-
The nurse is caring for a patient who is NPO for scheduled surgery. The nurse notes that the patient has been on long-term oral steroid therapy and would have been scheduled for a dose of Prednisone 10 mg orally at 0600 if not NPO. Which of the following actions should the nurse take?
a.
Notify the registered nurse.
b.
Contact the pharmacy to obtain an intravenous equivalent dose.
c.
Ask why the patient is taking steroid therapy.
d.
Give the oral steroid with a small sip of water.
ANS: A
Patients on chronic oral steroid therapy cannot abruptly stop their medication even though they are told to take nothing by mouth (NPO) before or after surgery. Serious complications, such as circulatory collapse, can develop if steroids are stopped abruptly. The RN should be notified and will need to clarify the medication with the physician. It is anticipated that the physician will order the patient’s steroid therapy to be given by a parenteral route as the patient is NPO. Pharmacists cannot convert oral steroid doses to IV doses without an order from the physician.
-
The nurse is caring for a patient who had an abdominal hysterectomy and reports pain from gas postoperatively. Which of the following actions should the nurse take?
a.
Offer a hot beverage.
b.
Provide an extra blanket.
c.
Apply an abdominal binder.
d.
Help the patient ambulate.
ANS: D
If gas pains occur, encourage ambulation, have patient lie prone, and pull the knees up to the chest to relieve pain. Encouraging early ambulation helps promote restoration of gastrointestinal (GI) functioning, which is the goal and will help relieve the gas pains.
-
The nurse is caring for a patient who the night before surgery is withdrawn and sad. The patient says, “I am scared of this surgery.” Which of the following would be the nurse’s best response?
a.
“It’s normal to be scared. What is it that scares you?”
b.
“I would be scared, too. You will make it through.”
c.
“Don’t be so concerned. Everything will be all right.”
d.
“Be happy, because this surgery will help you.”
- ANS: A
- The word surgery causes a common emotional reaction in patients. The nurse who understands this can reassure the patient that this is normal and then ask an open-ended question to collect data about this fear to determine what should be done next. B and C. Reassurance that you do not know to be 100% true should never be given. D. This answer is not therapeutic in that it does not explore and identify what is concerning the patient for possible intervention.
-
The nurse is to preoperatively administer 8 mg of morphine intramuscularly to a patient. The nurse has available morphine 10 mg/mL. How many milliliters should the nurse give?
a.
0.25 mL
b.
0.5 mL
c.
0.8 mL
d.
1.25 mL
ANS: C
8 mg
1 mL
= 0.8 mL
10 mg
-
The nurse is caring for a postoperative patient. Which of these outcomes would be most important for the patient’s postoperative nursing diagnosis of Pain related to new incision?
a.
Patient reports pain using a pain scale.
b.
Patient states alternative techniques to minimize pain.
c.
Patient states normal coping techniques for pain.
d.
Patient states pain relief is satisfactory.
ANS: D
The priority outcome for the nursing diagnosis of Pain is met if patients report a decreased level of pain that is satisfactory to them. A, B, and C may be helpful in achieving the goal of pain relief but are not the priority goal.
-
The nurse answers a patient’s call light and finds the patient sitting up in bed with a wound evisceration. What action should the nurse take first?
a.
Place the patient in low Fowler’s position.
b.
Cover the wound with sterile saline-soaked towels.
c.
Notify the physician immediately.
d.
Apply gentle pressure over the wound.
ANS: AFor evisceration, first place the patient in low Fowler’s position with flexed knees. Cover the wound with sterile dressings or towels moistened with warm sterile normal saline. Notify the physician immediately. Apply gentle pressure over the wound, and keep the patient still and calm.
-
The nurse is caring for a postoperative patient who becomes restless, hypotensive, tachycardic, and tachypneic. Which nursing action should be given priority?
a.
Notify the patient’s family.
b.
Ensure physician is informed.
c.
Monitor vital signs.
d.
Maintain a patent airway.
