The nurse is planning patient teaching for a patient who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching?

As soon as possible before the surgical procedure

The nurse is caring for a hospice patient who is scheduled for a surgical procedure to reduce the size of his spinal tumor in an effort to relieve his pain. The nurse should plan this patient care with the knowledge that his surgical procedure is classified as which of the following?

Palliative

A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The nurses teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg exercises prior to surgery?

Leg exercises improve circulation and prevent venous thrombosis.

During the care of a preoperative patient, the nurse has given the patient a preoperative benzodiazepine. The patient is now requesting to void. What action should the nurse take?

Offer the patient a bedpan or urinal.

The nurse is preparing a patient for surgery. The patient states that she is very nervous and really does not understand what the surgical procedure is for or how it will be performed. What is the most appropriate nursing action for the nurse to take?

Call the physician to review the procedure with the patient.

The nurse is caring for a patient who is admitted to the ER with the diagnosis of acute appendicitis. The nurse notes during the assessment that the patients ribs and xiphoid process are prominent. The patient states she exercises two to three times daily and her mother indicates that she is being treated for anorexia nervosa. How should the nurse best follow up these assessment data?

Facilitate a detailed analysis of the patients electrolyte levels.

The nurse is doing preoperative patient education with a 61-year-old male patient who has a 40-pack per year history of cigarette smoking. The patient will undergo an elective bunionectomy at a time that fits his work schedule in a few months. What would be the best instruction to give to this patient?

Stop smoking 4 to 8 weeks before the scheduled surgery to enhance pulmonary function and decrease infection.

You are providing preoperative teaching to a patient scheduled for hip replacement surgery in 1 month. During the preoperative teaching, the patient gives you a list of medications she takes, the dosage, and frequency. Which of the following interventions provides the patient with the most accurate information?

instruct the patient to stop taking St. Johns wort at least 2 weeks prior to surgery due to its interaction with anesthetic agents.

The nurse is creating the care plan for a 70-year-old obese patient who has been admitted to the postsurgical unit following a colon resection. This patients age and increased body mass index mean that she is at increased risk for what complication in the postoperative period?

Infection

The nurse is caring for a patient in the postoperative period following an abdominal hysterectomy. The patient states, I dont want to use my pain meds because theyll make me dependent and I wont get better as fast. Which response is most important when explaining the use of pain medication?

You will move more easily and heal more quickly with decreased pain. Dependence only occurs when it is administered for an extended period of time.

The nurse admitting a patient who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this patients diagnosis of type 1 diabetes affect the care that the nurse plans?

The nurse should assess the patients blood glucose levels vigilantly.

The nurse is checking the informed consent for a 17-year-old who has just been married and expecting her first child. She is scheduled for a cesarean section. She is still living with her parents and is on her parents health insurance. When obtaining informed consent for the cesarean section, who is legally responsible for signing?

The patient

The nurse is providing preoperative teaching to a patient scheduled for surgery. The nurse is instructing the patient on the use of deep breathing, coughing, and the use of incentive spirometry when the patient states, I dont know why youre focusing on my breathing. My surgery is on my hip, not my chest. What rationale for these instructions should the nurse provide?

To promote optimal lung expansion

One of the things a nurse has taught to a patient during preoperative teaching is to have nothing by mouth for the specified time before surgery. The patient asks the nurse why this is important. What is the

19.

A) B)

Feedback:

The major purpose of withholding food and fluid before surgery is to prevent aspiration. There is no scientific basis for withholding food and the development of pneumonia or interference with absorption of anesthetic agents. Constipation in patients in the postoperative period is related to the anesthesia, not from withholding food or fluid in the hours before surgery.

A patient is scheduled for a bowel resection in the morning and the patients orders include a cleansing enema tonight. The patient wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect?

Preventing aspiration of gastric contents
Preventing the accumulation of abdominal gas postoperatively

most

appropriate response for the patient?

You will need to have food and fluid restricted before surgery so you are not at risk for choking.

A patient is scheduled for a bowel resection in the morning and the patients orders include a cleansing enema tonight. The patient wants to know why this is necessary. The nurse should explain that the cleansing enema will have what therapeutic effect?

Preventing potential contamination of the peritoneum

The nurse is caring for a patient who is experiencing pain and anxiety following his prostatectomy. Which intervention will likely best assist in decreasing the patients pain and anxiety?

