Chapter 39: Surgical Patient

1.A 57-year-old patient who is being admitted for an appendectomy. The patient is a 2-pack-a-day smoker, has a history of diabetes, and is 20 pounds overweight. Which of the following potential postoperative complications should be the nurse’s highest concern for prevention?

a.
Atelectasis
b.
Negative nitrogen balance
c.
Delayed wound healing
d.
Hyperthermia

ANS: A

There is a significant association between smoking and postoperative pulmonary complications, specifically pneumonia and atelectasis. Chronic smoking increases the amount and thickness of mucous secretions in the lungs. Patients who are obese are more susceptible to developing atelectasis. Hyperthermia is incorrect because general anesthetics inhibit shivering, a protective reflex to maintain body temperature, and anesthetics cause vasodilation, which results in heat loss. Malnourished patients are more likely to have poor tolerance of anesthesia, negative nitrogen balance, delayed postoperative recovery, infection, and delayed wound healing.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:1131

OBJ: List factors to include in the preoperative assessment of a surgical patient.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2.The nurse working on a medical/surgical floor knows that pulmonary embolisms can be a deadly complication after surgery. Which of the following patients is most likely to develop a pulmonary embolism?

a.
45-year-old patient after bariatric surgery
b.
23-year-old patient with pneumonia
c.
13-year-old patient after appendectomy
d.
57-year-old patient after cholecystectomy

ANS: A

A patient who is obese usually has reduced ventilatory capacity because of the upward pressure against the diaphragm caused by an enlarged abdomen. There is also an increased risk for aspiration during the administration of anesthesia. The recumbent and supine positions required on the operating bed (table) for surgery further limit a patient’s ventilation. The increased workload of the heart and atherosclerotic blood vessels often results in compromised cardiovascular function. Because of these physiological changes, patients who are obese often have difficulty resuming normal physical activity after surgery. Hypertension, coronary artery disease, type 2 diabetes mellitus, and heart failure are common in this population. They are also more susceptible to developing embolism, atelectasis, and pneumonia after surgery than patients who are not obese.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 1131 OBJ: Identify factors to assess in a patient in postoperative recovery.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

3.A 45-year-old woman has been admitted for surgery to remove a cancerous abdominal tumor. She has been on chemotherapy and recently radiotherapy to shrink the tumor without success. To best facilitate wound healing, when is the best time for her to undergo surgery?

a.
During the radiotherapy treatments
b.
Immediately after the radiotherapy treatments
c.
2 to 3 weeks after radiotherapy treatments
d.
4 to 6 weeks after radiotherapy treatments

ANS: D

Ideally surgery takes place 4 to 6 weeks after the completion of radiation treatments to avoid wound-healing problems. The patient with cancer may have radiotherapy before surgery to reduce the size of a cancerous tumor to remove it surgically. Radiation causes fibrosis and vascular scarring in the radiated area. This causes tissues to become fragile and poorly oxygenated, increasing the risk for wound infection.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 1132 OBJ: Identify factors to assess in a patient in postoperative recovery.

TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity

4.Which of the following patients is most at risk for hypovolemic shock after emergency surgery?

a.
14-year-old adolescent with gastroenteritis
b.
59-year-old patient with pneumonia
c.
12-year-old patient with H1N1 flu
d.
28-year-old patient with a fractured ankle

ANS: A

Patients with gastroenteritis have gastrointestinal problems and are at greater risk of complications. Patients with preexisting renal, fluid and electrolyte, gastrointestinal, respiratory, or cardiovascular problems are at greatest risk for operative complications. For example, a patient who is dehydrated from vomiting preoperatively is at greater risk for hypovolemic shock.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 1133 OBJ: Identify factors to assess in a patient in postoperative recovery.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

5.A 56-year-old nondiabetic patient is undergoing orthopedic surgery. The perioperative nurse is monitoring the blood glucose level. What is the main rationale for monitoring his blood glucose level during surgery?

a.
She does not want the patient to develop an embolism.
b.
Research shows a strong relationship between wound infections and hyperglycemia.
c.
She knows that normal glucose levels promote platelet production.
d.
She is monitoring to prevent embolism.