ANS: D
The patient is obviously experiencing a complication and must be carefully monitored to ensure that a patent airway is maintained while vital signs are obtained, and then the physician and family should be informed.
-
The nurse is contributing to the plan of care for a surgical patient. The nurse recognizes that the most common human response to the stress associated with surgery is which of the following?
a.
Anxiety
b.
Depression
c.
Delirium
d.
Fear
ANS: A
Anxiety is a feeling of apprehension or uneasiness resulting from the uncertainties and risks associated with surgery, whereas fear, a feeling of dread from a source known to the patient, is an extreme reaction to surgery.
-
The nurse is caring for a patient who is scheduled for surgery. Which of these nursing actions should the nurse use to address the patient’s psychological concerns?
a.
Using correct, technical medical terminology in explanations
b.
Providing privacy to allow the patient to ask questions
c.
Instructing the patient to ask the surgeon all surgical questions
d.
Providing information to a patient who says, “I do not want to know”
- ANS: B
- Allowing the patient to express concerns and ask questions so that the patient has correct information will assist in reducing client anxiety. A. Understandable terms should be used but are not the best action here to reduce anxiety. C. Allowing the patient to ask questions as in “B” will reveal if general information is needed or if the surgeon needs to further explain information about the surgical procedure. In that case, the nurse would direct all surgical questions to the physician. D. The patient has the right to refuse information.
-
The nurse is caring for a patient who is to have a nephrectomy. The patient states that the surgeon said that this surgery is considered a “curative procedure.” Which of these responses would be appropriate by the nurse?
a.
“No, it is considered diagnostic surgery.”
b.
“Yes, it can be classified as a curative procedure.”
c.
“No, it is an exploratory procedure.”
d.
“It is considered palliative surgery.”
ANS: B
Curative surgery removes diseased or abnormal tissue. Diagnostic or exploratory surgery takes tissue samples for study to make a diagnosis, uses scopes to look into areas of the body, or involves an incision to open an area of the body for examination. Palliative surgery alleviates symptoms.
-
The nurse is caring for a patient who is to have a liver biopsy. The nurse recognizes that this is an example of which category of surgical procedures?
a.
Diagnostic
b.
Preventive
c.
Curative
d.
Palliative
ANS: A
Diagnostic surgery takes tissue samples for study to make a diagnosis. Preventive surgery removes tissue before it causes a problem. Curative surgery removes diseased or abnormal tissue. Palliative surgery alleviates symptoms.
-
The nurse is caring for a postoperative patient who has a nursing diagnosis of ineffective airway clearance. Which of these outcomes would be most appropriate for this patient?
a.
Observes demonstration of coughing and deep breathing exercises
b.
Explains coughing and deep breathing exercises
c.
Explains rationale for coughing and deep breathing exercises
d.
Correctly demonstrates coughing and deep breathing exercises
ANS: D
To clear the airway, effective coughing and deep breathing are needed, and demonstration is the best method for verifying correct technique. The airway will not be cleared with A, B, and C.
-
The nurse assists in preparing patients for surgery. Which of these patients would the nurse recognize as being in the best condition for surgery and at lower risk for complications?
a.
A 23-year-old patient 30 pounds less than ideal weight
b.
A 40-year-old patient who plans to quit smoking after surgery
c.
A 55-year-old patient who is a marathon runner
d.
A 66-year-old patient who is obese
ANS: C
Preoperative care focuses on helping the patient achieve the best possible surgical outcome by being in the healthiest possible condition for surgery. The 55-year-old patient who is a marathon runner is in the best condition for surgery due to exercise tolerance.
-
The nurse is caring for a preoperative patient. The patient asks, “What type of anesthesia causes a total loss of sensation and a complete loss of consciousness?” Which of these responses should the nurse give?
a.
“Epidural anesthesia”
b.
“Spinal anesthesia”
c.
“Local anesthesia”
d.
“General anesthesia”
- ANS: D
- General anesthesia causes the patient to lose sensation, consciousness, and reflexes. A, C, and D are local types of anesthesia that do not cause total loss of sensation and a complete loss of consciousness.
