Nokea
The nurse is caring for an older-adult patient who had a surgical repair of a hip fracture 2 days previously and has restrictions on ambulation. Based on this information, which of the following collaborative problems is priority for the patient?
- A. Potential complication: hypovolemic shock
- B. Potential complication: venous thromboembolism
- C. Potential complication: fluid and electrolyte imbalance
- D. Potential complication: impaired surgical wound healing
Correct Answer: B
Rationale: The patient is older and relatively immobile, two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient.
You may also like to solve these questions
The nurse is caring for a patient following gallbladder surgery, and the patient's T-tube is draining dark green fluid. Which of the following actions should the nurse take?
- A. Place the patient on bed rest.
- B. Notify the patient's surgeon.
- C. Document the colour and amount of drainage.
- D. Irrigate the T-tube with sterile normal saline.
Correct Answer: C
Rationale: A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and colour of the drainage is needed. The other actions are not necessary.
After removal of the nasogastric (NG) tube on the second postoperative day, the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. Which of the following actions should the nurse take?
- A. Reinsert the NG tube.
- B. Give the PRN IV opioid.
- C. Assist the patient to ambulate.
- D. Place the patient on NPO status.
Correct Answer: C
Rationale: Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient's discomfort. If distension persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains.
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 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.
The nurse is caring for a patient who is recovering from anaesthesia in the postanaesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure is 112/60, with a pulse of 72 and warm, dry skin. Which of the following actions is the most appropriate for the nurse to implement at this time?
- A. Increase the rate of the IV fluid replacement.
- B. Continue to take vital signs every 15 minutes.
- C. Administer oxygen therapy at 100% per mask.
- D. Notify the anaesthesia care provider (ACP) immediately.
Correct Answer: B
Rationale: A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anaesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration.