What is the nurse’s role in the informed consent process for a surgical procedure?
witnessing the signed informed consent document
rationale:
The nurse may witness the signed informed consent document. The health care provider will explain what takes place during the procedure, and provide benefits and risks. The client grants permission for surgery to be done.
The nurse has entered the room of a client who is postoperative day 1 and finds the client grimacing and guarding her incision. The client refuses the nurse's offer of p.r.n. analgesia and, on discussion, states that this refusal is motivated by his fear of becoming addicted to pain medications. How should the nurse respond to the client's concerns?
"Research has shown that there is very little risk of clients becoming addicted to painkillers after they have surgery."
rationale:
There is little danger of addiction to pain medications used in the postoperative management of pain. This acute condition of pain will subside over time and the client needs to be educated about this. The client does not need to be told that the dependency will occur later as most clients wean themselves off pain medication as the pain subsides over time. The client does not need to be told about hospital resources as this is not appropriate at this moment. People who are addicted to drugs do become more tolerant during their recovery which means they need more medication to decrease the pain.
The nurse recognizes that palliative surgery is performed for what purpose?
to lessen the intensity of an illness
rationale:
Palliative surgery is performed to help lessen the intensity of an illness; it is not meant to be curative but will help improve the client’s quality of life. A diagnostic surgery makes or confirms a diagnosis such as with a biopsy to check for cancer. A removal of a body part that is diseased is ablative surgery, such as an appendectomy. Restoring function to traumatized tissue is reconstructive surgery, such as with plastic surgery.
A postoperative home care client has developed thrombophlebitis in the right leg. What new plan of care will need to be added because of this complication?
Anticoagulant treatment and education about the increased risk of bleeding
rationale:
An anticoagulant is a drug (blood thinner) that treats, prevents, and reduces the risk of blood clots breaking off and traveling to vital organs of the body. Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative clients. Antibiotics are used for infection. Antihistamines block the histamine systematically, as in an allergic response and the histamine released by the stomach. An antigen is a toxin or other foreign substance that induces an immune response in the body, especially the production of antibodies.
A client is concerned about taking pain medication after surgery and asks, “Are there other things I can do to alleviate my pain?” Which is the best response by the nurse?
“Positioning and massage can also help to alleviate pain.”
rationale:
Pain management is an important nursing intervention during the postoperative period. Nonpharmacologic interventions such as positioning, back massage, distraction, and emotional support help the postoperative client feel more comfortable. Clients should move as much as allowed to encourage rehabilitation and prevent complications. Pain medications are administered as needed to control postoperative discomfort. Teaching the client to recognize and report pain is an important part of pain management.
The nurse is preparing a client for a colonoscopy. The nurse is familiar with the colonoscopy procedures at the hospital and is aware that which type of anesthesia is commonly used for this procedure?
conscious sedation
rationale:
Moderate sedation/analgesia is also known as conscious sedation or procedural sedation. It is used for short-term and minimally invasive procedures such as endoscopy procedures (e.g., colonoscopy). Spinal anesthesia, also called spinal block, subarachnoid block, intradural block, and intrathecal block, is a form of regional anesthesia involving the injection of a local anesthetic into the subarachnoid space. Nerve block or regional nerve blockade is any deliberate interruption of signals by an injection traveling along a nerve, often for the purpose of pain relief. Epidural administration is a medical route of administration in which a drug such as epidural analgesia and epidural anesthesia or contrast agent is injected into the epidural space around the spinal cord with use of an epidural catheter.
Following a successful coronary artery bypass graft (CABG), a 71-year-old male client has been transferred to the postanesthesia care unit (PACU). What is the priority for the client's nursing care during this stage of his recovery?
protecting and maintaining the client's airway
rationale:
As in all nursing contexts, the client's airway is
the priority. Preventing skin breakdown, treating pain, and performing
vigilant infection control are all important aspects of care, but each
is superseded by the importance of protecting the client's airway.
