EAQ Chapter 41 & 14

Five days after surgery, a patient calls the nurse and states that the wound is bleeding. After assessing the wound of the patient, the nurse notes that there is no drainage on the bandage at that time. What other sign may indicate that the patient's wound is bleeding?

Rapid thready pulse. If hemorrhage results internally, the dressing may sometimes remain dry while the abdominal cavity collects blood. The nurse should be attuned to less obvious signs of internal bleeding including restlessness, rapid thready pulse, decreased blood pressure, decreased urinary output, and cool and clammy skin. Even respirations are normal. The urinary output decreases and the blood pressure decreases when a patient is hemorrhaging.

The nurse is instructed to clean a patient's wounds using a wetting agent that does not delay the healing process. On the basis of this description, which wetting agent would the wound specialist tell the nurse to avoid?

Acetic acid.

The nurse is obtaining information regarding a patient's medication use before abdominal surgery. Which medication, if listed by the patient, would most concern the nurse?

Aspirin

Which is an accurate statement regarding the older adult facing surgery?

Disorientation or toxic reactions can occur in the older adult after the administration of anesthetics, sedatives, or analgesics.

Which statement is true regarding preoperative teaching?

Preoperative information helps lessen anxiety, reduce the amount of anesthesia required, decrease postoperative pain, and reduce corticosteroid production.

The nurse observes that an area of skin on an elderly patient has reddened. What dressing is the nurse likely to place on the wound?

Transparent dressing.

The nurse is caring for a patient who just underwent right hip replacement. The nurse would be most concerned with preventing which postoperative complication?

Embolus.

While inspecting a patient's wound, the nurse observes that the skin around the wound has softened and is broken. What does this finding indicate about the patient's wound?

It was covered with an occlusive dressing. The softening and breaking of the skin are indicative of maceration. This usually happens because of excessive moisture around the wound. An occlusive dressing prevents air from reaching the wound and keeps the wound moist, which may cause maceration. Dry or gauze dressings allow the passage of air through pores present on the dressing. These dressings do not make the wound moist and they can prevent maceration. Exposing the wound to open air for a long time may cause bacterial infection, which is characterized by the presence of pus.

During the preoperative assessment, the nurse learns the patient has an allergy to bananas. The nurse should be concerned about an allergy to which substance commonly used during surgery?

Latex. An allergy to bananas increase the patient's risk for an allergic reaction to latex, which is commonly used in surgery. This patient is not at an increased risk for an allergy to iodine, betadine, or penicillin.

A young teen with an incision calls the nurse. The patient states to the nurse, "I feel like something gave way in my wound." The nurse assesses the patient and suspects a possible wound dehiscence. What should the nurse do first?

Place a warm, moist sterile dressing over the area.

An emergency room nurse admits a patient with a wound to the sacral area. What data if obtained during the physical assessment indicate that the patient's wound is infected?

Foul odorous purulent drainage. The CDC (Centers for Disease Control and Prevention) labels a wound infected when it contains purulent drainage. The patient also has fever, tenderness and pain at the wound site, edema, and an elevated white blood cell (WBC) count. A wound that has approximated edges, has no tenderness or edema, and lacks foul odorous purulent discharge is free of infection.

While caring for a patient, the nurse finds that the patient's wound dressing has become yellow in color. What parameter does the nurse assess further to diagnose the abnormality?

Leukocyte count. Yellow discharge on a bandage implies purulent discharge, which is caused by infection. During acute infections, the leukocyte count increases; therefore, to confirm the presence of infection, the nurse should check the patient's leukocyte count. Decreased zinc and vitamin A concentrations cause a reduced healing process, but these do not indicate the presence of infection. An increased platelet count is characterized by thrombosis. Therefore, it is not necessary to check zinc concentration, vitamin A concentration, or platelet count to identify the presence of infection.

The primary health care provider instructs the nurse to administer preoperative medication before transferring a patient to the surgical suite. Which interventions does the nurse implement after administering the medication? Select all that apply.

The nurse provides a quiet environment. The nurse places the bed in a low position. The nurse raises the side rails of patient's bed. The nurse monitors the patient every 15 to 30 minutes. The patient may experience mild discomfort after receiving the preoperative medication. Therefore, the nurse supports the patient by providing a quiet environment. The patient may experience drowsiness or vertigo, so the nurse places the bed in a low position to prevent falls. The side rails of the bed are also raised to provide safety from falls. The nurse monitors the patient every 15 to 30 minutes to ensure that there are no complications. The nurse encourages the patient to void before administering the medications as the patient needs to be in bed after the medications are given.

Which statement is true regarding preoperative medication?

The preoperative phase is the optimal time to introduce the concept of patient-controlled analgesia (PCA) to the patient. An introduction to PCA preoperatively is advantageous because the patient is better able to comprehend the concept and operation of the equipment. After receiving preoperative medication, the patient must remain in bed. The nurse institutes safety procedures, such as keeping the bed in low position and the side rails up and monitoring the patient every 15 minutes until the patient leaves for surgery. The patient who has received an opioid analgesic usually requires a smaller amount of anesthetic once in surgery. Surgery cancels all medications prescribed before surgery except for conditions of long-standing duration, such as Dilantin for seizure control. The surgeon will represcribe medication as necessary after surgery.

What is the nurse's first step when caring for a patient needing wound care?

Checking the medical record for the primary health care provider's prescriptions. Checking the medical record for the primary health care provider's prescriptions provides the basis for care and verification by the nurse. Many nursing interventions require a primary health care provider's prescription. Washing hands is important, but not necessary until entering the room. Explaining the procedure is necessary once the nurse is ready to provide wound care. Assembling all equipment and supplies would be necessary once the nurse has verified what kind of treatment is needed

A nurse has just completed irrigation of a wound and will need to apply a transparent dressing. What should the nurse do to ensure that the dressing will adhere to the wound?

Dry skin thoroughly before applying dressing. Transparent dressings with adhesive backing do not adhere to damp surfaces. The dressing has an adhesive backing, and no tape or binder is needed. Gauze is not placed over the transparent dressing.

The nurse is teaching controlled coughing to a patient after abdominal surgery. Which is a priority action that should be taught in this case?

Splint the surgical incision with hands.

The nurse is providing educational packets to a patient before gallbladder removal surgery. What question should the nurse ask to determine if the patient can read and understand the material presented?

"Can you please tell me, in your own words, what you're reading in this packet?" The nurse should ask the patient to present, in his or her own words, the information in the packet. If the patient cannot read, he or she is unlikely to admit it. Therefore asking the patient if he or she can read or understand the packet would be unhelpful. Although the patient may be able to read what he or she sees in the packet, this is not the same as understanding what is in the packet.

Immediately after an injury, the wound healing process begins and follows the same pattern. Place the following phases of wound healing in the correct order.

