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The nurse is caring for a patient in the postoperative period who is on bed rest. Which of the following actions should the nurse implement?
- A. Assist the patient to the bathroom when required.
- B. Implement active ROM exercise every 1-2 hours.
- C. Place the patient in a chair for 20 minutes TID.
- D. Complete passive ROM exercises once per 12 hour shift.
Correct Answer: B
Rationale: When confined to bed, patients should alternately flex and extend all joints 10-12 times every 1-2 hours while awake. The muscular contraction produced by these exercises and by ambulation facilitates venous return from the lower extremities. A patient on bed rest is not to be assisted up to the bathroom or placed in a chair. If passive ROM exercise were to be completed, the frequency would be every 1-2 hours, not once per 12 hour shift.
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The nurse is caring for a patient and during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 38.2°C (100.8°F). Which of the following actions should the nurse take first?
- A. Have the patient use the incentive spirometer.
- B. Assess the surgical incision for redness and swelling.
- C. Administer the ordered PRN acetaminophen.
- D. Notify the patient's health care provider about the fever.
Correct Answer: A
Rationale: A temperature of 38.2°C (100.8°F) in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because evidence of wound infection does not usually occur before the third postoperative day, assessment of the incision is not likely to be useful.
The nurse is preparing an older-adult patient for discharge from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, 'I do not know if I can take care of myself with this patch over my eye.' Which of the following actions is the most appropriate for the nurse to implement?
- A. Refer the patient for home health care services.
- B. Discuss the specific concerns regarding self-care.
- C. Give the patient written instructions regarding care.
- D. Assess the patient's support system for care at home.
Correct Answer: B
Rationale: The nurse's initial action should be to assess exactly the patient's concerns about self-care. Referral to home health care and assessment of the patient's support system may be appropriate actions but will be based on further assessment of the patient's concerns. Written instructions should be given to the patient, but these are unlikely to address the patient's stated concern about self-care.
The nurse is caring for a patient who is being transferred from the postanesthesia care unit (PACU) to the clinical surgical unit. Which of the following actions should the nurse implement first on the clinical surgical unit?
- A. Assess the patient's pain.
- B. Take the patient's vital signs.
- C. Read the postoperative orders.
- D. Check the rate of the IV infusion.
Correct Answer: B
Rationale: Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer.
The nurse is caring for a patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU), who is restless and shouting at the nurse. The patient's oxygen saturation is 99%, and recent laboratory results are all normal. Which of the following actions by the nurse is most appropriate?
- A. Insert an oral or nasal airway.
- B. Notify the anesthesia care provider.
- C. Orient the patient to time, place, and person.
- D. Be sure that the patient's IV lines are secure.
Correct Answer: D
Rationale: Because the patient's assessment indicates physiological stability, the most likely cause of the patient's agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should ensure patient safety through interventions such as raising the bed rails and securing IV lines. Emergence delirium is common in patients recovering from anaesthesia, so there is no need to notify the anaesthesiologist. Insertion of an airway is not needed because the oxygen saturation is good. Orientation of the patient is needed but is not likely to be effective until the effects of anaesthesia have resolved more completely.
The nurse is caring for a patient with abdominal surgery and on the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. Which of the following actions should the nurse implement first?
- A. Reinforce the dressing.
- B. Take the patient's vital signs.
- C. Recheck the dressing in 1 hour for increased drainage.
- D. Notify the patient's surgeon of a potential hemorrhage.
Correct Answer: B
Rationale: New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing.