Scenarios and items in this section focus on the renal, genitourinary, gynecologic, hepatic, and gastrointestinal systems. Though specific functions of these systems vary, these concepts are considered together because:
• Anatomically, the primary organs for these systems are located within the abdomen or retroperitoneum
• Nursing assessments related to potential postsurgical complications are similar
• The nursing process focuses include detecting hidden bleeding; restoring thermal, fluid, and electrolyte balance; promoting oxygenation and pulmonary function; and ensuring integrity of surgical drains, stomas, and anastomoses
| ESSENTIAL CORE CONCEPTS | AFFILIATED CORE CURRICULUM CHAPTERS |
|---|---|
| Nursing Process | Chapter 2 |
| Assessment | |
| Planning and Intervention | |
| Evaluation | |
| Renal and Genitourinary Systems | Chapters 19, 44 |
| Anatomy, Structure, and Function | |
| Adrenals and Lymphatics | |
| Nephron, Cortex, and Medulla | |
| Sex-Related Variations | |
| Ureters, Bladder, Urethra, and Sphincters | |
| Physiologic Concerns | |
| Hormonal | |
| Prostaglandins and Erythropoietin | |
| Renin-Angiotensin | |
| Vitamin D | |
| Metabolic | |
| Fluid and Chemical Aldosterone and ADH | |
| Filtration and Clearance | |
| Pathology | |
| Acute Tubular Necrosis | |
| Acute vs. Chronic Renal Failure: Cause and Effect | |
| Azotemia and Oliguria | |
| Blood Flow, Pressure, and Ischemia | |
| End-Stage Renal Disease (ESRD) | |
| Prerenal-Intrarenal-Postrenal Alterations | |
| Stones, Toxicity, Trauma, and Chemical Changes | |
| Perianesthesia Priorities | |
| Hemorrhage, Fluid Shifts, Chemical Changes | |
| Stomas, Stents, and Catheters | |
| Strain (Urine), Drain (Wound), and Pain | |
| Surgical Interventions | |
| Lasers, Shocks, and Scopes | |
| Position-Related Outcomes | |
| Resections, Suspensions, and Organ Removal | |
| Gastrointestinal and Hepatic Systems | Chapters 19, 42, 55 |
| Anatomy, Structure, and Organ function | |
| Esophagus, Stomach, Intestine, and Colon | |
| Gallbladder, Liver, Pancreas, and Spleen | |
| Pathology | |
| Polyps, Tumors, and Stones | |
| Strictures, Obstructions, Trauma, and Adhesions | |
| Ulcers, Infarcts, and -itis’s | |
| Physiologic Balance | |
| Nutrition, Fluid, and Electrolytes | |
| Temperature, Hemostasis, and Sepsis | |
| Perianesthesia Priorities | |
| Drains, Tubes, and Stomas | |
| Hydration, Clots, and Electrolytes | |
| Lungs, Circulation, and Distention | |
| Position, Pain, and Thrombus | |
| Surgical Interventions | |
| Anastomoses and Pouches | |
| Biopsies, Scopes, and Scans | |
| -ectomy’s, Bypasses, -plasty’s and -otomy’s | |
| Position-Related Outcomes | |
| Gynecologic System | Chapter 45 |
| Anatomy, Structure, and Organ function | |
| Pathologic Conditions | |
| -cele’s, Hormones, Tumors, and Infections | |
| Ectopic Pregnancies and Abortions | |
| Perianesthesia Priorities | |
| Catheters, Drains, and Tubes | |
| Embolus, Electrolytes, and Hydration | |
| Sepsis, Position, and Hemostasis | |
| Surgical Interventions | |
| Aspirations, Dilations, and Ligations | |
| Hysterectomy, Oophorectomy, and Salpingectomy | |
| Lasers, -scope’s, and Suspensions | |
| Position-Related Outcomes |
ITEMS 9.1–9.26
9.1. Oliguria refers to:
a. retention of nitrogenous waste products.
b. less than 400 mL daily urine production.
c. unrecognized obstruction of urinary catheter.
d. a syndrome of uremia, alkalosis, and absent urine.
NOTE: Consider the scenario and items 9.2-9.5 together.
