Post Operative (ch19 - Lewis)
An older adult patient has a complication after a cardiac catheterization and has to remain in the intensive care unit (ICU) for an extra three days. For what is the patient most at risk? 1 Delirium 2 Depression 3 Alcohol withdrawal 4 Aggressive behaviors
1 Older adult patients who spend prolonged amounts of time in the ICU are at risk for delirium caused by ICU psychosis. Aggressive behaviors and depression can also be parts of ICU psychosis, but this disorder is most often characterized by delirium. There is not enough information in this scenario to determine if the patient is at risk for alcohol withdrawal.
A patient undergoes abdominal surgery. Before asking the patient to perform postoperative breathing exercises, what evaluation or intervention should the nurse perform? 1 Gauging the patient's level of pain 2 Evaluating the patient's vital signs 3 Assisting the patient out of bed and into a chair 4 Reviewing the primary health care provider's plan of care
1 Pain management is essential to postoperative care. Assessing the level of pain and offering an analgesic before performing postoperative breathing exercises or any activities will ease pain and facilitate compliance, thus decreasing the risk of complications. Checking vital signs, assisting the patient into a chair, and reviewing the primary health care provider's plan of care are all appropriate after the patient's pain level has been assessed.
What is the priority nursing action when a patient is transferred from the postanesthesia care unit (PACU) to the surgical unit after a lobectomy? 1 Assess the patient's pain. 2 Take the patient's vital signs. 3 Check the rate of the intravenous (IV) infusion. 4 Check the health care provider's postoperative prescriptions.
Correct2 The highest priority action by the nurse is to assess the physiologic stability of the patient. This is in part accomplished by taking the patient's vital signs. Assessing the patient's pain, checking the prescriptions, and checking the rate of IV infusion can take place in a rapid sequence after taking the vital signs.
The nurse is caring for a postoperative patient. What patient does the nurse determine is at the greatest risk for development of atelectasis? 1 A patient after a hypoxic episode during an acute asthma attack 2 An older adult patient who has undergone cardiothoracic surgery 3 A patient not adherent with the pulmonary regimen after surgery 4 A patient experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD)
Correct3 Atelectasis is a common postoperative complication that is prevented by a pulmonary regimen of interventions such as deep breathing, coughing, turning, and using an incentive spirometer. Patients who have received general anesthesia and are noncompliant with a pulmonary regimen are at highest risk for atelectasis. Patients who have experienced a hypoxic episode during an acute asthma attack or with an acute exacerbation of chronic obstructive pulmonary disease are at lower risk for atelectasis than are postoperative patients. Postoperative older adults who have had cardiothoracic surgery are also at risk for atelectasis if they do not adhere to a pulmonary regimen.
The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge? Select all that apply. 1 Vital signs baseline or stable 2 Minimal nausea and vomiting 3 Wants to go to the bathroom at home 4 Responsible adult taking patient home 5 Comfortable after intravenous (IV) opioid 15 minutes ago
Correct 1 , 2, 4 Ambulatory surgery discharge criteria include meeting Phase I postanesthesia care unit (PACU) discharge criteria, which include vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria include a responsible adult driving patient, no IV opioid drugs for the last 30 minutes, ability to void, ability to ambulate if not contraindicated, and receiving written discharge instruction, with patient understanding confirmed.
A patient with a history of bipolar disorder underwent an amputation of the left leg. The patient has diabetes and a complicated diabetic foot ulcer. Which factor will best determine the patient's ability to cope? 1 Ability to regain independence 2 Previous diagnosis of depression 3 Anxiety during the discharge process 4 Ability to complete the rehabilitation program
Correct1 Ability to regain independence will be the biggest factor in the patient's ability to cope after an amputation. Completing the rehabilitation program will help the patient meet this goal of independence. A previous diagnosis of depression and anxiety during the discharge process may cause problems with coping, but regaining independence is the biggest factor in the patient's coping ability.
