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 A

Explanation

Choice A reason:

This is the correct answer. This is to prevent the risk of leaving a foreign object inside the patient, which can cause serious complications such as infection, abscess, bowel obstruction, or perforation.

Choice B reason:

This is incorrect. Notifying anesthesia personnel is not the priority action when an incorrect sponge count is reported. Anesthesia personnel are not responsible for counting or searching for sponges, and they cannot intervene in the surgical procedure without the surgeon's consent. The surgeon is the one who needs to be informed first, as they have the authority and ability to search the wound and decide whether to continue or stop the surgery.

Choice C reason:

This is incorrect. Notifying risk management is not the priority action when an incorrect sponge count is reported. Risk management is a department that deals with identifying, assessing, and minimizing potential hazards in health care settings. While it is important to report any adverse events or errors to risk management, this should be done after ensuring the patient's safety and resolving the issue. The priority is to notify the surgeon and search for the missing sponge.

Choice D reason:

This is incorrect. Notifying operating room supervisor is not the priority action when an incorrect sponge count is reported. The operating room supervisor is a person who oversees the daily operations of the surgical suite, such as staffing, scheduling, equipment, and supplies. While they may be involved in addressing any problems or conflicts that arise in the OR, they are not directly responsible for counting or searching for sponges, and they cannot interfere with the surgical procedure without the surgeon's consent. The priority is to notify the surgeon and search for the missing sponge.

A. "I will use a walker or crutches to avoid putting too much weight on my new hip.” B. "I will keep my legs crossed when I sit or lie down to prevent dislocation.” C. "I will avoid bending my hip more than 90 degrees when I get dressed or use the toilet.” D. "I will take antibiotics as prescribed to prevent infection.” E. "I will report any signs of bleeding, swelling, redness or drainage from my incision."

Correct Answer is ["B"]

Explanation

Choice A reason:

This statement is correct and does not indicate a need for further teaching. The client should use a walker or crutches to avoid putting too much weight on the new hip and prevent dislocation or damage to the prosthesis.

Choice B reason:

This statement is incorrect and indicates a need for further teaching. The client should not keep the legs crossed when sitting or lying down, as this can cause dislocation of the new hip joint. The client should keep the affected leg in abduction at all times.

Choice C reason:

This statement is correct and does not indicate a need for further teaching. The client should avoid bending the hip more than 90 degrees when getting dressed or using the toilet, as this can also cause dislocation of the new hip joint. The client should use assistive devices such as a long-handled reacher or a raised toilet seat.

Choice D reason:

This statement is correct and does not indicate a need for further teaching. The client should take antibiotics as prescribed to prevent infection, which can be a serious complication of hip replacement surgery. The client should also report any signs of fever, chills, or increased pain.

Choice E reason:

This statement is correct and does not indicate a need for further teaching. The client should report any signs of bleeding, swelling, redness or drainage from the incision, as these can also indicate infection or hematoma formation. The client should keep the incision clean and dry and change the dressing as instructed.

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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

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?

Correct Answer is A

Explanation

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.)

Correct Answer is ["B"]

Explanation

A nurse is evaluating the discharge instructions for a client who had a mastectomy with lymph node dissection. The nurse instructs the client to avoid:

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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?

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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:

A nurse is caring for a patient who underwent surgery for appendicitis and has developed wound dehiscence with evisceration on postoperative day 3. What is the priority nursing intervention?

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