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. Palpable peripheral pulses. Palpable pulses are important for circulatory assessment but are not relevant in determining whether the patient can eat after surgery.

B. Clear lung sounds. Clear lung sounds are important for respiratory status, but they are not the primary factor in determining whether a patient can start clear liquids.

C. Adequate urinary drainage. Urinary drainage is important for monitoring kidney function postoperatively but is not a primary factor in whether a patient can eat clear liquids.

D. Bowel sounds in all quadrants. The presence of bowel sounds indicates that the gastrointestinal system is functioning well enough to begin processing liquids, making this an important assessment before offering fluids or food.

A. To achieve fast-acting pain relief, administer analgesics PO. B. Consider the client's individual expression of pain. C. Expect the client to express his pain both verbally and nonverbally. D. Use a scale from 0 to 10 to monitor the severity of the client's pain. E. Administer opioids with caution because they will eventually lead to addiction.

Correct Answer is ["B","C","D"]

Explanation

A. To achieve fast-acting pain relief, administer analgesics PO. Oral (PO) medications may not provide rapid pain relief, particularly postoperatively. IV or other forms of analgesia are preferred for fast-acting relief.

B. Consider the client's individual expression of pain. Pain is subjective, and the nurse should consider each patient’s unique expression of pain to provide appropriate pain management.

C. Expect the client to express his pain both verbally and nonverbally. Patients may express pain verbally or nonverbally, such as through facial expressions or body movements. The nurse must be attentive to both forms of expression.

D. Use a scale from 0 to 10 to monitor the severity of the client's pain. The 0 to 10 pain scale is a common and effective tool for assessing the severity of a patient's pain, allowing for appropriate intervention.

E. Administer opioids with caution because they will eventually lead to addiction. While opioids should be used cautiously, the focus should be on appropriate and safe pain management. Addiction is not an immediate concern for postoperative patients who require short-term use.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who had surgery earlier in the day using general anesthesia asks whether he can have something to eat. The diet order indicates clear liquids can be taken. Before giving a Jell O to the patient, the nurse should check for the presence of:

Correct Answer is D

Explanation

A nurse is caring for a client who is postoperative. When helping to manage the client's pain, which of the following principles should the nurse apply? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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