A nurse is obtaining a preoperative medical and surgical history from a client scheduled for a cataract extraction procedure. Which of the following client statements require further investigation by the nurse?

"l stopped taking aspirin last week."

"l did not put my contact lenses in this morning."

"l took my blood pressure meds with a sip of water."

"l had a cough and runny nose a couple days ago."

Answer and Explanation

The Correct Answer is D

A. "I stopped taking aspirin last week.": Stopping aspirin medication prior to surgery is often advised to reduce the risk of bleeding during and after the procedure. The nurse may confirm the timing of discontinuation with the client and verify if any other anticoagulant medications are being taken.

B. "I did not put my contact lenses in this morning.": Removing contact lenses before surgery is a routine precaution to prevent potential corneal abrasions or complications during the procedure. This statement indicates the client is following preoperative instructions.

C. "I took my blood pressure meds with a sip of water.": Taking blood pressure medications with a small amount of water is generally acceptable before surgery. However, the nurse may verify the specific medications the client is taking and their dosing schedule to ensure compliance.

D. "I had a cough and runny nose a couple days ago.": This statement requires further investigation as respiratory symptoms, such as cough and runny nose, may indicate an underlying respiratory infection. Infections can increase the risk of complications during surgery, such as anesthesia-related respiratory issues or postoperative infections. The nurse should assess the severity and duration of the symptoms, inquire about any fever or recent exposure to illnesses, and consider notifying the surgical team for further evaluation and decision-making regarding the client's surgical readiness.

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Correct Answer is C

Explanation

A. "Distributive shock occurs due to loss of myocardial contractility": This statement is incorrect. Distributive shock is not primarily caused by loss of myocardial contractility. Instead, distributive shock is characterized by widespread vasodilation, which leads to inadequate tissue perfusion despite normal or high cardiac output.

B. "Distributive shock occurs due to loss of blood volume": This statement is inaccurate. Distributive shock is not primarily caused by loss of blood volume. While hypovolemia (loss of blood volume) can lead to shock, distributive shock specifically involves excessive vasodilation, resulting in a relative hypovolemia due to pooling of blood in the expanded vascular bed.

C. "Distributive shock occurs due to systemic vasodilation": This statement is correct. Distributive shock, also known as vasodilatory shock, occurs due to widespread vasodilation of the systemic vasculature. This vasodilation leads to a decrease in systemic vascular resistance, which results in the redistribution of blood flow away from vital organs and tissues, leading to inadequate tissue perfusion and shock.

D. "Distributive shock occurs due to increased systemic vascular resistance": This statement is incorrect. Distributive shock is characterized by decreased systemic vascular resistance due to vasodilation, not increased systemic vascular resistance. Increased systemic vascular resistance is more commonly associated with conditions such as hypertension or obstructive shock.

A. Lower extremities edematous with decreased pulses and cool to the touch B. Pain, pallor, and paresthesia in the foot C. Murmur auscultated at the left 5th midclavicular line, slight dyspnea, and lower extremity edema D. Presence of an open wound near the ankle with serous drainage and pruritus

Correct Answer is B

Explanation

A. Lower extremities edematous with decreased pulses and cool to the touch While this finding suggests impaired circulation associated with peripheral artery disease, it does not indicate an immediate need for intervention. However, it requires timely assessment and intervention to prevent further complications.

B. Pain, pallor, and paresthesia in the foot This finding indicates critical limb ischemia, which is a severe complication of peripheral artery disease requiring immediate intervention. Pain, pallor (pale color), and paresthesia (abnormal sensations like tingling or numbness) suggest inadequate blood flow to the affected limb, putting the client at risk for tissue damage and limb loss if not promptly addressed.

C. Murmur auscultated at the left 5th midclavicular line, slight dyspnea, and lower extremity edema These findings are suggestive of cardiac issues such as heart failure rather than immediate complications of peripheral artery disease. While they require attention, they do not signify an urgent need for intervention specific to peripheral artery disease.

D. Presence of an open wound near the ankle with serous drainage and pruritus While an open wound warrants assessment and appropriate wound care, it does not indicate an immediate need for intervention unless there are signs of infection or severe tissue damage. In this scenario, the presentation of pain, pallor, and paresthesia indicates a more urgent need for intervention to prevent tissue necrosis and limb loss.

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A nurse is obtaining a preoperative medical and surgical history from a client scheduled for a cataract extraction procedure. Which of the following client statements require further investigation by the nurse?

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