Nokea
Which content and teaching modality best fit this particular situation?
- A. Have Gabrielle use the incentive spirometer while providing direction and encouragement
- B. Show Gabrielle the OR suite, taking time to point out the equipment and lights
- C. Have Gabrielle perform a series of arm and neck stretches
- D. Talk to Gabrielle and her mom about the likelihood of postoperative nausea and vomiting
Correct Answer: A
Rationale: Teaching Gabrielle to use the incentive spirometer with direction and encouragement is the most appropriate content and modality. It prepares her for postoperative respiratory exercises to prevent complications, is age-appropriate, and involves both her and her mother in the learning process.
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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.
A nurse is caring for a patient who is obese and has had abdominal surgery. The nurse prioritizes a plan to prevent what postoperative complication?
- A. Anesthetic interactions
- B. Impaired wound healing
- C. Weight gain
- D. Flatulence
Correct Answer: B
Rationale: Adipose (fatty) tissue has poor blood supply, which places the obese patient at risk for delayed wound healing, wound infection, and disruption in the integrity of the wound. Medication interactions are not the primary concern and are managed by the nurse anesthetist or anesthesiologist. Postoperative bleeding and flatulence (gas) after anesthesia are concerns for all patients, not just those with obesity.
A nurse in the PACU is preparing to receive a patient from surgery who sustained a ruptured spleen in a motor vehicle accident. Which of these system assessments will take priority?
- A. Neurologic system, ambulatory function
- B. Cardiovascular system, vital signs
- C. GI system, bowel function
- D. Integumentary, skin breakdown
Correct Answer: B
Rationale: The priority assessment focuses on the ruptured organ, blood loss, and monitoring for early signs of shock. Tachycardia, the first sign of shock, and decreasing blood pressure must be immediately reported to the health care provider. The neurologic system may be affected due to anesthesia, but ambulatory function is not the immediate priority. The nurse anticipates reduced or absent bowel sounds after surgery, but risk for blood loss is the priority. The nurse plans to promote wound healing and repositions the patient to prevent skin breakdown; however, hemorrhage and early detection of shock is the priority at this time.
Based on the objective and subjective assessment of this patient, which priority problem should the nurse identify to guide the perioperative plan of care?
- A. Bleeding risk
- B. Activity intolerance
- C. Acute anxiety
- D. Thermal injury risk
Correct Answer: C
Rationale: Gabrielle's calm but cooperative behavior, coupled with her reluctance to let go of her mother, indicates acute anxiety as the priority problem. Addressing anxiety is critical to ensure a smooth perioperative experience, as it can impact cooperation and emotional readiness for surgery.
While assessing a patient in the PACU following abdominal surgery, a nurse promptly contacts the surgeon for which of these findings? Select all that apply.
- A. Tachycardia
- B. IV with normal saline solution
- C. Wound drainage
- D. Patient restless
- E. Patient reports incisional pain 8/10
Correct Answer: A,C,D
Rationale: Increased wound drainage, restlessness, increasing pulse, and decreasing blood pressure are symptoms of blood loss/hemorrhage and must be promptly identified to prevent shock. Diminished bowel sounds are expected after surgery and anesthesia. Incisional pain is anticipated; the nurse uses prescriptions for analgesia to help resolve pain. Due to NPO status and blood loss from surgery, IV fluids are administered.