Question

Which statement applies to discharge planning for a postoperative client?

Answer 1

Correct Answers:

Discharge planning is not indicated for same-day surgeries

Rationale :

🔷 Alcohol potentiates anesthetics by enhancing central nervous system depression and increasing sedation risk.

🔷 Interferes with prescribed pain medications, leading to complications such as oversedation, nausea, or bleeding.

🔷 Avoiding alcohol for 24 hours postoperatively is a standard safety measure to reduce adverse effects and support healing.

🔷 Discharge planning begins on admission, ensuring that education and safety measures are reinforced throughout care.

🔷 Same-day surgery clients also require discharge teaching, since recovery continues at home.

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Answer 2

Correct Answers:

places the wheelchair as close to the bed as possible on the client's affected side.

Rationale :

🔹 Clients with hemiparesis (one-sided weakness) should transfer toward their strong/unaffected side for safety and stability.

🔹 Positioning the wheelchair on the affected side increases the risk of falls and injury because the weak side cannot support balance or weight.

🔹 The correct method is to place the wheelchair on the unaffected/strong side to promote independence and safety.

🔹 Dressing the affected arm first helps reduce strain and frustration, making ADLs easier.

🔹 Using Velcro shoes and placing grooming tools in the unaffected hand supports independence and functional ability.

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Answer 3

Correct Answers:

Monitoring for respiratory

Rationale :

🔹 Respiratory depression is the most critical complication of opioid epidural analgesia because opioids directly depress the respiratory center in the brainstem.

🔹 Nurses must closely monitor respiratory rate, oxygen saturation, and depth of breathing to detect early compromise.

🔹 Unrecognized respiratory depression can quickly progress to hypoxemia, loss of consciousness, or respiratory arrest, making it life-threatening.

🔹 While side effects such as nausea, vomiting, headache, or insertion site infection are important, they are not immediately life-threatening like impaired breathing.

🔹 Following the ABCs of nursing (Airway, Breathing, Circulation), ensuring adequate ventilation is always the top priority.

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Answer 4

Correct Answers:

Ginger

Rationale :

🔹 Ginger is widely used as a natural remedy to relieve nausea, motion sickness, and morning sickness due to its effects on the gastrointestinal system.

🔹 It works by enhancing gastric motility and reducing nausea-inducing signals in the gut-brain pathway.

🔹 Ginseng is generally used for improving energy and reducing stress, not for nausea.

🔹 Echinacea is taken to boost immune function and prevent or treat colds.

🔹 St. John’s wort is used primarily for mild to moderate depression.

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Answer 5

Correct Answers:

Arthritis

Rationale :

🔹 Nociceptive pain arises from actual or threatened damage to body tissues, typically involving skin, muscles, bones, joints, or viscera.

🔹 Arthritis causes inflammatory joint pain, which is a classic example of nociceptive pain because it activates pain receptors in tissues.

🔹 Trauma can also cause nociceptive pain, but in clinical teaching, arthritis is more directly linked as a chronic nociceptive condition.

🔹 Diabetes is associated with neuropathic pain, resulting from nerve damage rather than nociceptor activation.

🔹 Cancer pain can be mixed (nociceptive + neuropathic), but it is not exclusively nociceptive like arthritis.

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Answer 6

Correct Answers:

two finger-breadths

Rationale :

♦️Proper crutch fitting is essential to prevent nerve compression and ensure safe ambulation.♦️

♦️There should be about 2 finger-breadths (1.5–2 inches) between the top of the crutch and the client’s axilla when standing upright.

♦️This spacing prevents brachial plexus injury and allows weight to be supported by the hands and arms, not the armpits.

♦️Handgrips should be adjusted so the elbows are slightly flexed at about 20–30 degrees, promoting comfort and balance.

♦️Teaching safe crutch use at discharge reduces risk of falls, nerve injury, and improper gait.

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Answer 7

Correct Answers:

Rub the client's legs to promote circulation

Rationale :

🔹 Leg rubbing after surgery is unsafe because it may dislodge a blood clot if the client has developed a deep vein thrombosis (DVT).

🔹 Instead of rubbing, nurses should use sequential compression devices (SCDs), anti-embolism stockings, and encourage leg exercises to promote safe venous return.

🔹 Early ambulation (usually within 6–8 hours or as tolerated) is safe and effective for reducing complications such as DVT, pneumonia, and constipation.

🔹 Leg exercises every 2 hours help maintain circulation and muscle tone, supporting recovery.

🔹 Raising the head of the bed before moving a client assists in gradual position changes and helps prevent orthostatic hypotension.

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Answer 8

Correct Answers:

Dress the client in a clean hospital gown with underwear removed

Rationale :

🌟 Before surgery, the client must be placed in a clean hospital gown with underwear removed to maintain asepsis and allow access to operative sites.

🌟 Clients are kept NPO (nothing by mouth) before surgery to reduce the risk of aspiration, so giving water is unsafe.

🌟 Dentures must be removed to prevent airway obstruction during anesthesia or intubation.

🌟 Hair must be covered with a surgical cap, not just tied back, to prevent contamination of the sterile field.

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Answer 9

Correct Answers:

Cutting a structure out of the body

Rationale :

🔹 The suffix “-ectomy” specifically means surgical removal or excision of a body part or structure.

🔹 Examples include appendectomy (removal of appendix), cholecystectomy (removal of gallbladder), and tonsillectomy (removal of tonsils).

🔹 “-otomy” refers to cutting into or making an incision (e.g., tracheotomy).

🔹 “-ostomy” refers to creating an opening or outlet from the body (e.g., colostomy).