1. Hemostasis phase 2. Inflammatory phase 3. Reconstruction phase 4. Maturation phase Hemostasis begins as soon as the injury occurs. The inflammatory phase follows 24 to 48 hours later. Reconstruction begins on the third or fourth day and lasts for 2 to 3 weeks. The maturation phase begins approximately 3 weeks after injury.

A nurse has just finished placing the vacuum-assisted closure (VAC) device to a patient's wound. What amount of pressure should the nurse administer?

5 to 200 mm Hg Administration of intermittent or continuous negative pressure between 5 mm Hg and 200 mm Hg is acceptable according to health care provider prescription or patient comfort. The average is 125. Any value above 200 is inappropriate.

Which factors influence a patient's ability to tolerate a surgery? Select all that apply.

Age Physical condition Nutritional factors Children and elderly patients do not tolerate major surgical procedures well because their rate of metabolism is slower than adults. Therefore, they have a slower response to physiologic changes. Patients who have good overall general health have smoother and faster recovery periods than patients with existing health problems. Patients who have a sound nutritional diet recover faster. Culture does not affect a patient's ability to tolerate surgery, as recovery depends on biological factors and proper nutrition. Education is not related to a patient's ability to tolerate surgery.

A nursing student has been asked to order a tray for a patient with an open wound. Which tray should be ordered to provide the patient with adequate nutrition that will promote wound healing?

Baked fish, legumes, spinach, strawberries, and decaffeinated tea.

During the preoperative assessment, the nurse learns that the patient takes ginger for intestinal gas. Which preoperative test would the nurse anticipate because of this medication?

Blood clotting time The nurse should anticipate that blood clotting studies will be performed because ginger can increase clotting time and increase the risk for bleeding. An electrocardiogram was likely performed before surgery to determine a baseline and would not be affected by the ginger. Blood levels of ginger would not be tested. Orthostatic blood pressure measurement is not indicated at this time.

A preceptor is instructing a graduate nurse on the management of a vacuum-assisted closure device (wound VAC). What information should the preceptor stress to the graduate nurse?

Care must be taken to remove all materials from the wound. During dressing changes, care must be taken to remove all sponges and remnants from the wound. Material left on the wound may cause delays in healing and abscess formation. That the schedule for changing the device varies, the device applies negative pressure, and the device is used for acute and chronic wounds are important points for the graduate nurse to understand, but removing all material from the wound is the information that must be stressed to the nurse because it can affect the healing process.

A patient is assessed 30 minutes after a cholecystectomy (gallbladder removal), and 2 mL of drainage is noted in the Jackson-Pratt drainage system. After 3 hours the nurse notices that there has been no additional drainage and the patient is complaining of severe pain. What action should the nurse complete first?

Check the drainage system for kinks. A drainage system requires close monitoring. In addition to noting the color, consistency, and amount of drainage, it is important to check the tube's patency. Do not allow a tube to become kinked or occluded. The vital signs should be taken, and the patient medicated if needed; however, the nurse should check the patency of the tube first. If the patient's condition worsens, the primary health care provider should be notified.

A nurse is caring for a patient with a wound on the right arm. The wound is covered by a bandage. What would be the priority nursing assessment when inspecting the skin that is distal to the bandage?

Circulatory impairment.

A nursing professor asks the student what is the purpose of the vacuum-assisted closure device. What response should the student give?

It reduces edema and increases circulation. The vacuum-assisted closure device or wound VAC applies negative pressure to wounds. Healing of the wound is facilitated by an increase in blood flow, improved or increased fluid drainage, and enhanced wound closure as the pressure draws the edges of the wounds together. The use of negative pressure removes fluid from the area, decreases edema, and, as a result of decreased edema, increases blood flow. The blood flow is increased and not reduced. Bacterial count is reduced, and the VAC uses negative pressure and not positive pressure to heal.

The nurse observes that bacterial infection at the site of a wound has caused exudate to drain from the wound. What effect does the nurse expect?

It will slow the healing process. A bacterial infection of the skin causes fluid to drain from the wound. This slows the healing process. It will not quicken the healing process or cause intense pain in the patient. It will also not lead to hypovolemic shock as there is no internal hemorrhage.

The nurse is performing an initial assessment of a patient who just returned from surgery. The nurse notes bright red on the surgical dressing. What is the best action on the part of the nurse?

Outline the bloodstain in permanent marker and reassess frequently. Occasionally the patient will return from surgery with bloody drainage on the surgical dressing. The nurse should outline the drainage in permanent marker and reassess frequently. If the spot increases, the nurse should contact the primary health care provider. In general, the first dressing change is performed at a predetermined time by the surgeon; it is inappropriate for the nurse to change the dressing at this time. It is not necessary to call the primary health care provider and prepare the patient to return to surgery at this time.

A bandage is applied to the left arm of a patient. When the nurse assesses the patient's arm, it is cool to touch; the pulse is diminished, and the arm appears slightly blue. What should the nurse's immediate intervention be?

Readjust the bandage immediately. After a bandage is applied, the nurse must assess, document, and immediately report changes in circulation. The skin of the underlying body parts is distal to the bandage for coolness, pallor, cyanosis, diminished or absent pulse, and tingling or numbness. When applying a bandage it is acceptable to loosen and readjust as needed. Coolness, diminished pulse, and a blue color (cyanosis) indicate there is a circulatory impairment. Therefore the bandage must be readjusted immediately to prevent damage to the arm. Tightening the bandage will further compromise circulation. The arm may be placed in the sling, but the pressure needs to be relieved to reestablish circulation. Passive range-of-motion exercises will not eliminate the pressure that is causing the circulatory impairment.

The medical team has arrived to take the patient to surgery. Which observation, if made by the nurse, would prompt the nurse to, "stop the line" and prevent the patient from being taken to surgery?

The site for the surgery has not been marked.

Which is the true statement regarding informed consent?

The witness to the signing of a consent form verifies only that this is the person who signed the consent and that it was a voluntary consent. The witness to the signing of a consent form verifies only that this is the person who signed the consent and that it was a voluntary consent. The witness (often a nurse) is not verifying that the patient understands the procedure. Informed consent occurs when the surgeon discusses the surgical procedure, risks, and alternatives with the patient. Consent should not be obtained if the patient is disoriented, unconscious, mentally incompetent, or, in some agencies, under the influence of sedatives. If the patient's life is in danger and the family members cannot be located, the surgeon may legally perform surgery.

Three weeks after surgery, an African American patient comes to the clinic for follow-up. The nurse notices an overgrowth of scar tissue at the site. Which conclusion would be an accurate nursing evaluation of the finding?

This may be normal for this patient

The nurse is demonstrating how to care for a wound to a group of students. The nurse dresses the wound after cleaning it with warm water. What is an appropriate reason for the dressing? Select all that apply.

To protect the wound To absorb drainage To reduce discomfort

The nurse is caring for a patient who has undergone an appendectomy. While inspecting the patient's wound dressing, the nurse finds that the gauze is bright red in color. What does the nurse infer from this observation?

