Potter Perry Chapter 50 - Questions And Rationales 2022 Latest

Potter Perry Chapter 50 - Questions And Rationales 2022 Latest 1. The nurse is precepting a student nurse and explains that perioperative nursing care occurs a. Before, during, and after surgery. b. In preadmission testing. c. During the surgical procedure. d. In the postanesthesia care unit. - ANS: A Perioperative nursing care occurs before, during, and after a surgery. Preadmission testing occurs before surgery and is considered preoperative. Nursing care provided during the surgical procedure is considered intraoperative, and in the postanesthesia care unit, it is considered postoperative. All of these are parts of the perioperative phase, but each individual phase does not explain the term completely. 2. The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patient's laboratory tests and allergies. In which perioperative nursing phase would this work be completed? a. Perioperative b. Preoperative c. Intraoperative d. Postoperative - ANS: B Reviewing the patient's laboratory tests and allergies is done before surgery in the preoperative phase. Perioperative means before, during, and after surgery. Intraoperative means during the surgical procedure in the operating suite; postoperative means after the surgery and could occur in the postanesthesia care unit, in the ambulatory surgical area, or on the hospital unit. 3. The nurse is caring for a patient in the postanesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. This procedure would be classified as a. Elective. b. Urgent. c. Emergency. d. Major. - ANS: C An emergency procedure must be done immediately to save life or preserve function of a body part. An example would be repair of a perforated appendix, repair of a traumatic amputation, or control of internal hemorrhaging. An urgent procedure is necessary for a patient's health and often prevents additional problems form developing. An example would be excision of a cancerous tumor, removal of a gallbladder for stones, or vascular repair for obstructed artery. An elective procedure is performed on the basis of the patient's choice; it is not essential and is not always necessary for health. An example would be a bunionectomy, plastic surgery, or hernia reconstruction. A major procedure involves extensive reconstruction or alteration in body parts; it poses great risks to well-being. An example would be a coronary artery bypass or colon resection. 4. The nurse is caring for a patient in preadmission testing. The patient has been assigned a physical status classification by the American Society of Anesthesiologist of P3. Which of the following assessments would support this classification? a. Denial of any major illnesses or conditions b. Normal, healthy patient c. History of hypertension, 80 pounds overweight, history of asthma d. History of myocardial infarction that limits activity - ANS: C A P3 is a patient with a severe systemic disease. Patients with hypertension, obesity, diabetes mellitus, and asthma fit into this category. A P1 is a normal healthy patient. A P2 is a patient with mild systemic disease. A P4 is a patient with severe systemic disease that is a constant threat to life. 5. The patient has presented to the ambulatory surgery center to have a colonoscopy. The patient is scheduled to receive moderate sedation (conscious sedation) during the procedure. Moderate sedation is used routinely for procedures that require a. Performance on an outpatient basis. b. A depressed level of consciousness. c. Loss of sensation in an area of the body. d. The patient to be immobile. - ANS: B Moderate sedation (conscious sedation) is used routinely for procedures that do not require complete anesthesia, but rather a depressed level of consciousness. Not all patients who are treated on an outpatient basis receive moderate sedation. Regional anesthesia such as local anesthesia provides loss of sensation in an area of the body. General anesthesia is used for patients who need to be immobile and to not remember the surgical procedure. 6. The nurse is caring for a patient in the postanesthesia care unit who has undergone a left total knee arthroplasty. The anesthesia provider has indicated that the patient received a left femoral peripheral nerve block. Which assessment would be an expected finding for a patient with this type of regional block? a. Decreased pulse at the left posterior tibia b. Left toes cool to touch and slightly cyanotic c. Sensation decreased in the left leg d. Patient report of pain in the left foot - ANS: C Induction of regional anesthesia results in loss of sensation in an area of the body. The peripheral nerve block influences the portion of sensory pathways that are anesthetized in the targeted area of the body. Decreased pulse, toes cool to touch, and cyanosis are indications of decreased blood flow and are not expected findings. Reports of pain the in the left foot may indicate that the block is not working or is subsiding and is not an expected finding in the immediate postoperative period. 7. The nurse is preparing a patient for surgery. Aims of assessment before surgery include a. Establishing a patient's baseline of normal function. b. Planning for care after the procedure. c. Educating the patient and family about the procedure. d. Gathering appropriate equipment for the patient's needs. - ANS: A The aim of assessment of the patient before surgery is to establish the patient's normal preoperative function to prevent and minimize possible postoperative complications. Gathering appropriate equipment, planning care, and educating the patient and family are all important interventions that must be provided for the surgical patient; they are part of the nursing process but are not the reason for completing an assessment of the surgical patient. 