Operative Prep U's - scarlett
The nurse is aware that a religious group that refuses blood transfusions for religious reasons is:
Jehovah's Witnesses Explanation: Jehovah's Witnesses decline blood transfusions for religious reasons.
A client is having a surgical procedure that requires the client to be in the prone position. What is an expected client outcome?
The client remains free of perioperative positioning injury. Explanation: The potential for transient discomfort or permanent injury is present because many surgical positions are awkward. Hyperextending joints, compressing arteries, or pressing on nerves and bony prominences usually results in discomfort simply because the position must be sustained for a long period of time.
Following abdominal surgery, which factor predisposes a client to deep vein thrombosis?
The client will be immobile during and shortly after surgery. Explanation: Postoperative immobility and subsequent venous stasis predispose the client to deep vein thrombosis. Other predisposing factors for this condition include obesity and current pregnancy, which don't apply to this client. Exercise isn't a risk factor for deep vein thrombosis.
A perioperative nurse is conducting an in-service education program about maintaining surgical asepsis during the intraoperative period. Which of the following would the nurse emphasize?
The edges of a sterile package, once opened, are considered unsterile. Explanation: To maintain surgical asepsis, the edges of a sterile package, once opened, are considered unsterile. When moving around a sterile field, individuals must maintain a distance of at least 1 foot from the sterile field. If a tear occurs in a sterile drape, it must be replaced. Only scrubbed personnel and sterile items may come in contact with sterile areas. Circulating nurses can only contact unsterile areas.
The nurse is educating clients who require surgery for various ailments about the perioperative experience. What education provided by the nurse is most appropriate?
Three phases of surgery and safety measures for each phase Explanation: The perioperative period includes the preoperative, intraoperative, and postoperative phases. Specific safety guidelines are followed for all surgical clients. The information provided should be general enough to be informative about surgery and should not focus on individual surgeries, as all the clients are having different surgeries. Intraoperative techniques, expected pain levels, and pain medication are specific to the patient and type of surgery. The risks and benefits of the surgical procedure should be discussed by the physician.
The nurse is caring for a client during the immediate postoperative period and is assessing for signs of shock. What signs and symptoms indicate that the client may be in shock?
Weak and rapid pulse rate Explanation: Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock.
What is the major purpose of withholding food and fluid before surgery?
Prevent aspiration Explanation: The major purpose of withholding food and fluid before surgery is to prevent aspiration. Decreasing overhydration, decreasing urine output, and decreasing constipation are not major purposes of withholding food and fluid before surgery. Until recently, fluid and food were restricted preoperatively overnight and often longer. Currently, specific recommendations depend on the age of the client and the type of food eaten.
The perioperative nurse has a number of major responsibilities when a patient is admitted to a surgical unit or center. Which of the following is the most important function?
Verifies that operative consent is signed Explanation: All choices listed are essential but, without a signed consent form, surgery cannot occur.
Which of the following factors may contribute to rapid and shallow respirations in a postoperative client? Select all that apply.
-Pain -Constricting dressings -Abdominal distention -Obesity Explanation: Often, because of the effects of analgesic and anesthetic medications, respirations are slow. Shallow and rapid respirations may be caused by pain, constricting dressings, gastric dilation, abdominal distention, or obesity.
A nurse is writing a care plan for a client admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius?
Risk for Infection Explanation: The client has a significant risk for osteomyelitis and tetanus due to the fact that the fracture is open. Powerlessness and ineffective role performance are psychosocial diagnoses that may or may not apply, and which would be superseded by immediate physiologic threats such as infection. Surgical positioning injury is not plausible, since surgery is not likely indicated.
The nurse is teaching leg exercises to the client preoperatively. The client asks why the exercises are important. The best response by the nurse is:
"Leg exercises help prevent blood clots in your legs." Explanation: Leg exercises improve circulation of the lower extremities by preventing venous stasis, which can lead to deep vein thrombosis in the postoperative client.
