Med-Surg: PeriOp AQ
Postoperatively, a client asks, "Could I have a pillow under my knees? My legs feel stretched." With what response can the nurse best reinforce the preoperative teaching? <p>Postoperatively, a client asks, "Could I have a pillow under my knees? My legs feel stretched." With what response can the nurse <b>best</b> reinforce the preoperative teaching?</p>"I'll get pillows for you. I want you to be as rested as possible.""It's not a good idea, but you do look uncomfortable. I'll get one.""We don't allow pillows under the legs because you will get too warm.""A pillow under the knees can result in clot formation because it slows blood flow."
Flexing the hips and pressure against the popliteal space impedes venous return, increasing the risk for clot development. Although comfort and rest should be encouraged, placing pillows under the knees is contraindicated. Pillows under the knees produce pressure, not warmth.
In the first two and a half hours after a radical neck dissection, 40 mL of medium-red, bloody fluid is obtained from the client's drainage system. Average drainage is 16 mL/hr. What should the nurse do? Select all that apply. <p>In the first two and a half hours after a radical neck dissection, 40 mL of medium-red, bloody fluid is obtained from the client's drainage system. Average drainage is 16 mL/hr. What should the nurse do? <b>Select all that apply</b>.</p>Take vital signs.Change the dressing.Apply pressure over the site.Elevate the lower extremities.Notify the healthcare provider.
A drainage amount of 40 mL is excessive for the first two and a half hours after surgery. Eighty to 120 mL of drainage is expected in the first 24 hours postoperatively (an average of 5 mL/hour is the maximum amount excepted to be normal). Vital signs should be taken to determine the systemic response to blood loss. The healthcare provider should be notified of an excessive amount of drainage. A fresh postoperative dressing should not be disturbed because the manipulation can cause further bleeding; it can be reinforced by the nurse if needed. The healthcare provider should change the first dressing. Pressure should be applied in the event of a life-threatening hemorrhage, but the blood is contained within the drainage system; appropriate intervention can prevent hemorrhage. The head of the bed is kept elevated after neck surgery to decrease edema, which may compromise the airway.
A postoperative client returned from the postanesthesia care unit (PACU) this morning with a patient-controlled analgesia (PCA) pump running with a basal rate of hydromorphone. The nurse assesses the client's vital signs as blood pressure 90/60 mm Hg, heart rate 96 beats per min, and respiratory rate of 10 breaths per min. Which action should the nurse take next? <p>A postoperative client returned from the postanesthesia care unit (PACU) this morning with a patient-controlled analgesia (PCA) pump running with a basal rate of hydromorphone. The nurse assesses the client's vital signs as blood pressure 90/60 mm Hg, heart rate 96 beats per min, and respiratory rate of 10 breaths per min. Which action should the nurse take next?</p>Give naloxone intravenous push med (IVP) per protocol.Assess the client's pain level on a 10-point scale.Document the findings and reassess in 2 hours.Call the rapid response team.
A respiratory rate of 10 breaths per min is abnormal and needs to be treated immediately. Naloxone is an opioid antagonist and antidote and is used in PCA protocols for postoperative opioid-induced respiratory depression. Pain level also is a part of the PCA documentation protocol. According to protocol, PCA status needs to be documented every 2 hours for the first day and then every 4 hours. The rapid response team might still need to be called, but naloxone must be given first.
A healthcare provider informs a client that midazolam will be administered preoperatively. Later, the client asks the nurse why this medication is given. What primary reason should the nurse consider when formulating a response? <p>A healthcare provider informs a client that midazolam will be administered preoperatively. Later, the client asks the nurse why this medication is given. What <b>primary</b> reason should the nurse consider when formulating a response?</p>Reduces painInduces sedationProduces amnesiaLimits oral secretions
Midazolam, a benzodiazepine, depresses subcortical levels in the central nervous system and acts on the limbic system and reticular formation; it reduces anxiety and induces sedation. Analgesics are given to reduce pain. Although it induces amnesia, this is not the primary reason for its administration. Atropine, an anticholinergic, is given to decrease oral and respiratory secretions.
A client who is scheduled for a bowel resection is to receive antibiotics preoperatively. What does the nurse include when teaching the client about the purpose of the antibiotics? <p>A client who is scheduled for a bowel resection is to receive antibiotics preoperatively. What does the nurse include when teaching the client about the purpose of the antibiotics?</p>They prevent incisional infection.Antibiotics prevent postoperative pneumonia.These drugs limit the risk of a urinary tract infection.They are given to eliminate bacteria from the gastrointestinal (GI) tract.
