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The nurse has received shift report on a postoperative surgical client. Which medication prescription would indicate that the medication was being administered prophylactically?
- A. A 5% dextrose in 0.5 NSS to infuse at 100 mL/hr
- B. Percocet two tablets every 4 hours as needed for pain
- C. Humulin NPH 12 units at 0800
- D. Cefazolin 1 g IV every 6 hours for 24 hours
Correct Answer: D
Rationale: Cefazolin, an antibiotic, is commonly administered prophylactically to prevent postoperative infections. A 5% dextrose in 0.5 NSS is used for fluid maintenance, Percocet is for pain management, and Humulin NPH is for diabetes management, none of which are primarily prophylactic in this context.
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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.
The nurse is admitting and preparing the client for surgery. Following administration of lorazepam 2 mg orally, one time dose, which safety measure is most appropriate?
- A. Place the client in a semi-Fowler's position.
- B. Place the side rails in the up position.
- C. Remove the water pitcher from the bedside.
- D. Instruct the family to call for any client needs.
Correct Answer: B
Rationale: Lorazepam is a common hypnotic administered to reduce preoperative anxiety. The most appropriate safety measure is to limit the client's ability to get out of bed following administration of a preoperative sedative. Assistance is needed to maintain client safety. Placing the client in a semi-Fowler's position aids in gas exchange, but this is not indicated as a concern in this question and does not relate to a safety concern associated with this medication. Water should not be at the bedside for a client in the preoperative phase. Families can be helpful support for the client; however, it is the nurse's responsibility to maintain safety.
The nurse is caring for a client needing emergency surgery. Which preoperative teaching can be omitted when preparing a client for surgery?
- A. Effective coughing and deep breathing
- B. Types of postoperative pain medication
- C. Post-discharge diet
- D. Knowledge of surgical procedure
Correct Answer: C
Rationale: The preoperative teaching that could be omitted due to the need to obtain emergency surgery is explaining the post-discharge diet. This is not essential information to improve client participation in the postoperative recovery. Coughing and deep breathing are essential in the immediate postoperative period. Clients are often concerned about postoperative pain so instruction on pain medication can decrease anxiety. Knowledge of the surgical procedure must be explained by a physician when signing a surgical consent.
The nurse is reviewing a preoperative informed consent when preparing the client for surgery. Which content(s) of the informed consent is required? Select all that apply.
- A. Explanation of procedure
- B. Estimated time of procedure
- C. Potential risks
- D. Benefits of surgery
- E. Personnel present
- F. Description of alternatives
Correct Answer: A,C,D,F
Rationale: Informed consents should be in writing and contain an explanation of procedure and risks, description of benefits and alternative, an offer to answer questions about procedure, ability to withdraw consent, and statement informing the client if the protocol differs from customary procedure. An estimated time of procedure and personnel present are not required in the informed consent.
The PACU nurse is about to administer pain medication to an older adult client who is recovering from surgery. What does this client's age put them at increased risk for? Select all that apply.
- A. Acute confusion
- B. Respiratory depression
- C. Disorientation
- D. Infection
- E. Greater requirement for pain medication
Correct Answer: A,B,C,D
Rationale: The older adult client requiring pain medication postoperatively is at greater risk for confusion, disorientation, respiratory depression, and infection. The older adult client does not have a greater requirement for pain medication, because even standard doses may cause complications that would not occur in younger clients.