A patient, who is eight hours postappendectomy, has not voided since surgery. What action should the nurse take? 1 Encourage oral (PO) fluid intake. 2 Palpate the suprapubic area for bladder distention. 3 Insert an in and out catheter to assess for retention. 4 Check the medical record to determine the type of anesthetic given.
Correct2 The nurse needs to know first if there is urine in the bladder. The assessment can be done by palpating or scanning the suprapubic area. Encouraging PO fluid intake is appropriate if the patient can tolerate PO fluids and there is no bladder distention. Because of the risk of infection, an in and out catheter is not used for assessment purposes but to relieve known urine retention. No matter what type of anesthetic was administered, the nurse needs to determine if the patient has not voided because of a lack of urine output or if the issue is an alteration in micturition.
A patient had an estimated blood loss of 400 mL during abdominal surgery. The patient received 300 mL of 0.9% saline during surgery and now is experiencing hypotension postoperatively. What should the nurse anticipate for this patient? 1 Restoring circulating volume 2 Monitor pulse and blood pressure 3 An ECG to check circulatory status 4 Return to surgery to check for internal bleeding
1 The nurse should anticipate restoring circulating volume with intravenous (IV) infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. The nurse will need to do more than monitor pulse and blood pressure. An ECG may be done if there is no response to the fluid administration or there is a past history of cardiac disease or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if the patient's level of consciousness changes or the abdomen becomes firm and distended. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.
The nurse is reinforcing deep breathing and coughing techniques to a postoperative patient with an abdominal incision. Which important instruction should the nurse include in her teaching regarding safe use of this technique? 1 Splint the abdominal incision with a pillow. 2 Perform the technique two times every waking hour. 3 Limit fluid intake to thicken the secretions and membranes. 4 Encourage deep breathing and coughing if the patient is in pain or feels the urge to clear secretions.
1 When performing deep breathing and coughing exercises, the patient should splint the abdominal incision site with a pillow or folded blankets to support the incision. The patient may be instructed to perform the technique 10 times every hour if the condition allows. The nurse should assure the patient that the breathing and coughing techniques will not harm the incision site and are essential to mobilizing secretions. The patient should be instructed to drink sufficient water to keep the secretions thin.
The nurse is educating a patient that had a coronary bypass graft (CABG) about the risk of venous thromboembolism (VTE). What should the nurse be sure to include in the education to the patient? 1 Early ambulation 2 Turning every 2 hours 3 Splinting chest while coughing 4 Importance of taking pain medication
Correct1 Activity has proven vital in helping to prevent postoperative VTEs. Other forms of treatment include anticoagulants and sequential compression devices (SCDs). Splinting the chest while coughing, taking pain medication, and turning every 2 hours are important for the recovery of the coronary bypass patient but have little impact on preventing VTE.
An older patient is having problems with concentration and memory after extensive surgery to repair an abdominal aortic aneurysm. What determines if this is a factor of delirium or postoperative cognitive dysfunction? 1 Preexisting dementia identified before surgery 2 Ability of the patient to state name, location, and date 3 Ability to ambulate in the halls and follow commands 4 An undisturbed sleep-wake cycle in the critical care unit
Correct1 Dementia should be assessed preoperatively so interventions can be established after surgery to help the patient meet outcomes. Orientation of name, location, and date and ability to ambulate in halls and follow commands do not determine differences in concentration and memory. A disturbed sleep-wake cycle may cause postoperative cognitive dysfunction. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.
While caring for a patient after a colectomy on the first postoperative day, the nurse notes new bright-red drainage about 4 cm in diameter on the surgical dressing. What is the priority nursing action? 1 Take the patient's vital signs. 2 Mark the area on the dressing and document the finding. 3 Recheck the dressing in one hour for increased drainage. 4 Notify the health care provider of a potential hemorrhage.
Correct1 The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse then can report the findings to the provider. Marking the area is acceptable, but not the priority nursing action. Rechecking the dressing in an hour increases the risk of adverse outcomes by waiting more time to notify the health care provider about a potential bleeding complication. The health care provider should be notified after the nurse assesses the patient.
