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A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.)
- A. Administer antibiotics for 72 hours.
- B. Dispose of dressings properly.
- C. Ensure a sterile environment in the operating room.
- D. Perform proper hand hygiene.
- E. Remove and replace wet dressings.
Correct Answer: B,D,E
Rationale: Proper disposal of soiled dressings, performing hand hygiene, and removing wet dressings reduce infection risk. Prophylactic antibiotics are typically stopped after 24 hours if no infection is present, and the operating room environment is not the nurse's responsibility on the postoperative unit.
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A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.)
- A. Check all over-the-counter medications for acetaminophen.
- B. Do not take more pills each day than you are prescribed.
- C. Eat a high-fiber diet and drink plenty of water.
- D. If this gives you diarrhea, loperamide (Imodium) can help.
- E. You shouldn't drive while you are taking this medication.
Correct Answer: A,B,C,E
Rationale: Percocet contains acetaminophen, so the client must check other medications to avoid exceeding the 3000 mg daily limit. Adhering to the prescribed dose, maintaining a high-fiber diet to prevent constipation, and avoiding driving due to drowsiness are key instructions. Diarrhea is not a common side effect of opioids.
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 answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?
- A. Assess the client's blood pressure
- B. Perform hand hygiene and apply gloves
- C. Reinforce the dressing with a clean one
- D. Notify the surgeon immediately
Correct Answer: B
Rationale: Before assessing or treating drainage from the wound, the nurse must perform hand hygiene and don gloves to protect both the client and nurse from infection, adhering to standard precautions.
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.
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.