HESI: Perioperative Care

Which vital sign requires follow up by the nurse?

A. BP 160/80
B. Pulse of 68
C. Respiratory rate of 14
D. Temperature of 97.2 degrees F

A. BP 160/80

Rationale: This blood pressure is elevated and requires further action by the nurse. All of the other choices are within normal limits so they require nor further action by the nurse.

The nurse reviews the medications taken by Ms. Jackson. Ms. Jackson states that she has been taking two medications; Hydrochlorothiazide (Hydrodiuril), a diuretic, and warfarin (Coumadin), an anticoagulant, everyday for more than one year. What nursing action is most important?

A. Observe the appearance of the client’s oral mucosa.
B. Assess the client for any signs of excessive bruising.
C. Review common side effects of each of the medications.
D. Explain the need to withhold the warfarin prior to surgery.

D. Explain the need to withhold the warfarin prior to surgery.

Rationale: Anticoagulants increase the risk for bleeding during surgery and the postoperative period, so the nurse must explain the need to withhold warfarin prior to surgery and instruct the client to contact the surgeon to determine how long before the surgery the medication should be stopped. The other choices are relevant to the medications she is taking but since the client is receiving a an established daily dose for over a year, they are not the most important preoperative interventions.

The nurse then reviews Ms. Jackson’s preoperative lab results drawn earlier in the week. Which serum lab value requires follow-up by the nurse?

A. Sodium of 135 mEq/L
B. WBC of 14,000/mm3
C. Creatinine of 0.8 mg/dl
D. Hemoglobin of 14 g/dl

B. WBC of 14,000/mm3

Rationale: The normal WBC count is 5,000 to 10,000/mm3. An increase my indicate the onset of an infection which may be a contraindication to surgery. The nurse should notify the surgeon of this abnormal lab value.

The nurse talks to Ms. Jackson what to expect the day of the surgery and during the immediate postoperative period. The nurse provide instructions regarding cough and deep breathing exercises. Ms. Jackson performs a return demonstration by breathing in deeply through her mouth and exhaling forcefully and rapidly through pursed lips. Which action should the nurse implement?

A. Advise the client to avoid pursing her lips when exhaling.
B. Remind the client to cough after taking 2 to 3 breaths.
C. Demonstrate the deep breathing and cough technique again.
D. Document successful completion of the return demonstration.

C. Demonstrate the deep breathing and cough technique again.

Rationale: Ms. Jackson has demonstrated incorrect technique. When performing deep breathing exercises, the client should inhale through the nose and exhale slowly through the mouth without pursing the lips. The nurse should demonstrate the entire procedure again for best learning by the client.

When the nurse begins teaching the benefits of early mobilization following surgery, Ms. Jackson states, “Oh, I know if I stay in bed very long I will get bed sores.” How should the nurse respond?

A. “Getting a bedsore is very serious. Sometimes people die from infected bedsores.”
B. “The nurses will make sure you do not stay in bed long enough to get bedsores.”
C. “Bedsores are one of the many problems that can occur from prolonged bedrest.”
D. “Those are now called pressure ulcers, because they are caused by pressure.”

C. “Bedsores are one of the many problems that can occur from prolonged bedrest.”

Rationale: This response acknowledges the client’s previous learning and promotes further learning related to other complications of immobility such as thrombus formation, constipation, and atelectasis.

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The nurse dicusses postoperative pain management with Ms. Jackson and explains the use of a patient-controlled analgesia (PCA) pump. Ms. Jackson expresses fear that she might accidentally overdose herself, since she will be sleepy after surgery. How should the nurse respond?

A. “You will only use the PCA pump for the first 24 hours after surgery.”
B. “The surgeon will prescribe the dose of medication that is correct for you.”
C. “I will tell the surgeon that you prefer the nurses administer your pain medicine.”
D. “The pump has a controlled device that prevents you from taking too much medicine.”

D. “The pump has a controlled device that prevents you from taking too much medicine.”
While discussing postoperative pain management strategies with Ms. Jackson, the nurse observes Ms. Jackson begin to cry. What action should the nurse take?

