Nokea
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.
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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.
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 providing community instruction on the impact of aging and surgical incisional considerations. Which instructional area(s) would be included in the presentation? Select all that apply.
- A. Increase protein in the diet.
- B. Instruct on symptoms of wound/incision infection.
- C. Cleanse wound/incision with products such as soap and water.
- D. Avoid showering until healing has occurred.
- E. Wash with half-strength peroxide to prevent infection.
- F. Remove any crusted areas from incisional line.
Correct Answer: A,B,C
Rationale: The nurse realizes that there is a thinning of the skin and loss of subcutaneous tissue, which is normal in the aging process. Also, older adults may have a diminished immunological response, making them more susceptible to infection. For this reason, instructional areas would include areas which promote healing and diminish the risk of infection. Increasing protein in the diet promotes wound healing. Instructing on signs and symptoms of wound infection allows for early symptom recognition. Cleansing, as per physician instruction, but with products, such as soap and water, decreases bacteria on the skin. Showering may begin prior to healing with the stream of the water not directly on the incision. Peroxide is not recommended for wound/incisional care. Crusted areas should be allowed to heal and flake off. Removing the areas could open a wound allowing for bacteria to enter.
The surgical unit nurse is developing a postoperative plan of care. In which client's plan of care would the nurse document interventions of deep breathing, gastrointestinal assessment, and effective regulation of temperature?
- A. A client with gastrointestinal surgery and general anesthesia
- B. A client having a knee replacement and regional anesthesia
- C. A client having lower extremity muscle repair and spinal anesthesia
- D. A client with spinal stenosis and a regional nerve blockade
Correct Answer: A
Rationale: General anesthesia acts on the central nervous system to produce a loss of sensation, reflexes, and consciousness. The anesthesiologist monitors the vital functions of breathing, circulation, and temperature. Following general anesthesia, nurses must closely monitor for effective breathing and oxygenation, temperature regulation, and adequate fluid balance. Nursing interventions for those clients with regional anesthesia, spinal anesthesia, and regional nerve blockades focus on assessing for allergic reactions, neurovascular assessments to specific body regions, and side effects of the medication.
A physically fit 86-year-old is scheduled for right knee replacement. Which factor places the client at increased risk for complications during or after surgery?
- A. Age
- B. Type of surgery
- C. Ability to metabolize medication
- D. Nutritional status
Correct Answer: A
Rationale: General risk factors are related to age, nutritional status; use of alcohol, tobacco, and other substances; and physical condition. In this scenario, the risk to the client is age; the type of surgery, client's ability to metabolize medication, and client's nutritional status are not risk factors for complication in the scenario described.