Nokea
The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion?
- A. Describe the appearance of the dressing in the electronic health record
- B. Photograph the patients abdomen for later comparison using a smartphone
- C. Trace the outline of the drainage on the dressing for future comparison
- D. Remove and weigh the dressing, reapply it, and then repeat in 8 hours
Correct Answer: C
Rationale: Spots of drainage on a dressing are outlined with a pen, and the date and time of the outline are recorded on the dressing so that increased drainage can be easily seen. A dressing is never removed and then reapplied. Photographs normally require informed consent, so they would not be used for this purpose. Documentation is necessary, but does not confirm or rule out an increase in drainage.
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The PACU nurse is caring for a 45-year-old male patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply.
- A. Hypotension
- B. Hypervolemia
- C. Heart murmurs
- D. Dysrhythmias
- E. Hypertension
Correct Answer: A,D,E
Rationale: The primary cardiovascular complications seen in the PACU include hypotension and shock, hemorrhage, hypertension, and dysrhythmias. Heart murmurs are not adverse reactions to surgery. Hypervolemia is not a common cardiovascular complication seen in the PACU, though fluid balance must be vigilantly monitored.
The nurse is creating the plan of care for a patient who is status postsurgery for reduction of a femur fracture. What is the most important short-term goal for this patient?
- A. Relief of pain
- B. Adequate respiratory function
- C. Resumption of activities of daily living (ADLs)
- D. Unimpaired wound healing
Correct Answer: B
Rationale: Maintenance of the patients airway and breathing are imperative. Respiratory status is important because pulmonary complications are among the most frequent and serious problems encountered by the surgical patient. Wound healing and eventual resumption of ADLs would be later concerns. Pain management is a high priority, but respiratory function is a more acute physiological need.
The perioperative nurse is preparing to discharge a female patient home from day surgery performed under general anesthetic. What instruction should the nurse give the patient prior to the patient leaving the hospital?
- A. The patient should not drive herself home
- B. The patient should take an OTC sleeping pill for 2 nights
- C. The patient should attempt to eat a large meal at home to aid wound healing
- D. The patient should remain in bed for the first 48 hours postoperative
Correct Answer: A
Rationale: Although recovery time varies, depending on the type and extent of surgery and the patients overall condition, instructions usually advise limited activity for 24 to 48 hours. Complete bedrest is contraindicated in most cases, however. During this time, the patient should not drive a vehicle and should eat only as tolerated. The nurse does not normally make OTC recommendations for hypnotics.
The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what means?
- A. Late intention
- B. Second intention
- C. Third intention
- D. First intention
Correct Answer: C
Rationale: Third-intention healing or secondary suture is used for deep wounds that either had not been sutured early or that had the suture break down and are resutured later, which is what has happened in this case. Secondary suture brings the two opposing granulation surfaces back together; however, this usually results in a deeper and wider scar. These wounds are also packed postoperatively with moist gauze and covered with a dry, sterile dressing. Late intention is a term that sounds plausible, but is not used in practice. Second intention is when the wound is left open and the wound is filled with granular tissue. First intention wounds are wounds made aseptically with a minimum of tissue destruction.
A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do?
- A. Irrigate the Foley with 30 mL normal saline
- B. Notify the physician and continue to monitor the hourly urine output closely
- C. Decrease the IV fluid rate and massage the patients abdomen
- D. Have the patient sit in high-Fowlers position
Correct Answer: B
Rationale: If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/hr are reported. The urine output should continue to be monitored hourly by the nurse. Irrigation would not be warranted.