The patient's sutures have ruptured. The nurse should inspect the dressings of a postsurgical patient every hour for the first 4 hours after the procedure. This helps the nurse to identify any problems in the wound healing process. The presence of bright red gauze indicates that the patient has bleeding, which may be due to the rupture of sutures. The presence of blood is not indicative of normal wound healing. The gauze could be pale red if serum oozed from the sutures. Infected sutures are characterized by the presence of pus, and the gauze would appear yellow in color.

The nurse is caring for a postoperative patient. What measures does the nurse take to prevent venous stasis and thrombus formation in the patient? Select all that apply.

Encourages early ambulation Applies graded compression stockings. Encourages patient to perform leg exercises.

What should the nurse do to help prevent respiratory complications in a patient postoperatively?

Help the patient ambulate within a few hours of surgery, unless contraindicated Ambulation within a few hours of surgery helps return cardiovascular and respiratory functions to normal more quickly. Because coughing increases intracranial pressure, it is usually contraindicated in cranial-related and spinal-related surgeries. It is also contraindicated after cataract surgery. The nurse should encourage the patient to use the incentive spirometer device 8 to 10 breaths every hour. The best time to teach the patient about the incentive spirometer is in the preoperative phase.

The nurse is performing a preoperative assessment on a patient and notes that the patient appears anxious. The nurse understands that preoperative anxiety can have which effect on the patient postoperatively?

Increased recovery time. Anxiety before surgery can lead to increased length of recovery after surgery, increased pain medication requirements, and increased anesthesia needs. Preoperative anxiety has not been shown to increase risk for hemorrhage.

A patient is scheduled for surgery. The patient is being prepared to receive medication. Which actions does the nurse perform before starting the treatment? Select all that apply.

Measure the patient's vital signs. Ask the patient to use the bathroom. Ask the patient to sign a consent form. Vital signs should be measured to evaluate the patient's stability. All nursing care measures such as assisting the patient to the bathroom should be completed before the patient receives any premedication. The patient must sign a consent form before receiving any medications. Surgery cannot be legally or ethically performed until the patient understands the need for a procedure, the steps involved, risks, expected results, and alternative treatments. Coughing exercises should be taught in the preoperative period. It is not an action to be done before staring premedication. Asking for family history is irrelevant before starting premedication.

A patient with a large wound cries during sterile dressing changes because of severe pain. What is the best measure for the nurse to implement in an effort to improve patient comfort?

Medicate the patient 30 minutes before the dressing is to be changed.

The nurse is preparing to care for a patient who has undergone cardiothoracic surgery. During the immediate postoperative period, the nurse should assess which area of the skin for pressure-related breakdown?

Occipital skull The patient undergoing cardiothoracic surgery is on his or her back on a hard surface for an extended period of time. Therefore the patient should be assessed for skin breakdown on the occiput, olecranon, calcaneus, sacrum, coccyx, and other dependent areas. This patient would not be at risk for breakdown on the patella, ventral foot, or anterior pelvis.

A patient is 3 days postoperative after abdominal surgery. Which conditions would the nurse assessing the abdominal incision consider normal? Select all that apply.

Staples or sutures intact Clean, well-approximated edges A small amount of serous drainage Clean, well-approximated edges; intact staples or sutures; and a small amount of serous drainage are all normal assessment findings. A foul-smelling odor is an abnormal condition and a sign of infection. No tissue should be protruding when the patient coughs.

The nurse is assessing gastrointestinal function in a postoperative patient. Which assessment finding will indicate that there is normal peristalsis?

There are 5 to 30 gurgles in the abdomen per minute. If the nurse hears 5 to 30 gurgles in the abdomen per minute it indicates that the patient has normal peristalsis and the patient can consume foods and fluids. An absence of bowel sounds may indicate a decrease in or absence of intestinal peristalsis which needs to be reported immediately. Ability to turn every two hours will not indicate that the patient has normal gastrointestinal function but the turning exercise aids gastrointestinal functioning. Experiencing flatus after consuming food indicates intestinal gas which is relieved by limiting iced beverages and offering warm liquids.

The nurse is caring for a patient 6 hours after arrival on the floor after an appendectomy. The nurse notes the patient has not urinated since before the surgery. What should the nurse do first?

Encourage fluid intake Anesthesia can lead to urinary retention, so it is important to monitor the patient's urine output. If the patient has not urinated 8 hours after surgery, the nurse should palpate for urinary retention and alert the primary health care provider. However, this patient only returned from surgery 6 hours ago, so the appropriate action is to encourage oral fluid intake. It may be necessary to catheterize the patient, but this requires a primary health care provider prescription and is not appropriate at this time.

The nurse is dressing a chronic wound. What type of dressing is the nurse most likely to use?

Foam dressing. Foam dressings keep the wound moist and insulate it from external contamination. They also absorb drainage. They are therefore used for chronic wounds that take a long time to heal. Hydrocolloid dressings cannot absorb excess drainage. Surgical pads are used to cover small gauze dressings. Transparent film dressings are used for superficial wounds.

The nurse is caring for a patient who will have surgery in 3 hours, and the patient's morning medications are due now. Although most medications will be held before surgery because the patient has a prescription for nothing by mouth (NPO), the nurse anticipates administering which medication(s)? Select all that apply.

Oral phenobarbital Intravenous morphine Oral digoxin (Lanoxin) The nurse would plan to administer oral antiseizure and cardiac medications with a small sip of water the morning of the surgery. Intravenous morphine would be given to manage pain because this is not a PO medication. Although the enoxaparin (Lovenox) is a subcutaneous medication, it would most likely be held the day of the surgery because of an increased risk of bleeding during the operation. Oral multivitamins would be held before the surgery.

A postsurgery patient with an abdominal incision has been complaining of discomfort because of coughing. Which technique should the nurse instruct a patient to use when coughing?

Tell the patient to place the palms of the hands or a pillow over the incision and cough. If coughing occurs, apply a pillow, rolled bath blanket, or palms of the hands to the incisional area to lessen intraabdominal pressure; this technique is called splinting. Having the patient lie flat and cough forcibly may lead to wound dehiscence. Leaning forward with the head to the knees and assuming the prone position will be very uncomfortable for the patient as well as causing additional injury to the suture line.

The nurse on the preoperative floor is asked to act as witness for the signing of the surgery consent form. The nurse knows that by providing the signature, the nurse is verifying which information?

The consent was voluntary. The witness verifies only that the consent was voluntary and the identity of the person signing the form. It is the surgeon's responsibility to determine the patient's competency, education, and understanding before having the patient sign the form.

A preceptor is assisting a nursing student who is changing a sterile dry dressing. What intervention by the nursing student would indicate additional teaching is needed?

The student nurse cleans the wound from the outer skin to the incision using one swab. The wound should not be cleansed from the outside skin inward, but from the incision moving outward, using one swab per stroke. This aids in removing bacteria from wound areas. Skin outside of the wound is considered dirty. Wearing gloves during the procedure, performing hand hygiene before changing the dressing, and cleaning from the wound outward are correct and indicate no additional teaching is needed.

