Nokea
A 90-year-old female patient is scheduled to undergo a partial mastectomy for the treatment of breast cancer. What nursing diagnosis should the nurse prioritize when planning this patients postoperative care?
- A. Risk for Delayed Growth and Development related to prolonged hospitalization
- B. Risk for Decisional Conflict related to discharge planning
- C. Risk for Impaired Memory related to old age
- D. Risk for Infection related to reduced immune function
Correct Answer: D
Rationale: The lessened physiological reserve of older adults results in an increased risk for infection postoperatively. This physiological consideration is a priority over psychosocial considerations, which may or may not be applicable. Impaired memory is always attributed to a pathophysiological etiology, not advanced age.
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The clinic nurse is doing a preoperative assessment of a patient who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the patients medical history, the nurse notes that this patient had a kidney transplant 8 years ago and that the patient is taking immunosuppressive drugs. For what is this patient at increased risk when having surgery?
- A. Rejection of the kidney
- B. Rejection of the implanted lens
- C. Infection
- D. Adrenal storm
Correct Answer: C
Rationale: Because patients who are immunosuppressed are highly susceptible to infection, great care is taken to ensure strict asepsis. The patient is unlikely to experience rejection or adrenal storm.
The policies and procedures on a preoperative unit are being amended to bring them closer into alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most directly addresses the priorities of the SCIP?
- A. Actions aimed at increasing participation of families in planning care
- B. Actions aimed at preventing surgical site infections
- C. Actions aimed at increasing interdisciplinary collaboration
- D. Actions aimed at promoting the use of complementary and alternative medicine (CAM)
Correct Answer: B
Rationale: SCIP identifies performance measures aimed at preventing surgical complications, including venous thromboembolism (VTE) and surgical site infections (SSI). It does not explicitly address family participation, interdisciplinary collaboration, or CAM.
The nurse is planning patient teaching for a patient who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching?
- A. Upon the patients admission to the postanesthesia care unit (PACU)
- B. When the patient returns from the PACU
- C. During the intraoperative period
- D. As soon as possible before the surgical procedure
Correct Answer: D
Rationale: Teaching is most effective when provided before surgery. Preoperative teaching is initiated as soon as possible, beginning in the physicians office, clinic, or at the time of preadmission testing when diagnostic tests are performed. Upon admission to the PACU, the patient is usually drowsy, making this an inopportune time for teaching. Upon the patients return from the PACU, the patient may remain drowsy. During the intraoperative period, anesthesia alters the patients mental status, rendering teaching ineffective.
The nurse is preparing a patient for surgery prior to her hysterectomy without oophorectomy. The nurse is witnessing the patients signature on a consent form. Which comment by the patient would best indicate informed consent?
- A. I know Ill be fine because the physician said he has done this procedure hundreds of times
- B. I know Ill have pain after the surgery but theyll do their best to keep it to a minimum
- C. The physician is going to remove my uterus and told me about the risk of bleeding
- D. Because the physician isnt taking my ovaries, Ill still be able to have children
Correct Answer: C
Rationale: The surgeon must inform the patient of the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the early and late postoperative periods. The nurse clarifies the information provided, and, if the patient requests additional information, the nurse notifies the physician. In the correct response, the patient is able to tell the nurse what will occur during the procedure and the associated risks. This indicates the patient has a sufficient understanding of the procedure to provide informed consent. Clarification of information given may be necessary, but no additional information should be given. The other listed statements do not reflect an understanding of the surgery to be performed.
The nurse is creating the care plan for a 70-year-old obese patient who has been admitted to the postsurgical unit following a colon resection. This patients age and increased body mass index mean that she is at increased risk for what complication in the postoperative period?
- A. Hyperglycemia
- B. Azotemia
- C. Falls
- D. Infection
Correct Answer: D
Rationale: Like age, obesity increases the risk and severity of complications associated with surgery. During surgery, fatty tissues are especially susceptible to infection. In addition, obesity increases technical and mechanical problems related to surgery. Therefore, dehiscence (wound separation) and wound infections are more common. A postoperative patient who is obese will not likely be at greater risk for hyperglycemia, azotemia, or falls.