-
The nurse is contributing to the preoperative patient’s plan of care. Which of these statements by the patient would alert the nurse to plan interventions to help prevent postoperative complications?
a.
“I am 60 years old and in good health.”
b.
“This is my second surgery in 2 years.”
c.
“I have not had anything to eat or drink for 8 hours.”
d.
“I have chronic obstructive pulmonary disease.”
ANS: D
To help prepare patients with lung disorders for surgery, show them how to deep breathe and cough and use an incentive spirometer. A, B, and C do not pose apparent risks.
-
The nurse is caring for a patient who had spinal anesthesia. Which of the following effects from spinal anesthesia may affect the safety of the patient when getting out of bed for the first time postoperatively?
a.
Hypertension
b.
Hypotension
c.
Hyperventilation
d.
Hypoventilation
ANS: B
Hypotension results from sympathetic blockade causing vasodilation, which reduces venous return to the heart and therefore reduces cardiac output. Postural hypotension may occur if the patient rises too rapidly, creating a risk for falling.
-
The nurse is caring for a patient 23 hours after abdominal surgery. Which of the following patient data collection findings would require the nurse to take action?
a.
Hypoactive bowel sounds in four quadrants
b.
Report of flatus
c.
Lack of appetite
d.
Abdominal distention
ANS: D
The nurse must report signs of postoperative complications. A, B, and C are normal postoperative findings. If an ileus develops, abdominal distention, absent bowel sounds, and pain may result.
-
The nurse is to witness an adult patient’s consent for a knee arthroscopy. Which of these is essential for the nurse to confirm before witnessing the consent?
a.
What type of job the patient has
b.
When the patient last ate or drank
c.
Who is driving the patient home
d.
Which is the operative knee
ANS: D
It is essential as part of ensuring that the consent is correct that the nurse verify the surgical procedure and correct site, especially right or left, when applicable, are correctly written on the consent. A, B, and C do not have a bearing on the consent.
-
The nurse is caring for a postoperative patient. When the patient is allowed to get out of bed for the first time postoperatively, which of these measures would be most effective to ensure patient safety?
a.
Have the patient put on nonskid slippers before standing.
b.
Ensure that two caregivers assist the patient to stand.
c.
Dangle the patient at the bedside before standing is attempted.
d.
Teach the patient to request help before rising.
ANS: D
When patients get up postoperatively, especially for the first time, they may be weak and dizzy. Instruct the patient to request help and not get up alone. Then one or two health-care workers can assist the patient to put on nonskid slippers and dangle before standing to prevent falls.
-
The nurse is caring for a patient who has developed an increased temperature during the first 24 hours postoperatively. Which of these actions is a priority for the nurse to take?
a.
Providing passive range of motion exercises
b.
Encouraging coughing and deep breathing
c.
Giving antipyretic medication
d.
Restricting oral fluids
- ANS: B
- Usually, increased temperature during the first 24 hours postoperatively indicates atelectasis, if no other cause exists, so coughing and deep breathing should be encouraged to open the alveoli and prevent pneumonia. Option A will not affect the temperature. Option C does not affect the cause. D. Fluids should be encouraged as ordered, as dehydration can increase temperature as well.
-
The nurse is caring for a preoperative patient who expresses a fear of dying. What action should the nurse take?
a.
Tell the patient everything will be all right.
b.
Explain the national death rate from surgery.
c.
Allow the patient time to express concerns.
d.
Ask the family to comfort the patient.
- ANS: C
- Allow patients to express their concerns to allow inaccurate information to be corrected. A. Do not give false reassurance. B. National statistics are not likely helpful to the individual patient situation. D. The nurse should collect data first about the fear for planning care and not pass the issue to the family.
-
The nurse is reviewing the medication history of a preoperative patient who is NPO. The patient is noted to have been on long-term oral steroid therapy. What action should the nurse take?
a.
Ensure that the physician is informed of the patient’s history of steroid use.
b.
Hold steroid medication while the patient is receiving nothing by mouth.
c.
