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A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the client's plan of care to minimize the potential for this occurring? (Select all that apply.)
- A. Allow family and friends to visit as the client desires.
- B. Ask the client about coping techniques frequently used.
- C. Keep the client bathed and groomed.
- D. Place the client in a room secluded at the end of the hall.
- E. Provide the client with uninterrupted periods of sleep.
Correct Answer: A,B,C,E
Rationale: To minimize confusion, the nurse should encourage familiar visitors, assess coping techniques, maintain hygiene, and ensure adequate sleep. Secluding the client may increase sensory deprivation and confusion.
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A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort measures can the nurse provide? (Select all that apply.)
- A. Apply stimulation to the contralateral leg.
- B. Assess the client's willingness to try meditation.
- C. Elevate the client's operative leg and apply ice.
- D. Reduce the noise level in the client's environment.
- E. Turn the TV on loudly to distract the client.
Correct Answer: A,B,C,D
Rationale: Nonpharmacologic measures like contralateral stimulation, meditation, leg elevation with ice, and reducing environmental noise can help manage pain. Loud TV is not an effective diversion and may increase discomfort.
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 has the following orders: IV lactated Ringer's 125 mL/hr, NG tube to low continuous suction, Replace NG output every 4 hours with normal saline over 4 hours, Morphine sulfate 2 mg IV push every hour as needed for pain, NPO, Up in chair tonight. At 1600 (4:00 PM) the nurse measures the nasogastric (NG) output from noon to be 200 mL. What is the client's total IV rate for the next 4 hours? (Record your answer using a whole number.) mL/hr
- A. 150 mL/hr
- B. 175 mL/hr
- C. 200 mL/hr
- D. 225 mL/hr
Correct Answer: B
Rationale: The total IV rate is calculated as the baseline IV rate (125 mL/hr) plus the NG output replacement (200 mL over 4 hours = 50 mL/hr). Thus, 125 mL/hr + 50 mL/hr = 175 mL/hr.
A nurse entering the postoperative area learns which principles about the postoperative period? (Select all that apply.)
- A. All phases require the client to be in the hospital.
- B. Phase I involves immediate recovery in the PACU.
- C. Phase II ends when the client is stable and awake.
- D. Phase III involves extended recovery at home.
- E. Phase III ends when the client is fully recovered.
Correct Answer: B,D,E
Rationale: Phase I occurs in the PACU for immediate recovery, Phase II ends when the client is stable and awake, and Phase III involves extended recovery, often at home. Not all phases require hospitalization, and Phase III does not necessarily end with full recovery but with ongoing recovery at home.
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.