ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 14 : Perioperative Care Questions
Question 1 of 5
The nurse is providing community instruction on the impact of aging and surgical incisional considerations. Which instructional area(s) would be included in the presentation? Select all that apply.
Correct Answer: A,B,C
Rationale: The nurse realizes that there is a thinning of the skin and loss of subcutaneous tissue, which is normal in the aging process. Also, older adults may have a diminished immunological response, making them more susceptible to infection. For this reason, instructional areas would include areas which promote healing and diminish the risk of infection. Increasing protein in the diet promotes wound healing. Instructing on signs and symptoms of wound infection allows for early symptom recognition. Cleansing, as per physician instruction, but with products, such as soap and water, decreases bacteria on the skin. Showering may begin prior to healing with the stream of the water not directly on the incision. Peroxide is not recommended for wound/incisional care. Crusted areas should be allowed to heal and flake off. Removing the areas could open a wound allowing for bacteria to enter.
Question 2 of 5
The nurse is caring for a postoperative client who reports difficulty urinating. The client does not have a urinary catheter in place. Which nursing action(s) are most appropriate at this time? Select all that apply.
Correct Answer: A,B,D,E
Rationale: The nurse encourages the client to void within 8 hours of surgery to minimize the risk of a urinary tract infection. Ambulating the client to the bathroom promotes normal body positioning for urination. Running water is a common psychological strategy to cause urination. Offering to catheterize is a last option, and a prescription for catheterization must be in place for the nurse to proceed.
Question 3 of 5
The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?
Correct Answer: C
Rationale: Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus.
Question 4 of 5
The nurse is caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock?
Correct Answer: A
Rationale: Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock.
Question 5 of 5
The nurse is caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery?
Correct Answer: B
Rationale: The nurse should encourage the client to move legs frequently and do leg exercises to prevent venous stasis and other circulatory complications. The nurse should not place pillows under the client's knees or calves unless prescribed and should avoid placing pressure on the client's lower extremities. Placing the client in a side-lying position will not help prevent venous stasis and other circulatory complications in a client who has undergone surgery.