(ABC's always come first for nursing diagnosis)
A nurse is preparing to receive a client in post-anesthesia care unit (PACU). The client is diabetic and has undergone knee surgery. Which information would be most important for the receiving nurse to obtain to develop an appropriate plan of care for this client?
Amount of blood loss
rationale:
To plan care effectively in the postoperative period, the nurse needs to know about the amount of blood lost during the surgery, the type of surgery that was performed on the client, and whether there were any surgical or anesthetic complications. Information on chronic disease history and allergy history are done in the preoperative period, not in the postoperative period. Information on the environment in the operation room is checked by the circulatory nurse during the intraoperative care plan; it is not associated with the postoperative care plan.
A nurse is interacting with a client in the outpatient surgical unit intraoperatively. What is the nurse’s priority responsibility?
Client safety
rationale:
Client safety is the most important nurse responsibility during the intraoperative phase. Safety concerns include equipment, electrical, chemical, radiation, surgical verification, client transport and positioning, and continuous asepsis. Postoperative protocol education is done preoperatively. Establishing a nurse–client rapport and providing emotional support are important, but they are not the most important nursing responsibility during the intraoperative phase.
After conducting a preoperative health assessment, the nurse documents that the client has physical assessments supporting the medical diagnosis of emphysema. Based on this finding, which is the priority risk of complications in the postoperative period?
Impaired gas exchange
rationale:
A nurse should complete a focused assessment on
previous medical issues, especially the respiratory system, after
surgery. Respiratory disorders, such as emphysema, increase the risk
for respiratory depression from anesthesia as well as postoperative
pneumonia and atelectasis, causing impaired gas exchange. Impaired
physical mobility, constipation and urinary retention would be of
concern but not as important as impaired gas exchange related to the
diagnosis of emphysema.
A nurse is taking care of a client during the immediate postoperative period. Which duty performed during the immediate postoperative period is most important?
Monitor the client for complications.
rationale:
The immediate postoperative period refers to the
first 24 hours after surgery. During this time, the nurse monitors for
complications as the client recovers from anesthesia. Once the client
is stable, the nurse prepares a room for the client's return and
assesses the client to prevent or minimize potential complications.
The nurse ensures the safe recovery of the client after the client has stabilized.
A client returning to the floor after orthopedic surgery is reporting nausea. The nurse is aware that an appropriate intervention is to:
avoid strong-smelling foods.
rationale:
Nursing care for a client with nausea includes avoiding strong-smelling foods, providing oral hygiene, administering prescribed medications (especially medications ordered for nausea and vomiting), and avoiding use of a straw.
An operating room nurse is preparing for a surgical procedure on an infant. The nurse's perioperative care is based on what physiologic factor that puts infants at greater risk from surgery than adults?
lower total blood volume
rationale:
Infants are at a greater risk from surgery as a
result of various physiologic factors. A major factor is that the
infant has a lower total blood volume, making even a small loss of
blood a serious consideration. This loss of blood poses a risk for
dehydration and the inability to respond to the need for increased
oxygen during surgery. The loss of blood would cause a decreased
peripheral circulation but physiologically the infant has a normal
peripheral circulation. The infant has a small chest expansion due
body size and the infant's vascular rigidity is normal.
A nurse is caring for an older adult client who has been prescribed fluid restriction before surgery. What should the nurse check most carefully to assess the risks of fluid restriction in older adult clients?
vital signs
rationale:
The nurse should assess the client's vital signs,
weight, and sternal skin turgor prior to fluid restriction to serve as
a baseline for comparison. The period of fluid restriction before
surgery may be shortened for older adults to reduce their risk of
dehydration and hypotension. For most clients, vital signs are more
significant than other assessments in determining the risks of fluid restriction.
A nurse is assessing a client with asthma for latex allergy at the health care facility. Which symptoms does a person manifest during an allergic reaction due to latex products? Select all that apply.
