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 A

Explanation

A. Are communications links with personnel outside the room. Both the scrub person and the circulating nurse serve as communication links with the personnel outside the operating room. The scrub person may communicate regarding sterile equipment needs, while the circulating nurse communicates about patient status and surgical progress.

B. Set up initial sterile instruments and supplies. This is the responsibility of the scrub person, not the circulating nurse. The scrub person ensures that sterile instruments are ready and that the sterile field is set up properly.

C. Advise the team of breaks in sterile technique. Only the scrub person is typically responsible for maintaining sterile technique and calling attention to any breaches in sterility. The circulating nurse may assist with ensuring the environment is safe, but the scrub person is directly in charge of sterile technique.

D. Position lights on step stools. Positioning the lights is the responsibility of the circulating nurse. The scrub person’s role is more focused on the sterile field and assisting with surgical instruments.

A. dehiscence B. laceration C. evisceration D. autologous

Correct Answer is A

Explanation

A. Dehiscence: Dehiscence refers to the partial or total separation of the wound's layers, often occurring after surgery, such as when coughing increases intra-abdominal pressure.

B. Laceration: A laceration refers to a tear or break in the skin due to trauma, not a surgical complication.

C. Evisceration: Evisceration occurs when the internal organs protrude through the wound, which is a more severe complication than dehiscence.

D. Autologous: Autologous refers to using a person's own tissues or cells (e.g., blood transfusion), not a wound complication.

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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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