Nokea
The PACU nurse is caring for a male patient who had a hernia repair. The patients blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery?
- A. Dysrhythmias, blood loss, and hyperthermia
- B. Electrolyte imbalances and neurologic changes
- C. A parasympathetic reaction and low blood volumes
- D. Pain, hypoxia, or bladder distention
Correct Answer: D
Rationale: Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Dysrhythmias, blood loss, hyperthermia, electrolyte imbalances, and neurologic changes are not common postoperative reasons for hypertension. A parasympathetic reaction and low blood volumes would cause hypotension.
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The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect is the problem with the patient?
- A. Postoperative delirium
- B. Postoperative dementia
- C. Senile dementia
- D. Senile confusion
Correct Answer: A
Rationale: Postoperative delirium, characterized by confusion, perceptual and cognitive deficits, altered attention levels, disturbed sleep patterns, and impaired psychomotor skills, is a significant problem for older adults. Dementia does not have a sudden onset. Senile confusion is not a recognized health problem.
An adult patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the patient may be at risk for what?
- A. Hemorrhage and shock
- B. Aspiration
- C. Postoperative infection
- D. Hypertension and dysrhythmias
Correct Answer: A
Rationale: The patient with a hemorrhage presents with hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin. Aspiration would manifest in airway disturbance. Hypertension or dysrhythmias would be less likely to cause pallor and cool skin. An infection would not be present at this early postoperative stage.
The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer. Which of the following statements by the patient indicates that teaching has been effective?
- A. Ill make sure to limit my intake of protein
- B. Ill make sure that the bandage is wrapped tightly
- C. My foot should feel cool or cold while my legs healing
- D. Ill eat plenty of fruits and vegetables
Correct Answer: D
Rationale: Optimal nutritional status is important for wound healing; the patient should eat plenty of fruits and vegetables and not reduce protein intake. To avoid impeding circulation to the area, the bandage should be secure but not tight. If the patients foot feels cold, circulation is impaired, which inhibits wound healing.
The perioperative nurse is preparing to discharge a female patient home from day surgery performed under general anesthetic. What instruction should the nurse give the patient prior to the patient leaving the hospital?
- A. The patient should not drive herself home
- B. The patient should take an OTC sleeping pill for 2 nights
- C. The patient should attempt to eat a large meal at home to aid wound healing
- D. The patient should remain in bed for the first 48 hours postoperative
Correct Answer: A
Rationale: Although recovery time varies, depending on the type and extent of surgery and the patients overall condition, instructions usually advise limited activity for 24 to 48 hours. Complete bedrest is contraindicated in most cases, however. During this time, the patient should not drive a vehicle and should eat only as tolerated. The nurse does not normally make OTC recommendations for hypnotics.
The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication?
- A. Sepsis
- B. Infection
- C. Pulmonary embolism
- D. Hematoma
Correct Answer: C
Rationale: Patients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of an external pneumatic compression stocking significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection or sepsis would not be affected by an external pneumatic compression stocking. A hematoma or bruise would not be affected by the external pneumatic compression stocking unless the stockings were placed directly over the hematoma.