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An enterostomal therapy nurse is caring for a postoperative client with a gaping wound. Which nursing measure is most helpful when a wound dressing adheres to the wound bed?
- A. Place a transparent dressing between the wound and dressing.
- B. Place an emollient based ointment on the wound bed.
- C. Use normal saline to soak the dressing for removal.
- D. Allow the dressing to dry and release the wound bed.
Correct Answer: C
Rationale: When a dressing adheres to the wound bed, using normal saline to moisten the dressing material can loosen the dressing for easier dressing removal without damaging the new tissue or causing discomfort. The transparent dressing and ointment are not helpful in assisting with dressing removal. Allowing the dressing to dry promotes wound adherence.
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A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants?
- A. Scrub nurse
- B. Circulating nurse
- C. First assistant
- D. Certified registered nurse anesthetist
Correct Answer: A
Rationale: The scrub nurse is sterile and assists the surgical team by handing instruments to the surgeon, preparing sutures, receiving specimens to be sent to the lab, and counting sponges and needles. The circulating nurse is not sterile and obtains and opens sterile equipment, adjusts lights, and keeps records. The first assistant is involved with the client's preoperative care. The certified registered nurse anesthetist assists in the client's anesthesia.
The nurse is completing an assessment of the client prior to surgery. What area(s) of the client assessment should the nurse question further? Select all that apply.
- A. Medication
- B. Elimination
- C. Activity
- D. Support system
- E. Dietary preferences
Correct Answer: A,B,C,D
Rationale: When preparing a client for surgery, these areas need to be addressed: skin preparation, elimination, attire/grooming, prosthesis, foods and fluids, and care of valuables. In addition, medication, activity, and the client's support system must be assessed. Dietary preferences of the client would not be a priority during the preoperative assessment.
The client required reversal drugs after surgery. What nursing intervention is required when caring for a client who is treated with reversal drugs?
- A. Instruct the client to lie flat.
- B. Observe the client for an extended period.
- C. Help the client slowly move to an upright or standing position.
- D. Emphasize the dietary restriction.
Correct Answer: B
Rationale: If reversal drugs are required, the nurse must observe the client for an extended period because the reversal effects nearly always are shorter than the effects of the drugs being reversed. This may result in sedation. The client need not lie flat and may not require assistance for ambulation. There is no specific dietary restriction required when treated with reversal drugs.
The nurse is working in the preoperative area with a client going to surgery for a cholecystectomy. The client has histaminez-receptor antagonists prescribed preoperatively. The client asks the nurse why these medications are needed. What would be the nurse's best answer?
- A. These medications slow motor activity.
- B. These medications decrease the amount of anesthesia you will need.
- C. These medications decrease anxiety before surgery.
- D. These medications decrease gastric acidity and volume.
Correct Answer: D
Rationale: The anesthesiologist frequently prescribes preoperative medications. Common preoperative medications include the following: anticholinergics, which decrease respiratory tract secretions, dry mucous membranes, and interrupt vagal stimulation; anti anxiety drugs, which reduce preoperative anxiety, slow motor activity, and promote induction of anesthesia; histaminez-receptor antagonists, which decrease gastric acidity and volume; narcotics, which decrease the amount of anesthesia needed, help reduce anxiety and pain, and promote sleep; sedatives, which promote sleep, decrease anxiety, and reduce the amount of anesthesia needed; and tranquilizers, which reduce nausea, prevent emesis, and enhance preoperative sedation.
The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?
- A. Requirement of intermittent catheterization
- B. Calculus formation
- C. Urine retention
- D. Urinary infection
Correct Answer: C
Rationale: Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus.