Lloyd Bennett Surgical Scenario 5-vSim for Nursing EXAM STUDY GUIDE WITH VERIFIED SOLUTIONS

T or False? A patient who has had a fractured hip surgically repaired should be positioned with a wedge pillow between the legs to promote abduction. True. Rationale: Because of the risk of hip dislocation after hip arthroplasty with a posterior or posterolateral approach, maintaining proper patient positioning is essential. The patient should be in a supine position with his or her head slightly elevated and the affected leg in a neutral position. The use of an abduction splint, a wedge pillow, or two or three pillows placed between the legs prevents adduction beyond the midline of the body. Which of the following are appropriate interventions to prevent deep vein thrombosis postoperatively in a patient who has undergone hip arthroplasty? (Select all that apply.) Anti-embolism stockings Hip flexion (pillow under knee) Pneumatic compression device Prophylactic anticoagulants Ankle exercises 1-Anti-Embolism Stockings 2-Ankle Exercises 3-Pneumatic Compression Device 4-Prophylactic Anticoagulant Rationale: To prevent deep vein thrombosis (DVT), the nurse should encourage intake of fluids as well as ankle and foot exercises. The nurse may administer prophylactic anticoagulants or use anti-embolic stockings and a pneumatic compression device as ordered. Hip flexion is avoided to prevent dislocation of hip prosthesis. Brainpower Read More Previous Play Next Rewind 10 seconds Move forward 10 seconds Unmute 0:00 / 0:00 Full screen Which of the following does the nurse know is the most dangerous type of blood transfusion reaction? Acute hemolytic. Rationale: The most dangerous and potentially life-threatening type of transfusion reaction is an acute hemolytic reaction. This reaction occurs when the donor blood is incompatible with the recipient's, causing the recipient's antibodies to rapidly destroy the donor red blood cells. Which nursing action is appropriate before administering a unit of packed red blood cells? Educate the patient on the signs and symptoms of a blood reaction. Rationale: The nurse explains the procedure to the patient and instructs the patient on the signs and symptoms of a reaction. An IV, 20-gauge or larger, is used in a large vein. An inline blood warmer can be used in certain situations to maintain body temperature but is not required for all transfusions. The blood container should not be vented. The nurse must constantly monitor a patient receiving a blood transfusion to ensure that there are no reactions or complications. Which of the following are signs and symptoms of a blood transfusion reaction? (Select all that apply.) Fever, chills, or rigors Dyspnea Nausea Hypothermia Low back pain Dyspnea Nausea Fever, Chills, Or Rigors Low Back Pain. Rationale: Signs and symptoms of a transfusion reaction include fever, chills, respiratory distress, low back pain, nausea, pain at the IV site, or anything "unusual." Symptoms of an acute hemolytic reaction consist of fever, chills, low back pain, nausea, chest tightness, dyspnea, and anxiety. In a patient experiencing blood loss during surgery, in what direction would the nurse expect the postoperative hemoglobin level to change from the preoperative level? Decrease from preoperative level. Rationale: It is common to lose blood during this surgery. As the individual loses blood, the hemoglobin will decrease. Which of the following actions should the nurse avoid when preparing for a blood transfusion? Add the prescribed antibiotic to the blood container to reduce infection. Rationale: Medications are never added to the blood. The nurse verifies that the patient has signed a written consent. Special tubing that contains a blood filter to screen out fibrin clots and other particulate matter is used. The blood label, record, and identification are checked with another nurse or a physician.