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Questions and Answers
What should the nurse do if a patient requests to go to the bathroom after receiving premedication?
Which patient information is crucial to communicate to the healthcare provider before hernia repair surgery for a patient on Lasix?
Which of the following tasks can be delegated to a UAP on the day of surgery?
What is the most appropriate nursing intervention for a patient exhibiting signs of deep vein thrombosis (DVT)?
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In preparing a patient for surgery, which of the following actions should NOT be performed by the UAP?
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What is an important consideration when managing a patient who is requesting a bedpan before surgery?
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If a patient taking Lasix presents a potassium level of 3.1, which immediate action should be considered?
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What is the primary responsibility of the nurse regarding patient education before surgery?
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What assessment data should a nurse monitor to identify early fluid volume changes postoperatively?
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What should be the nurse's priority action for a postoperative patient showing increasing agitation and confusion?
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Which intervention is the most effective for a patient with a history of DVT to minimize venous thromboembolism risk?
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Which sign indicates that a patient may be experiencing fluid volume overload postoperatively?
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What vital sign change would signify a potential issue in a postoperative patient?
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Which assessment finding would most likely suggest a need for immediate intervention in a postoperative patient?
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What is a key sign that may indicate a postoperative patient is developing atelectasis?
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What characteristic is most indicative of surgical site infection in a postoperative patient?
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What is the first action the nurse should take for a patient suspected of having a DVT?
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Which action should be avoided for a patient with a suspected DVT?
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Why is early ambulation important after abdominal surgery?
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Which of the following should a patient do before receiving their premedication for surgery?
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What should a patient do when coughing after abdominal surgery?
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Which patient requires the highest priority assessment based on their postoperative condition?
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What is the best initial action for a patient in the PACU complaining of severe nausea?
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In the context of premedication, which action should the nurse take when a patient requests to use the bathroom?
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Which symptom indicates a postoperative patient may be developing a serious complication?
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After a cholecystectomy, which factor may indicate the need for further assessment?
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Which of the following patients should be monitored most closely for signs of deep vein thrombosis?
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Among the postoperative patients, who is at the greatest risk for aspiration?
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What is the most appropriate nursing intervention for a postoperative patient showing increasing lethargy and inability to ingest fluids?
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What is the primary responsibility of the nurse regarding patient consent before administering pain medications?
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Which factor is NOT part of Virchow's Triad that increases the risk of thrombus formation?
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What is a common intervention for preventing venous thromboembolism postoperatively?
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What is the expected consequence of administering general anesthesia?
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What should be monitored to assess for signs of infection during preoperative care?
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Which statement regarding Jehovah’s Witness patients is accurate?
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What are potential indicators of malignant hyperthermia during surgery?
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Which patient position is recommended to avoid airway obstruction after anesthesia?
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What is the primary purpose of a surgical time-out?
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What is the main focus of postoperative care regarding the airway?
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Which type of anesthesia involves loss of sensation in a larger region through nerve blocks?
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What is a common sign of deep vein thrombosis (DVT)?
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What is the preferred action if a patient with a catheter does not urinate within 6 hours post-surgery?
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Study Notes
Preoperative Assessment
- Nurses should monitor vital signs before and after administering medications.
- Nurses should monitor for significant changes in vital signs.
- Nurses should use therapeutic techniques to help reduce patient anxiety.
- Nurses should assess for risk factors such as predisposition for malignant hyperthermia, hypothermia, allergies, and dehydration.
- Nurses should review recent labs to assess for signs of dehydration or infection.
- Nurses should obtain informed consent and ensure it is signed before administering any medications.
- Nurses should confirm all allergies with the patient and ensure a current allergy band is in place.
- Nurses should review post-operative instructions, discharge instructions, and confirm the patient understands both.
- Nurses should assist patients to the bathroom before administration of pain medication and sedatives.
- Nurses should discuss any spiritual or cultural considerations that may impact patient care.
- Nurses should ensure cosmetics, nail polish, dentures, contacts, and non-spiritual jewelry are removed from the patient.
- Nurses should confirm the surgical site is clearly marked by the physician with their initials.
Cultural Implications
- Native American patients may deny pain, regardless of if they are experiencing pain or not.
- Native American patients may not express pain verbally but may exhibit facial expressions or body language indicating pain.
- Jehovah’s Witness patients may refuse blood products, so it is important to consult with them before the procedure to clarify their wishes.
