Nokea
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.
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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.
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.
An older adult who is scheduled for a hip replacement is taking several medications on a regular basis. Which group of medications does the nurse identify as a surgical risk for this patient?
- A. Anticoagulants
- B. Antacids
- C. Laxatives
- D. Sedatives
Correct Answer: A
Rationale: Anticoagulant medications increase the risk for hemorrhage intra- and postoperatively.
The nurse documents attainment of expected outcomes in the preoperative phase as part of the perioperative plan of care. Which outcomes were met for Gabrielle? Select all that apply.
- A. Correct return demonstration of postoperative activities designed to prevent complications
- B. Physical and emotional readiness for operative procedure; appropriate for age
- C. Decreased risk for surgical site, catheter-based, and community-acquired infections
- D. Caregiver articulation of when to call the provider for follow-up and/or intervention
- E. Pulse oximetry >98% on room air
Correct Answer: B,D,E
Rationale: Gabrielle's nervous but smiling response indicates physical and emotional readiness (B). The scenario implies her mother was engaged in discussions about postoperative care, suggesting caregiver articulation of follow-up needs (D). Pulse oximetry >98% on room air (E) is a standard preoperative outcome, assumed met given no contrary indications.
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.