Nokea
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.
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The nurse is creating a plan of care for a client who is about to undergo surgery. When should the nurse provide teaching to the client about care needed during the postoperative period?
- A. At discharge with an adult who will be responsible for the client
- B. On arrival to the surgical unit
- C. Following the surgical procedure
- D. At the time of discharge instructions
Correct Answer: A
Rationale: Because sedative medications affect memory for events surrounding their administration, the nurse must review discharge instructions with an adult who will be responsible for the client after discharge. Clients and family members can better be prepared and participate in the recovery period if they know what to expect. Anxiety is a factor on arrival to the surgical unit, which could interfere with learning. Pain could interfere with the learning process, following a surgical procedure.
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.
Several of the clients at the clinic are preparing to have surgery within the next 2 weeks. They are completing preoperative paperwork today with their visit. What is a reason(s) that people might need to have surgery? Select all that apply.
- A. Cosmetic
- B. Diagnostic
- C. Palliative
- D. Normative
- E. Causative
Correct Answer: A,B,C
Rationale: Reasons people have surgery include cosmetic reasons, diagnostic procedures, palliative surgeries, exploratory surgeries, and curative surgeries. Normative and causative are not reasons for surgery.
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 nurse is caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?
- A. Place pillows under the client's knees or calves.
- B. Encourage the client to move legs frequently and do leg exercises.
- C. Apply pressure on the client's lower extremities.
- D. Maintain the client in a side-lying position.
Correct Answer: B
Rationale: The nurse should encourage the client to move legs frequently and do leg exercises to prevent venous stasis and other circulatory complications. The nurse should not place pillows under the client's knees or calves unless prescribed and should avoid placing pressure on the client's lower extremities. Placing the client in a side-lying position will not help prevent venous stasis and other circulatory complications in a client who has undergone surgery.