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The client has undergone an abdominal perineal resection of the colon for colon cancer with a left lower quadrant colostomy. Which interventions should the nurse implement? Select all that apply.
- A. Assess the stoma for color every four (4) hours and prn.
- B. Encourage the client to turn, cough, and deep breathe every two (2) hours.
- C. Maintain the head of the bed 30 to 40 degrees elevated at all times.
- D. Auscultate for bowel sounds every four (4) hours.
- E. Administer pain medications sparingly to prevent addiction.
Correct Answer: A,B,D
Rationale: Stoma assessment monitors viability, coughing/deep breathing prevents atelectasis, and bowel sound checks assess GI function. HOB elevation is case-specific, and sparing pain medication risks undertreatment.
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The nurse is interviewing a surgical client in the holding area. Which information should the nurse report to the anesthesiologist? Select all that apply.
- A. The client has loose, decayed teeth.
- B. The client is experiencing anxiety.
- C. The client smokes two (2) packs of cigarettes a day.
- D. The client has had a chest x-ray which does not show infiltrates.
- E. The client reports using herbs.
Correct Answer: A,C,E
Rationale: Loose teeth risk airway obstruction, smoking affects respiratory function and anesthesia, and herbs (e.g., ginseng) may interact with anesthesia, requiring anesthesiologist notification. Anxiety is common, and clear x-rays are reassuring.
The nurse is caring for a male client scheduled for abdominal surgery. Which interventions should the nurse include in the plan of care? Select all that apply.
- A. Perform passive range-of-motion exercises.
- B. Discuss how to cough and deep breathe effectively.
- C. Tell the client he can have a meal in the PACU.
- D. Teach ways to manage postoperative pain.
- E. Discuss events which occur in the postanesthesia care unit.
Correct Answer: B,D,E
Rationale: Coughing/deep breathing prevents atelectasis, pain management enhances recovery, and PACU education reduces anxiety. Passive ROM is postoperative, and meals are not allowed in PACU.
The client is in the lithotomy position during surgery. Which nursing intervention should be implemented to decrease a complication from the positioning?
- A. Increase the intravenous fluids.
- B. Lower one leg at a time.
- C. Raise the foot of the stretcher.
- D. Administer epinephrine, a vasopressor.
Correct Answer: B
Rationale: Lowering legs sequentially prevents rapid blood pressure drops from venous pooling, reducing circulatory complications in lithotomy. Fluids, stretcher elevation, and epinephrine are unrelated.
The client is complaining of left shoulder pain. Which intervention should the nurse implement first?
- A. Assess the neurovascular status of the left hand.
- B. Check the medication administration record (MAR).
- C. Ask if the client wants pain medication.
- D. Administer the client's pain medication.
Correct Answer: A
Rationale: Assessing neurovascular status rules out referred pain from cardiac or vascular issues, the priority per ABCs. MAR checks, asking about medication, and administration follow.
Which nursing intervention has the highest priority when preparing the client for a surgical procedure?
- A. Pad the client's elbows and knees.
- B. Apply soft restraint straps to the extremities.
- C. Prepare the client's incision site.
- D. Document the temperature of the room.
Correct Answer: C
Rationale: Preparing the incision site ensures asepsis, reducing infection risk, the highest priority. Padding, restraints, and room temperature are secondary.