Nokea
The PACU nurse is about to administer pain medication to an older adult client who is recovering from surgery. What does this client's age put them at increased risk for? Select all that apply.
- A. Acute confusion
- B. Respiratory depression
- C. Disorientation
- D. Infection
- E. Greater requirement for pain medication
Correct Answer: A,B,C,D
Rationale: The older adult client requiring pain medication postoperatively is at greater risk for confusion, disorientation, respiratory depression, and infection. The older adult client does not have a greater requirement for pain medication, because even standard doses may cause complications that would not occur in younger clients.
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The nurse has received shift report on a postoperative surgical client. Which medication prescription would indicate that the medication was being administered prophylactically?
- A. A 5% dextrose in 0.5 NSS to infuse at 100 mL/hr
- B. Percocet two tablets every 4 hours as needed for pain
- C. Humulin NPH 12 units at 0800
- D. Cefazolin 1 g IV every 6 hours for 24 hours
Correct Answer: D
Rationale: Cefazolin, an antibiotic, is commonly administered prophylactically to prevent postoperative infections. A 5% dextrose in 0.5 NSS is used for fluid maintenance, Percocet is for pain management, and Humulin NPH is for diabetes management, none of which are primarily prophylactic in this context.
A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants?
- A. Scrub nurse
- B. Circulating nurse
- C. First assistant
- D. Certified registered nurse anesthetist
Correct Answer: A
Rationale: The scrub nurse is sterile and assists the surgical team by handing instruments to the surgeon, preparing sutures, receiving specimens to be sent to the lab, and counting sponges and needles. The circulating nurse is not sterile and obtains and opens sterile equipment, adjusts lights, and keeps records. The first assistant is involved with the client's preoperative care. The certified registered nurse anesthetist assists in the client's anesthesia.
The nurse is caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock?
- A. Weak and rapid pulse rate
- B. Warm, dry skin
- C. Pooling of secretions in the lungs
- D. Obstructed airway
Correct Answer: A
Rationale: Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock.
The nurse is caring for a client needing emergency surgery. Which preoperative teaching can be omitted when preparing a client for surgery?
- A. Effective coughing and deep breathing
- B. Types of postoperative pain medication
- C. Post-discharge diet
- D. Knowledge of surgical procedure
Correct Answer: C
Rationale: The preoperative teaching that could be omitted due to the need to obtain emergency surgery is explaining the post-discharge diet. This is not essential information to improve client participation in the postoperative recovery. Coughing and deep breathing are essential in the immediate postoperative period. Clients are often concerned about postoperative pain so instruction on pain medication can decrease anxiety. Knowledge of the surgical procedure must be explained by a physician when signing a surgical consent.
The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?
- A. The client is tolerating sips of water.
- B. The client reports a small bowel movement and flatus.
- C. The client is breathing calmly.
- D. The client states being hungry.
Correct Answer: B
Rationale: A bowel movement demonstrates that the nursing outcome of the return to function of the gastrointestinal track has been met. Tolerating sips of water, breathing calmly, and reports of hunger are components of meeting the outcome of functioning.