NURS309 Quiz #3: Perioperative Care Case Study

Following surgery, Ms. Jackson is admitted to the Post Anesthesia Care Unit. The operative report indicates that Ms. Jackson had 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, R 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.*

During the immediate 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 left hip.
B) Left hip dressing clean, dry, and intact.
C) Dressing present over hip incision.
D) Incision well-approximated with no drainage.

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

This documentation is concise 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? (drops per minute)

*13 drops per minute.*

75 ml/60 minutes × 10 gtts/1 ml = 12.5, which rounds up to 13 drops per minute.

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

At what rate should the infusion pump be set? (mL/hr)

*D) 200 ml/hour.*

100 ml/30 minutes = X ml/60 minutes. 30X = 100 × 60 = 200 ml/hour.

The nurse continues the postoperative assessment.

To assess for atelectasis, what action should the nurse take?
A) Auscultate the client’s breath sounds.
B) Observe the appearance of the sputum.
C) Determine the client’s temperature.
D) Measure the client’s blood pressure.

*A) Auscultate the client’s breath sounds.*

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.

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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 prescribed for PRN use.

*A) Document the assessment finding in the chart.*

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 dressing has a moderate amount of sanguineous drainage.

What action should the nurse implement? (select all that apply)
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.*

Gravity pulls drainage down, so the nurse should inspect the area below the surgical site for additional drainage. The nurse may also mark the amount of drainage on the dressing for later comparison.

*E) Mark the amount of drainage on the dressing.*

Marking the amount of drainage on the dressing 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.*

The nurse should first empty the drain and measure the drainage, then compress the drain to re-establish suction. Documentation of the findings and notification of the surgeon can then be done.

The nurse notifies the surgeon of the wound drainage.

What lab data is important for the nurse to report to the surgeon?
A) White blood cell count.
B) Hemoglobin and hematocrit.
C) Culture and sensitivity.
D) Type and cross match.

*B) Hemoglobin and hematocrit.*

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.

Based on the lab data provided by the nurse, the healthcare provider prescribes the transfusion of two units of packed 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 to 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.*

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

Ms. Jackson is currently receiving 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 the 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.*

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 1½ to 2 hours, if possible, but no longer than 4 hours (250 ml transfused at 125 ml/hour = 2 hours).

The 2 units of packed RBCs are transfused without complication. The drainage begins to decrease, and Ms. Jackson’s hemoglobin and hematocrit remain stable.

The nurse is assisting Ms. Jackson to the bedside commode on the second postoperative day. Ms. Jackson states, “I have never had to depend on 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 client’s remarks regarding feelings of helplessness relate to her sense of how she perceives herself and her present ability to care for herself.

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 on the 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.*

Increasing mobility should result in increased independence and an improved sense of control, which will reduce the client’s feelings of helplessness.

After Ms. Jackson ambulates with the physical therapist, the nurse prepares to change 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 dressing 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.*

When using surgical asepsis for wound care, the sterile gloves should be donned prior to cleaning the wound and applying the new sterile dressing.

While cleansing the incision, the nurse observes that the staples are intact, but a 2 cm gap has 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 bottom of incision.
C) Evisceration of incision noted at bottom edge.
D) Wound healing via secondary intention.

*B) Small area of dehiscence at bottom of incision.*

An unintentional opening in a surgical wound prior to healing is referred to as dehiscence.

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