N618- Med Surg Saunders Peri-op Q's Fundamentals ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Exam with verified detailed solutions ||\\//|| ||\\//|| ||\\//|| ||\\//||
Terms in this set (68) ||\\//|| ||\\//|| ||\\//|| ||\\//||
Original
1. 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? ||\\//|| ||\\//|| ||\\//||
1. Urinary output of 20 mL/hour
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
2. Temperature of 37.6°C (99.6°F)
||\\//|| ||\\//|| ||\\//|| ||\\//||
3. Blood pressure of 100/70 mm Hg
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
4. Serous drainage on the surgical dressing
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Correct answer: 1 ||\\//|| ||\\//||
Rationale: Urine output should be maintained at a minimum of 30 mL/hour for an adult. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
An output of less than 30 mL for 2 consecutive hours should be reported to the health care
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
provider. A temperature higher than 37.7°C (100°F) or lower than 36.1°C (97°F) and a falling
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
systolic blood pressure, lower than 90 mm Hg, are usually considered reportable
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
immediately. The client's preoperative or baseline blood pressure is used to make informed ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
postoperative comparisons. Moderate or light serous drainage from the surgical site is ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
considered normal. ||\\//||
2. The nurse is teaching a client about coughing and deep-breathing techniques to prevent
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
postoperative complications. Which statement is most appropriate for the nurse to make to ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
the client at this time as it relates to these techniques?
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
1. "Use of an incentive spirometer will help prevent pneumonia."
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
2. "Close monitoring of your oxygen saturation will detect hypoxemia."
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
3. "Administration of intravenous fluids will prevent or treat fluid imbalance."
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Correct answer: 1 ||\\//|| ||\\//||
,Rationale: 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 retained pulmonary secretions. Use of an incentive
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
spirometer helps to prevent pneumonia and atelectasis. Hypoxemia is an inadequate ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
will help to detect hypoxemia, monitoring is not directly related to coughing and deep-
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
a blockage of the pulmonary artery that disrupts blood flow to 1 or more lobes of the lung;
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
this is usually due to clot formation. Early ambulation and administration of blood thinners
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
helps to prevent this complication; however, it is not related to coughing and deep-breathing
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
techniques.
||\\//||
3. The nurse is creating 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?
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
1. Avoid oral hygiene and rinsing with mouthwash.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
2. Verify that the client has not eaten for the last 24 hours.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
3. Have the client void immediately before going into surgery.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
4. Report immediately any slight increase in blood pressure or pulse.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Correct answer: 3 ||\\//|| ||\\//||
Rationale: 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 (or longer as
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
is common during the preoperative period and is usually the result of anxiety.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Cognitive Ability: Creating ||\\//|| ||\\//||
Client Needs: Physiological Integrity ||\\//|| ||\\//|| ||\\//||
Integrated Process: Nursing Process: Planning ||\\//|| ||\\//|| ||\\//|| ||\\//||
Content Area: Fundamentals of Care: Perioperative Care ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Strategy(ies): Subject ||\\//||
Priority Concepts: Clinical Judgment, Palliation ||\\//|| ||\\//|| ||\\//|| ||\\//||
,4. A client with a 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?
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
1. Obtain a court order for the surgery.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
2. Have the charge nurse sign the informed consent immediately.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
3. Send the client to surgery without the consent form being signed.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
4. Obtain a telephone consent from a family member, following agency policy.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Correct answer: 4 ||\\//|| ||\\//||
Rationale: 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 2 persons who hear the family member's oral consent. The 2
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
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, a client may be unable 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
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
the data in the question do not indicate an emergency. Options 1, 2, and 3 are not
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
appropriate in this situation. Also, agency policies regarding informed consent should always ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
be followed.
||\\//||
Cognitive Ability: Applying ||\\//|| ||\\//||
Client Needs: Safe and Effective Care Environment
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Integrated Process: Nursing Process: Implementation ||\\//|| ||\\//|| ||\\//|| ||\\//||
Content Area: Fundamentals of Care: Perioperative Care ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Strategy(ies): Data in the Question, Strategic Words ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Priority Concepts: Ethics, Health Care Law ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
We have an expert-written solution to this problem!
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
5. 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? ||\\//||
, 1. "If it's any help, everyone is nervous before surgery."
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
2. "I will be happy to explain the entire surgical procedure to you."
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
3. "Can you share with me what you've been told about your surgery?"
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
4. "Let me tell you about the care you'll receive after surgery and the amount of pain you
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
can anticipate." ||\\//||
Correct answer: 3 ||\\//|| ||\\//||
Rationale: 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. Option 1 does not focus on the client's ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
anxiety. Explaining the entire surgical procedure may increase the client's anxiety. Option 4
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
avoids the client's anxiety and is focused on postoperative care.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
We have an expert-written solution to this problem!
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
6. The nurse is conducting preoperative teaching with a client about the use of an incentive
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
spirometer. The nurse should include which piece of information in discussions with the ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
client?