The GI tract contains numerous bacteria; antibiotics are given to decrease the number of microorganisms in the bowel before surgery. Preventing incisional infection is a potential complication prevented by the use of sterile technique when changing the dressing. Avoiding postoperative pneumonia is a potential complication prevented by coughing, deep breathing, and early ambulation postoperatively. Limiting the risk of a urinary tract infection is a potential complication prevented by hygiene, meatal care, and increased hydration postoperatively.
The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? <p>The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified?</p>PrimarySecondarySuperinfectionNosocomial
A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.
When monitoring a client 24 to 48 hours after abdominal surgery, the nurse should assess for which problem associated with anesthetic agents? <p>When monitoring a client 24 to 48 hours after abdominal surgery, the nurse should assess for which problem associated with anesthetic agents?</p>ColitisStomatitisParalytic ileusGastrocolic reflux
After abdominal or pelvic surgery clients are at risk for paralytic ileus as a result of receiving an anesthetic agent. The nurse can prevent or minimize paralytic ileus by increasing movement as soon as possible after surgery, through actions such as turning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool. Colitis, stomatitis, and gastrocolic reflux are not postoperative complications related to anesthetic agents.
A complete blood count (CBC), urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse? <p>A complete blood count (CBC), urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which is the <b>best </b>reply by the nurse?</p>"Don't worry; these tests are routine.""They are done to identify other health risks.""They determine whether surgery will be safe.""I don't know; your healthcare provider prescribed them."
Certain diagnostic tests (e.g., CBC, urinalysis, chest x-ray examination) are done preoperatively to rule out the existence of health problems that may increase the risks involved with surgery. Feelings will not be dispelled by telling the client not to worry; it also blocks further communication. Surgery poses a risk despite test results. Lack of knowledge without a statement of plans to obtain the information suggests incompetence on the part of the nurse.
A nurse is preparing to administer preoperative medication to a client scheduled for incision and drainage of a wound abscess. Which action is essential before the nurse administers the medication? <p>A nurse is preparing to administer preoperative medication to a client scheduled for incision and drainage of a wound abscess. Which action is  <b>essential</b> before the nurse administers the medication?</p>Verify the consent.Have the client void.Check the vital signs.Remove the client's dentures.
Consent must be acquired when the client is fully oriented and in a clear mental state. Informed consent is one way to help ensure client safety. It helps protect the client from any unwanted procedures and protects the surgeon and the facility from lawsuit claims related to unauthorized surgery or uninformed clients. Although important, having the client void, checking the vital signs, and removing the client's dentures can be implemented before surgery even if the client has received medication.
In the postanesthesia care unit a client received intrathecal morphine intraoperatively to control pain. Considering the administration of this medication, what should the nurse include as part of the client's initial 24-hour postoperative care? <p>In the postanesthesia care unit a client received intrathecal morphine intraoperatively to control pain. Considering the administration of this medication, what should the nurse include as part of the client's initial 24-hour postoperative care?</p>Monitoring of respiratory rate hourlyAssessing the client for tachycardiaAdministering naloxone every 3 to 4 hoursObserving the client for signs of central nervous system (CNS) excitement
Intrathecal morphine can depress respiratory function depending on the level it reaches within the spinal column; hourly assessments during the first 12 to 24 hours will allow for early intervention with an antidote if respiratory depression needs to be corrected. Bradycardia, not tachycardia, and hypotension occur. Administering naloxone every 3 to 4 hours is too infrequent if the client's respirations are depressed. The recommended adult dosage usually is 0.4 to 2 mg every 2 to 3 minutes, if indicated. CNS depression occurs secondary to hypoxia.
Which pulmonary risk may be increased in a postoperative client due to anesthesia? <p>Which pulmonary risk may be increased in a postoperative client due to anesthesia?</p>RhonchiFremitusDyspneaAtelectasis
Postoperative clients are at risk for atelectasis, which involves the collapse of the alveoli. This condition is caused by the effects of anesthesia. Rhonchi are continuous rumbling or snoring sounds caused by the obstruction of the larger airways. Fremitus is the vibration of the chest wall during vocalization. Dyspnea is shortness of breath; this condition is an after effect of atelectasis.
