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:

palpable peripheral pulses.

clear lung sounds.

adequate urinary drainage.

bowel sounds in all quadrants.

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is D

Explanation

A. Ask his wife to speak to him to reassure him.
This option is not ideal because the nurse should address the patient's concerns directly. It is important to ensure the patient is making an informed decision and is emotionally supported, but the spouse should not be the first point of contact for reassurance in this case.

B. Assure him that everything will go well.
While it is important to reassure the patient, the nurse should not make promises about the outcome. Assuring the patient everything will go well could lead to unrealistic expectations and may not address the underlying concern.

C. Tear up the surgical consent he signed.
Tearing up the consent is not an appropriate action. The nurse should not act on the patient's uncertainty before consulting the surgeon. The patient has the right to withdraw consent, and this should be addressed properly through communication with the surgeon.

D. Notify the surgeon right away of the situation.
The nurse should immediately notify the surgeon about the patient's change of mind. The surgeon is responsible for providing further clarification and addressing any concerns before proceeding with surgery. The patient must be fully informed and comfortable with their decision.

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 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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

If a patient states that he is having second thoughts and is not sure he wants to have the surgery, the nurse would

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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