ANWERED N120 HESI Case Study: Perioperative Care 2022/2023 Prospect.
After completing the admission interview, the nurse reviews Ms. Jackson's medical record and notes that the surgical consent form is filled out but is not signed by the client. What action should the nurse take? Ask Ms. Jackson if she has received sufficient information to sign the consent form. Call the operating room and notify the staff that the surgery needs to be cancelled. Notify the surgeon of the need to come to the client's room so the consent can be signed. Inform a family member of the need to serve as a witness to the client's signature. - answerAsk Ms. Jackson if she has received sufficient information to sign the consent form. The nurse may witness the client's signature if the nurse is able to determine that the client has been sufficiently informed of the necessary information. After Ms. Jackson ambulates with the physical therapist, the nurse prepares to change the surgical dressing. While obtaining supplies,
the nurse reviews the sterile procedure to be followed. At what step in the procedure should the nurse don sterile gloves? Prior to removing the dressing on the client's hip. Before opening the new sterile dressing package. Before cleansing the client's hip incision. After cleansing the client's hip incision. - answerBefore cleansing the client's hip incision. When using surgical asepsis for wound care, the sterile gloves should be donned prior to cleaning the wound and applying the new sterile dressing. After Ms. Jackson stops crying, she states, "My father was in so much pain before he died. Talking about pain brings back so many memories." How should the nurse respond? "We do not need to talk about pain control today if it makes you sad." "Perhaps you need to see a counselor to help you resolve your grief." "It sounds as if you went through a difficult time when your father died." "You need to focus on your own needs now and
not on past memories." - answer"It sounds as if you went through a difficult time when your father died." This open-ended acknowledgment of the client's distress is therapeutic and allows
the opportunity for further discussion by the client if desired. Based on the lab data provided by
the nurse, the HCP prescribes the transfusion of 2 units of packed red blood cells as soon as possible. Once the first unit of packed red blood cells is ready, the nurse obtains the blood from
the blood bank. When the nurse enters Ms. Jackson's room to begin the transfusion, the UAP is giving Ms. Jackson a partial bath. What action should the nurse take? Place the unit of blood in the medication refrigerator until the client's personal care is completed. Hang the transfusion of packed cells while the UAP continues to complete the client's personal care. Lock the unit of blood in the computerized medication cart and assist the UAP in completing the personal care. Return the blood to the blood bank and send the UAP to obtain the blood when the personal care is completed. - answerHang the transfusion of packed cells while the UAP continues to complete the client's personal care. Transfusion of the blood is a higher priority than personal care. If necessary, the remainder of the care can be delayed. During the postoperative assessment, the nurse observes Ms. Jackson's surgical site. The left hip dressing has a moderate
amount of sanguineous drainage. What action(s) should the nurse implement? Select all that apply Apply pressure to the site. Elevate the leg on a pillow. Observe the linens under the hip. Use sterile technique to replace the dressing. Mark the amount of drainage on the dressing. - answer*Observe the linens under the hip.* Gravity pulls drainage down, so the nurse should inspect the area below the surgical site for additional drainage. *Mark the amount of drainage on the dressing.* Marking the amount of drainage on the dressing will allow for later comparison. Meet the Client: Helen JacksonHelen Jackson, a 63-year-old Caucasian female, arrives at the surgery center for her preoperative appointment. She is scheduled to undergo left
hip replacement surgery in 1 week. The nurse begins the preoperative assessment by taking Ms. Jackson's vital signs. The nurse reviews the medications taken by Ms. Jackson. Ms. Jackson states she has been taking two medications; hydrochlorothiazide (Hydrodiuril), a diuretic, and warfarin (Coumadin), an anticoagulant, every day for more than a year. *Which vital sign requires follow-up by the nurse?