Patient Profile: C.J.

, a 49-year-old construction worker, is scheduled for a bronchoscopy for biopsy of a

right lung lesion. He initially sought medical care for hemoptysis and increasing fatigue. When the nurse
asked him to sign the operative permit, he stated that he was not certain if he should go ahead with the
procedure because he fears a diagnosis of cancer.

Subjective Data

Has never been hospitalized

✓ Has had no medical problems except mild obesity

✓ Has a cigarette smoking history of 40 pack-years

✓ Is married with two children, ages 6 and 8; both children have cystic fibrosis

✓ Is fearful that his wife will not be able to manage without him

Objective Data

Diagnostic studies: chest x-ray revealed mass in upper lobe of right lung

✓ Hematocrit: 31%

1. What factors in C.J's background or personal situation might influence his emotional response and
physical reactions to this surgery?

2. What should C.J. know if his consent for surgery is to be truly informed?

3. Priority Decision: CJ will be an outpatient for this procedure. What is the priority preoperative
teaching that should be done to prepare him for surgery?
4 What risk factors for surgical and anesthetic complications might you anticipate for C.J? What are the
potential interventions that might minimize the risks?

5. Priority Decision Based on the assessment data provided, what are the priority nursing diagnoses? Are
there any collaborative problems?

ANSWERS:

1. Factors in C.J.'s background or personal situation that might influence his emotional response and
physical reactions to this surgery include:

- Fear of a cancer diagnosis: C.J.'s fear of cancer may lead to increased anxiety, stress, and emotional
distress. It can affect his ability to cope with the surgical procedure and recovery process.

- Family situation: C.J. is married with two children who have cystic fibrosis. This adds an additional
emotional burden and concern about his family's well-being and his ability to provide for them if he is
diagnosed with a serious illness.

- Lack of previous hospitalization: Since C.J. has never been hospitalized before, he may have fears and
uncertainties about what to expect during the surgical procedure, hospital stay, and recovery process.

- Smoking history: C.J.'s 40 pack-year smoking history may contribute to guilt or self-blame for
potentially causing his health issues. It can also impact his respiratory function and increase the risk of
postoperative complications.

2. If C.J.'s consent for surgery is to be truly informed, he should know the following:

- Purpose of the procedure: C.J. should understand why the bronchoscopy with biopsy is necessary,
which is to evaluate the lung lesion and determine if it is cancerous or requires further treatment.
- Risks and benefits: The healthcare team should explain the potential risks associated with the
procedure, such as bleeding, infection, or damage to surrounding structures, as well as the benefits of
obtaining a definitive diagnosis.

- Alternatives: C.J. should be informed about alternative diagnostic procedures or treatment options, if
available, and their respective risks and benefits.

- Prognosis: Depending on the biopsy results, C.J. should be informed about the potential outcomes,
including the possibility of cancer and the available treatment options.

- Recovery and follow-up care: C.J. should be educated about the expected recovery process, including
pain management, activity restrictions, and the need for further tests or treatments after the procedure.

3. The priority preoperative teaching that should be done to prepare C.J. for surgery includes:

- Detailed explanation of the procedure: C.J. should be provided with clear and concise information
about what to expect during the bronchoscopy, including the use of sedation or anesthesia, the
insertion of the bronchoscope, and the potential sensations he may experience.

- Instructions regarding preoperative fasting: C.J. should be informed about the specific time frame for
fasting before the procedure to prevent complications, such as aspiration during anesthesia.

- Deep breathing and coughing exercises: C.J. should be taught deep breathing and coughing techniques
to promote lung expansion, reduce the risk of postoperative respiratory complications, and facilitate the
removal of secretions.

- Pain management: C.J. should receive information about the available methods of pain control during
and after the procedure, including the use of analgesics and non-pharmacological techniques.
- Postoperative care and discharge instructions: C.J. should be educated about postoperative care,
including wound care, activity restrictions, signs of complications, and the importance of attending
follow-up appointments.

4. Risk factors for surgical and anesthetic complications that might be anticipated for C.J. include:

- Smoking history: C.J.'s smoking history increases the risk of respiratory complications, such as
pneumonia, atelectasis, or bronchospasm. Interventions to minimize these risks may include smoking
cessation support, preoperative respiratory treatments, and early ambulation.

- Hematocrit of 31%: C.J.'s low hematocrit indicates anemia, which can affect oxygen delivery to tissues
during and after surgery. Potential interventions may include transfusion, optimization of iron levels,
and monitoring for signs of inadequate tissue perfusion.

- Obesity: Mild obesity can pose challenges during anesthesia

MULTIPLE CHOICE

1. The correct answer is a. To identify and correct problems before surgery and establish a baseline for
postoperative comparison.

Rationale: A thorough preoperative assessment is crucial for identifying any potential health issues,
risks, or factors that may affect the patient's surgery and recovery. It allows the nurse to gather
comprehensive information about the patient's medical history, current health status, allergies,
medications, and any potential complications. This assessment helps to identify and address any
problems or concerns before the surgery, ensuring that the patient is optimized for the procedure. It
also establishes a baseline for comparison postoperatively, enabling the healthcare team to monitor the
patient's condition and detect any changes or complications that may arise.

