Nokea
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.
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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 during an intraoperative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?
- A. Pulse rate of 110 beats/min
- B. Respiratory rate of 18 breaths/min
- C. Blood pressure of 104/62 mm Hg
- D. Temperature of 102.5?°F (39?°C)
Correct Answer: D
Rationale: Intraoperative hyperthermia can indicate a life-threatening condition called malignant hyperthermia. The circulating nurse closely monitors the client for signs of hyperthermia. The pulse rate, respiratory rate, and blood pressure did not indicate a significant concern.
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.
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 caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock?
- A. Weak and rapid pulse rate
- B. Warm, dry skin
- C. Pooling of secretions in the lungs
- D. Obstructed airway
Correct Answer: A
Rationale: Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock.