A. BP 160/80
B. Pulse of 68
C. Respiratory rate of 14
D. Temperature of 97.2 degrees F
Rationale: This blood pressure is elevated and requires further action by the nurse. All of the other choices are within normal limits so they require nor further action by the nurse.
A. Observe the appearance of the client’s oral mucosa.
B. Assess the client for any signs of excessive bruising.
C. Review common side effects of each of the medications.
D. Explain the need to withhold the warfarin prior to surgery.
Rationale: Anticoagulants increase the risk for bleeding during surgery and the postoperative period, so the nurse must explain the need to withhold warfarin prior to surgery and instruct the client to contact the surgeon to determine how long before the surgery the medication should be stopped. The other choices are relevant to the medications she is taking but since the client is receiving a an established daily dose for over a year, they are not the most important preoperative interventions.
A. Sodium of 135 mEq/L
B. WBC of 14,000/mm3
C. Creatinine of 0.8 mg/dl
D. Hemoglobin of 14 g/dl
Rationale: The normal WBC count is 5,000 to 10,000/mm3. An increase my indicate the onset of an infection which may be a contraindication to surgery. The nurse should notify the surgeon of this abnormal lab value.
A. Advise the client to avoid pursing her lips when exhaling.
B. Remind the client to cough after taking 2 to 3 breaths.
C. Demonstrate the deep breathing and cough technique again.
D. Document successful completion of the return demonstration.
Rationale: Ms. Jackson has demonstrated incorrect technique. When performing deep breathing exercises, the client should inhale through the nose and exhale slowly through the mouth without pursing the lips. The nurse should demonstrate the entire procedure again for best learning by the client.
A. “Getting a bedsore is very serious. Sometimes people die from infected bedsores.”
B. “The nurses will make sure you do not stay in bed long enough to get bedsores.”
C. “Bedsores are one of the many problems that can occur from prolonged bedrest.”
D. “Those are now called pressure ulcers, because they are caused by pressure.”
Rationale: This response acknowledges the client’s previous learning and promotes further learning related to other complications of immobility such as thrombus formation, constipation, and atelectasis.
A. “You will only use the PCA pump for the first 24 hours after surgery.”
B. “The surgeon will prescribe the dose of medication that is correct for you.”
C. “I will tell the surgeon that you prefer the nurses administer your pain medicine.”
D. “The pump has a controlled device that prevents you from taking too much medicine.”
A. Quietly sit with the client.
B. Offer reassurance about the surgery.
C. Calmly continue the preoperative instructions.
D. Leave the room until the client has composed herself.
Rationale: Offering one’s presence is a caring and therapeutic response.
A. “We do not need to talk about pain control today if it makes you sad.”
B. Perhaps you need to see a counselor to help you resolve your grief.”
C. “It sounds as if you went through a difficult time when your father died.”
D. “You need to focus on your own needs now and not on past memories.”
A. “Have you had anything to eat or drink since midnight?”
B. “Are any of your friends or family members here with you?”
C. “Do you understand you will be admitted to the hospital following surgery?”
D. “Did you bring any valuables with you that need to be stored during surgery?”
Rationale: Ensuring that the client has remained NPO for the prescribed length of time before surgery is critical to prevent vomiting and aspiration during surgery.
A. Ask Ms. Jackson is she has received sufficient information to sign the consent form.
B. Call the operating room and notify the staff that the surgery needs to be cancelled.
C. Notify the surgeon of the need to come to the client’s room so the consent can be signed.
D. Inform a family of the need to serve a as a witness to the client’s signature.
Rationale: The nurse may witness the client’s signature if the nurse is able to determine that the client has been sufficiently informed of necessary information.
A. Use a antimicrobial agent to cleanse the surgical site.
B. Take a photo of the markings to place in the chart.
C. Confirm that the left hip is the site of the scheduled surgery.
D. Reassure the client that the surgeon will not make a mistake.
Rationale: The nurse should ensure that the markings on the hips are correct to help reduce the potential for error during surgery. When the surgical site involves a distinction between left and rights sides of the body, marking the site is a required component of the Joint Commission’s universal protocol to prevent wrong site, wrong procedure, wrong person surgery.
A. Ineffective protection
B. Ineffective tissue profusion
C. Risk for preoperative-positioning injury
D. Risk for imbalanced body temperature
Rationale: During surgery the client may remain in one position for a prolonged period. The nurse must ensure that the client is protected from injury secondary to inappropriate positioning.
