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
The correct answer is A. Gather information on the patient’s current medications, including prescription drugs, over-the-counter drugs, herbal supplements, and vitamins. To ensure accuracy, nurses verify the medication list with the patient, family, caregivers, or community pharmacies and document the information in the patient’s EMR.
Choice A: Gather information on the patient’s current medications, including prescription drugs, over-the-counter drugs, herbal supplements, and vitamins. To ensure accuracy, nurses verify the medication list with the patient, family, caregivers, or community pharmacies and document the information in the patient’s EMR.
This choice accurately describes the comprehensive process of medication reconciliation. Nurses play a crucial role in gathering detailed information about all medications a patient is currently taking, including prescription drugs, over-the-counter medications, herbal supplements, and vitamins. This information is then verified with various sources such as the patient, their family, caregivers, or community pharmacies to ensure its accuracy. Finally, the verified information is documented in the patient’s Electronic Medical Record (EMR). This process helps prevent medication errors, ensures continuity of care, and enhances patient safety.
Choice B: Review the patient’s medication list to verify its accuracy and completeness. They also compare the list of current medications with new orders or prescriptions to detect any discrepancies or potential issues.
While this choice describes an important aspect of medication reconciliation, it is not as comprehensive as Choice A. Verifying the accuracy and completeness of the medication list and comparing it with new orders or prescriptions is a critical step in identifying discrepancies or potential issues. However, it does not encompass the initial gathering of information from various sources or the documentation process, which are essential components of medication reconciliation.
Choice C: Review the medication history provided by the patient and make changes in the medications based on the patient’s current health status. They communicate any medication changes to the patient and the healthcare team.
This choice focuses on reviewing the medication history and making changes based on the patient’s current health status. While this is an important aspect of patient care, it does not fully capture the scope of medication reconciliation. Medication reconciliation involves not only reviewing and updating medications but also gathering comprehensive information from multiple sources and ensuring accurate documentation. This choice lacks the emphasis on verification and documentation that is central to the medication reconciliation process.
Correct Answer is True
Explanation
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.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.