🔹 “-plasty” refers to repair, reconstruction, or revision of tissue (e.g., rhinoplasty).

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Answer 10

Correct Answers:

Permit the client to drink beverages containing caffeine
Measure the client's intake and output each hour
Assess the client's blood pressure and heart rate

Rationale :

🔵 A. Permit the client to drink beverages containing caffeine

♦️Caffeine is a mild central nervous system stimulant that also produces vasoconstrictive effects. These actions can help increase vascular tone and improve blood pressure in clients recovering from surgery.

♦️Postoperatively, clients may experience hypotension due to anesthesia effects, blood loss, or fluid shifts. Allowing caffeine (if not contraindicated) can provide a non-pharmacologic support to stabilize blood pressure.

♦️Beverages like coffee or tea should only be given once the client is cleared for oral intake and does not have nausea, vomiting, or NPO restrictions.

🔵 C. Measure the client's intake and output each hour

♦️Accurate I&O monitoring is vital for early detection of fluid imbalance. Hypotension can result from low circulating blood volume, either from fluid loss during surgery or inadequate postoperative replacement.

♦️Tracking urine output helps determine renal perfusion, which reflects cardiac output and blood pressure stability. Urine output less than 30 mL/hr can signal hypoperfusion or acute kidney injury.

♦️Hourly I&O assessment guides timely interventions such as IV fluid replacement, electrolyte correction, or medication adjustments.

🔵 D. Assess the client's blood pressure and heart rate

♦️Frequent monitoring of vital signs is essential to evaluate the client’s hemodynamic stability. Hypotension and tachycardia may indicate hypovolemia, internal bleeding, or sepsis.

♦️By closely observing blood pressure trends, the nurse can recognize early deterioration and alert the provider for interventions like fluids, vasopressors, or transfusions.

♦️Heart rate monitoring helps assess compensatory mechanisms, since the body often responds to low blood pressure with tachycardia to maintain perfusion.

🔵 E. Encourage the client to breathe deeply and cough

♦️Deep breathing expands the lungs fully, prevents atelectasis, and improves oxygen exchange, which is crucial for tissue perfusion and hemodynamic stability.

♦️Coughing promotes clearance of secretions, reducing the risk of postoperative pulmonary complications that could indirectly contribute to hypoxemia and low blood pressure.

♦️Improved ventilation and oxygen delivery also enhance venous return to the heart, supporting better cardiac output and stabilizing blood pressure.

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PNR 106 Nursing Foundations

No.

1 :
Which statement applies to discharge planning for a postoperative client?

2 :
The nurse supervises a student nurse assisting a client with left-sided weakness in performing activities of daily living. Which action by the student requires the nurse to intervene?

3 :
Which is a critical nursing assessment when monitoring a client receiving opioid epidural analgesia?

4 :
Chloe's patient states, "I often use herbs when I am nauseated." Which herb would Chloe's patient use?

5 :
A client is experiencing nociceptive pain. Which condition is associated with this type of pain?

6 :
When discharging a patient on crutches, it is imperative that he know there should be how much space between the top of the crutch and the axilla when his hands are gripping the crutches?

7 :
Which nursing action is unsafe when promoting the mobility of a client after surgery?

8 :
Which action will the nurse take to prepare a client for the operating room?

9 :
If the client is undergoing a surgery with the suffix "ectomy," what is the purpose of the surgical procedure?

10 :
Which nursing intervention will the nurse implement to promote increased blood pressure within 48 hours after a surgical procedure? Select all that apply. One, some, or all responses may be correct.

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PNR 106 Nursing Foundations

No.

1 : Which statement applies to discharge planning for a postoperative client?

2 : The nurse supervises a student nurse assisting a client with left-sided weakness in performing activities of daily living. Which action by the student requires the nurse to intervene?

3 : Which is a critical nursing assessment when monitoring a client receiving opioid epidural analgesia?

4 : Chloe's patient states, "I often use herbs when I am nauseated." Which herb would Chloe's patient use?

5 : A client is experiencing nociceptive pain. Which condition is associated with this type of pain?

6 : When discharging a patient on crutches, it is imperative that he know there should be how much space between the top of the crutch and the axilla when his hands are gripping the crutches?

7 : Which nursing action is unsafe when promoting the mobility of a client after surgery?

8 : Which action will the nurse take to prepare a client for the operating room?

9 : If the client is undergoing a surgery with the suffix "ectomy," what is the purpose of the surgical procedure?

10 : Which nursing intervention will the nurse implement to promote increased blood pressure within 48 hours after a surgical procedure? Select all that apply. One, some, or all responses may be correct.

1 :
Which statement applies to discharge planning for a postoperative client?

2 :
The nurse supervises a student nurse assisting a client with left-sided weakness in performing activities of daily living. Which action by the student requires the nurse to intervene?

3 :
Which is a critical nursing assessment when monitoring a client receiving opioid epidural analgesia?

4 :
Chloe's patient states, "I often use herbs when I am nauseated." Which herb would Chloe's patient use?

5 :
A client is experiencing nociceptive pain. Which condition is associated with this type of pain?

6 :
When discharging a patient on crutches, it is imperative that he know there should be how much space between the top of the crutch and the axilla when his hands are gripping the crutches?

7 :
Which nursing action is unsafe when promoting the mobility of a client after surgery?

8 :
Which action will the nurse take to prepare a client for the operating room?

9 :
If the client is undergoing a surgery with the suffix "ectomy," what is the purpose of the surgical procedure?

10 :
Which nursing intervention will the nurse implement to promote increased blood pressure within 48 hours after a surgical procedure? Select all that apply. One, some, or all responses may be correct.