Five days after a client has abdominal surgery a nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? <p>Five days after a client has abdominal surgery a nurse assesses the client’s incision site for signs of dehiscence. Which clinical finding supports the nurse’s conclusion that the client is experiencing wound dehiscence?</p>Increased bowel soundsLoosening of the suturesSerosanguineous drainagePurplish color of the incision
Serosanguineous drainage from the wound or on the dressing forewarns about separation of the wound edges (dehiscence); dehiscence may progress to movement of abdominal organs outside of the abdominal cavity (evisceration). Bowel sounds have no relationship to wound status; bowel sounds are expected around the third or fourth postoperative day as intestinal peristalsis returns. Loosening of sutures may occur after the initial wound edema subsides but is not a sign of failure of the suture line. A purplish incision is the expected coloration of a healing wound.
The day after surgery a client is encouraged to ambulate. The client angrily asks the nurse, "Why am I being made to walk so soon after surgery?" How should the nurse explain the primary purpose of early ambulation? <p>The day after surgery a client is encouraged to ambulate. The client angrily asks the nurse, "Why am I being made to walk so soon after surgery?" How should the nurse explain the <b>primary</b> purpose of early ambulation?</p>To promote healing of the incisionTo decrease the incidence of urinary tract infectionsTo use energy to help the client sleep better at nightTo keep blood from pooling in the legs to prevent clots
The muscular action during ambulation facilitates the return of venous blood to the heart; this reduces venous stasis and minimizes the risk of postoperative thrombophlebitis. Protein and vitamin C promote wound healing. Walking is not related to the prevention of urinary tract infections. Although activity during the day may promote sleeping at night, it is not the reason for ambulating after surgery.
A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider? <p>A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider?</p>Client pushes the airway out.Client has snoring respirations.Client's respirations are 16 breaths per minute and unlabored.Client's systolic blood pressure drops from 130 to 90 mm Hg.
A drop in blood pressure; rapid pulse rate; cold, clammy skin; and oliguria are signs of decreased blood volume and shock, which if not treated promptly can lead to death. The client pushing the airway out is an expected response; the client will push out the airway as the effects of anesthesia subside. Respirations of 16 breaths per minute is a common response postoperatively. If the client is experiencing a depressant effect of anesthesia, the nurse will assess shallow and slow respirations.
A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? <p>A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis?</p>Productive coughClubbing of the fingertipsCrackles at the height of inhalationDiminished breath sounds on auscultation
AAtelectasis refers to the collapse of alveoli; breath sounds over the area are diminished. A productive cough most often is associated with inflammation or infection, not atelectasis. Clubbing of the fingertips is a late sign of chronic hypoxia related to prolonged obstructive lung disease. Crackles at the height of inhalation are not specific to atelectasis. Crackles are associated with fluid in the alveoli, which occurs with heart failure and pulmonary edema.
A nurse is teaching a preoperative client about postoperative breathing exercises. Which information should the nurse include? Select all that apply. <p>A nurse is teaching a preoperative client about postoperative breathing exercises. Which information should the nurse include? <b>Select all that apply.</b> </p>Take short, frequent breathsExhale with the mouth open widePerform the exercises twice a dayPlace a hand on the abdomen while feeling it riseHold the breath for several seconds at the height of inspiration
Abdominal breathing improves lung expansion because it makes the contraction of the diaphragm more efficient. Placing the hand on the abdomen to watch it rise provides feedback, ensuring that abdominal rather than intercostal breathing is accomplished. Holding the breath for several seconds at the height of inspiration allows several additional seconds for oxygen and carbon dioxide to exchange in the alveoli. Short breaths do not expand the lungs; deep, slow breaths should be encouraged. Exhalation with pursed lips, not with an open mouth, promotes exhalation of air from the lung and minimizes trapping of air in the alveoli. Breathing exercises should be performed at least every two hours.
After a subtotal gastrectomy, a client has a nasogastric (NG) tube to continuous low suction. Three hours after the surgery, the client complains of nausea and abdominal pain. The client's abdomen appears distended. What should the nurse do first? <p>After a subtotal gastrectomy, a client has a nasogastric (NG) tube to continuous low suction. Three hours after the surgery, the client complains of nausea and abdominal pain. The client's abdomen appears distended. What should the nurse do first?</p>Instill 30 mL of air into the NG tubeAdminister the prescribed pain medicationInform the client that abdominal pain is common with NG tubesNotify the surgeon of the absence of bowel sounds
Abdominal distention, nausea, and abdominal pain can be signs of nasogastric tube blockage. Instilling 30 mL of air may reestablish patency. Although opioids usually are prescribed postoperatively, they tend to decrease peristalsis and may increase abdominal distention and nausea. It is not common for NG tubes to cause abdominal pain. There will be no stools for several days. Bowel sounds are not expected for several days after stomach or intestinal surgery.