A. Ensure that sufficient surgical are available.
B. Make sure that all surgical personnell are properly attired.
C. Review the scheduled procedure, site, and client.
D. Confirm that informed consent has been obtained
Rationale: A time out, the designated method for final verification before surgery begins, is a component of Joint Commission’s universal protocol to prevent wrong site, wrong procedure, wrong person surgery.
A. Position the client on her side.
B. Observe the surgical dressing.
C. Place the call bell within reach.
D. Remove the oral airway.
Rationale: During the immediate the postanesthesia period, the unconscious client should be positioned on the side to maintain an open airway and promote drainage of secretions.
A. No problems with dressing on the left hip.
B. Left hip dressing clean, dry, and intact.
C. Dressing present over left hip incision.
D. Incision well-approximated with no drainage.
Rationale: This documentation is concise and but thorough, providing a clear picture of the assessed data.
75mL/60 min x 10 drops/mL = 12.5, which rounds up to 13.
100 mL/30 min x 60 min/1 hour = 200 mL/hour
A. Auscultate the client’s breath sounds.
B. Observe the appearance of the sputum.
C. Determine the clients temperature.
D. Measure the client’s blood pressure.
Rationale: Atelectasis is a condition in which the alveoli collapse. Dull or absent breath sounds, along with changes in breathing patterns, are expected findings when atelectasis occurs
A. Document the assessment finding in the chart.
B. Notify the surgeon of the assessment finding.
C. Review the client’s serum electrolyte values.
D. Administer a laxative proscribed for PRN use.
Rationale: Hypoactive bowel sounds are an expected finding following general anesthesia, so the nurse should document this finding in the chart and continue to monitor the client.
A. Apply pressure to the site.
B. Elevate the leg on a pillow.
C. Observe the linens under the hip.
D. Use sterile technique to replace the dressing.
E. Mark the amount of drainage on the dressing.
Rationale: Gravity pulls drainage down, so the nurse should inspect the area below the surgical site for additional drainage.
E. Mark the amount of drainage on the dressing.
Rationale: This will allow for later comparison.
A. Compress the drain and re-establish suction.
B. Empty the drain and measure the amount of drainage.
C. Page the surgeon to report the finding.
D. Document the appearance of the drainage.
B. Hemoglobin and hematocrit
C. Culture and sensitivity
D. Type and cross match
Rationale: The nurse is reporting the amount of surgical drainage to the surgeon due to a concern for excessive blood loss. The surgeon needs to know information related to blood volume, provided by the hemoglobin and hematocrit levels. A and C are not correct because are information related to infection and they are not the data the surgeon needs at this time.
A. Place the unit of blood in the medication refrigerator until the client’s personal care is completed.
B. Hang the transfusion of packed cells while the UAP continues to complete the client’s personal care.
C. Lock the unit of blood in the computerized medication cart and assist the UAP in completing the personal care.
D. Return the blood back to the blood bank and send the UAP to obtain the blood when the personal care is completed.
Rationale: Transfusion of blood is a higher priority than personal care. If necessary, the remainder of the care can be delayed.
A. Stop the IV solution and transfuse the packed cells at 125 mL/hour via tubing connected to a bag of saline solution.
B. Infuse the Lactated Ringer’s solution through the IV tubing concurrently with blood at a combined rate of 75 mL/hour.
C. Flush the IV tubing with a 5 mL bolus of normal saline before and after the transfusion, and transfuse the blood within 1 hour.
D. Replace the Lactated Ringer’s solution with the unit of packed red blood cells and administer through the tubing at 75 mL/hour.
Rationale: Packed red blood cells are only compatible with normal saline. The blood should be connected to a bag of saline solution using special Y-tubing and administered within 1 1/2 to 2 hours, if possible, but no longer than 4 hours.
A. Disturbed body image.
B. Situational low self-esteem.
C. Anticipatory grieving.
D. Impaired physical mobility.
A. Frequent activity will distract the client from her concerns.
B. Maintaining a safe environment reduces client depression.
C. The client should depend of the physical therapist rather than the nurse
D. Increased mobility will promote an improved sense of control.
A. Prior to removing the dressing on the client’s hip.
B. Before opening the new sterile package.
C. Before cleansing the client’s hip incision.
D. After cleansing the client’s hip incision.
A. Bottom edges of incision approximated.
B. Small area of dehiscence at the bottom of the incision.
C. Evisceration of incision noted at the bottom edge.
D. Wound healing via secondary intention.