PerioPerative Care Case study 2023 Latest QuestioNs aNd aNsWers Graded a+

The nurse begins the preoperative assessment by taking Ms. Jackson's vital signs. 1. Which vital sign requires follow-up by the nurse? A) BP of 160/88. B) Pulse of 68. C) Respirations of 14. D) Temperature of 97.2° F. - ANSWER A) BP of 160/88. This blood pressure is elevated and requires further action by the nurse. The nurse reviews the medications taken by Ms. Jackson. Ms. Jackson states she has been taking two medications, hydrochlorothiazide (Hydrodiuril), a diuretic, and warfarin (Coumadin), an anticoagulant, every day for over a year. 2. What nursing action is most important? A) Observe the appearance of the client's oral mucosa. B) Assess the client for any signs of excessive bruising. C) Review common side effects of each of the medications. D) Explain the need to hold the warfarin prior to surgery. - ANSWER D) Explain the need to hold the warfarin prior to surgery. Anticoagulants increase the risk for bleeding during surgery and the postoperative period, so the nurse must explain the need to hold the warfarin prior to surgery and instruct the client to contact the surgeon to determine how long before surgery the medication should be stopped.