652 The Nursing Care of Adults with Medical and Surgical Health Problems

120. The nurse is planning care for a client with 125. The client’s identification armband was
severe postoperative pain. There is an order for removed to start an I.V. line as a part of the
10 mg MSO4. Which of the following should the preoperative preparation. The transport team has
nurse do first? arrived to transport the client to the operating
■ 1. Obtain an intravenous infusion system. room. The nurse notices that the client’s identifica-
■ 2. Prepare the medication for administration. tion band is not on his wrist. What is the nurse’s
■ 3. Contact the Pharmacy Department. best response?
■ 4. Contact the physician that ordered the medi- ■ 1. Send the removed armband with the chart
cation. and the client to the operating room.
■ 2. Place a new identification armband on the cli-
121. The client has returned to the surgery unit ent’s wrist before transport.
from the Post Anesthesia Care Unit (PACU). The
■ 3. Tape the cut armband back onto the client’s
client’s respirations are rapid and shallow, the pulse
wrist.
is 120, and the blood pressure is 88/52. The client’s
■ 4. Send the client without an armband because
level of consciousness is deteriorating. The nurse
she can verbally identify herself.
should do which of the following first?
■ 1. Call the Post Anesthesia Care Unit (PACU).
■ 2. Call the primary care physician.
■ 3. Call the respiratory therapist.
■ 4. Call the Rapid Response Team. Answers, Rationales, and Test
122. When completing the Preoperative Checklist Taking Strategies
on the nursing unit, the nurse discovers an allergy
that the client has not reported. What should the The answers and rationales for each question
nurse do first? follow below, along with keys ( ) to the cli-
■ 1. Administer the prescribed pre-anesthetic ent need (CN) and cognitive level (CL) for each
medication. question. Use these keys to further develop your
■ 2. Note this new allergy prominently at the front test-taking skills. For additional information about
of the chart. test-taking skills and strategies for answering ques-
■ 3. Contact the scrub nurse in the operating tions, refer to pages 10–21, and pages 25–26 in Part
room. 1 of this book.
■ 4. Inform the nurse anesthetist.
123. Which of the following activities should the
nurse encourage the unlicensed assistive personnel The Client Who Is Preparing
to assist with in the care of postoperative clients? for Surgery
Select all that apply.
■ 1. Empty and measure indwelling urinary cath- 1. 4. The health history is conducted to ascer-
eter collection bags. tain a client’s state of wellness or illness. A personal
■ 2. Reposition clients for pain relief. dialogue between a client and a nurse is conducted
■ 3. Teach clients the proper use of the incentive to obtain information. To achieve a relationship of
spirometer. mutual trust and respect, the nurse must have the
■ 4. Tell the nurse if clients report they are having ability to communicate a sincere interest in the
pain. client. The therapeutic communication must be
■ 5. Assess I.V. insertion site for redness. adapted to the responses, problems, and needs of
124. A very elderly, drowsy client with fragile skin the client. Reassurance and the remaining options
is being transferred from the surgery cart to the bed. do not demonstrate that the nurse is genuinely inter-
How should the nurse plan to direct the transfer to ested in the client’s needs.
prevent skin shearing? CN: Psychosocial adaptation;
■ 1. With two people at each side using a draw- CL: Synthesize
sheet.
■ 2. With two people, one at each side using a 2. 1, 2, 3. Treatment and diagnostic evaluation
drawsheet, and one person at the head. must be done in a latex-safe environment. Signs/
■ 3. With two people using a roller and a draw- symptoms may be mild to anaphylaxis. Clients with
sheet. latex allergy are advised to notify their health care
■ 4. With two people, one at each side using a providers and to wear a medical ID; however,
drawsheet, one person at the head, and one all metal and jewelry must be removed prior to sur-
person at the feet. gery as they could conduct an electrical current.

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 The Client Having Surgery 653

The surgery can be safely performed at a free- need to be notified. The surgical team should be
standing surgery center as long as latex precautions notified of the client’s allergy to iodine and it should
are observed. be documented in all the appropriate places, but the
surgeon would not need to be notified in advance of
CN: Safety and infection control;
the surgical procedure.
CL: Create
CN: Safety and infection control;
3. 3. Garlic has anticoagulant properties and CL: Synthesize
may pose a problem with bleeding if enough has
been taken too close to surgery. Therefore, the nurse 7. 4. When a client has a concern, it is impor-
must obtain more quantifiable details about the cli- tant to decrease her stress as much as possible. The
ent’s statement. The nurse should check the surgical nurse should call the operating room and inform
procedure, anesthesia preference, and blood pres- the intraoperative nurse. A special container with
sure status with the client. However, the part of the correct identification can be prepared so that
client’s statement that needs further investigation when the client is anesthetized and her hearing
concerns intake of an herb with anticoagulant prop- aid is removed, it will not be lost or broken. It is
erties before a surgical procedure. usual policy not to send personal belongings to
surgery because they are easily broken or lost in
CN: Pharmacological and parenteral
the transfer of an anesthetized client with higher
therapies; CL: Syntheszie
priority needs, but special needs do exist. In some
4. 1. The nurse should remove the face mask. instances the nurse does bring a client’s personal
The face mask contains nasal and oral droplets, belongings to the postanesthesia care unit, but in
which are easily transmitted to the hands as the this case the item involves the client’s ability to
mask dangles when left hanging around the neck. communicate. Because the trend is to use little pre-
When a face mask is not worn over the mouth and medication, clients are more alert and may want to
nose, it should be completely removed. talk with their surgical team before going to sleep.
Decreasing the client’s anxieties preoperatively
CN: Safety and infection control;
affects the amount of medication used to induce
CL: Synthesize
the client and her overall psychological and physi-
5. This is the correct surgical site. ologic status. Telling the client that she won’t need
to hear is insensitive.
CN: Basic care and comfort;
CL: Synthesize
8. 4. The client has deficient knowledge if he
smoked a cigarette after 4 a.m. because, even though
he did not have anything to eat or drink, smoking
has increased the production of gastric hydrochloric
acid, which can increase the risk of aspiration in
an anesthetized client. A gelatin dessert is a clear
liquid and is acceptable. Comfort measures, such as
brushing the teeth without swallowing or holding a
cold washcloth against the lips, are acceptable for a
client who is to have nothing by mouth.
CN: Reduction of risk potential;
CL: Evaluate
9. 2. Clients who are allergic to shellfish are
CN: Physiological adaptation; CL: Apply allergic to iodine skin preparations (Iodophor and
Betadine) or any other products containing iodine,
6. 1. A pimple close to the incision site may be such as dyes. Clients who are allergic to shellfish do
reason for the surgeon to cancel the surgical proce- not necessarily have an allergy to any other sub-
dure because it increases the risk of infection. If the stances or seafood.
client had an abnormal ECG, the nurse would notify
the anesthesiologist who will be administering the CN: Reduction of risk potential;
anesthesia. The anesthesiologist is the decision CL: Analyze
maker regarding the implications of the anesthesia 10. 2. The antibiotic is most effective in prevent-
on the cardiac system. The surgical team should ing infection, according to research, if it is given 30
be notified of the client’s hearing disability, but the to 60 minutes before the operative incision is made.
surgeon, who has already met the client, does not When the surgeon orders the antibiotic to be given

