Care of the Surgical Patient nclex
*Accept each patient as a unique individual.
*Identify through verbal and nonverbal cues patients who are at risk for alteration in
self-concept. The risk is increased if the patient has little support from others, a visible alteration,
or an alteration that will seriously affect functional ability.
* Allow time for patients and families to verbalize their feelings about the alteration, and do not
assume that all patients will have problems.
Identify and support strengths and effective coping mechanisms.
*Encourage the patient and family to be part of goal setting and decision-making throughout the
surgical experience.
*Provide teaching and honest information to the patient and family about all aspects of care.
*Work collaboratively with other members of the health care team to provide referrals and
resources as necessary to meet physical, psychological, and spiritual needs. - ANS-Nursing
Interventions to Facilitate Postoperative Coping and Adaptation
Answer: " The operating table is a firm surface; we need to be sure your skin looks okay."
Rationale: The client who has been on the operating table should be examined to ensure skin
breakdown hasn't occurred. The client would not be told that his covers looked messy, or that
the nurse was concerned about sponges or syringes underneath. The client's skin should be
assessed on admission; after surgery would not be the time to do this initial assessment to
document skin breakdown. - ANS-A postoperative client states "I don't understand why you are
checking my skin on my back. My surgery was on my stomach." What is the nurse's best
response?
a) "We needed to be sure you didn't have any skin breakdown before surgery."
b) "We wanted to be sure we didn't leave any sponges or syringes underneath you."
c) "The operating table is a firm surface; we need to be sure your skin looks okay."
d) "The covers underneath you need to be straightened out. They look messy."
Answer: "An advance directive will communicate your wishes for health care postoperatively in
case you are unable to do so."
Rationale: An advance directive allows the client to communicate instructions for health care
postoperatively in case of an inability to do so. Although an advance directive is either a living
will or a durable power of attorney for health care, and the hospital does like to determine if the
,client has these, these are not the best answers to the client's question. The nurse would not
want to explain to the client that he or she may not wake up after surgery. - ANS-The nurse is
preparing a client for surgery and asks if the client has an advance directive. The client asks
"What is an advance directive?" What is the nurse's best response to this?
a) "When you are going to have surgery, the hospital likes to have you fill out all paperwork
needed beforehand."
b) "An advance directive will communicate your wishes for health care postoperatively in case
you are unable to do so."
c) "An advance directive is a living will. Some people already have one when they come to the
hospital."
d) "We are not sure if you will wake up after surgery so the advance directive will let us know
your wishes just in case."
Answer: "I can have a hamburger and French fries as soon as I wake up."
Rationale: Oral fluid and food may be withheld until intestinal motility resumes. - ANS-Which
statement, if made by an adolescent preparing for abdominal surgery, would indicate to the
nurse that the client requires additional instruction?
a) "I might be sick to my stomach and throw up after surgery."
b) "I can have a hamburger and French fries as soon as I wake up."
c) "When I can eat again, the best meal would be steak and orange juice."
d) "The better I eat before surgery, the more likely I will heal."
Answer: "Let's talk about how you are feeling."
Rationale: This answer allows the patient to talk about his feelings and fears, and is therapeutic.
- ANS-A 70-year-old male is scheduled for surgery. He says to the nurse, "I am so
frightened—what if I don't wake up?" What would be the nurse's best response?
a) "You have a wonderful doctor."
b) "Let's talk about how you are feeling."
c) "Everyone wakes up from surgery!"
d) "Don't worry, you will be just fine."
Answer: "Research has shown that there is very little risk of clients becoming addicted to
painkillers after they have surgery."
Rationale: There is little danger of addiction to pain medications used in the postoperative
management of pain. - ANS-The nurse has entered the room of a client who is postoperative
day 1 and finds the client grimacing and guarding her incision. The client refuses the nurse's
offer of p.r.n. analgesia and, on discussion, states that this refusal is motivated by his fear of
becoming addicted to pain medications. How should the nurse respond to the client's concerns?
, a) "Actually, people who are not addicted to drugs before their surgery never develop a
tolerance or addiction during their recovery."
b) "You should remind yourself that treating your pain is important now, and that dealing with
any resulting dependency can come later."
c) "Research has shown that there is very little risk of clients becoming addicted to painkillers
after they have surgery."
d) "The hospital has excellent resources for dealing with any addiction that might result from the
medications you take to control your pain."
Answer: "The pumps allows the patient to self-administer limited doses of pain medication."
Rationale: PCA infusion pumps allow patients to self-administer doses of pain-relieving
medication within physician-prescribed time and dose limits. Patients activate the delivery of the
medication by pressing a button on a cord connected to the pump or a button directly on the
pump. - ANS-A nurse is explaining pain control methods to a patient undergoing a bowel
resection. The patient is interested in the PCA pump and asks the nurse to explain how it works.
What would be the nurse's correct response?
a) "The pump allows the patient to be completely free
of pain during the postoperative period."
b) "The pump allows the patient to take unlimited
amounts of medication as needed."
c) "The pump allows the patient to choose the type of
medication given postoperatively."
d) "The pump allows the patient to self-administer
limited doses of pain medication."uu
Answer: "The time-out checks to be sure that we have the right client and procedure."
Rationale: The time-out is a safety measure performed before any surgical procedure and
allows the operating room staff to determine they have the right client, procedure, and side (if
appropriate). The client's baseline vital signs should have already been performed. The
anesthesia is managed by the anesthetist or anesthesiologist when the procedural physician is
prepared for the beginning of the operation; however, this is not part of the time-out. The
preoperative antibiotic should be administered within 60 minutes of the surgery but is also not
part of the time-out. - ANS-The procedural physician has initiated performance of a time-out in
the operating room before surgery. The student nurse asks the operating room nurse why this is
important. What is the operating room nurse's best response?
a) "The time-out checks to be sure that we have the right client and procedure."
b) "We need to be sure the client has had the preoperative antibiotic."
c) "We are checking the client's baseline vital signs during time-out."
d) "The time-out allows us to make sure that the client has had adequate anesthesia."
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