* BP of 160/88 nnHg. Pulse of 68 beats/min. Respirations of 14 breaths/min. Temperature of 97.2° F (36.2° C). - answerBP of 160/88 mmHg. This blood pressure is elevated and requires further action by the nurse. Ms. Jackson is currently receiving Lactated Ringer's solution IV at a rate of 75 mL/hour. In transfusing the 250 mL unit of PRBCs, what action should the nurse implement? Stop the IV solution and transfuse the packed cells at 125 mL/hour via tubing connected to a bag of saline solution. Infuse the Lactated Ringer's solution through the IV tubing concurrently with the blood at a combined rate of 75 mL/hour. Flush the IV tubing with a 5 mL bolus of normal saline before and after the transfusion, and transfuse the blood within 1 hour. Replace the Lactated Ringer's solution with the unit of packed red blood cells and administer through the tubing at 75 mL/hour. - answerStop the IV solution and transfuse the packed cells at 125 mL/hour via tubing connected to a bag of saline solution. Packed red blood cells are only compatible with normal saline. The blood should be connected to a bag of saline solution using special Y-tubing and administered within 1½ to 2 hours, if possible, but no longer than 4 hours (250 mL transfused at 125 mL/hour = 2 hours). Ms. Jackson is discharged from the PACU to the acute care unit 2 hours later. She is responding to verbal stimuli and has stable vital signs. When Ms. Jackson arrives on the unit, the nurse notes that her IV is wide open. Review of Ms. Jackson's postoperative prescriptions indicates that 0.9% Normal Saline is to infuse at 75 mL/hour, alternating with Lactated Ringer's solution at 75 mL/hour. An infusion pump is not immediately available, so the nurse notes that the infusion tubing has a drop factor of 15 drops/mL and resets the IV. At what rate in drops/min, should the IV infuse? (Enter numeric value only. If rounding is required, round to the whole number.) - answer19 gtt/min 75 mL/60 minutes × 15 gtts/1 mL = 18.75, which rounds up to 19. Ms. Jackson is prepared for surgery. She states that she feels calm and is "ready to get it over with. Ms. Jackson is transferred to a stretcher and taken to the operating room (OR). The nurse assists Ms. Jackson off the stretcher and onto the OR table. After general anesthesia is induced, the nurse positions Ms. Jackson for surgery. Which nursing diagnosis has the highest priority at this time? Ineffective protection. Ineffective tissue perfusion. Risk for perioperative-positioning injury. Risk for imbalanced body temperature. - answerRisk for perioperative-positioning injury. During surgery the client may remain in one position for a prolonged period. The nurse must ensure that the client is protected from injury secondary to inappropriate positioning. Ms. Jackson shares her experiences related to her father's death with the nurse and expresses
After completing the admission interview, the nurse reviews Ms. Jackson's medical record and notes that the surgical consent form is filled out but is not signed by the client. What action should the nurse take? Ask Ms. Jackson if she has received sufficient information to sign the consent form. Call the operating room and notify the staff that the surgery needs to be cancelled. Notify the surgeon of the need to come to the client's room so the consent can be signed. Inform a family member of the need to serve as a witness to the client's signature. - answerAsk Ms. Jackson if she has received sufficient information to sign the consent form. The nurse may witness the client's signature if the nurse is able to determine that the client has been sufficiently informed of the necessary information. After Ms. Jackson ambulates with the physical therapist, the nurse prepares to change the surgical dressing. While obtaining supplies,
the nurse reviews the sterile procedure to be followed. At what step in the procedure should the nurse don sterile gloves? Prior to removing the dressing on the client's hip. Before opening the new sterile dressing package. Before cleansing the client's hip incision. After cleansing the client's hip incision. - answerBefore cleansing the client's hip incision. When using surgical asepsis for wound care, the sterile gloves should be donned prior to cleaning the wound and applying the new sterile dressing. After Ms. Jackson stops crying, she states, "My father was in so much pain before he died. Talking about pain brings back so many memories." How should the nurse respond? "We do not need to talk about pain control today if it makes you sad." "Perhaps you need to see a counselor to help you resolve your grief." "It sounds as if you went through a difficult time when your father died." "You need to focus on your own needs now and
not on past memories." - answer"It sounds as if you went through a difficult time when your father died." This open-ended acknowledgment of the client's distress is therapeutic and allows
the opportunity for further discussion by the client if desired. Based on the lab data provided by
the nurse, the HCP prescribes the transfusion of 2 units of packed red blood cells as soon as possible. Once the first unit of packed red blood cells is ready, the nurse obtains the blood from