Billings_Part 2_Chap 3_Test 14.indd 653 8/7/2010 10:27:04 AM

 654 The Nursing Care of Adults with Medical and Surgical Health Problems

at a specific time related to the scheduled time of of diabetes receiving D5LR I.V. fluids does not need
the surgical procedure, it is imperative that the anti- to have the serum glucose level checked unless
biotic is given on time. Legally, the nurse considers other clinical manifestations are present. The client
30 minutes on either side of the scheduled time to who has a high carbohydrate diet should be able to
be acceptable for administering medications; how- metabolize the glucose unless there are other health
ever, in this situation, giving the antibiotic 30 min- problems.
utes too soon can make the prophylactic antibiotic
CN: Reduction of risk potential;
ineffective. The postoperative dose of antibiotic is
CL: Analyze
not timed according to the preoperative dose. Peak
and titer levels are measured for some antibiotics, 15. 3. The nurse should notify the physician
but in this case the primary reason is to have the directly for specific orders based on the client’s
antibiotic infused before the time of the incision. glucose level. The nurse cannot ignore the elevated
glucose level. The surgical experience is stressful
CN: Reduction of risk potential;
and the client needs specific insulin coverage dur-
CL: Apply
ing the perioperative period. The nurse should not
11. 3. Nurses should provide the preoperative administer the insulin without checking with the
client individual and sincere attention by meeting surgeon because there are specific orders to with-
the client at eye level and introducing themselves hold all medications. It is not necessary to notify the
by name and role. The nurse should ask the client surgery department unless the physician cancels the
to tell her full name rather than asking if she is surgery.
Mrs. Smith because there might be another client by
CN: Pharmacological and parenteral
that name on the schedule. Nurses should not start
therapies; CL: Synthesize
the physical assessment or ask the client’s name
without first identifying themselves and their role 16. 3. Psychosocial integrity issues, including
out of courtesy and to relieve the client’s anxiety in coping mechanisms, situational role changes, and
the new environment of the surgical experience. body image changes, are more common in a client
who undergoes elective cosmetic surgical proce-
CN: Psychosocial adaptation; CL: Apply
dures. Reduction of risk potential, physiologic
12. 4. The nurse should notify the anesthesiolo- adaptation, and health promotion and maintenance
gist because a serum potassium level of 5.8 mEq/L are greater needs for clients who are undergoing
places the client at risk for arrhythmias when under surgical correction of functional, anatomic, or physi-
general anesthesia. The surgeon may be notified; ologic defects in nonelective surgical procedures.
however, the anesthesiologist will make the decision
CN: Psychosocial adaptation;
about whether to proceed with surgery. The nurse
CL: Analyze
should not automatically send a client with abnor-
mal laboratory findings to surgery because the pro- 17. 1. A client should not elect surgery to meet
cedure may be canceled. Once the client is inside someone else’s needs. The nurse should encourage
the operating room and sterile supplies have opened the client to share his feelings and his perception of
up for the procedure, the client is usually charged. the deformity and to clarify his reasons for elect-
The nurse should call ahead of time to communicate ing to have the surgery. It is normal to be somewhat
the abnormal laboratory result instead of placing a afraid, and it is good if a client says he feels “OK”
note on the front of the chart. A note would not be about the surgery. The fact that a client believes that
seen until after the client has been transported to the his wife will help him after surgery and that he will
operating room and the supplies have been opened. also be relatively independent reflects appropriate
adaptation. It is a common feeling among preop-
CN: Reduction of risk potential;
erative clients that they are ready to “get this over
CL: Synthesize
with,” indicating that the waiting period is stressful.
13. 4. Clients should be made aware that some CN: Psychosocial adaptation;
questions are asked for verification and safety with
CL: Evaluate
each new phase of treatment.
CN: Psychosocial adaptation;
18. 2. Brittle nails indicate poor nutrition. Poor
posture indicates that the client does not stand up
CL: Synthesize
straight and use her muscles to support herself.
14. 1, 2, 3. Clients who have diabetes mellitus A dull expression reflects the client’s affect and
controlled by diet, those with a high stress response emotional status. The client’s weight of 128 lb is
to surgery, or those who have been on steroid treat- within normal range.
ment for the last 3 months should have their serum
CN: Health promotion and maintenance;
glucose level assessed. A client with a family history
CL: Analyze

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 The Client Having Surgery 655

19. 4. The Joint Commission requires that dis- 23. 1. Clients who have had long-term multiple
charge instructions be written for the postoperative exposures to latex products, such as would occur
client. The nurse will review all instructions orally with six previous surgeries and recoveries, are at
and will demonstrate any skill. Clients need to be increased risk for latex allergies. The nurse should
given discharge instructions orally and in written explore what types of surgeries these were, how
form because of stress, medications, and the volume involved the client’s recoveries were, and whether
of material to be learned. Explaining all the instruc- signs of latex allergies have occurred in the past.
tions to a family member is important but does not Working as a sales clerk, having type 2 diabetes, or
replace the need for written instructions. undergoing laser surgery does not expose a client to
latex or increase the risk of latex allergy.
CN: Health promotion and maintenance;
CL: Synthesize CN: Health promotion and maintenance;
CL: Analyze
20. 1. The preadmission nurse, the first person in
contact with the client, starts the discharge plan- 24. 3. The nurse should assess the vital signs
ning for the client undergoing surgery. All nurses of the client who exhibits urticaria, rhinitis, and
involved with the client, from preadmission through conjunctivitis a few seconds after coming in contact
postoperative recovery, should continue to reinforce with rubber gloves, a plastic catheter, plastic I.V.
the discharge plan. tubing, and a plastic I.V. solution bag. The nurse
should recognize that these symptoms indicate that
CN: Health promotion and maintenance;
a type I allergic reaction is occurring, that the client
CL: Apply
is responding to the latex, and that the reaction can
21. 3. The nurse should have the client empty proceed into anaphylactic shock. The client does
his bladder before the premedication is adminis- not need to be distracted or assessed for pain. It is
tered. This will be more comfortable and safe for not necessary to lower the head of the bed.
the client. The purpose of the premedication is to
CN: Physiological adaptation;
decrease anxiety and promote a relaxed state. The
CL: Synthesize
client must have an empty bladder before being
transferred to the operating room, where he will 25. 4. The nurse would ask the client whether
be immobilized and receive I.V. fluids. The family he wears glasses to evaluate his preoperative cog-
does not have to be present, but it is usually desired. nitive-perceptual pattern. Asking about the client’s
Shaving the operative area is not generally recom- swallowing pattern would evaluate his nutritional-
mended because it can cause small nicks that harbor metabolic pattern. Asking about his need for special
bacteria. If the client must be shaved, it is usually equipment to walk would evaluate his activity-
done in the operating room holding area. The client exercise pattern. Asking the client about his history
should be comfortable at all times and offered a of smoking would evaluate his health perception–
warm blanket whenever he is cool, before or after health management pattern.
the premedication.
CN: Physiological adaptation;
CN: Basic care and comfort; CL: Analyze
CL: Synthesize
26. 3. The client is at risk for a difficult intu-
22. 4. The nurse should immediately think of bation because the neck must be hyperextended
the congenital metabolic tendency for malignant to pass the endotracheal tube. Assessment of the
hyperthermia, which occurs in the presence of cer- pupils should not be limited. If the client is posi-
tain kinds of anesthetics. Whenever a preoperative tioned appropriately during surgery, there is no risk
client states that a family member has had problems of postoperative neck pain or limited neck move-
with anesthesia or surgery, the nurse should inquire ment.
about the nature of the problems and whether other
CN: Reduction of risk potential;
family members have had similar problems. Reas-
CL: Analyze
suring the client that technology has changed will
do little to affect her fears and misses the opportu- 27. 1, 2, 3, 4. Splinting the incision is important
nity to evaluate the risk for malignant hyperthermia. to avoid stress on the surgical site and to promote
Encouraging the client to further express her con- comfort so that the client will adhere to the plan of
cerns and reassuring her that her feelings are normal care. Inhaling and exhaling are important to bring
are important, but missing a familial tendency of in adequate oxygen and clear out carbon dioxide;
malignant hyperthermia could be fatal. however, closing one nostril when inhaling would
be inappropriate and ineffective. The most impor-
CN: Reduction of risk potential;
tant step is asking the client to hold the inhaled
CL: Synthesize
breath for about 5 seconds, which keeps the alveoli

