During surgery, a patient has a nursing diagnosis of risk for perioperative positioning injury. What is a common risk factor for this nursing diagnosis?

Correct Answer: C

Rationale: In the context of perioperative positioning injury, musculoskeletal deformities are a common risk factor because they can limit the patient's ability to tolerate prolonged periods of immobility or specific positioning required during surgery. Musculoskeletal deformities can increase the risk of pressure ulcers, nerve compression, and musculoskeletal strain. Option A, skin lesions, may contribute to the risk of pressure ulcers but is not as directly related to positioning injury as musculoskeletal deformities. Option B, break in sterile technique, is more related to the risk of infection rather than positioning injury. Option D, electrical or mechanical equipment failure, is not a direct risk factor for perioperative positioning injury in this context. Educationally, understanding the risk factors for perioperative positioning injury is crucial for nurses to provide safe and effective care to surgical patients. Assessing and addressing these risk factors can help prevent complications and improve patient outcomes during the perioperative period.

Correct Answer: B

Rationale: In the context of medical-surgical nursing, the routine assessment of a patient's cardiovascular function upon admission to the Post-Anesthesia Care Unit (PACU) is crucial for ensuring patient safety and optimal recovery. Electrocardiographic (ECG) monitoring is the correct option because it provides continuous and real-time information about the patient's heart rhythm and electrical activity, allowing healthcare providers to promptly identify any cardiac abnormalities or complications post-surgery. Monitoring arterial blood gases (Option A) is essential for assessing oxygenation and ventilation status but is not specifically focused on cardiovascular function. Determining fluid and electrolyte status (Option C) is important for overall patient assessment but does not directly assess cardiovascular function upon admission. Direct arterial blood pressure monitoring (Option D) is valuable in hemodynamic monitoring but does not provide comprehensive information about the patient's cardiovascular function like ECG monitoring does. Educationally, understanding the rationale behind each assessment modality is crucial for nurses to prioritize and perform appropriate assessments based on the patient's condition. This knowledge ensures timely identification of potential cardiovascular complications, leading to prompt interventions and improved patient outcomes in the PACU setting.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Oxygen. The patient is shivering due to hypothermia, indicated by the low body temperature of 96.0°F (35.6°C). Applying warm blankets helps raise the body temperature, but supplemental oxygen is crucial to support tissue oxygenation and metabolism, which can be compromised in hypothermic patients. Option B) Vasodilating drugs would not directly address the underlying issue of hypothermia and shivering. Option C) Antidysrhythmic drugs are not indicated in this case as the patient's primary concern is hypothermia, not dysrhythmias. Option D) Analgesics or sedatives may mask symptoms like shivering but do not address the root cause of decreased body temperature and could potentially depress respiratory drive in a hypothermic patient. Educationally, this question highlights the importance of recognizing and managing hypothermia in postoperative patients. It emphasizes the need for interventions that target the underlying cause of shivering and low body temperature to prevent further complications. Understanding the rationale behind choosing oxygen as the treatment option reinforces the fundamental principles of thermoregulation and oxygenation in nursing practice.

Correct Answer: D

Rationale: In medical-surgical nursing, the use of a Hemovac is common for draining wound drainage. The rationale behind this is that a Hemovac is a closed wound drainage system that applies negative pressure to remove excess fluid from a surgical site, promoting healing and reducing the risk of infection. Wound drainage often contains blood, serum, and other fluids that need to be effectively removed to prevent complications. Regarding the other options: - Bile is not drained with a Hemovac. Bile drainage typically requires a different type of drain, such as a T-tube or a biliary drain. - Urine drainage is managed through urinary catheters like Foley catheters or suprapubic catheters, not a Hemovac. - Gastric contents are usually drained using gastric tubes or nasogastric tubes, not a Hemovac. Understanding the appropriate use of drainage systems is crucial for nurses caring for patients postoperatively. Knowing which drainage system is suitable for specific types of drainage helps in preventing complications and promoting patient recovery. Nurses need to have a sound knowledge of various drainage systems and their indications to provide effective patient care.

Correct Answer: B

Rationale: In the case of Mr. Jones, admitted with retinal detachment, the most appropriate position until doctor's orders are received is lying on his left side. This position helps to prevent pressure on the eye, reducing the risk of further damage to the detached retina. Lying flat on his back (Option A) can increase intraocular pressure, potentially exacerbating the retinal detachment. Lying on his right side (Option C) or on his abdomen (Option D) could also put undue pressure on the affected eye, worsening the condition. From an educational perspective, understanding proper positioning for patients with specific conditions is crucial in nursing practice. It is essential for nurses to be able to implement appropriate positioning techniques to promote patient comfort and prevent complications. In the case of retinal detachment, proper positioning can significantly impact the patient's outcome and recovery. This question highlights the importance of considering the physiological implications of patient positioning in the context of specific health conditions.