Nokea
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.
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The nurse documents attainment of expected outcomes in the preoperative phase as part of the perioperative plan of care. Which outcomes were met for Gabrielle? Select all that apply.
- A. Correct return demonstration of postoperative activities designed to prevent complications
- B. Physical and emotional readiness for operative procedure; appropriate for age
- C. Decreased risk for surgical site, catheter-based, and community-acquired infections
- D. Caregiver articulation of when to call the provider for follow-up and/or intervention
- E. Pulse oximetry >98% on room air
Correct Answer: B,D,E
Rationale: Gabrielle's nervous but smiling response indicates physical and emotional readiness (B). The scenario implies her mother was engaged in discussions about postoperative care, suggesting caregiver articulation of follow-up needs (D). Pulse oximetry >98% on room air (E) is a standard preoperative outcome, assumed met given no contrary indications.
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.
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.
A nurse on a surgical unit is aware that older adults develop reduced vital capacity as a result of normal physiologic changes. Based on these changes, which nursing intervention takes priority?
- A. Taking and recording vital signs every shift
- B. Turning, coughing, and deep breathing every 4 hours
- C. Encouraging increased intake of oral fluids
- D. Assessing bowel sounds daily
Correct Answer: B
Rationale: Reduced vital capacity in older adults decreases respiratory expansion, increasing the risk for pneumonia and atelectasis. Encouraging the patient to turn, cough, and deep breathe every 4 hours helps to prevent complications.
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.