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The nurse is teaching a postoperative client measures to reduce the risk of postoperative complications. Which teaching point would the nurse reinforce to decrease the risk of thrombophlebitis and phlebothrombosis?
- A. Massage the calves and thigh.
- B. Prop pillows under knees.
- C. Encourage ambulation twice daily.
- D. Avoid crossing the legs.
Correct Answer: D
Rationale: Venous stasis predisposes the client to venous inflammation and clot formation in the veins (thrombophlebitis) or clot formation with minimal or absent inflammation (phlebothrombosis). To decrease the risk of venous stasis, the nurse should teach ways to promote blood circulation and limiting trauma to the site. Avoiding leg crossing promotes circulation. Massaging the calves and thighs may cause further swelling and inflammation of the vein. Propping pillows under the knees decreases circulation. Ambulation is stressed each hour while awake.
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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 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.
The nurse has provided preoperative instructions to a client scheduled for surgery at an ambulatory care center. Which statement, made by the client, would indicate that further instruction is needed?
- A. If I do not follow the instructions, my surgery could be cancelled.
- B. The nurse will explain the details of the surgery before I sign a consent.
- C. My medical records will be sent to the ambulatory care center prior to my surgery.
- D. The physician will update my family after the procedure and provide specific discharge instructions.
Correct Answer: B
Rationale: Further instruction would be needed to clarify that the physician, not the nurse, explains the details of the surgery and obtains voluntary consent for the procedure. It is correct that preoperative instructions must be followed prior to surgery for the safety of the client, medical records are present for review prior to surgery, and the physician speaks with the family following the procedure and provides instructions for discharge.
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.
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.