After abdominoperineal resection, a male patient arrives in the PACU in supine, head-flat position. He is drowsily responsive, moans, and indicates abdominal cramping and nausea. The intermittent pneumatic compression leg wraps are functioning, and the nasogastric tube drains scant amounts of dark red fluid. One abdominal wound drain is in compressed position, and a perineal sump drain is attached to low suction.
9.2. The patient’s most immediate postoperative risk is the potential for:
a. deep vein thrombosis.
b. dumping syndrome.
c. inhalation of aspirated particles.
d. malnutrition from impaired absorption syndrome.
9.3. During assessment of the patient’s surgical condition, the PACU nurse is most concerned to observe:
a. 75 mL serosanguineous perineal drainage in 1 hour.
b. absent bowel sounds and a soft abdomen.
c. 45 mL tan nasogastric fluid and potassium = 4.7 mEq/L.
d. clear yellow urine and a light gray stoma.
NOTE: The scenario continues.
The patient received an inhalation anesthetic with intravenous (IV) opioid. The anesthesiologist placed an epidural catheter for postoperative pain management but did not inject any medication. The PACU nurse observes that the patient is “splinting” his respirations and chooses to begin the infusion promptly. The protocol for epidural bupivacaine and hydromorphone includes a bolus dose and parameters for titration.
9.4. Before initiating the epidural infusion, the nurse ensures that the anesthesiologist administers the test dose and that:
a. the patient rates his pain as “higher than 7” on the pain scale of 0 to 10.
b. an opioid agonist/antagonist is immediately available.
c. the IV catheter is patent and the site is without erythema.
d. the patient moves his feet, indicating the catheter rests in the intrathecal space.
9.5. After 1 hour of epidural medication, the patient rates his pain at a “7” on the 0-to-10 pain scale. With support of hospital protocols and physician collaboration, the PACU nurse should:
a. administer hydromorphone 2 mg intramuscularly while awaiting effect of epidural medication.
b. re-inject the epidural catheter with a small supplemental bolus.
c. double the infusion’s opioid concentration and then expand dosing parameters.
d. reposition the catheter and then adjust the infusion rate.
9.6. After open cholecystectomy, a patient remains in the PACU for 4 hours because of an unanticipated high census on the nursing unit. During this period, the PACU nurse measures T-tube drainage of 60 mL each hour. Dressings are dry, and the abdomen is soft and round with moderate incisional tenderness. The PACU nurse intervenes by:
a. documenting this normal hourly drainage volume.
b. stripping the tubing for patency.
c. informing the surgeon of the abdominal status.
d. attaching the T-tube to suction.
NOTE: Consider items 9.7-9.9 together.
9.7. After pancreaticoduodenectomy, a patient will most likely require regular:
a. serum glucose assessment.
b. glucocorticoid doses.
c. potassium supplementation.
d. platelet infusions.
9.8. With regard to this patient’s gastrointestinal assessment, the most appropriate nursing plan of care includes:
a. irrigating the nasogastric tube with 30 mL normal saline each hour.
b. asking the surgeon to identify tube locations and expected drainage.
c. quickly reinserting the nasogastric tube removed by the agitated patient.
d. anticipating absent bowel sounds and a firm, tympanic abdomen.
9.9. This patient’s surgery involves:
a. pancreatic reconstruction and removal of a liver lobe, duodenum, and gallbladder.
b. removing the spleen, biliary decompression with bile duct dilation, and creating an ileostomy.
c. cholecystectomy and diverting ascitic and pancreatic fluid into the superior vena cava.
d. resecting the pancreas, duodenum, lower stomach, and bile duct and constructing a gastrojejunostomy.
9.10. Decreased blood and renal perfusion pressures prompt:
a. renin release with renovascular constriction.
b. decreased urine excretion caused by ADH suppression.
c. aldosterone-induced sodium excretion.
d. renal vasodilation from angiotensin II effect.
NOTE: Consider the scenario and items 9.11-9.13 together.
A 55-year-old female patient has a long history of postoperative nausea and vomiting (PONV). The anesthetic plan during her vaginal hysterectomy includes preoperative placement of a scopolamine patch behind the left ear.
9.11. Scopolamine is classified as a/an:
a. class III antiemetic.
b. anticholinergic.
c. class II neuroleptic.
d. acetylcholinesterase.
