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In the post-operative period following the repair of a cleft palate, the nurse places the client in the side-lying position. The mother questions why. The nurse’s response is based on the know that this position:
a. Allows for observation of the suture line
b. Will allow the client to relax
c. Will allow for drainage
d. Allows for the best method for fluid intake
- Correct: C
- Rationale: In the initial period following a cleft palate repair, the nurse should anticipateincreased salivation, which can increase the client’s risk for aspiration. Placing a client in theside-lying position, will maintain an open airway and allow for drainage of oral secretions.
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While performing the pre-operative check list on a client, the nurse notes that theclient is having difficulty paying attention, increased heart rate and respirations andhas sweaty palms with trembling hands. The client states, “All I can think about isthe surgery and I keep wondering if everything will go alright.” Based on theinformation provided the nurse should classify the client’s anxiety at:
a. Mild
b. Moderate
c. Severe
d. Panic
- Correct: C
- Rationale: The client in this scenario is displaying obvious signs of sympathetic nervous systemstimulation. With the addition of client statements regarding the surgical procedure, the nurseshould classify their anxiety as severe.
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While preforming the discharge assessment on the client 2 day post opencholecystectomy, the nurse notes tachypnea, restlessness and hemoptysis. The nurseshould:
a. Evaluate the clients white blood cell count
b. Check client’s records for a positive TB test
c. Document findings, as physician assess client 45 minutes prior and determined the client was ready for discharge
d. Contact primary health care provider and report findings
- Correct: D
- Rationale: The client in the scenario is exhibiting potential signs of pulmonary embolism, apotential post-operative complication. It is possible that the client was not exhibiting theseclinical manifestations previously and therefore the physician should be notified.
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Discuss the degree of risk of surgery.
- 1.Major – involves a high degree of risk for a variety reasons; It may be complicated or prolonged, large losses of blood may occur, vital organs may be involved, or postoperative complications are possible.
- 2.Minor – normally involves little risk, produces few complications, and is often performed in an outpatient setting.
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