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A nurse is preparing a patient for a cesarean birth using spinal anesthesia. Which effects of anesthesia will the nurse teach the patient to expect? Select all that apply.
- A. Loss of consciousness
- B. Inability to speak
- C. Reduction or loss of deep tendon reflexes
- D. Loss of sensation below the injection
- E. Inability to move the lower extremities
- F. Prolonged pain relief after other anesthesia wears off
Correct Answer: D,E
Rationale: A localized loss of sensation, loss of motor function, and possible loss of reflexes occur with a regional anesthetic. Loss of consciousness, including speech and relaxation of skeletal muscles, occurs with general anesthesia. Prolonged pain relief after other anesthesia wears off and infiltration of the underlying tissues in an operative area occur with topical anesthesia.
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A nurse is caring for a postoperative patient who has been on bedrest for 5 days. What interventions will the nurse use to prevent deep vein thrombosis (DVT)? Select all that apply.
- A. Administering analgesics
- B. Documenting daily calf circumference
- C. Assessing vital signs every 4 hours
- D. Encouraging ambulation
- E. Applying intermittent pneumatic compression devices (IPCDs)
- F. Providing education on pain management
Correct Answer: D,E
Rationale: To prevent DVT, the nurse plans to apply an IPCD and antiembolism stockings. Assessments such as vital signs and calf circumference will detect but not prevent DVT. Maintaining bedrest continues to promote risk, and early ambulation helps prevent DVT.
Which content and teaching modality best fit this particular situation?
- A. Have Gabrielle use the incentive spirometer while providing direction and encouragement
- B. Show Gabrielle the OR suite, taking time to point out the equipment and lights
- C. Have Gabrielle perform a series of arm and neck stretches
- D. Talk to Gabrielle and her mom about the likelihood of postoperative nausea and vomiting
Correct Answer: A
Rationale: Teaching Gabrielle to use the incentive spirometer with direction and encouragement is the most appropriate content and modality. It prepares her for postoperative respiratory exercises to prevent complications, is age-appropriate, and involves both her and her mother in the learning process.
A nurse on a surgical unit is aware that older adults develop reduced vital capacity as a result of normal physiologic changes. Based on these changes, which nursing intervention takes priority?
- A. Taking and recording vital signs every shift
- B. Turning, coughing, and deep breathing every 4 hours
- C. Encouraging increased intake of oral fluids
- D. Assessing bowel sounds daily
Correct Answer: B
Rationale: Reduced vital capacity in older adults decreases respiratory expansion, increasing the risk for pneumonia and atelectasis. Encouraging the patient to turn, cough, and deep breathe every 4 hours helps to prevent complications.
When caring for a patient who returned from the operating room 8 hours ago, which finding requires follow-up assessment by the nurse?
- A. Patient reports discomfort at surgical site, scale of 5/10
- B. Patient voids small amounts every 20-30 minutes
- C. Patient is sleepy and awakens only to touch
- D. Patient reports thirst and dry mouth
Correct Answer: B
Rationale: This patient is displaying typical signs of urinary retention, voiding small frequent amounts. Discomfort is expected and can be managed with prescribed analgesics. Anesthesia or opioid analgesia promotes sedation from which this patient awakens to touch. Dry mouth and thirst can result from NPO status and possible anticholinergic medication intended to dry respiratory secretions during surgery.
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.