Nokea
The intraoperative nurse is transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year-old woman. The nurse should prioritize which of the following actions?
- A. Keeping the patient sterile
- B. Keeping the patient restrained
- C. Keeping the patient warm
- D. Keeping the patient hydrated
Correct Answer: C
Rationale: Special attention is given to keeping the patient warm because elderly patients are more susceptible to hypothermia. It is all important for the nurse to pay attention to hydration, but hypovolemia does not occur as quickly as hypothermia. The patient is never sterile and restraints are very rarely necessary.
You may also like to solve these questions
The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect is the problem with the patient?
- A. Postoperative delirium
- B. Postoperative dementia
- C. Senile dementia
- D. Senile confusion
Correct Answer: A
Rationale: Postoperative delirium, characterized by confusion, perceptual and cognitive deficits, altered attention levels, disturbed sleep patterns, and impaired psychomotor skills, is a significant problem for older adults. Dementia does not have a sudden onset. Senile confusion is not a recognized health problem.
You are caring for a 71-year-old patient who is 4 days postoperative for bilateral inguinal hernias. The patient has a history of congestive heart failure and peptic ulcer disease. The patient is highly reluctant to ambulate and will not drink fluids except for hot tea with her meals. The nurses aide reports to you that this patients vital signs are slightly elevated and that she has a nonproductive cough. When you assess the patient, you auscultate crackles at the base of the lungs. What would you suspect is wrong with your patient?
- A. Pulmonary embolism
- B. Hypervolemia
- C. Hypostatic pulmonary congestion
- D. Malignant hyperthermia
Correct Answer: C
Rationale: Hypostatic pulmonary congestion, caused by a weakened cardiovascular system that permits stagnation of secretions at lung bases, may develop; this condition occurs most frequently in elderly patients who are not mobilized effectively. The symptoms are often vague, with perhaps a slight elevation of temperature, pulse, and respiratory rate, as well as a cough. Physical examination reveals dullness and crackles at the base of the lungs. If the condition progresses, then the outcome may be fatal. A pulmonary embolism does not have this presentation and hypervolemia is unlikely due to the patients low fluid intake. Malignant hyperthermia occurs concurrent with the administration of anesthetic.
A patient underwent an open bowel resection 2 days ago and the nurses most recent assessment of the patients abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have caused the dehiscence?
- A. The patients surgical dressing was changed yesterday and today
- B. The patient has vomited three times in the past 12 hours
- C. The patient has begun voiding on the commode instead of a bedpan
- D. The patient used PCA until this morning
Correct Answer: B
Rationale: Vomiting can produce tension on wounds, particularly of the torso. Dressing changes and light mobilization are unlikely to cause dehiscence. The use of a PCA is not associated with wound dehiscence.
The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication?
- A. Sepsis
- B. Infection
- C. Pulmonary embolism
- D. Hematoma
Correct Answer: C
Rationale: Patients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of an external pneumatic compression stocking significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection or sepsis would not be affected by an external pneumatic compression stocking. A hematoma or bruise would not be affected by the external pneumatic compression stocking unless the stockings were placed directly over the hematoma.
The PACU nurse is caring for a male patient who had a hernia repair. The patients blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery?
- A. Dysrhythmias, blood loss, and hyperthermia
- B. Electrolyte imbalances and neurologic changes
- C. A parasympathetic reaction and low blood volumes
- D. Pain, hypoxia, or bladder distention
Correct Answer: D
Rationale: Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Dysrhythmias, blood loss, hyperthermia, electrolyte imbalances, and neurologic changes are not common postoperative reasons for hypertension. A parasympathetic reaction and low blood volumes would cause hypotension.