Peri-Op
Which important points would the nurse keep in mind when witnessing consent forms? Select all that apply. One, some, or all responses may be correct.
A. Confirm that the client's signature is authentic
B. Ensure that the client has given the consent voluntarily
C. Refrain from asking the student nurse to witness consent forms
D. Instruct the family member to assist if the client denies understanding of the procedure
E. Check if the client's caregiver has understood the procedures written in the consent form
A, B, C
When witnessing the consent form, the nurse would confirm that the client’s signature is authentic. The nurse would also ensure that the client has given the consent voluntarily. The nurse would never ask the student nurse to witness consent forms because it is a legal document. The nurse would inform the primary health care provider or nursing supervisor if the client denies understanding of the procedure in the consent form. It is important for the nurse to check if the client, rather than the caregiver, has understood the procedures written in the consent form.
Nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complication?
A. Pleural effusion
B. Empyema
C. Pneumothorax
D. Atelectasis
Atelectasis occurs after general anesthesia because of decreased respiratory depth and resulting collapse of alveoli. Pleural effusion is not a typical postoperative problem. Empyema would not be expected after surgery. Pneumothorax is not a common postoperative diagnosis.
When assessing verbal patients, a pain assessment may also include documentation of the patient’s description of the following elements.
Hint PQRST
P: Precipitation or provoking factors
Q: Quality
R: Radiation or region of pain
S: Severity of pain
T: Time pain occurs or onset
In which time frame would the nurse advise a client with a long leg cast for a fractured bone to take the prescribed as-needed oxycodone?
A. Just as a last resort
B. Before going to sleep
C. As the pain becomes intense
D. When the discomfort begins
D.
Pain is most effectively relieved when an analgesic is administered at the onset of pain, before it becomes intense; this prevents a pain cycle from occurring. Analgesics are less effective if administered when pain is at its peak. Before going to sleep, it may or may not be necessary; the medication should be taken when the client begins to feel uncomfortable within the parameters specified by the health care provider’s prescription. Analgesics are less effective if administered when pain is at its peak.
Medication used to reverse the effects of opioid overdose
What is narcan
Which action would the nurse take when observing that a postsurgical client has a urine output of 610 mL total in the first 24 hours after surgery?
A. Notify the provider
B. Slow the patient's intravenous infusion of normal saline.
C. Document the normal finding
D. Assess oral fluid intake
A. Notify the provider
Urine output of 720 mL or greater is normal postoperative output since it is more than 30mL/hour. The nurse would notify the provider of the abnormal finding and encourage PO fluids. Intravenous infusion would be an expected order to anticipate.
Which instruction would the nurse provide to a patient being discharged after surgery? Select all that apply. One, some, or all responses may be correct.
A. "Include extra protein, iron, and vitamin C in your diet."
B. "Wash your hands properly before changing dressings or preforming catheter care."
C. "You may resume your usual activities after completing the full course of antibiotics."
D. "Pain killers are to be taken only as prescribed, and you should notify the surgeon if there is any sudden increase in pain."
E. "You may resume your usual activities after completing the full course of antibiotics."
A, B, C, D
The patient should consume a diet rich in proteins, iron, and vitamin C after surgery. Vitamin C and proteins promote wound healing, and iron aids in red blood cell formation. Before handling the dressings and taking care of the catheter, care must be taken to wash hands properly to prevent infection. Proper dosage and frequency of pain medication should be explained to the patient. The patient should notify the surgeon if there is any sudden increase in pain or if the pain is not controlled. Antibiotic treatment timeline does not always correlate with the timeline for resuming usual activities. The time for the patient to resume regular activities should be determined by the surgeon
and not by the nurse. The amount of weight the patient can lift safely after surgery is specifically defined by the surgeon, not by the nurse.
p. 191
Identify at least 3 non-pharmacologic pain management strategies.
What is
Acupuncture
Art or music therapy
Biofeedback therapy
Chiropractic manipulation
Guided imagery
Heat or cold compress
Heat increases blood flow, relaxing muscles and easing stiffness; useful for chronic pain
Cold restricts blood flow causing reduced swelling; useful for acute pain or injury
Hypnosis
Massage
Essential oils
Which action is the nurse’s responsibility when administering prescribed opioid analgesics? Select all that apply. One, some, or all responses may be correct.
