Nokea
A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the client are being met?
- A. Drain output is clear and minimal
- B. Drain site is red and swollen
- C. Drain is clogged and not draining
- D. Client reports severe pain at drain site
Correct Answer: A
Rationale: A clear and minimal drain output indicates that the surgical site is healing appropriately and there is no significant infection or fluid accumulation. Redness and swelling, a clogged drain, or severe pain could indicate complications such as infection or obstruction, which would require further intervention.
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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 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.
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 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.