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kkiahtherese kkiahtherese
wrote...
Posts: 539
Rep: 3 0
6 years ago
A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best?
 
  a. Allow the client to walk to the bathroom.
  b. Delegate assisting the client to the nurse's aide.
  c. Give the client a bedpan or urinal to use.
  d. Insert a urinary catheter now instead of waiting.

Question 2

A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)?
 
  a. Assess the client's anxiety.
  b. Give the client a back rub.
  c. Remind the client to turn.
  d. Teach about postoperative care.

Question 3

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met?
 
  a. Drainage from the surgical site is 30 mL less than yesterday.
  b. There is no redness, warmth, or drainage at the insertion site.
  c. The client reports adequate pain control with medications.
  d. Urine is clear yellow and urine output is greater than 40 mL/hr.

Question 4

A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate?
 
  a. After you wash the surgical site, shave that area with your own razor.
  b. Be sure to wash the area where you will have surgery very thoroughly.
  c. Use a washcloth to wash the surgical site; do not take a full shower or bath.
  d. Wash the surgical site first, then shampoo and wash the rest of your body.
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Replies
wrote...
6 years ago
The answer to question 1

ANS: C
Although possibly uncomfortable or embarrassing for the client, the client should not be allowed out of bed after receiving sedation. The nurse should get the client a bedpan or urinal. The client may or may not need a urinary catheter.

The answer to question 2

ANS: B
A back rub reduces anxiety and can be delegated to the UAP. Once teaching has been done, the UAP can remind the client to turn, but this is not related to relieving anxiety. Assessing anxiety and teaching are not within the scope of practice for the UAP.

The answer to question 3

ANS: B
The priority client problem related to a surgical drain is the potential for infection. An insertion site that is free of redness, warmth, and drainage indicates that goals for this client problem are being met. The other assessments are normal, but not related to the drain.

The answer to question 4

ANS: B
The entire proposed surgical site needs to be washed thoroughly and completely with the antimicrobial soap. Shaving, if absolutely necessary, should be done in the operative suite immediately before the operation begins, using sterile equipment. The client needs a full shower or bath (shower preferred). The client should wash the surgical site last; dirty water from shampooing will run over the cleansed site if the site is washed first.
kkiahtherese Author
wrote...
6 years ago
Above and beyond my expectations for this site
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