Nokea
The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patients possible readiness to learn how to change her dressing? Select all that apply.
- A. The patient wants you to teach a family member to do dressing changes
- B. The patient expresses interest in the dressing change
- C. The patient is willing to look at the incision during a dressing change
- D. The patient expresses dislike of the surgical wound
- E. The patient assists in opening the packages of dressing material for the nurse
Correct Answer: B,C,E
Rationale: While changing the dressing, the nurse has an opportunity to teach the patient how to care for the incision and change the dressings at home. The nurse observes for indicators of the patients readiness to learn, such as looking at the incision, expressing interest, or assisting in the dressing change. Expressing dislike and wanting to delegate to a family member do not suggest readiness to learn.
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The nurse is caring for a patient after abdominal surgery in the PACU. The patients blood pressure has increased and the patient is restless. The patients oxygen saturation is 97%. What cause for this change in status should the nurse first suspect?
- A. The patient is hypothermic
- B. The patient is in shock
- C. The patient is in pain
- D. The patient is hypoxic
Correct Answer: C
Rationale: An increase in blood pressure and restlessness are symptoms of pain. The patients oxygen saturation is 97%, so hypothermia, hypoxia, and shock are not likely causes of the patients restlessness.
The recovery room nurse is admitting a patient from the OR following the patients successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted patient?
- A. Heart rate and rhythm
- B. Skin integrity
- C. Core body temperature
- D. Airway patency
Correct Answer: D
Rationale: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).
The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do?
- A. Sit in a chair for 10 minutes prior to ambulating
- B. Drink plenty of fluids to increase circulating blood volume
- C. Stand upright for 2 to 3 minutes prior to ambulating
- D. Perform range-of-motion exercises for each joint
Correct Answer: C
Rationale: Older adults are at an increased risk for orthostatic hypotension secondary to age-related changes in vascular tone. The patient should sit up and then stand for 2 to 3 minutes before ambulating to alleviate orthostatic hypotension. The nurse should assess the patients ability to mobilize safely, but full assessment of range of motion in all joints is not normally necessary. Sitting in a chair and increasing fluid intake are insufficient to prevent orthostatic hypotension and consequent falls.
The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurses first response?
- A. Return the patient to his previous position and call the physician
- B. Place saline-soaked sterile dressings on the wound
- C. Assess the patients blood pressure and pulse
- D. Pull the dehiscence closed using gloved hands
Correct Answer: B
Rationale: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the patients vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.
An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patients vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next?
- A. Administer a dose of IV analgesic
- B. Apply a cool cloth to the patients forehead
- C. Offer the patient a small amount of ice chips
- D. Turn the patient completely to one side
Correct Answer: D
Rationale: Turning the patient completely to one side allows collected fluid to escape from the side of the mouth if the patient vomits. After turning the patient to the side, the nurse can offer a cool cloth to the patients forehead. Ice chips can increase feelings of nausea. An analgesic is not administered for nausea and vomiting.