A presurgical client asks, "Why will I go to the PACU instead of just going straight up to the postsurgical unit?" What is the nurse's best response?
"The PACU allows you to recover from the effects of anesthesia, and you'll stay in the PACU until you're oriented, have stable vital signs, and are without complications." Explanation: The PACU provides care for the client while he or she recovers from the effects of anesthesia. The client must be oriented, have stable vital signs, and show no evidence of hemorrhage or other complications. Clients will sometimes recover in the ICU, but this is considered an extension of the PACU. The PACU does allow the client to recover from anesthesia, but the environment is calm and quiet as clients are initially disoriented and confused as they begin to awaken and reorient. Clients are not usually placed in the medical-surgical unit for recovery and, although hospitals are occasionally short of beds, the PACU is not used for client triage. Incisions are very rarely modified in the immediate postoperative period.
A nurse is assessing a client who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?
Assess for a patent airway. Explanation: Postoperatively, the nurse assesses for a patent airway. The client's ability to manage secretions has a direct bearing on airway patency. However, airway patency is the overarching goal. This immediate physiologic need is prioritized over communication, though this is an important consideration. Infection is not normally a threat in the immediate postoperative period.
In which instance may a surgeon operate without informed consent?
Emergency situations Explanation: In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the client's informed consent.
What complication in the immediate postoperative period should the nurse understand requires early intervention to prevent?
Hypoxemia and hypercapnia Explanation: The primary objective in the immediate postoperative period is to maintain ventilation and thus prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Both can occur if the airway is obstructed and ventilation is reduced (hypoventilation). Besides administering supplemental oxygen (as prescribed), the nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds.
A 55-year-old patient arrives at the operating room. The nurse is reviewing the medical record and notes that the patient has a history of osteoporosis in her lower back and hips. The patient is scheduled to receive epidural anesthesia. Which of the following nursing diagnoses would be a priority for this patient?
Risk for perioperative positioning injury related to operative position Explanation: Although any of the nursing diagnoses might apply for this patient, the priority would be risk for perioperative positioning injury related to the patient's history of osteoporosis. The bone loss associated with this condition necessitates careful manipulation and positioning during surgery.
Select the nutrient that is important for postoperative wound healing because it helps form collagen.
Vitamin C Explanation: Vitamin C is important for capillary formation, tissue synthesis, and wound healing through collagen formation. Vitamin A decreases the inflammatory response in wounds. Magnesium is essential for wound repair, and protein allows collagen deposition.
The circulating nurse is admitting a client prior to surgery and proceeds to greet the client and discuss what the client can expect in surgery. What aspect of therapeutic communication should the nurse implement?
Use a tone that decreases the client's anxiety. Explanation: When discussing what the client can expect in surgery, the nurse uses basic communication skills, such as touch and eye contact, to reduce anxiety. The nurse should use language the client can understand. The nurse should not withhold communication until the client initiates dialogue; the nurse most often needs to initiate and guide dialogue, while still responding to client leading. Giving medication is not a communication skill.
Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective?
Vital signs within normal limits; absence of chills and cough Explanation: Pneumonia is characterized by chills, fever, tachypnea, tachycardia, and sometimes cough.
A client is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting "coffee-ground" like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the client most likely anticipate that the surgery will be scheduled?
Without delay because the bleed is emergent Explanation: Emergency surgeries are unplanned and occur with little time for preparation for the patient or the perioperative team. An active bleed is considered an emergency, and the patient requires immediate attention because the disorder may be life threatening. The surgery would not likely be deferred until after elective surgeries have been completed.
It is important for the nurse to assist a postsurgical client to sit up and turn the head to one side when vomiting in order to
avoid aspiration. Explanation: The nurse helps the client to sit up and turn the head to one side when vomiting in order to avoid aspiration. This does not maximize comfort and does not help to avoid dizziness. Encouraging the client to breathe deeply helps eliminate inhaled anesthetics.