Use of guided imagery along with pain medication

A patient is on call to the OR for an aortobifemoral bypass and the nurse administers the ordered preoperative medication. After administering a preoperative medication to the patient, what should the nurse do?

Place the bed in a low position with the side rails up.

The nurse is performing a preadmission assessment of a patient scheduled for a bilateral mastectomy. Of

what purpose of the preadmission assessment should the nurse be aware?

Verifies completion of preoperative diagnostic testing

A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What should the nurse include in the care given to this patient? Select all that apply.

Establishing an IV line

Verifying the surgical site with the patient

Taking measures to ensure the patients comfort

An OR nurse will be participating in the intraoperative phase of a patients kidney transplant. What action will the nurse prioritize in this aspect of nursing care?

Monitoring the patients physiologic status

The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung lobe resection to treat lung cancer. What underlying principle should guide the nurses preoperative assessment of an elderly patient?

Elderly patients have less physiologic reserve than younger patients.

The PACU nurse is caring for a patient who has been deemed ready to go to the postsurgical floor after her surgery. What would the PACU nurse be responsible for reporting to the nurse on the floor? Select all that apply.

The patients preoperative level of consciousness

The presence of family and/or significant others

The patients full name

A 77-year-old mans coronary artery bypass graft has been successful and discharge planning is underway. When planning the patients subsequent care, the nurse should know that the postoperative phase of perioperative nursing ends at what time?

When a follow-up evaluation in the clinical or home setting is done

The nurse is caring for a trauma victim in the ED who will require emergency surgery due to injuries. Before the patient leaves the ED for the OR, the patient goes into cardiac arrest. The nurse assists in the successful resuscitation and proceeds to release the patient to the OR staff. When can the ED nurse perform the preoperative assessment?

When assisting with the resuscitation

The admitting nurse in a short-stay surgical unit is responsible for numerous aspects of care. What must the nurse verify before the patient is taken to the preoperative holding area?

That preoperative teaching was performed

The clinic nurse is doing a preoperative assessment of a patient who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the patients medical history, the nurse notes that this patient had a kidney transplant 8 years ago and that the patient is taking immunosuppressive drugs. For what is this patient at increased risk when having surgery?

Infection

The nurse is planning the care of a patient who has type 1 diabetes and who will be undergoing knee replacement surgery. This patients care plan should reflect an increased risk of what postsurgical complications? Select all that apply.

Hypoglycemia

Acidosis

Glucosuria

The surgical nurse is preparing to send a patient from the presurgical area to the OR and is reviewing the patients informed consent form. What are the criteria for legally valid informed consent? Select all that apply.

Consent must be freely given.

Consent must be obtained by a physician.

Signature must be witnessed by a professional staff member.

You are the nurse caring for an unconscious trauma victim who needs emergency surgery. The patient is a 55-year-old man with an adult son. He is legally divorced and is planning to be remarried in a few weeks. His parents are at the hospital with the other family members. The physician has explained the need for surgery, the procedure to be done, and the risks to the children, the parents, and the fianc. Who should be asked to sign the surgery consent form?

The son

The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The childs parents are thought to be en route to the hospital but have not yet arrived. No other family members are present and attempts to contact the parents have been unsuccessful. The child needs emergency surgery to save her life. How should the need for informed consent be addressed?

Surgery should be done without informed consent.

The nurse is caring for a 78-year-old female patient who is scheduled for surgery to remove her brain tumor. The patient is very apprehensive and keeps asking when she will get her preoperative medicine. The medicine is ordered to be given on call to OR. When would be the best time to give this medication?

After being notified by the OR and before other preoperative preparations

The nurse is preparing to send a patient to the OR for a scheduled surgery. What should the nurse ensure is on the chart when it accompanies the patient to surgery? Select all that apply.

Laboratory reports

Nurses notes

Verification form

You are caring for an 88-year-old woman who is scheduled for a right mastectomy. You know that elderly patients are frequently more anxious prior to surgery than younger patients. What would you increase with this patient to decrease her anxiety?

Therapeutic touch

The policies and procedures on a preoperative unit are being amended to bring them closer into alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most directly addresses the priorities of the SCIP?