A. Count the client's respirations.
B. Document the intensity of the client's pain.
C. Withhold the medication if the client reports pruuritus.
D. Verify the number of doses in the locked cabinet before administering the prescribed dose.
E. Discard the medication in the client's toilet before leaving the room if the medication is refused.
A, B, D
Opioid analgesics can cause respiratory depression; the nurse must monitor respirations. The intensity of pain must be documented before and after administering an analgesic to evaluate its effectiveness. Because of the potential for abuse, the nurse is legally required to verify an accurate count of doses before taking a dose from the locked source and at the change of the shift. Pruritus is a common side effect of opioids that can be managed with antihistamines. It is not an allergic response, so it does not preclude administration. The nurse would not discard an opioid in a client’s room. Any waste of an opioid must be witnessed by another nurse.
After assessing a patient and identifying a need for a pain medication and giving the pain medication, this is the next priority action.
What is Reassessing the patients pain level in 30 minutes
Which statement made by the patient indicates a need for further preoperative teaching about the risk for infection at the surgical site?
A. " I should clean the skin around the surgical site."
B. "I should avoid using soap or bathing on the day of surgery."
C. "The area around the surgical site is clipped immediately before surgery."
D. " I should shower with antiseptic solution on the day of surgery."
B. "I should avoid using soap or bathing on the day of surgery."
Avoiding the use of soap when showering on the day of surgery will increase microbial contamination. The nurse recommends that the patient clean around the surgical site to prevent microorganisms at the surgical site. If necessary, hair around the surgical site will be clipped immediately before surgery with sterile supplies. The nurse recommends that the patient shower with antiseptic solution to reduce the risk for contamination of the surgical site.
p. 171
Which action will the nurse take to avoid postural hypotension when getting a postoperative client out of bed?
A. Avoid giving the prescribed PRN morphine sulfate before getting the client up
B. Have the client sit on the edge of the bed for a few minutes before standing up
C. Withhold the prescribed calcium channel blockers until the client is already up
D. Educate the client about the reasons to avoid getting up soon after surgery.
B.
Having a client sit on the edge of the bed for a few minutes will allow the neurocirculatory reflexes to adjust to the force of gravity when an upright position is assumed. Although morphine sulfate administration may lower blood pressure, the nurse would not withhold analgesia from a postoperative client, especially before activity. Calcium channel blockers may also lower blood pressure, but the nurse would not withhold a prescribed medication. Early ambulation postoperatively is recommended to avoid postoperative complications such as venous thromboembolism and deconditioning.
A condition that results when a person ingests a substance or engages in an activity that can be pleasurable but the continued use/ act of which becomes compulsive and interferes with ordinary life responsibilities.
What is addiction?
A client who had thoracic surgery reports pain at the incision site when coughing and deep breathing. Which action would the nurse take?
A. Instruct the client to splint the wound with a pillow when coughing.
B. Place the client in the supine position and inspect the site of the incision.
C. Assess the intensity of the pain and administer the prescribed analgesic.
D. Notify the health care provider immediately and then check for wound dehiscence.
A
Supporting the wound with a pillow when coughing relieves some of the pain because it provides support to the incised chest wall. Pain at the incision site when coughing and deep breathing is expected; it does not indicate a need to place the client in the supine position and to inspect the wound site. Analgesics will not relieve the discomfort associated with coughing unless stress placed on the incision by coughing is relieved. Pain at the incision site just when coughing and deep breathing is expected; it does not indicate a need to call the health care provider and then check for wound dehiscence.
The primary nurse, leaving the unit for lunch, provides a verbal report for the covering nurse. The report included one client’s prescription for morphine: 2 mg intravenously (IV) every 3 hours for abdominal pain secondary to major abdominal surgery that morning. During the primary nurse’s lunch, the client complains of pain at a level 8 out of 10 on the pain scale. Which action would the covering nurse perform first?
A. Determine the documented time of the last administration of pain medication.
B. Verify that the written prescription matches the administration record.
C. Encourage non pharmacological measures initially to relieve the pain.
D. Explain that the primary nurse will be back from lunch in a few minutes.
B. Verify that the written prescription matches the administration record.
Before administering any medication for the first time, the nurse must verify the accuracy of the prescription. The prescription as it appears in the medication administration record is verified against the prescription written by the health care provider in the client’s medical record. This ensures that the prescription was transcribed accurately. Checking when the pain medication was last given is done after the prescription is verified. Nonpharmacological measures are used for mild to moderate pain, not pain at a level 8 on a 0 to 10 scale that is associated with recent major abdominal surgery. The client’s pain must be addressed immediately. The covering nurse should verify and give the pain medication as prescribed.
