Nokea
A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort?
- A. Allow the client to assume a position of comfort
- B. Allow the client's family to remain at the bedside
- C. Give the client a warm, non-carbonated drink
- D. Provide warm blankets or cool blankets as desired
- E. Pull the curtains around the bed to provide privacy
Correct Answer: A,B,D,E
Rationale: There are many nonpharmacologic comfort measures the nurse can employ, such as allowing the client to remain in the position that is most comfortable, letting the family stay with the client, providing warmth or cooling measures as requested by the client, and providing privacy. The client in the preoperative holding area is NPO, so drinks should not be provided.
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A nursing instructor is teaching students about different surgical procedures and their classifications. Which procedures are correctly classified?
- A. Hemicolectomy: diagnostic
- B. Liver biopsy: diagnostic
- C. Spinal cord decompression: palliative
- D. Total shoulder replacement: restorative
- E. Mastectomy: restorative
Correct Answer: B,E
Rationale: A diagnostic procedure is used to determine cell type of cancer and to determine the cause of a problem, such as a liver biopsy. A restorative procedure aims to improve functional ability, such as a total shoulder replacement. A curative procedure either removes or repairs the causative problem, such as a mastectomy or hemicolectomy, which are not diagnostic or palliative.
A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate?
- A. After you wash the surgical site, shave the area with your own razor
- B. Be sure to wash the area where you will have surgery very thoroughly
- C. Use a washcloth to wash the surgical sites, do not take a full shower or bath
- D. Wash the surgical site first, then shampoo and wash the rest of your body
Correct Answer: B
Rationale: The proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap. Shaving, if absolutely necessary, should be done in the operative suite immediately before the operation begins, using sterile equipment. The client needs a full shower or bath (shower preferred). Washing the surgical site last ensures that soap does not run over the cleansed site if other areas are washed first.
The Surgical Care Improvement Project (SCIP) includes which core measures?
- A. Preventing infection
- B. Preventing serious cardiac events
- C. Preventing thrombembolic events
- D. Improving surgical technique
- E. Enhancing postoperative recovery
Correct Answer: B,C,E
Rationale: The SCIP project includes core measures to prevent infection, serious cardiac events, and thrombembolic events such as deep vein thrombosis.
A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best?
- A. Malnourished clients will have fragile skin
- B. Malnourished clients always have other problems
- C. Many drugs are bound to protein in the body
- D. Poorer wound healing
- E. Weakness and fatigue are common in malnutrition
Correct Answer: A,C,D,E
Rationale: Malnutrition can lead to poorer surgical outcomes for several reasons, including fragile skin that might break down, altered pharmacokinetics due to protein binding, poorer wound healing, and weakness or fatigue that can interfere with recovery. Malnutrition is not always associated with other comorbidities.
A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the client are being met?
- A. Drain output is clear and minimal
- B. Drain site is red and swollen
- C. Drain is clogged and not draining
- D. Client reports severe pain at drain site
Correct Answer: A
Rationale: A clear and minimal drain output indicates that the surgical site is healing appropriately and there is no significant infection or fluid accumulation. Redness and swelling, a clogged drain, or severe pain could indicate complications such as infection or obstruction, which would require further intervention.