The essential core of nursing practice is to deliver holistic, patient-centered care. This includes assessment and evaluation, providing a variety of interventions, patient and caregiver teaching, and being a member of the interprofessional healthcare team.

True

False

Answer and Explanation

The Correct Answer is A

Choice A: True

The essential core of nursing practice indeed revolves around delivering holistic, patient-centered care. This approach integrates the art and science of nursing to ensure comprehensive care that addresses the physical, emotional, social, and spiritual needs of patients. Holistic care involves thorough assessment and evaluation to understand the patient’s overall health status and needs. Nurses provide a variety of interventions, from administering medications to performing procedures, to support patient health and recovery. Additionally, patient and caregiver teaching is crucial for empowering individuals to manage their health effectively. Nurses also play a vital role as members of the interprofessional healthcare team, collaborating with other healthcare professionals to ensure coordinated and effective care.

Choice B: False

The statement that the essential core of nursing practice is not to deliver holistic, patient-centered care is incorrect. Holistic, patient-centered care is a fundamental principle of nursing practice. It emphasizes the importance of treating the whole person rather than just the symptoms of a disease. This approach ensures that care is tailored to the individual needs of each patient, promoting better health outcomes and patient satisfaction. By focusing on holistic care, nurses can address the diverse aspects of a patient’s well-being, including their physical, emotional, social, and spiritual needs.

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

Explanation

Choice A reason:

Changing the patient’s position every 3 to 4 hours is crucial to prevent complications such as pressure ulcers and deep vein thrombosis (DVT). Immobility can lead to the development of pressure ulcers, especially in patients who are bedridden or have limited mobility. Regular repositioning helps to alleviate pressure on vulnerable areas of the body, promoting better circulation and preventing skin breakdown. Additionally, changing positions can help in preventing DVT by encouraging blood flow and reducing the risk of blood clots forming in the legs.

Choice B reason:

Providing adequate and regular pain medication is essential for postoperative care to ensure patient comfort and facilitate recovery. Pain management is a critical aspect of postoperative care as unmanaged pain can lead to complications such as increased heart rate, hypertension, and delayed wound healing. Adequate pain control allows the patient to participate in necessary activities such as deep breathing exercises and ambulation, which are vital for preventing complications like pneumonia and promoting overall recovery. Pain medication should be administered as prescribed, and the patient’s pain levels should be regularly assessed and documented.

Choice C reason:

Encouraging deep breathing and coughing is vital for preventing respiratory complications such as atelectasis and pneumonia. After surgery, patients are at risk of developing these complications due to the effects of anesthesia and prolonged immobility. Deep breathing exercises help to expand the lungs fully, improving oxygenation and preventing the collapse of alveoli. Coughing helps to clear secretions from the airways, reducing the risk of infection. Nurses should instruct patients on how to perform these exercises effectively and encourage them to do so regularly.

Choice D reason:

Placing the conscious patient in a supine position with the head of the bed elevated is important for maintaining airway patency and promoting optimal respiratory function. Elevating the head of the bed helps to reduce the risk of aspiration and improves lung expansion, facilitating better breathing. This position is particularly beneficial for patients who may have residual effects of anesthesia or are at risk of respiratory complications. It also helps in reducing the workload on the heart and improving overall comfort.

Choice E reason:

Encouraging bed rest for the first 4 hours after surgery is generally not recommended as early mobilization is crucial for preventing complications such as DVT, pulmonary embolism, and muscle atrophy. While it is important to ensure that the patient is stable before encouraging movement, prolonged bed rest can lead to adverse outcomes. Instead, patients should be encouraged to engage in light activities as soon as they are able, under the supervision of healthcare professionals. This helps to promote circulation, improve respiratory function, and enhance overall recovery.

A. Operative site B. Airway C. Pulse D. Skin integrity

Correct Answer is B

Explanation

Choice A reason:
Assessing the operative site is important to monitor for signs of bleeding, infection, or other complications. However, it is not the most critical, high-priority assessment immediately after surgery. While the condition of the surgical site can provide valuable information about the patient’s recovery and potential complications, it does not take precedence over ensuring the patient’s airway is clear and they are breathing adequately. The operative site can be assessed once the patient’s airway, breathing, and circulation are stable.
Choice B reason:
Airway assessment is the most critical, high-priority assessment in the PACU. Ensuring that the patient’s airway is clear and they are breathing properly is paramount because anesthesia can depress the central nervous system, leading to compromised airway patency and respiratory function. The primary goal in the immediate postoperative period is to ensure that the patient is ventilating adequately to prevent hypoxia and other respiratory complications. This involves checking for airway obstruction, monitoring respiratory rate, and ensuring that oxygen saturation levels are within normal ranges (typically 95-100% for healthy individuals). Any issues with the airway must be addressed immediately to prevent life-threatening complications.
Choice C reason:
Assessing the pulse is crucial for monitoring the patient’s cardiovascular status, including heart rate and rhythm. This can help detect arrhythmias, hypovolemia, or other cardiovascular issues that may arise postoperatively. However, while important, it is secondary to ensuring that the patient’s airway is clear and they are breathing adequately. The pulse can be assessed once the airway and breathing are confirmed to be stable. Normal pulse rates for adults typically range from 60 to 100 beats per minute.
Choice D reason:
Assessing skin integrity is important for identifying signs of pressure ulcers, infection, or other skin-related issues. However, this assessment is not the highest priority immediately after surgery. Ensuring the patient’s airway, breathing, and circulation are stable takes precedence. Skin integrity can be assessed once the patient is stable and other critical assessments have been completed. Maintaining skin integrity is essential for overall patient care, but it does not supersede the need to ensure the patient is breathing properly and has a clear airway.

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The essential core of nursing practice is to deliver holistic, patient-centered care. This includes assessment and evaluation, providing a variety of interventions, patient and caregiver teaching, and being a member of the interprofessional healthcare team.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The following 4 questions pertain to this case study: Exhibits Indicate which nursing interventions the post-surgical unit nurse should complete. (Select all that apply)

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

Explanation

The following 4 questions pertain to this case study: Exhibits In PACU, many assessments and interventions are done simultaneously. However, the most critical, high-priority assessment is:

Correct Answer is B

Explanation

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