Nokea
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.
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A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN?
- A. Cleaning around the drain per agency protocol
- B. Placing a new sterile gauze under the drain
- C. Securing the drain safety pin to the sheets
- D. Using sterile technique to empty the drain
Correct Answer: C
Rationale: The safety pin that prevents the drain from slipping back into the client's body should be pinned to the client's gown, not the bedding. Pinning it to the sheets could cause the drain to pull out when the client moves. The other actions are appropriate.
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.
The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first?
- A. Client with a blood pressure of 100/50 mm Hg
- B. Client with a pulse of 118 per minute
- C. Client with a respiratory rate of 8 breaths/min
- D. Client with a temperature of 96°F (35.6°C)
Correct Answer: C
Rationale: The respiratory rate is the most critical vital sign for any client who has undergone general anesthesia or is a postoperative client. A respiratory rate of 8 breaths/min is abnormally low and requires immediate assessment. The other vital signs, while concerning, are less critical in this context.
A postoperative client states that the sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best?
- A. Let me call the surgeon to see if you really need them.
- B. No, you have to use those for 24 hours after surgery.
- C. OK, we can remove them since you are stable now.
- D. To prevent blood clots, you need them a few more hours.
Correct Answer: D
Rationale: According to the Surgical Care Improvement Project (SCIP), prophylactic measures to prevent thrombembolic events, such as sequential compression devices, are continued for 24 hours after surgery. The nurse should explain this to the client to promote compliance. Calling the surgeon is unnecessary, and simply refusing or agreeing to remove them does not address the client's concerns or provide education.