Question 1 of 9
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Which is a general nursing goal for a patient who has undergone general anesthesia?
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- Encourage cough and deep breathingEncouraging coughing and deep breathing is an intervention. Maintaining patent airway and adequate respiratory exchange is a general nursing goal.
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- Promote comfort and restPromoting comfort and rest is a general nursing goal.
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- Prevent atelectasisPreventing atelectasis is a specific goal. Maintaining patent airway and adequate respiratory exchange is a general nursing goal.
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- Provide patient educationProviding patient education is an intervention.
Question 2 of 9
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Which criterion is used to determine when it is appropriate to transfer a patient from the postanesthesia care unit (PACU) to an inpatient unit? Select all that apply. One, some, or all responses may be correct.
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- Vital signs are stable.The patient remains in the PACU until the vital signs are stable.
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- The patient receives a score of 9 or 10 on the readiness for transfer scoring system.Activity, respiration, circulation, consciousness, skin color, and oxygen saturation are each given a score. A patient with a score of 9 or 10 is ready for transfer to the nursing unit.
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- The patient has a pain level of 8 or less.There is no specific pain level used to determine readiness for transfer.
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- The patient is awake and able to respond to stimuli.The patient remains in the PACU until the patient is awake and able to respond to stimuli.
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- The patient has voided.A patient without a catheter in place must void within 4 to 8 hours depending on the type of surgery and the anesthesia used. This may take place in PACU or on the inpatient unit.
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- A family member is available to authorize the transfer.A family member is not required to authorize the transfer.
Question 3 of 9
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Postoperative coughing to remove secretions may be contraindicated for a patient who has undergone which type of surgery? Select all that apply. One, some, or all responses may be correct.
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- CraniotomyCoughing to remove secretions may be contraindicated for patients who have undergone hernia repair or brain, eye, ear, jaw, or plastic surgery.
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- Hernia repairCoughing to remove secretions may be contraindicated for patients who have undergone hernia repair or brain, eye, ear, jaw, or plastic surgery.
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- Cataract surgeryCoughing to remove secretions may be contraindicated for patients who have undergone hernia repair or brain, eye, ear, jaw, or plastic surgery.
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- Abdominal surgeryMost surgeries (including abdominal surgeries) require coughing to prevent the respiratory complications that are common after surgery.
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- Total joint replacementMost surgeries (including total joint replacement surgeries) require coughing to prevent the respiratory complications that are common after surgery.
Question 4 of 9
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Which intervention would the nurse use for pain management during the early postoperative phase? Select all that apply. One, some, or all responses may be correct.
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- MedicationMedication should be given consistently for the first 24 to 48 hours postoperatively.
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- Leg exercisesLeg exercises and holistic methods are not used during the early postoperative phase.
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- Holistic methodLeg exercises and holistic methods are not used during the early postoperative phase.
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- Position changeIf the patient complains of pain and it is too soon to give more analgesia, reposition the patient.
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- Relaxation techniquesTeaching relaxation techniques can help decrease the patient’s discomfort.
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- Oxygen administrationOxygen administration may help prevent respiratory complications.
Question 5 of 9
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Which action would the nurse encourage for a patient 24 hours after abdominal surgery to ensure prompt healing of the wound?
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- Splinting the incisionSplinting the incision during activity, coughing, and deep breathing are necessary for prevention of dehiscence and/or evisceration.
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- Forcefully exhaling breathsForceful exhalation without splinting may put excess pressure on the wound.
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- Increasing vitamin B intakeNutrients that promote wound healing include protein, vitamin C, zinc, copper, and iron.
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- Maintaining the affected area in a position higher than the heartMaintaining the affected area in a position higher than the heart decreases blood flow which slows healing.
Question 6 of 9
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Which action would the nurse take when providing discharge instructions for a patient who underwent general anesthesia for a hernia repair?
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- Advising the patient not to resume normal activities for at least 48 hours after surgeryAdvise surgery patients who have received anesthesia or procedural sedation not to resume normal activities for at least 24 (not 48) hours after surgery.
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- Advising the patient not to make important decisions for at least 24 hours after surgeryAdvise surgery patients who have received anesthesia or procedural sedation not to make important decisions for at least 24 hours after surgery.
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- Instructing the patient to begin weaning from the pain medicationMedication should be given consistently for the first 24 to 48 hours postoperatively.
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- Instructing the patient to apply a warm cloth to the forehead and back of neck to help reduce nauseaApplying a cool cloth to the forehead and back of the neck helps reduce nausea.
Question 7 of 9
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Which immediate action would the nurse take for a postoperative patient with an indwelling catheter in place whose 2-hour urinary output is 40 mL?
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- Document the findings.After contacting the health care provider, it would be appropriate to document the findings.
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- Notify the surgeon.If urinary flow is less than 60 mL over a 2-hour period, the surgeon must be notified.
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- Verify that potassium has been added to the infusing intravenous solution.No potassium additive should be given until the urine flow is at least 30 mL/h. Potassium may cause hyperkalemia if kidney function is not adequate.
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- Prepare the patient to return to surgery.It is not appropriate to prepare the patient for a return to surgery at this time.
Question 8 of 9
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Which nursing intervention would be appropriate for a patient on strict bed rest after brain surgery?
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- Raise the head of the bed to 30 degrees to facilitate venous drainage.Raising the head of the bed is often contraindicated after brain surgery because it can increase the intercranial pressure.
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- Perform range-of-motion (ROM) exercises at least four times a day.ROM should be performed at least four times a day on patients on bed rest. The patient may do active ROM on most joints, but passive ROM must be done on joints the patient is unable to exercise unless physical therapy visits have been prescribed.
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- Sit the patient on the side of the bed, allowing the legs to dangle over the side with the feet on the floor or a foot stool.Patients on strict bed rest are not allowed to sit up.
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- Massage the earlobes to promote relaxation.A treatment for hiccoughs is to massage the earlobes; there is no indication that the patient is experiencing hiccoughs.
Question 9 of 9
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After receiving education about postoperative abdominal distention, which statement made by a nursing student indicates the need for further teaching?
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- “General anesthesia can lead to increased peristalsis.”General anesthesia can lead to decreased or absent peristalsis. This indicates a need for further education.
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- “I should allow the patient to take only small amounts of liquid at a time.”Taking only small amounts of food and liquid at a time will help prevent gas from building up.
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- “The patient should not be allowed to use a straw.”Refraining the patient from drinking with a straw will help prevent gas from building up.
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- “Placing the patient in the modified Trendelenburg position can help with evacuation of flatus.”Placing the patient in the modified Trendelenburg position will help to evacuate flatus.