery has a blood glucose of 18 mmol/L. The patient says, “I feel fine, so I don't think it matters.” What is the nurse's best response?
What is recognize that significant hyperglycemia can increase perioperative complications and notify the appropriate provider?
The nurse is preparing a patient for surgery. Which finding should be reported before the patient is transferred to the operating room?
A. Patient is nervous
B. Patient has a blood pressure of 128/76 mmHg
C. Patient reports eating breakfast despite being instructed to remain NPO
D. Patient has removed their jewellery
C
A patient undergoing a lengthy surgery is positioned supine. Which nursing action is most important for preventing positioning-related injury?
What is protecting pressure points and maintaining appropriate body alignment?
A patient 4 hours after abdominal surgery reports increasing abdominal pain. The nurse notes a heart rate of 118/min, BP 92/58 mmHg, cool skin, and increasing drainage on the dressing. What complication should the nurse suspect?
What is postoperative hemorrhage?
patient suddenly develops shortness of breath, chest pain, tachycardia, and decreased oxygen saturation following surgery. What complication should the nurse suspect?
What is pulmonary embolism?
A patient awaiting surgery suddenly reports crushing chest pain, shortness of breath, and nausea. The surgical consent has already been signed. What should the nurse do?
What is stop the preoperative process and immediately assess and notify the appropriate healthcare team?
A patient says, “I'm worried that I won't know how to breathe or cough after surgery because my incision will hurt.” Which nursing intervention is most appropriate?
What is teach and practice splinting the incision while coughing and deep breathing before surgery?
During surgery, the patient's temperature begins to decrease. Which complication is the nurse particularly concerned about because hypothermia can affect coagulation and recovery?
What is perioperative hypothermia?
A patient 8 hours after surgery has not voided. The patient reports lower abdominal pressure and the nurse palpates a distended bladder. What is the most likely problem?
What is postoperative urinary retention?
A patient tells the nurse, “Something just popped when I coughed.” The nurse observes separation of the abdominal incision with internal tissue visible. What is the priority nursing action?
What is cover the area with sterile saline-moistened dressings, position the patient appropriately, and notify the surgical team immediately?
The nurse is completing the preoperative assessment of four patients. Which patient requires the most immediate follow-up?
A. Patient who is anxious about surgery
B. Patient who reports mild incisional pain from a previous procedure
C. Patient with a temperature of 38.5°C and productive cough
D. Patient who asks when they can eat after surgery
The infection/respiratory findings may significantly affect the safety of proceeding with surgery.
A patient is scheduled for bowel surgery and tells the nurse, “I don't understand why I need to get out of bed so soon after surgery.” Which explanation demonstrates the best understanding?
What is early mobilization helps reduce complications such as atelectasis, venous thromboembolism, and postoperative deconditioning?
During surgery, the patient's heart rate rapidly increases, muscle rigidity develops, and body temperature begins to rise. The nurse recognizes a potentially life-threatening reaction to anesthesia. What should happen?
What is immediately recognize suspected malignant hyperthermia and activate the emergency treatment protocol?
The nurse receives report on four postoperative patients. Which patient should be assessed first?
A. Patient with pain rated 10/10
B. Patient with severe nausea after anesthesia
C. Patient with a respiratory rate of 9/min after receiving an opioid
D. Patient with a temperature of 40.0°C
Airway and breathing take priority, and opioid-induced respiratory depression can be life-threatening.
A patient who had abdominal surgery suddenly develops severe abdominal pain, tachycardia, hypotension, pallor, and decreased urine output. Which finding provides the strongest evidence of inadequate tissue perfusion?
A. Severe abdominal pain
B. Heart rate of 124/min
C. BP 84/50 mmHg
D. Urine output of 10 mL/hr
Very low urine output is an important indicator of reduced renal perfusion and systemic hypoperfusion.