Fundamentals Perioperative Care Case Study

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Preoperative Teaching The nurse talks with Ms. Jackson about what to expect the day of surgery and during the immediate postoperative period. The nurse provides instructions regarding cough and deep breathing exercises. Ms. Jackson performs a return demonstration by breathing in through her mouth deeply and exhaling through pursed lips forcefully and rapidly. 4. What action should the nurse implement? A) Advise the client to avoid pursing her lips when exhaling. B) Remind the client to cough after taking two to three breaths. C) Demonstrate the deep breathing and coughing technique again. D) Document successful completion of the return demonstration.
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C) Demonstrate the deep breathing and coughing technique again. CORRECT Ms. Jackson has demonstrated incorrect technique. When performing deep breathing exercises, the client should inhale through the nose and exhale slowly through the mouth without pursing the lips. The nurse should demonstrate the entire procedure again for best learning by the client.
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Immediate Postoperative Care Following surgery, Ms. Jackson is admitted to the Post Anesthesia Care Unit. The operative report indicates that Ms. Jackson had a left hip replacement under general anesthesia. The initial nursing assessment reveals that Ms. Jackson is not responding to verbal stimuli. Her vital signs are T 97.6° F, P 88, R 14, and BP 130/70. 14. What action should the nurse implement first? A) Position the client on her side. B) Observe the surgical dressing. C) Place the call bell within reach. D) Remove the oral airway.
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A) Position the client on her side. During the immediate postanesthesia period, the unconscious client should be positioned on the side to maintain an open airway and promote drainage of secretions.
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Pharmacologic Calculations When Ms. Jackson arrives on the unit, the nurse notes that her IV is wide open. Review of Ms. Jackson’s postoperative prescriptions indicates that 0.9% Normal Saline is to infuse at 75 ml/hour, alternating with Lactated Ringer’s solution at 75 ml/hour. An infusion pump is not immediately available, so the nurse notes that the infusion tubing has a drop factor of 10 drops/ml and resets the IV. 16. At what rate should the IV infuse? A) 8 drops per minute. B) 10 drops per minute. C) 13 drops per minute. D) 21 drops per minute.
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C) 13 drops per minute. CORRECT 75 ml/60 minutes × 10 gtts/1 ml = 12.5, which rounds up to 13 drops per minute.
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While the nurse begins to assess the client, another nurse finds an infusion pump and prepares a prescribed \”now\” dose of an intravenous antibiotic. The prescription is for 2 grams of cefazolin (Ancef), which arrives from the pharmacy diluted in 100 ml of normal saline and is to be administered over 30 minutes. 17. At what rate should the infusion pump be set? A) 20 ml/hour. B) 50 ml/hour. C) 100 ml/hour. D) 200 ml/hour.
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D) 200 ml/hour. CORRECT 100 ml/30 minutes = X ml/60 minutes. 30X = 100 × 60 = 200 ml/hour.
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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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