HESI Patient Review: Perioperative Care – John Hale 2

Of the following, which are also appropriate at this time?

a. Contact lenses should be removed
b. Mr. Hale should be asked to void
c. Vital signs should be taken and recorded
d. Mrs. Hale should be asked to leave

a. Contact lenses should be removed

Contact lenses should be removed before surgery. Any dentures should also be removed, to avoid the possibility of airway obstruction or interference with intubation. Preferably, a family member can hold or secure personal items, including any jewelry or eyeglasses, until they are needed.

b. Mr. Hale should be asked to void

Mr. Hale should urinate before surgery, before any preanesthesia medications are given. The bladder should be emptied to prevent urinary incontinence during surgery and avoid urinary retention after surgery. Also, a full bladder could obstruct surgical view and possibly be injured during surgery.

c. Vital signs should be taken and recorded

Vital signs should be taken before surgery, and recorded. Preoperative vital signs establish a baseline for postoperative comparison. Baseline vital signs should be determined before the depressant effects of any preanesthesia medications have taken effect. Mr. Hale’s baseline vital signs are BP 124/80, apical pulse rate 86, respiratory rate 20. His temperature, taken with a tympanic thermometer, is 36.6 degrees C (97.9 degrees F). Preoperative blood pressure and pulse rate may be higher than usual, because of the emotional stress associated with surgery.

Upon arrival in the Preoperative Holding Area, Mr. Hale’s identity is confirmed. This is best done by:

a. Asking his name
b. Asking him what surgery he is scheduled for
c. Checking his identification bracelet and asking his name and birth date

c. Checking his identification bracelet and asking his name and birth date

To insure accuracy of patient identification, at least two patient identifiers should be used. Checking a patient’s identification bracelet and asking his name and birth date are acceptable safe ways to confirm identity. The patient’s identification bracelet should contain his full name (correctly spelled), birth date, and an assigned identification number. The name, birth date, and identification number on the patient’s identification bracelet should match the patient identity information contained in the patient’s medical record and on the surgery schedule.

Surgical site marking is required for some procedures. For which of the following procedures would site marking be required?

a. Left leg above the knee amputation
b. Right inguinal hernia repair
c. Cesarean section
d. Cataract removal left eye
e. Exploratory laparotomy

a. Left leg above the knee amputation

Surgical site marking is designed to prevent wrong procedure and wrong site surgery. Site marking directs the surgical team to the correct location for the surgical procedure. Surgical site marking is required for all procedures that involve right/left distinction, multiple structures (e.g., finger, toes etc.), or levels (e.g., spinal surgery). For a left leg above the knee amputation, the left leg would be marked at the level of the amputation.

b. Right inguinal hernia repair

Surgical site marking is designed to prevent wrong procedure and wrong site surgery. Site marking directs the surgical team to the correct location for the surgical procedure. Surgical site marking is required for all procedures that involve right/left distinction, multiple structures (e.g., finger, toes etc.), or levels (e.g., spinal surgery). For a right inguinal hernia repair, the right side of the lower abdomen would be marked.

d. Cataract removal left eye

Surgical site marking is designed to prevent wrong procedure and wrong site surgery. Site marking directs the surgical team to the correct location for the surgical procedure. Surgical site marking is required for all procedures that involve right/left distinction, multiple structures (e.g., finger, toes etc.), or levels (e.g., spinal surgery). For left eye cataract removal, the skin area adjacent to the left eye would be marked.

Versed (midazolam hydrochloride) is often used as preanesthesia medication prior to general anesthesia. You expect that the Versed (midazolam hydrochloride) will:

a. Promote systemic muscle relaxation
b. Induce local analgesia
c. Induce systemic analgesia
d. Decrease Mr. Hale’s anxiety
e. Provide for amnesia of perioperative events

a. Promote systemic muscle relaxation

Versed (midazolam hydrochloride) causes central nervous system depression that should promote muscle relaxation in Mr. Hale.

d. Decrease Mr. Hale’s anxiety

Versed (midazolam hydrochloride), a short-acting benzodiazepine, should have an anti-anxiety effect on Mr. Hale. It is a potent short-acting sedative agent that should also make him drowsy.

e. Provide for amnesia of perioperative events

Versed (midazolam hydrochloride) should effectively provide for anterograde amnesia of perioperative events.