Administer the steroid medication topically.
d.
Monitor vital signs and document.
ANS: A
Patients on chronic oral steroid therapy cannot abruptly stop their medication even though they are told to take nothing by mouth (NPO) before or after surgery. Serious complications, such as circulatory collapse, can develop if steroids are stopped abruptly. The physician should be informed so the patient’s steroid therapy can be given by a parenteral route if the patient is NPO.
-
The nurse is contributing to the intraoperative plan of care for a patient undergoing an appendectomy. Which of these would be an intraoperative outcome for this patient?
a.
Verbalizes fears
b.
Demonstrates leg exercises
c.
Remains free from injury
d.
States understanding of discharge instructions
- ANS: C
- Risk for perioperative-positioning injury related to positioning, chemicals, electrical equipment, and effect of being anesthetized is an intraoperative concern of the nurse and has an outcome of being free from injury. A and B are preoperative outcomes. D is a postoperative outcome.
-
The nurse is caring for a patient in the perianesthesia unit. What is the nurse’s priority responsibility for the patient while in this unit?
a.
Monitoring urine output
b.
Maintaining a patent airway
c.
Assessing readiness for discharge
d.
Administering pain medication
ANS: B
Ensuring a patent airway is the highest priority. The other options will be done but are not the highest priority.
-
The nurse recommends early ambulation as ordered be included in the patient’s plan of care. Which of the following can be prevented by early ambulation?
a.
Increased peristalsis
b.
Coughing
c.
Thrombophlebitis
d.
Impaired wound healing
- ANS: C
- Assist with early postoperative ambulation as ordered to prevent thrombosis. A. Peristalsis should increase to prevent an ileus. B. The patient should be encouraged to cough to prevent respiratory problems. D. Wound healing is not directly aided by early ambulation.
-
The nurse is dangling a patient with an abdominal incision, when the incision suddenly eviscerates. What action should the nurse take after positioning the patient supine with flexed knees?
a.
Cleanse the abdomen.
b.
Apply an abdominal binder securely.
c.
Apply sterile saline-moistened dressings.
d.
Administer pain medication.
ANS: C
Place the patient in low Fowler’s position with flexed knees. Cover the wound with sterile dressings or towels moistened with warm sterile normal saline. Notify the physician immediately of this surgical emergency. Apply gentle pressure over the wound, and keep the patient still and calm.
-
The nurse is assisting a postoperative patient to use an incentive spirometer. Which of these patient instructions are appropriate?
a.
Inhale deeply until the target is reached.
b.
Do not hold breath after inhaling.
c.
Exhale five times before inhaling.
d.
Exhale deeply until the target is reached.
ANS: A
Instructions for incentive spirometer use include the following: Sit upright, at 45 degrees minimum, if possible. Take two normal breaths. Place mouthpiece of spirometer in mouth. Inhale deeply until target, designated by spirometer light or rising ball, is reached, and hold breath for 3 to 5 seconds. Exhale completely. Perform 10 sets of breaths each hour.
-
The nurse works on a preoperative unit. For which of the following conditions does the nurse recognize urgent surgery is needed?
a.
Ruptured appendix
b.
Hernia repair
c.
Fracture repair
d.
Aortic aneurysm
- ANS: C
- Urgent surgery is the need for an operation within 24 to 30 hours. Options A and D require emergency surgery. Option B is elective surgery.
-
The nurse is assisting during surgery when a patient develops malignant hyperthermia. Which of the following protocols would the nurse be prepared to assist with as directed?
a.
Administer oxygen, and continue the anesthesia and surgery.
b.
Immediately cease anesthesia and surgery, cool patient, and administer dantrolene sodium.
c.
Switch to a different type of anesthetic agent to continue the surgery.
d.
Warm the patient, administer fluids, and then continue surgery.
ANS: B
Surgery is stopped, and anesthesia is discontinued immediately. Oxygen is given, and the patient is cooled. Dantrolene sodium (Dantrium), a muscle relaxant, is given.
