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A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?
- A. Assess the client's blood pressure
- B. Perform hand hygiene and apply gloves
- C. Reinforce the dressing with a clean one
- D. Notify the surgeon immediately
Correct Answer: B
Rationale: Before assessing or treating drainage from the wound, the nurse must perform hand hygiene and don gloves to protect both the client and nurse from infection, adhering to standard precautions.
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A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which medication and dose does the nurse prepare to administer?
- A. Flumazenil (Romazicon) 0.2 to 1 mg
- B. Flumazenil (Romazicon) 2 to 10 mg
- C. Flumazenil (Romazicon) 3 to 15 mg
- D. Naloxone (Narcan) 0.4 to 2 mg
Correct Answer: A
Rationale: Flumazenil is a benzodiazepine antagonist used to reverse the effects of midazolam. The correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist and would not be appropriate for reversing benzodiazepine-induced respiratory depression.
A postoperative client reports discomfort but denies serious pain and does not want medication. What action by the nurse is best to promote comfort?
- A. Assess the client's pain on a 0-to-10 scale
- B. Reposition the client gently
- C. Offer a warm blanket
- D. Encourage deep breathing exercises
Correct Answer: B
Rationale: Repositioning the client can help alleviate discomfort without medication, addressing the client's immediate needs. Assessing pain is important but does not directly promote comfort. Offering a blanket or encouraging breathing exercises may help but are less specific to addressing discomfort.
A postoperative client states that the sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best?
- A. Let me call the surgeon to see if you really need them.
- B. No, you have to use those for 24 hours after surgery.
- C. OK, we can remove them since you are stable now.
- D. To prevent blood clots, you need them a few more hours.
Correct Answer: D
Rationale: According to the Surgical Care Improvement Project (SCIP), prophylactic measures to prevent thrombembolic events, such as sequential compression devices, are continued for 24 hours after surgery. The nurse should explain this to the client to promote compliance. Calling the surgeon is unnecessary, and simply refusing or agreeing to remove them does not address the client's concerns or provide education.
The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first?
- A. Client with a blood pressure of 100/50 mm Hg
- B. Client with a pulse of 118 per minute
- C. Client with a respiratory rate of 8 breaths/min
- D. Client with a temperature of 96°F (35.6°C)
Correct Answer: C
Rationale: The respiratory rate is the most critical vital sign for any client who has undergone general anesthesia or is a postoperative client. A respiratory rate of 8 breaths/min is abnormally low and requires immediate assessment. The other vital signs, while concerning, are less critical in this context.
An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states 'She needs to get back to her old self.' What response by the nurse is best?
- A. Everyone comes out of surgery differently.
- B. Let's just give her some more time, okay?
- C. She may have had a stroke during surgery.
- D. Older people take longer to wake up.
Correct Answer: D
Rationale: Due to age-related changes, older adults may take longer to metabolize anesthetic agents and pain medications, leading to delayed recovery of cognitive status. The nurse should educate the family on this common occurrence. The other responses either lack specific information or suggest rare complications without evidence.