A client is scheduled for an abdominal surgery. What is the priority preoperative nursing objective when caring for this client? <p>A client is scheduled for an abdominal surgery. What is the <b>priority</b> preoperative nursing objective when caring for this client?</p>Recording accurate vital signsAlleviating the client's anxietyTeaching about early ambulationMaintaining the client's nutritional status
Anxiety experienced by a preoperative client can be a disruptive force that may affect the client's ability to cope psychologically and physiologically. Anxiety must be alleviated for other nursing measures to be effective. Although vital signs are recorded because they will serve as a baseline in postoperative assessment, they are not the priority. Learning is hampered by high anxiety levels. The diet is limited before surgery so that residue in the intestines is decreased.
On the second day after surgery, a client reports pain in the right calf. What should the nurse do first? <p>On the second day after surgery, a client reports pain in the right calf. What should the nurse do <b>first?</b> </p>Apply a warm soak.Document the symptom.Elevate the leg above the heart.Notify the primary healthcare provider.
Calf pain may be a sign of thrombophlebitis, which can lead to pulmonary embolism. A postoperative client with pain in the calf should be confined to bed immediately and the primary healthcare provider notified. A prescription for application of heat may be given after a diagnosis is made; application of heat is a dependent nursing function. Documentation is not the priority; this is a potentially serious complication. The leg should not be elevated above heart level without a prescription; gravity may dislodge a thrombus, creating an embolism.
A client is admitted to the hospital for acute pain in the hip, and a total hip replacement surgery is scheduled. The client was diagnosed recently with early dementia. The client appears oriented and alert and responds appropriately when interviewed. When the nurse is providing preoperative teaching, the client says, "I don't want to have that surgery." The client's spouse voices a desire to proceed with the surgery to provide relief for the client. How should the nurse respond? <p>A client is admitted to the hospital for acute pain in the hip, and a total hip replacement surgery is scheduled. The client was diagnosed recently with early dementia. The client appears oriented and alert and responds appropriately when interviewed. When the nurse is providing preoperative teaching, the client says, "I don’t want to have that surgery." The client’s spouse voices a desire to proceed with the surgery to provide relief for the client. How should the nurse respond?</p>Discuss with the client feelings about having surgery.Ask the client if a power of attorney for health care has been established.Continue with preparation for surgery as the spouse has requested.Continue with teaching, ensuring that the client understands the process.
Consent for surgery should be given by the client; the spouse cannot do this unless he or she has power of attorney for health care. Although it is important to discuss feelings with the client, this does not address the legal issue. The legal issue needs to be clarified first. If the client does not want surgery, preoperative teaching probably will not be effective, because the client will not be receptive. The legal issue needs to be clarified first.
The nurse administers oxygen to a client during the early postoperative period after open heart surgery. Why is this necessary? <p>The nurse administers oxygen to a client during the early postoperative period after open heart surgery. Why is this necessary?</p>The client will have closed-chest drainage in place.Hypoxia can precipitate respiratory alkalosis.Reduced oxygen levels can stimulate dysrhythmias.Increased respiratory rates add to postoperative pain.
Inadequate oxygenation can cause premature ventricular complexes. Although the client will have closed-chest drainage in place, it does not explain why adequate oxygenation is important. Hypoxia can precipitate respiratory acidosis; hyperventilation causes respiratory alkalosis. Postoperative pain can increase the respiratory rate; increased respiratory rate does not increase the pain level.
A nurse is caring for several postoperative clients who had abdominal surgery. What independent nursing intervention can help prevent the development of thrombophlebitis? <p>A nurse is caring for several postoperative clients who had abdominal surgery. What independent nursing intervention can help prevent the development of thrombophlebitis?</p>Encouraging adequate fluidsMassaging the client's legs gentlyApplying sequential compression devicesHelping the client to perform in-bed exercises
Inactivity causes venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation; early ambulation or exercise of the lower extremities reduces the occurrence of this complication. Although encouraging adequate fluids may help, it is not an independent nursing intervention. Postoperative clients often are nothing by mouth until peristalsis returns. Massaging is contraindicated because any developing clot may dislodge. Applying sequential compression devices is helpful, but it is not an independent activity; a sequential compression device requires a healthcare provider's prescription.
