ATI Med-surg: Perioperative Nursing Rated A+

ATI Med-surg: Perioperative Nursing Rated A+ What should the nurse do before witnessing the client signing an informed consent who has expressed fears of the surgery? Ask the surgeon to speak to the client for clarification Medication history: which medicine puts the client at risk for complications with anesthetic? captopril (ace inhibitor) Jehovah's witnesses are not allowed to accept blood Surgical suites are kept at cool temps with low humidity because it helps reduce risk of ____ risk for infection Bowel obstruction, 24 hour vomiting, pain: 8, hard distended abdomen and absent bowel sounds. Notify provider then? insert an NG tube To maintain surgical asepsis; intervention is necessary when you notice: the scrub nurse is wearing a watch under his scrubs Which medicine should be discontinued 48 hours prior to surgery? warfarin Client's wound has eviscerated, after applying sterile, saline soaked dressing what should the nurse do next? Obtain vital signs to assess for shock What is an unexpected finding for a post-op client? urine output of 20 mL/hr Client receiving succinylcholine; what should you do if pt develops malignant hyperthermia? administer Dantrolene Post-op pt; what intervention to prevent respiratory complications? client splint incision when coughing and deep breathing Pt. with penrose drain; intervention: use sterile technique when performing dressing changes Client with a Jackson-Pratt (JP) drain? empty and compress the reservoir as needed Client receives versed and fentanyl for moderate sedation: Rep rate goes from 16 to 6 O2 sat: 92-85%; what do you do? administer reversal agents NG tube on continuous low suction. What finding do you report? gastric distention client to undergo moderate sedation...client understands teaching when they state: "I can expect to feel sleepy for several hours after procedure" Post total hip arthroplasty. Client is at increased risk for infection when: They have had long term use of corticosteroids Further teaching to a post abdominal surgery is needed to a client who states: "I will remain on bed rest until my follow-up appt" reoperative teaching to client: client is scared, what do you do? Provide concise, factual information Pt is having a mastectomy; needs further teaching when they state: "I'll wait a week to do hand strengthening exercises" What finding shows the pt in PACU is ready to be discharged? client is able to move all 4 limbs Client has a PCA pump; teaching? family should NOT push pump if you are asleep What lab value should be reported before surgery? potassium level at 2.8 mEq/L (normal is 3.5-5) After oral surgery; tongue is swollen and obstructing airway: what should the nurse do first? head tilt ABC's Which post-op pt should be assessed first? pt post thoracotomy who has a chest tube with 150 mL of bright red blood in collection chamber after 1 hr Nurse assessing client recovering spinal anesthesia; which sensation should return first? Touch Recovering from spinal anesthesia; when should you notify the provider: reports of chest pain and SOB Prevention of neuromuscular complications during surgery; intervention: support bony prominences with foam padding Post-op pt; prevent thrombi in the post-op period; pt should? Perform dorsal/plantar felxion of feet every hour Pt with total hysterectomy 2 day prior; reveals right calf to be red, edematous, and warm to touch; what