A nurse is monitoring a patient during the postoperative period following a surgical procedure. Which actions should be included in the plan of care? (Select all that apply.)

Assess and document patient's level of pain.

Administer contrast material.

Administer intravenous fluids as ordered.

Administer antineoplastic agents as ordered.

Administer pain medication as ordered.

Answer and Explanation

Correct Answer : A,C,E

A. Assess and document patient's level of pain: Monitoring and documenting pain is essential for effective pain management and patient comfort.

B. Administer contrast material: Administering contrast material is not typically required in the immediate postoperative period unless specifically ordered for diagnostic imaging.

C. Administer intravenous fluids as ordered: IV fluids are often needed postoperatively to maintain hydration and support recovery.

D. Administer antineoplastic agents as ordered: Antineoplastic agents are used for cancer treatment and are not a standard part of postoperative care unless the patient is undergoing concurrent cancer therapy.

E. Administer pain medication as ordered: Administering pain medication as ordered is crucial for managing postoperative pain and promoting recovery.

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Correct Answer is A

Explanation

A. Standing orders: Standing orders are prewritten orders for specific situations. For a patient post-procedure, standing orders might include pain management protocols that would be activated based on the pain assessment.

B. STAT orders: STAT orders are urgent and are typically used in emergency situations. A pain score of 5/10 does not usually warrant a STAT order.

C. Automatic stop orders: Automatic stop orders are used to discontinue a medication after a certain period or dosage has been reached. They don’t apply directly to managing current pain levels.

D. Verbal orders: Verbal orders are given in person or over the phone when a written order is not possible. These should be minimized to avoid errors and are less likely to be used for routine pain management.

A. Ensure that the skin is clean and dry. B. Don gloves prior to administration. C. Take the patient's vital signs. D. Apply to non irritated areas of the skin.

Correct Answer is A

Explanation

A. Ensure that the skin is clean and dry. Cleaning and drying the skin removes dirt, oils, and moisture that could impede the absorption of the medication. This is the first step to ensure maximum efficacy of the topical ointment.

B. Don gloves prior to administration. While wearing gloves is important for infection control and personal protection, it does not directly facilitate the absorption of the ointment into the patient's skin.

C. Take the patient's vital signs. Checking vital signs is a general nursing practice but is unrelated to the application of topical ointments and does not affect absorption.

D. Apply to non-irritated areas of the skin. Applying to non-irritated skin is important to avoid exacerbating skin issues, but it’s not the first step to facilitate absorption. Ensuring the skin is clean and dry takes precedence.

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A nurse is monitoring a patient during the postoperative period following a surgical procedure. Which actions should be included in the plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a pain assessment, noting 5 on a 10-point scale, for a postoperative patient who is 24 hours post procedure. Which type of order should the nurse anticipate that the health-care provider has written?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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