Billings_Part 2_Chap 3_Test 14.indd 655 8/7/2010 10:27:08 AM

 656 The Nursing Care of Adults with Medical and Surgical Health Problems

expanded. This step should be stressed the most. 33. 3. Glycopyrrolate is an anticholinergic given
Repeating the exercise 5 to 10 times hourly is the for its ability to reduce oral and respiratory secre-
second most important point to emphasize in this tions before general anesthesia. Increased heart rate
teaching plan. and respiratory rate would be adverse effects of the
CN: Reduction of risk potential; drug. Amnesia should not be an effect of the drug.
CL: Create CN: Pharmacological and parenteral
28. 2. The nurse should call the surgeon for therapies; CL: Apply
a serum creatinine level of 2.6 mg/dL, which is 34. 1. The nurse can administer atropine sulfate,
higher than the normal range of 0.5 to 1.0 mg/dL. an anticholinergic, to a client with diabetes. Atro-
An elevated serum creatinine value indicates pine is contraindicated in clients with glaucoma
that the kidneys are not filtering effectively and because it increases intraocular pressure. It is con-
has important implications for the surgical client traindicated in clients with urine retention because
because many anesthesia and analgesia medications it relaxes smooth muscle in the urinary tract and
need to be filtered out through the renal system. can exacerbate the problem. It is contraindicated in
The red blood cell count, hemoglobin level, and clients with gastrointestinal obstruction because it
blood urea nitrogen level are within normal limits relaxes smooth muscle in the gut and may worsen
and do not need to be reported to the surgeon. the obstruction.
CN: Reduction of risk potential; CN: Pharmacological and parenteral
CL: Analyze therapies; CL: Apply
29. 1. Midazolam hydrochloride causes ante- 35. 3. Because droperidol causes tachycardia and
grade amnesia or decreased ability to remember orthostatic hypotension, the client should be moved
events that occurred around the time of sedation. slowly after receiving this medication. Inapsine
Nausea, mild agitation, and blurred vision are produces a tranquilizing effect and does affect the
adverse effects of Versed. central nervous, respiratory, or psychoneurologic
CN: Pharmacological and parenteral system, but the primary reason for moving the cli-
therapies; CL: Evaluate ent slowly is the potential cardiovascular effects of
hypotension.
30. 3. The client should be encouraged to take
slow, deep breaths because midazolam hydrochlo- CN: Pharmacological and parenteral
ride is a respiratory depressant. The nurse should therapies; CL: Apply
assess the client’s blood pressure, monitor the pulse 36. 2. Research findings have shown that enox-
oximeter, and keep the client calm and relaxed, but aparin and low-dose heparin given 6 to 12 hours
the client will slip into very shallow, ineffective preoperatively reduce the incidence of deep vein
breathing if not encouraged to deep-breathe. thrombosis and pulmonary emboli by 60% in cli-
CN: Pharmacological and parenteral ents who are at risk for deep vein thrombosis, such
therapies; CL: Synthesize as those who are placed in the lithotomy position.
Lovenox has no effect on red blood cell production,
31. 1. The nurse should have an Ambu bag in postoperative bleeding, or tissue healing.
the client’s room because midazolam hydrochloride
can lead to respiratory arrest if it is administered CN: Pharmacological and parenteral
too quickly. The client does not need to be shocked therapies; CL: Evaluate
back into a normal rhythm or to receive epineph- 37. 4. The nurse does not need to ask about all
rine unless cardiac compromise developed after the drugs used in the last 18 months unless the client is
respiratory arrest. The client would receive titrated still taking them. The nurse does need to know all
dosing of flumazenil to reverse the Versed, but first drugs the client is currently taking, including herbs
the nurse should ventilate the client. and vitamins, over-the-counter medications such
CN: Pharmacological and parenteral as aspirin taken in the past 6 weeks, the amount of
therapies; CL: Synthesize alcohol consumed, and use of illegal drugs, because
these can interfere with the anesthetic and analge-
32. 2. Metoclopramide is an antiemetic given sic agents. Steroid use is of concern because it can
because of its gastric emptying ability, which is suppress the adrenal cortex for up to 1 year, and
necessary in gastrointestinal procedures. It does not supplemental steroids may need to be administered
increase gastric pH, reduce anxiety, or inhibit respi- in times of stress such as surgery.
ratory secretions.
CN: Reduction of risk potential;
CN: Pharmacological and parenteral CL: Apply
therapies; CL: Evaluate

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 The Client Having Surgery 657

38. 2. The nurse should notify the surgery 42. 1. The 68-year-old client is at greater risk
department and document the past surgery in the because an older adult client is more likely to have
chart in the preoperative notes so that the client’s comorbid conditions, a less-effective immune sys-
hip is not externally rotated and the hip dislocated tem, and less collagen in the integumentary system.
while she is in the lithotomy position. The prosthe-
CN: Physiological adaptation;
sis should not be a problem as long as the periop-
CL: Analyze
erative nurse places the grounding pad away from
the prosthesis site. The perioperative nurse will 43. 1. The child having her 15th laser procedure
inform the rest of the team, but the primary reason for a hemangioma should not have a balloon unless
to inform the perioperative nurse is related to safe it is latex free because this child has had numerous
positioning of the client. The surgeon can hand- exposures to latex thus far. If she has not already
write an addendum to the history and initial and developed some sensitivity, the nurse should help
date the entry. The history and physical information the family be aware of latex products to avoid when
can then be retyped at a later date. possible. A client who is having a tonsillectomy,
inguinal hernia repair, or orchiopexy is probably
CN: Reduction of risk potential;
having surgery for the first time and has not been
CL: Apply
exposed to latex, although it is a good practice to
39. 3. The nurse should notify the anesthesiolo- use latex-free products whenever possible and to
gist because supplemental prednisone suppresses inquire about past exposure.
the adrenal cortex’s natural ability to produce
CN: Safety and infection control;
increased corticosteroids in times of stress such
CL: Synthesize
as surgery. The anesthesiologist may need to order
supplemental steroid coverage during the periop- 44. 2. An autotransfusion is acceptable for the
erative period. The nurse should document the client who is in danger of cardiac arrest. An auto-
prednisone with current medications, but it is a transfusion cannot be collected from a client who
priority to inform the anesthesiologist. Because the has cancer, a contaminated wound, or contamination
poison ivy is not in the surgical field, the surgeon from Escherichia coli because of a ruptured bowel.
does not need to be called regarding the skin dis-
CN: Pharmacological and parenteral
ruption.
therapies; CL: Apply
CN: Pharmacological and parenteral
therapies; CL: Synthesize
45. 2. After a scope or catheter has been inserted
into the urethra, the mucosal membrane is irritated
40. 2. The client who has a significant cigarette and the client feels the need to void even though the
smoking history and an operative manipulation bladder may not be full. The nurse should encour-
close to the diaphragm (the gallbladder is against age the client to force fluids to make the urine
the liver) is at increased risk for atelectasis and dilute. The client should not ignore the urge to void.
pneumonia. Postoperatively this client will be reluc- The client should be encouraged to use the bath-
tant to deep-breathe because of pain, in addition to room; there is no need to use the bedpan. The client
having residual lung damage from smoking. There- does not need assistance to the bathroom because
fore, the client is at greater-than-average risk for this procedure does not require any anesthesia
pulmonary complications. The client does not have except a topical anesthetic for the male client.
an increased risk of prolonged immobility (unless
CN: Basic care and comfort;
slowed by a respiratory problem), deep vein throm-
CL: Synthesize
bosis (as long as the client performs leg exercises),
or delayed wound healing (as long as the client 46. 4. Early ambulation is the most significant
maintains appropriate nutrition). general nursing measure to prevent postoperative
complications and has been advocated for more than
CN: Reduction of risk potential;
40 years. Walking the client increases vital capacity
CL: Analyze
and maintains normal respiratory functioning, stimu-
41. 4. The purpose of separating the public from lates circulation, prevents venous stasis, improves
the restricted-attire area of the operating room is to gastrointestinal and genitourinary function, increases
provide an aseptic environment and prevent con- muscle tone, and increases wound healing. The
tamination of the environment by organisms. The client should maintain a healthy diet, manage pain,
client’s privacy is protected, but the main purpose is and have regular bowel movements. However, early
infection control. ambulation is the most important intervention.
CN: Safety and infection control; CN: Reduction of risk potential;
CL: Apply CL: Synthesize

