ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 14 : Perioperative Care Questions
Question 1 of 5
The nurse is completing an assessment of the client prior to surgery. What area(s) of the client assessment should the nurse question further? Select all that apply.
Correct Answer: A,B,C,D
Rationale: When preparing a client for surgery, these areas need to be addressed: skin preparation, elimination, attire/grooming, prosthesis, foods and fluids, and care of valuables. In addition, medication, activity, and the client's support system must be assessed. Dietary preferences of the client would not be a priority during the preoperative assessment.
Question 2 of 5
The nurse is reviewing a preoperative informed consent when preparing the client for surgery. Which content(s) of the informed consent is required? Select all that apply.
Correct Answer: A,C,D,F
Rationale: Informed consents should be in writing and contain an explanation of procedure and risks, description of benefits and alternative, an offer to answer questions about procedure, ability to withdraw consent, and statement informing the client if the protocol differs from customary procedure. An estimated time of procedure and personnel present are not required in the informed consent.
Question 3 of 5
The nurse is caring for a client who is 2 hours postoperative. The client states, 'I am nauseated.' Which action(s) should the nurse perform? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Nausea is a frequent symptom in the postoperative period. When a client reports nausea, the nurse should provide an emesis basin in case the client vomits, check the medication administration record to provide a prescribed antiemetic, obtain vital signs per postoperative protocol, and encourage deep breathing. Liquids should be held until the nausea subsides.
Question 4 of 5
The nurse is providing community instruction on the impact of aging and surgical incisional considerations. Which instructional area(s) would be included in the presentation? Select all that apply.
Correct Answer: A,B,C
Rationale: The nurse realizes that there is a thinning of the skin and loss of subcutaneous tissue, which is normal in the aging process. Also, older adults may have a diminished immunological response, making them more susceptible to infection. For this reason, instructional areas would include areas which promote healing and diminish the risk of infection. Increasing protein in the diet promotes wound healing. Instructing on signs and symptoms of wound infection allows for early symptom recognition. Cleansing, as per physician instruction, but with products, such as soap and water, decreases bacteria on the skin. Showering may begin prior to healing with the stream of the water not directly on the incision. Peroxide is not recommended for wound/incisional care. Crusted areas should be allowed to heal and flake off. Removing the areas could open a wound allowing for bacteria to enter.
Question 5 of 5
The nurse is caring for a postoperative client who reports difficulty urinating. The client does not have a urinary catheter in place. Which nursing action(s) are most appropriate at this time? Select all that apply.
Correct Answer: A,B,D,E
Rationale: The nurse encourages the client to void within 8 hours of surgery to minimize the risk of a urinary tract infection. Ambulating the client to the bathroom promotes normal body positioning for urination. Running water is a common psychological strategy to cause urination. Offering to catheterize is a last option, and a prescription for catheterization must be in place for the nurse to proceed.