-
The nurse is collecting data for a patient who had an epidural anesthetic during surgery. What finding by the nurse is a priority to report?
a.
Patient reports a feeling of heaviness in the legs.
b.
Patient experiences chills and shaking postoperatively.
c.
Patient’s blood pressure is 100/60 mm Hg.
d.
Patient reports a feeling of numbness in the legs.
- ANS: C
- Hypotension results from sympathetic blockade causing vasodilation, which reduces venous return to the heart and therefore reduces cardiac output and must be reported. A, D. As the block wears off, patients feel as if their legs are very heavy and numb. This is normal. B. This is not related to the epidural.
-
The nurse is caring for a postoperative patient who 30 minutes prior to transfer from the perianesthesia unit (PACU) received an intravenous analgesic. Pain medication orders are for morphine 10 mg IM every 3 hours PRN. An hour after arrival on the nursing unit, the patient reports pain of 8 on a 0 to 10 pain scale. What action should the nurse take?
a.
Explain that intramuscular analgesic cannot be given for another 1.5 hours.
b.
Repeat same intravenous medication the patient received in the PACU.
c.
Administer the intramuscular medication now and then every 3 hours as ordered.
d.
Give the patient nonnarcotic analgesics.
ANS: C
For the first dose of an IM analgesic postoperatively, patients in pain should not have to wait the ordered time interval of the IM dose after an IV analgesic dose (i.e., 3 hr if the IM order is morphine 10 mg IM q3hr PRN). Having to wait when the IV analgesic is no longer effective can cause needless pain.
-
The nurse is caring for a patient after ambulatory surgery. The patient’s oxygen saturation must be above what level for the nurse to consider readiness for discharge?
a.
70%
b.
80%
c.
85%
d.
90%
ANS: D
Oxygen saturation must be above 90% for discharge.
-
The nurse is assisting in the surgical holding area. The nurse understands that which of the following schedules are recommended for prophylactic antibiotics?
a.
4 hours prior to surgery
b.
1 hour prior to surgery
c.
During surgery
d.
Within the first 2 hours postoperatively
ANS: B
Studies have shown that preventing surgical site infections include giving prophylactic antibiotics within 1 hour prior to surgery (which means the actual incision time).
-
The nurse is caring for a patient after a hernia repair who reports pain of 4 on a 0 to 10 scale. The patient’s orders include ibuprofen (Motrin) 400 mg orally every 6 hours prn for pain. Which of the following actions should the nurse take?
a.
Start the ibuprofen on the second postoperative day.
b.
Hold the ibuprofen due to risk of gastrointestinal (GI) upset.
c.
Give the ibuprofen as ordered for pain.
d.
Consult the physician for a stronger analgesic.
ANS: C
Ibuprofen can be effectively used for postoperative pain relief. See Box 12.9.
-
The home health nurse is visiting a patient recovering after an abdominal hysterectomy. Which of these actions should the home health nurse take before promoting patient intake of oral fluids?
a.
Determine that the patient has passed flatus.
b.
Ensure bowel sounds can be detected.
c.
Check for the absence of pain.
d.
Verify physician’s order for intake.
Traditionally after GI surgery, bowel sounds were monitored by the nurse and the patient was kept NPO until flatus and bowel sounds returned. No evidence exists to support this practice. However, research about this practice shows that bowel sounds are not correlated with bowel motility and a patient’s ability to safely drink and eat postoperatively. In fact, patients can be hydrated and fed early for nutrition to promote healing and faster recovery (Box 12.11). Pain is expected after surgical intervention and should be treated with analgesics.
-
The nurse is caring for a postoperative patient at risk for deep vein thrombosis. Which of the following actions should the nurse recommend be included in the patient’s plan of care? (Select all that apply.)
a.
Ambulate the patient tid.
b.
Massage the patient’s legs daily.
c.
Apply antiembolic stockings.
d.
Place a pillow under the patient’s knees.
e.
Perform leg exercises 10 times hourly while awake.