ANS: B

Evidence has shown that there is a relationship between wound and tissue infection and blood glucose levels. Poor control of blood glucose levels (specifically hyperglycemia) during and after surgery increases the risk for wound infection and patient mortality in certain types of surgery. PT and APTT blood tests are monitored to prevent embolism. Perioperative nurses work with their medical colleagues to maintain normal glucose levels in the postoperative period to reduce the risk for wound and tissue infection.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:1133

OBJ: Describe intraoperative factors that affect a patient’s postoperative course.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

6.The perioperative nurse is admitting a patient for an elective surgery. She questions the patient about issues with anesthesia, to assess the patient for malignant hyperthermia. Which of the following is a late sign of malignant hyperthermia?

a.
High CO2 levels
b.
Tachycardia
c.
Elevated temperature
d.
Tachypnea

ANS: C

Malignant hyperthermia is a life-threatening complication. Early signs of malignant hyperthermia include high levels of CO2, tachypnea, and tachycardia. Elevated temperature occurs in the late stages.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1135

OBJ: Describe intraoperative factors that affect a patient’s postoperative course.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

7.A 44-year-old patient with breast cancer who is scheduled to undergo a right-side mastectomy. Ideally when should preoperative teaching begin?

a.
As soon as she is diagnosed with breast cancer
b.
One week before surgery
c.
The day before surgery
d.
The day of surgery

ANS: B

Preoperative teaching is most useful when started the week before admission and reinforced immediately before surgery. Teaching performed when the patient is less anxious will result in more effective learning. Anxiety and fear are barriers to learning.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1144OBJ:Prepare a patient for surgery.

TOP:Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

8.The preoperative nurse who is providing patient teaching to a 49-year-old patient who is scheduled to undergo a right-side inguinal surgery repair. The nurse informs the patient that the American Society of Anesthesiologists recommend that patients undergoing surgery with a general anesthesia fast from meat and fried foods for how many hours before surgery?

a.
2
b.
4
c.
6
d.
8

ANS: D

The American Society of Anesthesiologists (ASA) provides recommendations on fluid and food intake before procedures requiring general anesthesia, regional anesthesia, or sedation/analgesia. The ASA recommendations include fasting from intake of clear liquids for 2 or more hours, and a light meal of toast and clear liquids for 6 hours. The patient also cannot have any meat or fried foods 8 hours before surgery, unless explicitly specified by the anesthesiologist or surgeon.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:1145OBJ:Design a preoperative teaching plan.

TOP:Nursing Process: Planning

MSC: Client Needs: Safe and Effective Care Environment

9.A nurse working in an ambulatory care surgery center is preparing to discharge a postoperative patient. The nurse knows that the convalescence period will occur:

a.
1 to 2 hours after surgery.
b.
at home.
c.
once the patient has been monitored overnight in the hospital.
d.
2 to 4 hours after surgery.

ANS: B

For a patient following ambulatory surgery, convalescence will occur at home, the immediate recovery period normally lasts only 1 to 2 hours. For a hospitalized patient the immediate postoperative period often lasts a few hours, with convalescence taking 1 or more days, depending on the extent of surgery and a patient’s response. Patient who are admitted to stay overnight at the hospital are not classified as ambulatory care surgery center.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:1153

OBJ: Explain the differences in caring for a patient undergoing outpatient surgery versus a patient undergoing inpatient surgery. TOP: Nursing Process: Evaluation

MSC:Client Needs: Physiological Integrity

10.The nurse instructs the postoperative patient to perform leg exercises every hour in order to do which of the following?

a.
Maintain muscle tone.
b.
Increase venous return.
c.
Exercise fatigued muscles.
d.
Assess range of joint motion.

