The nurse assesses clients in the preoperative holding area. Which clients do the nurse clear for surgery? (Select all that apply.)

Question

1. Had breakfast en route to the hospital
2. Complained of feeling weak and jittery
3. Voided before preoperative medications
4. Was unable to demonstrate leg exercises
5. Determined vital signs as above baseline
6. Developed rash after starting IV infusion

Answer 1

2, 3
2. Feeling weak and jittery are consistent with clinical indicators for hypoglycemia and are common complaints before surgery because the client fasts for 6 to 8 hours before the procedure. Frequently, the nurse performs fingerstick glucose to determine the client's blood sugar; if the client is hypoglycemic, the provider can prescribe a small dose of IV glucose to increase the blood sugar.
3. Voiding before preoperative medications is a good idea because benzodiazepines and opioids commonly used before surgery can cause urinary stasis, dizziness, post-ural hypotension, and other factors that increase the risk of client injury. In addition, the client goes to surgery with an empty bladder so the postoperative health care team can evaluate the client's intraoperative urine output.
1. The client increases the risk of aspirating gastric contents by eating shortly before the surgery; the nurse holds this client for surgery and collaborates with the surgical team to determine when the client can go to surgery.
4. The client unable to demonstrate leg exercises is unable to repeat a simple skill from preoperative teaching; thus, the nurse holds this client until the nurse completes an assessment of the client's preoperative preparation to ensure other preparations were conducted properly.
5. The nurse holds this client until the nurse conducts additional assessments before concluding that the client is ready for surgery. The nurse must review client medica-tions, history, and gather additional information before clearing a client with abnor-mal vital signs.
6. The client potentially has a hypersensitivity reaction to latex or another substance that should be clarified before sending the client to surgery.