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 ["B","C","E"]
Explanation
Choice A: Properly cleaning all reusable equipment once each day
While cleaning reusable equipment is important, it should be done after each use, not just once a day. This ensures that any potential pathogens are removed before the equipment is used on another patient, thereby preventing cross-contamination.
Choice B: Appropriately using PPE
This is a correct answer. Personal Protective Equipment (PPE) such as gloves, masks, gowns, and eye protection are essential in preventing the spread of infection. Proper use of PPE helps protect both healthcare workers and patients from exposure to infectious agents.
Choice C: Ensuring all environmental surfaces are properly cleaned, disinfected, and maintained
This is another correct answer. Regular cleaning and disinfection of environmental surfaces, such as bed rails, doorknobs, and medical equipment, are crucial in preventing the spread of infections. Maintaining a clean environment reduces the risk of healthcare-associated infections.
Choice D: Avoiding all invasive interventions
Avoiding invasive interventions is not a practical or realistic approach to preventing infections. While minimizing unnecessary invasive procedures can reduce infection risk, many invasive interventions are necessary for patient care. Instead, proper aseptic techniques should be used during these procedures to prevent infections.
Choice E: Performing hand washing or using an alcohol-based hand sanitizer before and after patient contact or procedures
This is also a correct answer. Hand hygiene is one of the most effective measures to prevent the spread of infections. Washing hands with soap and water or using an alcohol-based hand sanitizer before and after patient contact or procedures significantly reduces the transmission of pathogens.
Correct Answer is A
Explanation
Choice A: True
Chemotherapy drugs work by targeting rapidly dividing cells, a characteristic of cancer cells. However, they cannot selectively distinguish between cancer cells and normal cells that also divide rapidly, such as those in the bone marrow, digestive tract, and hair follicles. This lack of selectivity leads to the common side effects of chemotherapy, such as hair loss, nausea, and decreased blood cell counts. The inability to differentiate between normal and cancer cells is a significant limitation of traditional chemotherapy.
Choice B: False
This choice is incorrect. If chemotherapy drugs could selectively target only cancer cells, the treatment would have fewer side effects and be more effective. However, the non-selective nature of these drugs means they also damage normal, healthy cells that divide rapidly. This non-selectivity is why patients undergoing chemotherapy often experience a range of side effects, as the treatment impacts both cancerous and healthy cells.
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