A 75-year-old patient is having an exploratory laparotomy tomorrow. The wife tells the nurse that at night the patient gets up and walks around his room. What priority action does the nurse take after hearing this information?

Correct Answer: B

Rationale: The priority action is developing a safety plan because a 75-year-old patient wandering at night preoperatively risks falls, especially with potential sedation or unfamiliar settings. Notifying the provider is secondary unless immediate issues arise. Ordering sleep medication addresses symptoms, not safety, and requires assessment first. Telling the patient not to get up is impractical without support. The rationale prioritizes safety: elderly patients have higher fall risks due to age-related declines in balance and strength, amplified by hospital environments. A plan (e.g., bed alarms, assistance) prevents injury, aligning with nursing's proactive risk management, ensuring the patient's stability for surgery.

Correct Answer: A

Rationale: Essential surgical scrub techniques include using a broad-spectrum antimicrobial , holding hands higher than elbows , and scrubbing 3-5 minutes (choice E, not listed). Two-minute scrubs are insufficient; alcohol-based solutions are alternatives, not primary. The rationale ensures sterility: broad-spectrum agents kill pathogens, elevated hands prevent recontamination, and 3-5 minutes ensures thoroughness per guidelines (e.g., AORN). Nursing adheres to this, reducing infection risk, distinct from shorter or less effective methods.

Correct Answer: D

Rationale: The postoperative period begins with completion of surgery and transfer to the PACU , marking recovery onset. Arousal in OR , preoperative planning , and closure are earlier. The rationale defines timing: postoperative care starts post-procedure, focusing on stabilization in PACU, distinct from intraoperative or preoperative phases. Nursing shifts to monitoring and intervention, ensuring smooth transition, critical for recovery initiation.

Correct Answer: A

Rationale: The nurse first assesses airway and gas exchange , per ABCs. Pain rating , positioning , and PCA follow. The rationale prioritizes survival: post-anesthesia, airway obstruction or hypoxia (e.g., from sedation) is immediate risk. Nursing ensures breathing before addressing comfort or meds, aligning with critical care principles, distinct from secondary tasks.

Correct Answer: C

Rationale: Passing flatus or stool best indicates peristalsis resumption. Bowel sounds , hunger , and cramping are less definitive. The rationale focuses on function: flatus/stool confirm GI motility post-anesthesia, unlike sounds (early, inconsistent) or subjective signs. Nursing monitors this, ensuring recovery, critical for diet advancement, distinct from preliminary indicators.