The surgeon asks the nurse to apply an abdominal binder on a patient after surgery. What is the function of the abdominal binder? Select all that apply.

To decrease tension around the wound To hold the dressing in place To provide comfort to the patient Binders are elasticized fabric bands used to decrease the tension around a wound or a suture line. Abdominal binders are placed on abdominal incisions. They make it easier for the patient to breathe deeply or cough because they hold the dressing in place. Binders support the dressing and provide comfort to the patient. Binders do not help the patient breathe slowly as they do not affect the patient's breathing. The abdominal binder is not designed to help a patient lose weight.

A nurse is concerned about a patient with fragile skin. What action will decrease trauma to the skin surrounding the wound?

Using the thumb to retract skin away from the tape. Using the thumb to retract the skin from the tape minimizes skin trauma and decreases patient discomfort. Removing the bandage slowly may not prevent trauma to the skin. Unless prescribed, petroleum jelly is usually not applied to the skin. Alcohol may be irritating to the skin.

The nurse is caring for a patient who has undergone an appendectomy. The nurse observes that the patient has difficulty coughing. Which suggestion given by the nurse would help the patient to cough effectively during this recovery period?

"Use a pillow to support the incisional site while coughing." Patients who have undergone abdominal surgery have difficulty coughing because of increased intra-abdominal pressure. Therefore, the nurse should suggest the patient apply a pillow to the incisional area because it provides support (like a splint) and reduces pain caused by intra-abdominal pressure. Breathing exercises do not help reduce the pressure or the urge to cough. The patient may have trouble doing breathing exercises because they cause stress on the abdominal muscles. Placing a pillow below the neck may cause choking due to obstruction of the passage of fluids. Gargling produces stress on the abdomen, so this should not be suggested as a way to help the patient cough more effectively.

Which are true statements regarding medications and surgery? Select all that apply.

A seriously ill patient may receive as many as 20 medications in a perioperative setting at one time. Review of the patient's current medication regimen is essential to promote a safe surgical outcome. The patient's chart should be "flagged" to alert all health care providers to the patient's allergy status. Medications that have anticoagulant effects should be discontinued before surgery, according to surgeon's instructions. Review of the patient's current medication regimen is essential; the use of multiple medications predisposes patients to adverse drug reactions and interactions with other medications. Numerous medications may be given in the perioperative setting. The patient's chart should be "flagged" to alert all health care providers to the patient's allergy status; the patient with a history of allergic responsiveness has a greater potential for demonstrating hypersensitivity reactions to anesthetic agents. Patients should discontinue all anticoagulants before surgery according to surgeon's instructions. Herbal remedies and dietary supplements should be included in the patient's medication review; even though they are natural, they act like medications and may interact or potentiate other medications or interfere with surgical procedures.

The nurse observes that a burn wound in an elderly diabetic patient is taking a longer time to heal than a similar wound in a 10-year-old child. What factors are known to cause delayed healing? Select all that apply.

Age Chronic illness Age, infection, nutrition, and chronic illness are factors that affect the healing of wounds. Young children and adults have improved metabolism and heal more quickly than elderly patients. Patients with a chronic illness such as diabetes take a longer time to heal due to decreased metabolism. A wound free from infection heals faster; proper nutrition also helps the healing process. But in this case, age and illness are causing a delay in wound healing. Affect, body mass and physique do not affect wound healing.

A patient's lab reports indicate reduced bone marrow function and a decreased white blood cell count. After reviewing these reports, the nurse suspects that these symptoms are side effects of a particular medicine. Which medication was the patient most likely taking?

Chemotherapy medication. Chemotherapy medications destroy rapidly dividing cancer cells but also reduce the function of bone marrow and decrease the white blood cell count by inhibiting cell division. Antibiotic medications destroy bacteria but do not affect the function of bone marrow. Antihistamines act by inhibiting the actions of histamine. Anti-inflammatory medications reduce inflammation in tissues throughout the body and may suppress protein synthesis, wound contraction, and inflammation. These medications do not, however, affect the function of bone marrow or white blood cell count.

What is a routine type of sedation that might be used for a surgical procedure that does not require complete anesthesia but rather a depressed level of consciousness?

Conscious sedation Conscious sedation is a routine type of sedation that might be used for a surgical procedure that does not require complete anesthesia but rather a depressed level of consciousness. A patient under conscious sedation must independently retain a patent airway and airway reflexes and be able to respond appropriately to physical and verbal stimuli. Local anesthesia involves loss of sensation at the desired site. The anesthetic agent can be injected or applied topically. Bier block, also known as intravenous regional anesthesia, is when an anesthetic agent is injected via an intravenous (IV) line into an extremity below the level of a tourniquet after blood has been withdrawn. Regional anesthesia results in loss of sensation in an area of the body. The method of induction influences the portion of sensory pathways that is anesthetized.

A few days after a patient's abdominal operation, the nurse observes an increase in the flow of serosanguineous drainage into the wound dressing. What immediate risk to the patient will the nurse assess?

Dehiscence. Dehiscence is the spontaneous opening of the incision a few days after the operation. Obesity, poor nutrition, excessive coughing, and multiple trauma are some of the risk factors that may cause dehiscence. If the nurse observes an increase in the flow of serosanguineous drainage (a mixture of serum and blood) into the dressing, it indicates impending dehiscence. Hematoma is the pooling of blood under the skin. Internal hemorrhage is indicated by swelling around the wound. Sloughing is the shedding of dead tissue

The nurse observes that there is swelling at the intravenous site in a postoperative patient. The nurse also finds that the site is cool to the touch. What does the nurse suspect?

IV infiltration Swelling at the intravenous site which is also cool to touch indicates that the IV solution has become infiltrated. Infiltration may occur because of movement or inadvertent dislodgment of the needle when the patient ambulates. Dehydration may be seen in the patient if the patient's fluid intake and output has reduced considerably. Fluid overload may be indicated if there is swelling in the legs and arms. Difficulty in breathing, anxiety, and pale skin are symptoms of pulmonary edema.

The nurse is caring for a diabetic patient who has injuries due to an accident. The nurse finds that the patient has delayed wound healing. What food does the nurse suggest to the patient to promote faster wound healing?

Oranges. Vitamin and nutrients play a major role in the process of wound healing, and vitamin C is particularly helpful. Vitamin C maintains tissue integrity and enhances the process of wound healing. Therefore, the nurse should suggest the patient eat fruits that contain vitamin C, such as oranges. Fruits such as apples, peaches, and watermelon do not contain large amounts of vitamin C, so they may be less helpful in promoting wound healing.

A nurse has to complete a dressing change on a patient. What essential information should be documented in the chart after the dressing change? Select all that apply.

Patient's response Status of the wound Location of the wound Type of dressing applied After a dressing change, document the location of the wound, status of the wound, and description of the exudate or drainage. In addition, document the dressing applied and any teaching and any response to therapy. The patient's level of consciousness and medication may be documented, but these are usually not addressed during wound care.

