surgicalRnurseRobtainsRaRcompleteRsetRofRvitalRsigns.RWhatRisRtheRrationaleRforRthisRnursingR action?
a. ThisRisRdoneRtoRcompleteRtheRfirstRactionRinRaRhead-to-toeR assessment.
ThisRisRdoneRtoRcompareRandRmonitorRforRvitalRsignRvariationRduring
b. transport.
ThisRisRdoneRtoRensureRthatRtheRmedical-surgicalRnurseRchecksRonRthe
c. postoperativeRpatient.
ThisRisRdoneRtoRfollow RhospitalRpolicyRandRprocedureRforRcareRofRthe
d. surgicalRpatient.
ANS:RB
BeforeRtheRPACURnurseRleavesRtheRacuteRcareRarea,RtheRstaffRnurseRassumingRcareRforRtheRpatientRtakesRaR completeRsetRofRvitalRsignsRtoRcompareRwithRPACURfindings. RMinorRvitalRsignRvariationsRnormallyRoccurRafter
transportingRtheRpatient.RTheRPACURnurseRreviewsRtheRpatient’sRinformationRwithRtheRmedical-
surgicalRnurse,RincludingRtheRsurgicalRandRPACURcourse,RphysicianRorders,RandRtheRpatient’sRcondition. RWhileRvitalRsignsRmayRorRmayRnotRbeRtheRfirstRactionRinRaRhead-to-
toeRassessment,RthisRisRnotRtheRrationaleRforRthisRsituation.RWhileRfollowingRpolicyRorRascertainingRthatRtheRfloorRnurseRchecksRonRtheRpatientRareRgoodRreasonsRforRsafeRcare,RtheyRareRnotRtheRbestRrationaleRforRobtainingRvitalR
signs.
2. TheRnurseRisRcaringRforRaRpatientRwhoRwillRundergoRaRremovalRofRaRlungRlobe.RWhichRlevelRofRcareRwillRthepatientRrequireRimmediatelyRpostRprocedure?
a. AcuteRcare—medical-surgicalRunit
b. AcuteRcare—intensiveRcareRunit
c. AmbulatoryRsurgery
d. AmbulatoryRsurgery—extendedRstay
ANS:RB
PatientsRundergoingRextensiveRsurgeryRandRrequiringRanesthesiaRofRlongRdurationRrecoverRslowly.RIfRaRpatientRisRundergoingRmajorRsurgeryRsuchRasRaRprocedureRonRtheRlung,RaRstayRinRtheRhospitalRandRspecificallyRinRtheRinten
siveRcareRunitRisRrequiredRtoRmonitorRforRpotentialRrisksRtoRwell-being.RThisRpatientRwouldRrequireRmoreRcareRthanRcanRbeRprovidedRonRaRmedical-
surgicalRunit.RItRisRnotRappropriateRforRthisRtypeRofRpatientRtoRgoRhomeRafterRtheRprocedureRorRtoRstayRinRanRextendedRstayRareaRofRanRambulatoryRsurgeryRareaRbecauseRofRtheRcomplexityRandR associatedRrisks.
,3. TheRnurseRisRcaringRforRaRgroupRofRpatients.RWhichRpatientRwillRtheRnurseRseeRfirst?
a. ARpatientRwhoRhadRcataractRsurgeryRisR coughing.
ARpatientRwhoRhadRvascularRrepairRofRtheRrightRlegRisRnotRdoingRrightRleg
b. exercises.
ARpatientRafterRkneeRsurgeryRisRwearingRintermittentRpneumatic
c. compressionRdevicesRandRreceivingRheparin.
326
, A RpatientRafterRsurgeryRhasRvitalRsignsRtakenReveryR15RminutesRtwice,
d. everyR30RminutesRtwice,RhourlyRforR2 RhoursRthenReveryR4R hours.
ANS:RA
ForRpatientsRwhoRhaveRhadReye,Rintracranial,RorRspinalRsurgery,RcoughingRmayRbeRcontraindicatedRbecauseRofRtheRpotentialRincreaseRinRintraocularRorRintracranialRpressure. RTheRnurseRwillRneedRtoRseeRthisRpatientRfirstRtoRcontrolRt
heRcoughRandRintraocularRpressure.RAllRtheRrestRareRnormalRpostoperativeR patients.RLegRexerciseRshouldRnotRbeR performedRonRtheRoperativeRlegRwithRvascularRsurgery.RARpatientRafterRkneeRsurgeryRshouldRreceiveR heparinRandR beRwe
aringRintermittentRpneumaticRcompressionRdevices;RwhileRtheRnurseRwillR checkRonRtheRpatient,RitRdoesRnotRhaveRtoRbeRfirst.RMonitoringRvitalRsignsRafterRsurgeryRisRrequiredRandRthisRisRtheRstandardRschedule.
4. TheRnurseRdemonstratesRpostoperativeRexercisesRforRaRpatient.RInRwhichRorderRwillRtheRnurseRinstructRthepatientRtoRperformRtheRexercises?
1. Turning
2. Breathing
3. Coughing
4. LegRexercises
a. 4,R1,R2,R3
b. 1,R2,R3,R4
c. 2,R3,R4,R1
d. 3,R1,R4,R2
ANS:RA
TheRsequenceRofRexercisesRisRlegRexercises,Rturning,Rbreathing,RandRcoughing. RMULTIPL
ERRESPONSE
1. TheR nurseR isR participatingR inR aR “time-out.”RInRwhichR activitiesRwillR theR nurseR beR involved?R (SelectRallthatR apply.)
a. VerifyRtheRcorrectRsite.
b. VerifyRtheRcorrectRpatient.
c. VerifyRtheRcorrectR procedure.
d. PerformR“time-out”R afterR surgery.
e. PerformRtheRactualRmarkingRofRtheRoperativeRsite.
ANS:RA,R B,R C