The verbal report you receive from the Post Anesthesia Care Unit (PACU) nurse should include:

a. The name of the surgical procedure Mr. Hale had
b. Mr. Hale’s relevant health history
c. Mr. Hale’s fluid status and IV therapy
d. Information about any tubes or drains
e. Information about anesthesia and drugs that were administered
f. The condition of Mr. Hale’s surgical incision
g. Mr. Hale’s religious preference

a. The name of the surgical procedure Mr. Hale had

Knowing the procedure the patient had is critical. Your surgical care plan should include standards of care relevant to the surgical procedure, individualized for Mr. Hale.

b. Mr. Hale’s relevant health history

Comprehensive medical information is collected on every patient prior to surgery. Relevant data in a concise format should be communicated to nurses in all areas. Relevant information from the patient’s history includes the patient’s age, allergies, medication use, and major health problems (including substance abuse history). Any identified latex sensitivity should also be communicated. Latex-sensitive patients require use of latex-safe equipment, and use of nonlatex gloves by caregivers. The PACU nurse tells you about Mr. Hale and his history of diabetes. A recent fingerstick glucose reading was 142 mg/dl.

c. Mr. Hale’s fluid status and IV therapy

Fluid balance is a critical assessment postoperatively. Fluids are generally restricted preoperatively and fluid loss is common during surgery. Fluids are generally administered during and after surgery to correct deficits and maintain fluid balance. Knowledge of efforts to maintain fluid balance during and after surgery is critical. Urine output also provides information about fluid status and should be reported. The PACU nurse reports that Mr. Hale received one unit of packed red cells during surgery. In PACU, Lactated Ringer’s infused at 125 mL per hour, and continues to infuse. Mr. Hale does not have a Foley catheter and has not voided.

d. Information about any tubes or drains

Tubes and drains need ongoing assessment and care. Tubes present should be determined when a patient is received from PACU. The PACU nurse reports that Mr. Hale has a vented nasogastric (NG) tube to be connected to suction. NG tube drainage has been bloody, and 75 mL has drained since surgery. Mr. Hale does not have a Foley catheter and he has not voided.

e. Information about anesthesia and drugs that were administered

Knowing about anesthetics and medications that were administered will enable you to determine drug-specific assessments and interventions, and also to plan for Mr. Hale’s pain control. The PACU nurse reports that Mr. Hale had general anesthesia. In PACU, morphine sulfate 2 mg IV was given just prior to bringing Mr. Hale to the Surgical Unit. At that time, Mr. Hale complained of incisional pain, rated as 7 on a scale of 1-10. Morphine provided relief of pain. In PACU, because the depressant effects of anesthetics are generally still in effect, a small dose of a narcotic analgesic usually achieves analgesia.

f. The condition of Mr. Hale’s surgical incision

The condition of the surgical incision should be reported, including type of wound closure and any dressing. Any bleeding or other drainage at the incision should also be reported. The PACU nurse tells you that Mr. Hale has a midline incision with staples. A gauze dressing applied over the wound is intact, with a quarter-size area of bloody drainage circled.

You assess Mr. Hale. The most critical, high-priority assessment to be done is:

a. Operative site
b. Skin integrity
c. Pulse
d. Airway
e. Blood pressure

d. Airway

The nurse’s initial priority when admitting a patient to the Surgical Unit is to determine and insure the adequacy of the patient’s airway and breathing. The patient’s airway should be assessed for patency. Respiratory rate, rhythm, and quality should be determined. Breath sounds should be auscultated as soon as possible. Mr. Hale is breathing on his own at 16 regular, deep breaths per minute. You know that to meet criteria for discharge from the Post Anesthesia Care Unit (PACU), Mr. Hale had a SpO2 of 94-100% on room air for a minimum of five minutes. SpO2 measures O2 saturation noninvasively by means of pulse oximetry.