ANS: B

The number one priority in a surgical setting is to prevent deep vein thrombosis (DVT) complications. By increasing venous return there is less stasis therefore decreasing the risk of DVT. Early measures directed at preventing venous stasis are aimed at preventing DVT during convalescence. On the surgical nursing unit, begin these interventions as soon as possible. Encourage patients to perform leg exercises at least every hour while awake unless contraindicated by surgery. Maintaining muscle tone, exercising fatigued muscles, and assessing range of joint motion are all reasons to perform leg exercises.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1162

OBJ:Describe the rationale for nursing interventions designed to prevent postoperative complications.TOP:Nursing Process: Evaluation

MSC:Client Needs: Physiological Integrity

11.A patient with a ruptured abdominal aortic aneurysm needs to have major surgery. The nurse explains to the family that major surgery:

a.
is an excision or removal of a diseased body part.
b.
involves extensive surgery to reconstruct body parts.
c.
is not necessary but may prevent additional problems.
d.
is a surgical exploration that allows the physician or health care provider to confirm a diagnosis.

ANS: B

Major surgery involves extensive reconstruction or alteration in body parts; poses great risks to the patient’s well-being. Urgent surgery is necessary for the patient’s health and will possibly prevent additional problems from developing. Elective surgery is performed on a basis of the patient’s choice. It is not always essential, and it is not always necessary for health. Diagnostic surgical exploration allows the physician or health care provider to confirm a diagnosis.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1132

OBJ: Differentiate among classifications of surgery and types of anesthesia.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

12.A patient is awaiting surgery. The nurse’s best rationale for assessing vital signs is to do which of the following?

a.
Assess the patient’s anxiety level.
b.
Determine the patient’s basal temperature.
c.
Establish a baseline for vital signs comparisons.
d.
Assess for any changes that may indicate infection.

ANS: C

Preoperative vital signs provide a baseline for intraoperative and postoperative comparison, because anesthetic agents and medications can alter vital signs. Preoperative assessment of vital signs is also important to detect fluid and electrolyte abnormalities. An elevated temperature is cause for concern. If a patient has an underlying infection, elective surgery will often be postponed until the infection is treated or resolved.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:1138

OBJ: List factors to include in the preoperative assessment of a surgical patient.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

13.The operating room environment is deliberately kept cool. When the nurse assesses the patient in the post anesthesia care unit, the patient is shivering. The nurse needs to understand that shivering may do which of the following?

a.
Be a side effect of anesthesia.
b.
Indicate a problem of the hypothalamus.
c.
Indicate the beginning of the infectious process.
d.
Be a normal response to stabilize blood pressure.

ANS: A

The operating room environment is cool, and the patient’s depressed level of body function results in a lowering of metabolism and fall in body temperature. When patients begin to awaken, they often complain of feeling cold and uncomfortable. Shivering is not always a sign of hypothermia, but rather a side effect of certain anesthetic agents. If a patient develops a fever, notify the surgeon immediately. The chances of the shivering being a problem with the hypothalamus, indicating infection (such as fever with sepsis) are very low in this case.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 1154 OBJ: Identify factors to assess in a patient in postoperative recovery.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

14.A patient with a ruptured abdominal aortic aneurysm needs to have major surgery. The family asks the nurse what type of anesthesia the patient will receive. The best response is which of the following?

a.
Local anesthesia
b.
Regional anesthesia
c.
Moderate sedation
d.
General anesthesia

ANS: D

General anesthesia is administered during major procedures requiring extensive tissue manipulation or any time analgesia, muscle relaxation, immobility, and control of the autonomic nervous system are required. Local anesthesia involves loss of sensation at the desired surgical site by inhibiting peripheral nerve conduction. It is used during minor procedures performed in ambulatory surgery. Regional anesthesia results in loss of sensation in an area of the body by anesthetizing sensory pathways. This type of anesthesia is accomplished by injecting a local anesthetic along the pathway of a nerve from the spinal cord. Administration techniques include peripheral nerve blocks and spinal, epidural, and caudal blocks. A patient requires careful monitoring during and immediately after regional anesthesia for return of sensation and movement distal to the regional anesthesia. Intravenous moderate sedation/analgesia or conscious sedation is routinely used for diagnostic or therapeutic procedures (e.g., colonoscopy or certain laparoscopies) that do not require complete anesthesia but simply a decreased level of consciousness.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:1152

OBJ: Differentiate among classifications of surgery and types of anesthesia.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