In which phase of perioperative care will the nurse prepare the client's skin, encourage the client to void, and remove the client's dentures?
preoperative Explanation: Preoperative care begins with the decision to perform surgery and continues until the client reaches the operating area. During this time, the nurse will physically prepare the client for surgery, and nursing actions may include skin preparation, hair removal, and food and fluids management.
The circulating nurse is performing a skin preparation for a client who is unconscious from general anesthesia when the scrub nurse states, "I know her, she sure has gotten fat!" What is the best response by the circulating nurse?
"It is inappropriate to make comments even when clients appear to be unconscious from anesthesia." Explanation: Unintended intraoperative awareness refers to a client becoming cognizant of surgical interventions while under general anesthesia and then recalling the incident. Neuromuscular blocks, sometimes required for surgical muscle relaxation, intensify the fear of the patient experiencing awareness because they are then unable to communicate during the episode. The frequency of anesthesia awareness may be as high as 0.1% to 0.2% of general anesthesia patients, equivalent to about 30,000 cases per year in the United States.
A client has been transported to the operating room for emergent surgery. Which statement by the nurse best supports the need for emergent surgery?
"The client was unresponsive, had a distended abdomen, and had unstable vital signs after a motor vehicle accident." Explanation: Emergency surgery means that the client requires immediate attention and the disorder may be life threatening. A client with unstable vital signs and a distended abdomen after a motor vehicle accident requires immediate attention. A client with left abdominal pain may not need surgery. Epigastric pain with vomiting for 1 day is usually not an indication for emergent surgery. Lacerations to the face require sutures, not emergent surgery. A thyroidectomy to treat hyperthyroidism is a required surgery, not an emergent one.
The nurse is completing a preoperative assessment. The nurse notices the client is tearful and constantly wringing their hands. The client states, "I'm really nervous about this surgery. Do you think it will be ok?" What is the nurse's best response?
"What are your concerns?" Explanation: Asking the client about their concerns is an open-ended therapeutic technique. It allows the client to guide the conversation and address their emotional state. Asking about family support changes the subject and is not therapeutic. Discussing the surgical team and the low death rate associated with a procedure minimizes the client's feelings and is not therapeutic.
When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority?
-Impaired Gas Exchange -Fluid Volume Deficit -Altered Comfort -Anxiety -Risk for Infection Explanation: According to the Maslow's hierarchy of deeds, airway and gas exchange is of the highest priority. Next would be the deficiency in fluid volume. Altered comfort would be higher than anxiety because decreasing pain may alleviate/reduce anxiety. Lastly, a risk for diagnosis is not a current problem but an important teaching point to reduce the risk.
The operating nurse is caring for a patient who is receiving general anesthesia. Organize the nursing interventions in chronological order of the stages of general anesthesia, beginning with Stage I (1) and ending with Stage IV (4).
-Keep discussions about the client to a minimum. -Avoid auditory and physical stimuli. -Place client into operative position. -Prepare for and assist in treatment of cardiac and/or respiratory arrest. Explanation: In Stage I, the client is still conscious and aware of the environment. Therefore, discussions about the client should be kept to a minimum. Stage II is an excitement stage, whereby the client may present with varying behaviors and is susceptible to external stimuli. The nurse should avoid auditory and physical stimuli to facilitate smooth induction of the anesthesia. During Stage III, the client is unconscious and placed into the operative position. Stage IV is characterized by medullary depression and is a life-threatening situation. The nurse prepared for and assists in treatment of cardiac and/or respiratory arrest.
The nurse is providing preoperative care to a client who is anxious about total hip replacement surgery. "What if I can never walk again? I don't want to end up like my father!" What are some ways the nurse might help alleviate the client's anxiety? Select all that apply.
