Exam 14: Clients Having Surgery

The PACU nurse notes that a client is beginning to become increasingly restless. Nursing assessment includes blood pressure measurements dropping from (120/82) g to (90/60) mm Hg, with heart rate increased to 120 beats/min, and dressings dry and intact. Which action by the nurse takes priority?

A client calls the Telehealth nurse on the third postoperative day and describes a "giving way" sensation in the abdomen that occurred after coughing. To assess for a possible evisceration, the nurse asks if

Which action should receive high priority in an elderly client being placed on the operating room table?

A client scheduled for a dilation and evacuation following a miscarriage is visibly upset and states that she is frightened and does not know what to expect. The perioperative nurse best demonstrates understanding of the situation by saying

The preoperative assessment finding that the nurse would report to the surgeon for preoperative treatment is

In the first 3 days after surgery, the nurse would anticipate the fluid and electrolyte adjustment of

During the preoperative interview, the client's statement that would alert the nurse to an increased risk during surgery is "I

A client has the nursing diagnosis Fear related to the unknown regarding upcoming surgery. The nurse would know that goals for this diagnosis have been met when the client says "I feel a little better now because

The nurse explains to a preoperative class of six clients awaiting surgery that studies indicate the primary benefit of the class is to

After administration of preoperative medications, the nurse takes the precaution of

During preoperative teaching, the nurse advises the client who smokes on an important health promotion measure to take before elective surgery, which is to

The methodology likely to be most effective in meeting a client's teaching/learning needs preoperatively is

Important actions the nurse takes to avoid "wrong site surgery" include (Select all that apply)

On the preoperative assessment, the nurse notes the suggestion of susceptibility to malignant hyperthermia during surgery in the client's statement that

During the operative period, a client under general anesthesia experiences masseter muscle rigidity. The nurse-anesthetist recognizes this to be a manifestation of

A client who is extremely overweight has been advised to lose weight before surgery. To encourage the client, the nurse knows that the most appropriate statement is

The nurse explains to a client that because of alterations in liver function caused by cirrhosis, the client is predisposed to postoperative fluid shifts and wound infection related to

For a client admitted to the PACU with an oral airway in place, the nursing intervention that would be inappropriate is