15.All patients undergoing surgery need to have preoperative preparation. When physically preparing the patient, the most appropriate action for the nurse to take is which of the following?

a.
Leaving all of the patient’s jewelry in place
b.
Removing the patient’s makeup and nail polish
c.
Providing the patient with sips of water for a dry mouth
d.
Removing the patient’s hearing aid before transport to the operating room

ANS: B

Jewelry is removed so it can be safeguarded. In addition, swelling may occur postoperatively. Makeup and nail polish are removed so the patient’s skin and mucous membranes can be assessed to determine oxygenation, saturation of blood, and application of a pulse oximeter. Patients are to maintain NPO to prevent postoperative GI complications and to prevent aspiration because the gag reflex is suppressed. Although patients need to remove hearing aids, do not have them do this until immediately before surgery; allowing the patient to wear hearing aids will facilitate communication between the patient and health care providers.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1148OBJ:Prepare a patient for surgery.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

16.Intraoperatively, the circulating nurse observes a member of the surgical team breach aseptic technique. As a result of this incident the postoperative patient can be at risk for which of the following?

a.
Paralytic ileus
b.
Malignant hyperthermia
c.
Development of infection
d.
Alteration in pulmonary hygiene

ANS: C

The circulating nurse assists the anesthesia provider with endotracheal intubation, calculating blood loss and urinary output, and administering blood. This nurse monitors sterile technique of surgical team members and a safe OR environment. A nurse also assists the surgeon and scrub nurse by operating nonsterile equipment, providing additional instruments and supplies, maintaining accurate and complete documentation, and tracking sponge, needle, and instrument counts. Paralytic ileus is a loss of function of the intestine, which causes abdominal distention. Anesthetic agents slow gastrointestinal functioning. Malignant hyperthermia results from administration of certain anesthetic agents. Alteration in pulmonary hygiene occurs when the postoperative patient does not cough and deep breathe.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:1150

OBJ: Describe intraoperative factors that affect a patient’s postoperative course.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

17.A patient asks a nurse to explain the differences between general anesthesia and regional anesthesia. What is the correct response relating to general anesthesia?

a.
“General anesthesia inhibits peripheral nerve conduction.”
b.
“Under general anesthesia all sensation and consciousness is lost.”
c.
“Under general anesthesia there is a loss of sensation in a specific area of the body.”
d.
“General anesthesia is routinely used for procedures that only require a decreased level of consciousness.”

ANS: B

General anesthesia is administered during major procedures requiring extensive tissue manipulation or any time analgesia, muscle relaxation, immobility, and control of the autonomic nervous system are required. Regional anesthesia results in loss of sensation in an area of the body by anesthetizing sensory pathways. This type of anesthesia is

accomplished by injecting a local anesthetic along the pathway of a nerve from the spinal cord. Administration techniques include peripheral nerve blocks and spinal, epidural, and caudal blocks. A patient requires careful monitoring during and immediately after regional anesthesia for return of sensation and movement distal to the regional anesthesia.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1152

OBJ: Differentiate among classifications of surgery and types of anesthesia.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

18.The nurse is conducting preoperative teaching with the patient and family. The nurse teaches the patient the proper use of the incentive spirometer. The nurse knows that the patient understands the need for this intervention when the patient states, “I use this device to:

a.
help my cough reflex.”
b.
expand my lungs after surgery.”
c.
increase my lung circulation.”
d.
keep me from coughing.”

ANS: B

To facilitate deep breathing the incentive spirometer encourages forced inspiration to prevent atelectasis. Every preoperative teaching program includes explanation and demonstration of postoperative exercises, which include: diaphragmatic breathing, incentive spirometry, controlled coughing, turning, and leg exercises. Coughing assists in removing retained mucus in the airways. A deep, productive cough is more beneficial than merely clearing the throat. A patient needs to anticipate postoperative discomfort and understand the importance of coughing, even when it is difficult.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1146

OBJ:Describe the rationale for nursing interventions designed to prevent postoperative complications.TOP:Nursing Process: Evaluation

