Question

1. Simone, a 56 year-old female, arrives through the outpatient department for her preoperative appointment for a right hip replacement surgery in 8 days. Assessment of Simone begins with vital signs. Which vital sign requires follow-up by the nurse? Give rationale for your answer.

-BP of 164/88

-Pulse of 70

-Respirations 16

-Temperature of 98.2

2. The nurse proceeded to review Simone’s medications. She has been taking hydrochlorothizide (diuretic), warfarin (anti-coagulant), and a multivitamin. What instruction by the nurse is most important? Give a rationale for your answer.

-Observe the appearance of the client’s oral mucosa

-Assess the client for signs of petechia or ecchymotic areas

-Review the side effects of each medication

-Explain the need to withhold the warfarin prior to surgery   

3. The nurse next concern is Simone’s lab test results drawn 3 days ago. Which blood lab value requires follow-up by the nurse? Give a rationale for your answer.

-Creatinine of 0.9 mg/dl

-Hemoglobin of 14 g/dl

-WBC of 13,000/mm3   

-Sodium of 136 mEq/L

4. The nurse discuss with Simone about what to expect the day of and during the immediate postoperative period. She provides her with instructions regarding cough and deep breathing exercises. Simone performs a return demonstration by breathing in deeply through her mouth and exhaling forcefully and rapidly through pursed lips. What action should the nurse implement? Give a rationale for your answer.

-Instruct the client to avoid pursing her lips when exhaling.

-Document successful completion of the return demonstration

-Demonstrate the deep breathing and coughing technique again  

-Remind the client to cough after taking 2 to 3 breaths.

5. The nurse also discusses postoperative pain with Simone and explains the use of a patient-controlled analgesia (PCA) pump. Simone is afraid of accidentally overdosing herself since she will be recovering from sedation after surgery. How should the nurse respond? What is the rationale for your answer?

-You will only use the PCA pump for the first 24 fours after surgery

-The PCA pump has a control device that will prevent you from taking too much medicine   

-I will inform the surgeon that you prefer the nurse administer your pain medication as needed

-The surgeon will prescribe the dose of medication that is correct for you

6. The day of the surgery, Simone arrives about 4 hours before surgery. Which question is most important for the nurse to ask Simone during the admission interview? What is the rationale for your answer?

-Did you bring any valuables with you that need to locked up during surgery?

-Do you understand you will be admitted to the hospital after surgery?

-Did any family members or friends accompany you here?

-Have you had anything to eat or drink since midnight?   

7. Simone is ready for surgery. She states that she feels calm and is ready. She is transferred to the operating room. After general anesthesia is induced, the nurse positions Simone for surgery. Once the OR team assembles, the circulating nurse calls for a time out. Which action should the nurse take during the time out (Universal Protocol)? What is the rationale for your answer?

-Check that all surgical personnel are properly attired

-Ensure that sufficient surgical supplies are available

-Review the scheduled procedure, site, and client     

-Confirm that informed consent has been obtained

8. Postoperatively, which action should the nurse take to assess Simone for atelectasis? Give a rationale for your answer.

-Observe the appearance of the sputum

-Auscultate the client’s breath sounds   

-Auscultate the client’s bowel sounds

-Measure the client’s respiratory rate and rhythm

9. Postoperatively, the nurse assesses Simone’s bowel sounds and note that they are hypoactive. What action should the nurse implement in response to this finding? What is the rationale behind your answer?

-Notify the surgeon of the assessment finding

-Review the client’s serum electrolyte values

-Document the assessment finding in the chart  

-Administer a laxative prescribed for PRN us

10. Reassessment during the postoperative period of Simone’s surgical dressing reveals moderate amount of sanguineous drainage and that the Hemovac drain is full of sanguineous drainage. Which action should the nurse implement first? What is the rationale for your answer?

-Document the appearance of the drainage

-Empty the drain and measure the amount of drainage   

-Compress the drain and re-establish suction

-Page the surgeon to report the finding

Answer 1

1.The blood pressure of simone is elevated which require further action by the nurse.

hypertension is a serious health problem.Abnormally high blood pressure is called hypertension.It is diagnosed by measuring blood oressure.The systolic preesure would be tge first reading which means the heart pumps blood through the body.Second reading is diasystolic pressure meabs a pressure of which heart relaxes and refills tge blood.

causes...stress and lifestyle and dietary factors.

treatment...weight loss

quit smoking

avoid alchol

low sodium and fat diet

well balanced diet like green leafy vegetables,whole grains,low fat and cholestrol diet,drink milk.

medications such as ...

beta blockers

angiotensin 2 receptors

calcium channel blockers

diuretics.

complications of high b.p are...

heart disease

kidney problems

eye damage

stroke

artherisclorosis

2. Warafarin is an anticoagulant which increase the risk of bleeding during surgery and in postoperative period for a time before and after the procedure.

3.White bloid cells are responsiblr for defendes tge body from viruses,bacterial infections and any other external factors tgat poses a threat to health.The normal WBC count is 4000-11000.An increase may indication the onset of an infection which is contraindicated to surgery.

4.It is inportant to practice deep breathing and coughing exercises so that patient is ablr to do exercises easily during the day and after surgery.The exercises help in breathing,clear lungs and lower the risk of pneumonia.breathe and cough every hour while patient awake for the first 2 or 3 days after surgery.

Deep Breathing Exercises
Do these exercises every hour when you’re awake.
1. Breathe in deeply and slowly through your nose, expanding your lower rib cage, and letting your abdomen move forward.
2. Hold for a count of 3 to 5.
3. Breathe out slowly and completely through pursed lips. Don’t force your breath out.
4. Rest and repeat 10 times every hour. Rest longer if you become dizzy or lightheaded.

Coughing Exercises
It’s best to do coughing exercises when you’re feeling comfortable. Your healthcare provider will tell you if you shouldn’t do the coughing exercises in this handout.
1. If you’re lying on your back, bend your knees (if your surgeon says you can), and rest your feet on the bed.
2. Depending on the surgery you had, support your incision firmly with your hands or a small pillow before you try to cough.
3. Breathe in deeply and cough firmly. If you cough up some mucous, clear it into a tissue. Repeat the coughing until there isn’t any more mucous. If you have a lot of mucous, you may need to take a break so you don’t get too tired.