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What two assessments are your next priorities?

a. Operative site
b. Skin color
c. Skin integrity
d. Pulse
e. Blood pressure
f. Orientation

d. Pulse

After assessing a patient’s airway and breathing, the adequacy of circulation should be determined. The patient’s pulse should be checked. You check Mr. Hale’s apical pulse. His heart rate is regular at 72 beats per minute. His baseline pulse rate before surgery was 86. Pulse is strong.

e. Blood Pressure

After assessing a patient’s airway and breathing, the adequacy of circulation should be assessed. BP should be determined. BP reflects the adequacy of circulation and cardiac output. You check Mr. Hale’s BP and get a reading of 110/72. Mr. Hale’s baseline BP before surgery was 124/80.

When checking for evidence of cyanosis, which of the following body areas should be observed?

a. Axillae
b. Nailbeds
c. Lips
d. Palms of the hands
e. Sternum
f. Earlobes

b. Nailbeds

Cyanosis is most evident in specific body areas, such as the nailbeds.

c. Lips

Cyanosis is most evident in specific body areas, such as the lips.

d. Palms of the hands

Cyanosis is most evident in specific body areas, such as the palms of the hands.

f. Earlobes

Cyanosis is most evident in specific body areas, such as the earlobes.

You also check Mr. Hale’s temperature. Which body temperature variation do you expect?

a. High body temperature
b. Low body temperature

b. Low body temperature

Postoperative patients often have a low body temperature that persists even after they are discharged from PACU. The cool room temperature in the OR (generally 68-75 degrees F) contributes to a low body temperature. This cool temperature discourages bacterial growth, minimizes risk for surgical wound infection, and provides a relatively comfortable environment for the surgical team. Anesthetics also contribute to low body temperature. Central nervous system depression associated with general anesthesia interferes with physiological mechanisms that maintain body temperature within normal limits. Peripheral vasodilation associated with spinal anesthesia causes heat loss. In the OR, measures to prevent heat loss include warming of infusions and irrigation fluids, and limiting patient exposure as much as possible (including covering of the patient’s head).

When a postoperative patient is not responsive, or when an alert postoperative patient is vomiting, which position is preferred?

a. Semi-Fowler’s (30 degrees)
b. Fowler’s (90 degrees)
c. Supine
d. Side-lying

d. Side-lying

When a postoperative patient is not responsive, or when an alert postoperative patient is vomiting, the side-lying position is preferred, to prevent aspiration or obstruction of air passages with mucous or vomit. The depressant effects of general anesthetics can suppress the gag reflex. The patient may not be able to swallow and manage secretions or vomit. The side-lying position facilitates discharge of mucous or vomit from the patient’s mouth.

Which of the following apply to Mr. Hale in this postoperative period?

a. Acute Pain
b. Self-Care Deficit: Bathing/Hygiene
c. Impaired Verbal Communication
d. Impaired Oral Mucous Membrane
e. Risk for Impaired Skin Integrity
f. Deficient Fluid Volume
g. Disturbed Self-Concept

a. Acute Pain

Acute pain is expected after major abdominal surgery. Even though Mr. Hale is now comfortable, because he recently received pain medication, it is expected that pain will return if medication is not continued. When pain is severe, it is more difficult to control. Acute Pain is a collaborative problem. To minimize and control pain, medical and nursing interventions are indicated. Morphine has been ordered by the physician. Nursing interventions to promote comfort will also be used with Mr. Hale. These include proper positioning, and providing for hygiene and back care.

b. Self-Care Deficit: Bathing/Hygiene

Because of imposed immobility, difficulty moving, depressant effects of medications, and fatigue from the trauma of surgery, Mr. Hale temporarily needs assistance with activities of daily living. The nursing diagnosis Self-Care Deficit: Bathing/Hygiene applies to his care.

d. Impaired Oral Mucous Membrane

Mr. Hale’s mouth and lips are dry and cracked. The nursing diagnosis Impaired Oral Mucous Membrane applies to his care. Lack of oral fluid intake contributes to dry mouth and lips. Dry mouth and lips can also be associated with fluid volume deficit and dehydration. Mouth care is indicated to alleviate the discomfort of dry mouth and lips. Mouth care may include brushing teeth, mouth rinsing, chewing gum, sucking of ice chips (if permitted), and use of a water-soluble lubricant on the lips.

e. Risk for Impaired Skin Integrity

Because of imposed immobility and difficulty moving, Mr. Hale is at risk for the development of pressure ulcers. Repositioning Mr. Hale at least every two hours, avoiding pressure on bony prominences, and insuring that his skin is clean and dry, should help prevent pressure ulcers.

