Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition - Perioperative Care

Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition - Perioperative Care Related

Review Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition - Perioperative Care related questions and content

The nurse is assigned a client scheduled for an outpatient colonoscopy in an ambulatory care setting. During which phase of perioperative care would the nurse document the admission vital signs in the recovery room?

  • A. During the preoperative phase
  • B. During the intraoperative phase
  • C. During the transfer phase
  • D. During the postoperative phase
Correct Answer: D

Rationale: The nurse realizes that documentation of vital signs in the recovery room begins the postoperative phase of perioperative care. The preoperative phase occurs until the client reaches the operating area. The intra operative phase includes the entire surgical procedure until the transfer to the recovery area. There is no transfer phase of perioperative care.

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The nurse is reviewing a postoperative client's chart prior to a physician's office visit. Lab reports reveal a prior WBC of 40,000/mm3 (40*10s/L), a current WBC count of 8,000/mms (8*10s/L), and a current wound culture negative, following a Staphylococcus aureus infection. Tertiary intention of wound healing is documented at the last visit. Which current assessment of wound healing is anticipated?

  • A. Wound edges well approximated. No redness/swelling noted.
  • B. Edges of incision well approximated with the center of incision open. Green purulent drainage noted.
  • C. Wound edges sutured. Scant amount of drainage noted. No foul odor.
  • D. Wound packed with 0.5-in (1.25-cm) sterile packing material; interior pink.
Correct Answer: C

Rationale: The scenario stated a previous wound infection that has resolved. Sutured wound edges are present once the wound has been cleaned of infection as noted in tertiary intention of wound healing. Well-approximated edges are healing without infection. Wound packing is noted in secondary intention. Green purulent drainage is noted with a wound infection.

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?

  • A. Place a dry, sterile dressing over the protruding organs.
  • B. Place a pressure dressing over the opening and secure.
  • C. Have the client lay quietly on back and call the physician.
  • D. Moisten sterile gauze with sterile normal saline and place on the protruding organ.
Correct Answer: D

Rationale: A wound evisceration occurs when the wound completely separates, and the internal organs protrude. The first action by the nurse would be to cover the protruding organs with sterile dressings moistened with sterile normal saline. Once the client is safe, the nurse can notify the physician. The client is positioned in a manner that places the least stress on the organs. Dry or pressure dressings are not placed over the protruding organ.

The nurse is caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?

  • A. Place pillows under the client's knees or calves.
  • B. Encourage the client to move legs frequently and do leg exercises.
  • C. Apply pressure on the client's lower extremities.
  • D. Maintain the client in a side-lying position.
Correct Answer: B

Rationale: The nurse should encourage the client to move legs frequently and do leg exercises to prevent venous stasis and other circulatory complications. The nurse should not place pillows under the client's knees or calves unless prescribed and should avoid placing pressure on the client's lower extremities. Placing the client in a side-lying position will not help prevent venous stasis and other circulatory complications in a client who has undergone surgery.

The nurse is creating a plan of care for a client who is about to undergo surgery. When should the nurse provide teaching to the client about care needed during the postoperative period?

  • A. At discharge with an adult who will be responsible for the client
  • B. On arrival to the surgical unit
  • C. Following the surgical procedure
  • D. At the time of discharge instructions
Correct Answer: A

Rationale: Because sedative medications affect memory for events surrounding their administration, the nurse must review discharge instructions with an adult who will be responsible for the client after discharge. Clients and family members can better be prepared and participate in the recovery period if they know what to expect. Anxiety is a factor on arrival to the surgical unit, which could interfere with learning. Pain could interfere with the learning process, following a surgical procedure.

The nurse is admitting and preparing the client for surgery. Following administration of lorazepam 2 mg orally, one time dose, which safety measure is most appropriate?

  • A. Place the client in a semi-Fowler's position.
  • B. Place the side rails in the up position.
  • C. Remove the water pitcher from the bedside.
  • D. Instruct the family to call for any client needs.
Correct Answer: B

Rationale: Lorazepam is a common hypnotic administered to reduce preoperative anxiety. The most appropriate safety measure is to limit the client's ability to get out of bed following administration of a preoperative sedative. Assistance is needed to maintain client safety. Placing the client in a semi-Fowler's position aids in gas exchange, but this is not indicated as a concern in this question and does not relate to a safety concern associated with this medication. Water should not be at the bedside for a client in the preoperative phase. Families can be helpful support for the client; however, it is the nurse's responsibility to maintain safety.

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