Chapter 37 Perioperative Nursing Care NCLEX Style Questions Rated 100% Correct!!

he nurse is caring for a patient who is about to have surgery. Which intervention will be included in the patient's care to meet the goals for Risk for perioperative positioning injury r/t immobilization during surgical procedure? a. Orient the patient to the OR environment and place the call light within reach. b. Watch for early signs of hypovolemia caused by patient's NPO status since midnight. c. Use therapeutic touch and guided imagery to allay patient's fears of surgery. d. Pad all bony prominences and avoid hyperextension of extremities. - ANS: D Risk for perioperative positioning injury is addressed by ensuring that the patient's skin and bony prominences are well padded during the surgery. In addition, hyperextension of extremities may lead to joint damage, so this should be avoided as well. The other interventions are appropriate for perioperative care but do not relate directly to the nursing diagnosis of positioning injury potential. The nurse is caring for a male patient who will soon have open heart surgery. The patient's chest is covered with thick hair so the surgical technician comes in to shave the patient's skin near the operative site. Which action by the technician requires intervention by the nurse to correct the technique? a. A straight safety razor and antibiotic foam is used b. Disposable electric trimmers are used to trim the hair c. Antibacterial soap is used prior to hair removal d. Only the hair directly around the surgical site is removed - ANS: A Disposable electric trimmers should be used to remove excess hair from operativesites. Antibacterial soap is commonly used to clean the skin before surgical procedures. Only the hair around the surgical site is removed. A straight razor should never be used because small nicks in the skin can occur, increasing infection risk. The nurse is caring for a patient who has just been brought to the postoperative unit following major surgery. The patient has many tubes and monitors in place. Which will the nurse assess first? a. The patient's intravenous lines b. The patient's urinary catheter c. The patient's nasogastric tube d. The patient's endotracheal tube - ANS: D