Nokea
Ten minutes after the nurse administered the ordered preoperative opioid by intravenous (IV) injection, the patient asks to get up to go to the bathroom to urinate. Which of the following actions is best for the nurse to implement?
- A. Assist the patient to the bathroom and ensure a call bell is within reach.
- B. Offer a urinal or bedpan and position the patient in bed to promote voiding.
- C. Allow the patient up to the bathroom because the onset of the medication takes more than 10 minutes.
- D. Ask the patient to wait because catheterization is performed at the beginning of the surgical procedure.
Correct Answer: B
Rationale: The patient will be at risk for a fall after receiving the opioid, so the best nursing action is to have the patient use a bedpan or urinal. Having the patient get up either with assistance or independently increases the risk for a fall. The patient will be uncomfortable and risk involuntary incontinence if the bladder is full during transport to the operating room.
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The clinic nurse is reviewing the complete blood cell count (CBC) results for a patient who is scheduled for surgery in a few days. The results are white blood cell count (WBC) 10.2 ?? 10/1, hemoglobin 150 g/1, hematocrit 45%, platelets 150 ?? 10/1. Which of the following actions should the nurse take?
- A. Send the CBC results to the surgery facility.
- B. Call the surgeon and anaesthesiologist immediately.
- C. Ask the patient about any symptoms of a recent infection.
- D. Discuss the possibility of blood transfusion with the patient.
Correct Answer: A
Rationale: The nurse should be sure that the CBC results, which are normal, are available at the surgical facility to avoid delay of the procedure. With normal results, there is no need to notify the surgeon or anaesthesiologist, discuss blood transfusion, or ask about recent infection.
A patient arrives at the ambulatory surgery centre for a scheduled outpatient surgery. Which of the following information is of most concern to the nurse?
- A. The patient has not had outpatient surgery before.
- B. The patient is planning to drive home after surgery.
- C. The patient may not have paid sick leave from work.
- D. The patient had a glass of water a few hours before arriving.
Correct Answer: B
Rationale: After outpatient surgery, the patient should not drive home and will need assistance with transportation and home care. The patient's experience with outpatient surgery is assessed, but it does not have as much application to the patient's physiological safety. The patient's insurance coverage is important to establish, but this is not usually the nurse's role or a priority in nursing care. Having clear liquids a few hours before surgery does not usually increase risk for aspiration as the guideline indicates that clear fluids can be taken up to two hours before surgery.
According to the ASA Physical Status Classification System, which of the following assessments is consistent with a rating of ASA III?
- A. Persistent asthma, controlled with an inhaler and corticosteroids
- B. Poorly controlled asthma and is wheezing
- C. Is in status asthmaticus and on a ventilator
- D. Has no significant health problems
Correct Answer: A
Rationale: A patient assessed as a rating of III on the ASA Physical Status Classification System has a history of persistent asthma controlled with β-adrenergic agonist inhaler and inhaled corticosteroids and is not wheezing. Poorly controlled asthma and wheezing is a rating of IV. No significant health problems, past or present, is a rating of I. A patient in status asthmaticus, intubated and on a ventilator, receiving corticosteroids intravenously, is rated as a V.
The nurse is admitting a female patient for an outpatient surgery procedure. Which of the following information is most important to report to the anaesthesiologist before surgery?
- A. The patient's lack of knowledge about postoperative pain control measures
- B. The patient's statement that her last menstrual period was 8 weeks previously
- C. The patient's history of a postoperative infection following a prior cholecystectomy
- D. The patient's concern that she will be unable to care for her children postoperatively
Correct Answer: B
Rationale: This statement suggests that the patient may be pregnant, and pregnancy testing is needed before administration of anaesthetic agents. Although the other data also may be communicated with the surgeon and anaesthesiologist, they will affect postoperative care and do not indicate a need for further assessment before surgery.
The nurse is preparing a patient for abdominal surgery who takes a diuretic and a β-blocker pill to control blood pressure. Which of the following patient information is most important for the nurse to communicate to the health care provider before surgery?
- A. Pulse rate 59 beats/minute
- B. Hematocrit 35%
- C. Blood pressure 142/78 mm/Hg
- D. Serum potassium 3.3 mmol/L
Correct Answer: D
Rationale: The low potassium level may increase the risk for intraoperative complications such as dysrhythmias. Slightly elevated blood pressure is common before surgery because of patient anxiety. The heart rate would be expected in a patient taking a β-blocker. The hematocrit is in the low normal range but does not require any intervention before surgery.