ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 31 : Perioperative Nursing Questions
Question 1 of 5
An adult patient awaiting surgery says to the nurse, 'I am so frightened-what if I don't wake up?' What is the nurse's best response?
Correct Answer: B
Rationale: An open-ended question that allows the patient to express concerns, fears, and feelings is therapeutic and most appropriate. The other options suggest 'yes/no' answers or suggest issues that may not be present. This type of communication does not allow the patient to clarify their thoughts.
Question 2 of 5
During preoperative teaching about pain management, the patient asks the nurse to explain how a PCA pump works. What will the nurse teach the patient about PCA?
Correct Answer: D
Rationale: The nurse educates the patient that the PCA pump allows patients to self-administer doses of pain-relieving medication within health care provider-prescribed times and dose limits. It is not realistic to promise absence of pain or unlimited access to medication nor allow the patient to select the pain medication prescribed.
Question 3 of 5
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?
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.
Question 4 of 5
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.
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.
Question 5 of 5
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.
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.