An abdominal cholecystectomy is performed on a client with gangrene of the gallbladder. During the first 24 hours postoperatively, when should analgesics be administered? <p>An abdominal cholecystectomy is performed on a client with gangrene of the gallbladder. During the first 24 hours postoperatively, when should analgesics be administered?</p>If repositioning is ineffectiveWhen the pain becomes severeIn gradually increasing dosagesAs prescribed by the health care provider
Relief from pain helps the client cooperate with coughing, deep breathing, turning, and ambulating. These activities help prevent pneumonia, a frequent complication, because the proximity of the incision to the diaphragm limits lung expansion. Repositioning will not relieve pain associated with deep breathing and coughing, although it may relieve mild incisional pain. Analgesics should be given as prescribed to enable the client to successfully take part in postsurgical activity. Analgesics are less effective if given when pain has intensified; they should be given before pain is unbearable for best results. Pain is most intense during the first 24 hours, and analgesics should be administered as prescribed. Pain, and therefore analgesic dosages, decreases gradually as the postoperative period progresses.
A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When should the nurse begin to teach the client about how to care for the wound? <p>A client is hospitalized for intravenous antibiotic therapy and an incision and drainage of an abscess that developed at the site of a puncture wound. When should the nurse begin to teach the client about how to care for the wound?</p>In the preoperative period2 days before dischargeOn the first postoperative dayDuring the first dressing change
Teaching for the postoperative period should begin as soon as the decision for surgery is made; knowledge of what to expect decreases anxiety and may improve adherence to the treatment regimen. Several days before discharge is too late; the client must have time to ask questions and demonstrate the ability to care for the wound. Teaching begins preoperatively. On the first postoperative day the client may be in too much discomfort to concentrate on learning. During the first dressing change the client may be in too much discomfort to concentrate on learning.
A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions? <p>A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions?</p>"Inhale completely and exhale in short, rapid breaths.""Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale.""Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale.""Exhale halfway, then inhale a rapid, small breath; repeat several times."
The correct procedure to maximize use of an incentive spirometer is to exhale completely, then take a slow, deep breath through the spirometer and hold it as long as possible. This procedure will maximize inspiratory function by expanding the lungs. The client should practice using the incentive spirometer before surgery. When teaching clients, it is important to provide exact step-by-step instructions, thus not leaving out any critical points.
What is an acute, life-threatening complication for which a nurse should assess a client in the early postoperative period after a radical nephrectomy? <p>What is an acute, life-threatening complication for which a nurse should assess a client in the early postoperative period after a radical nephrectomy?</p>SepsisHemorrhageRenal failureParalytic ileus
The kidney, an extremely vascular organ, receives a large percentage of the blood flow, and hemorrhage from the operative site can occur. Sepsis and renal failure may occur later in the postoperative period. Paralytic ileus can occur, but it is not life threatening.
A nurse is caring for a client who had a nephrectomy because of cancer of the kidney. Which factor will influence the client's ability to deep breathe and cough postoperatively? <p>A nurse is caring for a client who had a nephrectomy because of cancer of the kidney. Which factor will influence the client’s ability to deep breathe and cough postoperatively?</p>Location of the surgical incisionIncreased anxiety about the prognosisInflammatory process associated with surgeryPulmonary congestion from preoperative medications
The location of the surgical site in relation to the diaphragm increases incisional pain when deep breathing or coughing. Anxiety about the prognosis should not interfere with the ability to deep breathe and cough, especially when encouraged by the nurse. Inflammatory changes will cause discomfort in the area of any incision but are not necessarily the prime factor preventing deep breathing after a nephrectomy. The client will need to cough and deep breathe if there is congestion in the lungs.