Billings_Part 2_Chap 3_Test 14.indd 657 8/7/2010 10:27:10 AM

 658 The Nursing Care of Adults with Medical and Surgical Health Problems

The Client Who Is Receiving or 52. 3. Spinal anesthesia is an extensive conduc-

Recovering from Anesthesia tion nerve block that is produced when a local anes-
thetic is introduced into the subarachnoid space at
47. 1. The client is demonstrating signs of the lumbar level. A few minutes after induction of
malignant hyperthermia. Unless the body is cooled a spinal anesthetic, anesthesia and paralysis affect
and the influx of calcium into the muscle cells is the toes and perineum and then, gradually the legs
reversed, lethal cardiac arrhythmia and hypermetab- and abdomen. When the autonomic nervous system
olism occur. The client’s body temperature can rise is blocked, vasodilation occurs and hypotension
as high as 109° F (42.8° C) as body muscles contract. occurs. The client will feel sensation to the toes
Dantrolene, an I.V. skeletal muscle relaxant, is used before the perineal area. A spinal headache due to
to reverse muscle rigidity. Elevating the head of loss of fluid is a severe headache that occurs while
the bed will not reverse the hyperthermia. Adding in the upright position, but is relieved in the lying
fluids and inserting an indwelling urinary catheter position.
are not immediately beneficial steps in reversing the CN: Physiological adaptation;
progression of malignant hyperthermia. CL: Analyze
CN: Management of care; CL: Synthesize 53. 3. The nurse should check the client’s base-
48. 2. The nurse should first attempt to find out line data to ascertain whether the client’s pupil has
what the client’s concerns are and address them. always been enlarged or this is a new finding. The
Providing too much information with details can preoperative assessment is valuable as the baseline
increase the client’s anxiety and does not address for comparison of all subsequent assessments made
specific concerns. Padding the stirrups will provide throughout the perioperative period. The nurse may
comfort, but does not address concerns. Having an determine that a more involved neurologic examina-
all-female team may or may not be the source of the tion is indicated or may choose to assess other signs
client’s concerns. using the Glasgow Coma Scale, administer oxygen,
or call the surgeon, but the nurse still needs to know
CN: Psychosocial adaptation; the baseline data before proceeding.
CL: Synthesize
CN: Physiological adaptation;
49. 3. The client is in the lithotomy position. The CL: Synthesize
reverse Trendelenburg position is when the client
is lying supine with the head lower than the rest of 54. 1. The nurse should check the dressing for
the body. A low Fowler’s position is when the client signs of bleeding to establish a baseline for future
is sitting up at a 30- to 45-degree angle. The prone assessments of the dressing and to verify that there is
position is when the client is lying face down. no obvious sign of hemorrhage. The nurse does not
need to empty peri-incisional drains at this time. All
CN: Management of care; CL: Apply drains should have been emptied and reconstituted
50. 4. Airway flow is always the first assess- by the postanesthesia care nurse before the client was
ment. Once the nurse establishes that the client has transferred to the surgical floor. Assessing the client’s
a patent airway, the pulse oximeter is applied to pain level and assessing the bladder are important;
measure the oxygen saturation, the respiratory rate however, it is more important to assess the surgi-
is counted, and the breath sounds are auscultated cal site for bleeding because hemorrhage is a life-
bilaterally. threatening complication of any surgical procedure.
CN: Physiological adaptation; CN: Physiological adaptation;
CL: Analyze CL: Synthesize
51. 1. The last area to regain sensation is the 55. 2. Adult clients are induced for general anes-
perineal area, and the nurse should check the client thesia by breathing in an inhalant anesthetic mixed
for a distended bladder. The client has received a large with oxygen through a facial mask and receiving
volume of I.V. fluids since the epidural was inserted, intravenous medication to make them sleepy. Cli-
and the client may not feel the urge to void or may be ents are not induced with the premedication. Clients
unable to void. In that case, the nurse should obtain usually are not induced with the intravenous infu-
an order to catheterize the client before the bladder sion or the mask alone.
becomes so distended as to cause bladder spasms. The CN: Basic care and comfort;
nurse should assess for a spinal headache, postopera- CL: Synthesize
tive pain, and the client’s ability to move after deter-
mining whether the bladder is distended. 56. 4. Children are induced for general anesthe-
sia by giving them medication through a facial mask
CN: Reduction of risk potential; to make them sleepy. Children are not induced with
CL: Analyze a injection. Children usually are not induced by

Billings_Part 2_Chap 3_Test 14.indd 658 8/7/2010 10:27:10 AM

 The Client Having Surgery 659

use of a facial mask with I.V. administration started 62. 2, 3, 4, 5. Flumazenil should be administered
while they are still awake. in small quantities such as 0.2 mg over 15 to 30 sec-
CN: Basic care and comfort; onds but never as a bolus. Flumazenil may be given
CL: Synthesize undiluted in incremental doses. Adverse effects of
flumazenil may include shivering and hypotension.
57. 3. Sodium pentothal, a short-acting barbitu- The nurse should monitor the client’s level of con-
rate, can cause hypotension, which may be espe- sciousness while recovering from sedation. Fluma-
cially problematic for the client with impaired car- zenil should be administered through a free-flowing
diac functioning. Sodium pentothal does not cause I.V. line in a large vein because extravasation causes
bradycardia, complete muscle relaxation, hyperten- local irritation.
sion, or tachypnea.
CN: Pharmacological and parenteral
CN: Pharmacological and parenteral therapies; CL: Synthesize
therapies; CL: Apply
63. 2. It is important for the nurse to cover this
58. 1. Propofol, a nonbarbiturate anesthetic, client with warm blankets because he is at high risk
causes less nausea and vomiting because of a direct for hypothermia secondary to age, spinal anesthesia,
antiemetic action. It does not cause hypotension or placement in a lithotomy position in the cool operat-
skeletal muscle movement, and it does not act slowly. ing room for 1.5 hours, instillation of 4,000 mL of
CN: Pharmacological and parenteral room temperature bladder irrigation, and ongoing
therapies; CL: Analyze bladder irrigation. Spinal anesthesia causes vasodila-
tion, which results in heat loss from the core to the
59. 4. Desflurane and sevoflurane are volatile periphery. The nurse will empty the catheter drainage
liquid anesthesia agents that are used for outpatient bag and hang new bags of irrigation as needed, but the
surgeries primarily because they are rapidly elimi- client’s potential for hypothermia should be addressed
nated. They have the added benefits of being better first. The client will not be turned at this time.
tolerated and nonirritating to the respiratory tract,
and they have predictable cardiovascular effects. CN: Reduction of risk potential;
However, rapid elimination is an important consid- CL: Synthesize
eration for outpatient procedures. 64. 3. The client who is 5 feet 1 inch tall and
CN: Pharmacological and parenteral weighs 200 lb would be expected to retain the
therapies; CL: Apply anesthetic agents longer because adipose tissue
absorbs the drug before the desired systemic effect is
60. 3. A heart rate of 150 bpm or greater, hypoten- reached for anesthesia maintenance. Nursing inter-
sion, and muscle rigidity are early signs of malignant ventions are aimed at encouraging the obese client
hyperthermia. The nurse should quickly assemble to turn, cough, and deep-breathe despite feeling
emergency supplies and personnel because malig- sleepy and tired. The sooner this client ambulates,
nant hyperthermia is potentially and rapidly fatal the sooner the retained anesthesia will be worked
in more than 50% of cases. Rapid, extreme rise in out of the adipose tissue.
temperature is a late sign. Another factor influencing
the analysis is that the client has a large body frame, CN: Reduction of risk potential;
and having large, bulky muscles is a risk factor for CL: Analyze
malignant hyperthermia. The client’s vital signs are 65. 1. The nurse should encourage the client
well out of the range of normal; analysis of the data to avoid holding his operated arm, the arm with
and swift intervention are indicated. Excessive blood the intravenous regional nerve block (Bier block),
loss is unlikely and the data do not support this con- close to her face because she has no motor control
clusion. Although clients do have changes in vital over it. With the cast in place she could hit herself
signs when in acute pain, the nurse would expect in the eye, nose, or mouth and cause soft-tissue
the client to be hypertensive, not hypotensive. damage. It is acceptable for the client to hold the
CN: Physiological adaptation; operated arm with the unoperated arm or to use the
CL: Analyze unoperated arm. The nurse should administer the
analgesic before the intravenous regional anesthetic
61. 2. One of the earliest signs of hypoxia is rest- completely wears off so that the pain does not peak
lessness and agitation. Decreased level of conscious- before pain medication is administered.
ness and somnolence are later signs of hypoxia.
Chills can be related to the anesthetic agent used but CN: Reduction of risk potential;
are not indicative of hypoxia. Urgency is not related CL: Synthesize
to hypoxia. 66. 3. The nurse should monitor the client’s
CN: Physiological adaptation; respirations closely for 4 to 6 hours because
CL: Analyze naloxone has a shorter duration of action than