9.12. The PACU nurse anticipates the scopolamine may affect the patient’s PACU care by contributing to:
a. agitation and excitement.
b. malignant hyperthermia.
c. delayed awakening.
d. dizziness and excessive salivation.
9.13. Two hours postoperatively, the PACU nurse prepares the patient for transfer from PACU. With regard to the patient’s surgical outcomes, the nurse is most concerned when nursing assessment reveals:
a. lumbar pain and occipital headache.
b. soft abdomen and menstrual-like cramps.
c. leg pain during foot dorsiflexion.
d. no sanguineous fluid in wound drain or on perineal pad.
9.14. Deficits related to intraoperative positioning are least affected by a patient’s:
a. duration of surgery.
b. anesthetic technique.
c. geriatric age.
d. physical condition.
NOTE: Consider the scenario and items 9.15-9.17 together.
NOTE: Consider the scenario and items 9.23-9.25 together.
After a 4-hour exploratory laparotomy, transverse colon and tumor resection, and creation of colostomy, a male patient has persistent hypotension in the PACU with blood pressure at 80/42. Cardiac rhythm is sinus with heart rate at 102 bpm. The patient has a preoperative history of seasonal allergy, migraine headaches, and osteoarthritis. No hemodynamic monitoring catheters were inserted. Urine volume remains 40 mL/hr, and 5% dextrose in 0.45% normal saline with 20 mEq of potassium chloride is infusing at 150 mL/hr. The patient’s temperature is 37° C (98.6° F), and he is responsive to verbal stimuli, with moderate pain managed using morphine delivered with patient-controlled analgesia (PCA) technique. Hemoglobin is 12.5 g/dL, and potassium is 3.8 mEq/L.
9.23. The most likely potential explanation for the patient’s hypotension is:
a. extracellular fluid deficit from hypertonic intravenous infusions.
b. perioperative myocardial infarction with shock.
c. unrecognized preoperative gastrointestinal fluid loss.
d. fluid relocation with altered capillary permeability.
9.24. Perianesthesia nursing and medical goals for the patient focus on:
a. instituting renal replacement therapy.
b. supporting cardiac output and renal perfusion.
c. recirculating intraintestinal fluid.
d. increasing osmotic pressure with whole blood.
NOTE: The scenario continues.
The patient ultimately receives 3000 mL of lactated Ringer’s solution during a 3-hour stay in the PACU. When approved for discharge from Phase I PACU, the patient is alert, has moderate pain, has no audible rales, and denies dyspnea. Urine output remains 35 mL/hr; blood pressure is consistently 100/52, heart rate is 98 bpm with normal sinus rhythm, and oxygen saturation is 98%.
9.25. The PACU nurse communicates the patient’s fluid status to the nurse on the surgical nursing unit and anticipates that:
a. fluid reabsorption will occur when capillaries heal.
b. spontaneous diuresis will begin within 6 hours.
c. low-rate hypotonic fluids will prevent tissue edema.
d. pain will increase cardiac tone and decrease afterload.
9.26. Renal failure from prerenal origins differs from acute tubular necrosis (ATN) by the amount of:
a. urine production.
b. concentrating ability.
c. nephron damage.
d. renin release.
ITEMS 9.27–9.47
NOTE: Consider the scenario and items 9.27-9.28 together.
A female patient was scheduled for laparoscopy to evaluate recurrent abdominal pain. The surgeon anticipated a left salpingectomy and oophorectomy. The patient received succinylcholine for intubation, midazolam, and fentanyl. The surgeon’s plan changed intraoperatively, and the patient’s surgery ended quickly after lysis of adhesions and laser treatment of endometriosis. The patient arrives in the PACU apneic and not moving. Respiratory support is provided with a mechanical ventilator, a rash scatters across her chest and upper arm, and the patient shows no muscle response to nerve stimulator impulses.
9.27. The nurse considers the patient’s response to intraoperative muscle relaxants and anticipates:
a. a permanent paralysis from atypical response.
b. any arm movements will precede intercostal action.
c. abdominal muscle function will precede eye opening.
d. brief sensory deficit from allergic reaction.
NOTE: The scenario continues.
Within 90 minutes, the patient is alert, demonstrates adequate muscle strength, and is extubated. By late afternoon, she is fully awake, sipping fluids, and slowly preparing for discharge home. The patient mentions pain when smiling, turning her head, and moving about.
