Chapter 37 Perioperative Nursing Care

Chapter 37  Perioperative Nursing Care

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. The nurse is caring for a patient who is about to have surgery. Which intervention will be included in the patient’s care to meet the goals for Risk for perioperative positioning injury r/t immobilization during surgical procedure?
a.
Orient the patient to the OR environment and place the call light within reach.
b.
Watch for early signs of hypovolemia caused by patient’s NPO status since midnight.
c.
Use therapeutic touch and guided imagery to allay patient’s fears of surgery.
d.
Pad all bony prominences and avoid hyperextension of extremities.

ANS: D
Risk for perioperative positioning injury is addressed by ensuring that the patient’s skin and bony prominences are well padded during the surgery. In addition, hyperextension of extremities may lead to joint damage, so this should be avoided as well. The other interventions are appropriate for perioperative care but do not relate directly to the nursing diagnosis of positioning injury potential.

DIF: Applying REF: p. 911 TOP: Planning
MSC: NCLEX Client Needs Category: Reduction of Risk Potential: Potential for Complications from Surgical Procedures NOT: Concepts: Safety

2. The nurse is caring for a male patient who will soon have open heart surgery. The patient’s chest is covered with thick hair so the surgical technician comes in to shave the patient’s skin near the operative site. Which action by the technician requires intervention by the nurse to correct the technique?
a.
A straight safety razor and antibiotic foam is used
b.
Disposable electric trimmers are used to trim the hair
c.
Antibacterial soap is used prior to hair removal
d.
Only the hair directly around the surgical site is removed

ANS: A
Disposable electric trimmers should be used to remove excess hair from operative
sites. Antibacterial soap is commonly used to clean the skin before surgical procedures. Only the hair around the surgical site is removed. A straight razor should never be used because small nicks in the skin can occur, increasing infection risk.

DIF: Remembering REF: p. 911 TOP: Implementation
MSC: NCLEX Client Needs Category: Safety and Infection Control: Safe Use of Equipment
NOT: Concepts: Infection

3. The nurse is caring for a patient who has just been brought to the postoperative unit following major surgery. The patient has many tubes and monitors in place. Which will the nurse assess first?
a.
The patient’s intravenous lines
b.
The patient’s urinary catheter
c.
The patient’s nasogastric tube
d.
The patient’s endotracheal tube

ANS: D
Airway maintenance and protection is the highest priority for this patient, so the nurse should assess the endotracheal tube first to ensure that it is patent and positioned correctly. The other tubes may be assessed afterward.

DIF: Applying REF: p. 922 | p. 932 TOP: Assessment
MSC: NCLEX Client Needs Category: Management of Care: Establishing Priorities
NOT: Concepts: Clinical Judgment

4. The nurse is caring for a patient who has a family history of reactions to general anesthesia. Which medication will the anesthesiologist have ready as a precautionary measure before the patient’s surgery is started?
a.
Protamine sulfate
b.
Dantrolene sodium (Dantrium)
c.
Activated charcoal with sorbitol
d.
Folinic acid (Leucovorin)

ANS: B
Malignant hyperthermia is a dangerous anesthesia reaction caused by a genetic defect that may be passed down via family history. Knowing this, the anesthesiologist should have Dantrium ready as a precaution because it is a mainstay of treatment for malignant hyperthermia.

DIF: Applying REF: p. 917 TOP: Implementation
MSC: NCLEX Client Needs Category: Reduction of Risk Potential: Potential for Complications from Surgical Procedures NOT: Concepts: Clinical Judgment

5. Which action by the nurse best demonstrates accountability in the operating room?
a.
Applying warm blankets when the patient reports feeling chilly
b.
Holding the patient’s hand to allay anxiety before anesthesia is administered
c.
Double-checking that the surgical site is clearly marked and visible after draping
d.
Using calming speech with a reassuring tone of voice when speaking with the patient

ANS: C
Accountability is accomplished by ensuring that proper precautions are taken to prevent errors from happening. The nurse can prevent wrong-site surgery by making sure that the surgical site is clearly marked and visible after the draping is completed. The surgeon could inadvertently operate on the incorrect site if the markings are covered by the surgical drapes. The other actions of the nurse are appropriate but do not demonstrate accountability and error prevention.

DIF: Applying REF: p. 931 TOP: Implementation
MSC: NCLEX Client Needs Category: Safety and Infection Control: Error Prevention
NOT: Concepts: Safety