A patient that is an alcoholic had a hernia operation and is restless and irritable. On assessment, the nurse finds that the patient has auditory hallucinations. What is the most appropriate nursing action? 1 Conclude that these effects are due to alcohol withdrawal. 2 Consider the situation normal, due to the anesthetic drugs. 3 Conclude that the patient suffers from a psychotic disorder. 4 Infer that the patient is suffering from pain and suggest using pain killers.
Correct1 The patient is irritable and restless due to loss of the inhibitory effects of alcohol; this is also causing the hallucinations. The patient does not have a history of psychotic illness; therefore, the symptoms cannot be attributed to a psychotic disorder. Anesthetic drugs may cause delirium, but not hallucinations. Pain may cause restlessness and irritability, but not hallucinations.
A patient with asthma develops wheezing on the postanesthesia care unit. The nurse finds that the patient is tachypneic, has dyspnea, and has reduced oxygen saturation. How will the nurse prevent further pulmonary complications? 1 Administer bronchodilators. 2 Provide incentive spirometry. 3 Encourage chest physical therapy. 4 Provide nebulization of histamine vapors.
Correct1 The presence of wheeze, tachypnea, and reduced oxygen saturation indicates bronchospasm. The use of bronchodilators relieves bronchospasm and promotes a patent airway. Incentive spirometry is useful in managing atelectasis when the airway is patent. Chest physical therapy is helpful to clear secretions from the respiratory tract. Histamine vapors aggravate bronchospasm and therefore should be avoided.
A patient on the postoperative unit was given a large dose of opioids during a surgical procedure and is now hypoxemic. What would the nurse expect to be prescribed to manage hypoxemia in this patient? 1 Opioids 2 Naloxone 3 Benzodiazepines 4
Correct2 Shallow respiration associated with hypoxemia and reduced respiratory rate in a patient who received large doses of opioids indicates hypoventilation due to medullary depression. Drugs that reverse the effect of opioids should be administered to stimulate the medullary respiratory center such as naloxone. Opioids and benzodiazepines should be avoided because they further aggravate medullary depression. In severe medullary depression, the patient may need mechanical ventilation.
A patient is admitted to the postanesthesia care unit (PACU) after colon surgery. During the initial assessment, the patient tells the nurse they are going to "throw up." Which statement by the nurse reflects a priority nursing intervention? 1 "I need to check your vital signs." 2 "Let me help you turn to your side." 3 "Here is a sip of ginger-ale for you." 4 "I can give you some antinausea medicine."
Correct2 If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs. Checking vital signs does not address the nausea. It may not be appropriate to give the patient oral fluids immediately following bowel surgery. Administering an antiemetic may be appropriate after turning the patient to the side. Test-Taking Tip: As you answer each question, write a few words about why you think that answer is correct; in other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to identify it. This will permit you to recognize areas that need further review. It will also help you to see how correct your "guessing" can be. Remember: on the licensure examination you must answer each question before moving on to the next question.
A patient is admitted to the postanesthesia care unit (PACU) after colon surgery. During the initial assessment, the patient tells the nurse they are going to "throw up." Which statement by the nurse reflects a priority nursing intervention? 1 "I need to check your vital signs." 2 "Let me help you turn to your side." 3 "Here is a sip of ginger-ale for you." 4 "I can give you some antinausea medicine."
Correct2 If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs. Checking vital signs does not address the nausea. It may not be appropriate to give the patient oral fluids immediately following bowel surgery. Administering an antiemetic may be appropriate after turning the patient to the side. Test-Taking Tip: As you answer each question, write a few words about why you think that answer is correct; in other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to identify it. This will permit you to recognize areas that need further review. It will also help you to see how correct your "guessing" can be. Remember: on the licensure examination you must answer each question before moving on to the next question.
