Nokea
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.
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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 reviewing a postoperative client's chart prior to a physician's office visit. Lab reports reveal a prior WBC of 40,000/mm3 (40*10s/L), a current WBC count of 8,000/mms (8*10s/L), and a current wound culture negative, following a Staphylococcus aureus infection. Tertiary intention of wound healing is documented at the last visit. Which current assessment of wound healing is anticipated?
- A. Wound edges well approximated. No redness/swelling noted.
- B. Edges of incision well approximated with the center of incision open. Green purulent drainage noted.
- C. Wound edges sutured. Scant amount of drainage noted. No foul odor.
- D. Wound packed with 0.5-in (1.25-cm) sterile packing material; interior pink.
Correct Answer: C
Rationale: The scenario stated a previous wound infection that has resolved. Sutured wound edges are present once the wound has been cleaned of infection as noted in tertiary intention of wound healing. Well-approximated edges are healing without infection. Wound packing is noted in secondary intention. Green purulent drainage is noted with a wound infection.
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 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.
The nurse is working in the preoperative area with a client going to surgery for a cholecystectomy. The client has histaminez-receptor antagonists prescribed preoperatively. The client asks the nurse why these medications are needed. What would be the nurse's best answer?
- A. These medications slow motor activity.
- B. These medications decrease the amount of anesthesia you will need.
- C. These medications decrease anxiety before surgery.
- D. These medications decrease gastric acidity and volume.
Correct Answer: D
Rationale: The anesthesiologist frequently prescribes preoperative medications. Common preoperative medications include the following: anticholinergics, which decrease respiratory tract secretions, dry mucous membranes, and interrupt vagal stimulation; anti anxiety drugs, which reduce preoperative anxiety, slow motor activity, and promote induction of anesthesia; histaminez-receptor antagonists, which decrease gastric acidity and volume; narcotics, which decrease the amount of anesthesia needed, help reduce anxiety and pain, and promote sleep; sedatives, which promote sleep, decrease anxiety, and reduce the amount of anesthesia needed; and tranquilizers, which reduce nausea, prevent emesis, and enhance preoperative sedation.