9.28. This discomfort is probably related to:
a. nerve compression during lithotomy position.
b. intraabdominal tissue burn.
c. muscle strain from postanesthetic vomiting.
d. intraoperative muscle fasciculation.
9.29. A 38-year-old male patient is scheduled for a cystoscopy, ureteral stent placement, and extracorporeal shock wave lithotripsy (ESWL). The patient’s preoperative history and physical assessment document allergies to fish, milk, and eggs and recent episodes of conjunctivitis, eye swelling, and itchy, red hands at work. The preanesthesia nurse consults the anesthesia provider to express her concern about this patient’s increased risk to develop:
a. bronchospasm during endotracheal intubation.
b. anaphylaxis after propofol sedation.
c. corneal abrasion from lateral position.
d. upper quadrant pain with IV morphine sulfate.
9.30. The capacity of a normally functioning bladder is approximately:
a. 250 mL of urine.
b. 500 mL of urine.
c. 1000 mL of urine.
d. 1500 mL of urine.
NOTE: Consider the scenario and items 9.31-9.33 together.
After a motor vehicle accident, a comatose motorcyclist was admitted to the hospital with multiple injuries. Six hours later, a depressed skull fracture was surgically repaired. Now, 24 hours after injury, his abdomen has been explored, his spleen excised, and the patient had an open reduction and internal fixation of a left hip fracture.
9.31. During initial assessment, the PACU nurse would be most concerned about:
a. platelets of 98,000/mm3.
b. temperature of 39.8° C (103.6° F).
c. urine output of 29 mL/hr.
d. hemoglobin of 9.8 g/dL.
NOTE: The scenario continues.
During PACU admission procedures, this patient actively shivers, blood pressure is 100/50, and respiratory rate is 28 breaths/min. ECG indicates sinus tachycardia; shivering artifact makes initial SpO2 measurement difficult.
9.32. The PACU nurse:
a. automatically initiates analgesia protocol.
b. applies active rewarming device.
c. administers butorphanol to suppress shivering.
d. documents skin warmth, dryness, and redness.
9.33. Classic indicators of early respiratory distress in an adult with septic shock are:
a. hyperventilation with respiratory alkalosis and elevated lactate.
b. hypoventilation with decreased pulse pressure and excess circulating corticosteroids.
c. hyperventilation with peripheral cyanosis and acidosis.
d. hypoventilation with elevated lactate and low serum glucose.
9.34. Risk of nephrotoxicity from aminoglycoside antibiotics may be reduced by providing concurrent:
a. nonsteroidal antiinflammatory drugs (NSAIDs).
b. adequate intravascular volume using isotonic crystalloid solutions.
c. high-dose thiazide diuretics.
d. potassium supplementation.
NOTE: Consider the scenario and items 9.35-9.36 together.
A healthy middle-aged woman had an uneventful abdominal hysterectomy that ended 2 hours ago; intraoperative blood loss was 100 mL. She is drowsy and states abdominal pain score is “6” (on a 0-to-10 numeric rating scale). Blood pressure is low-normal though generally only 10% less than her preoperative measures; in the PACU her blood pressure dipped to 88/48 twice. The patient’s cardiac rhythm is sinus at a consistent rate of 128 bpm.
9.35. The PACU nurse’s ongoing assessment of this patient considers this situation’s most likely explanation is:
a. fever-induced tachycardia related to hyperdynamic sepsis.
b. neurogenic vasodilation related to untreated hypothermia.
c. decreased venous return related to evolving silent myocardial infarction.
d. reflex tachycardia related to intravascular volume deficit.
9.36. The most appropriate collaborative nurse-physician interventions for the patient’s immediate care are:
a. restrict fluids, and administer oxygen and phenylephrine 0.3 mg prn.
b. rapid crystalloid infusion and measure hemoglobin.
c. acetaminophen suppository and titrate esmolol infusion.
d. active rewarming, labetalol 5 mg, and measure prothrombin time.
NOTE: Consider the scenario and items 9.37-9.42 together.
At 2 am, an “on-call” PACU nurse is phoned to care for a 25-year-old female patient after an emergency laparoscopy and salpingectomy to remove an ectopic pregnancy.