2. The correct answer is c. Have the client void.

Rationale: Before administering preoperative medications, it is important for the client to empty their
bladder by voiding. This helps prevent discomfort and potential complications during the surgery. A full
bladder can interfere with surgical access, increase the risk of injury, and may require catheterization.
Therefore, ensuring that the client has emptied their bladder is a necessary step before administering
preoperative medications. Verification of consent, checking vital signs, and removing dentures may be
part of the preoperative process, but having the client void is specifically important to prevent
complications related to bladder distension during surgery.

3. The most appropriate nursing diagnosis to address the long-term needs of a client with cataract
undergoing surgery is:

b. Sensory perceptual alteration related to lens extraction and replacement.

Rationale: Cataract surgery involves the removal and replacement of the lens, which can result in
sensory perceptual alterations. The client may experience changes in vision, depth perception, and color
perception. This nursing diagnosis addresses the long-term needs of the client as it focuses on the
potential alterations in sensory perception that may persist even after the surgery.

4. The responsibility of the nurse upon noting a WBC count of 15,000 on the routine CB report for a
client scheduled for cholecystectomy with right scapular pain is:

a. To notify the surgeon at once; this is an elevated WBC count indicating an inflammatory reaction.

Rationale: An elevated WBC count can indicate an inflammatory process or infection. Given the client's
right scapular pain and the upcoming surgery, it is important to notify the surgeon promptly as the
elevated WBC count may require further evaluation and possible intervention before proceeding with
the surgery.

5. The nursing actions that follow the administration of preoperative medications (atropine 0.3 mg IM
and Demerol 50 mg IM) to Mrs. Sy, scheduled for surgery in 2 days, are:
a. Have her void soon after receiving the medication.

Rationale: Atropine is known to cause urinary retention, so it is important to have the client void soon
after receiving the medication. This helps prevent bladder distension and potential complications during
and after surgery. Allowing the family to be with the client, bringing valuables to the nursing station, and
reinforcing pre-op teaching may also be important nursing actions, but ensuring that the client voids
after receiving the medication is the priority action immediately following its administration.6. The
laboratory tests that assess coagulation are:

a. Partial thromboplastin time (PTT).

b. Prothrombin time (PT).

c. Platelet count.

Rationale: Coagulation tests assess the clotting ability of the blood. The partial thromboplastin time
(PTT) and prothrombin time (PT) measure the time it takes for blood to clot, while the platelet count
assesses the number of platelets, which are important for clot formation. Hemoglobin is not directly
related to coagulation but measures the oxygen-carrying capacity of the blood.

7. The appropriate action for the nurse in the care of a client with a perforated gastric ulcer who cannot
sign the operative consent form due to sedation with opioid analgesics is:

a. Obtain a telephone consent from the family member witnessed by two persons.

Rationale: In emergency situations where the patient is unable to provide consent, obtaining a
telephone consent from a family member witnessed by two persons can be a valid option. It allows for
timely decision-making and ensures that the client receives necessary surgical intervention. However, it
is important to follow institutional policies and legal requirements regarding consent in emergency
situations. Obtaining a court order for surgery or sending the client to surgery without consent would
not be appropriate. Having the hospital chaplain sign the informed consent is not a standard practice
and does not fulfill the legal requirements for consent.8. The response by the nurse that is most likely to
stimulate further discussion between the client and the nurse is:
d. "Can you share with me what you've been told about your surgery?"

Rationale: This response encourages open communication and active participation from the client. It
shows empathy and interest in the client's perspective and concerns. By asking the client to share what
they have been told about the surgery, the nurse can address any misconceptions, provide accurate
information, and explore specific fears or questions the client may have.

9. The action the nurse should take in the care of a client preparing for transfer to the operating room
(OR) is:

b. Ensure that the client has voided.

Rationale: Ensuring that the client has voided before transfer to the OR is important to prevent
discomfort and potential complications during the procedure. It helps minimize the need for
catheterization and reduces the risk of bladder distension. Administering daily medications, verifying
fasting status, and practicing postoperative breathing exercises may be part of the preoperative routine,
but ensuring that the client has voided is the immediate action needed before transfer to the OR.

10. The medication that the nurse would clarify whether to give to the client and not withhold based on
the physician's order for nothing per mouth (NPO) status after midnight is:

c. Cyclobenzaprine (Flexeril)

Rationale: Nothing per mouth (NPO) status after midnight typically means withholding oral medications
to prevent aspiration during anesthesia. However, cyclobenzaprine is a muscle relaxant that is not
usually associated with an increased risk of aspiration. Therefore, the nurse would clarify whether to
give or withhold cyclobenzaprine as it may be appropriate to administer even when the client is NPO.
Conjugated estrogen, atenolol, and ferrous sulfate are oral medications that would generally be
withheld in accordance with NPO status.