A nurse preparing to get a patient out of bed for the first time since surgery will initially:

place a walker at the side of the bed.

allow the patient to sit with the head of bed raised to the high Fowler's position.

assist the patient to sit and dangle his or her legs on the side of the bed.

assist the patient from a supine position to a standing position.

Answer and Explanation

The Correct Answer is C

A. Place a walker at the side of the bed. A walker may not be necessary for all patients and should only be used if prescribed by the healthcare provider.

B. Allow the patient to sit with the head of bed raised to the high Fowler’s position. This helps with postural adjustment but is not the best first step before dangling the legs.

C. Assist the patient to sit and dangle his or her legs on the side of the bed. Gradual movement from lying to sitting to standing helps prevent orthostatic hypotension, which is common after surgery.

D. Assist the patient from a supine position to a standing position. Moving too quickly can cause dizziness, falls, and syncope due to orthostatic hypotension.

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Correct Answer is A

Explanation

A. When still conscious, participate in marking the surgical site. The surgical site marking should be done with patient participation before anesthesia to confirm accuracy and prevent wrong-site surgery.

B. Have a photograph of the surgical site in the medical record. Photographs are not a standard requirement for surgical verification.

C. Have the unit nurse confirm their identity. Identity confirmation is necessary but not sufficient to prevent wrong-site surgery. Marking the site is the key step.

D. Verbally state the location of the surgical site and the expected procedure. Verbal confirmation is important but should be combined with physical marking of the site to ensure accuracy.

A. IV line patency B. urine output C. airway patency D. wound drainage

Correct Answer is C

Explanation

A. IV line patency: IV access is important for fluid and medication administration, but it is not the highest priority immediately postoperatively.

B. Urine output: Monitoring urine output is important for assessing kidney function and fluid balance, but airway management takes precedence.

C. Airway patency: The priority in the immediate postoperative period is maintaining a patent airway, as patients are at risk for respiratory complications such as obstruction, hypoxia, and aspiration due to anesthesia effects.

D. Wound drainage: Assessing wound drainage is necessary to monitor for excessive bleeding or infection, but it is not the top priority compared to airway patency.

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A nurse preparing to get a patient out of bed for the first time since surgery will initially:

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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