I's & O's
Which of the following is a potential postoperative concern regarding a client who has already resumed eating solid foods?
A. Failure to pass stool within 12 hours of eating solid food
B. Failure to pass stool within 48 hours of eating solid food
C. Passage of excess flatus
D. Client reports a decreased appetite
B. Failure to pass stool within 48 hours of eating solid food
The nurse is caring for a patient on the second postoperative day following an abdominal surgery for the removal of a cyst and obtains a temperature of 100.5°F. Which action should the nurse take first?
A. Have the patient use the incentive spirometer
B. Administer PRN acetaminophen
C. Ask the provider to prescribe an antibiotic
D. Assess the surgical incision for redness and swelling
A. Have the patient use the incentive spirometer
The nurse is providing discharge teaching to a 46 year old female client who had a laparoscopic cholecystectomy at an outpatient surgery center. Which statement made by the client indicates an understanding of the discharge instructions?
A. “I should wait until my pain is severe before taking pain medication”
B. “Since I did not have general anesthesia, I will be able to drive myself home.”
C. “It is expected after this surgery to have a temperature of up to 101.9°F.”
D. “I will have someone stay with me for the next 24 hours in case I feel dizzy.”
D. “I will have someone stay with me for the next 24 hours in case I feel dizzy.”
During your assessment of your client, the client reports that she has not had a bowel movement or passed gas since surgery. Your assessment findings include a distended abdomen and absent bowel sounds in all four quadrants. You notify the provider. What nursing invention(s) can you perform without a provider’s order?
A. Insert a nasogastric tube and attach it to intermittent suction
B. Administer IV fluids
C. Encourage ambulation, maintain NPO status, monitor intake and output
D. Encourage at least 3000 mL of fluids and three large meals per day
C. Encourage ambulation, maintain NPO status, monitor intake and output
Following an abdominal surgery, early ambulation is identified in a client’s plan of care. When the nurse encourages the client to ambulate, the client refuses to get out of bed and walk. What rationale can be given by the nurse to the client that best explains the need for early ambulation?
A. Early ambulation maintains muscle tone
B. Early ambulation will help the client be ready for discharge
C. Early ambulation will decrease the client’s pain
D. Early ambulation is the best way to prevent post-op complications
D. Early ambulation is the best way to prevent post-op complications
A client had surgery at an outpatient surgery center. Which of the following criteria support that this client is ready to be discharged (select all that apply)?
A. Vital signs are stable or returned to baseline
B. Minimal nausea and vomiting
C. Wants to go to the bathroom at home
D. Client has a responsible adult to drive the client home
E. Client is comfortable after a dose of IV morphine 15 minutes ago
A. Vital signs are stable or returned to baseline
B. Minimal nausea and vomiting
D. Client has a responsible adult to drive the client home
At shift change, the nurse recognizes that a postoperative client has not voided for eight hours. Which action should the nurse take first?
A. Perform a bladder scan
B. Encourage increased oral intake
C. Insert a straight catheter per the PRN order
D. Notify the provider
A. Perform a bladder scan
The nurse is working on a surgical floor, and is preparing to receive an admission from the post anesthesia care unit (PACU). What should the nurse’s initial action be when arriving to the unit?
A. Assess the client’s pain
B. Review the physician’s postoperative orders
C. Verify the rate of the IV infusion
D. Assess the client’s vital signs
D. Assess the client’s vital signs
The nurse is teaching incisional care to a client who is discharging later that day after abdominal surgery. Which of the following instruction must the nurse include as a priority?
A. Do not rub or touch the site
B. Practice proper hand hygiene
C. Clean the incision site with soap and water
D. Splint the incisional site often
B. Practice proper hand hygiene
The nurse is reviewing the data of patients who are scheduled for surgery. Which patient is at the highest risk for skin breakdown due to positioning during surgery?
A. A 22 year old with no prior medical history
B. A 30-year-old who takes sertraline daily
C. A 42-year-old with controlled hypertension
D. A 79-year-old with type II diabetes
D. 79-year-old with type II diabetes
Populations at higher risk for skin breakdown during surgical procedures include the elderly, obese, malnourished, and/or those with comorbidities such as kidney disease, diabetes, and circulatory concerns.
A patient arrives at the ambulatory surgery center for a scheduled laparoscopy procedure in outpatient surgery. Which information is of most concern to the nurse?
A. The patient is planning to drive home after surgery.
B. The patient had a sip of water 4 hours before arriving.
C. The patient’s insurance does not cover outpatient surgery.
D. The patient has not had surgery using general anesthesia before.
A After outpatient surgery, the patient should not drive home and will need assistance with transportation and home care.
The patient’s experience with surgery is assessed, but it does not have as much application to the patient’s physiologic safety. The patient’s insurance coverage is important to establish, but this is not usually the nurse’s role or a priority in nursing care. Having clear liquids a few hours before surgery does not usually increase risk for aspiration (clear liquids ok two hours prior).
Which are the roles of a preoperative nurse in the health-care facility? Select all that apply.
A. Clarify information and ensure patient understanding.
B. Witness the consent form even if the patient did not sign it in the presence of the nurse
C. Complete all pre-operative teaching based on the surgical intervention
D. Collect information and paperwork necessary for the procedure
E. Correct common misconceptions and ease concerns of the patient and family
A, C, D, E.
All are correct except signing a consent that was not witnessed by the nurse. If the patient does not understand the procedure, the surgeon should be asked to discuss it again with the patient. All pre-op teaching should be completed including what to expect post-operatively and what to do post-op to prevent complications (turn, cough, deep breathing; how to get out of bed/ambulation; DVT prevention including leg exercises and TEDs/SCDs; pain management; diet; etc.).
You are caring for a patient post transurethral resection of the prostate (TURP). The indwelling urinary catheter has not drained in the past two hours, and there has been zero output. What should you do first?
A. Replace the catheter
B. Continue to monitor the output
C. Call the provider
D. Check for any kinks in the catheter
D. Check the tubing for any kinks.
A 38-year-old female is admitted for an elective surgical procedure. Which information obtained during the preoperative assessment is most important to report to the anesthesiologist before surgery?
A. The patient's lack of knowledge about postoperative pain control measures
B. The patient's concern that she had a reaction to anesthesia after her last surgery
C. The patient’s history of a postoperative infection following a prior cholecystectomy
D. The patient's concern that she will be unable to care for her children postoperatively
B. The patient's concern that she had a reaction to anesthesia after her last surgery. This makes the patient more likely to have life-threatening complications during this surgery and needs to be further assessed. Although the other data may also be communicated with the surgeon and anesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery.
The nurse is providing pre-op teaching to an alert older man with hearing & vision deficits. His wife usually answers questions for the pt. Which action should be taken?
A. Use printed materials for instruction so pt will have more time to review material.
B. Direct the teaching toward the wife.
C. Provide additional time for the patient to understand preop instructions & carry out procedures.
D. Ask the patient's wife to wait in the hall in order to focus preop teaching w/ the pt himself.
C The nurse should allow more time when doing preoperative teaching and preparation for older patients with sensory deficits.
Because the patient has visual deficits, he will not be able to use written material for learning. The teaching should be directed toward both the patient and the wife because both will need to understand preoperative procedures and teaching.