Nokea
The nurse is caring for a patient who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the patients ribs and xiphoid process are prominent. The patient states she exercises two to three times daily and her mother indicates that she is being treated for anorexia nervosa. How should the nurse best follow up these assessment data?
- A. Inform the postoperative team about the patients risk for wound dehiscence
- B. Evaluate the patients ability to manage her pain level
- C. Facilitate a detailed analysis of the patients electrolyte levels
- D. Instruct the patient on the need for a high-sodium diet to promote healing
Correct Answer: C
Rationale: The surgical team should be informed about the patients medical history regarding anorexia nervosa. Any nutritional deficiency, such as malnutrition, should be corrected before surgery to provide adequate protein for tissue repair. The electrolyte levels should be evaluated and corrected to prevent metabolic abnormalities in the operative and postoperative phase. The risk of wound dehiscence is more likely associated with obesity. Instruction on proper nutrition should take place in the postoperative period, and a consultation should be made with her psychiatric specialist. Evaluation of pain management is always important, but not particularly significant in this scenario.
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The nurses teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery?
- A. Leg exercises increase the patients muscle mass postoperatively
- B. Leg exercises improve circulation and prevent venous thrombosis
- C. Leg exercises help to prevent pressure sores to the sacrum and heels
- D. Leg exercise help increase the patients level of consciousness after surgery
Correct Answer: B
Rationale: Exercise of the extremities includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side) unless contraindicated by type of surgical procedure (e.g., hip replacement). When the patient does leg exercises postoperatively, circulation is increased, which helps to prevent blood clots from forming. Leg exercises do not prevent pressure sores to the sacrum, or increase the patients level of consciousness. Leg exercises have the potential to increase strength and mobility, but are unlikely to make a change to muscle mass in the short term.
The admitting nurse in a short-stay surgical unit is responsible for numerous aspects of care. What must the nurse verify before the patient is taken to the preoperative holding area?
- A. That preoperative teaching was performed
- B. That the family is aware of the length of the surgery
- C. That follow-up home care is not necessary
- D. That the family understands the patient will be discharged immediately after surgery
Correct Answer: A
Rationale: The nurse needs to be sure that the patient and family understand that the patient will first go to the preoperative holding area before going to the OR for the surgical procedure and then will spend some time in the PACU before being discharged home with the family later that day. Other preoperative teaching content should also be verified and reinforced, as needed. The nurse should ensure that any plans for follow-up home care are in place.
A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this patient? Select all that apply.
- A. Establishing an IV line
- B. Verifying the surgical site with the patient
- C. Taking measures to ensure the patients comfort
- D. Applying a grounding device to the patient
- E. Preparing the medications to be administered in the OR
Correct Answer: A,B,C
Rationale: In the holding area, the nurse reviews charts, identifies patients, verifies surgical site and marks site per institutional policy, establishes IV lines, administers medications, if prescribed, and takes measures to ensure each patients comfort. A nurse in the preoperative holding area does not prepare medications to be administered by anyone else. A grounding device is applied in the OR.
The nurse is performing a preadmission assessment of a patient scheduled for a bilateral mastectomy. Of what purpose of the preadmission assessment should the nurse be aware?
- A. Verifies completion of preoperative diagnostic testing
- B. Discusses and reviews patients health insurance coverage
- C. Determines the patients suitability as a surgical candidate
- D. Informs the patient of need for postoperative transportation
Correct Answer: A
Rationale: Purposes of preadmission testing (PAT) include verifying completion of preoperative diagnostic testing. The nurses role in PAT does not normally involve financial considerations or addressing transportation. The physician determines the patients suitability for surgery.
The nurse is caring for a patient who is experiencing pain and anxiety following his prostatectomy. Which intervention will likely best assist in decreasing the patients pain and anxiety?
- A. Administration of NSAIDs rather than opioids
- B. Allowing the patient to increase activity
- C. Use of guided imagery along with pain medication
- D. Use of deep breathing and coughing exercises
Correct Answer: C
Rationale: The use of guided imagery will enhance pain relief and assist in reduction of anxiety. It may be combined with analgesics. Deep breathing and the increase in activity may produce increased pain. Replacing opioids with NSAIDs may cause an increase in pain.