The nurse is preparing to care for a patient who has just returned from major abdominal surgery. Which intervention by the nurse in the immediate postoperative period will best prevent cardiovascular complications?

Place sequential compression devices (SCDs) on the patient's legs. In the immediate postoperative period, the nurse should place the SCDs on the patient's legs to promote venous blood return while the patient is immobile. Although the patient should ambulate as soon as possible, this is not the best action in the immediate postoperative period. Turning, coughing, and deep breathing are important interventions for the respiratory system. The nurse should facilitate the movement of the patient's arms and legs, not restrict it.

A postsurgical mastectomy patient has a bandage on the left breast. To assess if the patient is bleeding, which measure should the nurse take?

Place the hands under the patient to assess for flowing blood. To prevent undetected hemorrhaging, the nurse must inspect the dressing or incision and the area under the patient. Exudate follows the flow of gravity; therefore depending on the contour of the body, the dressing remains dry even though blood and exudates are flowing under the body. Placing the hands under the patient will reveal blood that has flowed backward under the patient. Assessing the corners of the gauze will not reveal hidden blood. The original dressing is usually removed by the primary health care provider. Weighing the bandage is not feasible. Topics

A patient has come to the postanesthesia care unit (PACU) after hip replacement surgery. After the nursing assessment, the health care team needs to set up a plan of care. What would the nurse anticipate to be the highest priority nursing concern?

Skin integrity

The nurse is caring for a patient 12 hours after abdominal surgery. How can the nurse best facilitate controlled coughing in the postoperative patient?

Teach the patient to splint the incision with a pillow to help prevent pain. The nurse should teach the patient to splint the incision to prevent pain and protect the incision while coughing. The patient should not prevent coughs. The nurse should ensure that the patient's pain is well controlled. A patient with uncontrolled pain is less likely to perform the necessary postoperative exercise to prevent complications. The patient should take several deep breaths before coughing.

The nurse is providing teaching to a patient and his wife regarding postoperative care before a right shoulder replacement. Which comment by the nurse is the best way to facilitate understanding in the patient and his wife?

"What questions do you have at this time?" The nurse should ask open-ended questions to determine the patient and his wife's understanding of the teaching. Asking, "Do you have any questions?" does not facilitate a discussion. Although it is important to determine the patient's concerns, asking if he is concerned about the postoperative concerns requires only a "yes" or "no" answer and does not facilitate discussion. Although a packet may be helpful in facilitating the patient's learning, the nurse should not assume that all questions will be answered by the packet.

In the operating room, a patient tells a circulating nurse that the cataract in the patient's left eye will be removed. If the nurse notes that the consent form indicates that surgery is to be performed on the right eye, what is the nurse's first action?

Ask the patient to state his or her name. Ensuring proper identification of a patient is the responsibility of all members of the surgical team. In a specialty surgical setting where many patients undergo the same type of surgery each day, such as cataract removal, it is possible that the patient and the record do not match. Nurses should not make assumptions in the care of their patients. The surgical team should perform a time-out where all the team members participate in the identification of the patient. The surgeon and the anesthesiologist are notified later, once the nurse confirms the patient's name and identity. The nurse should not assume that the patient is confused due to age or premedication. . Preoperative medications can be checked after identifying the patient. The patient should first be identified and then further procedures should be carried out.

A patient needs surgical removal of an inflamed gallbladder. What screening tests does the nurse anticipate the surgeon will prescribe? Select all that apply.

Chest x-ray Electrocardiogram Blood sugar levels The screening tests focus on the body systems that are likely to be affected by the surgery. A chest x-ray and an electrocardiogram (ECG) help determine the patient's heart and lung function. Blood sugar levels help determine postoperative wound healing and chances of infection. An electroencephalogram (EEG) is required for patients suffering from epilepsy and other brain-related disorders. A bone density scan is performed in females after menopause and is not required for this type of procedure.

When assessing a patient's surgical dressing, the nurse finds separation of the wound edges and pale red, watery discharge on the gauze. After assessing the patient, the nurse requests an NPO order (receive nothing by mouth). What condition could be the possible reason for requesting NPO?

The patient has wound dehiscence. Dehiscence is caused by a rupture of sutures and is characterized by separation of the wound edges as well as pale red discharge on surgical dressings. In this case, to prevent further damage, the patient is instructed to have bed rest and nothing is given by mouth. Cellulitis is an infection of the skin and is characterized by heat, pain, and erythema. An abscess is a localized infection characterized by the formation of pus and the presence of inflammation around the wound. Excavation is characterized by the passage of fluids into the blood from subcutaneous tissue.

If a patient with an abdominal incision begins to cough, which intervention is the most appropriate?

Apply a pillow to the incision with slight pressure.

The nurse is providing care for a patient after a right hip replacement. The nurse knows it is vital to turn the patient every 2 hours while the patient is immobile; however, the patient refuses to turn in bed. What is the best action on the part of the nurse?

Ask the patient why he refuses to turn in bed The patient may refuse to turn in bed because he feels weak, is in too much pain, or is afraid to reinjure his hip. The nurse can base her interventions around his response. It may be necessary to provide more pain medication, but this is presumptive. The nurse can ask the charge nurse to help her turn the patient once the patient has agreed and is prepared to turn. Although it may be helpful to explain the risks of immobility to the patient, this may not be the best intervention at this time.

Which complications are associated with surgical incisions in a patient? Select all that apply.

Dehiscence Evisceration After a surgery, there is a risk for dehiscence or separation of a surgical incision or rupture of a wound closure within 3 to 14 days. It is associated with postoperative complications such as distention, vomiting, excessive coughing, dehydration, or infection. Another complication related to surgical wounds is wound evisceration or protrusion of an internal organ through a wound or surgical incision. Cachexia refers to ill health, malnutrition, and wasting as a result of chronic disease, which may cause dehiscence in a patient two weeks after the surgery. Singultus is an involuntary contraction of the diaphragm followed by rapid closure of the glottis. Paralytic ileus is a decrease in or absence of intestinal peristalsis that may occur after abdominal surgery.

A patient is scheduled for surgery. The patient has been fasting for the whole night. The surgery was postponed for 3 hours, and the patient feels hungry. What is the most appropriate nursing action?

Give clear liquids to the patient. Patients usually have a fasting period before surgery. However, if the surgery gets postponed, the patient may be allowed clear liquids. Clear liquids can be metabolized within 2 hours and may not interfere with the gastrointestinal function or the anesthesia process. Solid food, fried food, and fatty food should not be given to the patient. Solid food requires 6 hours to metabolize. Fried food and fatty food requires hours to metabolize.

Which essential problems should be placed on the nursing care plan of a patient with a wound? Select all that apply.

Infection Nutrition Skin integrity

What are the different categories of anesthesia used in surgical procedures? Select all that apply.

