To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, what will the nurse do?

Correct Answer: D

Rationale: In the postoperative period, preventing airway obstruction is crucial for the unconscious or semiconscious patient. Positioning the patient in a side-lying position (Option D) is the correct choice because it helps maintain a clear airway by preventing the tongue from obstructing the air passage. This position also allows for drainage of oral secretions, reducing the risk of aspiration. Encouraging deep breathing (Option A) is important for improving lung function but does not directly address the risk of airway obstruction in an unconscious patient. Elevating the head of the bed (Option B) is beneficial for preventing aspiration in conscious patients but may not be sufficient to prevent airway obstruction in an unconscious or semiconscious individual. Administering oxygen per mask (Option C) is important for oxygenation but does not directly address airway patency. Educationally, this question highlights the critical nursing intervention of maintaining a patent airway in postoperative patients. Understanding the rationale behind positioning the patient in a side-lying position can help nurses provide safe and effective care to prevent complications such as respiratory distress or aspiration.

Correct Answer: D

Rationale: The correct answer is D) After assessing the nature and intensity of the patient's pain. This option reflects the principle of individualized, patient-centered care, which is essential in pain management. Administering pain medication based on the patient's specific needs and pain level ensures optimal pain relief and minimizes the risk of overmedication or undermedication. Assessing pain before administering medication also aligns with evidence-based practice guidelines, promoting safe and effective pain management. Option A) Before all planned painful activities is incorrect because administering pain medication preemptively without assessing the patient's current pain level may lead to unnecessary medication administration and potential adverse effects. Option B) Every 2 to 4 hours during the first 48 hours is incorrect as it suggests a fixed dosing schedule without considering the patient's actual pain experience and response to the medication, which may result in inadequate pain control or unnecessary medication administration. Option C) Every 4 hours as the patient requests the medication is incorrect because it does not emphasize the importance of pain assessment before administering the medication. Relying solely on patient requests may lead to undermedication if the patient does not feel comfortable requesting medication or overmedication if the patient requests medication too frequently without proper assessment. In an educational context, understanding the rationale behind individualized pain management is crucial for nurses caring for patients postoperatively or with acute pain. By prioritizing pain assessment before medication administration, nurses can ensure safe and effective pain relief tailored to each patient's needs, promoting better outcomes and patient satisfaction.

Correct Answer: C

Rationale: In this scenario, option C is the correct answer as it indicates that Mr. Jones understands his postoperative regimen. By choosing to watch baseball games on TV instead of driving to the stadium, Mr. Jones demonstrates an understanding of the importance of avoiding activities that could strain him post-surgery, such as driving or engaging in physical exertion. Option A is incorrect because it shows a plan to go to an amusement park and ride roller coasters, which could pose a risk to Mr. Jones' recovery due to the physical demands and potential for injury. Option B is incorrect as it suggests reliance on someone else for basic self-care tasks that Mr. Jones should be able to manage independently after discharge. Option D is incorrect as it focuses on retirement due to job requirements, which is not directly related to understanding postoperative care. This question assesses the patient's comprehension of their discharge instructions and ability to make appropriate choices for their recovery. Educationally, this question highlights the importance of patient education in promoting postoperative recovery and preventing complications. It emphasizes the need for patients to comprehend and follow their discharge instructions to ensure a successful outcome and reduce the risk of readmission or postoperative issues.

Correct Answer: C

Rationale: In the context of assisting a patient with impaired vision due to patches on both eyes, the correct option (C) advises the family member to offer their arm and walk in front of Mr. Johnstone. This is the most appropriate choice because walking in front allows the family member to guide and support Mr. Johnstone effectively by leading him and providing verbal cues about obstacles or changes in terrain. This position also enables the family member to maintain visual contact with Mr. Johnstone, ensuring his safety during the walk. The incorrect options (A) and (D) suggest walking behind Mr. Johnstone, which may not provide adequate support and guidance, especially considering his impaired vision. Walking behind him can lead to potential accidents or falls as the family member may not be able to offer timely assistance or communicate effectively with him. Option (B) of grasping him by the arm and walking in front of him is not ideal as it may cause discomfort or anxiety for Mr. Johnstone by invading his personal space and impeding his movement. Educationally, this scenario highlights the importance of understanding the specific needs of patients with visual impairments and the appropriate techniques for assisting them in mobility. It emphasizes the significance of positioning, communication, and support in ensuring the safety and well-being of individuals with temporary or permanent vision loss. By choosing the correct option, the family member can provide effective assistance to Mr. Johnstone during his recovery period.

Correct Answer: C

Rationale: In planning Mrs. Filbert's care during an acute attack of Meniere disease, the most important action would be to instruct her about prescribed dietary modifications (Option C). Meniere disease is characterized by inner ear fluid imbalance, leading to vertigo and dizziness. Dietary modifications, such as reducing salt intake, can help manage symptoms by reducing fluid retention in the inner ear. This intervention directly addresses the physiological root of the condition. The other options are less relevant or potentially detrimental in this situation. Option A focuses on emotional support, which is important but not the priority during an acute attack. Option B, keeping siderails up and assisting with mobility, may be important for fall prevention but does not address the acute symptoms of Meniere disease. Option D, encouraging ambulation, could exacerbate symptoms like vertigo and nausea during an acute attack. In an educational context, understanding the rationale behind prioritizing interventions based on the pathophysiology of a condition is crucial for providing safe and effective patient care. By choosing the correct intervention, healthcare providers can improve patient outcomes and quality of care.