AG2 Exam 4 Review

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?

• Urine output of 20ml/hour

• Temperature of 37.6 C

• Blood pressure of 114/70

• Serous drainage on the surgical dressing

Answer explanation

Urine output should be maintained at a minimum of 30mL/hour for an adult. An output of less than that for each of 2 consecutive hours should be reported to the health care provider.

A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition?

• Hypoxemia

• Fluid imbalance

• Pneumonia

• Pulmonary embolism

Answer explanation

Postoperative respiratory problems are atelectasis, pneumonia and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by the retention of pulmonary secretions.

The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?

• Avoid oral hygiene and rinsing with mouthwash

• Verify that the client has not eaten for the last 24 hours

• Have the client void immediately before going into surgery

• Report immediately any slight increase in BP or pulse

Answer explanation

The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A slight increase in BP and pulse is common during the preoperative period due to anxiety.

A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?

• Obtain a court order for the surgery

• Have the charge nurse sign the informed consent immediately

• Send the client to surgery without the consent form being signed

• Obtain a telephone consent from a family member, following agency policy

Answer explanation

Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency the client may not be able to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but tin this case it is not an emergency. Agency policies regarding informed consent should always be followed.

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

• "If it's any help, everyone is nervous before surgery."

• "Can you share with me what you've been told about your surgery?"

• "I will be happy to explain the entire surgical procedure with you."

• "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate".

Answer explanation

Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply

• Contact the surgeon

• Instruct the client to remain quiet

• Place a sterile saline dressing and icepacks over the wound

• Prepare the client for wound closure

• Document the findings and actions taken

Answer explanation

Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low fowlers position and the client is kept quite and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

A nurse is caring for a client who develops malignant hyperthermia. Which of the following actions should the nurse take? SATA

• Infuse iced IV fluids

• Provide 100% O2

• Place cooling blanket on client

• Treat complication while continuing surgery

• Administer IV dantrolene

Answer explanation

Measures to cool down patient and maintain a patent airway is priority. Administer IV dantrolene which is a muscle relaxant that treats malignant hyperthermia. The procedure should be canceled immediately

A nurse is caring for a client who reports a headache following an epidural regional nerve block. Which of the following actions should the nurse take?

• Decrease the clients fluid intake

• Apply pressure to the puncture site

• Place head of bed flat

• Instruct client to lie prone

Answer explanation

Client is experiencing a headache due to CSF leak. Increasing fluids would help replace CSF loss, applying pressure to site will not stop leakage as CSF composition is different from blood, keeping head of bed flat promotes dura tear to seal, lying prone will worsen the headache

A client is to receive proprofol as an IV anesthetic. For what reason should the nurse question the order?

• Age 45

• Female gender

• Allergy to soybeans

• O2 sat of 96 on room air

Answer explanation

allergy to eggs and soybean oil are contraindications

A nurse is assessing a client's lab values before surgery. Which of the following results should the nurse report to the provider? (SATA)

• Potassium 3.9

• Sodium 145

• Creatinine 2.8

• Blood glucose 235

• WBC 17,850

Answer explanation

Potassium and sodium are WNL, Creatinine is 0.6~1.3, blood glucose should be 70~110, WBCs should be 4,500~10,000