Nokea
An adult patient awaiting surgery says to the nurse, 'I am so frightened-what if I don't wake up?' What is the nurse's best response?
- A. Are you worried about the anesthesia?
- B. Tell me what concerns you most.
- C. Your surgeon is great; she operated on my aunt!
- D. Many people are anxious before surgery.
Correct Answer: B
Rationale: An open-ended question that allows the patient to express concerns, fears, and feelings is therapeutic and most appropriate. The other options suggest 'yes/no' answers or suggest issues that may not be present. This type of communication does not allow the patient to clarify their thoughts.
You may also like to solve these questions
A nurse is preparing a patient for a cesarean birth using spinal anesthesia. Which effects of anesthesia will the nurse teach the patient to expect? Select all that apply.
- A. Loss of consciousness
- B. Inability to speak
- C. Reduction or loss of deep tendon reflexes
- D. Loss of sensation below the injection
- E. Inability to move the lower extremities
- F. Prolonged pain relief after other anesthesia wears off
Correct Answer: D,E
Rationale: A localized loss of sensation, loss of motor function, and possible loss of reflexes occur with a regional anesthetic. Loss of consciousness, including speech and relaxation of skeletal muscles, occurs with general anesthesia. Prolonged pain relief after other anesthesia wears off and infiltration of the underlying tissues in an operative area occur with topical anesthesia.
During preoperative teaching about pain management, the patient asks the nurse to explain how a PCA pump works. What will the nurse teach the patient about PCA?
- A. It allows the patient to be completely free of pain during the postoperative period.
- B. It allows the patient to take unlimited amounts of medication as needed.
- C. It allows the patient to choose the type of medication given postoperatively.
- D. It permits the patient to self-administer limited doses of pain medication.
Correct Answer: D
Rationale: The nurse educates the patient that the PCA pump allows patients to self-administer doses of pain-relieving medication within health care provider-prescribed times and dose limits. It is not realistic to promise absence of pain or unlimited access to medication nor allow the patient to select the pain medication prescribed.
A nurse in the PACU is preparing to receive a patient from surgery who sustained a ruptured spleen in a motor vehicle accident. Which of these system assessments will take priority?
- A. Neurologic system, ambulatory function
- B. Cardiovascular system, vital signs
- C. GI system, bowel function
- D. Integumentary, skin breakdown
Correct Answer: B
Rationale: The priority assessment focuses on the ruptured organ, blood loss, and monitoring for early signs of shock. Tachycardia, the first sign of shock, and decreasing blood pressure must be immediately reported to the health care provider. The neurologic system may be affected due to anesthesia, but ambulatory function is not the immediate priority. The nurse anticipates reduced or absent bowel sounds after surgery, but risk for blood loss is the priority. The nurse plans to promote wound healing and repositions the patient to prevent skin breakdown; however, hemorrhage and early detection of shock is the priority at this time.
A nurse on a surgical unit is aware that older adults develop reduced vital capacity as a result of normal physiologic changes. Based on these changes, which nursing intervention takes priority?
- A. Taking and recording vital signs every shift
- B. Turning, coughing, and deep breathing every 4 hours
- C. Encouraging increased intake of oral fluids
- D. Assessing bowel sounds daily
Correct Answer: B
Rationale: Reduced vital capacity in older adults decreases respiratory expansion, increasing the risk for pneumonia and atelectasis. Encouraging the patient to turn, cough, and deep breathe every 4 hours helps to prevent complications.
An older adult who is scheduled for a hip replacement is taking several medications on a regular basis. Which group of medications does the nurse identify as a surgical risk for this patient?
- A. Anticoagulants
- B. Antacids
- C. Laxatives
- D. Sedatives
Correct Answer: A
Rationale: Anticoagulant medications increase the risk for hemorrhage intra- and postoperatively.