A postoperative client is being discharged home after a minor same-day surgery that required moderate sedation. The PACU nurse is reviewing discharge instructions with the client and the client's spouse. For each potential action, click to specify if the potential nursing action is appropriate or not appropriate for this client. (Select All That Apply)
Review with the client and spouse when to notify the physician.
Instruct the client to sign their advance directive form
Discuss appropriate wound care
Educate on activity Imitations.
Provide information about dietary restrictions.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Review with the client and spouse when to notify the physician: Appropriate
Rationale: It is essential to inform the client and their spouse about signs and symptoms that would require notifying the physician, such as increased pain, fever, or unusual symptoms. This helps ensure the client can recognize and report any issues promptly.
Instruct the client to sign their advance directive form: Inappropriate
Rationale: Advance directive forms should be completed well before a surgical procedure and are not typically addressed at the time of discharge following a minor same-day surgery. This is not directly related to the immediate postoperative care and discharge instructions.
Discuss appropriate wound care: Appropriate
Rationale: Providing instructions on how to care for the wound is crucial for preventing infection and promoting proper healing. This information is essential for the client's recovery and should be reviewed before discharge.
Educate on activity limitations: Appropriate
Rationale: Informing the client about activity restrictions helps prevent complications and supports appropriate healing. This education is crucial for ensuring the client follows guidelines that will aid in their recovery.
Provide information about dietary restrictions: Appropriate
Rationale: Depending on the type of surgery and sedation, there may be dietary restrictions or guidelines to follow. Providing this information helps the client manage their diet appropriately after discharge.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Assessing the surgical site before surgery: While assessing the surgical site is important, it is not the primary purpose of skin cleaning preparation. The focus is on reducing infection risk.
B. Providing comfort for the client: Comfort may be a secondary benefit, but it is not the main goal of surgical skin cleaning. The primary purpose is to reduce infection risk.
C. Reducing the risk of post-operative wound infection: Surgical skin cleaning preparation is aimed at minimizing the number of microorganisms on the skin to reduce the risk of postoperative wound infections. This is the key reason for preoperative skin preparation.
D. Sterilizing the skin for easier scalpel cutting: Skin cannot be completely sterilized, and the ease of scalpel cutting is not related to the cleanliness of the skin. The goal is infection control, not making the skin easier to cut.
Correct Answer is ["B","D","E"]
Explanation
A. Reddish streak proximal to the insertion site: This indicates phlebitis, not infiltration.
B. Skin is pale and taut: This is a sign of infiltration as fluid accumulates in the tissue around the IV site.
C. The vein is firm and cord-like: This is indicative of phlebitis or thrombophlebitis, not infiltration.
D. IV fluid leaking from insertion site: This is a clear sign of infiltration, where fluid leaks out of the vein into surrounding tissue.
E. Warmth at the insertion site: This can be a sign of infiltration or inflammation, depending on the context.
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