Which site would the nurse assess first for the amount of drainage from a client discharged from the post anesthesia care unit (PACU)?
Foley catheter
Nasogastric tube
Intravenous (IV) catheter
Surgical incisions
D. Surgical incision
Reviewing the amount of drainage on the dressing of a client is an observation the nurse would make when reviewing the surgical incision site. Focused assessment of the Foley catheter and the nasogastric tube should be made when observing tubes attached to a client after an operation. When a client is receiving IV fluids, the nurse would check the catheter insertion site.
DAILY DOUBLE *** WORTH DOUBLE POINTS***
The nurse is teaching a patient and the family about the use of a patient-controlled analgesia device post surgery. The patient is concerned about possibly overdosing on the morphine the device delivers. Which statement by the nurse would be best to allay the patient’s fears?
A. "The pump will keep a record of how many times you use the medication."
B. "The dose and frequency of the medication are prescribed by the primary care provider."
C. "The pump has a battery backup to keep track of how much medicine you use when walking with the device as well."
D. "The device has a lockout that won't let medication be delivered if you've already had the maximum amount of medication."
D.
Although all of these statements are correct, the answer that best allays the patient’s fears addresses the lockout interval of the device, because it addresses the patient’s concern about receiving too much medication. The pump keeping a record of how many times the patient uses the medication, the fact that the primary care provider decides the dosage and frequency, and the pump’s battery backup do not address the patient’s particular concerns.
p. 529
Which statement by the family member of a patient having surgery indicates a need for further teaching?
A. The best place for us to wait is the designated surgical waiting area.
B. The type of anesthesia used is the only factor that determines the length of the patient's stay in the post anesthesia care unit (PACU).
C. After surgery, the patient will be taken to the post anesthesia care unit (PACU) for 1 to 2 hours.
D. After the patient leaves the admission area, there is a preparation time of 30 minutes to 1 hour before actual surgery.
B.
Educating family members can help reduce anxiety and fear about a patient’s surgical procedure. The type of anesthesia used influences the length of the patient’s stay in the PACU, but so does the type of surgery, any complications, and patient response. During the procedure, the family members should wait in the designated area according to the facility’s policy and surgeon’s preference; often, this is a surgical waiting area where the health care team can quickly find them. The patient’s PACU stay is usually 1 to 2 hours. After the patient leaves the admission area, there is usually additional preparation time of 30 minutes to 1 hour before the actual surgery.
p. 175
Which assessment finding would be important for the nurse to report to the health care provider when caring for a client who is in the postanesthesia care unit after receiving general anesthesia?
Attempting to push the airway out
Unresponsive to verbal stimulation
Respirations at 16 breaths/minute and unlabored
Systolic blood pressure decrease from 130 mm Hg to 90 mm Hg
D. Systolic blood pressure decrease from 130 mm Hg to 90 mm Hg
Decreasing blood pressure postoperatively may indicate hemorrhage and requires prompt interventions such as increasing fluid infusions, transfusion, or return to the operating room. Attempting to push out the airway is an indication that the client may be able to breathe independently, a normal response after general anesthesia. Clients who have had general anesthesia are unresponsive to verbal stimulation until they start to recover from the effects of general anesthesia. A respiratory rate of 16 breaths/minute is within the normal range.
The nurse is taking care of a client who has chronic back pain. Which nursing considerations would be made when determining the client’s plan of care? Select all that apply. One, some, or all responses may be correct.
A. Ask the client about the acceptable level of pain.
B. Eliminate all activities that precipitate the pain.
C. Administer the pain medications regularly around the clock.
D. Use a different pain scale each time to promote patient education.
E. Assess the client's pain every 15 minutes
A, C,
The nurse works together with the client to determine the tolerable level of pain. Considering that the client has chronic, not acute, pain, the goal of pain management is to decrease pain to a tolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide a stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client’s pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client’s pain level because it helps ensure consistency and accuracy in the pain assessment. Only management of acute pain, such as postoperative pain, requires pain assessment at frequent intervals.