ANS: A, C, E
For the patient at risk of developing deep vein thrombosis, it is important to encourage hourly leg exercises while awake, assist with early ambulation, apply knee- or thigh-length antiembolic stockings, and give low molecular weight heparin if ordered. It is also important to avoid pressure under the knee from pillows to prevent clot formation. Legs should not be massaged, as a clot, if present, could be dislodged and become an embolus.
-
The nurse has reinforced preoperative teaching with a patient about coughing and deep breathing techniques. Which of the following statements by the client would indicate a correct understanding of the teaching? (Select all that apply.)
a.
“I should cough and deep breathe 10 times every hour while awake.”
b.
“I should avoid deep breathing after surgery.”
c.
“I should take shallow breaths after surgery to prevent pain.”
d.
“I should cough and deep breathe beginning 2 days after my surgery.”
e.
“Coughing and deep breathing helps prevent respiratory problems.”
ANS: A, E
Deep breathing helps prevent the development of atelectasis. Coughing moves secretions to prevent pneumonia. They are done 10 times hourly while the patient is awake for 24 to 48 hours postoperatively.
-
The practical/vocational nurse is preparing a patient for surgery who has asthma and is hard of hearing. Which of the following are within the scope of practice for the nurse? (Select all that apply.)
a.
Provide emotional support.
b.
Apply antiembolism devices as ordered.
c.
Assist patient with insertion of hearing aids.
d.
Reinforce registered nurse’s instructions.
e.
Send inhaler to surgery with patient.
f.
Provide information for informed consent.
ANS: A, B, C, D, E
All but F are within the scope of practice for a practical/vocational. The physician provides information for informed consent.
-
The intraoperative practical/vocational nurse is caring for a patient who is undergoing abdominal surgery with general anesthesia. What interventions should the nurse implement? (Select all that apply.)
a.
Assist physician as directed.
b.
Assist with patient positioning.
c.
Encourage leg exercises.
d.
Assist the patient to change position in bed every 4 hours.
e.
Monitor for unilateral swelling of the calf.
f.
Participate in a time out before surgery begins.
- ANS: A, B, F
- The surgical (second assistant) technician: assists physician (may be an RN, LPN/LVN, or surgical technologist). B and F are focused on preventing complications for this patient in surgery. The practical/vocational nurse can participate in positioning as directed. Everyone must participate in the time out. C, D, and E are postoperative interventions for respiratory and circulatory complications, not intraoperative interventions. Also, the patient should move more than every 4 hours.
-
The nurse is caring for a preoperative patient. The patient asks the nurse what types of anesthesia cause a loss of sensation in a specific area of the body while the patient remains alert. Which of these responses should the nurse give? (Select all that apply.)
a.
“Epidural anesthesia.”
b.
“General anesthesia.”
c.
“Local anesthesia.”
d.
“Spinal anesthesia.”
ANS: A, C, D
Local anesthesia causes a loss of sensation in a specific area of the body while the patient remains alert. Epidural and spinal anesthesia are forms of local anesthesia. General anesthesia causes a loss of consciousness.
-
The nurse is assisting in preparing the patient for surgery. Which surgical consent would the nurse recognize as being a legal consent? (Select all that apply.)
a.
Consent signed by 36-year-old patient 1 hour after receiving lorazepam (Ativan).
b.
Consent signed by 16-year-old patient for his or her own urgent surgery.
c.
Consent signed by a foster mother for a 17-year-old patient.
d.
Consent signed by a 60-year-old patient 1 hour before receiving morphine.
e.
Consent signed by a 17-year-old for her infant’s surgery.
f.
Consent signed by a 28-year-old for his own elective surgery.
- ANS: D, E, F
- The patient is an adult and no narcotics have been given that may impair judgment, so it is a legal consent. E. The consent is being signed by the child’s legal parent. F. The patient is an adult signing for his own surgery without evidence of impairment. A, B, and C are not legal consents, because in A, narcotics have been given within 3 hours of the signing; in B, the patient is a minor and cannot give consent; and in C, the patient’s legal guardian must give consent.