1. Inhale as rapidly as possible.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
2. Keep a loose seal between the lips and the mouthpiece.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
3. After maximum inspiration, hold the breath for 15 seconds and exhale.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
4. The best results are achieved when sitting up or with the head of the bed elevated 45 to
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
90 degrees.
||\\//||
Correct answer: 4 ||\\//|| ||\\//||
Rationale: For optimal lung expansion with the incentive spirometer, the client should ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
assume the semi Fowler's or high Fowler's position. The mouthpiece should be covered
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
completely and tightly while the client inhales slowly, with a constant flow through the unit. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
The breath should be held for 5 seconds before exhaling slowly.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Exam with verified detailed solutions ||\\//|| ||\\//|| ||\\//|| ||\\//||
Terms in this set (68) ||\\//|| ||\\//|| ||\\//|| ||\\//||
Original
1. 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? ||\\//|| ||\\//|| ||\\//||
1. Urinary output of 20 mL/hour
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
2. Temperature of 37.6°C (99.6°F)
||\\//|| ||\\//|| ||\\//|| ||\\//||
3. Blood pressure of 100/70 mm Hg
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
4. Serous drainage on the surgical dressing
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Correct answer: 1 ||\\//|| ||\\//||
Rationale: Urine output should be maintained at a minimum of 30 mL/hour for an adult. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
An output of less than 30 mL for 2 consecutive hours should be reported to the health care
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
provider. A temperature higher than 37.7°C (100°F) or lower than 36.1°C (97°F) and a falling
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
systolic blood pressure, lower than 90 mm Hg, are usually considered reportable
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
immediately. The client's preoperative or baseline blood pressure is used to make informed ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
postoperative comparisons. Moderate or light serous drainage from the surgical site is ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
considered normal. ||\\//||
2. The nurse is teaching a client about coughing and deep-breathing techniques to prevent
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
postoperative complications. Which statement is most appropriate for the nurse to make to ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
the client at this time as it relates to these techniques?
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
1. "Use of an incentive spirometer will help prevent pneumonia."
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
2. "Close monitoring of your oxygen saturation will detect hypoxemia."
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
3. "Administration of intravenous fluids will prevent or treat fluid imbalance."
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
4. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Correct answer: 1 ||\\//|| ||\\//||
,Rationale: 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 retained pulmonary secretions. Use of an incentive
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
spirometer helps to prevent pneumonia and atelectasis. Hypoxemia is an inadequate ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
will help to detect hypoxemia, monitoring is not directly related to coughing and deep-
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of
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a blockage of the pulmonary artery that disrupts blood flow to 1 or more lobes of the lung;
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
this is usually due to clot formation. Early ambulation and administration of blood thinners
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helps to prevent this complication; however, it is not related to coughing and deep-breathing
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techniques.
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3. The nurse is creating a plan of care for a client scheduled for surgery. The nurse should
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include which activity in the nursing care plan for the client on the day of surgery?
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
1. Avoid oral hygiene and rinsing with mouthwash.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
2. Verify that the client has not eaten for the last 24 hours.
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3. Have the client void immediately before going into surgery.
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4. Report immediately any slight increase in blood pressure or pulse.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Correct answer: 3 ||\\//|| ||\\//||
Rationale: 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.
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The client usually has a restriction of food and fluids for 6 to 8 hours (or longer as
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prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
is common during the preoperative period and is usually the result of anxiety.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Cognitive Ability: Creating ||\\//|| ||\\//||
Client Needs: Physiological Integrity ||\\//|| ||\\//|| ||\\//||
Integrated Process: Nursing Process: Planning ||\\//|| ||\\//|| ||\\//|| ||\\//||
Content Area: Fundamentals of Care: Perioperative Care ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Strategy(ies): Subject ||\\//||
Priority Concepts: Clinical Judgment, Palliation ||\\//|| ||\\//|| ||\\//|| ||\\//||
,4. A client with a 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?
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
1. Obtain a court order for the surgery.
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2. Have the charge nurse sign the informed consent immediately.
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3. Send the client to surgery without the consent form being signed.
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4. Obtain a telephone consent from a family member, following agency policy.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Correct answer: 4 ||\\//|| ||\\//||
Rationale: 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 2 persons who hear the family member's oral consent. The 2
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
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
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confused, unconscious, mentally incompetent, or under the influence of sedatives. In an
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emergency, a client may be unable 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
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
the data in the question do not indicate an emergency. Options 1, 2, and 3 are not
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
appropriate in this situation. Also, agency policies regarding informed consent should always ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
be followed.
||\\//||
Cognitive Ability: Applying ||\\//|| ||\\//||
Client Needs: Safe and Effective Care Environment
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Integrated Process: Nursing Process: Implementation ||\\//|| ||\\//|| ||\\//|| ||\\//||
Content Area: Fundamentals of Care: Perioperative Care ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Strategy(ies): Data in the Question, Strategic Words ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Priority Concepts: Ethics, Health Care Law ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
We have an expert-written solution to this problem!
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
5. 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? ||\\//||
, 1. "If it's any help, everyone is nervous before surgery."
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
2. "I will be happy to explain the entire surgical procedure to you."
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3. "Can you share with me what you've been told about your surgery?"
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4. "Let me tell you about the care you'll receive after surgery and the amount of pain you
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
can anticipate." ||\\//||
Correct answer: 3 ||\\//|| ||\\//||
Rationale: 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. Option 1 does not focus on the client's ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
anxiety. Explaining the entire surgical procedure may increase the client's anxiety. Option 4
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
avoids the client's anxiety and is focused on postoperative care.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
We have an expert-written solution to this problem!
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
6. The nurse is conducting preoperative teaching with a client about the use of an incentive
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spirometer. The nurse should include which piece of information in discussions with the ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
client?
1. Inhale as rapidly as possible.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
2. Keep a loose seal between the lips and the mouthpiece.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
3. After maximum inspiration, hold the breath for 15 seconds and exhale.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
4. The best results are achieved when sitting up or with the head of the bed elevated 45 to
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
90 degrees.
||\\//||
Correct answer: 4 ||\\//|| ||\\//||
Rationale: For optimal lung expansion with the incentive spirometer, the client should ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
assume the semi Fowler's or high Fowler's position. The mouthpiece should be covered
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
completely and tightly while the client inhales slowly, with a constant flow through the unit. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
The breath should be held for 5 seconds before exhaling slowly.
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