8. The nurse is completing a medication history for the surgical patient in preadmission testing. Which of the following medications should the nurse instruct the patient to hold in preparation for surgery? a. Ibuprofen b. Acetaminophen c. Vitamin C d. Miconazole - ANS: A Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen inhibit platelet aggregation and prolong bleeding time, increasing susceptibility to postoperative bleeding. Acetaminophen is a pain reliever that has no special implications for surgery. Vitamin C actually assists in wound healing and has no special implications for surgery. Miconazole is an antifungal and has no special implications for surgery. 9. The nurse is caring for a potential surgical patient in the preadmission testing unit. The medication history indicates that the patient is currently taking warfarin (Coumadin). Which of the following actions should the nurse take? a. Consult with the physician regarding a radiological examination of the chest. b. Consult with the physician regarding an international normalized ratio (INR). c. Consult with the physician regarding blood urea nitrogen (BUN). d. Consult with the physician regarding a complete blood count (CBC). - ANS: B Warfarin is an anticoagulant that is utilized for different maladies, but its action is to increase the time it takes for the blood to clot. This action can put the surgical patient at risk for bleeding tendencies. Typically, if at all possible, this medication is held several days before a surgical procedure to decrease this risk. INR, PT (prothrombin time), APTT (activated partial thromboplastin time), and platelet counts reveal the clotting ability of the blood. Chest x-ray, BUN, and CBC are diagnostic screening tools for surgery but are not specific to warfarin. 10. The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Reasons for this intervention include a. Management of pain. b. Decreased healing time. c. Prevention of atelectasis. d. Decreased thrombus formation. - ANS: C During general anesthesia, the lungs are not fully inflated during surgery and the cough reflex is suppressed, so mucus collects within airway passages. After surgery, patients may have reduced lung volume and may require greater effort to cough and deep breathe; inadequate lung expansion can lead to atelectasis and pneumonia. Purposely utilizing diaphragmatic breathing can decrease this risk. Diaphragmatic breathing, except for the components of distraction, minimal increased level of oxygen, and minimal chest wall movement, does not influence pain, healing time, or thrombus formation. Better, more effective interventions are available for these situations. 11. The nurse is caring for a postoperative patient on the medical-surgical floor. To prevent venous stasis and the formation of thrombus after general anesthesia, the nurse encourages a. Coughing. b. Diaphragmatic breathing. c. Incentive spirometry. d. Leg exercises. - ANS: D After general anesthesia, circulation slows, and when the rate of blood slows, a greater tendency for clot formation is noted. Immobilization results in decreased muscular contractions in the lower extremities; these promote venous stasis. Coughing, diaphragmatic breathing, and incentive spirometry are utilized to decrease atelectasis. 12. The nurse is caring for a preoperative patient. The nurse teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurse's best next step? a. Assess for the presence of anxiety, pain, or fatigue. b. Ask the patient why he does not want to do the exercises. c. Encourage the patient to practice at a later date. d. Assess the educational methods used to educate the patient. - ANS: A If the patient is unable to perform leg exercises after sound educational principles and demonstration are provided, the nurse should look for circumstances that may be impacting the patient's ability to learn. In this case, the patient can be anticipating the upcoming surgery and may be experiencing anxiety. The patient may also be in pain or may be fatigued; both of these can affect the ability to learn. Assessment of educational methods may be needed, but in this case, sound principles and demonstration are being utilized. Asking anyone why can cause defensiveness and may not help in attaining the answer. In this case, the patient really may want to participate and may not know why he is unable to learn. The nurse is aware that the patient is unable to do the exercises. Moving forward without ascertaining that learning has occurred will not help the patient in meeting goals. 13. Which nursing assessment would indicate that the patient is performing diaphragmatic breathing correctly? a. Hands placed on border of rib cage with fingers extended will touch as chest wall contracts. b. Hands placed on chest wall with fingers extended will separate as chest wall contracts. c. The patient will feel upward movement of the diaphragm during inspiration. d. The patient will feel downward movement of the diaphragm during expiration. - ANS: A Positioning the hands along the borders of the rib cage allows the patient to feel movement of the chest and abdomen as the diaphragm descends and the lungs expand. As the patient takes a deep breath and slowly exhales, the middle fingers will touch while the chest wall contracts. The fingers will separate as the chest wall expands. The patient will feel normal downward movement of the diaphragm during inspiration and normal upward movement during expiration. 