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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.
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A postoperative client is being assessed in the postanesthesia care unit (PACU). Which assessment takes priority?
- A. Airway patency
- B. Breathing pattern
- C. Circulation status
- D. Cardiac rhythm
Correct Answer: A
Rationale: Assessing the airway always takes priority, followed by breathing and circulation. Bleeding and cardiac rhythm are part of the circulation assessment, but airway patency is the most critical in the immediate postoperative period.
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.
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 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.
A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort measures can the nurse provide? (Select all that apply.)
- A. Apply stimulation to the contralateral leg.
- B. Assess the client's willingness to try meditation.
- C. Elevate the client's operative leg and apply ice.
- D. Reduce the noise level in the client's environment.
- E. Turn the TV on loudly to distract the client.
Correct Answer: A,B,C,D
Rationale: Nonpharmacologic measures like contralateral stimulation, meditation, leg elevation with ice, and reducing environmental noise can help manage pain. Loud TV is not an effective diversion and may increase discomfort.