Actions aimed at preventing surgical site infections

A 90-year-old female patient is scheduled to undergo a partial mastectomy for the treatment of breast cancer. What nursing diagnosis should the nurse prioritize when planning this patients postoperative care?

Risk for Infection related to reduced immune function

A clinic nurse is conducting a preoperative interview with an adult patient who will soon be scheduled to undergo cardiac surgery. What interview question most directly addresses the patients safety?

What prescription and nonprescription medications do you currently take?

The nurse is preparing an elderly patient for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the patient?

Hypothermia

The OR nurse acts in the circulating role during a patients scheduled cesarean section. For what task is this nurse solely responsible?

Performing documentation

A 21-year-old patient is positioned on the OR bed prior to knee surgery to correct a sports-related injury. The anesthesiologist administers the appropriate anesthetic. The OR nurse should anticipate which of the following events as the teams next step in the care of this patient?

Intubating

A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which patient most closely during the intraoperative period because of the increased risk for hypothermia?

A 74-year-old woman with a low body mass index

The anesthetist is coming to the surgical admissions unit to see a patient prior to surgery scheduled for tomorrow morning. Which of the following is the priority information that the nurse should provide to the anesthetist during the visit?

Latex allergy

An OR nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the OR?

Mask covering the nose and mouth

An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what?

Sterile surfaces or articles may touch other sterile surfaces.

The surgical patient is a 35-year-old woman who has been administered general anesthesia. The nurse recognizes that the patient is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage?

Restrain the patient.

A patient waiting in the presurgical holding area asks the nurse, Why exactly do they have to put a breathing tube into me? My surgery is on my knee. What is the best rationale for intubation during a surgical procedure that the nurse should describe?

The tube provides an airway for ventilation.
The tube protects the patients esophagus from trauma

The circulating nurse in an outpatient surgery center is assessing a patient who is scheduled to receive moderate sedation. What principle should guide the care of a patient receiving this form of anesthesia?

The patient must never be left unattended by the nurse.

A nurse is caring for a patient following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache?

Keep the patient positioned supine.

The OR will be caring for a patient who will receive a transsacral block. For what patient would the use of a transsacral block be appropriate for pain control?

An older adult man who will undergo an inguinal hernia repair

The circulating nurse will be participating in a 78-year-old patients total hip replacement. Which of the following considerations should the nurse prioritize during the preparation of the patient in the OR?

Pressure points should be assessed and well padded.

The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient?

The patient may be at risk for malignant hyperthermia.

While the surgical patient is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the patients weight. How should the nurse best respond?

Discourage the colleague from making such comments.

You are caring for a male patient who has had spinal anesthesia. The patient is under a physicians order to lie flat postoperatively. When the patient asks to go to the bathroom, you encourage him to adhere to the physicians order. What rationale for complying with this order should the nurse explain to the patient?

Preventing the onset of a headache

The nurse is packing a patients abdominal wound with sterile, half-inch Iodoform gauze. During the procedure, the nurse drops some of the gauze onto the patients abdomen 2 inches (5 cm) away from the wound. What should the nurse do?

Discard the gauze packing and repack the wound with new Iodoform gauze.

The nurse is performing wound care on a 68-year-old postsurgical patient. Which of the following practices violates the principles of surgical asepsis?

Pouring solution onto a sterile field cloth

A patient is scheduled for surgery the next day and the different phases of the patients surgical experience will require input from members of numerous health disciplines. How should the patients care best be coordinated?

By implementing an interdisciplinary approach to care

Prior to a patients scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the patients care. What is the main rationale for organizing perioperative care in this collaborative manner?

Evidence-based practice

An intraoperative nurse is applying interventions that will address surgical patients risks for perioperative positioning injury. Which of the following factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply.

Absence of reflexes

Diminished ability to communicate

Loss of pain sensation

Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the patients accompanying documentation includes which of the following?

Informed consent

A patient will be undergoing a total hip arthroplasty later in the day and it is anticipated that the patient may require blood transfusion during surgery. How can the nurse best ensure the patients safety if a blood transfusion is required?

Ensure that the patient has had a current cross-match.

The circulating nurse is admitting a patient prior to surgery and proceeds to greet the patient and discuss what the patient can expect in surgery. What aspect of therapeutic communication should the nurse implement?