A. Quietly sit with the client.
B. Offer reassurance about the surgery.
C. Calmly continue the preoperative instructions.
D. Leave the room until the client has composed herself.

A. Quietly sit with the client.

Rationale: Offering one’s presence is a caring and therapeutic response.

After Ms. Jackson stops crying, she states, “My father was in so much pain before he died. Talking about pain brings back so many memories.” How should the nurse respond?

A. “We do not need to talk about pain control today if it makes you sad.”
B. Perhaps you need to see a counselor to help you resolve your grief.”
C. “It sounds as if you went through a difficult time when your father died.”
D. “You need to focus on your own needs now and not on past memories.”

C. “It sounds as if you went through a difficult time when your father died.”
Ms. Jackson shares her experiences related to her fathers death with the nurse and expresses appreciation for the nurses caring attitude. Ms. Jackson leaves after the preooperative teaching is completed, with plans to meet with the surgeon that afternoon and return to the surgery center the morning of the surgery. The next week, Ms. Jackson arrives at the surgery center 3 hours before her scheduled surgery. Which question is most important for the nurse to ask Ms. Jackson during the admission interview?

A. “Have you had anything to eat or drink since midnight?”
B. “Are any of your friends or family members here with you?”
C. “Do you understand you will be admitted to the hospital following surgery?”
D. “Did you bring any valuables with you that need to be stored during surgery?”

A. “Have you had anything to eat or drink since midnight?”

Rationale: Ensuring that the client has remained NPO for the prescribed length of time before surgery is critical to prevent vomiting and aspiration during surgery.

After completing the admission interview, the nurse reviews Ms. Jackson’s medical record and notes that the surgical consent form is filled out but not signed by the client. What action should the nurse take?

A. Ask Ms. Jackson is she has received sufficient information to sign the consent form.
B. Call the operating room and notify the staff that the surgery needs to be cancelled.
C. Notify the surgeon of the need to come to the client’s room so the consent can be signed.
D. Inform a family of the need to serve a as a witness to the client’s signature.

A. Ask Ms. Jackson is she has received sufficient information to sign the consent form.

Rationale: The nurse may witness the client’s signature if the nurse is able to determine that the client has been sufficiently informed of necessary information.

The nurse observes that the word, “Yes” has been marked on Ms. Jackson’s left hip, and the word, “No” has been written on her right hip. What action should the nurse implement?

A. Use a antimicrobial agent to cleanse the surgical site.
B. Take a photo of the markings to place in the chart.
C. Confirm that the left hip is the site of the scheduled surgery.
D. Reassure the client that the surgeon will not make a mistake.

C. Confirm that the left hip is the site of the scheduled surgery.

Rationale: The nurse should ensure that the markings on the hips are correct to help reduce the potential for error during surgery. When the surgical site involves a distinction between left and rights sides of the body, marking the site is a required component of the Joint Commission’s universal protocol to prevent wrong site, wrong procedure, wrong person surgery.

Ms. Jackson is transferred to a stretcher and taken to the operating room (OR). The nurse assists Ms. Jackson off the stretcher and onto the OR table. After general anesthesia is induced, the nurse positions Ms. Jackson for surgery. Which nursing diagnosis has the highest priority at this time?

A. Ineffective protection
B. Ineffective tissue profusion
C. Risk for preoperative-positioning injury
D. Risk for imbalanced body temperature

C. Risk for preoperative-positioning injury

Rationale: During surgery the client may remain in one position for a prolonged period. The nurse must ensure that the client is protected from injury secondary to inappropriate positioning.

Once the OR team has assembled in the room, the circulating nurse calls for a time out. What action should the nurse take during the time out?

A. Ensure that sufficient surgical are available.
B. Make sure that all surgical personnell are properly attired.
C. Review the scheduled procedure, site, and client.
D. Confirm that informed consent has been obtained

C. Review the scheduled procedure, site, and client.

Rationale: A time out, the designated method for final verification before surgery begins, is a component of Joint Commission’s universal protocol to prevent wrong site, wrong procedure, wrong person surgery.

The surgery is succesfully completed without complications. Following surgery, Ms. Jackson is admitted to the Post Anesthesia Care Unit. The operative report indicates that Ms. Jackson has a left hip replacement under general anesthesia. The initial nursing assessment reveals that Ms. Jackson is not responding to verbal stimuli. Her vital signs are T 97.6 F, P 88, RR 14, and BP 130/70. What action should the nurse implement first?

A. Position the client on her side.
B. Observe the surgical dressing.
C. Place the call bell within reach.
D. Remove the oral airway.

A. Position the client on her side.

Rationale: During the immediate the postanesthesia period, the unconscious client should be positioned on the side to maintain an open airway and promote drainage of secretions.

While assessing Ms. Jackson, the nurse observes that the surgical dressing is in place on the left hip, with no visible drainage. How should the nurse document this finding?

A. No problems with dressing on the left hip.
B. Left hip dressing clean, dry, and intact.
C. Dressing present over left hip incision.
D. Incision well-approximated with no drainage.

B. Left hip dressing clean, dry, and intact.

Rationale: This documentation is concise and but thorough, providing a clear picture of the assessed data.

When Ms. Jackson arrives on the unit, the nurse notes that her IV is wide open. Review of Ms. Jackson’s postoperative prescriptions indicates that 0.9% Normal saline is to infuse at 75 mL/hour, alternating with Lactated Ringer’s solution at 75 mL/hour. An infusion pump is not immediately available, so the nurse notes that the infusion tubing has a drop factor of 10 drops/mL and resets the IV. At what rate should the IV infuse?
13 drops/minute

75mL/60 min x 10 drops/mL = 12.5, which rounds up to 13.

While the nurse begins to assess the client, another nurse finds an infusion pump and prepares to prescribe a “now” dose of an intravenous antibiotic. The prescription is for 2 grams cefazolin (Ancef), which arrives from the pharmacy diluted in 100 mL of normal saline and is to be administered over 30 minutes. At what should the infusion pump be set?
200 mL/hour

100 mL/30 min x 60 min/1 hour = 200 mL/hour

What action should the nurse take to assess for atelectasis?

A. Auscultate the client’s breath sounds.
B. Observe the appearance of the sputum.
C. Determine the clients temperature.
D. Measure the client’s blood pressure.

A. Auscultate the client’s breath sounds.

Rationale: Atelectasis is a condition in which the alveoli collapse. Dull or absent breath sounds, along with changes in breathing patterns, are expected findings when atelectasis occurs

The nurse determines that Ms. Jackson’s bowel sounds are hypoactive. What action should the nurse implement in response to this finding?

A. Document the assessment finding in the chart.
B. Notify the surgeon of the assessment finding.
C. Review the client’s serum electrolyte values.
D. Administer a laxative proscribed for PRN use.

A. Document the assessment finding in the chart.

Rationale: Hypoactive bowel sounds are an expected finding following general anesthesia, so the nurse should document this finding in the chart and continue to monitor the client.

During the postoperative assessment, the nurse observes Ms. Jackson’s surgical site. The left hip has a moderate amount of sanguineous drainage. What action(s) should the nurse implement?

A. Apply pressure to the site.
B. Elevate the leg on a pillow.
C. Observe the linens under the hip.
D. Use sterile technique to replace the dressing.
E. Mark the amount of drainage on the dressing.

C. Observe the linens under the hip.

Rationale: Gravity pulls drainage down, so the nurse should inspect the area below the surgical site for additional drainage.

E. Mark the amount of drainage on the dressing.

Rationale: This will allow for later comparison.

The nurse observes that the Hemovac drain is full of sanguineous drainage. What action should the nurse implement first?

A. Compress the drain and re-establish suction.
B. Empty the drain and measure the amount of drainage.
C. Page the surgeon to report the finding.
D. Document the appearance of the drainage.

B. Empty the drain and measure the amount of drainage.
The nurse notifies the surgeon of the wound drainage. What lab data is important for the nurse to report to the surgeon?

