Nokea
The nurse is completing an assessment of the client prior to surgery. What area(s) of the client assessment should the nurse question further? Select all that apply.
- A. Medication
- B. Elimination
- C. Activity
- D. Support system
- E. Dietary preferences
Correct Answer: A,B,C,D
Rationale: When preparing a client for surgery, these areas need to be addressed: skin preparation, elimination, attire/grooming, prosthesis, foods and fluids, and care of valuables. In addition, medication, activity, and the client's support system must be assessed. Dietary preferences of the client would not be a priority during the preoperative assessment.
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The nurse is reviewing a preoperative informed consent when preparing the client for surgery. Which content(s) of the informed consent is required? Select all that apply.
- A. Explanation of procedure
- B. Estimated time of procedure
- C. Potential risks
- D. Benefits of surgery
- E. Personnel present
- F. Description of alternatives
Correct Answer: A,C,D,F
Rationale: Informed consents should be in writing and contain an explanation of procedure and risks, description of benefits and alternative, an offer to answer questions about procedure, ability to withdraw consent, and statement informing the client if the protocol differs from customary procedure. An estimated time of procedure and personnel present are not required in the informed consent.
The nurse is caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock?
- A. Weak and rapid pulse rate
- B. Warm, dry skin
- C. Pooling of secretions in the lungs
- D. Obstructed airway
Correct Answer: A
Rationale: Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock.
The client required reversal drugs after surgery. What nursing intervention is required when caring for a client who is treated with reversal drugs?
- A. Instruct the client to lie flat.
- B. Observe the client for an extended period.
- C. Help the client slowly move to an upright or standing position.
- D. Emphasize the dietary restriction.
Correct Answer: B
Rationale: If reversal drugs are required, the nurse must observe the client for an extended period because the reversal effects nearly always are shorter than the effects of the drugs being reversed. This may result in sedation. The client need not lie flat and may not require assistance for ambulation. There is no specific dietary restriction required when treated with reversal drugs.
The nurse has received shift report on a postoperative surgical client. Which medication prescription would indicate that the medication was being administered prophylactically?
- A. A 5% dextrose in 0.5 NSS to infuse at 100 mL/hr
- B. Percocet two tablets every 4 hours as needed for pain
- C. Humulin NPH 12 units at 0800
- D. Cefazolin 1 g IV every 6 hours for 24 hours
Correct Answer: D
Rationale: Cefazolin, an antibiotic, is commonly administered prophylactically to prevent postoperative infections. A 5% dextrose in 0.5 NSS is used for fluid maintenance, Percocet is for pain management, and Humulin NPH is for diabetes management, none of which are primarily prophylactic in this context.
Several of the clients at the clinic are preparing to have surgery within the next 2 weeks. They are completing preoperative paperwork today with their visit. What is a reason(s) that people might need to have surgery? Select all that apply.
- A. Cosmetic
- B. Diagnostic
- C. Palliative
- D. Normative
- E. Causative
Correct Answer: A,B,C
Rationale: Reasons people have surgery include cosmetic reasons, diagnostic procedures, palliative surgeries, exploratory surgeries, and curative surgeries. Normative and causative are not reasons for surgery.