A 65-year-old patient is one day post-op from abdominal surgery. The nurse notes the patient is restless, tachycardic, and has a low urine output. The patient is complaining of severe abdominal pain, and the surgical site appears distended. What action should the nurse prioritize?
A) Administering pain medication
B) Notifying the surgeon immediately
C) Encouraging ambulation
D) Providing warm blankets
E) Offering oral fluids
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Rationale: These symptoms are indicative of potential complications post-abdominal surgery, such as hemorrhage or internal organ perforation. Timely intervention is crucial to prevent further deterioration, and notifying the surgeon promptly is the priority action to ensure swift assessment and intervention. Correct Answer: B) Notifying the surgeon immediately
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NCLEX Questions Critical Thinking: Postoperative Care Symptoms
A patient has just returned from the post-anesthesia care unit (PACU) following surgery. The nurse assesses the patient and notes diminished breath sounds on the right side, increased respiratory rate, and restlessness. What action should the nurse take initially?
A) Elevate the head of the bed
B) Administer oxygen therapy
C) Notify the healthcare provider
D) Encourage deep breathing exercises
E) Apply warm compresses to the chest
Rationale: Diminished breath sounds on one side along with increased respiratory rate could indicate a post-op complication like atelectasis or pneumothorax. Administering oxygen would help improve oxygenation while further assessments and interventions are initiated. Correct Answer: B) Administer oxygen therapy
1000 Medical-Surgical Questions
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NCLEX Focus Exploring Postoperative Care: Causes and Diagnosis
A patient who underwent knee replacement surgery 24 hours ago complains of sudden shortness of breath, chest pain, and cough. On assessment, the nurse finds the patient diaphoretic and anxious. What action should the nurse prioritize?
A) Administering pain medication
B) Elevating the legs
C) Notifying the Rapid Response Team
D) Encouraging deep breathing exercises
E) Checking vital signs
Rationale: The symptoms described raise concern for a potential pulmonary embolism, a life-threatening complication post-surgery. Activating the Rapid Response Team allows for immediate intervention and transfer to a higher level of care. Correct Answer: C) Notifying the Rapid Response Team
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NCLEX Questions: Focus on Medications for Postoperative Care
A patient underwent gallbladder removal surgery yesterday and complains of severe incisional pain. The nurse assesses the surgical site and finds redness, warmth, and purulent drainage. What action should the nurse take first?
A) Administering oral pain medication
B) Notifying the surgeon
C) Applying a warm compress to the incision
D) Encouraging increased fluid intake
E) Removing the dressing and assessing further
Correct Answer: B) Notifying the surgeon
Rationale: The signs and symptoms suggest a potential surgical site infection. Notifying the surgeon promptly is crucial to initiate appropriate interventions such as wound cultures, antibiotic therapy, and possible debridement to prevent further complications.
1000 AANP Questions
A 55-year-old patient is scheduled for elective surgery tomorrow morning. The nurse is performing a pre-operative assessment and discovers the patient has a history of adverse reactions to anesthesia, specifically nausea and vomiting. What action should the nurse take?
A) Document the findings in the patient’s chart
B) Inform the anesthesiologist immediately
C) Provide antiemetic medication preemptively
D) Proceed with standard pre-op protocols
E) Notify the surgeon of the patient’s history
Correct Answer: B) Inform the anesthesiologist immediately
Rationale: A history of adverse reactions to anesthesia, especially nausea and vomiting, requires prompt communication with the anesthesiologist. This information is critical for the anesthesia plan to minimize the risk of complications during and after surgery.
POP QUIZ
NCLEX Review: Postoperative Care Treatments
A patient is scheduled for abdominal surgery in the morning. During the pre-operative assessment, the nurse discovers the patient is wearing a necklace with a metal pendant. What action should the nurse take?
A) Ask the patient to remove the necklace and place it in a locker
B) Tape the necklace securely to the patient’s chest
C) Request the surgeon’s advice on removing the necklace
D) Inform the operating room staff about the necklace
E) Allow the patient to keep the necklace on
Rationale: Metal objects can interfere with surgical equipment, causing burns or other complications during surgery. The nurse should instruct the patient to remove the necklace and secure it in a safe place to ensure the patient’s safety during the procedure. Correct Answer: A) Ask the patient to remove the necklace and place it in a locker
Understanding Postoperative Care: NCLEX Priority Questions
A patient is being prepared for surgery and is anxious about the upcoming procedure. The nurse notes increased heart rate, shallow breathing, and restlessness. What action should the nurse prioritize?
A) Administer a sedative medication
B) Begin teaching relaxation techniques
C) Notify the surgeon of the patient’s anxiety
D) Proceed with pre-op preparations
E) Reassure the patient and provide emotional support
Rationale: Addressing the patient’s anxiety is crucial before surgery to promote a more positive experience and minimize potential complications related to increased stress. Reassurance and emotional support from the nurse can help alleviate anxiety, promoting a calmer state for the patient before the procedure. Correct Answer: E) Reassure the patient and provide emotional support
Understanding Postoperative Care: Causes and Symptoms
A 70-year-old patient is scheduled for hip replacement surgery. During the pre-operative assessment, the nurse discovers that the patient takes anticoagulant medication daily. What action should the nurse take?
A) Continue administering the anticoagulant as prescribed
B) Hold the anticoagulant and notify the surgeon immediately
C) Administer an additional dose of anticoagulant
D) Consult with the pharmacist for an alternative anticoagulant
E) Instruct the patient to stop taking the anticoagulant
Rationale: Anticoagulants increase the risk of bleeding during surgery. Holding the anticoagulant and promptly informing the surgeon ensures a coordinated approach to manage the patient’s anticoagulation therapy around the surgical procedure, reducing the risk of excessive bleeding during surgery. Correct Answer: B) Hold the anticoagulant and notify the surgeon immediately
Understanding Postoperative Care: NCLEX Delegation Questions
A patient is scheduled for a laparoscopic procedure and has been fasting since midnight. The surgery is delayed due to unforeseen emergencies. The patient reports feeling thirsty and asks for water. What action should the nurse take?
A) Allow the patient a small sip of water
B) Offer ice chips to moisten the mouth
C) Inform the surgeon of the patient’s request
D) Delay the surgery until the patient is hydrated
E) Explain the importance of maintaining the fasting period
Rationale: Maintaining the fasting period before surgery is crucial to prevent aspiration during anesthesia. Educating the patient about the importance of continued fasting, offering ice chips for oral comfort without breaking the fast, and informing the healthcare team ensures adherence to pre-operative protocols for patient safety during surgery. Correct Answer: E) Explain the importance of maintaining the fasting period
HOMEPAGE
A patient scheduled for gallbladder removal surgery expresses concerns about post-operative pain management. The nurse explains the various pain relief options available. What intervention should the nurse prioritize for effective pain management?
A) Educate the patient on relaxation techniques
B) Discuss the importance of ambulation after surgery
C) Collaborate with the healthcare team to develop a pain management plan
D) Administer a high dose of pain medication before surgery
E) Encourage the patient to use over-the-counter pain relievers
Rationale: A comprehensive pain management plan involving the patient, healthcare team, and various modalities (medication, relaxation techniques, ambulation, etc.) is essential for addressing post-operative pain effectively while minimizing adverse effects and ensuring patient comfort and recovery. Correct Answer: C) Collaborate with the healthcare team to develop a pain management plan