-Make sure the client understands what will happen during surgery. -Listen empathetically to the client's concerns about the procedure. -Review the client's postoperative goals following the procedure. -Ask the client if he would like to speak with a clergyperson. Explanation: Preparing the client emotionally and spiritually is as important as doing so physically. Anxiety and fear, if extreme, can affect a client's condition during and after surgery. Careful preoperative teaching and listening by the nurse about what will happen and what to expect can help allay some of these fears and anxieties.
An older adult has developed a sacral pressure ulcer. What should the nurse assess in order to ensure adequate wound healing and prevent poor outcomes for this client? Select all that apply.
-Nutritional status -Caloric intake -Quality of food ingested Explanation: Nutritional intake that supports a competent immune response plays an important role in reducing the incidence of infections; clients whose nutritional status is compromised have a delayed postoperative recovery and often experience more severe infections and delayed wound healing. The nurse must assess the client's nutritional status, caloric intake, and quality of foods ingested.
The nurse is caring for a client postoperatively from a spinal tumor resection. The nurse assesses that the client has partial paralysis. What anticipated problems should the nurse include in the client's care plan? Select all that apply.
-Risk for impaired physical mobility -Risk for injury -Risk for powerlessness -Risk for knowledge deficit Explanation: The change in the client's muscle strength will effect the client's ability to carry out activities that he or she was once used to being able to perform independently. Due to the partial paralysis, the client is now at risk for impaired physical mobility related to a decreased range of motion. The client is at risk for injury due to a possible unsteady gait. The development of partial paralysis is a loss for the client, and there is the potential for feelings of powerlessness related to inability to control situation and being dependent on others. It is not likely that the nurse has been able to accurately assess sexual dysfunction. Not all clients with partial paralysis experience sexual dysfunction because this is dependent on the extent of spinal injury or nerve compression. Given that teaching is needed, it implies that there is a knowledge deficit.
The nursing instructor is talking with her class about spinal anesthesia. What would be the nursing care intervention required when caring for a client recovering from spinal anesthesia? Select all that apply.
-Turn the client from side to side at least every 2 hours, if permitted. -Assist the client to a sitting position at the side of the bed. -Instruct the client to stay in bed until sensation and movement returns. -Monitor respiratory rate and sensation every 2 hours or as per ordered. Explanation: The client who has received spinal anesthesia should remain in bed until sensation and movement returns. Also, the respiratory rate and sensation must be monitored every 2 hours. If permitted, the nurse should turn the client from side to side at least every 2 hours. The client who has received spinal anesthesia should be permitted to sit. If client complains of a headache, the client should not be encouraged to increase activity. The client may have to remain lying flat for a longer period of time.
In the immediate postoperative period, vital signs are taken at least every
15 minutes. Explanation: Pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours.
A patient is scheduled to have a heart valve replacement with a porcine valve. Which patient does the nurse understand may refuse the use of any porcine-based product?
A patient of Jewish faith Explanation: Cultural, ethnic, and religious diversity are important considerations for all health care professionals. Nurses in the perioperative area should be aware of medications that may be prohibited by certain groups (e.g., Muslims and those of the Jewish faith cannot use porcine-based products [heparin (porcine or bovine)], Buddhists may choose not to use bovine products). The other faiths listed would not object to porcine-based products.
The on-call perioperative team is called for a surgery to be performed as soon as they arrive. What surgical procedure is considered emergent?
A repair of multiple stab wounds Explanation: Repair of multiple stab wounds is emergent. Removal of kidney stones is urgent. An exploratory laparotomy is required. A face lift is optional.
A client is scheduled for an invasive procedure. What priority documentation is needed regarding the procedure?
A signed consent form from the client Explanation: A signed consent is required and is important for initiating invasive procedures. The nurse should therefore check for the client's signed consent form. A health history, medication reconciliation, and postoperative prescriptions are good items to have but are not required before performing an invasive procedure.
