Nokea
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.
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The nurse has received shift report on a postoperative surgical client. Which medication prescription would indicate that the medication was being administered prophylactically?
- A. A 5% dextrose in 0.5 NSS to infuse at 100 mL/hr
- B. Percocet two tablets every 4 hours as needed for pain
- C. Humulin NPH 12 units at 0800
- D. Cefazolin 1 g IV every 6 hours for 24 hours
Correct Answer: D
Rationale: Cefazolin, an antibiotic, is commonly administered prophylactically to prevent postoperative infections. A 5% dextrose in 0.5 NSS is used for fluid maintenance, Percocet is for pain management, and Humulin NPH is for diabetes management, none of which are primarily prophylactic in this context.
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.
The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?
- A. The client is tolerating sips of water.
- B. The client reports a small bowel movement and flatus.
- C. The client is breathing calmly.
- D. The client states being hungry.
Correct Answer: B
Rationale: A bowel movement demonstrates that the nursing outcome of the return to function of the gastrointestinal track has been met. Tolerating sips of water, breathing calmly, and reports of hunger are components of meeting the outcome of functioning.
Which nursing statement would best ease a client's anxiety before an emergency operative procedure?
- A. You will be just fine; the operating room nurses will take good care of you.
- B. It is best to take deep breaths and relax before the procedure.
- C. Let me explain to you what will happen next.
- D. We will keep your family informed of your progress.
Correct Answer: C
Rationale: Many clients feel fearful of knowing little about the operative procedure and what to expect. This fear causes anxiety and can lead to a poorer response to surgery and surgical complications. Explanations of what the client is to expect can help to decrease anxiety. False reassurance of being fine does not diminish anxiety. Deep breathing and relaxation techniques can be helpful to the client but addressing the source of the anxiety is more beneficial. Keeping the family informed helps the family and is not client focused.
The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed?
- A. If I do not follow the instructions, my surgery could be cancelled.
- B. The nurse will explain the details of the surgery before I sign a consent.
- C. My medical records will be sent to the ambulatory care center prior to my surgery.
- D. The physician will update my family after the procedure and provide specific discharge instructions.
Correct Answer: B
Rationale: Further instruction would be needed to clarify that the physician, not the nurse, explains the details of the surgery and obtains voluntary consent for the procedure. It is correct that preoperative instructions must be followed prior to surgery for the safety of the client, medical records are present for review prior to surgery, and the physician speaks with the family following the procedure and provides instructions for discharge.