Med-Surg Exam 1

Because of an unexpected emergency case, a client scheduled for colon surgery at 8 am has been rescheduled for 11 am. What is the nurse's best action related to preoperative prophylactic antibiotic administration according to the Surgical Care Improvement Project (SCIP) guidelines? A Administer the preoperative antibiotic at 7 am as originally prescribed. B Administer the antibiotic at the same time as the other prescribed preoperative drugs. C Adjust the antibiotic administration time to be within 1 hour before the surgical incision. D Hold the preoperative antibiotic until the client is actually in the operating room and has been anesthetized. - correct answer C - The goal of prophylaxis is to establish bactericidal tissue and serum levels at the time of skin incision. The SCIP recommendations are that the antibiotic be administered 1 hour before the actual surgical incision. Giving the drug at 7 AM seriously interferes with maintaining the blood (serum) level at the proper level when the surgery is actually taking place. Administering the antibiotic with the other preoperative drugs may or may not be within the recommended time frame. Waiting until the client is anesthetized is too late for best antibiotic action and peak serum levels. What will withdrawal of alcohol before surgery lead to? - correct answer Delirium Tremens An 81-year-old client, scheduled for a long orthopedic procedure, appears to have a low body mass index. In addition to the body mass index value, which additional client information is most important for the nurse to report to the surgeon and perioperative team as indicating an increased risk for skin breakdown? A Negative nitrogen balance B Previous abdominal surgery C Allergy to latex products D Change in mental status upon admission - correct answer A - A negative nitrogen balance can be a sign of inadequate protein intake and malnutrition, resulting in a low BMI. These factors contribute to skin breakdown. Although the change in mental status can increase the risk for skin breakdown after surgery if the client is not aware of the need to change position, it is not the most critical risk factor at this time. The allergy to latex products is critical information to communicate to the perioperative team but does not contribute to skin breakdown. The preoperative admitting nurse notices that the client scheduled for total joint replacement surgery in 2 hours has a smell of alcohol on his breath even though he has just stated that he has fasted completely for the past 10 hours. What is the nurse's best first action? A Accept the client's statement and continue the preoperative preparation. B Report the discrepancy to the surgeon and anesthesiologist immediately. C Tell the client the observation and provide the opportunity for him to explain. D Remind the client that alcohol consumption may require changes in anesthesia procedure. - correct answer C - Although alcohol consumption before a surgical procedure with anesthesia can cause serious problems, the nurse should not "jump to conclusions" with his or her observations. Before informing the surgeon and anesthesiologist, the nurse should provide the client with the opportunity to explain the alcohol smell on his breath. Some mouthwashes contain chemicals and alcohol that could leave a perceptible odor. Also, the nurse could be mistaken about the odor. The patient states the surgeon discussed the addition of a second procedure to the one indicated on the consent. The patient is visibly upset that the consent he is asked to sign with the surgical resident reflects only one procedure and cannot understand why the nurse and resident do not have the authority to "fix" the consent. In addition, he states he will not take his wedding ring off because it has never left his hand since his wife put it there 30 years ago. 1. How would you address the patient's immediate concern regarding the consent? 2. Under what conditions could the second procedure be performed? 3. What remedy would you propose to prevent such occurrences in the future? 4. How will you respond to the patient's unwillingness to remove his wedding ring? - correct answer 1. How would you address the patient's immediate concern regarding the consent? Focus your answer on the safety aspect of the situation while acknowledging the patient's frustration. Inform the patient that you will contact the surgeon to clarify the consent in terms of accuracy and that neither you nor the surgical resident not have the authority to alter the consent without the surgeon's knowledge. Document it in the medical record. 2. Under what conditions could the second procedure be performed? The second procedure could be performed if a new consent is developed with both procedures listed and signed by the patient. This new consent can only be used if the patient is not under the influence of preoperative drugs that could cloud his judgment and if the patient has received adequate information regarding both procedures to be able to make an informed choice. 3. What remedy would you propose to prevent such occurrences in the future? Discuss the occurrence with the perioperative team, review existing policy, and make changes as needed. Propose a process for facilitating communication among departments and team members. 