Nokea
A patient underwent an open bowel resection 2 days ago and the nurses most recent assessment of the patients abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have caused the dehiscence?
- A. The patients surgical dressing was changed yesterday and today
- B. The patient has vomited three times in the past 12 hours
- C. The patient has begun voiding on the commode instead of a bedpan
- D. The patient used PCA until this morning
Correct Answer: B
Rationale: Vomiting can produce tension on wounds, particularly of the torso. Dressing changes and light mobilization are unlikely to cause dehiscence. The use of a PCA is not associated with wound dehiscence.
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The nurses aide notifies the nurse that a patient has decreased oxygen saturation levels. The nurse assesses the patient and finds that he is tachypnic, has crackles on auscultation, and his sputum is frothy and pink. The nurse should suspect what complication?
- A. Pulmonary embolism
- B. Atelectasis
- C. Laryngospasm
- D. Flash pulmonary edema
Correct Answer: D
Rationale: Flash pulmonary edema occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation; tachypnea; tachycardia; decreased pulse oximetry readings; frothy, pink sputum; and crackles on auscultation. Laryngospasm does not cause crackles or frothy, pink sputum. The patient with atelectasis has decreased breath sounds over the affected area; the scenario does not indicate this. A pulmonary embolism does not cause this symptomatology.
The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention?
- A. Check the patients oxygen saturation level, continue to monitor for apnea, and perform a focused assessment
- B. Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw
- C. Assess the arterial pulses, and place the patient in the Trendelenburg position
- D. Reintubate the patient
Correct Answer: B
Rationale: When a nurse finds a patient who is not breathing, the priority intervention is to open the airway and treat a possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the head back and then pushes forward on the angle of the lower jaw or performs the jaw thrust method to open the airway. This is an emergency and requires the basic life support intervention of airway, breathing, and circulation assessment. Arterial pulses should be checked only after airway and breathing have been established. Reintubation and resuscitation would begin after rapidly ruling out a hypopharyngeal obstruction.
The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion?
- A. Describe the appearance of the dressing in the electronic health record
- B. Photograph the patients abdomen for later comparison using a smartphone
- C. Trace the outline of the drainage on the dressing for future comparison
- D. Remove and weigh the dressing, reapply it, and then repeat in 8 hours
Correct Answer: C
Rationale: Spots of drainage on a dressing are outlined with a pen, and the date and time of the outline are recorded on the dressing so that increased drainage can be easily seen. A dressing is never removed and then reapplied. Photographs normally require informed consent, so they would not be used for this purpose. Documentation is necessary, but does not confirm or rule out an increase in drainage.
The nurse is caring for an 82-year-old female patient in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurses subsequent assessment?
- A. Postoperative confusion in older adults is an indication of impaired oxygenation or possibly a stroke during surgery
- B. Confusion, restlessness, and agitation are expected postoperative findings in older adults and they will diminish in time
- C. Postoperative confusion is common in the older adult patient, but it could also indicate a significant blood loss
- D. Confusion, restlessness, and agitation indicate an underlying cognitive deficit such as dementia
Correct Answer: C
Rationale: Postoperative confusion is common in the older adult patient, but it could also indicate blood loss and the potential for hypovolemic shock; it is a critical symptom for the nurse to identify. Despite being common, it is not considered to be an expected finding. Postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery, but blood loss is more likely. A new onset of confusion, restlessness, and agitation does not necessarily suggest an underlying cognitive disorder.
The PACU nurse is caring for a male patient who had a hernia repair. The patients blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery?
- A. Dysrhythmias, blood loss, and hyperthermia
- B. Electrolyte imbalances and neurologic changes
- C. A parasympathetic reaction and low blood volumes
- D. Pain, hypoxia, or bladder distention
Correct Answer: D
Rationale: Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Dysrhythmias, blood loss, hyperthermia, electrolyte imbalances, and neurologic changes are not common postoperative reasons for hypertension. A parasympathetic reaction and low blood volumes would cause hypotension.