When obtaining an admission history of a preoperative client, the nurse learns that the client is taking several herbal supplements. Which is the priority nursing action? <p>When obtaining an admission history of a preoperative client, the nurse learns that the client is taking several herbal supplements. Which is the <b>priority</b> nursing action?</p>Provide the client with information about the usefulness of herbal therapiesInform the client about taking supplemental vitamins rather than herbsTeach the client about herbal supplementsAsk the client which herbs have been taken
The nurse must find out which herbs the client has been taking because some herbs can cause hemorrhage, and the healthcare provider may need to postpone the surgery until the client has been free of herbal supplements for a period of time. Although the client may be interested in the usefulness of the herbal therapies being taken, this is not the appropriate time for this teaching. Teaching or talking about the differences in supplemental vitamins and herbs is not the priority in this situation. Although some herbs are dangerous, others have proved beneficial, but this teaching is not the priority action.
The nurse is caring for a client who is postoperative day 2 from an open cholecystectomy and notes the presence of bibasilar crackles. The nurse suspects atelectasis. Which nursing actions will be appropriate for this client? Select all that apply . <p>The nurse is caring for a client who is postoperative day 2 from an open cholecystectomy and notes the presence of bibasilar crackles. The nurse suspects atelectasis. Which nursing actions will be appropriate for this client? <b>Select all that apply</b> <i>.</i> </p>Encourage turning, coughing, and deep breathing exercisesPerform frequent breath sounds assessmentDecrease by mouth fluid intakeOffer a high-potassium dietObtain a chest x-ray
This client likely has postoperative atelectasis[1][2] and requires frequent breath sounds assessment because of the presence of adventitious breath sounds. Also, the client should turn, cough, and deep breathe to prevent further atelectasis and pneumonia. The client may be encouraged to increase intake to facilitate thinning of any secretions that may be present. High-potassium diet will have no effect on the resolution of atelectasis. Obtaining a chest x-ray is not a nursing action and requires a healthcare provider prescription; the nurse can review or request an x-ray.
A client who is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to do what? <p>A client who is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to do what?</p>Decrease peristalsisMinimize electrolyte imbalanceDecrease bacteria in the intestinesTreat inflammation caused by the malignancy
To decrease the possibility of contamination, the bacteria count in the colon is lowered with antibiotics before surgery. Preoperative antibiotics do not have an effect on peristalsis, electrolyte balance, or treating inflammation.
The nurse suspects that an intraoperative client has a distended bladder. Which method is correct to assess for this condition? <p> <div> The nurse suspects that an intraoperative client has a distended bladder. Which method is correct to assess for this condition? </div> </p>Inspect and palpate in the epigastric region.Auscultate and percuss in the inguinal areas.Percuss and palpate in the hypogastric region.Percuss and palpate bilaterally in the lumbar areas.
To detect a distended bladder, percussion and palpation should be performed over the hypogastric region of the abdomen. Percussion of a distended bladder would produce a dull sound and feel firm on palpation. Inspecting and palpating in the epigastric region, auscultating and percussing in the inguinal areas, or percussing and palpating bilaterally in the lumbar areas are all inaccurate procedures to assess for a distended bladder.
A client is scheduled for head and neck surgery. Although the healthcare provider has explained the surgery, the client still has moderate to severe anxiety. Which action should the nurse take initially? <p>A client is scheduled for head and neck surgery. Although the healthcare provider has explained the surgery, the client still has moderate to severe anxiety. Which action should the nurse take initially?</p>Attempt to discover what the client is concerned about.Elaborate on what the healthcare provider has already said.Teach the client to use the suction equipment preoperatively.Plan for postoperative communication because a tracheostomy is likely.
Various aspects of hospitalization and diagnosis may cause the client to become anxious. The nurse should identify what concerns the client the most. Anxiety interferes with learning, and it is the healthcare provider's responsibility to explain the surgery. Teaching the client to use the suction equipment preoperatively may cause the client unnecessary anxiety. A tracheostomy may not be performed; it depends on the type of surgery.
A client with a history of recurrent cholecystitis is scheduled for an abdominal cholecystectomy. What should the nurse specifically emphasize when planning preoperative teaching for this client? a. Possible complications b. Food and fluid restrictions c. Coughing and deep breathing d. Isometric exercises of the extremities
c. Coughing and deep breathing The operative site's proximity to the diaphragm results in the client taking shallow respirations to limit pain; failure to expand the lungs can cause hypostatic pneumonia. The healthcare provider explores possible complications when providing information for an informed consent. The nurse should not emphasize possible complications because it may increase the client's anxiety. Preoperative teaching should focus on the interventions that prevent complications. Food and fluid restrictions should be included in preoperative teaching; however, this is not the priority. Isometric exercises of the extremities are unnecessary; the client will be allowed out of bed within several hours after surgery.
