Nokea
Based on the objective and subjective assessment of this patient, which priority problem should the nurse identify to guide the perioperative plan of care?
- A. Bleeding risk
- B. Activity intolerance
- C. Acute anxiety
- D. Thermal injury risk
Correct Answer: C
Rationale: Gabrielle's calm but cooperative behavior, coupled with her reluctance to let go of her mother, indicates acute anxiety as the priority problem. Addressing anxiety is critical to ensure a smooth perioperative experience, as it can impact cooperation and emotional readiness for surgery.
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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 has been asked to witness a patient signature on an informed consent form for surgery. What communication from the surgeon does the nurse expect the patient to receive before signing the form? Select all that apply.
- A. Option of nontreatment
- B. Underlying disease process and its natural course
- C. Notice that once the form is signed, the patient cannot withdraw the consent
- D. Explanation of the guaranteed outcome of the procedure or treatment
- E. Name and qualifications of the provider of the procedure or treatment
- F. Explanation of the risks and benefits of the procedure or treatment
Correct Answer: A,B,E,F
Rationale: The information communicated while obtaining informed consent includes the description of the procedure or treatment; potential alternative therapies; the option of nontreatment; the underlying disease process and its natural course; the name and qualifications of the health care provider performing the procedure or treatment; explanation of the risks and benefits; explanation that the patient has the right to refuse treatment; explanation that consent can be withdrawn; and explanation of expected (not guaranteed) outcome, recovery, and rehabilitation plan and course.
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.
Which solution is reasonable and safe for this transition of care?
- A. Gabrielle's mom will be given time alone with Gabrielle in the preoperative room to provide comfort to Gabrielle
- B. Gabrielle's mom will accompany Gabrielle to the surgical suite and remain with Gabrielle until the inhaled anesthesia takes effect
- C. Gabrielle's mom will be at the preoperative bedside while the nurse initiates IV therapy and administers an IV sedative
- D. Gabrielle's mom will administer an oral sedative to Gabrielle under the supervision of the nurse
Correct Answer: B
Rationale: Allowing Gabrielle's mother to accompany her to the surgical suite until anesthesia takes effect is a safe and reasonable solution. It provides comfort and reduces anxiety during the transition, while ensuring clinical safety under controlled conditions.
A nurse is caring for a postoperative patient who has been on bedrest for 5 days. What interventions will the nurse use to prevent deep vein thrombosis (DVT)? Select all that apply.
- A. Administering analgesics
- B. Documenting daily calf circumference
- C. Assessing vital signs every 4 hours
- D. Encouraging ambulation
- E. Applying intermittent pneumatic compression devices (IPCDs)
- F. Providing education on pain management
Correct Answer: D,E
Rationale: To prevent DVT, the nurse plans to apply an IPCD and antiembolism stockings. Assessments such as vital signs and calf circumference will detect but not prevent DVT. Maintaining bedrest continues to promote risk, and early ambulation helps prevent DVT.