Use a tone that decreases the patients anxiety.

A patient who underwent a bowel resection to correct diverticula suffered irreparable nerve damage.During the case review, the team is determining if incorrect positioning may have contributed to the patients nerve damage. What surgical position places the patient at highest risk for nerve damage?

Trendelenburg

The patients surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the surgical wound. This requires the nurse to prioritize assessments related to what complication?

Anaphylaxis

As an intraoperative nurse, you are the advocate for each of the patients who receives care in the surgical setting. How can you best exemplify the principles of patient advocacy?

By maintaining each of your patients privacy

The nurse is caring for a patient who is scheduled to have a needle biopsy of the pleura. The patient has had a consultation with the anesthesiologist and a conduction block will be used. Which local conduction block can be used to block the nerves leading to the chest?

Paravertebral block

When creating plans of nursing care for patients who are undergoing surgery using general anesthetic, what nursing diagnoses should the nurse identify? Select all that apply.

Disturbed sensory perception related to anesthetic

Risk of latex allergy response related to surgical exposure

Anxiety related to surgical concerns

The intraoperative nurse is implementing a care plan that addresses the surgical patients risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication?

Hypoxia

The perioperative nurse is constantly assessing the surgical patient for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the patient is developing malignant hyperthermia?

Tachycardia

As a perioperative nurse, you know that the National Patient Safety Goals have the potential to improve patient outcomes in a wide variety of health care settings. Which of these Goals has the most direct relevance to the OR?

Reduce the risk of fires

The perioperative nurse has completed the presurgical assessment of an 82-year-old female patient who is scheduled for a left total knee replacement. When planning this patients care, the nurse should address the consequences of the patients aging cardiovascular system. These include an increased risk of which of the following?

Hypervolemia

The nurse knows that elderly patients are at higher risk for complications and adverse outcomes during the intraoperative period. What is the best rationale for this phenomenon?

The elderly patient has reduced ability to adjust rapidly to emotional and physical stress.

As an intraoperative nurse, you know that the patients emotional state can influence the outcome of his or her surgical procedure. How would you best reinforce the patients ability to influence outcome?

Incorporate cultural and religious considerations, as appropriate.

Maintaining an aseptic environment in the OR is essential to patient safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field?

1 foot

The OR nurse is providing care for a 25-year-old major trauma patient who has been involved in a motorcycle accident. The nurse should know that the patient is at increased risk for what complication of surgery?

Anesthesia awareness

The OR nurse is participating in the appendectomy of a 20 year-old female patient who has a dangerously low body mass index. The nurse recognizes the patients consequent risk for hypothermia. What action should the nurse implement to prevent the development of hypothermia?

Ensure that IV fluids are warmed to the patients body temperature.

A 68-year-old patient is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding area to meet the patient and quickly realizes that the patient is profoundly anxious. What is the most appropriate intervention for the nurse to apply?

Clearly explain any information that the patient seeks.

A 59-year-old male patient is scheduled for a hemorrhoidectomy. The OR nurse should anticipate assisting the other team members with positioning the patient in what manner?

Lithotomy position

The recovery room nurse is admitting a patient from the OR following the patients successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted patient?

Airway patency

An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patients vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next?

Turn the patient completely to one side.

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?

The patient should not drive herself home.

The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do?

Stand upright for 2 to 3 minutes prior to ambulating.

The perioperative nurse is providing care for a patient who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The patient is reluctant to ambulate, citing the need to recover in bed. For what complication is the patient most at risk?

Atelectasis

The nurse is caring for a patient on the medicalsurgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?

Red, warm, tender incision

The nurse is preparing to change a patients abdominal dressing. The nurse recognizes the first step is to provide the patient with information regarding the procedure. Which of the following explanations should the nurse provide to the patient?

During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to.

A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do?

Notify the physician and continue to monitor the hourly urine output closely.

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?

Pulmonary embolism

The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the patients blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the patients skin is cold, moist, and pale. Of what is the patient showing signs?

Hypovolemic shock

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?

Pain, hypoxia, or bladder distention

The nurse is caring for a patient after abdominal surgery in the PACU. The patients blood pressure has increased and the patient is restless. The patients oxygen saturation is 97%. What cause for this change in status should the nurse first suspect?

