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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.
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An enterostomal therapy nurse is caring for a postoperative client with a gaping wound. Which nursing measure is most helpful when a wound dressing adheres to the wound bed?
- A. Place a transparent dressing between the wound and dressing.
- B. Place an emollient based ointment on the wound bed.
- C. Use normal saline to soak the dressing for removal.
- D. Allow the dressing to dry and release the wound bed.
Correct Answer: C
Rationale: When a dressing adheres to the wound bed, using normal saline to moisten the dressing material can loosen the dressing for easier dressing removal without damaging the new tissue or causing discomfort. The transparent dressing and ointment are not helpful in assisting with dressing removal. Allowing the dressing to dry promotes wound adherence.
A physically fit 86-year-old is scheduled for right knee replacement. Which factor places the client at increased risk for complications during or after surgery?
- A. Age
- B. Type of surgery
- C. Ability to metabolize medication
- D. Nutritional status
Correct Answer: A
Rationale: General risk factors are related to age, nutritional status; use of alcohol, tobacco, and other substances; and physical condition. In this scenario, the risk to the client is age; the type of surgery, client's ability to metabolize medication, and client's nutritional status are not risk factors for complication in the scenario described.
The nurse is caring for a client during an intraoperative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?
- A. Pulse rate of 110 beats/min
- B. Respiratory rate of 18 breaths/min
- C. Blood pressure of 104/62 mm Hg
- D. Temperature of 102.5?°F (39?°C)
Correct Answer: D
Rationale: Intraoperative hyperthermia can indicate a life-threatening condition called malignant hyperthermia. The circulating nurse closely monitors the client for signs of hyperthermia. The pulse rate, respiratory rate, and blood pressure did not indicate a significant concern.
The nurse is teaching a postoperative client measures to reduce the risk of postoperative complications. Which teaching point would the nurse reinforce to decrease the risk of thrombophlebitis and phlebothrombosis?
- A. Massage the calves and thigh.
- B. Prop pillows under knees.
- C. Encourage ambulation twice daily.
- D. Avoid crossing the legs.
Correct Answer: D
Rationale: Venous stasis predisposes the client to venous inflammation and clot formation in the veins (thrombophlebitis) or clot formation with minimal or absent inflammation (phlebothrombosis). To decrease the risk of venous stasis, the nurse should teach ways to promote blood circulation and limiting trauma to the site. Avoiding leg crossing promotes circulation. Massaging the calves and thighs may cause further swelling and inflammation of the vein. Propping pillows under the knees decreases circulation. Ambulation is stressed each hour while awake.
The client required reversal drugs after surgery. What nursing intervention is required when caring for a client who is treated with reversal drugs?
- A. Instruct the client to lie flat.
- B. Observe the client for an extended period.
- C. Help the client slowly move to an upright or standing position.
- D. Emphasize the dietary restriction.
Correct Answer: B
Rationale: If reversal drugs are required, the nurse must observe the client for an extended period because the reversal effects nearly always are shorter than the effects of the drugs being reversed. This may result in sedation. The client need not lie flat and may not require assistance for ambulation. There is no specific dietary restriction required when treated with reversal drugs.