Nokea
A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do?
- A. Irrigate the Foley with 30 mL normal saline
- B. Notify the physician and continue to monitor the hourly urine output closely
- C. Decrease the IV fluid rate and massage the patients abdomen
- D. Have the patient sit in high-Fowlers position
Correct Answer: B
Rationale: If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/hr are reported. The urine output should continue to be monitored hourly by the nurse. Irrigation would not be warranted.
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The nurse is creating the plan of care for a patient who is status postsurgery for reduction of a femur fracture. What is the most important short-term goal for this patient?
- A. Relief of pain
- B. Adequate respiratory function
- C. Resumption of activities of daily living (ADLs)
- D. Unimpaired wound healing
Correct Answer: B
Rationale: Maintenance of the patients airway and breathing are imperative. Respiratory status is important because pulmonary complications are among the most frequent and serious problems encountered by the surgical patient. Wound healing and eventual resumption of ADLs would be later concerns. Pain management is a high priority, but respiratory function is a more acute physiological need.
The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication?
- A. Sepsis
- B. Infection
- C. Pulmonary embolism
- D. Hematoma
Correct Answer: C
Rationale: Patients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of an external pneumatic compression stocking significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection or sepsis would not be affected by an external pneumatic compression stocking. A hematoma or bruise would not be affected by the external pneumatic compression stocking unless the stockings were placed directly over the hematoma.
The nurse is admitting a patient to the medicalsurgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia?
- A. Encourage the patient to eat a balanced diet that is high in protein
- B. Encourage the patient to limit his activity for the first 72 hours
- C. Encourage the patient to take his medications as ordered
- D. Encourage the patient to use the incentive spirometer every 2 hours
Correct Answer: D
Rationale: To clear secretions and prevent pneumonia, the nurse encourages the patient to turn frequently, take deep breaths, cough, and use the incentive spirometer at least every 2 hours. These pulmonary exercises should begin as soon as the patient arrives on the clinical unit and continue until the patient is discharged. A balanced, high protein diet; visiting family in the waiting room; or taking medications as ordered would not help to clear secretions or prevent pneumonia.
A postoperative patient rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be the nurses first action?
- A. Leave and promptly notify the physician
- B. Quickly attempt to determine the cause of hemorrhage
- C. Begin resuscitation
- D. Put the patient in the Trendelenberg position
Correct Answer: B
Rationale: Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures. Resuscitation is not necessarily required and the nurse must not leave the patient. The Trendelenberg position would be contraindicated.
The nurse is caring for a patient on the medicalsurgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?
- A. Presence of an indwelling urinary catheter
- B. Rectal temperature of 99.5 F (37.5 C)
- C. Red, warm, tender incision
- D. White blood cell (WBC) count of 8,000 /mL
Correct Answer: C
Rationale: Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a patient to infection, but by itself does not indicate infection. An oral temperature of 99.5 F may not signal infection in a postoperative patient because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000 /mL.