In general, when urine output is measurable, urine output less than _____mL per hour can reflect volume depletion with poor renal perfusion, and should be reported.
30
If a postoperative patient is not catheterized and has not yet voided, other indicators of volume depletion are important. Besides a decreased urine output, other indicators of volume depletion can include:

a. Decreasing blood pressure
b. Tachycardia
c. Flushed skin
d. Dry mouth

a. Decreasing blood pressure

When fluid volume is depleted, physiological compensation occurs. Peripheral vasoconstriction helps to maintain blood pressure and the perfusion of major organs. Postural hypotension may be present. Over time, if fluid volume remains depleted, compensation mechanisms fail and blood pressure decreases. Postural hypotension and/or decreasing blood pressure should be reported.

b. Tachycardia

When fluid volume is depleted, physiological compensation occurs. Heart rate increases to perfuse tissues and organs at a faster rate. Increasing heart rate should be reported.

d. Dry mouth

When fluid volume is depleted, physiological compensation occurs. Peripheral tissues and mucous membranes are poorly perfused, as blood is directed at perfusion of major organs. Oral mucous membranes will be dry.

Which actions on your part are indicated in response to Mr. Hale’s reluctance to use the incentive spirometer?

a. Continue to encourage Mr. Hale to use his incentive spirometer and cough
b. Suggest that Mr. Hale self-administer morphine before using the incentive spirometer
c. Ask the respiratory therapist to work with Mr. Hale
d. Call the physician

a. Continue to encourage Mr. Hale to use his incentive spirometer and cough

It is important that you continue to encourage Mr. Hale to deep breathe and cough, with use of the incentive spirometer.

b. Suggest that Mr. Hale self-administer morphine before using the incentive spirometer

Advising Mr. Hale to self-administer morphine before deep breathing and coughing should help to control any associated discomfort. Use of pain medication before an uncomfortable procedure usually increases cooperation during the procedure. The action of IV morphine peaks at 20 minutes. Mr. Hale can administer a dose 20 minutes before deep breathing and coughing to see if this helps.

Because Mr. Hale is receiving morphine, it is important to know its possible effects. These include which of the following?

a. Increase in heart rate
b. Increase in gastrointestinal peristalsis
c. Decrease in blood pressure
d. Decrease in respiratory rate
e. Pupillary constriction
f. Urinary retention

c. Decrease in blood pressure

Morphine is a central nervous system depressant. It can be expected to cause a decrease in blood pressure. Severe hypotension would be an adverse effect.

d. Decrease in respiratory rate

Morphine is a central nervous system depressant. It can be expected to decrease respiratory rate. Severe respiratory depression (slow, shallow respirations) would be a major adverse effect of morphine. Respirations should be closely monitored when a patient is receiving morphine. Opioids are generally withheld if respiratory rate decreases below 8-10 breaths per minute. Since sedation generally occurs before respiratory depression, a patient who is using a patient controlled analgesia device is less likely to experience respiratory depression. The narcotic antagonist Narcan (naloxone) is kept available on the nursing unit in case it is needed to treat opioid-induced respiratory depression.

e. Pupillary constriction

Morphine is expected to cause constriction of the pupils (miosis). This would be a normal observation in a person receiving morphine.

f. Urinary retention

Morphine is a central nervous system depressant. It can contribute to postoperative urinary retention. Mr. Hale has not yet voided after surgery.

You palpate Mr. Hale’s lower abdomen and note suprapubic distention. This is most likely a result of:

a. Bleeding
b. A distended urinary bladder
c. Tension in abdominal muscles
d. Inflammation secondary to surgical manipulation

b. A distended urinary bladder

Mr. Hale’s suprapubic distention is probably a result of a distended bladder. Urinary retention is not uncommon after surgery with general anesthesia and Mr. Hale has not yet voided. Urinary retention can impair bladder and kidney function, places stress on the surgical site, and is uncomfortable. It should be alleviated. Mr. Hale states he feels the need to pass urine but knows he can’t do so until he stands up.

