A nurse is monitoring a patient during the postoperative period following a surgical procedure. Which actions should be included in the plan of care? (Select all that apply.)

Assess and document patient's level of pain.

Administer contrast material.

Administer intravenous fluids as ordered.

Administer antineoplastic agents as ordered.

Administer pain medication as ordered.

Answer and Explanation

Correct Answer : A,C,E

A. Assess and document patient's level of pain: Monitoring and documenting pain is essential for effective pain management and patient comfort.

B. Administer contrast material: Administering contrast material is not typically required in the immediate postoperative period unless specifically ordered for diagnostic imaging.

C. Administer intravenous fluids as ordered: IV fluids are often needed postoperatively to maintain hydration and support recovery.

D. Administer antineoplastic agents as ordered: Antineoplastic agents are used for cancer treatment and are not a standard part of postoperative care unless the patient is undergoing concurrent cancer therapy.

E. Administer pain medication as ordered: Administering pain medication as ordered is crucial for managing postoperative pain and promoting recovery.

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Correct Answer is B

Explanation

A. Notify the charge nurse that patients may have received inappropriate medication dosages.
Jumping to conclusions about inappropriate dosages without first investigating the rationale for the dosing is premature and could cause unnecessary alarm.

B. Evaluate the laboratory values of each patient to determine liver and kidney function as a possible reason for decreased dosages. Lower dosages are often prescribed for older adults due to decreased liver and kidney function, which can affect drug metabolism and excretion. Evaluating lab values ensures that these dosages are appropriate and safe.

C. Do not worry about the discrepancy because this is not the nurse's unit.
Ignoring the discrepancy is not appropriate, as it’s important for all nurses to advocate for patient safety, regardless of the unit.

D. Call the nursing supervisor to investigate the nurse's concerns.
The nursing supervisor may need to be involved, but the first step is to review the relevant clinical data (lab values) to assess the situation.

A. The patient is experiencing withdrawal symptoms. B. The patient is habituated to the medication. C. The patient is addicted to the medication. D. The patient is experiencing tolerance.

Correct Answer is D

Explanation

A. The patient is experiencing withdrawal symptoms: Withdrawal symptoms occur when a patient stops taking a medication suddenly after long-term use. However, the scenario does not describe withdrawal symptoms, but rather a loss of effectiveness of the medication.

B. The patient is habituated to the medication: Habituation refers to psychological dependence on a medication, which does not directly explain why the medication is no longer effective.

C. The patient is addicted to the medication: Addiction involves compulsive use of a drug despite harmful consequences and does not explain the loss of effectiveness described.

D. The patient is experiencing tolerance: Tolerance occurs when the body becomes accustomed to a drug, and higher doses are needed to achieve the same effect. The scenario describes tolerance, where the patient feels the medication no longer works.

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A nurse is monitoring a patient during the postoperative period following a surgical procedure. Which actions should be included in the plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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