The following 4 questions pertain to this case study:
Indicate which nursing interventions the post-surgical unit nurse should complete. (Select all that apply)
Changing the patient’s position every 3 to 4 hours.
Provide adequate and regular pain medication.
Encourage deep breathing and coughing.
Place the conscious patient in a supine position with the head of the bed elevated.
Encourage bed rest for the first 4 hours after surgery.
Correct Answer : A,B,C,D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: True
The statement that a patient with alkalosis can develop hyperkalemia is generally incorrect. Alkalosis, which is a condition characterized by a higher-than-normal pH in the blood, typically leads to hypokalemia rather than hyperkalemia. This occurs because alkalosis causes potassium to shift from the extracellular fluid into the cells, reducing the plasma potassium concentration. Therefore, it is uncommon for alkalosis to result in hyperkalemia.
Choice B: False
The correct answer is that a patient with alkalosis is unlikely to develop hyperkalemia. Alkalosis usually causes a decrease in plasma potassium levels, leading to hypokalemia. This is due to the movement of potassium ions into the cells in exchange for hydrogen ions, which are moved out of the cells to help buffer the increased pH. Consequently, the plasma potassium concentration drops, making hyperkalemia an unlikely outcome in the presence of alkalosis.
Correct Answer is B
Explanation
Choice A Reason: Fluid Volume Overload
Fluid volume overload, also known as hypervolemia, occurs when there is an excess of fluid in the body. This condition is often characterized by symptoms such as swelling (edema), shortness of breath, and high blood pressure. In the context of the patient’s scenario, fluid volume overload would typically present with signs like jugular venous distention, pulmonary congestion, and possibly ascites. The patient’s blood pressure is 109/70, which is not indicative of hypertension typically seen in fluid overload. Additionally, the patient’s lung sounds are clear, which further suggests that there is no pulmonary congestion. The lab results do not show a significant decrease in sodium levels, which might be expected in fluid overload due to dilutional hyponatremia.
Choice B Reason: Fluid Volume Deficit
Fluid volume deficit, or hypovolemia, is a condition where there is a significant loss of body fluids. This can result from severe diarrhea, as seen in the patient’s case. Symptoms of fluid volume deficit include lightheadedness, weakness, and muscle twitching, all of which the patient is experiencing. The patient’s blood pressure is on the lower side (109/70) and he gets lightheaded when standing up, indicating orthostatic hypotension, a common sign of fluid volume deficit. The elevated BUN (30 mg/dL) and creatinine (1.8 mg/dL) levels suggest dehydration and reduced kidney perfusion. The high potassium level (5.6 mEq/L) can be attributed to the body’s attempt to conserve water and sodium, leading to potassium retention. The ECG changes in the T wave and PR interval are consistent with hyperkalemia, which can occur in dehydration and kidney dysfunction.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today