A client who had surgery yesterday tells the nurse, "I don't want to get out of bed because it hurts too much.” Which responses by the nurse are appropriate? (Select all that apply.)

"I understand how you feel, but staying in bed can cause complications.”

"You need to get out of bed at least three times a day to prevent blood clots.”

"Let me give you some pain medication and then we can try getting up.”

"Getting out of bed will help you heal faster and reduce your pain.”

"Why don't you want to get out of bed? Are you afraid of something?".

Answer and Explanation

Correct Answer : C,D

Choice A reason:

This response is not appropriate because it does not acknowledge the patient's pain or offer any pain relief. It also sounds dismissive and unsympathetic to the patient's feelings. A better response would be to empathize with the patient and explain the benefits and risks of early mobilization in a respectful way.

Choice B reason:

This response is not appropriate because it does not address the patient's pain or provide any pain relief. It also sounds demanding and authoritarian, which may increase the patient's anxiety and resistance. A better response would be to collaborate with the patient and set realistic and individualized goals for mobility.

Choice C reason:

This response is appropriate because it acknowledges the patient's pain and offers a solution to reduce it. It also shows respect for the patient's autonomy and readiness by suggesting rather than ordering to get up. It also implies that the nurse will assist and support the patient during the activity.

Choice D reason:

This response is appropriate because it provides positive reinforcement and education to the patient. It explains how early mobilization can enhance wound healing and decrease pain by improving blood circulation, preventing complications, and restoring function.

Choice E reason:

This response is not appropriate because it sounds accusatory and judgmental. It may make the patient feel defensive or guilty for expressing their pain or reluctance. A better response would be to explore the patient's concerns and fears in a non-threatening way and provide reassurance and information as needed.

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Correct Answer is B

Explanation

Choice A reason:

Hypothermia, bradycardia, and hypotension are not signs of malignant hyperthermia, but rather signs of hypovolemia, shock, or anesthesia overdose. Malignant hyperthermia is a rare but life-threatening condition that occurs when a patient is exposed to certain anesthetic agents and develops a hypermetabolic response that leads to high fever, muscle rigidity, tachycardia, hypertension, acidosis, and rhabdomyolysis.

Choice B reason:

Hyperthermia, tachycardia, and hypertension are the classic signs of malignant hyperthermia. The patient may also experience increased carbon dioxide production, decreased oxygen saturation, dysrhythmias, cyanosis, muscle breakdown, and organ failure. The nurse should monitor the patient's vital signs, temperature, blood gases, electrolytes, and urine output closely and notify the anesthesia care provider immediately if malignant hyperthermia is suspected. The treatment involves stopping the anesthetic agent, administering 100% oxygen, cooling the patient with ice packs and cold intravenous fluids, and giving dantrolene sodium intravenously to relax the muscles.

Choice C reason:

Hypothermia, tachypnea, and hypertension are not consistent with malignant hyperthermia. Hypothermia may occur due to exposure to cold operating room environment or intravenous fluids. Tachypnea may be caused by pain, anxiety, hypoxia, or acidosis. Hypertension may be related to stress, pain, or sympathetic stimulation. These signs are not specific to malignant hyperthermia and do not indicate a hypermetabolic state.

Choice D reason:

Hyperthermia, bradypnea, and hypotension are not typical of malignant hyperthermia. Hyperthermia may occur due to infection, inflammation, or dehydration. Bradypnea may be a result of oversedation, opioid administration, or respiratory depression. Hypotension may be due to blood loss, dehydration, or vasodilation. These signs do not reflect a hypermetabolic state or muscle rigidity that are characteristic of malignant hyperthermia.

A. "I can resume my normal activities in a week.” B. "I can take acetaminophen for pain relief.” C. "I can shower tomorrow and pat my incisions dry.” D. "I can eat a low-fat diet for the first month.” E. "I can expect some drainage from my incisions.".

Correct Answer is ["E"]

Explanation

Choice A reason:

This statement is correct and does not indicate a need for further teaching. The client can resume normal activities in a week after a laparoscopic cholecystectomy.

Choice B reason:

This statement is correct and does not indicate a need for further teaching. The client can take acetaminophen for pain relief after a laparoscopic cholecystectomy.

Choice C reason:

This statement is correct and does not indicate a need for further teaching. The client can shower the day after surgery and pat the incisions dry to prevent infection.

Choice D reason:

This statement is correct and does not indicate a need for further teaching. The client can eat a low-fat diet for the first month to avoid stimulating the gallbladder and causing pain.

Choice E reason:

This statement is incorrect and indicates a need for further teaching. The client should not expect any drainage from the incisions, as this could indicate infection or leakage of bile. The client should report any drainage to the provider immediately. A) “I can resume my normal activities in a week.” B) “I can take acetaminophen for pain relief.” C) “I can shower tomorrow and pat my incisions dry.” D) “I can eat a low-fat diet for the first month.” E) “I can expect some drainage from my incisions.”

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A client who had surgery yesterday tells the nurse, "I don't want to get out of bed because it hurts too much.” Which responses by the nurse are appropriate? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the induction of general anesthesia for a client who is undergoing a cholecystectomy. The nurse monitors the client for signs of malignant hyperthermia, which include:

Correct Answer is B

Explanation

A nurse is reviewing discharge instructions with a client who had a laparoscopic cholecystectomy. Which of the following statements by the client indicates a need for further teaching? (Select all that apply.)

Correct Answer is ["E"]

Explanation

The circulating nurse notices that an incorrect sponge count has been reported by the scrub nurse during an abdominal surgery. What action should be taken by the circulating nurse?

The nurse is caring for a client who had spinal anesthesia for surgery on his right foot. Which assessment finding requires immediate intervention by the nurse?

A nurse is caring for a patient who had spinal surgery and is at risk for deep vein thrombosis (DVT) Which of the following nursing interventions is most effective in preventing DVT?

A client who had surgery yesterday tells the nurse, "I don't want to get out of bed because it hurts too much.” Which responses by the nurse are appropriate? (Select all that apply.)

A nurse is assessing a client who had an appendectomy 24 hours ago. The nurse observes redness, warmth, swelling, and purulent drainage at the incision site. The nurse suspects that the client has developed:

A client who had abdominal surgery reports feeling "a pop”. in his incisional area followed by severe pain when he turned in bed earlier in his shift; he now reports feeling "wet”. in his abdominal area under his gown and dressing. The nurse should:

The nurse is caring for a client who has just returned from surgery following an open reduction internal fixation (ORIF) of a fractured hip. The nurse should monitor for which of the following complications?

A nurse is evaluating a client's understanding of postoperative instructions after a total hip replacement surgery. Which of the following statements by the client indicates a need for further teaching? (Select all that apply.)