Nokea
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.
You may also like to solve these questions
A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats per minute and now needs a beta blocker. The student asks why this was needed. What response by the nurse is best?
- A. Tachycardia increases the workload of the heart
- B. Tachycardia requires less oxygen delivery
- C. A high heart rate reduces cardiac effort
- D. A high heart rate prevents surgical stress
Correct Answer: A
Rationale: Tachycardia increases the workload of the heart and requires more oxygen delivery to the myocardial tissues. This added strain is not needed on top of the physical and emotional stress of surgery. The other statements are not accurate.
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.
An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nursing physical activity on which assessment?
- A. Change in behavior
- B. Daily white blood cell count
- C. Presence of fever and chills
- D. Tolerance of increasing activity
Correct Answer: A
Rationale: Older people have an age-related decrease in immune system functioning and may not show classic signs of infection such as increased white blood cell count, fever and chills, or obvious localized signs of infection. A change in behavior often signals an infection or onset of other illness in the older client.
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.
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.