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When caring for a patient who returned from the operating room 8 hours ago, which finding requires follow-up assessment by the nurse?
- A. Patient reports discomfort at surgical site, scale of 5/10
- B. Patient voids small amounts every 20-30 minutes
- C. Patient is sleepy and awakens only to touch
- D. Patient reports thirst and dry mouth
Correct Answer: B
Rationale: This patient is displaying typical signs of urinary retention, voiding small frequent amounts. Discomfort is expected and can be managed with prescribed analgesics. Anesthesia or opioid analgesia promotes sedation from which this patient awakens to touch. Dry mouth and thirst can result from NPO status and possible anticholinergic medication intended to dry respiratory secretions during surgery.
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A nurse teaches a patient the rationale for performing leg exercises after surgery. How does the nurse best explain the purpose of the exercises to the patient?
- A. Improves respiratory function
- B. Maintains functional abilities
- C. Provides diversional activities
- D. Increases venous return
Correct Answer: D
Rationale: Leg exercises promote venous return and decrease complications related to venous stasis causing DVT and help prevent muscle weakness. These exercises also decrease risk for thrombophlebitis and emboli.
A nurse is caring for a postoperative patient who has been on bedrest for 5 days. What interventions will the nurse use to prevent deep vein thrombosis (DVT)? Select all that apply.
- A. Administering analgesics
- B. Documenting daily calf circumference
- C. Assessing vital signs every 4 hours
- D. Encouraging ambulation
- E. Applying intermittent pneumatic compression devices (IPCDs)
- F. Providing education on pain management
Correct Answer: D,E
Rationale: To prevent DVT, the nurse plans to apply an IPCD and antiembolism stockings. Assessments such as vital signs and calf circumference will detect but not prevent DVT. Maintaining bedrest continues to promote risk, and early ambulation helps prevent DVT.
An older adult who is scheduled for a hip replacement is taking several medications on a regular basis. Which group of medications does the nurse identify as a surgical risk for this patient?
- A. Anticoagulants
- B. Antacids
- C. Laxatives
- D. Sedatives
Correct Answer: A
Rationale: Anticoagulant medications increase the risk for hemorrhage intra- and postoperatively.
A nurse is planning caring for a patient who had thoracic surgery. Which nursing interventions are most appropriate for patients undergoing this type of surgery?
- A. Observing for incisional wound healing
- B. Monitoring vital signs, especially pulse and blood pressure
- C. Instructing the patient on the proper use of the incentive spirometer
- D. Applying antiembolism stockings
Correct Answer: A,B,C
Rationale: A thoracic incision, near or overlying the lungs, makes it difficult or painful for patients to take deep breaths and cough. The nurse uses analgesics, repositioning, coughing and deep breathing, and an incentive spirometer to promote respiratory expansion and airway clearance to decrease the risk for respiratory complications. Monitoring vital signs is also critical to detect complications early.
A nurse is preparing a patient for a cesarean birth using spinal anesthesia. Which effects of anesthesia will the nurse teach the patient to expect? Select all that apply.
- A. Loss of consciousness
- B. Inability to speak
- C. Reduction or loss of deep tendon reflexes
- D. Loss of sensation below the injection
- E. Inability to move the lower extremities
- F. Prolonged pain relief after other anesthesia wears off
Correct Answer: D,E
Rationale: A localized loss of sensation, loss of motor function, and possible loss of reflexes occur with a regional anesthetic. Loss of consciousness, including speech and relaxation of skeletal muscles, occurs with general anesthesia. Prolonged pain relief after other anesthesia wears off and infiltration of the underlying tissues in an operative area occur with topical anesthesia.