Local anesthesia Conscious sedation General anesthesia Regional anesthesia Local anesthesia involves loss of sensation at the desired site and is commonly used for minor surgical procedures, such as a biopsy of a tumor or removal of a growth. Conscious sedation involves giving drugs that depress the central nervous system or provide analgesia in order to relieve anxiety or provide amnesia during surgical diagnostic procedures. General anesthesia is used for major surgery requiring extensive tissue manipulation and it produces amnesia, analgesia, muscle paralysis, and sedation. Regional anesthesia causes loss of sensation in an area of the body and is used for some surgical procedures and pain management. Epidural anesthesia is a type of general anesthesia.

A nurse is trying to remove a bandage when the gauze becomes stuck to the wound bed. What is the most effective method to remove the bandage?

Moisten the gauze with sterile normal saline If a dry dressing adheres to the wound bed, it can be moistened with sterile water or sterile normal saline. The patient should not be asked to remove the gauze, and ripping the gauze can cause additional trauma to the wound. Allowing the patient to moisten the gauze with a showerhead can cause water to enter the wound.

The nurse observes that a keloid has developed on a patient's skin at the site of injury. To what reason does the nurse attribute this formation?

Overgrowth of collagen.

An elderly patient with fragile skin will need dressing changes three times daily. Which intervention is essential for the nurse to implement to prevent a problem with skin integrity?

Reinforcing the bandage with paper tape. Many facilities prefer tape for safety and maintenance of skin integrity. The skin of the elderly patient is fragile and sometimes does not tolerate adhesives; therefore paper tape should be used. The skin on the wound should not be scrubbed vigorously because this can result in further trauma to the area. The bandages should not be placed extra tightly because it could put stress on the suture line. Use of adhesives may not be tolerated by the elderly patient.

For removing staples from a surgical incision, which intervention is most appropriate?

Remove every other staple first, and replace with Steri-Strips while ensuring that the incision remains closed. Routinely, every other staple is removed first and replaced with Steri-Strips, unless the physician orders differently. You would want to monitor that the incision remains closed during the procedure Unless ordered differently, all the staples are removed at the same time. Starting in the middle of the incision would not reduce the stress on the edges of the incision. Removing all the staples at once will put more stress on the incision, causing an increased risk for the edges to pull apart.

The nurse is performing a preoperative assessment on a patient before elective knee replacement surgery. The patient reports an allergy to latex. What should the nurse do first?

Seek more information. The nurse should determine more information regarding the allergy, including date of onset, details surrounding the event, and the type and extent of the reaction. The nurse should document the finding and contact the surgeon, but the nurse must first seek more information. It is not appropriate to cancel the surgery at this time.

Which statement by the nurse about the effects of ambulation in the postoperative period indicates effective learning?

"Early ambulation helps to hasten postoperative recovery." Early ambulation after surgery increases circulation and metabolism and therefore hastens postoperative recovery in the patient. Ambulation is contraindicated in patients with severe infection as the patient may be weak and needs to conserve energy. Patients should get in and out of bed as soon as possible after the surgery to prevent deep-vein thrombosis. Early ambulation improves kidney function and prevents urinary retention. There are low chances of thrombophlebitis as early ambulation increases circulation

The nurse on a general surgery floor is preparing to care for four postoperative patients. Which patient would the nurse see first?

85-year-old woman who had a right hip replacement The nurse should first see the 85-year-old patient who recently underwent a hip replacement. This patient should be seen before the 86-year-old who had an intraarticular injection because it is a more significant surgery and can lead to more significant complications. Younger individuals, such as the 18- and 54-year-old patients, are generally more stable after surgery.

In classifying wounds, which classification results from the presence of gastrointestinal (GI) products?

Contaminated A contaminated wound results from the presence of GI products; from acute, nonpurulent inflammation; or when aseptic technique is broken during surgery. A clean-contaminated wound is a surgical incision made into the respiratory, gastrointestinal, or genitourinary tract after special presurgical preparation. A dirty wound is a wound that is infected before surgery. A clean wound is an uninfected surgical wound.

The nurse is providing preoperative teaching to a patient regarding dietary needs in the postoperative period. What is the best action on the part of the nurse?

Determine the patient's current eating habits The nurse should first determine the patient's current eating habits to help the patient understand how the diet should change in the postoperative period. The patient's understanding of a healthy diet is important but does not apply at this time. The nurse can then educate the patient to increase or decrease intake of fats, carbohydrates, and proteins based on the patient's current diet.

The nurse observes that a surgical wound in a diabetic patient is taking longer than usual to heal. What clinical findings does the nurse expect in this patient?

Disruption in the normal metabolism of substances that aid healing. Wounds in diabetic patients take a longer time to heal. This occurs due to decreased oxygen and nutrients at the cellular level, disruptions in the normal metabolism of substances that aid healing, and an inability of the body to fight infection. Fibroblast function, collagen synthesis, and phagocytosis are affected, leading to a poor immune system. An elevated temperature and complaints of increased pain by the patient indicate an infection.

The nurse in the ambulatory surgery center learns that the patient scheduled for surgery at 11 am drank water at 7 am. What is the best action on the part of the nurse?

Document the finding The patient can have clear liquids until 2 hours before the surgery unless the patient has a condition that causes delayed gastric emptying. Therefore the appropriate action by the nurse would be to document the finding and continue the assessment. The nurse should report this information as part of the preoperative assessment to the physician, but the nurse should finish the assessment first. The surgery does not need to be cancelled at this time. The patient should be educated on the risks of aspiration, but this is not the most correct option.

The nurse is assessing a patient's wound. What measures will the nurse take during the assessment? Select all that apply.

Ensure that every abrasion, laceration, and incision is noted. Be alert for signs of redness, swelling, and pain. Ensure that the location and appearance of the wound is documented every day. The nurse assesses all skin areas when inspecting a wound. The nurse ensures that every abrasion, laceration, and incision is noted. This helps in making a proper diagnosis of the wound. The nurse is also alert for signs of inflammation such as redness, swelling, or pain. The nurse documents the location and appearance of the wound every day as changes can occur rapidly. Freedom from pain is not realistic. Ensuring that the dressing is changed only in case of a prescription is a part of the planning process.

The nurse is attending to an elderly patient scheduled for a hernia operation. The nurse understands that due to aging, the patient may have rigid blood vessel walls and a reduction in sympathetic and parasympathetic innervations to the heart. What risks increase in this patient following a surgery? Select all that apply.

Hemorrhage Increased systolic blood pressure Increased diastolic blood pressure As the body ages, the blood vessel walls become rigid, causing a reduction in sympathetic and parasympathetic innervations to the heart. These changes may increase the risk of hemorrhage following a surgery. The patient may also develop an increase in systolic and diastolic pressures. In postoperative patients, lung expansion may be reduced due to decreased strength of the respiratory muscles. Following a surgery, the patient could have a decreased ability to eliminate drugs due to reduced renal function.

