Because of the rapid elimination of volatile liquids used for general anesthesia, what should the nurse anticipate the patient will need early in the anesthesia recovery period?

Correct Answer: C

Rationale: In the context of the ATI Medical Surgical Proctored Exam, the correct answer to the question about the needs of a patient during the anesthesia recovery period is option C: Observation for respiratory depression. This is because volatile liquids used for general anesthesia are rapidly eliminated from the body, which can lead to respiratory depression as the patient emerges from anesthesia. Monitoring the patient's respiratory status closely is crucial to ensure adequate oxygenation and ventilation post-anesthesia. Option A, warm blankets, may be needed for temperature regulation but is not the priority in this scenario. Option B, analgesic medication, is important for pain management but not the immediate concern during the early recovery period. Option D, airway protection in anticipation of vomiting, is also a valid consideration post-anesthesia, but ensuring adequate respiratory function takes precedence to prevent complications like hypoxia. Educationally, understanding the physiological effects of anesthesia and the potential complications that can arise during the recovery period is essential for nurses caring for post-anesthesia patients. Prioritizing the patient's safety and well-being by focusing on respiratory status monitoring aligns with evidence-based practice and patient-centered care principles.

Correct Answer: C

Rationale: In the postoperative period, promoting effective coughing, deep breathing, and ambulation are crucial to prevent complications such as pneumonia, atelectasis, and thromboembolism. The most important action for the nurse to take to support these activities is to provide adequate and regular pain medication (Option C). By managing the patient's pain effectively, the nurse can help alleviate discomfort, which in turn promotes better engagement in activities like coughing, deep breathing, and ambulation. Pain control is essential as uncontrolled pain can hinder a patient's willingness and ability to participate in these essential postoperative activities. Teaching the patient controlled breathing (Option A) and explaining the rationale for the activities (Option B) are important aspects of patient education but providing pain relief takes precedence in this scenario. Pain can be a significant barrier to a patient's willingness to engage in these activities, so addressing pain first is key. Using an incentive spirometer to motivate the patient (Option D) is a valuable intervention to improve lung function; however, it is not the most critical action in this situation. Without adequate pain control, the patient may not be able to effectively utilize the incentive spirometer due to discomfort. In an educational context, this question highlights the importance of prioritizing interventions based on patient needs. Pain management is a fundamental aspect of postoperative care that can significantly impact a patient's ability to participate in essential activities for recovery. Nurses must address pain effectively to optimize patient outcomes and promote successful postoperative recovery.

Correct Answer: C

Rationale: In the context of a patient experiencing emotional and physiologic stress post-major surgery, the correct answer is C) Fluid retention. This stress can lead to the release of stress hormones like cortisol and aldosterone, which can cause the body to retain sodium and water, resulting in fluid retention. This can manifest as edema and contribute to complications like heart failure. Option A) Diuresis is incorrect because stress typically leads to fluid retention, not diuresis, which is the increased production of urine. Option B) Hyperkalemia is incorrect as stress typically does not directly cause high levels of potassium in the blood. Hyperkalemia is more commonly associated with conditions like kidney disease or certain medications. Option D) Impaired blood coagulation is incorrect in this scenario because stress-induced fluid retention does not directly impact blood coagulation. Impaired blood coagulation is more commonly associated with factors like clotting disorders or medications affecting coagulation. Educationally, understanding the physiological responses to stress and surgery is crucial for nurses to provide optimal care to postoperative patients. Recognizing the impact of stress on fluid balance can help nurses anticipate and manage potential complications related to fluid retention.

Correct Answer: D

Rationale: In the context of a hemiplegic patient, the correct initial goal for ambulation is the ability to transfer from bed to chair (Option D). This is because successful bed to chair transfers are crucial for promoting independence and mobility in hemiplegic patients. Mastering this skill enhances the patient's ability to perform activities of daily living and is a fundamental step towards eventual ambulation. Option A, acceptance of altered body image, is not the immediate priority for achieving ambulation. While addressing body image concerns is important for overall psychological well-being, it is not directly related to the physical ability to ambulate. Option B, balance training, is essential for safe ambulation, but before focusing on balance, the patient must first demonstrate the ability to transfer from bed to chair effectively. Without this foundational skill, balance training may not be as effective or safe. Option C, adequate energy level, is important for sustaining ambulation efforts, but it is not the initial step in the care plan. Energy levels can be addressed and improved once the patient has successfully mastered bed to chair transfers and is progressing towards ambulation. In an educational context, understanding the sequential and progressive nature of rehabilitation goals in hemiplegic patients is crucial for developing effective care plans. By prioritizing tasks based on their significance and impact on the patient's functional independence, healthcare professionals can optimize outcomes and promote successful rehabilitation.

Correct Answer: A

Rationale: The correct answer is A) permit drainage of aqueous humor from the anterior chamber. A peripheral iridectomy is a surgical procedure performed to create a small hole in the iris to allow for better drainage of aqueous humor in conditions like narrow-angle glaucoma. This procedure helps to relieve intraocular pressure and prevent further damage to the optic nerve. Option B) promoting the formation of permanent anterior synechiae with the cornea is incorrect because synechiae are adhesions between structures in the eye, which can lead to complications like angle-closure glaucoma, not the intended outcome of the procedure. Option C) promoting the formation of permanent posterior synechiae with the lens is also incorrect. Posterior synechiae are adhesions between the iris and the lens, which can lead to issues like posterior capsular opacification, not the goal of a peripheral iridectomy. Option D) gaining access to the lens for easy removal is not the purpose of a peripheral iridectomy. This procedure is specifically performed to address issues related to intraocular pressure and aqueous humor drainage, not for accessing or removing the lens. Understanding the purpose and implications of a peripheral iridectomy is crucial for nurses and healthcare professionals working with patients with glaucoma or other eye conditions requiring this procedure. It is essential to grasp the rationale behind each option to provide safe and effective care to patients undergoing such surgeries.