Billings_Part 2_Chap 3_Test 14.indd 659 8/7/2010 10:27:11 AM

 660 The Nursing Care of Adults with Medical and Surgical Health Problems

opioids. The client may need repeated doses of the nurse who reported giving the medication that
naloxone to prevent or treat a recurrence of the the medication had been given. Finally, the nurse
respiratory depression. Naloxone is usually effective should determine if there is a discrepancy between
in a few minutes; however, its effects last only 1 to administration and documentation.
2 hours and ongoing monitoring of the client’s respi-
CN: Management of care;
ratory rate will be necessary. The client’s dosage of
CL: Synthesize
morphine will be decreased or a new drug will be
ordered to prevent another instance of respiratory 73. 4. Following surgery, clients are at risk for
depression. respiratory complications and should take the nec-
essary actions to prevent these. The nurse should
CN: Pharmacological and parenteral
first be sure that the client understands how to do
therapies; CL: Synthesize
the exercises and the potential complications if they
67. 3. Abnormal coagulation test results have are not done. It is not the wife’s responsibility to
been associated with naloxone (Narcan), and the make the client do the exercise, but she can help.
nurse should monitor surgical clients closely for Increasing fluid intake and frequent turning are
bleeding. Dizziness, biliary colic, and urine reten- appropriate, but not sufficient for aerating the lungs.
tion are not associated with naloxone.
CN: Health promotion and maintenance;
CN: Pharmacological and parenteral CL: Synthesize
therapies; CL: Analyze
74. 3. An indwelling urinary catheter increases
68. 3. The client who receives epidural anes- the risk of urinary tract infection because microbes
thesia is at decreased risk for a headache because a ascend the catheter and travel to the bladder. The
noncutting needle is used instead of a side angle- nurse should try to facilitate the client’s ability to
cutting needle. The epidural needle is a 25G to 27G void by using the sitting position for a woman or the
needle, which is much smaller than a 17G needle. standing position for a man and by running warm
The injection made for an epidural is an extradural, water over the perineum. If such conservative meth-
not a subarachnoid, injection as for spinal anesthe- ods fail, the nurse should obtain an order to cath-
sia. The onset of spinal anesthesia is faster because a eterize the client every 4 hours using a small French
larger dose of medication is usually administered. straight catheter until the client can void on his or
her own.
CN: Physiological adaptation;
CL: Analyze CN: Reduction of risk potential;
CL: Synthesize
69. 3. Spinal anesthesia does not cause para-
sympathetic blockage. The spinal anesthetic agent 75. 4. The first cognitive response that returns
usually is injected into the L2 subarachnoid space, after anesthesia is orientation to person. The nurse
where it produces sympathetic, sensory, and motor assesses this by asking the client his name. Orien-
blockade. tation to place and time usually occurs after ori-
entation by the nurse because of confusion from
CN: Pharmacological and parenteral
anesthesia and waking in an unfamiliar place. The
therapies; CL: Apply
nurse can then continue to assess and document the
70. 0.5 mL. Multiply 2.5 mg/5 mg by the unknown client’s cognitive ability to remember information.
X mg/1 mL. Cross-multiply to get 5X=2.5 mL. Divide The nurse does not need to notify the surgeon. The
both sides of the equation by 5 to get X = 0.5 mL. client’s cognitive response is normal. It is not neces-
sary to ask the wife to reorient the client; however,
CN: Pharmacological and parenteral
she can continue to talk to him and help him regain
therapies; CL: Apply
consciousness.
71. 3. In order to prevent burns, the nurse should CN: Physiological adaptation;
assess the client’s temperature every 15 minutes
CL: Synthesize
when using an external warming device.
CN: Safety and infection control;
76. 3. Potassium in an I.V. solution may be
irritating to a vein. The nurse should assess the I.V.
CL: Apply
site before taking any of the other actions listed. The
infusion may have to be slowed and/or stopped, and
the physician contacted. An outdated parenteral
The Client Who Has Had Surgery fluid setup does not cause pain, but may be a source
of infection.
72. 2, 3, 1, 4. The oncoming nurse should first
assess the client for pain. Next, the nurse should CN: Pharmacological and parenteral
check the documentation and then validate with therapies; CL: Synthesize