- If a patient refuses to remove cultural jewelry, the nurse should attempt to tape it down to prevent complications during surgery.
Anesthesia
- Local anesthesia involves loss of sensation but not loss of consciousness.
- Local anesthesia is appropriate for minor procedures such as sutures, or a small cut.
- Regional anesthesia involves loss of sensation, but not loss of consciousness.
- Regional anesthesia numbs a larger region of the body and is often used for epidural or spinal procedures, or regional nerve blocks.
- It is administered by injection.
- General anesthesia renders the patient unconscious, requiring airway support.
- General anesthesia is administered by an anesthesiologist.
- Moderate sedation is a combination of IV medications and inhaled anesthetics.
- Moderate sedation is used for procedures outside of the OR.
- Moderate sedation does not require an anesthesiologist.
- Moderate sedation reduces anxiety and allows the patient to remain conscious but without pain.
Safety
- Before administering anesthesia, the nurse should confirm the patient’s identity, the scheduled procedure, and the surgical site.
- The nurse should ensure consent forms have been signed.
- The nurse should document all allergies and vital signs when the patient is admitted to the OR.
- The nurse should ensure oxygen saturation is monitored, especially for high-risk patients.
- The nurse should ensure the surgical site is marked appropriately.
- The nurse should confirm the patient’s identity, the scheduled procedure, and the surgical site, with the entire OR team - all members should confirm their name and role, before making the first incision.
- The nurse should review the patient’s medical history and current medications and report any concerns to the physician.
- The nurse should have emergency equipment readily accessible in the event of a crisis.
Malignant Hyperthermia
- Malignant hyperthermia is a genetic condition that is triggered by inhaled anesthetics.
- It often presents with muscle rigidity, tachycardia, pyrexia, and tachypnea.
- The primary treatment is Dantrolene.
- Dantrolene slows metabolism and helps reduce muscle contraction.
- Preventive measures include a thorough pre-operative assessment including a family history and genetic testing.
- Malignant hyperthermia is a potentially life-threatening situation requiring immediate attention.
Postoperative Considerations
- The priority for postoperative care is ensuring the patient has a patent airway and adequate circulation.
- The nurse should monitor closely for airway obstruction, risk of aspiration, and any signs of hypoxemia.
- Nurses should utilize appropriate positioning to maintain an open patent airway.
- The nurse should monitor for signs of hypotension and hypertension, as these can indicate potential complications.
- The nurse should encourage coughing and deep breathing to help prevent atelectasis, which is a common cause of hypoxemia following surgery.
Drains
- Drains are placed by the surgeon to help facilitate wound drainage.
- The nurse should ensure the drains are functioning and not blocked, and that the proper type of drain is in place.
- The nurse should monitor drainage volume, color, and consistency and report any abnormalities to the physician immediately.
- The nurse should ensure the drain is secured to the patient's skin and that the drain tubing is not kinked.
- The nurse should clean the drain site and surrounding area thoroughly.
- The nurse should document the amount and type of drain output in the patient’s chart.
Urinary Catheters
- Urinary catheters are placed when deemed necessary to facilitate urinary drainage.
- The nurse should attempt to remove the urinary catheter as soon as possible to prevent infection.
- The nurse should maintain a specific protocol for placing, cleaning, and maintaining urinary catheters to minimize the risk of infection.
- The nurse should ensure the urinary drainage bag is below the level of the bladder.
- The nurse should monitor the patient for signs of urinary tract infection, such as burning, urgency, or foul-smelling urine.
- The nurse should document the characteristics of the urine in the patient’s chart.
Venous Thromboembolism
- A venous thromboembolism (VTE) occurs when a blood clot forms in a deep vein, usually in the lower extremities.
- A pulmonary embolism (PE) occurs when the blood clot dislodges from a deep vein and travels to the pulmonary arteries.
- Common signs and symptoms of DVT include redness, swelling, warmth, and tenderness in the affected leg.
- Common signs and symptoms of PE include shortness of breath, chest pain, tachycardia, and anxiety.
- Virchow’s Triad describes three factors that increase the risk of thrombus formation: stasis, hypercoagulability, and endothelial damage.
- The nurse should monitor for any signs and symptoms of DVT or PE.
- The nurse should implement preventative measures to help reduce the risk of VTE.
- The nurse should educate patients about the signs and symptoms of VTE.