14. The nurse is caring for a postoperative patient with an abdominal incision. A pillow is used during coughing to provide a. Pain relief. b. Splinting. c. Distraction. d. Anxiety reduction. - ANS: B Surgical incisions cut through muscles, tissues, and nerve endings. Deep breathing and coughing exercises place additional stress on the suture line and cause discomfort. Splinting incisions with hands and a pillow provides firm support and reduces incisional pull. Providing a pillow during coughing does not provide distraction or reduce anxiety. Providing a pillow does not provide pain relief. Coughing can increase anxiety because it can cause pain. 15. The nurse is encouraging a reluctant postoperative patient to deep breathe and cough. What explanation can the nurse provide that may encourage the patient to cough more effectively? a. "If you don't deep breathe and cough, you will get pneumonia." b. "Deep breathing and coughing will clear out the anesthesia." c. "Coughing will not harm the incision if done correctly." d. "You will need to cough only a few times during this shift." - ANS: C If coughing is done correctly with proper support of the incision, it will not harm the incision. Deep breathing and coughing help to clear out mucus in the respiratory system that has been caused by the anesthesia. Although it is correct that a patient may experience atelectasis and pneumonia if deep breathing and coughing are not performed, the way this is worded sounds threatening and could be communicated in a more therapeutic manner. Deep breathing and coughing is encouraged every 2 hours while the patient is awake. 16. The nurse and the nursing assistant are assisting a postoperative patient to turn in the bed. To assist in minimizing discomfort, which instruction should the nurse provide to the patient? a. "Close your eyes and think about something pleasant." b. "Hold your breath and count to three." c. "Hold my shoulders with your hands." d. "Place your hand over your incision." - ANS: D Instruct the patient to place right hand over incisional area to splint it, providing support and minimizing pulling during turning. Closing one's eyes, holding one's breath, and holding the nurse's shoulders do not help support the incision during a turn. 17. The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide first? a. Perform hand hygiene. b. Place in reverse Trendelenburg position. c. Explain use of the mouthpiece. d. Instruct the patient to inhale slowly. - ANS: A Performing hand hygiene reduces microorganisms. Placing the patient in the correct position such as high Fowler's or reverse Trendelenburg for the bariatric patient would be the next step in the process. Demonstration of use of the mouthpiece followed by the instruction to inhale slowly would be the last step in this scenario. 18. The nurse and the nursing assistant are caring for a group of postoperative patients who need turning, coughing, deep breathing, incentive spirometer, and leg exercises. The nurse directs the nursing assistant to a. Teach and demonstrate postoperative exercises. b. Inform the nurse if the patient is unwilling to perform exercises. c. Document in the medical record when exercises are completed. d. Do nothing associated with postoperative exercises. - ANS: B The nurse may delegate activities to individuals who are competent, within their scope of practice, and willing to be legally responsible—all while maintaining responsibility for follow-up and outcome. The nurse can delegate to a nursing assistant to encourage patients to practice postoperative exercises regularly after instruction, and to inform the nurse if the patient is unwilling to perform these exercises. The skills of demonstrating and teaching postoperative exercises and documenting are not within the scope of practice for the nursing assistant. Doing nothing is not appropriate. 19. The nurse is providing preoperative teaching for the ambulatory surgery patient who will be having a cyst removed from the right arm. Which would be the best explanation for diet progression after surgery? a. "Start with clear liquids, soup, and crackers. Advance to a normal diet as you tolerate." b. "There is no limitation on your diet. You can have whatever you want." c. "Stay on clear liquids for 24 hours. Then you can progress to a normal diet." d. "Start with clear liquids for 2 hours, then full liquids for 2 hours. Then progress to a normal diet." - ANS: A The type of surgery that patients undergo determines how quickly they can resume normal physical activity and regular eating habits. It is normal to progress gradually in activity and eating, and if the patient tolerates activity and diet well, he/she can progress more quickly. A common complication after surgery is nausea and vomiting. This can be caused by the anesthesia, fluid imbalance from being NPO, and pain. The gastrointestinal tract may be hypoactive owing to anesthesia. It is best to start with a clear liquid to see if the patient can tolerate the liquid without vomiting. If so, progressing to soup and crackers and advancing as the patient tolerates is appropriate. Starting with a heavy, greasy meal could cause nausea and vomiting. There is no need to stay on clear liquids for 24 hours after this procedure. Putting a time frame on the progression is too prescriptive. Progression should be adjusted for the patient's needs. 20. The nurse explains the pain relief measures available after surgery during preoperative teaching for a surgical patient. Which of the following comments from the patient indicates the need for additional education on this topic? a. "I will take the pain medication as the physician prescribes it." b. "I will be asked to rate my pain on a pain scale." c. "I will have minimal pain because of the anesthesia." d. "I will take my pain medications before doing postoperative exercises." - ANS: C Pain after surgery is expected and is one of the patient's fears. Anesthesia will be provided during the procedure itself, and the patient should not experience pain during the procedure. Pain management is utilized after the postoperative phase. Inform the patient of interventions available for pain relief, including medication, relaxation, and distraction. The patient needs to know and understand how to take the medications that the physician will prescribe postoperatively. During the stay in the facility, the level of pain is frequently assessed by the nurses. Coordinating pain medication with postoperative exercises helps to minimize discomfort and allows the exercises to be more effective...