Billings_Part 2_Chap 3_Test 14.indd 660 8/7/2010 10:27:12 AM

 The Client Having Surgery 661

77. 2. The client’s body temperature dropped prevent atelectasis and pulmonary infection. The
2.5° F from the preoperative to postoperative phase. nurse must assist the client in filling the alveoli in
The client lost heat during the preoperative period. the lower posterior lobes of the lungs. An incentive
The client has not had time to regain the heat she spirometer is a good visual biofeedback instrument
has lost and should not be discharged postopera- that the client had practiced with preoperatively.
tively until her postoperative vital signs, which Changing the client’s position from lying to sitting
include body temperature, are closer to her preop- for deep breathing will expand alveoli in the lower
erative vital signs. The client’s pulse rate, respira- posterior lobes. There is no indication that a surgical
tory rate, and blood pressure have compensated wound infection is occurring. An antibiotic is not
according to the client’s hypothermic state and will indicated at this time. Pain medication will decrease
reflect changes as the client warms up. There are no respirations and the client is not indicating pain at
indications that the client needs more pain medica- the moment.
tion, oxygen, or I.V. fluids. CN: Physiological adaptation;
CN: Physiological adaptation; CL: Synthesize
CL: Synthesize 81. 3. The nurse should take the client’s blood
78. 1, 3, 4, 5. When assessing a postoperative pressure. She is likely experiencing orthostatic
client for perfusion and the manifestation of shock, hypotension. The PCA pump does not need to be
nursing assessment should include an inspection discontinued because, as soon as the blood pres-
for cyanotic mucous membranes; cold, moist, pale sure stabilizes, the pain medication can be resumed.
skin; and the level of oxygen saturation in relation Administering oxygen is not necessary unless the
to hemoglobin. The nurse should also compare the oxygen saturation also drops. The client should sit
client’s postoperative vital signs with his preopera- in the chair until the blood pressure stabilizes.
tive vital signs to determine how much physiologic CN: Pharmacological and parenteral
stress has occurred during the intraoperative period. therapies; CL: Synthesize
A client who is perfusing well would have warm,
dry skin. A client well hydrated would have good 82.
skin turgor. The nurse would also assess fluid status
using the intake and output record. If hemoglobin 4. Splint the incisional site.
and hematocrit were available, the values would be
included in the assessment. 1. Inhale through the nose.
CN: Management of care; CL: Analyze
3. Exhale through pursed lips.
79. 3. The nurse is helping the client manage her
pain and comfort level. The nurse has completed
2. Cough deeply from the lungs.
her assessment of the client and should now dim
the lights and create a quiet environment. Such non-
The client must first splint the incision to avoid
pharmacologic measures as adjusting the light level
increased intolerable pain or he may not cooperate
in the room facilitate pain management. Decreasing
with the pulmonary ventilation. The next step is to
stimulation from the environment, such as bright-
inhale oxygen to expand the alveoli for a few sec-
ness to the optic nerve, promotes the client’s ability
onds and then exhale carbon dioxide in successive
to relax skeletal muscles and fall asleep. It is too
steps 5 to 10 times. The client should try to cough
soon to reassess vital signs. Checking that the family
on the end of the exhalation to remove retained
is comfortable is important but is not the next thing
secretions from the larger airways.
to do for this client. Increasing the oxygen flow rate
is not indicated, and if needed should have been CN: Reduction of risk potential;
done before repositioning the client. CL: Synthesize
CN: Management of care; CL: Synthesize 83. 3. The client who has not had the gag reflex
anesthetized is the client who had a repair of the
80. 4. When a postoperative client has a tempera- carpal tunnel syndrome under local anesthesia
ture elevation to greater than 100° F (37.8° C) in the
because the area being anesthetized was the tissue
first 24 hours after surgery, the temperature eleva-
in the wrist. The client who had a bronchoscopy
tion is usually related to atelectasis. Because this
received a local anesthetic on the vocal cords, and
client had upper abdominal surgery with manipula-
the nurse should check the gag reflex or ability to
tion around the diaphragm, the client is more prone
swallow before administering fluids. Clients who
to guarding the operative site and shallow breathing.
had general anesthesia or intravenous conscious
Encouraging the client to take deep breaths and use
sedation received medication for central nervous
incentive spirometry are appropriate measures to
system sedation, and the nurse should assess the

Billings_Part 2_Chap 3_Test 14.indd 661 8/7/2010 10:27:13 AM

 662 The Nursing Care of Adults with Medical and Surgical Health Problems

level of consciousness and ability to swallow before the emergency alarm because this is not a cardiac
administering fluids. or respiratory arrest. The nurse should have the
visitors and family leave the room to decrease the
CN: Reduction of risk potential;
chance of airborne contamination, but the primary
CL: Analyze
focus should be on covering the wound with a
84. 3. When the urine output is less than 30 mL/ moist, sterile covering.
hour, the nurse should assess for potential causes
CN: Safety and infection control;
such as hypovolemia or hemorrhage. The nurse
CL: Synthesize
should assess and evaluate the client’s vital signs,
intake and output, dressing, and available laboratory 89. 2, 3, 4. WBC count should be above normal
values and notify the physician. Bowel obstruction, (4,500 to 11,000/mm3) with an acute infection or
although possible after surgery, is characterized inflammatory response such as a postoperative
most notably by abdominal distention and absent wound infection. Redness and swelling beyond the
bowel sounds, not decreased urine output. The incision line is expected with a wound infection.
nurse would not expect the client to have hyperten- An elevated temperature such as 102° F (38.9° C)
sion, but rather hypotension. on the third to fourth postoperative day indicates
an infection process rather than an inflammatory
CN: Physiological adaptation;
process. An elevation in the segmented neutrophils
CL: Synthesize
demonstrates that the most mature WBCs have
85. 3. A client who had a left thoracoscopy is responded to the invading bacteria at the incision
placed in the lateral position, in which the most site, which is an expected response. Typically, post-
common injury is an injury to the brachial plexus. operative pain begins to lessen by the fourth day.
Numbness and tingling in the arm suggests a bra-
CN: Physiological adaptation;
chial plexus injury. There is no undue pressure on
CL: Analyze
the ankles or knees during thoracic surgery.
CN: Physiological adaptation;
90. 4. A wet-to-dry dressing should be able to
dry out between dressing changes. Thus, the dress-
CL: Analyze
ing should be moist, not dry, when applied. As the
86. 3. Although any client may experience moist dressing dries, the wound will be debrided
nausea and vomiting secondary to anesthetics or of necrotic tissue, exudate, and so forth. Normal
postoperative analgesics, the client who has had saline is most commonly used to moisten the
manipulation of the abdominal organs is more prone sponge; Burrow’s solution will irritate the wound.
to postoperative nausea and vomiting than the cli- The sponge should not be packed into the wound
ent who has had a procedure such as a total joint tightly because the circulation to the site could be
replacement, open heart surgery, or a mastectomy. impaired. The moist sponge should be placed so
that all surfaces of the wound are in contact with the
CN: Physiological adaptation;
dressing. Then the sponge is covered and protected
CL: Analyze
by a dry sterile dressing to prevent contamination
87. 3. The nurse should inform the client that from the external environment.
as the incision heals uneven lumps might appear
CN: Safety and infection control;
under the incision line because the collagen is
CL: Synthesize
growing new tissue at different rates. Eventually, the
lumps will even out and the tissue will be smooth. 91. 3. After emptying a Jackson-Pratt drainage
The client can touch the incision with clean hands bulb, the nurse should compress the bulb, plug it to
as needed to perform incisional care. The client establish suction, and then document the amount
should not clean the incision with hydrogen perox- and type of drainage emptied. Irrigating a Jackson-
ide because it may dry out the natural skin oils. The Pratt drain is inappropriate because it could con-
surgeon will remove the staples for the client. taminate the wound. The Jackson-Pratt drain is not
usually connected to wall suction. The purpose of
CN: Reduction of risk potential;
the Jackson-Pratt drain is to remove bloody drainage
CL: Synthesize
from the deep tissues of the incision; clamping the
88. 2. When a wound eviscerates (abdominal drain would be counterproductive.
organs protruding through the opened incision),
CN: Reduction of risk potential;
the nurse should cover the open area with a ster-
CL: Synthesize
ile dressing moistened with sterile normal saline
and then cover it with a dry dressing. The surgeon 92. 1. Performing leg exercises, including ankle
should then be notified to take the client back to pumping, ankle rotation, and quadriceps setting
the operating room to close the incision under exercises, will help prevent stasis of blood in the
general anesthesia. The nurse should not press lower extremities, which can lead to blood clot

