ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 31 Questions
Question 1 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 2 of 5
A nurse is preparing a patient for same-day surgery. Which of these patient-related findings must the nurse report immediately?
Correct Answer: B
Rationale: Patients receiving anticoagulants are at risk for bleeding or hemorrhage during invasive and surgical procedures. Wanting to know an anticipated discharge date is expected, the surgeon can fill out the consent form prior to sedation, and a slight increase in blood pressure is possible related to anxiety before surgery.
Question 3 of 5
An older adult who is scheduled for a hip replacement is taking several medications on a regular basis. Which group of medications does the nurse identify as a surgical risk for this patient?
Correct Answer: A
Rationale: Anticoagulant medications increase the risk for hemorrhage intra- and postoperatively.
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.