Review Complication prevention

Perioperative Nursing > Medical Surgical

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Complication prevention

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Total Questions : 5

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Question 1:

A nurse is caring for a client who had a laparoscopic cholecystectomy. Which of the following interventions should the nurse implement to prevent postoperative nausea and vomiting?

A. Administer an antiemetic as ordered. B. Encourage the client to drink carbonated beverages. C. Place the client in a supine position. D. Apply pressure to the client's abdomen.

Answer and Explanation

Choice A:

Administering an antiemetic as ordered can help prevent postoperative nausea and vomiting by blocking the receptors in the brain that trigger the vomiting reflex. This is a common intervention for clients who have undergone laparoscopic cholecystectomy, as they may experience nausea and vomiting due to the effects of anesthesia, pain, or the carbon dioxide gas used to inflate the abdomen during the procedure.

Choice B:

Encouraging the client to drink carbonated beverages is not a good intervention to prevent postoperative nausea and vomiting, as carbonated beverages can increase gastric distension and pressure, which can worsen nausea and vomiting. Carbonated beverages can also cause belching, which can introduce air into the stomach and increase the risk of aspiration.

Choice C:

Placing the client in a supine position is not a good intervention to prevent postoperative nausea and vomiting, as supine position can decrease gastric emptying and increase the risk of aspiration. Supine position can also impair respiratory function and cause hypoxemia, which can trigger nausea and vomiting. The client should be placed in a semi-Fowler's position or on their side with their head elevated to facilitate gastric emptying and prevent aspiration.

Choice D:

Applying pressure to the client's abdomen is not a good intervention to prevent postoperative nausea and vomiting, as pressure can cause pain and discomfort, which can worsen nausea and vomiting. Pressure can also interfere with wound healing and increase the risk of infection or bleeding. The client's abdomen should be assessed for distension, tenderness, or signs of complications, but not pressed.

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Question 2:

A nurse is assessing a client who had a thyroidectomy. The nurse suspects that the client is experiencing hypocalcemia due to inadvertent damage to the parathyroid glands. Which of the following statements by the client supports this suspicion?

A. "I feel tingling in my fingers and toes.” B. "I have difficulty swallowing and speaking.” C. "I have a dry mouth and increased thirst.” D. "I feel muscle weakness and fatigue.”

Answer and Explanation

Choice A:

Tingling in the fingers and toes is a sign of paresthesia, which is a common symptom of hypocalcemia. Hypocalcemia occurs when the blood calcium level is too low, which can happen after a thyroidectomy if the parathyroid glands are damaged or removed. The parathyroid glands produce parathyroid hormone, which regulates calcium balance in the body. Without enough parathyroid hormone, calcium levels drop and cause neuromuscular irritability and numbness or tingling sensations.

Choice B:

Difficulty swallowing and speaking is not a specific sign of hypocalcemia, but rather a possible complication of a thyroidectomy due to injury to the recurrent laryngeal nerve. This nerve innervates the muscles of the larynx, which control voice production and swallowing. Damage to this nerve can cause hoarseness, weak voice, or vocal cord paralysis.

Choice C:

Dry mouth and increased thirst are not signs of hypocalcemia, but rather signs of dehydration. Dehydration can occur for various reasons, such as fluid loss, inadequate fluid intake, or increased fluid needs. Dehydration can affect the electrolyte balance in the body, but it does not directly cause hypocalcemia.

Choice D:

Muscle weakness and fatigue are not specific signs of hypocalcemia, but rather general signs of malaise. Malaise can occur for various reasons, such as infection, inflammation, stress, or chronic illness. Malaise can affect the physical and mental well-being of a person, but it does not directly cause hypocalcemia.

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Question 3:

A nurse is preparing a client for discharge after a mastectomy. The nurse teaches the client how to perform arm exercises to prevent lymphedema and promote mobility. Which of the following statements by the client indicates an understanding of the teaching?

