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An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patients vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next?
- A. Administer a dose of IV analgesic
- B. Apply a cool cloth to the patients forehead
- C. Offer the patient a small amount of ice chips
- D. Turn the patient completely to one side
Correct Answer: D
Rationale: Turning the patient completely to one side allows collected fluid to escape from the side of the mouth if the patient vomits. After turning the patient to the side, the nurse can offer a cool cloth to the patients forehead. Ice chips can increase feelings of nausea. An analgesic is not administered for nausea and vomiting.
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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.
The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply.
- A. Provide all discharge instructions in writing
- B. Provide the nurses or surgeons contact information
- C. Give prescriptions to the patient
- D. Irrigate the patients incision and perform a sterile dressing change
- E. Administer a bolus dose of an opioid analgesic
Correct Answer: A,B,C
Rationale: Before discharging the patient, the nurse provides written instructions, prescriptions and the nurses or surgeons telephone number. Administration of an opioid would necessitate further monitoring to ensure safety. A dressing change would not normally be ordered on the day of surgery.
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 surgeons preoperative assessment of a patient has identified that the patient is at a high risk for venous thromboembolism. Once the patient is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the patients risk of developing this complication?
- A. Maintain the head of the bed at 45 degrees or higher
- B. Encourage early ambulation
- C. Encourage oral fluid intake
- D. Perform passive range-of-motion exercises every 8 hours
Correct Answer: B
Rationale: The benefits of early ambulation and leg exercises in preventing DVT cannot be overemphasized, and these activities are recommended for all patients, regardless of their risk. Increasing the head of the bed is not effective. Ambulation is superior to passive range-of-motion exercises. Fluid intake is important, but is less protective than early ambulation.
The nurse is preparing to change a patients abdominal dressing. The nurse recognizes the first step is to provide the patient with information regarding the procedure. Which of the following explanations should the nurse provide to the patient?
- A. The dressing change is often painful, and we will be giving you pain medication prior to the procedure so you do not have to worry
- B. During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to
- C. The dressing change should not be painful, but you can never be sure, and infection is always a concern
- D. The best time for doing a dressing change is during lunch so we are not interrupted. I will provide privacy, and it should not be painful
Correct Answer: B
Rationale: When having dressings changed, the patient needs to be informed that the dressing change is a simple procedure with little discomfort; privacy will be provided; and the patient is free to look at the incision or even assist in the dressing change itself. If the patient decides to look at the incision, assurance is given that the incision will shrink as it heals and that the redness will likely fade. Dressing changes should not be painful, but giving pain medication prior to the procedure is always a good preventive measure. Telling the patient that the dressing change should not be painful, but you can never be sure, and infection is always a concern does not offer the patient any real information or options and serves only to create fear. The best time for dressing changes is when it is most convenient for the patient; nutrition is important so interrupting lunch is probably a poor choice.