-
The nurse is witnessing an adult patient’s surgical consent. Which of the following would the nurse need to confirm before witnessing the surgical consent? (Select all that apply.)
a.
The patient’s next of kin
b.
Whether the patient is informed about the surgery
c.
If family members have questions related to the surgery
d.
When the patient last ate or drank
e.
The last time a sedative was administered
ANS: B, E
As the patient’s advocate, ensure before the consent is signed that the patient is informed about the surgery and has no further questions for the physician. If the patient has questions, the consent should not be signed, and the physician should be contacted to answer the patient’s questions. The consent cannot be signed if the patient is under the influence of sedatives or narcotics, so timing of their administration must be verified.
-
The nurse notes upon the patient’s return to the surgical unit postoperatively that the surgical dressing covering the Penrose drain is dry and intact. Two hours later, the patient reports pain of 5 on a scale of 0 to 10 at the incisional site. The nurse checks the dressing and finds a 1 ´ 1 inch area of serosanguineous drainage on the dressing. What action should the nurse take? (Select all that apply.)
a.
Monitor the drainage at the incisional site.
b.
Notify the registered nurse immediately.
c.
Review the analgesic administration record.
d.
Culture the drainage on the dressing.
e.
Apply pressure to the incisional site.
ANS: A, C
Moderate serosanguineous drainage is expected from a Penrose drain, so monitoring the dressing is all that is needed at this time, as this is a small amount of drainage. The pain level requires intervention, and verifying the last time pain medication was administered is the first step.
-
The nurse provides recommendations for the plan of care for a patient scheduled to undergo a cholecystectomy. What is the best rationale for including preoperative teaching of deep breathing exercises to prevent postoperative complications for this patient? (Select all that apply.)
a.
Anesthesia increases retention of respiratory secretions.
b.
Anesthesia decreases production of respiratory secretions.
c.
Location of incision contributes to decreased lung expansion.
d.
Incisional pain promotes decreased lung expansion.
ANS: A, C, D
Lung expansion is needed to prevent complications such as pneumonia. During anesthesia, the patient is not taking deep breaths, so secretions are not being mobilized. The high incisional location near the diaphragm will decrease the patient’s willingness to take deep breaths, especially if painful.
-
The nurse is caring for a postoperative patient. When getting the patient out of bed for the first time postoperatively, which action should the nurse take to maintain safety? (Select all that apply.)
a.
Have the patient stand with no assistance.
b.
Assist the patient to stand in one motion.
c.
Dangle the patient at the bedside.
d.
Instruct the patient to place the nurse light on to get up.
e.
Use two people to assist patient.
ANS: C, D, E
When patients get up postoperatively, especially for the first time, they may be dizzy and weak. They can be a fall risk. Ideally, two health-care workers should assist the patient to dangle before standing to prevent falls the first time getting up.
-
The postoperative nurse is caring for a patient who had abdominal surgery with general anesthesia. What interventions should the nurse implement? (Select all that apply.)
a.
Monitor first voiding after catheter removal.
b.
Position carefully and pad bony prominences.
c.
Encourage use of incentive spirometer as ordered.
d.
Assist the patient to change position in bed every 4 hours.
e.
Monitor for unilateral swelling of the calf.
f.
Monitor pain level each hour that patient is awake.
ANS: A, C, E, F
A, C, E, F are focused on preventing postoperative complications for this patient. C, E. These interventions prevent postoperative respiratory and circulatory complications. B is an intraoperative intervention. D. The patient should move more than every 4 hours.
-
The nurse is contributing to an education program for older adults who are preparing for joint replacement surgery. Which of the following interventions should the nurse use to enhance older patient learning? (Select all that apply.)
a.
Conduct session in a room with bright, fluorescent lighting.
b.
Utilize medical terminology to promote understanding.
c.
Provide handouts with black print on white nonglare paper.
d.
Convey positive attitude and self-care promotion for older adults.
e.
Avoid repetition in presentation.
ANS: C, D
See Box 12.3. C and D are correct. A, B, and E should be avoided.
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