What nursing actions are indicated to facilitate voiding?

a. Increase Mr. Hale’s IV flow rate
b. Suggest to the physician that Mr. Hale be permitted to stand to attempt to void
c. Allow Mr. Hale to drink some sips of water
d. Run the water in the Mr. Hale’s room

b. Suggest to the physician that Mr. Hale be permitted to stand to attempt to void

It would be appropriate to ask the physician that Mr. Hale be allowed to stand to void. For men, standing facilitates voiding. You obtain an order for Mr. Hale to stand for voiding.

d. Run the water in the Mr. Hale’s room

Hearing running water can be a stimulus for voiding in a person who is not voiding. Letting Mr. Hale hear running water is appropriate. You run the water in his room.

You assist Mr. Hale to sitting position on the side of the bed and allow him to dangle for a few minutes. This will help to prevent _________ when Mr. Hale stands.

a. Orthostatic hypotension
b. Orthostatic hypertension
c. Orthostatic paresis
d. Orthostatic paralysis

a. Orthostatic hypotension

Orthostatic hypotension, accompanied by dizziness, can occur with standing. Under normal circumstances, in response to a position change from horizontal to vertical, sympathetic vasoconstriction prevents pooling of blood in the lower extremities and helps to maintain adequate blood pressure and perfusion of vital organs. Residual effects of the anesthetics and analgesics Mr. Hale received, along with the fact that Mr. Hale has been recumbent and immobile (although for a short time), may make this autonomic response sluggish, and increase the possibility of orthostatic hypotension. Gradual position changes from supine to sitting to standing allow time for the autonomic nervous system to adapt and should help to prevent dizziness and possible injury in Mr. Hale. Mr. Hale’s blood pressure drops slightly with sitting and he complains of some dizziness that quickly subsides.

You assess Mr. Hale specifically for any signs of deep vein thrombosis (DVT) in his legs. Signs of DVT secondary to surgery generally become evident after 24 hours. With DVT, the area of thrombosis may be:

a. Painful
b. Swollen
c. Reddened
d. Necrotic
e. Pruritic
f. Warm to touch

a. Painful

Inflammation associated with deep vein thrombosis (DVT) generally causes tenderness at the affected area.

b. Swollen

With deep vein thrombosis (DVT) in a lower leg vein, inflammation causes swelling that can increase calf circumference (girth).

c. Reddened

Inflammation associated with deep vein thrombosis (DVT) in a lower leg vein can cause localized redness at the affected area.

f. Warm to touch

Inflammation associated with deep vein thrombosis (DVT) in a lower leg vein can cause localized warmth at the affected area.

You assess a postoperative patient and find calf tenderness and swelling. What should you do in response to these findings?

a. Massage the calf to relieve venous congestion
b. Raise the knee gatch of the bed to alleviate venous stasis
c. Encourage the patient to walk to increase peripheral blood flow
d. Elevate the patient’s legs to promote venous return to the heart

d. Elevate the patient’s legs to promote venous return to the heart

Calf tenderness and swelling could indicate that deep vein thrombosis (DVT) is present. The physician should be notified so the patient can be evaluated. Whether or not DVT is present, leg elevation will be useful in alleviating swelling and discomfort, by promoting venous return to the heart.

Mr. Hale will remain NPO and have a nasogastric (NG) tube until gastrointestinal (GI) function has returned. To check for return of GI function you:

a. Ask Mr. Hale to move his bowels
b. Insert a rectal tube
c. Inspect for bowel sounds
d. Ask Mr. Hale if he has passed gas
e. Auscultate for bowel sounds

d. Ask Mr. Hale if he has passed gas

Passing of gas or having a bowel movement would indicate the presence of peristalsis and return of gastrointestinal (GI) function.

e. Auscultate for bowel sounds

The presence of bowel sounds, determined with auscultation, would indicate the presence of peristalsis and return of gastrointestinal (GI) function.

Fingerstick blood glucose indicates adequate glucose control without insulin. Blood glucose level is now tested on which of the following schedules?

a. Every six hours
b. Before meals and at bedtime
c. After meals and at bedtime

b. Before meals and at bedtime

When a person with diabetes is eating, glucose checks are usually done before meals and at bedtime.