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The nurse is caring for a client who is 2 hours postoperative. The client states, 'I am nauseated.' Which action(s) should the nurse perform? Select all that apply.
- A. Provide an emesis basin.
- B. Check the medication record for antiemetic medication prescription.
- C. Obtain vital signs.
- D. Encourage deep breathing.
- E. Have the client drink 8 oz (240 mL) of water.
Correct Answer: A,B,C,D
Rationale: Nausea is a frequent symptom in the postoperative period. When a client reports nausea, the nurse should provide an emesis basin in case the client vomits, check the medication administration record to provide a prescribed antiemetic, obtain vital signs per postoperative protocol, and encourage deep breathing. Liquids should be held until the nausea subsides.
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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.
Several of the clients at the clinic are preparing to have surgery within the next 2 weeks. They are completing preoperative paperwork today with their visit. What is a reason(s) that people might need to have surgery? Select all that apply.
- A. Cosmetic
- B. Diagnostic
- C. Palliative
- D. Normative
- E. Causative
Correct Answer: A,B,C
Rationale: Reasons people have surgery include cosmetic reasons, diagnostic procedures, palliative surgeries, exploratory surgeries, and curative surgeries. Normative and causative are not reasons for surgery.
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.
The nurse is caring for a postoperative client who reports difficulty urinating. The client does not have a urinary catheter in place. Which nursing action(s) are most appropriate at this time? Select all that apply.
- A. Run water to assist in the let-down reflex.
- B. Assist to the bathroom.
- C. Place a urinary catheter.
- D. Assist the client to stand.
- E. Measure urinary output.
Correct Answer: A,B,D,E
Rationale: The nurse encourages the client to void within 8 hours of surgery to minimize the risk of a urinary tract infection. Ambulating the client to the bathroom promotes normal body positioning for urination. Running water is a common psychological strategy to cause urination. Offering to catheterize is a last option, and a prescription for catheterization must be in place for the nurse to proceed.