A. WBC
B. Hemoglobin and hematocrit
C. Culture and sensitivity
D. Type and cross match

B. Hemoglobin and hematocrit

Rationale: The nurse is reporting the amount of surgical drainage to the surgeon due to a concern for excessive blood loss. The surgeon needs to know information related to blood volume, provided by the hemoglobin and hematocrit levels. A and C are not correct because are information related to infection and they are not the data the surgeon needs at this time.

Based on the lab data provided by the nurse, the health care provider prescribes the transfusion of 2 units of red blood cells as soon as possible. Once the first unit of packed red blood cells is ready, the nurse obtains the blood from the blood bank. When the nurse enters Ms. Jackson’s room to begin the transfusion, the UAP is giving Ms. Jackson a partial bath. What action should the nurse take?

A. Place the unit of blood in the medication refrigerator until the client’s personal care is completed.
B. Hang the transfusion of packed cells while the UAP continues to complete the client’s personal care.
C. Lock the unit of blood in the computerized medication cart and assist the UAP in completing the personal care.
D. Return the blood back to the blood bank and send the UAP to obtain the blood when the personal care is completed.

B. Hang the transfusion of packed cells while the UAP continues to complete the client’s personal care.

Rationale: Transfusion of blood is a higher priority than personal care. If necessary, the remainder of the care can be delayed.

Ms. Jackson is currently recieving Lactated Ringer’s solution IV at a rate of 75 mL/hour. In transfusing the 250-mL unit of packed red blood cells, what action should the nurse implement?

A. Stop the IV solution and transfuse the packed cells at 125 mL/hour via tubing connected to a bag of saline solution.
B. Infuse the Lactated Ringer’s solution through the IV tubing concurrently with blood at a combined rate of 75 mL/hour.
C. Flush the IV tubing with a 5 mL bolus of normal saline before and after the transfusion, and transfuse the blood within 1 hour.
D. Replace the Lactated Ringer’s solution with the unit of packed red blood cells and administer through the tubing at 75 mL/hour.

A. Stop the IV solution and transfuse the packed cells at 125 mL/hour via tubing connected to a bag of saline solution.

Rationale: Packed red blood cells are only compatible with normal saline. The blood should be connected to a bag of saline solution using special Y-tubing and administered within 1 1/2 to 2 hours, if possible, but no longer than 4 hours.

The nurse is assisting Ms. Jackson to the bedside commode on the second postoperative day. Ms. Jackson states, “I have never had to depend of anyone before.I like to take care of myself. I feel so helpless.” In response to these remarks, the nurse plans care for Ms. Jackson based on the identification of which nursing diagnosis?

A. Disturbed body image.
B. Situational low self-esteem.
C. Anticipatory grieving.
D. Impaired physical mobility.

B. Situational low self-esteem.
The nurse teaches Ms. Jackson safe transfer techniques and consults with the physical therapist to begin ambulation activities as soon as possible. What is the rationale for the inclusion of these actions in Ms. Jackson’s plan of care?

A. Frequent activity will distract the client from her concerns.
B. Maintaining a safe environment reduces client depression.
C. The client should depend of the physical therapist rather than the nurse
D. Increased mobility will promote an improved sense of control.

D. Increased mobility will promote an improved sense of control.
After Ms. Jackson ambulates with the physical therapist, the nurse prepares to the surgical dressing. While obtaining supplies, the nurse reviews the sterile procedure to be followed. At what step in the procedure should the nurse don sterile gloves?

A. Prior to removing the dressing on the client’s hip.
B. Before opening the new sterile package.
C. Before cleansing the client’s hip incision.
D. After cleansing the client’s hip incision.

C. Before cleansing the client’s hip incision.
While cleansing the incision, the nurse observes that the staples are intact, but a 2-cm gap opened at the bottom of the incision. How should the nurse document this finding?

A. Bottom edges of incision approximated.
B. Small area of dehiscence at the bottom of the incision.
C. Evisceration of incision noted at the bottom edge.
D. Wound healing via secondary intention.

B. Small area of dehiscence at the bottom of the incision.
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