The nurse finds that a postoperative patient has low oxygen saturation and crackles on auscultation. Which is an appropriate nursing action? 1 Suction the airway. 2 Restrict fluid intake. 3 Monitor mental status. 4
Correct2 Pulmonary edema in a postoperative patient is due to fluid overload. Therefore fluid restriction is the most appropriate intervention. In addition, oxygen therapy and diuretics can be administered. The airway is suctioned if there is any secretion retained in the system. Monitoring of mental status is done in the early postoperative period to determine emergence from anesthesia. Lateral recovery position is used in the early postoperative period to keep the airway patent and prevent aspiration in case the patient vomits. Test-Taking Tip: Make educated guesses when necessary.
The nurse is assessing a patient's surgical dressing on the first postoperative day and notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first? 1 Recheck in one hour for increased drainage 2 Assess the patient's blood pressure and heart rate 3 Remove the dressing and assess the surgical incision 4 Notify the health care provider of a potential hemorrhage
Correct2 The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse then can report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.
The nurse is monitoring a patient who is about to be transferred to the clinical unit from the postanesthesia care unit (PACU). Which assessment data require the most immediate attention? 1 Oxygen saturation of 94% 2 Pulse rate 128 beats/minute 3 Respiratory rate of 13/minute 4 Temperature of 99.8° F (37.7° C)
Correct2 The most important aspect of the cardiovascular assessment is frequent monitoring of vital signs. They usually are monitored every 15 minutes in Phase I, or more often until stabilized, and then at less frequent intervals in Phase II. Notify the anesthesia care provider (ACP) or the health care provider if the pulse rate is less than 60 beats/minute or greater than 120 beats/minute. The oxygen saturation should be above 90%, so 94% is good. A respiratory rate of 13 is normal. A temperature of 99.8 is expected.
A patient underwent a laparoscopic assisted hysterectomy the day before and is now experiencing chills and a temperature of 102.2 °F (39 °C). Which nursing action is priority? 1 Administer the final dose of antibiotic. 2 Notify the primary health care provider. 3 Have the patient deep breath and cough. 4 Administer as needed acetaminophen (Tylenol).
Correct2 The patient is demonstrating signs of septicemia. Therefore the priority nursing action is to notify the primary health care provider so tests and treatments can be prescribed. Administering the antibiotic and having the patient deep breath and cough help prevent infections, but the patient is exhibiting signs and symptoms of infection in spite of these interventions. Acetaminophen treats the fever but not the source of the problem.
The nurse receives an unconscious postoperative patient in the post anesthesia care unit (PACU). What position would be the safest to place this patient immediately after the operation? 1 Supine 2 Lateral 3 Semi-Fowler's 4 High Fowler's
Correct2 Unless contraindicated by the surgical procedure, the unconscious patient is positioned in lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient usually is returned to a supine position with the head of the bed elevated. Supine, semi-Fowler's, and high Fowler's positions are all supine; they are not as helpful in keeping the airway open and reducing the risk of aspiration.
A nurse is caring for a patient who had a bowel resection 10 hours before. The patient weighs 200 pounds (91 kg) and has a urine output of 240 cc for the past eight hours. What action should the nurse take? 1 Encourage oral (PO) fluids 2 Continue to monitor the urine output 3 Notify the primary health care provider 4 Administer a 500 cc normal saline intravenous (IV) bolus
Correct3 The formula for determining adequate urine output is 0.5 mL/kg/hr. This patient, weighing 91 kg, needs to have 45 cc per hour or about 365 cc of urine in eight hours. It often takes three to five days for the bowel to begin working postabdominal surgery; therefore, it would be inappropriate at this time to encourage PO fluids. Continuing to monitor the urine output, instead of calling the primary health care provider, would delay identifying and treating the cause for the low urine output. The nurse must obtain a prescription for the normal saline bolus before administration.
A postoperative patient is delirious, restless, and shouting at the nurse about pain. What does the nurse consider may be a cause of this behavior? 1 A new diagnosis of psychosis 2 Increased ability to tolerate pain 3 Anesthetic agents used in surgery 4 Inadequately timed administration of pain medication
Correct3 Anesthetic agents used in surgery can cause short-term psychotic type behaviors that are relieved after the anesthetic drugs have cleared the body. A new diagnosis of psychosis is not warranted in the acute phase following surgery. The patient may not be tolerating the pain, but the delirium, yelling, and restlessness denote short-term psychotic-like behavior caused by the anesthetic agents and postoperative pain medications. The nurse should administer pain medications as soon as safely possible.
