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A nurse in the PACU is preparing to receive a patient from surgery who sustained a ruptured spleen in a motor vehicle accident. Which of these system assessments will take priority?
- A. Neurologic system, ambulatory function
- B. Cardiovascular system, vital signs
- C. GI system, bowel function
- D. Integumentary, skin breakdown
Correct Answer: B
Rationale: The priority assessment focuses on the ruptured organ, blood loss, and monitoring for early signs of shock. Tachycardia, the first sign of shock, and decreasing blood pressure must be immediately reported to the health care provider. The neurologic system may be affected due to anesthesia, but ambulatory function is not the immediate priority. The nurse anticipates reduced or absent bowel sounds after surgery, but risk for blood loss is the priority. The nurse plans to promote wound healing and repositions the patient to prevent skin breakdown; however, hemorrhage and early detection of shock is the priority at this time.
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While assessing a patient in the PACU following abdominal surgery, a nurse promptly contacts the surgeon for which of these findings? Select all that apply.
- A. Tachycardia
- B. IV with normal saline solution
- C. Wound drainage
- D. Patient restless
- E. Patient reports incisional pain 8/10
Correct Answer: A,C,D
Rationale: Increased wound drainage, restlessness, increasing pulse, and decreasing blood pressure are symptoms of blood loss/hemorrhage and must be promptly identified to prevent shock. Diminished bowel sounds are expected after surgery and anesthesia. Incisional pain is anticipated; the nurse uses prescriptions for analgesia to help resolve pain. Due to NPO status and blood loss from surgery, IV fluids are administered.
A nurse is caring for a patient who is obese and has had abdominal surgery. The nurse prioritizes a plan to prevent what postoperative complication?
- A. Anesthetic interactions
- B. Impaired wound healing
- C. Weight gain
- D. Flatulence
Correct Answer: B
Rationale: Adipose (fatty) tissue has poor blood supply, which places the obese patient at risk for delayed wound healing, wound infection, and disruption in the integrity of the wound. Medication interactions are not the primary concern and are managed by the nurse anesthetist or anesthesiologist. Postoperative bleeding and flatulence (gas) after anesthesia are concerns for all patients, not just those with obesity.
A nurse has been asked to witness a patient signature on an informed consent form for surgery. What communication from the surgeon does the nurse expect the patient to receive before signing the form? Select all that apply.
- A. Option of nontreatment
- B. Underlying disease process and its natural course
- C. Notice that once the form is signed, the patient cannot withdraw the consent
- D. Explanation of the guaranteed outcome of the procedure or treatment
- E. Name and qualifications of the provider of the procedure or treatment
- F. Explanation of the risks and benefits of the procedure or treatment
Correct Answer: A,B,E,F
Rationale: The information communicated while obtaining informed consent includes the description of the procedure or treatment; potential alternative therapies; the option of nontreatment; the underlying disease process and its natural course; the name and qualifications of the health care provider performing the procedure or treatment; explanation of the risks and benefits; explanation that the patient has the right to refuse treatment; explanation that consent can be withdrawn; and explanation of expected (not guaranteed) outcome, recovery, and rehabilitation plan and course.
Based on the objective and subjective assessment of this patient, which priority problem should the nurse identify to guide the perioperative plan of care?
- A. Bleeding risk
- B. Activity intolerance
- C. Acute anxiety
- D. Thermal injury risk
Correct Answer: C
Rationale: Gabrielle's calm but cooperative behavior, coupled with her reluctance to let go of her mother, indicates acute anxiety as the priority problem. Addressing anxiety is critical to ensure a smooth perioperative experience, as it can impact cooperation and emotional readiness for surgery.
A nurse is providing teaching for a patient scheduled to have same-day surgery. Which teaching method would be most effective in preoperative teaching for ambulatory surgery?
- A. Lecture
- B. Discussion
- C. Audiovisuals
- D. Written instructions
Correct Answer: D
Rationale: Written instructions are most effective in providing information for same-day surgery.