Nokea
A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate?
- A. Explain the rationale for giving the medicine now
- B. Leave the room and come back in 15 minutes
- C. Provide holistic client care and come back later
- D. Tell the client you must start the medication now
Correct Answer: A
Rationale: The preoperative antibiotic must be given within 60 minutes of the surgical start time to ensure the proper amount is in the tissues when the incision is made. The nurse should explain the rationale to the client for this timing. The other options do not take this timing into consideration and do not give the client the information needed to be cooperative.
You may also like to solve these questions
A nursing instructor is teaching students about different surgical procedures and their classifications. Which procedures are correctly classified?
- A. Hemicolectomy: diagnostic
- B. Liver biopsy: diagnostic
- C. Spinal cord decompression: palliative
- D. Total shoulder replacement: restorative
- E. Mastectomy: restorative
Correct Answer: B,E
Rationale: A diagnostic procedure is used to determine cell type of cancer and to determine the cause of a problem, such as a liver biopsy. A restorative procedure aims to improve functional ability, such as a total shoulder replacement. A curative procedure either removes or repairs the causative problem, such as a mastectomy or hemicolectomy, which are not diagnostic or palliative.
A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical claim?
- A. Allergy to bee and wasp sting
- B. History of lactose intolerance
- C. No previous experience with surgery
- D. Use of herbal supplements
Correct Answer: D
Rationale: Some herbs and supplements can interact with medications, so this information needs to be reported as the priority. An allergy to bee and wasp stings should not affect the client during surgery. Lactose intolerance should also not affect the client during surgery but will need to be noted before a postoperative diet is ordered. A lack of experience with surgery may increase anxiety and may require higher teaching needs, but is not the priority over client safety.
A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best?
- A. It helps prevent ulcers from the stress of the surgery
- B. It reduces stomach acid to prevent aspiration
- C. Since you don't have ulcers, I will have to ask
- D. The physician prescribed this medication for you
Correct Answer: B
Rationale: Ranitidine (Zantac) is given preoperatively to reduce gastric acid production, which lowers the risk of aspiration during surgery. This is the most accurate explanation. Preventing ulcers is not the primary purpose in this context, and the other options do not provide a clear rationale.
Splinting an incision is an intervention to accomplish what goal?
- A. Provide extra support during coughing
- B. Reduce the need for analgesia
- C. Prevent shallow breathing
- D. Explain that some pain is normal
Correct Answer: A
Rationale: Splinting an incision provides extra support during coughing and activity and helps decrease pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing can lead to atelectasis and pneumonia. The client should know some pain is normal and expected after surgery, but that answer alone does not provide any interventions to help the client.
A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate?
- A. After you wash the surgical site, shave the area with your own razor
- B. Be sure to wash the area where you will have surgery very thoroughly
- C. Use a washcloth to wash the surgical sites, do not take a full shower or bath
- D. Wash the surgical site first, then shampoo and wash the rest of your body
Correct Answer: B
Rationale: The proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap. Shaving, if absolutely necessary, should be done in the operative suite immediately before the operation begins, using sterile equipment. The client needs a full shower or bath (shower preferred). Washing the surgical site last ensures that soap does not run over the cleansed site if other areas are washed first.