Fundamentals Perioperative Care Case Study
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Postoperative Wound Management During the postoperative assessment, the nurse observes Ms. Jackson's surgical site. The left hip dressing has a moderate amount of sanguineous drainage. 20. What action should the nurse implement? A) Apply pressure to the site. B) Elevate the leg on a pillow. C) Observe the linens under the hip. D) Use sterile technique to replace the dressing.
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C) Observe the linens under the hip. CORRECT Gravity pulls drainage down, so the nurse should inspect the area below the surgical site for additional drainage. The nurse may also mark the amount of drainage on the dressing for later comparison.
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Ms. Jackson is currently receiving Lactated Ringer's solution IV at a rate of 75 ml/hour. 24. In transfusing the 250 ml unit of packed red blood cells, what action should the nurse implement? A) Stop the IV solution and transfuse the packed cells at 125 ml/hour via tubing connected to a bag of saline solution. B) Infuse the Lactated Ringer's solution through the IV tubing concurrently with the blood at a combined rate of 75 ml/hour. C) Flush the IV tubing with a 5 ml bolus of normal saline before and after the transfusion, and transfuse the blood within 1 hour. D) Replace the Lactated Ringer's solution with the unit of packed red blood cells and administer through the tubing at 75 ml/hour.
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A) Stop the IV solution and transfuse the packed cells at 125 ml/hour via tubing connected to a bag of saline solution. CORRECT Packed red blood cells are only compatible with normal saline. The blood should be connected to a bag of saline solution using special Y-tubing and administered within 1½ to 2 hours, if possible, but no longer than 4 hours (250 ml transfused at 125 ml/hour = 2 hours).
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Nursing Plan of Care The nurse is assisting Ms. Jackson to the bedside commode on the second postoperative day. Ms. Jackson states, \"I have never had to depend on anyone before. I like to take care of myself. I feel so helpless.\" 25. In response to these remarks, the nurse plans care for Ms. Jackson based on the identification of which nursing diagnosis? A) Disturbed body image. B) Altered self-concept. C) Anticipatory grieving. D) Impaired physical mobility.
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B) Altered self-concept. CORRECT The client's remarks regarding feelings of helplessness relate to her sense of how she perceives herself; her self-concept.
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Dressing Change After Ms. Jackson ambulates with the physical therapist, the nurse prepares to change the surgical dressing. While obtaining supplies, the nurse reviews the sterile procedure to be followed. 27. At what step in the procedure should the nurse don sterile gloves? A) Prior to removing the dressing on the client's hip. B) Before opening the new sterile dressing package. C) Before cleansing the client's hip incision. D) After cleansing the client's hip incision.
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C) Before cleansing the client's hip incision. CORRECT When using surgical asepsis for wound care, the sterile gloves should be donned prior to cleaning the wound and applying the new sterile dressing.
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While cleansing the incision, the nurse observes that the staples are intact, but a 2 cm gap has opened at the bottom of the incision. http://biology-forums.com/index.php?topic=109414.0 28. How should the nurse document this finding? A) Bottom edges of incision approximated. B) Small area of dehiscence at bottom of incision. C) Evisceration of incision noted at bottom edge. D) Wound healing via secondary intention.
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B) Small area of dehiscence at bottom of incision. CORRECT An unintentional opening in a surgical wound prior to healing is referred to as dehiscence.
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