A postoperative client is being discharged home after a minor same-day surgery that required moderate sedation. The PACU nurse is reviewing discharge instructions with the client and the client's spouse. For each potential action, click to specify if the potential nursing action is appropriate or not appropriate for this client. (Select All That Apply)

Review with the client and spouse when to notify the physician.

Instruct the client to sign their advance directive form

Discuss appropriate wound care

Educate on activity Imitations.

Provide information about dietary restrictions.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Review with the client and spouse when to notify the physician: Appropriate
Rationale: It is essential to inform the client and their spouse about signs and symptoms that would require notifying the physician, such as increased pain, fever, or unusual symptoms. This helps ensure the client can recognize and report any issues promptly.
Instruct the client to sign their advance directive form: Inappropriate
Rationale: Advance directive forms should be completed well before a surgical procedure and are not typically addressed at the time of discharge following a minor same-day surgery. This is not directly related to the immediate postoperative care and discharge instructions.
Discuss appropriate wound care: Appropriate
Rationale: Providing instructions on how to care for the wound is crucial for preventing infection and promoting proper healing. This information is essential for the client's recovery and should be reviewed before discharge.
Educate on activity limitations: Appropriate
Rationale: Informing the client about activity restrictions helps prevent complications and supports appropriate healing. This education is crucial for ensuring the client follows guidelines that will aid in their recovery.
Provide information about dietary restrictions: Appropriate
Rationale: Depending on the type of surgery and sedation, there may be dietary restrictions or guidelines to follow. Providing this information helps the client manage their diet appropriately after discharge.

Nursing Test Bank

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

Explanation

A. Record intake and output: This task is within the UAP's scope of practice as it involves documenting fluid balance.

B. Assess bowel sounds: This task requires clinical judgment and assessment skills and should be performed by a licensed nurse.

C. Obtain routine vital signs: This is appropriate for the UAP to perform, as it involves routine measurements that do not require clinical assessment.

D. Document the presence of edema: The UAP can document observable findings such as edema, which is within their scope of practice.

A. Neuromuscular blockers B. Inhaled general anesthesia C. Intravenous general anesthesia D. Regional anesthesia

Correct Answer is D

Explanation

A. Neuromuscular blockers: These are used to induce paralysis and do not affect consciousness or maintain reflexes such as the gag reflex.
B. Inhaled general anesthesia: Generally, inhaled general anesthesia suppresses all reflexes, including the gag reflex.
C. Intravenous general anesthesia: This type of anesthesia typically induces a loss of consciousness and suppression of reflexes, including the gag reflex.
D. Regional anesthesia: This type of anesthesia blocks sensation in a specific area of the body while the client remains conscious and retains reflexes, including the gag reflex.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse asks the unlicensed assistive personnel (UAP) to assist in determining the fluid status of a client. Which of the following actions should the nurse delegate to the UAP? (Select All That Apply)

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

Explanation

The nurse is educating a group of student nurses about the different types of anesthesia. The student demonstrates an understanding of the teaching when they state that a client would maintain a gag reflex with what anesthesia?

Correct Answer is D

Explanation

A nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL. Which condition most likely caused this serum phosphorus level?

The nurse is caring for a client with a serum magnesium of 2.9 mEq/L. The nurse should anticipate a prescription from the primary healthcare provider for what treatment?

Orders were written for a client to be weaned off of total parenteral nutrition (TPN) and started on a low-residue diet. The TPN solution has been infusing at a continuous rate of 90 ml/hr for three weeks. Which of the following orders should the nurse anticipate next?

A client with acute pain is prescribed a sustained-release opioid that is administered every 12 hours. After 6 hours, the client complains of increasing pain that is rated as 9/10. Which intervention by the nurse is most appropriate to address the client's pain?

A client has just undergone a bedside central venous catheter insertion using ultrasound guidance. The nurse knows to check which diagnostic result before initiating the client's prescribed intravenous solution flow rate at 100 mL/hr?

The nurse is preparing to care for a client with an electrolyte imbalance. After reviewing the electronic health record, what finding should the nurse understand places that client at the greatest risk for developing a potassium deficit?

The nurse is reviewing serum laboratory values for a client who is scheduled for surgery tomorrow. Which value requires the nurse to promptly notify the surgeon?