- Local inflammation
- Pruritus or itch
- Redness
rationale:
When a person is allergic to natural rubber latex
products, the allergy is manifested by local inflammation, pruritus,
and redness. Cough and headache are not allergic reactions caused by
latex products.
The nurse is assessing a client who has had abdominal surgery under general anesthesia. Which condition in this client would the nurse report to the surgeon?
Urine output 20 mL/hour
rationale:
A urine output less than 30 mL/hour should be reported because of potential complications related to decreased renal perfusion and function. Intermittent, sluggish bowel sounds after abdominal surgery would be expected. The bowel may take several days or longer to resume normal activity and function. A dry, intact abdominal dressing is normal. A reduction in pain indicates effectiveness of the analgesic.
A nursing student is reviewing information about general anesthesia and the loss of reflexes during the surgical stage. Place the following reflexes in the progression that they are lost starting from first to last.
- Lid
- Pharyngeal
- Laryngeal
- Corneal
rationale:
During the surgical stage of general anesthesia, the
reflexes are lost in the following order: lid, pharyngeal, laryngeal,
gag, and corneal.
A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice? Select all that apply.
- positioning the client on the operating table
- counting sponges before and after surgery
- monitoring the client’s vital signs
rationale:
The RN's role is a supportive one for the client,
monitoring vital signs and positioning the client on the operating
room table. The RN also helps maintain safety by counting sponges and
instruments that may have been used during the surgery. The RN is
unable to administer anesthetics, such as inhalation agents or
regional nerve blocks, without an advanced practice degree.
A 2-year-old is undergoing a surgical repair of a fractured radius and ulna. What nursing action is developmentally appropriate for this child?
Place an IV after the child has received a rectal anxiolytic agent.
rationale:
Rectal anxiolytic agents are commonly administered
to toddlers prior to painful procedures (such as blood draws and IV
placement) to help ease their transition. A toddler should spend as
much time as they can with their caregiver to ease anxiety; the
caregiver may meet you in the recovery room and may come back with
them to the operating room. The client may be allowed to bring a
security item into surgery, but bringing all of the stuffed
animals is excessive and an infection control risk.
A client is scheduled for liposuction surgery to reduce weight. Which action should the nurse take immediately after surgery?
Listen to bowel sounds
rationale:
During the postoperative period, key nursing
responsibilities focus on determining that all body systems are
functioning adequately. This would include listening to the client’s
bowel sounds. The surgical dressing is first changed by the surgeon at
a future date. Liposuction does not necessarily require a weight loss
diet after surgery, thus monitoring the client’s weight loss will not
be needed.
A client who is in the holding area awaiting knee replacement surgery tells the nurse, “I am afraid of getting HIV if I have to have a blood transfusion during this surgery.” What is the appropriate nursing response?
“The risk of acquiring a blood-borne disease from a blood transfusion is very small.”
rationale:
The nurse will teach that the chance of acquiring a blood-borne disease from a blood transfusion is very small. Giving blood preoperatively may have been ideal, but that does not address the client’s immediate concern. Although transfusions are not commonly associated with knee replacement surgery, this does not address the client’s concern. Siblings should not donate blood for a client because antigens in the transfused blood sensitizes the client recipient, which would rule them out as a future organ or tissue donor for the client.
Which statement accurately represents a recommended guideline when providing postoperative care for the following clients?
If vital signs are progressively increasing or decreasing from the baseline, notify the health care provider of possible internal bleeding.
rationale:
A continued decrease in blood pressure or an increase in heart rate could indicate internal bleeding, and the health care provider should be notified. If an adult client has a urine output of less than 30 mL/hr, the health care provider should be notified, unless this is expected. When large amounts of fresh blood are present, the dressing should be reinforced with more bandages and the health care provider notified. Fever is not expected after surgery.
A nurse is reviewing the intraoperative record of a client who has been admitted to the surgical unit following abdominal surgery. The nurse notes that the client received an injection of a local anesthetic agent into the subarachnoid space. The nurse identifies this as:
spinal anesthesia.