A patient has been admitted to the postanesthesia care unit (PACU). Which of these assessment findings require the nurse's immediate action? 1 The patient is groggy but arouses to voice. 2 The patient indicates that he or she is in pain. 3 The patient is restless, agitated, and hypotensive. 4 The Jackson-Pratt is draining serosanguinous fluid.
Correct3 Assessment in the PACU begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Restlessness, agitation, and hypotension are clinical manifestations of inadequate oxygenation. Identification of inadequate oxygenation and ventilation or respiratory compromise requires prompt intervention. Pain, sedation, and draining serosanguinous fluid are expected findings. Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early.
In caring for the postoperative patient on the clinical unit after transfer from the postanesthesia care unit (PACU), which care can be delegated to the unlicensed assistive personnel (UAP)? 1 Monitor the patient's pain 2 Do the admission vital signs 3 Assist the patient to take deep breaths and cough 4 Change the dressing when there is excess drainage
Correct3 The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The registered nurse (RN) should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The licensed practical nurse (LPN) or RN will monitor and treat the patient's pain and change the dressings.
The nurse caring for a postoperative patient assesses clinical manifestations of early pulmonary edema. What manifestations does the nurse determine correlates with this disorder? 1 Early-morning cough 2 Increased urine output 3 Paroxysmal nocturnal dyspnea 4 Crackles heard on auscultation
Correct3 The most common cause of pulmonary edema is left-sided congestive heart failure, which commonly manifests as shortness of breath and crackles in the lungs. Between the two, shortness of breath in the form of paroxysmal nocturnal dyspnea is the earlier symptom, although crackles are more common. An early-morning cough may be seen with respiratory infection or chronic obstructive pulmonary disease but is not usually a symptom of pulmonary edema. In pulmonary edema, urine output is typically decreased due to fluid retention. Crackles heard on auscultation of the lungs are one of the more common symptoms of pulmonary edema, along with coughing of frothy pink-tinged sputum.
A nurse cares for a patient with acute pulmonary edema. What findings would the nurse expect to assess? 1 Vertigo and headache 2 Palpitations and nausea 3 Anxiety and distended neck veins 4 Dry, hacking cough and chest pain
Correct3 The patient experiencing acute pulmonary edema would most likely experience anxiety related to hypoxia. Distended neck veins would be present because of decreased cardiac output resulting in right-sided heart congestion, causing blood to back up into the neck veins. Vertigo and headaches, and palpitations and nausea, may be present but are not as distinct and common as anxiety, distended neck veins, and shortness of breath. The cough associated with pulmonary edema will be moist and productive. In severe cases, this may present as pink and frothy sputum. Chest pain may also be present.
The nurse is caring for a patient at risk for developing syncope. Which nursing intervention is important to prevent this occurrence in this postoperative patient? 1 Administer oxygen therapy. 2 Administer analgesics before ambulation. 3 Make changes in the patient's position slowly. 4 Encourage deep breathing and coughing exercises.
Correct3 To prevent syncope in a postoperative patient, the nurse should slowly change the patient's position. Progression to ambulation can be achieved by first raising the head of the patient's bed for 1 to 2 minutes and then assisting the patient to sit, with legs dangling, while monitoring the pulse rate. If no changes or complaints are noted, start ambulation with ongoing monitoring of the pulse. Oxygen therapy and deep breathing and coughing exercises are interventions to improve pulmonary function, not to prevent syncope. Administering analgesics before ambulation makes the activity painless and encourages the patient to become more active.
Two days after colectomy for an abdominal mass, the patient reports gas pains and abdominal distension. The nurse plans care for the patient on the basis of the knowledge that these symptoms occur as a result of which condition? 1 Constipation 2 Nasogastric suctioning 3 Slowed gastric emptying 4 Inflammation of the bowel at the anastomosis site
Correct3 Until peristalsis returns to normal after anesthesia, the patient may experience slowed gastric motility, leading to gas pains and abdominal distension. Colectomy does not require a nasogastric tube; the bowel should not be inflamed following surgery unless infection is present. Constipation may occur following surgery; however, with bowel manipulation, slowed gastric emptying is the most common reason for gas pains and abdominal distention because of gas.
A nurse is providing postoperative care for a patient who has undergone exploratory abdominal surgery. To prevent the complication of atelectasis, what interventions should the nurse perform? 1 Medicating the patient with a narcotic analgesic as prescribed 2 Providing an abdominal binder to help the patient in ambulation 3 Encouraging the use of an incentive spirometer at least every hour 4 Turning the patient from one side to the other at least every 2 to 4 hours
Correct3 Use of an incentive spirometer after surgery encourages the patient to take deep, slow breaths, which facilitates the opening of terminal airways, mobilizes secretions, and prevents postoperative atelectasis. Narcotic analgesics, use of an abdominal binder for ambulation, and frequent turning in bed may indirectly support recovery and prevention of complications postoperatively. However, these interventions do not specifically address prevention of atelectasis and pneumonia in the way that the use of an incentive spirometer does.
The patient donated a kidney and early ambulation is included in the plan of care; however, the patient refuses to get up and walk. What explanation should the nurse give to the patient for early ambulation? 1 "Early walking keeps your legs limber and strong." 2 "Early ambulation will help you be ready to go home." 3 "Early ambulation will help you get rid of your syncope and pain." 4 "Early walking is the best way to prevent postoperative complications."
Correct4 The best rationale is that early ambulation will prevent postoperative complications that then can be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and venous thromboembolism (VTE), speeds wound healing, increases vital capacity, and maintains normal respiratory function. These things help the patient to be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management always should occur before walking
A nurse is caring for an older adult patient, who had a knee replacement the previous day. The patient denies any pain. Which response by the nurse would be most appropriate? 1 "Excellent. You must be able to handle a lot of pain." 2 "Great. It is wise to only take the pain medication if you need it." 3 "It is important that you take pain medication. It will help you recover quicker." 4 "Almost everyone has pain after this surgery. Are you certain that you are not experiencing pain?"
Correct4 Thoroughly assessing the presence of pain is imperative, especially for those who deny any pain after surgery, especially the elderly. Gerontology patients may hesitate about reporting pain because of the belief that pain should be tolerated and is inevitable postsurgery. It is not appropriate to compliment the patient on being able to handle pain. The patient will not develop an addiction to pain medication, so it is not appropriate to tell the patient he or she should only take it when necessary. The nurse should not tell the patient that pain medication will help him or her recover quicker, because that could give the patient false reassurance. Test-Taking Tip: The presence of absolute words and phrases can also help you determine the correct answer to a multiple-choice item. If answer choices contain an absolute (e.g., none, never, must, cannot), be very cautious. Remember that there are not many things in the world that are absolute, and in an area as complex as nursing, an absolute may be a reason to eliminate it from consideration as the best choice. This is only a guideline and should not be taken to be true 100% of the time; however, it can help you reduce the number of choices.
A patient who is still drowsy and recovering from anesthesia has been vomiting. How can the nurse prevent aspiration in this patient? 1 Avoid using suctioning devices. 2 Position the patient in prone position. 3 Position the patient in supine position. 4 Place the patient in lateral recovery position.
Correct4 Aspiration of the vomitus can be prevented by placing the patient in the lateral recovery position. This position helps the vomitus escape through the mouth. A suctioning device may be used to remove the vomitus to prevent aspiration. Supine and prone positions are less helpful in preventing aspiration than the lateral recovery position.
The nurse is developing a care plan for the postoperative patient in order to prevent complications and promote ambulation, coughing, deep breathing, and turning. What actions can the nurse provide to achieve desired outcomes? 1 Explain easily the rationale for these activities. 2 Have family in the room for support and encouragement. 3 Warn about pneumonia and clotting if the actions are not completed. 4 Administer enough analgesics to promote relative freedom from pain.
