Nokea
The nurse is preparing an older-adult patient for discharge from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, 'I do not know if I can take care of myself with this patch over my eye.' Which of the following actions is the most appropriate for the nurse to implement?
- A. Refer the patient for home health care services.
- B. Discuss the specific concerns regarding self-care.
- C. Give the patient written instructions regarding care.
- D. Assess the patient's support system for care at home.
Correct Answer: B
Rationale: The nurse's initial action should be to assess exactly the patient's concerns about self-care. Referral to home health care and assessment of the patient's support system may be appropriate actions but will be based on further assessment of the patient's concerns. Written instructions should be given to the patient, but these are unlikely to address the patient's stated concern about self-care.
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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.
The nurse is caring for an older adult in the postanesthesia unit. Which of the following age-related considerations may impact postoperative recovery?
- A. Increased thoracic compliance
- B. Decreased ability to cough
- C. Increased lung tissue
- D. Decreased compliance with deep breathing and coughing
Correct Answer: B
Rationale: The older adult has a decrease in respiratory function, including decreased ability to cough, decreased thoracic compliance (not increased), and decreased (not increased) lung tissue. There is no noted decrease in compliance related to postoperative deep breathing and coughing.
The nurse is caring for a patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU), who is restless and shouting at the nurse. The patient's oxygen saturation is 99%, and recent laboratory results are all normal. Which of the following actions by the nurse is most appropriate?
- A. Insert an oral or nasal airway.
- B. Notify the anesthesia care provider.
- C. Orient the patient to time, place, and person.
- D. Be sure that the patient's IV lines are secure.
Correct Answer: D
Rationale: Because the patient's assessment indicates physiological stability, the most likely cause of the patient's agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should ensure patient safety through interventions such as raising the bed rails and securing IV lines. Emergence delirium is common in patients recovering from anaesthesia, so there is no need to notify the anaesthesiologist. Insertion of an airway is not needed because the oxygen saturation is good. Orientation of the patient is needed but is not likely to be effective until the effects of anaesthesia have resolved more completely.
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 in the postoperative period who is on bed rest. Which of the following actions should the nurse implement?
- A. Assist the patient to the bathroom when required.
- B. Implement active ROM exercise every 1-2 hours.
- C. Place the patient in a chair for 20 minutes TID.
- D. Complete passive ROM exercises once per 12 hour shift.
Correct Answer: B
Rationale: When confined to bed, patients should alternately flex and extend all joints 10-12 times every 1-2 hours while awake. The muscular contraction produced by these exercises and by ambulation facilitates venous return from the lower extremities. A patient on bed rest is not to be assisted up to the bathroom or placed in a chair. If passive ROM exercise were to be completed, the frequency would be every 1-2 hours, not once per 12 hour shift.