The physician has ordered for a patient's leg wound to be irrigated using an antiseptic solution. What would the nurse do to reduce the chance of contamination?

Have the solution flow from the least contaminated to the most contaminated area. The irrigating solution needs to flow from the least contaminated to the most contaminated area to avoid contamination of clean tissue by exudates. Within the wound, the irrigating solution should be directed from healthy tissue and toward unhealthy tissue to reduce trauma to healthy tissue. The tip of the syringe should be placed approximately 1 inch above the area to be irrigated to avoid contamination. The irrigating solution should be instilled gently into the wound to minimize tissue damage, trauma, irritation, and bleeding.

Which food allergy indicates that a patient is susceptible to latex allergy? Select all that apply.

Kiwi fruit Chestnuts Avocadoes The patient with an allergy to kiwi fruit, chestnuts, and avocadoes shows a cross-sensitivity to latex. If the patient has an allergy to these foods, then the patient needs to be assessed for latex allergy as well. Allergies to oranges and pineapples do not show a cross-sensitivity to latex.

The nurse is caring for a patient with a deep stab wound. What foods does the nurse advise the patient to include in the diet to facilitate faster healing? Select all that apply.

Milk and eggs Baked potatoes Dark green vegetables Seafood and red meat A diet rich in proteins; carbohydrates; lipids; vitamins A and C; thiamine, pyridoxine; and minerals like zinc, iron, and copper are required for wound healing. Milk and eggs provide proteins. Baked potatoes provide vitamin C. Dark green vegetables provide Vitamin A. Seafood and red meat provide zinc. Gelatin dessert lacks the nutrition required for healing.

A patient returns from abdominal surgery at 1300 with a heart rate of 78, respiratory rate of 14, and blood pressure 128/86. At 1400 the patient complains of light-headedness; the heart rate is 132, respiratory rate is 22, and blood pressure is 84/58. What should the nurse do first?

Prepare the patient to return to surgery. The patient is demonstrating the symptoms of hemorrhage and should be prepared to return to surgery. Although the vital signs should be documented, this is not the nurse's first action. Encouraging deep breathing is not the best action at this time. Naloxone is used to reverse the respiratory depression effects of opioid medications and is not appropriate based on this patient's condition.

A patient returns to the gastrointestinal unit at a health care facility. A T-tube is draining normal-colored bile. What essential information about the draining system should be reinforced during patient teaching?

Protecting the skin around the wound. It is essential for the skin around the T-tube to be protected to prevent tissue damage because bile is very irritating to the skin. The patient should be taught to monitor output and use paper tape if skin is fragile. A safety pin is sometimes used to secure the vacuum, but the skin breakdown caused by bile is the priority.

The nurse observes that a postsurgical patient is experiencing symptoms of atelectasis. Which intervention does the nurse implement before reporting to the primary health care provider?

Raises the head of the bed.

The nurse is caring for a patient who underwent a surgery. Three days after the surgical procedure, the nurse is ordered to remove the sutures but notices a thick liquid oozing from the suture site. What should the nurse do in this situation?

Stop the process and leave the remaining sutures intact. If the nurse observes a thick liquid oozing from the suture site while removing sutures, the nurse should immediately stop the process. Oozing could indicate that the wound is not completely healed. The nurse should not suture back the removed stitches or simply dress the wound. Instead, the nurse should let the wound remain open for a period of time, which helps to prevent further injury, and avoid wetting the wound. The nurse should not completely remove the sutures because it may cause infection due to incomplete healing.

The nurse is planning care after a right hip replacement in a patient who smokes cigarettes. Which postoperative instruction would be most important to prevent respiratory complications in a patient who smokes cigarettes?

Use the incentive spirometer 10 times every hour while awake. Patients who smoke and undergo anesthesia for surgery are at an increased risk for atelectasis and pneumonia. It is important for these patients to diligently perform breathing exercises such as using the incentive spirometer. The patient should increase fluid intake to prevent constipation, shift position in bed often to prevent pressure sores, and extend and flex the toes often to prevent deep venous thrombosis.

The clinical coordinator is teaching a student nurse about various wound healing processes. Which statement should the nurse make while teaching the student about tertiary intention?

"Initially, wounds should be left open." The wound healing process is categorized into three types based on the severity of the wound. In the tertiary intention healing method, the wounds are left open and are closed only when the infection is controlled. This type of healing occurs when wounds are contaminated by microbes. Unlike primary intention, tertiary intention does not begin during the inflammatory phase of healing. The primary intention method of healing can be seen when the patient has a wound with minor scarring. The secondary intention of healing often is found in patients who have wounds with open skin edges. The primary health care professional should cover open wounds with gauze to prevent infection.

The nurse is assessing a patient with a gangrenous leg. While collecting the patient's medical history, the nurse finds that the patient had developed the gangrene after lower-limb surgery. Which class of surgical wound does the nurse expect the patient has?

Class IV. Surgical wounds are classified based on the level of contamination and infection. If the surgical wounds are not properly cared for they may cause tissue necrosis. Tissue necrosis results in gangrene, and such wounds are classified as class IV. A clean surgical incision has the least chance of being infected and is categorized as a class I (clean) surgical wound. Wounds that are at risk of being contaminated are categorized as class II (clean contaminated) surgical wounds. Wounds that are fresh without any pus formation and nonpurulent inflammation are categorized as class III (contaminated) wounds.

A student nurse is finishing up a wet-to-dry dressing change. What measure should the student nurse take immediately on completion of the dressing change?

Document the patient's therapy and progress. Once the dressing change has been completed, the nurse should document the patient's progress and therapy. There is no indication that the charge nurse needs to be notified, nor the primary health care provider. A charge for use of the supplies is necessary but is not a priority. Topics

The nurse is caring for a patient with an intestinal obstruction. Suddenly the patient becomes tachycardic, tachypneic, and hypotensive. On assessment the nurse notes a boardlike abdomen and suspects an intestinal perforation. The nurse knows to prepare the patient for which type of surgery?

Emergent Bowel perforation is a medical emergency and must be surgically treated immediately to preserve life. This surgery would not be considered urgent or elective, and a transplant would not occur.

The nurse is performing a preoperative assessment on a patient and notes that the patient appears anxious. The nurse understands that preoperative anxiety can have which effect on the patient postoperatively

Increased recovery time Anxiety before surgery can lead to increased length of recovery after surgery, increased pain medication requirements, and increased anesthesia needs. Preoperative anxiety has not been shown to increase risk for hemorrhage.

Which statement regarding culture and ethnic considerations is considered to be a true statement?

Native Americans are often stoic when ill. Native Americans are often stoic when ill. Complaints of pain to the nurse may be in general terms, and undertreatment of pain is common. Verbal consent has more meaning than written consent among Arab Americans because it is based on trust. Chinese Americans may not ask for pain medications after surgery and may require education about pain relief. Direct eye contact may be avoided and considered disrespectful to many Southeast Asians and American Indians.

Which interventions does the nurse implement while encouraging early ambulation in a postoperative patient? Select all that apply

The nurse clamps the nasogastric tube, if present, while the patient ambulates. The nurse asks the patient to bend, lower, and press back knees hard against bed. The nurse asks the patient to sit on side of bed before ambulating for the first time. If the patient has a nasogastric tube, it needs to be clamped while ambulating to prevent stomach contents from draining out. The nurse asks the patient to perform muscle-strengthening exercises such as bending, lowering, and pressing back knees hard against the bed to facilitate easy ambulation. The nurse asks the patient to sit on the side of the bed before ambulating for the first time to prevent fluctuation of the vital signs. The nurse encourages the patient to walk farther at each ambulation to improve stamina and functioning. It is necessary to obtain help from another colleague while ambulating an unsteady patient receiving IV fluids, to prevent any accidents.

Which of the following are common postoperative complications likely to be found in obese patients? Select all that apply. Correct 1

Embolus Atelectasis Pneumonia Obese patients are more susceptible to the development of postoperative complications. Embolus forms from venous stasis in the lower extremities. Atelectasis and pneumonia occur because of immobility, reduced ventilatory function, increased secretions, and problems in lung expansion. Hemorrhage can happen in patients with bleeding disorders. An obese patient is not at any higher risk of electrolyte imbalances than a patient of normal body weight.

A patient has lacerations on the thigh after a biking accident. What precautions does the nurse take to ensure appropriate wound healing? Select all that apply.

The nurse ensures that the surrounding skin is clean and dry. The nurse ensures that therapeutic body position is maintained. The nurse ensures that dressings and drains are positioned correctly. The nurse ensures appropriate nutrition for faster healing. The nurse takes adequate precautions to ensure appropriate wound healing in the patient. The nurse ensures that the surrounding skin and tissue is clean and dry to avoid bacterial infection. The nurse ensures that the patient is lying in the correct position so that the wound is not disturbed and there is no undue pressure on the wound. The nurse ensures that dressings, compression stockings, and drains are placed correctly to avoid contamination. The nurse also ensures that the patient receives adequate nutrition that helps with faster healing. The nurse changes the dressing as prescribed by the primary health care provider.

The nurse is caring for a patient with cholecystitis who is scheduled for gallbladder removal surgery in 2 hours. Although the patient reports that the patient's pain is well controlled, the patient remains tachycardic, tachypneic, and diaphoretic. When asked what is bothering him, the patient replies, "Nothing. Everything's fine. Will you just leave me alone?" What is the best response on the part of the nurse?

"I'm hearing you say everything is fine, but you seem upset. I would like to help, if I can." Although the patient states he is fine, his appearance and vital signs suggest otherwise. It is common for patients to be anxious or afraid before surgery. Acknowledging that the patient states he is fine but seems otherwise prompts the patient in a nonthreatening manner to be open about his concerns. Telling the patient not to worry because the surgery is safe does not validate the patient's concerns. It would be inappropriate to say nothing after first attempting to prompt the patient to discuss his concerns. It would be presumptuous to sit with the patient after he has asked the nurse to leave, and may make the patient more agitated.

The nurse is caring for a patient before elective surgery. For which preoperative tasks is the nurse responsible? Select all that apply.

Ensuring the consent form is signed Educating the patient about postoperative care needs Determining the patient's current level of pain The role of the nurse in the preoperative period is to assess the patient's health status, educate the patient about postoperative care needs and expectations, and ensure the consent form has been signed, among other tasks. The nurse will also determine the patient's current level of pain. The operating physician should explain the risks and benefits of the surgery and have the patient sign the consent form.

What is the usual interval at which nursing assessments, including vital signs, are monitored in the postoperative phase?

Fifteen minutes times 4; every 30 minutes times 4; every hour times 4; then every 4 hours The usual interval at which nursing assessments, including vital signs, are monitored in the postoperative phase is every 15 minutes times 4; every 30 minutes times 4; every hour times 4; then every 4 hours. This "times four" gauge is the maximum time that should elapse between assessments. Five minutes times 4 is not the typical interval of assessments routinely performed by nurses. Thirty minutes times 4 leaves too much time between assessments for optimal patient safety and monitoring of potential postoperative complications. Four hours followed by once a shift is far beneath the standard of care generally accepted on postoperative units. Potential patient complications would be missed.

Which interventions does the nurse implement to prevent thrombus formation in a patient after a knee surgery? Select all that apply.

The nurse instructs the patient not to cross legs when in bed. The nurse instructs the patient to perform leg exercises every two hours. The nurse encourages the patient to get out of bed as much as possible. The patient is at risk for thrombosis after a surgery due to inactivity and injury to the blood vessels due to anesthesia. The nurse instructs the patient not to cross legs when in bed as it impedes blood flow in the legs. The nurse instructs the patient to perform leg exercises every two hours and also encourages the patient to get out of bed as much as possible. Reducing fluids and juices in diet is necessary to prevent edema in a patient with deep-vein thrombosis. The nurse avoids using knee gatch as it hinders venous return in the patient.

The nurse observes that a postoperative patient is unable to void after seven hours. Which intervention does the nurse implement to encourage voiding in the patient?

The nurse makes the patient listen to running water. Noninvasive measures like having the patient listen to running water may facilitate voiding in the patient. Placing the patient's hands in warm water, or ambulating to the bathroom or bedside commode if the patient is able, are other measures to encourage voiding in patients. Increasing the patient's fluid intake will not help the patient to void as anesthesia depresses urinary function. Deep breathing helps to remove trapped mucus and surgical gases from the lungs, but does not facilitate urination. The nurse needs to obtain a prescription for catheterization only after all noninvasive measures for facilitating voiding have failed.

Which interventions does the nurse implement while providing care for a postoperative patient who is unconscious? Select all that apply.

The nurse raises the side rails of the bed. The nurse keeps the call light within reach. The nurse raises the bed to a 45-degree angle. The nurse assesses blood pressure and heart rate. The level of consciousness in a postsurgical patient is altered. Therefore, the nurse raises the side rails of the bed to prevent falls. The nurse also keeps a call light within the patient's reach to help the patient inform about any complications immediately. The nurse raises the bed to a 45-degree angle to reduce the chances of aspirating vomitus. The nurse assesses blood pressure and heart rate frequently as postoperative complications can occur suddenly. The nurse does not place a pillow under the patient's head until the patient has regained complete consciousness as this may cause the tongue to obstruct the airway.

Which condition in the postoperative patient will indicate that the fluid status is normal?

The patient's urinary output is 30 mL/hour. A urinary output of 30 mL/hour indicates that the patient's fluid balance is normal. The absence of foul-smelling urine may indicate that the patient does not have infection. The fluid status may or may not be normal in such a patient. A normal bowel movement may indicate that there is normal kidney function in the patient, but may not help indicate the fluid status. Inability to consume large amount of fluids indicates a problem in a gastrointestinal function.