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The nurse is providing community instruction on the impact of aging and surgical incisional considerations. Which instructional area(s) would be included in the presentation? Select all that apply.
- A. Increase protein in the diet.
- B. Instruct on symptoms of wound/incision infection.
- C. Cleanse wound/incision with products such as soap and water.
- D. Avoid showering until healing has occurred.
- E. Wash with half-strength peroxide to prevent infection.
- F. Remove any crusted areas from incisional line.
Correct Answer: A,B,C
Rationale: The nurse realizes that there is a thinning of the skin and loss of subcutaneous tissue, which is normal in the aging process. Also, older adults may have a diminished immunological response, making them more susceptible to infection. For this reason, instructional areas would include areas which promote healing and diminish the risk of infection. Increasing protein in the diet promotes wound healing. Instructing on signs and symptoms of wound infection allows for early symptom recognition. Cleansing, as per physician instruction, but with products, such as soap and water, decreases bacteria on the skin. Showering may begin prior to healing with the stream of the water not directly on the incision. Peroxide is not recommended for wound/incisional care. Crusted areas should be allowed to heal and flake off. Removing the areas could open a wound allowing for bacteria to enter.
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Which nursing statement would best ease a client's anxiety before an emergency operative procedure?
- A. You will be just fine; the operating room nurses will take good care of you.
- B. It is best to take deep breaths and relax before the procedure.
- C. Let me explain to you what will happen next.
- D. We will keep your family informed of your progress.
Correct Answer: C
Rationale: Many clients feel fearful of knowing little about the operative procedure and what to expect. This fear causes anxiety and can lead to a poorer response to surgery and surgical complications. Explanations of what the client is to expect can help to decrease anxiety. False reassurance of being fine does not diminish anxiety. Deep breathing and relaxation techniques can be helpful to the client but addressing the source of the anxiety is more beneficial. Keeping the family informed helps the family and is not client focused.
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.
The nurse is completing an assessment of the client prior to surgery. What area(s) of the client assessment should the nurse question further? Select all that apply.
- A. Medication
- B. Elimination
- C. Activity
- D. Support system
- E. Dietary preferences
Correct Answer: A,B,C,D
Rationale: When preparing a client for surgery, these areas need to be addressed: skin preparation, elimination, attire/grooming, prosthesis, foods and fluids, and care of valuables. In addition, medication, activity, and the client's support system must be assessed. Dietary preferences of the client would not be a priority during the preoperative assessment.
The nurse is working in the preoperative area with a client going to surgery for a cholecystectomy. The client has histaminez-receptor antagonists prescribed preoperatively. The client asks the nurse why these medications are needed. What would be the nurse's best answer?
- A. These medications slow motor activity.
- B. These medications decrease the amount of anesthesia you will need.
- C. These medications decrease anxiety before surgery.
- D. These medications decrease gastric acidity and volume.
Correct Answer: D
Rationale: The anesthesiologist frequently prescribes preoperative medications. Common preoperative medications include the following: anticholinergics, which decrease respiratory tract secretions, dry mucous membranes, and interrupt vagal stimulation; anti anxiety drugs, which reduce preoperative anxiety, slow motor activity, and promote induction of anesthesia; histaminez-receptor antagonists, which decrease gastric acidity and volume; narcotics, which decrease the amount of anesthesia needed, help reduce anxiety and pain, and promote sleep; sedatives, which promote sleep, decrease anxiety, and reduce the amount of anesthesia needed; and tranquilizers, which reduce nausea, prevent emesis, and enhance preoperative sedation.
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.