A. "I will start with gentle shoulder shrugs and circles.” B. "I will lift my arm above my head several times a day.” C. "I will use my affected arm for normal activities as much as possible.” D. "I will wear a compression sleeve on my affected arm.”

Answer and Explanation

Choice A:

This is incorrect because gentle shoulder shrugs and circles are not enough to prevent lymphedema and promote mobility. The client needs to perform more active and progressive exercises that involve the full range of motion of the shoulder joint.

Choice B:

This is incorrect because lifting the arm above the head several times a day is too aggressive and may cause swelling and pain. The client should gradually increase the elevation of the arm over several weeks, starting with 90 degrees and then progressing to 120 degrees.

Choice C:

This is correct because using the affected arm for normal activities as much as possible helps to restore function and prevent stiffness. The client should avoid heavy lifting, tight clothing, blood pressure measurements, and injections on the affected arm, but otherwise should use it for daily tasks such as combing hair, dressing, and eating.

Choice D:

This is incorrect because wearing a compression sleeve on the affected arm is not recommended for routine use after a mastectomy. Compression sleeves are only indicated for clients who have developed lymphedema and need to reduce the swelling. They may also be used for air travel or strenuous exercise, but only with a physician's prescription.

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Question 4:

A nurse is caring for a client who had an abdominal hysterectomy. The nurse observes that the client has a low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. Which of the following actions should the nurse take first?

A. Notify the provider of the findings. B. Obtain a wound culture from the surgical site. C. Administer an antibiotic as ordered. D. Increase the frequency of perineal care.

Answer and Explanation

Choice A:

The client has signs of a possible infection, such as low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. These are complications of hysterectomy that require immediate attention from the provider. The provider may order further tests, such as a wound culture or blood tests, and prescribe antibiotics or other treatments. Therefore, notifying the provider is the first action the nurse should take.

Choice B:

Obtaining a wound culture from the surgical site may be necessary to identify the type of infection and the appropriate antibiotic therapy. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and follow their orders.

Choice C:

Administering an antibiotic as ordered may help treat the infection and reduce the risk of further complications. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and obtain a wound culture if ordered to determine the best antibiotic for the client.

Choice D:

Increasing the frequency of perineal care may help prevent or reduce infection by keeping the area clean and dry. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and administer an antibiotic as ordered to treat the infection.

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Question 5:

A nurse is reviewing the discharge instructions for a client who had a total hip replacement. Which of the following statements by the client indicate a need for further teaching? (Select all that apply.)

A. "I will use a pillow between my legs when I sleep.” B. "I will avoid crossing my legs or bending forward.” C. "I will report any signs of infection or bleeding to my doctor.” D. "I will resume my normal activities as soon as I feel better.” E. "I will take my anticoagulant medication as prescribed.”

Answer and Explanation

Choice A:

This is a correct statement by the client. Using a pillow between the legs when sleeping helps to maintain the hip in abduction and prevent dislocation of the prosthesis.

Choice B:

This is also a correct statement by the client. Avoiding crossing the legs or bending forward prevents excessive flexion of the hip and reduces the risk of dislocation.

Choice C:

This is another correct statement by the client. Reporting any signs of infection or bleeding to the doctor is important to prevent complications such as wound infection, hematoma, or sepsis.

Choice D:

This is an incorrect statement by the client that indicates a need for further teaching. Resuming normal activities as soon as the client feels better is not advisable, as it may cause excessive stress on the joint and lead to loosening or fracture of the prosthesis. The client should follow a gradual rehabilitation program and avoid activities that involve high impact, twisting, or lifting.

Choice E:

This is also an incorrect statement by the client that indicates a need for further teaching. Taking anticoagulant medication as prescribed is not enough to prevent thromboembolic events after a total hip replacement. The client should also wear compression stockings, use intermittent pneumatic compression devices, and perform ankle and foot exercises as instructed. The client should also monitor for signs of bleeding or bruising and report any abnormal findings to the doctor.

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Complication prevention

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