Nokea
A nurse is preparing a patient for same-day surgery. Which of these patient-related findings must the nurse report immediately?
- A. Asking how long after the surgery they can leave the hospital
- B. Received an oral anticoagulant last night
- C. Surgeon has not yet filled out the consent form
- D. Blood pressure is 142/86
Correct Answer: B
Rationale: Patients receiving anticoagulants are at risk for bleeding or hemorrhage during invasive and surgical procedures. Wanting to know an anticipated discharge date is expected, the surgeon can fill out the consent form prior to sedation, and a slight increase in blood pressure is possible related to anxiety before surgery.
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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.
A nurse is planning caring for a patient who had thoracic surgery. Which nursing interventions are most appropriate for patients undergoing this type of surgery?
- A. Observing for incisional wound healing
- B. Monitoring vital signs, especially pulse and blood pressure
- C. Instructing the patient on the proper use of the incentive spirometer
- D. Applying antiembolism stockings
Correct Answer: A,B,C
Rationale: A thoracic incision, near or overlying the lungs, makes it difficult or painful for patients to take deep breaths and cough. The nurse uses analgesics, repositioning, coughing and deep breathing, and an incentive spirometer to promote respiratory expansion and airway clearance to decrease the risk for respiratory complications. Monitoring vital signs is also critical to detect complications early.
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 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.
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.