MSC:Client Needs: Physiological Integrity

MULTIPLE RESPONSE

1.When is it appropriate to ask a surgeon to clarify information for a patient who is undergoing surgery? (Select all that apply.)

a.
Before the informed consent has been signed
b.
When a patient is confused about the reason for the procedure
c.
When a patient understands the risks involved in a procedure
d.
If there is confusion about the procedure after the informed consent is signed
e.
After the surgery has been performed

ANS: A, B, D

Patients need to sign all consent forms before you administer any preoperative medications that alter the patient’s consciousness. The primary responsibility for informing the patient rests with the surgeon and anesthesia care personnel. However, if the patient is confused or uncertain about a procedure, you are ethically obligated to contact the surgeon and/or anesthesia care provider so that further discussion and clarification are provided to meet the patient’s needs. The patient always has the right to refuse surgery or treatment even after giving written consent.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1142 | 1144OBJ:Prepare a patient for surgery.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

2.The nurse is providing preoperative teaching for a patient regarding pain control after surgery. Which of the following statements is/are true regarding the use of postoperative analgesia? (Select all that apply.)

a.
“Analgesics will not provide adequate relief if you wait until the pain becomes excruciating before using them.”
b.
“Pain control will help you recover from surgery quicker.”
c.
“You shouldn’t be concerned about becoming addicted to your pain medications immediately after surgery.”
d.
“You will remain pain-free as long as you take your pain medications as prescribed.”
e.
“A PCA pump is commonly used to help patients control their pain.”
f.
“Take pain medication carefully as it will lengthen your recovery period.”

ANS: A, B, C, E

Analgesics will not provide adequate pain relief if the patient waits until the pain becomes excruciating before using or requesting an analgesic. Even though around-the-clock (ATC) analgesia is more effective, most patients still have analgesics ordered prn (as needed). Pain control is essential for a surgical patient to recover quickly. Encourage the patient to use analgesics as needed and not be fearful of any dependence on pain medications after surgery. Patient-controlled analgesia (PCA) is common and provides patients with control over pain. Explain to a patient how to operate a pump and the importance of administering medication as soon as pain becomes persistent. The patient also needs to know it takes time for a drug to act and that the drug will rarely eliminate all the discomfort. Pain medication will not lengthen the recovery period, it will shorten it.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:1146OBJ:Design a preoperative teaching plan.

TOP:Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

3.A student nurse has been assigned to a 67-year-old patient who is undergoing thoracic surgery to remove a tumor. As part of the preoperative teaching, the student nurse discusses the importance of coughing. Which of the following statements is true regarding why postoperative coughing is important? (Select all that apply.)

a.
“Coughing assists in removing retained mucus in the airways.”
b.
“It won’t hurt to cough with adequate pain control.”
c.
“You can splint your incision when coughing to minimize pain.”
d.
“Deep breathing and coughing will remove anesthesia gases from your lungs.”
e.
“Deep breathing involves fast, shallow, breaths and then one big breath.”
f.
“Coughing is not encouraged because of the potential or dehiscence at the surgical site.”

ANS: A, C, D

A patient learns to use the diaphragm during deep breathing to take slow, deep, and relaxed breaths. Eventually a patient’s lung volume improves. Deep breathing also helps to clear any anesthetic gases from the airways. To facilitate deep breathing a health care provider often orders an incentive spirometer for a patient. Coughing assists in removing retained mucus in the airways. A deep, productive cough is more beneficial than merely clearing the throat. Teach the patient to splint an abdominal or thoracic incision to minimize pain during coughing. Pain control is essential for effective deep breathing and coughing; educate the patient to ask for pain medications as needed. Deep breathing also helps to clear any anesthetic gases from the airways. The patient needs to anticipate postoperative discomfort and understand the importance of coughing, even when it is painful. Deep breathing is not fast and shallow, it is slow and deep. Coughing and deep breathing are encouraged even if dehiscence is a possibility, teaching them to splint wound.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1146 | 1169

OBJ:Describe the rationale for nursing interventions designed to prevent postoperative complications.TOP:Nursing Process: Planning

MSC:Client Needs: Physiological Integrity