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The nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the patient?
- A. The patient should take three deep breaths and cough hard three times, at least every 15 minutes for the immediately postoperative period
- B. The patient should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs
- C. The patient should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs
- D. The patient should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly
Correct Answer: C
Rationale: The patient assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to take a deep, slow breath and how to exhale slowly. After practicing deep breathing several times, the patient is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough from deep in the lungs.
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The nurses teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery?
- A. Leg exercises increase the patients muscle mass postoperatively
- B. Leg exercises improve circulation and prevent venous thrombosis
- C. Leg exercises help to prevent pressure sores to the sacrum and heels
- D. Leg exercise help increase the patients level of consciousness after surgery
Correct Answer: B
Rationale: Exercise of the extremities includes extension and flexion of the knee and hip joints (similar to bicycle riding while lying on the side) unless contraindicated by type of surgical procedure (e.g., hip replacement). When the patient does leg exercises postoperatively, circulation is increased, which helps to prevent blood clots from forming. Leg exercises do not prevent pressure sores to the sacrum, or increase the patients level of consciousness. Leg exercises have the potential to increase strength and mobility, but are unlikely to make a change to muscle mass in the short term.
The policies and procedures on a preoperative unit are being amended to bring them closer into alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most directly addresses the priorities of the SCIP?
- A. Actions aimed at increasing participation of families in planning care
- B. Actions aimed at preventing surgical site infections
- C. Actions aimed at increasing interdisciplinary collaboration
- D. Actions aimed at promoting the use of complementary and alternative medicine (CAM)
Correct Answer: B
Rationale: SCIP identifies performance measures aimed at preventing surgical complications, including venous thromboembolism (VTE) and surgical site infections (SSI). It does not explicitly address family participation, interdisciplinary collaboration, or CAM.
The nurse is performing a preadmission assessment of a patient scheduled for a bilateral mastectomy. Of what purpose of the preadmission assessment should the nurse be aware?
- A. Verifies completion of preoperative diagnostic testing
- B. Discusses and reviews patients health insurance coverage
- C. Determines the patients suitability as a surgical candidate
- D. Informs the patient of need for postoperative transportation
Correct Answer: A
Rationale: Purposes of preadmission testing (PAT) include verifying completion of preoperative diagnostic testing. The nurses role in PAT does not normally involve financial considerations or addressing transportation. The physician determines the patients suitability for surgery.
The admitting nurse in a short-stay surgical unit is responsible for numerous aspects of care. What must the nurse verify before the patient is taken to the preoperative holding area?
- A. That preoperative teaching was performed
- B. That the family is aware of the length of the surgery
- C. That follow-up home care is not necessary
- D. That the family understands the patient will be discharged immediately after surgery
Correct Answer: A
Rationale: The nurse needs to be sure that the patient and family understand that the patient will first go to the preoperative holding area before going to the OR for the surgical procedure and then will spend some time in the PACU before being discharged home with the family later that day. Other preoperative teaching content should also be verified and reinforced, as needed. The nurse should ensure that any plans for follow-up home care are in place.
The PACU nurse is caring for a patient who has been deemed ready to go to the postsurgical floor after her surgery. What would the PACU nurse be responsible for reporting to the nurse on the floor? Select all that apply.
- A. The names of the anesthetics that were used
- B. The identities of the staff in the OR
- C. The patients preoperative level of consciousness
- D. The presence of family and/or significant others
- E. The patients full name
Correct Answer: C,D,E
Rationale: The PACU nurse is responsible for informing the floor nurse of the patients intraoperative factors (e.g., insertion of drains or catheters, administration of blood or medications during surgery, or occurrence of unexpected events), preoperative level of consciousness, presence of family and/or significant others, and identification of the patient by name. The PACU nurse does not tell which anesthetic was used, only the type and amount used. The PACU nurse does not identify the staff that was in the OR with the patient.