9.37. According to ASPAN’s Standards of Perianesthesia Nursing Practice, recommended postanesthesia care for the patient includes:
a. observation in the ICU by a PACU nurse and an ICU nurse in the adjacent isolation room.
b. care by a registered nurse and visitation in PACU by two family members.
c. presence of two registered nurses in the PACU for duration of Phase I period.
d. one registered nurse at the bedside and an anesthesiologist available by pager in the obstetric suite.
9.38. Before transfer to an inpatient hospital bed, the PACU nurse administers Rho(D) immune globulin (Rho-GAM) to the patient, who is Rh negative, to prevent:
a. hemolysis of maternal erythrocytes.
b. maternal Rh sensitivity and antibody formation.
c. antibody stimulation in a future Rh negative fetus.
d. maternal conversion to Rh positivity.
9.39. A preoperative intervention intended to reduce potential adverse outcomes related to the patient’s position during laparoscopy would most likely include:
a. H2 antagonists.
b. bladder distention.
c. antiembolic stockings.
d. beta blockers.
9.40. At 4:20 am, 30 minutes after admission to the PACU, the nurse is most concerned when the patient’s assessment reveals:
a. bradycardia and moderate vaginal bleeding.
b. severe right shoulder pain and nausea.
c. tachycardia and a flat, silent abdomen.
d. painful, firm abdomen and bloody bandages.
9.41. The PACU nurse discovers that the patient is unable to dorsiflex the great toe on her right foot. This deficit may indicate intraoperative:
a. sciatic nerve injury.
b. posterior tibial nerve compression.
c. femoral nerve pressure.
d. peroneal nerve dysfunction.
9.42. During laparoscopy, peripheral nerve injury is most often related to:
a. lithotomy position.
b. intramuscular injection.
c. retractor pressure.
d. prolonged hip extension.
NOTE: Consider items 9.43-9.45 together.
9.43. During a hemorrhoidectomy, sphincterotomy, and repair of a large rectal fistula, a male patient received cisatracurium. This medication is a:
a. short-acting, depolarizing muscle relaxant.
b. drug with the same onset time as succinylcholine.
c. depolarizing relaxant reversible with flumazenil.
d. nondepolarizing muscle relaxant of intermediate duration.
9.44. Potentiation of cisatracurium effects is least likely with:
a. postoperative neostigmine 2.5 mg.
b. isoflurane at 1.25 monitored anesthesia care to maintain anesthesia.
c. intraoperative gentamicin 80 mg.
d. concurrent administration of lidocaine 100 mg.
9.45. With regard to the patient’s surgical procedure, the Phase I PACU nurse has the most concern when:
a. sanguineous drainage saturates dressings twice in 1 hour.
b. postoperative urination is difficult.
c. the patient reports significant perineal pressure and severe rectal pain.
d. no drainage and absent perineal sensation occur.
9.46. A female patient’s Crohn’s disease was surgically treated with a 4-hour total proctocolectomy and creation of a continent ileostomy. On the same day in the Phase I PACU, she mentions right heel pain and an aching back. At this time, the most appropriate nursing intervention is to:
a. request an anticoagulation protocol to monitor risk of deep vein thrombus.
b. reposition the patient’s feet to limit contact with the stretcher.
c. further assess the patient for right leg compartment syndrome.
d. provide sedation and frequent analgesic so the patient will relax and doze.
9.47. A patient with a blood urea nitrogen (BUN) of 55 mg/dL and serum creatinine of 5.2 mg/dL is considered:
a. anuric.
b. cachectic.
c. oliguric.
d. azotemic.
ITEMS 9.48–9.73
9.48. The patient’s surgeon orders that the patient receive 1 g vancomycin before her low anterior resection. The preanesthesia nurse administers the vancomycin over at least 60 minutes to reduce the potential for:
a. postoperative ototoxicity.
b. bile duct spasm.
c. hypotensive response.
d. delayed muscle relaxant metabolism.
NOTE: Consider items 9.49-9.52 together.
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9.49. A male patient’s temperature is 34.9° C (94.8° F) when he is admitted to the PACU after general anesthesia for exploratory laparotomy and right colectomy. Physiologic consequences related to this temperature include:
a. rapid return to alertness and lower oxygen demand.
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