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The nurse is caring for the client in the preoperative period and documenting rationale for a palliative surgical procedure. Which rationale is appropriate?
- A. The physician needs additional information to plan medical treatment.
- B. The client wishes to improve body structures and elects a procedure.
- C. The physician is repairing a deformity from birth or disease process.
- D. The client and physician are focusing on symptom relief not a cure.
Correct Answer: D
Rationale: The nurse realizes a palliative surgical procedure is focused on the relief of symptoms or enhancement of function without a cure. Diagnostic surgical procedures provide additional information for medical diagnosis and treatment. Cosmetic surgery procedures are elective, with the purpose of improving body appearance. Reconstructive surgery corrects a deformity.
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The surgical unit nurse is developing a postoperative plan of care. In which client's plan of care would the nurse document interventions of deep breathing, gastrointestinal assessment, and effective regulation of temperature?
- A. A client with gastrointestinal surgery and general anesthesia
- B. A client having a knee replacement and regional anesthesia
- C. A client having lower extremity muscle repair and spinal anesthesia
- D. A client with spinal stenosis and a regional nerve blockade
Correct Answer: A
Rationale: General anesthesia acts on the central nervous system to produce a loss of sensation, reflexes, and consciousness. The anesthesiologist monitors the vital functions of breathing, circulation, and temperature. Following general anesthesia, nurses must closely monitor for effective breathing and oxygenation, temperature regulation, and adequate fluid balance. Nursing interventions for those clients with regional anesthesia, spinal anesthesia, and regional nerve blockades focus on assessing for allergic reactions, neurovascular assessments to specific body regions, and side effects of the medication.
The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?
- A. The client is tolerating sips of water.
- B. The client reports a small bowel movement and flatus.
- C. The client is breathing calmly.
- D. The client states being hungry.
Correct Answer: B
Rationale: A bowel movement demonstrates that the nursing outcome of the return to function of the gastrointestinal track has been met. Tolerating sips of water, breathing calmly, and reports of hunger are components of meeting the outcome of functioning.
The PACU nurse is about to administer pain medication to an older adult client who is recovering from surgery. What does this client's age put them at increased risk for? Select all that apply.
- A. Acute confusion
- B. Respiratory depression
- C. Disorientation
- D. Infection
- E. Greater requirement for pain medication
Correct Answer: A,B,C,D
Rationale: The older adult client requiring pain medication postoperatively is at greater risk for confusion, disorientation, respiratory depression, and infection. The older adult client does not have a greater requirement for pain medication, because even standard doses may cause complications that would not occur in younger clients.
The nurse is caring for a client who is 2 hours postoperative. The client states, 'I am nauseated.' Which action(s) should the nurse perform? Select all that apply.
- A. Provide an emesis basin.
- B. Check the medication record for antiemetic medication prescription.
- C. Obtain vital signs.
- D. Encourage deep breathing.
- E. Have the client drink 8 oz (240 mL) of water.
Correct Answer: A,B,C,D
Rationale: Nausea is a frequent symptom in the postoperative period. When a client reports nausea, the nurse should provide an emesis basin in case the client vomits, check the medication administration record to provide a prescribed antiemetic, obtain vital signs per postoperative protocol, and encourage deep breathing. Liquids should be held until the nausea subsides.
The nurse is caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?
- A. Place pillows under the client's knees or calves.
- B. Encourage the client to move legs frequently and do leg exercises.
- C. Apply pressure on the client's lower extremities.
- D. Maintain the client in a side-lying position.
Correct Answer: B
Rationale: The nurse should encourage the client to move legs frequently and do leg exercises to prevent venous stasis and other circulatory complications. The nurse should not place pillows under the client's knees or calves unless prescribed and should avoid placing pressure on the client's lower extremities. Placing the client in a side-lying position will not help prevent venous stasis and other circulatory complications in a client who has undergone surgery.