Billings_Part 2_Chap 3_Test 14.indd 662 8/7/2010 10:27:13 AM

 The Client Having Surgery 663

formation. Encouraging the client to cough and surgical procedure and because edema may develop
deep-breathe is an important postoperative interven- during the postoperative period.
tion; however, it is directed at preventing pneumo-
CN: Reduction of risk potential;
nia, not pulmonary emboli. The nurse should not
CL: Analyze
massage the calves because a deep vein thrombus
could dislodge and travel to the pulmonary vas- 97. 2. Hypotension and tachycardia are com-
culature. Antiembolism stockings should be worn mon adverse effects of droperidol and should be
continuously during the postoperative period. monitored closely by the nurse. Hypotension and
tachycardia are not common adverse effects of
CN: Physiological adaptation;
ondansetron hydrochloride, prochlorperazine, or
CL: Synthesize
promethazine.
93. 2. Naloxone hydrochloride is the antidote for CN: Pharmacological and parenteral
morphine sulfate. The signs of overdose on mor-
therapies; CL: Analyze
phine sulfate are a respiration rate of 2 to 4 breaths/
minute, bradycardia, and hypotension. Flumazenil 98. 1. The nurse should assess but not disturb
is the antidote for midazolam. Doxacurium is a the epidural dressing because the catheter can be
nondepolarizing muscle relaxant. Remifentanil is an easily dislodged and organisms can easily be trans-
opioid used as an anesthetic adjunct. mitted into the central nervous system. The nurse
should not have to change the dressing at all if a
CN: Pharmacological and parenteral
waterproof dressing is applied over the epidural
therapies; CL: Synthesize
site. Even with strict aseptic technique, a drain into
94. 2. The client admitted for same-day surgery a sterile cavity is a direct route for transmission of
should not drive home after the surgical procedure organisms and places a client at increased risk of
because it is unsafe. Even without an anesthetic, infection.
the surgical event can be more stressful than antici-
CN: Pharmacological and parenteral
pated. It is acceptable to have someone arrive after
therapies; CL: Apply
the surgery has started to take the client home.
A taxi is permissible but not desirable. 99. 2. The client who has epidural pain man-
agement postoperatively can ambulate because a
CN: Reduction of risk potential;
low concentration of local analgesia causes sen-
CL: Evaluate
sory blockage only. The catheter is placed so that
95. 3. The client has deficient knowledge when constant pain management plus patient-controlled
stating that pain from a laparoscopic cholecystec- administration of an analgesic dose can block
tomy is related to a large incision and manipulation sensory innervation. Motor function should not be
of tissue. The nurse should explain that there are affected since the catheter is placed above the dura
four puncture sites for the incision and that gas is lining the spinal fluid. If the catheter would move
used to distend the abdominal cavity to keep the through the dura sac, spinal analgesia would occur,
abdominal organs away from the operative site. affecting motor function as well as sympathetic
There is no real manipulation of tissue to produce nervous system function.
pain. The pain that clients do experience from this
CN: Pharmacological and parenteral
procedure is related to the gas, which irritates the
therapies; CL: Apply
diaphragm. The client should start on clear liquids
and advance to bland foods until the gas is gone. 100. 3. Portable wound suction units can be emp-
Walking helps to eliminate the gas from the abdomi- tied and drained. The nurse should compress the
nal cavity within 12 to 24 hours after surgery. unit after emptying to create suction before reinsert-
ing the plug. It is normal for the suction unit to be
CN: Reduction of risk potential;
full six hours after surgery, and the nurse does not
CL: Evaluate
need to notify the surgeon. The drainage unit should
96. 3. The urine output does not have to be be emptied when full or every 8 hours. The drain in
checked every 15 minutes for a client who has had the incision should remain in place until the sur-
an arthroscopy because this client probably does geon removes it. While all drainage should be noted
not have a catheter in place. If the client voids, the as output on the chart, recording the amount with-
output would be recorded. Assessments every 15 out emptying the drainage unit is not accurate nor is
minutes during the first hour would include vital it safe practice.
signs, pulse oximeter values, and pain to monitor
CN: Safety and infection control;
the client’s comfort level and check for compartment
CL: Synthesize
syndrome. Neurovascular checks distal to the opera-
tive site are especially vital because a tourniquet 101. 1. The nurse should ask the location of the
was used proximal to the operative site during the client’s pain because Lortab is an opioid, which

Billings_Part 2_Chap 3_Test 14.indd 663 8/7/2010 10:27:14 AM

 664 The Nursing Care of Adults with Medical and Surgical Health Problems

can be constipating. By the third day, many clients who has had an inguinal hernia repair can be dis-
become constipated and are feeling distended, with charged from same-day surgery. Ingestion of fluids
sharp, cramping pain due to gas, which is treated without nausea and vomiting is important, but
with ambulation, not more opioids. The client’s eating solid foods is not a requirement for discharge
emptying his bladder should not affect his pain from same-day surgery. Being completely pain-free
level. The nurse should look at the client’s chart to is an unrealistic expectation for the time frame and
determine when the client’s last dose of pain medi- is not a requirement for leaving same-day surgery.
cation was administered, rather than asking the cli- However, the client should be comfortable and his
ent. The client’s statement regarding his pain level pain should be controlled. It is not a requirement for
before the surgery is not relevant to whether the the client to ambulate in the hallway, but the cli-
nurse should administer the Lortab. ent should be able to sit up and go to the bathroom
without assistance.
CN: Physiological adaptation;
CL: Synthesize CN: Reduction of risk potential;
CL: Analyze
102. 1. Blood and serous fluid is drained from the
operative site to prevent hematoma formation or a 106. 3. The ability to self-dose is a requirement for
collection of fluid that could become a site for infec- the client to use PCA. Having a family member or
tion. This also minimizes postoperative swelling, court-appointed advocate present is not a require-
which can be painful. A simple explanation such as ment for initiating PCA. The nurse teaches the client
this is appropriate because the client is just wak- about how to use PCA and monitors effectiveness of
ing up from surgery. Blood from the operative site the pain medication; however, it is not necessary for
can be collected through an autotransfusion system the nurse to assist with the dosing.
so that it can be transfused to the client during or
CN: Pharmacological and parenteral
immediately after surgery. However, strict guide-
therapies; CL: Evaluate
lines about volume of blood lost, how quickly the
device fills, and how long the blood has been out of 107. 2. The client’s body temperature should be
the client’s body govern whether the blood can be assessed every 4 hours during the first 24 hours
transfused. Therefore, although it is possible that because the client is still at risk for hypothermia or
the drainage system to which the client refers is an malignant hyperthermia. The client does not need
autotransfusion system, it is more likely that the to be checked every 2 hours unless indicated by an
client has a simple Hemovac drain. It is incorrect to abnormal finding.
tell a client not to worry about something even if she
CN: Reduction of risk potential;
is in the drowsy state of awakening from anesthesia.
CL: Apply
It is inappropriate to ignore the client and give her
something to make her drowsy instead of addressing 108. 1. The client’s systolic blood pressure is drop-
his concerns. ping and the pulse pressure is narrowing, indicating
impending shock. The nurse should notify the sur-
CN: Psychosocial adaptation;
geon. Elevating the head of the bed will not increase
CL: Synthesize
the blood pressure. Administering pain medication
103. 1. The purpose of the Jackson-Pratt drainage could cause the blood pressure to drop further. The
tube is to drain off the purulent drainage from the intake and output record may indicate decreased
sterile peritoneal cavity and prevent peritonitis. A urine output related to shock but the nurse should
Jackson-Pratt drain cannot prevent bleeding. The first contact the health care provider.
Jackson-Pratt drain has no effect on pressure on the
CN: Reduction of risk potential;
bladder. There is no reason to be concerned about
CL: Synthesize
pressure on the gallbladder.
CN: Reduction of risk potential;
109. 1. The client who has been positioned in the
lithotomy position under general anesthesia may
CL: Apply
experience discomfort in the shoulders postopera-
104. 2. Biliary drainage tubes (T tubes) are placed tively because the client is placed in the Trende-
in the common bile duct and drain bile, which is lenburg position to expose the perineal area. The
dark yellow-orange. Serosanguineous drainage is client’s weight is then shifted toward the shoulders
thin and pinkish red. Bile is not clear and is not and the client experiences muscle soreness postop-
green unless it comes in contact with gastric fluid. eratively.
CN: Reduction of risk potential; CN: Basic care and comfort;
CL: Analyze CL: Apply
105. 1. Urinary elimination in the first 8 hours 110. 2. The client should drink a minimum of
postoperatively is a requirement before the client 2,500 mL of fluid per day (not 1,500 mL) to keep

