When the nurse applies a painful stimulus to the nail beds of an unconscious patient, the
patient responds with internal rotation, adduction, and flexion of the arms. The nurse
documents this as
a. flexion withdrawal.
b. localization of pain.
c. decorticate posturing.
d. decerebrate posturing.
Give this one a try later!
ANS: C
Internal rotation, adduction, and flexion of the arms in an unconscious patient
is documented as decorticate posturing. Extension of the arms and legs is
decerebrate posturing. Because the flexion is generalized, it does not indicate
localization of pain or flexion withdrawal.
,What is the rationale for using preoperative checklists on the day of surgery?
a. The patient is correctly identified.
b. All preoperative orders and procedures have been carried out and records are
complete.
c. Patients' families have been informed as to where they can accompany and wait for
patients.
d. Preoperative medications are the last procedure before the patient is transported to
the operating room.
Give this one a try later!
b. Preoperative checklists are a tool used to ensure that the many preparations
and precautions performed before surgery have been completed and
documented. Patient identification, instructions to the family, and
administration of preoperative medications are often documented on the
checklist, which ensures that no details are omitted.
A postoperative patient has not voided for 8 hours after return to the clinical unit. Which
action should the nurse take first?
a. Perform a bladder scan.
b. Encourage increased oral fluid intake.
c. Assist the patient to ambulate to the bathroom.
d. Insert a straight catheter as indicated on the PRN order.
Give this one a try later!
ANS: A
The initial action should be to assess the bladder for distention. If the bladder
is distended, providing the patient with privacy (by walking with them to the
bathroom) will be helpful. Because of the risk for urinary tract infection,
catheterization should only be done after other measures have been tried
, without success. There is no indication to notify the surgeon about this
common postoperative problem unless all measures to empty the bladder are
unsuccessful.
What type of procedural information should be given to a patient in preparation for
ambulatory surgery (select all that apply)?
a. How pain will be controlled
b. Any fluid and food restrictions
c. Characteristics of monitoring equipment
d. What odors and sensations may be experienced
e. Technique and practice of coughing and deep breathing, if appropriate
Give this one a try later!
a, b, e. Procedural information includes what will or should be done for
surgical preparation, including what to bring and what to wear to the surgery
center, length and type of food and fluid restrictions, physical preparation
required, pain control, need for coughing and deep breathing (if appropriate),
and procedures done before and during surgery (such as vital signs, IV lines,
and how anesthesia is administered). The other options are sensory and
process information (see Table 18-6).
During a preoperative physical examination, the nurse is alerted to the possibility of
compromised respiratory function during or after surgery in a patient with which
problem?
a. Obesity
b. Dehydration
c. Enlarged liver
d. Decreased peripheral pulses
patient responds with internal rotation, adduction, and flexion of the arms. The nurse
documents this as
a. flexion withdrawal.
b. localization of pain.
c. decorticate posturing.
d. decerebrate posturing.
Give this one a try later!
ANS: C
Internal rotation, adduction, and flexion of the arms in an unconscious patient
is documented as decorticate posturing. Extension of the arms and legs is
decerebrate posturing. Because the flexion is generalized, it does not indicate
localization of pain or flexion withdrawal.
,What is the rationale for using preoperative checklists on the day of surgery?
a. The patient is correctly identified.
b. All preoperative orders and procedures have been carried out and records are
complete.
c. Patients' families have been informed as to where they can accompany and wait for
patients.
d. Preoperative medications are the last procedure before the patient is transported to
the operating room.
Give this one a try later!
b. Preoperative checklists are a tool used to ensure that the many preparations
and precautions performed before surgery have been completed and
documented. Patient identification, instructions to the family, and
administration of preoperative medications are often documented on the
checklist, which ensures that no details are omitted.
A postoperative patient has not voided for 8 hours after return to the clinical unit. Which
action should the nurse take first?
a. Perform a bladder scan.
b. Encourage increased oral fluid intake.
c. Assist the patient to ambulate to the bathroom.
d. Insert a straight catheter as indicated on the PRN order.
Give this one a try later!
ANS: A
The initial action should be to assess the bladder for distention. If the bladder
is distended, providing the patient with privacy (by walking with them to the
bathroom) will be helpful. Because of the risk for urinary tract infection,
catheterization should only be done after other measures have been tried
, without success. There is no indication to notify the surgeon about this
common postoperative problem unless all measures to empty the bladder are
unsuccessful.
What type of procedural information should be given to a patient in preparation for
ambulatory surgery (select all that apply)?
a. How pain will be controlled
b. Any fluid and food restrictions
c. Characteristics of monitoring equipment
d. What odors and sensations may be experienced
e. Technique and practice of coughing and deep breathing, if appropriate
Give this one a try later!
a, b, e. Procedural information includes what will or should be done for
surgical preparation, including what to bring and what to wear to the surgery
center, length and type of food and fluid restrictions, physical preparation
required, pain control, need for coughing and deep breathing (if appropriate),
and procedures done before and during surgery (such as vital signs, IV lines,
and how anesthesia is administered). The other options are sensory and
process information (see Table 18-6).
During a preoperative physical examination, the nurse is alerted to the possibility of
compromised respiratory function during or after surgery in a patient with which
problem?
a. Obesity
b. Dehydration
c. Enlarged liver
d. Decreased peripheral pulses
