Nokea
What best describes Mrs. West’s change in vital signs postoperatively?
- A. Decrease in BP indicates shock is imminent
- B. Elevated temperature indicates wound infection
- C. Decrease in BP is consistent with hypertension
- D. Elevation in temperature is consistent with normal postoperative recovery
Correct Answer: D
Rationale: A mild fever is common after surgery due to inflammatory response.
You may also like to solve these questions
The nurse knows that a patient taught sleep hygiene practices needs further instruction when he says
- A. Once I go to bed, I should get up if I am not asleep after 20 minutes.
- B. It’s okay to have my usual two glasses of wine in the evening before bed.
- C. A couple of crackers with cheese and a glass of milk may help to relax before bed.
- D. I should go to the gym earlier in the day so that I’m done at least 6 hours before bedtime.
Correct Answer: B
Rationale: The correct answer is B. Alcohol disrupts sleep architecture, making it counterproductive for sleep hygiene. Getting up after 20 minutes (A) is a recommended practice, and exercising early (D) promotes better sleep.
A client is scheduled for a cholecystectomy in the morning. In planning the postoperative care, the priority nursing diagnosis for the client will be at high-risk for:
- A. knowledge deficit.
- B. urinary retention.
- C. impaired physical mobility.
- D. ineffective breathing pattern.
Correct Answer: D
Rationale: The client may have a knowledge deficit, but reducing the risk for knowledge deficit is not a postoperative priority nursing diagnosis. The client will have a Foley catheter for a day or two after the surgery. Urinary retention is usually not a problem once the Foley catheter is removed. A client having a cholecystectomy should not be physically impaired. The client is encouraged to begin ambulating soon after surgery. Because of the location of the incision, the cholecystectomy client is reluctant to breath deeply and is at risk for developing pneumonia. These clients have to be reminded and encouraged to take deep breaths.
A 54-year-old client has cholelithiasis and is admitted for an elective cholecystectomy. The client is 5 feet 3 inches tall, weighs 205 pounds, and has smoked one pack of cigarettes per day for 35 years. The client will be NPO at midnight. When the client's spouse asks why the client cannot have breakfast the morning before surgery, the nurse should explain:
- A. Your spouse is a good-sized person and it won't hurt to miss breakfast.
- B. Eating breakfast and having food in the stomach could cause vomiting and aspiration during surgery.
- C. Your spouse will be too busy in the morning preparing for surgery to have time to eat breakfast.
- D. Not eating breakfast will prevent fecal contamination of the abdominal operative site.
Correct Answer: B
Rationale: The client's size has nothing to do with an NPO status. Clients are at greatest risk for aspiration and vomiting during surgery when food and/or liquids are in the stomach. Preparation on the morning of surgery is time consuming, but it does not affect a client's NPO status. The gallbladder lies under the surface of the liver and is a part of the biliary tract, not the intestinal tract. Cholecystectomy does not involve the intestinal tract or its contents.
Lack of adequate nutrition in older adults may lead to:
- A. Delayed wound healing
- B. Shorter hospital stays
- C. Improved immune status
- D. Decreased mortality rates
Correct Answer: A
Rationale: Poor nutrition weakens tissues and impairs the body's ability to repair itself, resulting in delayed wound healing and increased susceptibility to infections.
A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors?
- A. Bring a list of all medications and their purposes.
- B. Keep the doctor's phone number close by.
- C. Ensure all providers wash their hands before entering the room.
- D. Document the name of each caregiver who enters the room.
Correct Answer: A
Rationale: The correct answer is A: Bring a list of all medications and their purposes. This is important as it helps prevent medication errors during the surgical procedure. By having a list of medications and their purposes, the healthcare team can ensure they are administering the correct medications and dosages. This also helps in preventing drug interactions or allergies.
Option B (Keep the doctor's phone number close by) may be helpful in case of emergencies, but it does not directly address preventing errors during the surgical procedure. Option C (Ensure all providers wash their hands before entering the room) is important for infection control but is not specifically related to preventing errors. Option D (Document the name of each caregiver who enters the room) is not as critical as having a list of medications, as it does not directly impact the safety and well-being of the client during the surgical procedure.