4. How will you respond to the patient's unwillingness to remove his wedding ring? Explain to him that removal of the ring is not necessary if the finger is not the operative site. Tape the ring in place if agency policy permits. If the agency does not permit this action, explain why and have his wife keep the ring with her until she sees him after surgery. Colostomy surgery is categorized as what type of surgery? Cosmetic Curative Diagnostic Palliative - correct answer Pallative - Palliative surgery is performed to relieve symptoms of a disease process, but does not cure the disease. Cosmetic surgery is performed primarily to alter or enhance personal appearance. Curative surgery is performed to resolve a health problem by repairing or removing the cause. Diagnostic surgery is performed to determine the origin and cause of a disorder or the cell type for cancer. In going through the preoperative checklist, the nurse notices that the client's armband does not match the handwritten name on the informed consent, but it matches the stamped name. What does the nurse do first? Call admissions. Cancel the surgery. Contact the surgeon. Talk to the operating team. - correct answer Talk to the operating team - The operating team should be called to see if any clients with similar names are having surgery done. The client should confirm the spelling of his or her last name. Also, confirm the procedure that is expected to be done and compare it with the informed consent form. Calling admissions is not the first step; the stamp is correct. Canceling surgery is not done by the floor nurse. This is an administrative issue, and not one for the surgeon. As the nurse obtains the informed consent, the client asks, "Now what exactly are they going to do to me?" What is the nurse's response? Contact the anesthesiologist. Contact the surgeon. Explain the procedure. Have the client sign the form. - correct answer Contact the surgeon - The nurse is not responsible for providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the health care provider and dispel myths that the client or family may have heard about the surgical experience. The anesthesiologist is responsible for the anesthesia, not the surgical details. Although the nurse is only witnessing the signature, it is the nurse's role to ensure that the facts are clarified before the consent form is signed. The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction? "I will wake up with a tube in my throat." "I will have a bandage on my chest." "My family will not be able to see me right away." "Pain medication will take away my pain." - correct answer "Pain medication.." - Pain medication will minimize pain, but will not take it away completely. The client statement about waking up with a tube in the throat is accurate, because the client will be intubated. Following heart surgery, a dressing is placed on the chest. The client will not be able to see family immediately because he or she will go to recovery first An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? Call the legal department to draft the paperwork. Document this in the chart. Thank the person and do nothing else. Talk to the client. - correct answer Talk to the client - The nurse should determine the client's wishes and state of mind. The nurse should not call the legal department or document in the client's chart before speaking with the client. Doing nothing is not appropriate. A preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best physical outcomes? Instruct the client to quit smoking. Teach about the dangers of tobacco. Teach the importance of incentive spirometry. Tell the client where the smoking lounge is. - correct answer Teach the importance of incentive spirometry - Incentive spirometry is good for lung hygiene; it encourages deep breathing. The nurse can suggest quitting or advise about the dangers of tobacco, but it is not therapeutic to instruct it at this time. Directing the client to the smoking lounge is not helpful or therapeutic. During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? "I am taking vitamins." "I drink a glass of wine a night." "I had a heart attack 4 months ago." "I don't like latex balloons." - correct answer "heart attack.." - Cardiac problems increase surgical risks, and the risk for a myocardial infarction during surgery is higher in clients who have heart problems. The type of vitamins the client takes should be assessed, but this is not the highest risk. Moderate alcohol consumption is not considered high-risk behavior. A dislike for latex is not the same as a latex allergy (however, it might be a good idea to ask why the client doesn't like latex balloons). The nurse completes the preoperative checklist on a client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure? Age 59 years General anesthesia complications experienced by the client's brother Diet-controlled diabetes mellitus Ten pounds over the client's ideal body weight - correct answer Diet-controller DM - Diabetes contributes an increased risk for surgery or postsurgical complications. Older adults are at greater risk for surgical procedures, but this client is not classified as an older adult. Family medical history and problems with anesthetics may indicate possible reactions to anesthesia, but this is not the best answer. Obesity increases the risk for poor wound healing, but being 10 pounds overweight does not categorize this client as obese. Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist? Creatinine, 1.9 mg/dL Fasting glucose, 80 mg/dL Potassium, 3.9 mEq/L Sodium, 140 mEq/L - correct answer Creatinine - A creatinine of 1.9 mg/dL is outside the normal range and may indicate renal problems. A fasting glucose of 80 mg/dL, a potassium level of 3.9 mEq/L, and sodium level of 140 mEq/L are normal laboratory values A client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. Why is this preoperative procedure done? Decrease expected blood loss during surgery Eliminate any risk of infection Ensure that the bowel is sterile Reduce the number of intestinal bacteria - correct answer Reduce number of bacteria - Bowel or intestinal preparations are performed to empty the bowel to minimize the leaking of bowel contents, prevent injury to the colon, and reduce the number of intestinal bacteria. Decreasing expected blood loss and sterilizing the bowel are not the goals of a bowel preparation. While the bowel prep may reduce the number of intestinal bacteria, it will not completely eliminate the risk of infection. The nurse is instructing a client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching? "I will take off my stockings one to three times a day for 30 minutes." "My stockings are too loose." "These stockings will prevent blood clots." "These stockings help promote blood flow." - correct answer "will prevent blood clots" - Antiembolism stockings alone will not prevent deep vein thrombosis (DVT). However, along with exercise, they will help promote venous return, which aids in preventing DVT. Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. Stockings should be neither too loose (ineffective) nor too tight (inhibit blood flow). Antiembolism stockings may be used during and after surgery to promote venous return. Which task would be best for the charge nurse to assign to the LPN/LVN working in the surgery admitting area? Provide preoperative teaching to a client who needs insertion of a tunneled central venous catheter. Insert a retention catheter in a client who requires a flap graft of a sacral pressure ulcer. Obtain the medical history from a client who is scheduled for a total hip replacement. Assess the client who is being admitted for an elective laparoscopic cholecystectomy - correct answer Insert retention catheter - Insertion of a catheter is within the scope of skills approved for the LPN/LVN. Preoperative teaching and physical assessment of a preoperative client are under the scope of the RN. History information would be completed by the RN on the unit. At 8:00 a.m., the registered nurse is admitting a client scheduled for sinus surgery to the outpatient surgery department. Which information given by the client is of most immediate concern to the nurse? An allergy to iodine and shellfish Being nauseated after a previous surgery Having a small glass of juice at 7:00 a.m. Expressing anxiety about the surgery - correct answer glass of juice - Clients need to be NPO for a sufficient length of time before surgery. Intake of food or fluids may delay the start time of the surgery, so the nurse must notify the surgeon and anesthesiologist for possible rescheduling. The nurse should confirm that all allergies are charted, and that the client has the correct allergy band identification. Many clients experience nausea after surgery; the nurse should document this in the client's information as well. The nurse should talk with the client and explore the anxiety; this is a normal feeling before surgery. A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order does the nurse accomplish first? Use electric clippers to cut hair at the surgical site. Start an infusion of lactated Ringer's solution at 75 mL/hr. Administer one-half of the client's usual lispro insulin dose. Draw blood for glucose, electrolyte, and complete blood count values. - correct answer Draw blood - If blood work is abnormal, the surgery may be rescheduled. The blood sample needs to be drawn and sent to the laboratory first to confirm that results are within normal limits. Removal of hair can be accomplished in the operating room directly before the start of surgery. The IV infusion can be accomplished after the laboratory orders have been completed. The nurse should check blood glucose with the laboratory orders before administration of lispro. An unidentified client from the emergency department requires immediate surgery, but he is not conscious and no one is with him. What must the nurse, who is verifying the informed consent, do? Ensure written consultation of two noninvolved physicians. Read the surgeon's consult to determine whether the client's condition is life-threatening. Sign the operative permit. Withhold surgery until the next of kin is notified - correct answer Written consultation of 2 noninvolved physicians - In a life-threatening situation in which every effort has been made to contact the person with medical power of attorney, consent is desired but not essential. In place of written or oral consent, written consultation by at least two physicians who are not associated with the case may be requested by the health care provider. It is not within the nurse's role to make a judgment about the client based on the surgeon's consult. Signing documents on the client's behalf is not legal. Withholding surgery is not in this client's best interests. While at the scrub sink, the scrub person informs the circulating nurse that she now wears artificial nails because her own nails break frequently posing a risk for a glove puncture. What is the nurse's best response? A. Ask the scrub person to wear double-gloves to prevent puncture or contamination. B. Confirm with the scrub person that artificial nails are acceptable and do not affect hand hygiene. C. Support the scrub person's rationale that broken nails are a serious source of cross-contamination. D. Remind the scrub person that artificial nails alter skin flora, impede hand hygiene, and are not permitted. - correct answer D - Although a punctured glove can cause contamination, artificial nails have been proven to harbor many pathogenic organisms even after the person has correctly performed an appropriate scrub. The World Health Organization's Guidelines on Hand Hygiene in Health Care warn against their presence in scrubbed