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A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care?
- A. Married young adult who is the primary caregiver for children
- B. Middle-aged client who is post long time replacement, needs physical therapy
- C. Older adult who lives at home despite some memory loss
- D. Young client who lives alone, has family and friends nearby
Correct Answer: C
Rationale: The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The client's physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed. The other clients all have evidence of a support system and no known potential for serious safety issues.
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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.
The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best?
- A. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met
- B. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy
- C. Hold educational meetings with the nursing and surgical staff on infection prevention
- D. Monitor staff on both units for consistent adherence to established hand hygiene practices
Correct Answer: A
Rationale: The SCIP project contains core measures that are mandatory for all surgical clients and focuses on preventing infection, serious cardiac events, and venous thromboembolism. The managers should start by reviewing charts to see if the guidelines of this project were implemented. The other actions may be necessary too, but first the managers need to assess the situation.
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 nurse working in the preoperative holding area performs which functions to ensure client safety?
- A. Allow small sips of plain water
- B. Check that consent forms are appropriately completed
- C. Ensure the client has an armband on
- D. Have the client help mark the surgical site
- E. Allow the client to use the toilet before giving sedation
Correct Answer: B,C,D,E
Rationale: Providing for client safety is a priority function of the preoperative nurse. Checking for appropriately completed consent, verifying the client's identity, having the client assist in marking the surgical site if applicable, and allowing the client to use the toilet prior to sedation are important safety measures. The preoperative client should be NPO, so water should not be provided.
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.