the blood bank. When the nurse enters Ms. Jackson's room to begin the transfusion, the UAP is giving Ms. Jackson a partial bath. What action should the nurse take? Place the unit of blood in the medication refrigerator until the client's personal care is completed. Hang the transfusion of packed cells while the UAP continues to complete the client's personal care. Lock the unit of blood in the computerized medication cart and assist the UAP in completing the personal care. Return the blood to the blood bank and send the UAP to obtain the blood when the personal care is completed. - answerHang the transfusion of packed cells while the UAP continues to complete the client's personal care. Transfusion of the blood is a higher priority than personal care. If necessary, the remainder of the care can be delayed. During the postoperative assessment, the nurse observes Ms. Jackson's surgical site. The left hip dressing has a moderate
amount of sanguineous drainage. What action(s) should the nurse implement? Select all that apply Apply pressure to the site. Elevate the leg on a pillow. Observe the linens under the hip. Use sterile technique to replace the dressing. Mark the amount of drainage on the dressing. - answer*Observe the linens under the hip.* Gravity pulls drainage down, so the nurse should inspect the area below the surgical site for additional drainage. *Mark the amount of drainage on the dressing.* Marking the amount of drainage on the dressing will allow for later comparison. Meet the Client: Helen JacksonHelen Jackson, a 63-year-old Caucasian female, arrives at the surgery center for her preoperative appointment. She is scheduled to undergo left
hip replacement surgery in 1 week. The nurse begins the preoperative assessment by taking Ms. Jackson's vital signs. The nurse reviews the medications taken by Ms. Jackson. Ms. Jackson states she has been taking two medications; hydrochlorothiazide (Hydrodiuril), a diuretic, and warfarin (Coumadin), an anticoagulant, every day for more than a year. *Which vital sign requires follow-up by the nurse?* BP of 160/88 nnHg. Pulse of 68 beats/min. Respirations of 14 breaths/min. Temperature of 97.2° F (36.2° C). - answerBP of 160/88 mmHg. This blood pressure is elevated and requires further action by the nurse. Ms. Jackson is currently receiving Lactated Ringer's solution IV at a rate of 75 mL/hour. In transfusing the 250 mL unit of PRBCs, what action should the nurse implement? Stop the IV solution and transfuse the packed cells at 125 mL/hour via tubing connected to a bag of saline solution. Infuse the Lactated Ringer's solution through the IV tubing concurrently with the blood at a combined rate of 75 mL/hour. Flush the IV tubing with a 5 mL bolus of normal saline before and after the transfusion, and transfuse the blood within 1 hour. Replace the Lactated Ringer's solution with the unit of packed red blood cells and administer through the tubing at 75 mL/hour. - answerStop the IV solution and transfuse the packed cells at 125 mL/hour via tubing connected to a bag of saline solution. Packed red blood cells are only compatible with normal saline. The blood should be connected to a bag of saline solution using special Y-tubing and administered within 1½ to 2 hours, if possible, but no longer than 4 hours (250 mL transfused at 125 mL/hour = 2 hours). Ms. Jackson is discharged from the PACU to the acute care unit 2 hours later. She is responding to verbal stimuli and has stable vital signs. When Ms. Jackson arrives on the unit, the nurse notes that her IV is wide open. Review of Ms. Jackson's postoperative prescriptions indicates that 0.9% Normal Saline is to infuse at 75 mL/hour, alternating with Lactated Ringer's solution at 75 mL/hour. An infusion pump is not immediately available, so the nurse notes that the infusion tubing has a drop factor of 15 drops/mL and resets the IV. At what rate in drops/min, should the IV infuse? (Enter numeric value only. If rounding is required, round to the whole number.) - answer19 gtt/min 75 mL/60 minutes × 15 gtts/1 mL = 18.75, which rounds up to 19. Ms. Jackson is prepared for surgery. She states that she feels calm and is "ready to get it over with. Ms. Jackson is transferred to a stretcher and taken to the operating room (OR). The nurse assists Ms. Jackson off the stretcher and onto the OR table. After general anesthesia is induced, the nurse positions Ms. Jackson for surgery. Which nursing diagnosis has the highest priority at this time? Ineffective protection. Ineffective tissue perfusion. Risk for perioperative-positioning injury. Risk for imbalanced body temperature. - answerRisk for perioperative-positioning injury. During surgery the client may remain in one position for a prolonged period. The nurse must ensure that the client is protected from injury secondary to inappropriate positioning. Ms. Jackson shares her experiences related to her father's death with the nurse and expresses
