Nokea
The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do?
- A. Sit in a chair for 10 minutes prior to ambulating
- B. Drink plenty of fluids to increase circulating blood volume
- C. Stand upright for 2 to 3 minutes prior to ambulating
- D. Perform range-of-motion exercises for each joint
Correct Answer: C
Rationale: Older adults are at an increased risk for orthostatic hypotension secondary to age-related changes in vascular tone. The patient should sit up and then stand for 2 to 3 minutes before ambulating to alleviate orthostatic hypotension. The nurse should assess the patients ability to mobilize safely, but full assessment of range of motion in all joints is not normally necessary. Sitting in a chair and increasing fluid intake are insufficient to prevent orthostatic hypotension and consequent falls.
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The nurse is caring for a patient on the medicalsurgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?
- A. Presence of an indwelling urinary catheter
- B. Rectal temperature of 99.5 F (37.5 C)
- C. Red, warm, tender incision
- D. White blood cell (WBC) count of 8,000 /mL
Correct Answer: C
Rationale: Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a patient to infection, but by itself does not indicate infection. An oral temperature of 99.5 F may not signal infection in a postoperative patient because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000 /mL.
The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurses first response?
- A. Return the patient to his previous position and call the physician
- B. Place saline-soaked sterile dressings on the wound
- C. Assess the patients blood pressure and pulse
- D. Pull the dehiscence closed using gloved hands
Correct Answer: B
Rationale: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the patients vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.
The nursing instructor is discussing postoperative care with a group of nursing students. A student nurse asks, Why does the patient go to the PACU instead of just going straight up to the postsurgical unit? What is the nursing instructors best response?
- A. The PACU allows the patient to recover from anesthesia in a stimulating environment to facilitate awakening and reorientation
- B. The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications
- C. Frequently, patients are placed in the medicalsurgical unit to recover, but hospitals are usually short of beds, and the PACU is an excellent place to triage patients
- D. Patients remain in the PACU for a predetermined time because the surgeon will often need to reinforce or alter the patients incision in the hours following surgery
Correct Answer: B
Rationale: The PACU provides care for the patient while he or she recovers from the effects of anesthesia. The patient must be oriented, have stable vital signs, and show no evidence of hemorrhage or other complications. Patients will sometimes recover in the ICU, but this is considered an extension of the PACU. The PACU does allow the patient to recover from anesthesia, but the environment is calm and quiet as patients are initially disoriented and confused as they begin to awaken and reorient. Patients are not usually placed in the medicalsurgical unit for recovery and, although hospitals are occasionally short of beds, the PACU is not used for patient triage. Incisions are very rarely modified in the immediate postoperative period.
The home health nurse is caring for a postoperative patient who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the patients postoperative day 2. During the visit, the nurse will assess for wound infection. For most patients, what is the earliest postoperative day that a wound infection becomes evident?
- A. Day 9
- B. Day 7
- C. Day 5
- D. Day 3
Correct Answer: C
Rationale: Wound infection may not be evident until at least postoperative day 5. This makes the other options incorrect.
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.