A nurse preparing to get a patient out of bed for the first time since surgery will initially:

place a walker at the side of the bed.

allow the patient to sit with the head of bed raised to the high Fowler's position.

assist the patient to sit and dangle his or her legs on the side of the bed.

assist the patient from a supine position to a standing position.

Answer and Explanation

The Correct Answer is C

A. Place a walker at the side of the bed. A walker may not be necessary for all patients and should only be used if prescribed by the healthcare provider.

B. Allow the patient to sit with the head of bed raised to the high Fowler’s position. This helps with postural adjustment but is not the best first step before dangling the legs.

C. Assist the patient to sit and dangle his or her legs on the side of the bed. Gradual movement from lying to sitting to standing helps prevent orthostatic hypotension, which is common after surgery.

D. Assist the patient from a supine position to a standing position. Moving too quickly can cause dizziness, falls, and syncope due to orthostatic hypotension.

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Correct Answer is D

Explanation

A. Ask a family member to take care of it. This is a reasonable option, but if a family member cannot be located, other procedures should be followed to secure the ring.

B. Tape it in place on his finger. Taping the ring on the finger is not advisable as it could create a risk of injury during the surgery and would not be secure. Rings should typically be removed or securely stored.

C. Inform him that the hospital cannot be responsible for its loss. While the hospital cannot be responsible for the loss of personal items, this does not address the need to remove or secure the ring before surgery for safety reasons.

D. Remind him it must be removed, and lock it in the narcotic cabinet. This is the most appropriate action. Jewelry should be removed prior to surgery to avoid injury, and it can be safely stored in a secure location such as the narcotic cabinet or a personal locker.

A. head of bed at 45 degrees with head and neck midline. B. side lying. C. supine. D. head of bed at 30 degrees with head and neck midline.

Correct Answer is B

Explanation

A. Head of bed at 45 degrees with head and neck midline. Although the head of the bed at 45 degrees can be appropriate for some patients, it is not the best position to maintain a patent airway for a drowsy postoperative patient. This position can lead to airway obstruction, especially if the patient is drowsy.

B. Side lying. The side-lying position is the best choice for a patient who is drowsy and requires verbal stimulation to remain aroused. This position prevents aspiration and ensures that the airway remains patent by allowing any secretions or fluids to drain from the mouth. It is especially useful in the postoperative period to prevent airway obstruction.

C. Supine. The supine position is not ideal for a drowsy postoperative patient, as it can increase the risk of airway obstruction. The tongue may fall back and obstruct the airway, particularly if the patient is drowsy.

D. Head of bed at 30 degrees with head and neck midline. Although elevating the head of the bed at 30 degrees is common, it is not the best choice for a drowsy patient at risk for airway obstruction. Side-lying would be more effective in preventing aspiration and maintaining the airway.

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A nurse preparing to get a patient out of bed for the first time since surgery will initially:

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Naxlex Comprehensive Predictor Exams

While completing the preoperative checklist, a patient who is almost ready for transport to the operating room states that he does not want to remove his wedding band. The nurse should:

Correct Answer is D

Explanation

A patient who has returned to the surgical nursing unit from the post-anesthesia care unit (PACU) is drowsy and requires verbal stimulation to remain aroused. The best position to maintain an airway for this patient is:

Correct Answer is B

Explanation

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