Diagnostic Tests
- A chest x-ray can help visualize a PE.
- Arterial Blood Gases (ABGs), electrolytes, complete blood count (CBC), and coagulation studies can help reveal changes in blood gas levels, electrolytes, red blood count, and clotting factor levels.
- Ventilation-perfusion (V/Q) scan can measure airflow and blood flow in the lungs.
- Electrocardiogram (ECG) can help identify dysrhythmias.
- A spiral CT with contrast can provide more detailed images of the lungs.
- D-dimer is a protein fragment in the blood that is released during clot breakdown.
- Pulmonary angiography is a more invasive procedure that uses fluoroscopy to visualize the blood vessels in the lungs.
Interventions
- For patients diagnosed with non-massive PE, the nurse should administer oxygen, encourage bed rest, and administer anticoagulant therapy.
- For patients diagnosed with massive PE, the nurse should administer supplemental oxygen, place the patient in a semi-Fowler's position, prepare for intubation, and initiate thrombolytic therapy.
- The nurse should monitor the patient closely for changes in their condition, such as a decline in oxygen saturation or respiratory distress.
- Patients with a history of PE or who are at high risk for developing a PE should be referred to a specialist.
Prevention
- The nurse should implement preventative measures to reduce the risk of VTE in at-risk patients.
- Measures include maintaining a healthy lifestyle, exercising regularly, avoiding prolonged sitting, and using compression stockings.
- The nurse should educate patients on the importance of these preventative measures as they can significantly reduce the risk of PE development.
- The nurse should encourage patients to report changes in their condition, such as any new or worsening calf pain, to their provider immediately.
Practice Questions
- The nurse is admitting a patient to the clinical unit from surgery.
- The nurse needs to assess the patient thoroughly, including vital signs, level of consciousness, pain, and overall well-being.
- The nurse needs to monitor the patient’s respiratory, cardiovascular, and neurological status, paying attention to any complications from surgery or anesthesia.
- The nurse needs to review and document any medications the patient is receiving, including pain medication.
- The nurse needs to ensure the patient understands the post-operative instructions and discharge plans.
- The nurse needs to communicate with the patient, their family, and the physician about the patient’s overall care.
Monitoring Postoperative Fluid Volume
- Monitor intake and output: This helps assess fluid balance.
- Assess skin turgor: Decreased skin turgor suggests dehydration.
- Listen to lung sounds: Crackles or rales can indicate fluid overload.
- Monitor respiratory rate: Tachypnea can be a sign of fluid overload.
- Assess level of consciousness: Confusion or lethargy can be a sign of fluid imbalance.
Postoperative Agitation and Confusion
- Perform a focused neurological assessment: To determine the cause of the agitation.
- Notify the health care provider immediately: To report the change in mental status.
- Assess the patient’s vital signs: To monitor for any changes in heart rate, blood pressure, or oxygen saturation.
Minimizing DVT Risk After Hip Surgery
- Educate patient on early ambulation and leg exercises: This promotes blood flow and reduces venous stasis.
Prioritizing Postoperative Patient Assessment
- Postoperative Day 2 after knee arthroplasty with severe shortness of breath and chest pain: This is the highest priority, potentially indicating a pulmonary embolism.
- Postoperative Day 3 after abdominal surgery with right calf swelling and tenderness: Elevated pain level and increased fatigue in the right calf likely indicates a DVT.
- Postoperative Day 1 after cholecystectomy with abdominal pain, diaphoresis, and a temperature of 100.6: This could indicate infection or complications.
- Postoperative Day 3 after a laparoscopic appendectomy with nausea, vomiting, lethargy and chapped lips: While concerning, this is the lowest priority as the patient can tolerate clear liquids.
Management of Postoperative Nausea
- Administer the PRN antiemetic to reduce risk of aspiration: This is the priority intervention to alleviate nausea and prevent the risk of aspiration.
Postoperative Patient Education: Abdominal Surgery
- Educate the patient on splinting the abdomen when coughing: This technique is crucial for reducing pain and minimizing strain on the surgical incision.
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Description
This quiz covers essential preoperative assessment protocols that nurses should follow to ensure patient safety. It includes monitoring vital signs, assessing risk factors, obtaining informed consent, and understanding cultural considerations. Successful completion of this quiz will enhance your knowledge of crucial nursing practices before surgery.
