Nokea
The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?
- A. Requirement of intermittent catheterization
- B. Calculus formation
- C. Urine retention
- D. Urinary infection
Correct Answer: C
Rationale: Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus.
You may also like to solve these questions
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 the client in the preoperative period and documenting rationale for a palliative surgical procedure. Which rationale is appropriate?
- A. The physician needs additional information to plan medical treatment.
- B. The client wishes to improve body structures and elects a procedure.
- C. The physician is repairing a deformity from birth or disease process.
- D. The client and physician are focusing on symptom relief not a cure.
Correct Answer: D
Rationale: The nurse realizes a palliative surgical procedure is focused on the relief of symptoms or enhancement of function without a cure. Diagnostic surgical procedures provide additional information for medical diagnosis and treatment. Cosmetic surgery procedures are elective, with the purpose of improving body appearance. Reconstructive surgery corrects a deformity.
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.
A nurse is assessing the postoperative client on the second postoperative day. What assessment finding requires the nurse to immediately notify the health care provider?
- A. The client has an absence of bowel sounds.
- B. The client's lungs reveal rales in the bases.
- C. The client states a moderate amount of pain at the incisional site.
- D. A moderate amount of serous drainage is noted on the operative dressing.
Correct Answer: A
Rationale: A nursing assessment finding of concern on the second postoperative day is the absence of bowel sounds, which may indicate a paralytic ileus. Other assessment findings may include abdominal pain and distention as fluids, solids, and gas do not move through the intestinal tract. Rales in the bases are a frequent finding postoperatively, especially if general anesthesia was administered. Encourage the client to cough and breathe deep. Pain is a common symptom following a surgical procedure. Serous drainage on the postoperative dressing needs to be monitored and brought to the physician's attention when assessing the client.
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.