The policies and procedures on a preoperative unit are being amended to bring them closer into alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most directly addresses the priorities of the SCIP?
Actions aimed at preventing surgical site infections Explanation: SCIP identifies performance measures aimed at preventing surgical complications, including venous thromboembolism (VTE) and surgical site infections (SSI). It does not explicitly address family participation, interdisciplinary collaboration, or CAM.
The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk?
Atelectasis Explanation: Atelectasis occurs when the postoperative client fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia occurs rarely and usually in situations where the client loses a significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the client is most at risk for atelectasis
Which is the least important issue concerning safety for the perioperative team before proceeding to the operating room?
Client's ambulatory aids Explanation: It is imperative that the entire perioperative team participates in verifying the client's identity, the correct surgical procedure, and the appropriate surgical site before preceding to the OR. The client's ambulatory aids are not an important safety concern before proceeding to the OR.
The nurse is assigned a client scheduled for an outpatient colonoscopy in an ambulatory care setting. During which phase of perioperative care would the nurse document the admission vital signs in the recovery room?
During the postoperative phase Explanation: The nurse realizes that documentation of vital signs in the recovery room begins the postoperative phase of perioperative care. The preoperative phase occurs until the client reaches the operating area. The intra operative phase includes the entire surgical procedure until the transfer to the recovery area. There is no transfer phase of perioperative care.
The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)?
Early ambulation Explanation: For clients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The client does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The client should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be given with warfarin because it will increase the client's risk for bleeding.
Prior to a client's scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the client's care. What is the main rationale for organizing perioperative care in this collaborative manner?
Evidence-based practice Explanation: Collaboration of the surgical team using evidence-based practice tailored to a specific case results in optimal client care and improved outcomes. None of the other listed factors is the basis for the collaboration of the surgical team.
The perioperative nurse has completed the presurgical assessment of an 82-year-old female client who is scheduled for a left total knee replacement. When planning this client's care, the nurse should address the consequences of the client's aging cardiovascular system. These include an increased risk of which of the following?
Hypervolemia Explanation: The aging heart and blood vessels have decreased ability to respond to stress. Reduced cardiac output and limited cardiac reserve make the elderly client vulnerable to changes in circulating volume and blood oxygen levels. There is not an increased risk for hypopnea, hyperkalemia, or hyperphosphatemia because of an aging cardiovascular system.
A client with a skull fracture after falling from a ladder requires surgery. The nurse should anticipate transporting the client to surgery during what time frame?
Immediately Explanation: Emergent surgery occurs when the client requires immediate attention. A fractured skull is an indication for emergent surgery. An urgent surgery occurs when the client requires prompt attention, usually within 24-30 hours. Any surgery scheduled beyond 30 hours is classified as required or elective; a fractured skull does not meet the requirements for elective or required surgery.
A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery?
Leg exercises improve circulation and prevent venous thrombosis. Explanation: Exercise of the extremities includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side) unless contraindicated by type of surgical procedure (e.g., hip replacement). When the client does leg exercises postoperatively, circulation is increased, which helps to prevent blood clots from forming. Leg exercises do not prevent pressure sores to the sacrum, or increase the client's level of consciousness. Leg exercises have the potential to increase strength and mobility, but are unlikely to make a change to muscle mass in the short term.
Which action should not be allowed when wearing masks in the operating room?
Letting masks hang around the neck Explanation: Masks are changed between clients and should not be worn outside the surgical department. Masks should fit tightly and cover the nose and the mouth completely. The mask must be either on or off; it must not be allowed to hang around the neck.
A client has undergone surgery to repair a hernia, with no complications. In the immediate postoperative period, which action by the nurse is most appropriate?
Monitor vital signs every 15 minutes Explanation: Pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours immediately after surgery. Obtaining an arterial blood gas measurement every 5 minutes would be painful to the client unless a special device is inserted to obtain arterial blood samples. With no complications, this is not indicated for this client. Urinary output is monitored frequently, usually hourly. While it may be necessary to assess pupillary response during the immediate postoperative phase, it does not need to be done every 5 minutes.
During the admission history the client reports to the nurse of taking the usual dose of warfarin the previous day. What is an appropriate nursing action?
Notify the surgeon that the client took warfarin the day before surgery. Explanation: Warfarin (Coumadin), an anticoagulant, places the client at risk for excessive bleeding during the intraoperative and postoperative periods.
Regarding the surgical client, which phase refers to the period of time that spans the entire surgical experience?
Perioperative Explanation: Perioperative period includes the preoperative, intraoperative, and postoperative phases. The preoperative phase is the period of time from when the decision for surgical intervention is made to when the client is transferred to the operating room. The intraoperative phase is the period of time from when the client is transferred to the operating room to when he or she is admitted to the postanesthesia care unit. The postoperative phase is the period of time that begins with the admission of the client to the postanesthesia care unit and ends after a follow-up evaluation in the clinical setting or home.
The nurse has administered preanesthetic medication. What action should the nurse take next?
Place the client on bed rest with the side rails up. Explanation: Preanesthetic medication can make the client lightheaded and dizzy. Safety is a priority, so the client should remain in bed with the side rails up. The consent form should be signed before the client is medicated. Consents signed after the client is medicated are not legal. Reviewing the home medications and educating the client should take place before the client is medicated.
What intervention by the nurse is most effective for reducing hospital-acquired infections?
Proper hand-washing techniques Explanation: Efforts to prevent wound infection are directed at reducing risks, such as thorough hand washing. (Preoperative and intraoperative risks and interventions are discussed in Chapters 17 and 18.) Postoperative care of the wound centers on assessing the wound, preventing contamination and infection before wound edges have sealed, and enhancing healing.
The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the client do?
Stand upright for 2 to 3 minutes prior to ambulating. Explanation: Older adults are at an increased risk for orthostatic hypotension secondary to age-related changes in vascular tone. The client should sit up and then stand for 2 to 3 minutes before ambulating to alleviate orthostatic hypotension. The nurse should assess the client's ability to mobilize safely, but full assessment of range of motion in all joints is not normally necessary. Sitting in a chair and increasing fluid intake are insufficient to prevent orthostatic hypotension and consequent falls.
The nurse is educating a client scheduled for elective surgery. The client currently takes aspirin daily. What education should the nurse provide with regard to this medication?
Stop taking the aspirin 7 days before the surgery, unless otherwise directed by your physician. Explanation: Aspirin should be stopped at least 7 to 10 days before surgery. The other directions provided are incorrect.
The perioperative nurse is constantly assessing the surgical client for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the client is developing malignant hyperthermia?
Tachycardia Explanation: The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. Tachycardia (heart rate greater than 150 beats per minute) is often the earliest sign. Oliguria, hypotension, and increased temperature are later signs of malignant hyperthermia.
The nurse is caring for a client during an intra operative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?
Temperature of 102.5°F (39°C) Explanation: Intra operative hyperthermia can indicate a life-threatening condition called malignant hyperthermia. The circulating nurse closely monitors the client for signs of hyperthermia. The pulse rate, respiratory rate, and blood pressure did not indicate a significant concern.
The nurse is caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock?
Weak and rapid pulse rate Explanation: Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock.
The nurse is assigned to a group of clients and will be providing education to all of them. The client most in need of teaching is the client who
is to perform daily foot checks as a result of diabetes Explanation: People who have a chronic illness, as in diabetes, and/or a disability are among those most in need to health education. These people need health education to participate and assume responsibility for their own self-care which can help them adapt to their chronic illness, prevent complications, continue prescribed therapy, solve problems, prevent crisis situations, and reduce the potential for rehospitalization. The other clients have temporary conditions - one is postoperative, another has iron deficiency anemia, and the third has a urinary tract infection.