The patient is in pain.

The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what means?

Third intention

The nurse is caring for an 82-year-old female patient in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurses subsequent assessment?

Postoperative confusion is common in the older adult patent, but it could also indicate a significant blood loss.

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?

Hemorrhage and shock

The nursing instructor is discussing postoperative care with a group of nursing students. A student nurse asks, Why does the patient go to the PACU instead of just going straight up to the postsurgical unit? What is the nursing instructors best response?

The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications.

The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention?

Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw.

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?

Ill eat plenty of fruits and vegetables.

The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority?

Maintaining a patent airway

The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurses first response?

Place saline-soaked sterile dressings on the wound.

The PACU nurse is caring for a 45-year-old male patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply

Hypotension

Dysrhythmias

Hypertension

A postoperative patient rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be the nurses first action?

Quickly attempt to determine the cause of hemorrhage.

The intraoperative nurse is transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year-old woman. The nurse should prioritize which of the following actions?

Keeping the patient warm

A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? Select all that apply.

Stable blood pressure

Sufficient oxygen saturation

Adequate respiratory function

The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply.

Provide all discharge instructions in writing.

Provide the nurses or surgeons contact information.

Give prescriptions to the patient.

The nursing instructor is discussing the difference between ambulatory surgical centers and hospital- based surgical units. A student asks why some patients have surgery in the hospital and others are sent to ambulatory surgery centers. What is the instructors best response?

Patients admitted to the hospital for surgery usually have multiple health needs.

The nurse just received a postoperative patient from the PACU to the medicalsurgical unit. The patient is an 84-year-old woman who had surgery for a left hip replacement. Which of the following concerns should the nurse prioritize for this patient in the first few hours on the unit?

Close monitoring of neurologic status

The nurses aide notifies the nurse that a patient has decreased oxygen saturation levels. The nurse assesses the patient and finds that he is tachypnic, has crackles on auscultation, and his sputum is frothy and pink. The nurse should suspect what complication?

Flash pulmonary edema

The nurse is performing the shift assessment of a postsurgical patient. The nurse finds his mental status, level of consciousness, speech, and orientation are intact and at baseline, but the patient tells you he is very anxious. What should the nurse do next?

Assess the patients oxygen levels.

The nurse is creating the plan of care for a patient who is status postsurgery for reduction of a femur fracture. What is the most important short-term goal for this patient?

Adequate respiratory function

You are caring for a 71-year-old patient who is 4 days postoperative for bilateral inguinal hernias. The patient has a history of congestive heart failure and peptic ulcer disease. The patient is highly reluctant to ambulate and will not drink fluids except for hot tea with her meals. The nurses aide reports to you that this patients vital signs are slightly elevated and that she has a nonproductive cough. When you assess the patient, you auscultate crackles at the base of the lungs. What would you suspect is wrong with your patient?

Hypostatic pulmonary congestion

The nurse is admitting a patient to the medicalsurgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia?

Encourage the patient to use the incentive spirometer every 2 hours.

A surgical patient has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). The nurse should know that the requirements for safe and effective use of PCA include what?

A clear understanding of the need to self-dose

A patient underwent an open bowel resection 2 days ago and the nurses most recent assessment of the patients abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have caused the dehiscence?

The patient has vomited three times in the past 12 hours.

The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion?

Trace the outline of the drainage on the dressing for future comparison.

The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patients possible readiness to learn how to change her dressing? Select all that apply.

The patient expresses interest in the dressing change.
The patient is willing to look at the incision during a dressing change.

The patient assists in opening the packages of dressing material for the nurse.

The nursing instructor is talking with a group of medicalsurgical students about deep vein thrombosis (DVT). A student asks what factors contribute to the formation of a DVT. What would be the instructors best response?

Dehydration is a contributory factor to the formation of deep vein thrombi.

The home health nurse is caring for a postoperative patient who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the patients postoperatative day 2. During the visit, the nurse will assess for wound infection. For most patients, what is the earliest postoperative day that a wound infection becomes evident?

Day 5

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?

Postoperative delirium

The surgeons preoperative assessment of a patient has identified that the patient is at a high risk for venous thromboembolism. Once the patient is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the patients risk of developing this complication?

Encourage early ambulation.