Midterm Exam Practice for Perioperative Nursing PDF

Midterm 70 MC questions - 2 hours to write the exam. Worth 30%, from 0900 - 1100. Content from weeks 1 - 6 - **Signed Consent** **Legal preparation for surgery** - Patient/family aware and informed of procedure - All required forms must be present, signed on chart, such as: - - -...

Midterm 70 MC questions - 2 hours to write the exam. Worth 30%, from 0900 - 1100. Content from weeks 1 - 6 - **Signed Consent** **Legal preparation for surgery** - Patient/family aware and informed of procedure - All required forms must be present, signed on chart, such as: - - - - **Informed consent** 1. 2. 3. **RN's role can include:** - Verifying consent is informed and advocating for patient as required (e.g., pt unclear about procedure, options, risks, alternatives, potential complications); support pt to withdraw consent at any time if indicated - Witnessing patient signature on consent, but only if consent is informed - Verifying signed informed consent is on the chart in the immediate preoperative period [Note:] in some cases, surgeon may obtain consent in the OR holding area prior to medications, and in this case a consent will be unsigned and unverified on the chart on transport to OR - **Near Miss/No Harm Incidents** A patient safety incident (or adverse event) is- "an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient" (Canadian Patient Safety Institute, 2015) Canadian Patient Safety Institute defines the following 3 types of patient safety incidents: 1. Harmful Incident: "an incident that resulted in patient harm (previously known as '"preventable adverse event" ') "; 2. Near Miss: "an incident that did not reach the patient (no harm resulted)" 3. No-harm Incident: "an incident that reached the patient, but no discernable harm resulted" **Medication Errors:** - Contributing factors: neglecting routine procedures; checking dose calculations; administering unfamiliar meds; order neglect; failure to comply with the rights; failure to perform required assessments (e.g., BP, CBG) - System factors: distraction, illegible orders, transcription errors, inappropriate abbreviations - Design of products: e.g., labelling **Incidence or Occurrence Report** - An incident or occurrence- any event that is not consistent with the routine, expected care of a patient or the standard procedures in place on a health care unit. - When an incident occurs, the nurse, documents an objective description of what happened; what the nurse observed; and the follow-up actions taken, including notification of the patient\'s health care provider in the patient\'s medical record. - Evaluate and document the patient\'s response to the incident. - Analysis of incident reports helps identify trends in an organization that provide justification for changes in policies and procedures or for in-service programs. - **[Do not]** include any reference to an incident in the medical record; enables lawyer to argue that the reference makes the incident report part of the medical record and therefore subject to attorney review. - **Chain of Prevention** - [Patient assessment and measuring vital signs are the main components of "monitoring"] - Weakness of one or more of the components (rings) of the chain will inevitably result in failure of the whole system (i.e., pt. deterioration and cardiac arrest); - If the components of the chain are present and strong, this should be measurable as a reduction in the number of preventable cardiac arrests **6 Physiological Parameters for Monitoring** 1. Respiratory rate 2. Oxygen saturation 3. Temperature 4. Systolic BP 5. Pulse rate 6. Level of consciousness - **Pre-op and Peri-op phases** (Consent is preop) ***PREOPERATIVE***  A screenshot of a medical information Description automatically generated **Practice questions:** A client scheduled for a surgical procedure in 2 days and reports use of ginkgo daily. What is the priority intervention? Notify the anesthesia care provider, since this herb interferes with anesthetics. The client tells the nurse in the preoperative setting that she has noticed she has a reaction when wearing rubber gloves. What is the most appropriate action? Ask additional questions to assess for a possible latex allergy. (screening) A client is scheduled for surgery requiring general anesthesia at an ambulatory surgical center. The nurse asks the client when they ate last. The client replies that a light breakfast was consumed a couple of hours before coming to the surgery center. What should the nurse do first? Notify the anesthesia care provider of when and what the client last ate. What is the nurse's role when assisting a client with informed consent before an operative procedure? Asks the client to explain what surgical procedure they are having and ensures that the client understands the operation to be performed is given. A screenshot of a medical information Description automatically generated  ***INTRAOPERATIVE*** **Practice question:** What is the proper attire for the semi-restricted area of the surgery department? Surgical attire and head cover Which of the following activities might a nurse perform in the role of a scrub nurse during surgery? (Select all that apply.) Preparing the instrument table, coordinating activities occurring in the operating room & maintaining accurate counts of sponges, needles, and instruments.  **Classification of Anesthesia** 1. General 2. Regional (epidural, spinal) 3. Moderate (conscious sedation) 4. Local **Practice question** A client is scheduled for an abdominal hysterectomy. She is extremely anxious and has a tendency to hyperventilate when upset. What is the most appropriate type of anesthetic for this client? A general anesthetic. **Potential Intraoperative Complications** - Anaphylactic reactions - Anesthesia awareness - Major blood loss - **Malignant hyperthermia (MH):** Rare multifactorial genetically inherited autosomal dominant disorder  ***POSTOPERATIVE*** **Nursing considerations:**  **I SBAR-R** I-identification S-situation B-background R-recommendation R-repeat back \*usually by phone **Initial post-op assessment/checks upon pt's return from PACU to clinical unit** 1. Assessments 2. Equipment -- educated pt 3. Positioning -- side lying if drowsy/immobile 4. Communicating with pt and family 5. Processing pot-op orders **Focused assessments:** CVS status - Watch for signs of hemorrhage or shock (weak, rapid, thready pulse) - Hypotension - Cool, clammy skin - Decreased urine output (less than 30 ml/hr) **Predicting and managing potential post op complications**  - **Primary intention**: Wound edges are brought together, either naturally or with stitches, staples or glue for quick healing with minimal scarring. Small. - **Secondary** stays open to drain. - **Tertiary** is temporarily open and then closed. Larger wound. Packing. **Surgical Site Infection (SSI) or Surgical Wound Infection** - Usually occurs 3-6 days after surgery - Potential Causes: poor aseptic technique; preop contaminated wound; client conditions (e.g. diabetes, immunocompromise) - Assessment: fever, chills, warm, tender, painful, inflamed, incision, edema, tight sutures, elevated WBCs; [Nursing Interventions:] - Monitor T, signs of infection (REEDA: redness, edema, ecchymosis, drainage, approximation of wound) - Notify MRP id signs of wound infection - Maintain patency of drains and assess drainage amount, color, consistency - Maintain asepsis, change dressing as ordered, - Administer antibiotics as ordered **Evisceration:** - Usually occurs 6-8 days after surgery - Most common for obese clients, clients with abdominal surgery, those with poor wound healing factors [Emergency nursing interventions:] - Call for help and ask that the surgeon be notified and necessary supplies be brought to the patient's room. - Stay with the patient - Place the client in **low Fowler's with the knees bent**. - Cover the wound with a sterile normal saline dressing and keep the dressing moist - Take vital signs and monitor the clients closely for signs of shock - Prepare the client for surgery or wound closure as necessary - Document the occurrence, actions taken and the client's response A medical information sheet with text AI-generated content may be incorrect.  **When pt is ready for discharge:** [Pt education:] - new meds along with why they are prescribed and how and when to take them. - self-care at home and when to contact HCP - **Canadian Patient Safety Institute (CPSI) Surgical Time-Out **  - **\*\*Post-Op Complications (v/n, urinary retention, pain, delirium)** A screenshot of a medical document AI-generated content may be incorrect. Physical assessment: IPPA (palpation - percussion) **GI assessment: IAPP** (percuss - palpation) - Early oral feeding for non-critical adults following surgery (within 24 hrs) post op is evidence-based - Presence of bowel sounds or passing flatus not a required to start clear fluids - Large abdominal surgeries-usually NPO with NG insitu and these patients would be progressed more slowly as expected **PCA** [SAFETY:] - only the patient should push the button; bolus doses may also be administered by RN if ordered for breakthrough pain - **sedation** is an extremely useful assessment parameter to observe the clinical effects of opioids; sedation is the most important predictor of respiratory depression in patients receiving IV opioids. **COWS (clinical opiate withdrawal scale)**  A screenshot of a medical report AI-generated content may be incorrect.  - **Pneumonia prevention** **Pneumonia:** inflammation of the lung parenchyma, Indigenous Canadians over 18 at risk for higher rates of pneumonia. [Acquisition of Organisms:] - Aspiration of microbes in secretions from nasopharynx or oropharynx - Inhalation of microbes in air (e.g., *M. pneumonia;* fungal) - Hematogenous spread of infection elsewhere in body (e.g., S*taphylococcus aureus*) Classification by: - Causative agent: - bacteria, viruses, - \**Mycoplasma*, - fungi, - parasites, - chemicals \* *Group of bacteria that lack cell walls-12/100 species infect humans* **Community Acquired Pneumonia (CAP)** - "lower respiratory tract infection of the lung parenchyma with onset in the community or during the first 2 days of hospitalization" - Globally a leading cause of ↑morbidity and ↑mortality - Highest incidence in winter - Smoking key risk factor - Abrupt onset of fever and chills **Causative Organisms** - Most common cause: ***[Streptococcus