Correct4 Even when a patient understands the importance of postoperative activities, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate. Warning the patient about pneumonia and clotting will not enhance proper activities if pain is not managed. Family encouragement and understanding of the rationale for completing these actions are important; however, pain control is the most helpful way to ensure ambulation, coughing, deep breathing, and turning can be performed.
An older adult patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this patient? 1 Check the chart for intraoperative complications. 2 Check the effectiveness of the analgesics received. 3 Check which medications were used for anesthesia. 4 Check the preoperative assessment for previous delirium or dementia.
Correct4 If the patient's airway, breathing, and circulation are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed, because these can all contribute to delirium.
The nurse is caring for a group of patients. What patient should the nurse be sure to institute interventions for the prevention of thrombophlebitis? 1 A patient with a 25-year smoking history 2 A female patient in the fifth month of pregnancy 3 An older adult patient taking anticoagulant medications 4 A hospitalized patient who has been on bed rest for 3 days
Correct4 Patients at highest risk for thrombophlebitis are those who stand, sit, or remain on bed rest for prolonged periods. Hypercoagulable states, such as pregnancy, and vessel wall trauma due to the effects of smoking also may place a person at risk for thrombophlebitis. An older adult patient taking anticoagulant medications would be at less risk for thrombophlebitis.
A postoperative patient develops fever, abdominal pain, and diarrhea despite being on long-term antibiotics. What should the nurse evaluate for? 1 Wound infection 2 Urinary infection 3 Respiratory infection 4 Clostridium difficile infection
Correct4 Prolonged use of antibiotics increases the risk of Clostridium difficile infection by damaging the normal flora of the intestine. The infection is manifested as fever, diarrhea, and abdominal pain. Wound infection, urinary infection, and respiratory infection may present with fever, but these infections rarely present with diarrhea and abdominal pain.
A patient with a history of psychosis has newly developed anxiety and is combative with the nurse. What does the nurse know may be causes of this change in behavior? 1 Delirium 2 Excessive sleep 3 Hyperoxygenation 4 Electrolyte imbalances
Correct4 The nurse knows electrolyte imbalances can cause an acute change in a patient's behavior. A new onset of anxiety and combativeness may cause delirium rather than the other way around. Sleep deprivation, not excessive sleep, would cause anxiety and aggression. Hyperoxygenation would not cause such behavior changes; hypoxemia does. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.
A patient is having elective cosmetic surgery performed on the face. The patient will remain at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? 1 Manage patient pain 2 Control the bleeding 3 Maintain fluid balance 4 Manage oxygenation status
Correct4 The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise the patient's ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase the risk for upper airway edema, causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action.
A patient is being discharged after having a laparoscopic cholecystectomy. The nurse should instruct the patient to notify the surgeon immediately if which condition develops? 1 Constipation 2 Right shoulder pain 3 Decreased appetite 4 Temperature of 103° F
Correct4 The primary health care provider should be notified immediately if the patient experiences an increase in temperature higher than 101° F because this may be indicative of an infectious process that will require immediate interventions to resolve. Right shoulder pain is expected after a laparoscopic surgery and is resolved within 48 to 72 hours. Constipation and decreased appetite may occur. If these do not resolve after discharge, the patient should be instructed to contact the primary health care provider.
A patient on the postoperative unit reports difficulty breathing. The nurse discovers that the patient received large doses of skeletal muscle relaxants during surgery. What should the nurse include in the patient's plan of care to promote breathing? 1 Administering opioids 2 Loosening the dressings 3 Repositioning the patient 4 Administering drugs for reversal of paralysis
Correct4 The use of skeletal muscle relaxants may paralyze the muscles required for breathing. Administering drugs for reversal of paralysis may make breathing easier. Use of opioids aggravates the condition by causing respiratory depression. Loosening the dressing and repositioning the patient are helpful when the breathing difficulty is caused by mechanical restriction but may not help in this case.