Billings_Part 2_Chap 3_Test 14.indd 664 8/7/2010 10:27:14 AM

 The Client Having Surgery 665

secretions liquefied and easier to cough up and 115. 2. When the client cannot sign the opera-
eliminate from the upper respiratory tract. The cli- tive consent and it is a true life-saving emergency,
ent should use pain medication before coughing. consent may be obtained over the telephone from
The nurse should monitor the client’s breath sounds the client’s next-of-kin or guardian. The surgeon
and temperature to detect early signs of infection. must obtain the telephone consent, but if it is a true
The nurse should assist with early ambulation. life-saving emergency the surgeon often is already in
CN: Reduction of risk potential; surgery, so the nurse makes the telephone call and
CL: Synthesize another nurse witnesses the call. Some institutions
have a special consent form for emergency surgery.
111. 3. The client should sit in an upright posi- Consent can be waived in situations in which no
tion when doing breathing exercises to allow for family is available; however, if the family can be
full chest expansion of both lungs and all fields and reached by telephone before surgery, verbal consent
bases. Using an incentive spirometer every hour is legally required.
while awake is appropriate and allows the client
visual feedback. Placing his hands lightly over the CN: Management of care;
lower ribs and upper abdomen allows the client CL: Synthesize
to see muscles of inspiration and expiration and is 116. 3. There are risks with both the surgical
appropriate. Coughing deeply from the lungs after procedure and the general anesthesia required for
four deep breaths allows the client to effectively a craniotomy. The risks involved in the procedure
cough up secretions. are a part of the informed consent. Other informa-
CN: Reduction of risk potential; tion that is part of an informed consent includes
CL: Evaluate potential complications, expected benefits, inability
of the surgeon to predict results, irreversibility of
112. 2. Muscle cramping is a sign of hypokalemia. the procedure (if applicable), and other available
Potassium is an electrolyte lost with nasogastric treatments. Talking about the effects of the diabe-
suctioning. Confusion is seen with hypercalcemia. tes on healing, explaining how the craniotomy is
Edema is seen with protein deficit or fluid volume performed, and explaining the consequences of
overload. Tremors are seen with hypomagnesemia. declining treatment (e.g., death if the tumor is not
CN: Reduction of risk potential; removed) represent appropriate actions to provide
CL: Analyze information to the client.
CN: Management of care;
CL: Evaluate
Legal and Ethical Issues Associated
117. 2. All health care facilities reimbursed under
with Surgery Medicare and Medicaid are required under the 1991
Patient Self-Determination Act to recognize clients’
113. 3. The most critical piece of information is advance directives such as health care proxies or
the client identification bracelet. Misidentification living wills. Advance directives are an important
of clients can result in serious harm to the client. part of perioperative care and should be respected
The nurse also needs the admitting records and by all health care professionals caring for the client.
Addressograph labels as part of verifying the cli- The nurse should not be involved in specific ques-
ent’s identification. The location of the family is not tions regarding how the client is going to pay for
included in verifying identification. health care services except as an advocate address-
CN: Reduction of risk potential; ing the client’s psychosocial needs.
CL: Synthesize CN: Management of care; CL: Apply
114. 4. The nurse is not is not required to have 118. 2. When the client cannot read or write, the
the anesthesia note on the chart before the client consent can be read to the client and the client can
is transported to the operating room suite. The sign in the presence of two witnesses. The client
anesthesia record is on the chart after the surgi- (not the next-of-kin) should always sign for himself
cal procedure is completed and is a good source of unless he is a minor or not of sound mind. The court
client information. The operative consent, history does not appoint a guardian for a person of sound
and physical information, and laboratory test results mind just because he cannot read or write. Hospital
should be on the chart before the client is trans- personnel would not and could not sign a consent
ported to the operating suite. form for a client.
CN: Management of care; CN: Management of care;
CL: Apply CL: Apply

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 666 The Nursing Care of Adults with Medical and Surgical Health Problems

Managing Care Quality and Safety care once the client is transferred to the surgical
unit. The respiratory therapist may be a part of the
119. 2, 3, 4. The root cause of wrong-site surgery Rapid Response Team but should not be called first.
involves a breakdown in communication between CN: Management of care;
the client and family and the health care team. CL: Synthesize
Information retrieved from the client in the preop-
erative assessment, such as the client’s name, surgi- 122. 4. The nurse anesthetist administers the anes-
cal site, and procedure, should be verbally assessed thetic agent and monitors the client’s physical status
and verified with medical records and radiographic throughout the surgery; the nurse anesthetist must
diagnostic reports. This information should be com- have knowledge of all known allergies for client
piled in a checklist that the intraoperative team can safety. The completed chart (with the Preoperative
recheck, avoid unnecessary distraction and delay in Checklist) accompanies the client to the operating
the operating room. The nurse in the operating room room; any unusual last-minute observations that
is responsible for calling a “time-out” so that every may have a bearing on anesthesia or surgery are
surgical team member can double-check the correct noted prominently at the front of the chart. The pre-
site of surgery, verify the site using the operative anesthetic medication can cause light-headedness
consent form, and mark the operative site on the or drowsiness. The nurse in the scrub role provides
client. The client should mark the operative site in sterile instruments and supplies to the surgeon dur-
the preoperative period, not the surgeon, in order to ing the procedure.
avoid any miscommunication about the correct site CN: Safety and infection control;
of surgery. Showing the client an anatomic model CL: Synthesize
will assist the client in understanding the location
of the surgery, but it will not prevent anyone from 123. 1, 2, 4. Nurses can delegate to the unlicensed
identifying the wrong site on the client. assistive personnel (UAP) to observe clients and
promote their comfort following surgery, and to
CN: Safety and infection control; empty and measure urinary catheter drainage bags.
CL: Apply UAPs cannot teach clients; that is the responsibil-
120. 4. The nurse should first contact the physi- ity of the registered nurse or respiratory therapist.
cian because the order for the morphine is not UAPs cannot assess I.V. insertion sites, which is the
complete. The purpose of The Joint Commission’s responsibility of a registered nurse.
National Patient Safety Goals is to promote specific CN: Management of care; CL: Synthesize
improvements in client safety. A requirement to
meet this goal is to standardize a list of abbrevia- 124. 4. The nurse should plan for two people,
tions, acronyms, symbols, and dose designations one at each side using a drawsheet, one person at
that are not to be used throughout the organization. the head, and one person at the feet to transfer an
One abbreviation not to be used is MSO4 because elderly, drowsy client with fragile skin to avoid
it can apply to morphine as well as magnesium shearing of the integumentary system. Using only
sulfate. There is no mention of an IV system being two or three people allows for dragging of some part
needed. The morphine should not be in the medi- of the client, which leads to shearing of the depen-
cation cabinet because the order is not complete. dent part.
Although pharmacy may offer a suggestion as to CN: Safety and infection control;
what the medication ordered is, the best means to CL: Synthesize
confirm the intent of the order is to contact the phy-
sician who wrote the order. 125. 2. The client must have an identification
bracelet properly secured on her person before being
CN: Safety and infection control; CL: transported to the operating room to ensure cor-
Synthesize rect identification. It is incorrect to send the client
121. 4. The nurse should first call the Rapid without a properly secured identification bracelet.
Response Team (RRT), or medical emergency team The perioperative nurse must verify the client’s
that provides a team approach to evaluate and treat identification by checking for the same name on the
immediately clients with alterations in vital signs or chart, armband, and schedule and by the client’s
neurological deterioration. The client’s vital signs statement. The preoperative nurse may be asked
have changed since the client was in the PACU and to physically identify the client and obtain a new
immediate action is required to manage the changes; armband.
the staff in PACU are not responsible for managing CN: Management of care; CL: Synthesize

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