pneumonia]*** - Atypical organisms: *Legionella, Mycoplasma, Chlamydia*, viral - Risk factors: COPD, recent antibiotic use, conditions that increase risk aspiration (e.g., impaired LOC, tube feeding, CVA) **Hospital Acquired Pneumonia (HAP)** - HAP -- "pneumonia occurring 48 hours or longer after hospital admission and [not incubating at the time] of hospitalization" - 25% of all ICU infections - High morbidity/mortality rates **Causative Organisms** - Majority ***[bacterial]**-Pseudomonas, Enterobacter, S. aureus, MRSA, S. pneumoniae* - Majority caused by bacteria entering lungs from pharyngeal secretion aspiration - Predisposing factors: immunosuppression; ET tube; general debility - Contaminated respiratory equipment (e.g., suctioning, ventilators) **Ventilator Associated Pneumonia (VAP)** **Fungal Pneumonia** Very aggressive, close monitoring with the abx medication, [not person to person] Organisms (e.g., Candidiasis; Aspergillosis) [Isolation not needed] Treatment: IV Amphotericin B: highly toxic+++ **Aspiration Pneumonia** "Sequelae of abnormal entry of secretions or substances into the lower airway" Follows aspiration of material from mouth or stomach into trachea and lungs. Serious and common on elderly in LTC -- along with risks factors [Forms:] - Obstructive (inert substances e.g., barium); - Chemical (e.g., gastric enzymes) 48-72 hrs post enzymatic injury; - Bacterial (oropharyngeal flora); **Opportunistic Pneumonia** High risk: severe protein-calorie malnutrition; immune deficiencies; transplants/ immunosuppressants; radiation tx; chemo; prolonged corticosteroids; [Insidious onset:] fever, tachypnea; tachycardia; dyspnea; non-productive cough; hypoxemia) **Pneumococcal Pneumonia (PP)** - *Streptococcus pneumoniae* is known in medical microbiology as the **pneumococcus**, referring to its morphology and its consistent involvement in **pneumococcal pneumonia**. - Most common cause of [bacterial pneumonia]. - Clinical Manifestations: Fever, chills, productive cough, purulent sputum **Pneumonia: Clinical Manifestations** - Typical: sudden onset of fever, chills, cough productive of purulent sputum, pleuritic chest pain (sometimes); confusion (older adults); pulmonary consolidation; dullness to percussion; ↑fremitus; bronchial breath sounds; crackles -- most commonly cause by *Strep. pneumoniae* - Atypical: gradual onset; dry cough; extra-pulmonary symptoms (headache, myalgia, fatigue, sore throat, nausea, vomiting, diarrhea) -usually caused by *Mycoplasma pneumoniae* /*"walking pneumonia"* - Viral pneumonia: [highly variable]; chills, fever, dry nonproductive cough; extra-pulmonary symptoms; also associated with measles, varicella-zoster, and herpes simplex or influenza viral infections Plural pain: Sharp, stabbing, burning - **C**onfusion - **U**rea (BUN) - **R**espiratory rate - **B**P - Age (\> **65**) **ABG -- Arterial Blood for Blood Gases** PaO2: normal 80-100 BUN: normal 2.1 to 8.5 mmol/L  **WBC normal:** 4,500 to 11,000 WBCs per microliter (4.5 to 11.0 × 10^9^/L) If bicarb is high -- kidneys are dealing with this for a while. Partially compensated: ph is still abnormal Fully compensated: ph is back to normal NOW YOUR RANGES **Pneumonia: Collaborative Care** - Abx (for bacterial & mycoplasm) - O2 - Droplet/contact precautions (minimum 72 hrs) - ↑fluid intake (at least 3 L/day if not contraindicated); IV fluids; 1500 calories (small, frequent meals) **Viral Pneumonia** - [CAP Prevention]: - ↑natural resistance: diet, hand hygiene, rest, exercise - Treat URIs promptly with supportive measures; see MD if symptoms persist after 7 days - Vulnerable: flu (annual) & pneumococcal vaccines (at least once) **Pneumonia: Prevention** - [HAP Prevention:] - Identify at risk clients - Altered LOC-↓ risk aspiration (side lying upright) - Turn and reposition q 2h - Oral hygiene - Feeding tube precautions - Dysphasia-feeding precautions - Immobile-turning & DB&C/incentive spirometry - Strict medical asepsis and IPAC - Maintenance inhalers - Hand hygiene - Exercise & early mobilization **Acute Intervention** - Respiratory assessment - ↑HOB (if not contraindicated) - Oxygen, inc. spirometry - Medications (bronchodilators, analgesics, antibiotics) - position "good lung down" (lateral) position-promotes max lung expansion - Mobilize - Systemic fluids to liquefy secretions - Balance rest/activity **Vaccines** Viral pneumonia - No definitive treatment - Influenza A -- amantadine - Influenza A & B -- zanamivir (Relenza), oseltamivir (Tamiflu) - Influenza vaccine - [Mainstay (fundamental) treatment] (elderly, LTC residents, COPD, DM, health care workers) - Influenza infection - Amantadine **Pneumococcal vaccine:** - Indicated for: - those at risk: chronic illness (e.g., lung and/or heart disease; DM) - Recovering from severe illness - 65 years or older - Residing in LTC - Current recommendations (PHAC- public health agency of canada, 2007) - Can be given at same time as flu vaccine, but each should be given in a different site - -- x1 per lifetime - or...Every 5 years: asplenic; nephrotic syndrome; renal failure; AIDS; transplant recipient - **NEWS Trigger System** National Early Warning Score  Improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes.