Nokea
The nursing instructor is talking with a group of medicalsurgical students about deep vein thrombosis (DVT). A student asks what factors contribute to the formation of a DVT. What would be the instructors best response?
- A. There is a genetic link in the formation of deep vein thrombi
- B. Hypervolemia is often present in patients who go on to develop deep vein thrombi
- C. No known factors contribute to the formation of deep vein thrombi; they just occur
- D. Dehydration is a contributory factor to the formation of deep vein thrombi
Correct Answer: D
Rationale: The stress response that is initiated by surgery inhibits the fibrinolytic system, resulting in blood hypercoagulability. Dehydration, low cardiac output, blood pooling in the extremities, and bedrest add to the risk of thrombosis formation. Hypervolemia is not a risk factor and there are no known genetic factors.
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The surgeons preoperative assessment of a patient has identified that the patient is at a high risk for venous thromboembolism. Once the patient is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the patients risk of developing this complication?
- A. Maintain the head of the bed at 45 degrees or higher
- B. Encourage early ambulation
- C. Encourage oral fluid intake
- D. Perform passive range-of-motion exercises every 8 hours
Correct Answer: B
Rationale: The benefits of early ambulation and leg exercises in preventing DVT cannot be overemphasized, and these activities are recommended for all patients, regardless of their risk. Increasing the head of the bed is not effective. Ambulation is superior to passive range-of-motion exercises. Fluid intake is important, but is less protective than early ambulation.
The intraoperative nurse is transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year-old woman. The nurse should prioritize which of the following actions?
- A. Keeping the patient sterile
- B. Keeping the patient restrained
- C. Keeping the patient warm
- D. Keeping the patient hydrated
Correct Answer: C
Rationale: Special attention is given to keeping the patient warm because elderly patients are more susceptible to hypothermia. It is all important for the nurse to pay attention to hydration, but hypovolemia does not occur as quickly as hypothermia. The patient is never sterile and restraints are very rarely necessary.
The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the patients blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the patients skin is cold, moist, and pale. Of what is the patient showing signs?
- A. Hypothermia
- B. Hypovolemic shock
- C. Neurogenic shock
- D. Malignant hyperthermia
Correct Answer: B
Rationale: The patient is exhibiting symptoms of hypovolemic shock; therefore, the nurse should notify the patients physician and anticipate orders for fluid and/or blood product replacement. Neurogenic shock does not normally result in tachycardia and malignant hyperthermia would not present at this stage in the operative experience. Hypothermia does not cause hypotension and tachycardia.
The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion?
- A. Describe the appearance of the dressing in the electronic health record
- B. Photograph the patients abdomen for later comparison using a smartphone
- C. Trace the outline of the drainage on the dressing for future comparison
- D. Remove and weigh the dressing, reapply it, and then repeat in 8 hours
Correct Answer: C
Rationale: Spots of drainage on a dressing are outlined with a pen, and the date and time of the outline are recorded on the dressing so that increased drainage can be easily seen. A dressing is never removed and then reapplied. Photographs normally require informed consent, so they would not be used for this purpose. Documentation is necessary, but does not confirm or rule out an increase in drainage.
The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patients possible readiness to learn how to change her dressing? Select all that apply.
- A. The patient wants you to teach a family member to do dressing changes
- B. The patient expresses interest in the dressing change
- C. The patient is willing to look at the incision during a dressing change
- D. The patient expresses dislike of the surgical wound
- E. The patient assists in opening the packages of dressing material for the nurse
Correct Answer: B,C,E
Rationale: While changing the dressing, the nurse has an opportunity to teach the patient how to care for the incision and change the dressings at home. The nurse observes for indicators of the patients readiness to learn, such as looking at the incision, expressing interest, or assisting in the dressing change. Expressing dislike and wanting to delegate to a family member do not suggest readiness to learn.