Nokea
The nurse documents attainment of expected outcomes in the preoperative phase as part of the perioperative plan of care. Which outcomes were met for Gabrielle? Select all that apply.
- A. Correct return demonstration of postoperative activities designed to prevent complications
- B. Physical and emotional readiness for operative procedure; appropriate for age
- C. Decreased risk for surgical site, catheter-based, and community-acquired infections
- D. Caregiver articulation of when to call the provider for follow-up and/or intervention
- E. Pulse oximetry >98% on room air
Correct Answer: B,D,E
Rationale: Gabrielle's nervous but smiling response indicates physical and emotional readiness (B). The scenario implies her mother was engaged in discussions about postoperative care, suggesting caregiver articulation of follow-up needs (D). Pulse oximetry >98% on room air (E) is a standard preoperative outcome, assumed met given no contrary indications.
You may also like to solve these questions
A nurse teaches a patient the rationale for performing leg exercises after surgery. How does the nurse best explain the purpose of the exercises to the patient?
- A. Improves respiratory function
- B. Maintains functional abilities
- C. Provides diversional activities
- D. Increases venous return
Correct Answer: D
Rationale: Leg exercises promote venous return and decrease complications related to venous stasis causing DVT and help prevent muscle weakness. These exercises also decrease risk for thrombophlebitis and emboli.
A nurse is preparing a patient for same-day surgery. Which of these patient-related findings must the nurse report immediately?
- A. Asking how long after the surgery they can leave the hospital
- B. Received an oral anticoagulant last night
- C. Surgeon has not yet filled out the consent form
- D. Blood pressure is 142/86
Correct Answer: B
Rationale: Patients receiving anticoagulants are at risk for bleeding or hemorrhage during invasive and surgical procedures. Wanting to know an anticipated discharge date is expected, the surgeon can fill out the consent form prior to sedation, and a slight increase in blood pressure is possible related to anxiety before surgery.
An adult patient awaiting surgery says to the nurse, 'I am so frightened-what if I don't wake up?' What is the nurse's best response?
- A. Are you worried about the anesthesia?
- B. Tell me what concerns you most.
- C. Your surgeon is great; she operated on my aunt!
- D. Many people are anxious before surgery.
Correct Answer: B
Rationale: An open-ended question that allows the patient to express concerns, fears, and feelings is therapeutic and most appropriate. The other options suggest 'yes/no' answers or suggest issues that may not be present. This type of communication does not allow the patient to clarify their thoughts.
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 is preparing a patient for a cesarean birth using spinal anesthesia. Which effects of anesthesia will the nurse teach the patient to expect? Select all that apply.
- A. Loss of consciousness
- B. Inability to speak
- C. Reduction or loss of deep tendon reflexes
- D. Loss of sensation below the injection
- E. Inability to move the lower extremities
- F. Prolonged pain relief after other anesthesia wears off
Correct Answer: D,E
Rationale: A localized loss of sensation, loss of motor function, and possible loss of reflexes occur with a regional anesthetic. Loss of consciousness, including speech and relaxation of skeletal muscles, occurs with general anesthesia. Prolonged pain relief after other anesthesia wears off and infiltration of the underlying tissues in an operative area occur with topical anesthesia.