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A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin, and muscle wasting. What action by the nurse is best?
- A. Consult the surgeon about a postoperative dietitian referral
- B. Document the findings thoroughly in the client's chart
- C. Encourage the client to eat more after recovering from surgery
- D. Refer the client to Meals on Wheels after discharge
Correct Answer: A
Rationale: This client has signs of malnutrition, which can impact recovery from surgery. The nurse should consult the surgeon about prescribing a consultation with a dietitian in the preoperative period to optimize the client's nutritional status. Documenting findings is important but not sufficient alone. Encouraging the client to eat more may be helpful, but a professional nutritional assessment is needed. Meals on Wheels may not address immediate preoperative needs.
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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.
A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority with this client?
- A. Hydrocodone (Vicodin)
- B. Lorazepam (Ativan)
- C. Metoclopramide (Reglan)
- D. Morphine sulfate (Morphine)
Correct Answer: C
Rationale: Metoclopramide (Reglan) increases gastric emptying, an important issue for this client who was eating just prior to the operation to reduce the risk of aspiration. The other drugs are appropriate for pain or anxiety management but are not the priority in this scenario.
A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort?
- A. Allow the client to assume a position of comfort
- B. Allow the client's family to remain at the bedside
- C. Give the client a warm, non-carbonated drink
- D. Provide warm blankets or cool blankets as desired
- E. Pull the curtains around the bed to provide privacy
Correct Answer: A,B,D,E
Rationale: There are many nonpharmacologic comfort measures the nurse can employ, such as allowing the client to remain in the position that is most comfortable, letting the family stay with the client, providing warmth or cooling measures as requested by the client, and providing privacy. The client in the preoperative holding area is NPO, so drinks should not be provided.
A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best?
- A. Allow the client to walk to the bathroom
- B. Assist the client to the bathroom
- C. Give the client a bedpan or urinal to use
- D. Insert a urinary catheter now instead of waiting
Correct Answer: C
Rationale: Although possibly uncomfortable or embarrassing for the client, the client should not be allowed out of bed after sedation due to safety concerns. Providing a bedpan or urinal is the safest option. The client may or may not need a urinary catheter, depending on the surgical procedure.
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.