Mrs. Hogan returns to your clinical unit following discharge from the recovery room. Her vital signs are stable and her family is with her. Postoperative leg exercises should be initiated:
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Solution
stat
Option D: Leg exercises, deep breathing and coughing, moving, and turning should begin as soon as the client’s condition is stable.
Option B: The family can be extremely helpful in encouraging the client to do them, in supporting the incision, etc.
Option A: A doctor’s order is not necessary – this is a nursing responsibility.
Mrs. Hogan is transported to the recovery room following her cholecystectomy. As you continue to check her vital signs you note a continuing trend in Mrs. Hogan’s status: her BP is gradually dropping and her pulse rate is increasing. Your most appropriate nursing action is to:
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Solution
immediately report signs of shock to the head nurse and/or surgeon and monitor VS closely
Option C: These are signs of impending shock, which may be true shock or a reaction to anesthesia. Your most appropriate action is to report your findings quickly and accurately and to continue to monitor Mrs. Hogan carefully.
Mrs. Hogan is scheduled for surgery 2 days later and is to be given atropine 0.3 mg IM and Demerol 50 mg IM one hour preoperatively. Which nursing actions follow the giving of the pre op medication?
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Solution
allow her family to be with her before the medication takes effect
Options A, C, and D: These should all take place prior to administration of the drugs. The family may also be involved earlier but certainly should have that time immediately after the medication is given and before it takes full effect to be with their loved ones. Good planning of nursing care can facilitate this.
On the morning of Mrs. Hogan’s planned cholecystectomy, she awakens with a pain in her right scapular area and thinks she slept in poor position. While doing the pre-op checklist, you note that on her routine CB report, her WBC is 15,000. Your responsibility at this point is:
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Solution
to notify the surgeon at once; this is an elevated WBC indicating an inflammatory reaction
Option A: A WBC count of 15,000 probably indicates acute cholecystitis, especially considering Mrs. Hogan’s new pain. The surgeon should be called as he/she may treat the acute attack medically and delay the surgery for several days, weeks, or months.
Mrs. Hogan, a 43-year-old woman, is admitted to your unit for cholecystectomy.
You are responsible for teaching Mrs. Hogan deep breathing and coughing exercises. Why are these exercises especially important for Mrs. Hogan?
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Solution
the incision in gallbladder surgery is in the subcostal area, which makes the client reluctant to take a deep breath and cough
Option A: This is true: the rationale for deep breathing and coughing is to prevent postoperative pulmonary complications such as pneumonia and atelectasis.
Option B: The risk of pulmonary problems is somewhat increased in clients with biliary tract surgery because of their high abdominal incisions.
Option C: This assumes the stereotype of the person with gallbladder disease – fair, fat and forty – which is not necessarily the case. Splinting the incision with the hands or a pillow is very helpful in controlling the pain during coughing.
Potential post intracranial surgery problems include all but which of the following?
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Solution
extracranial hemorrhage
Option B: Hemorrhage is predominantly intracranial, although there may be some bloody drainage on external dressings.
Option A: Increased ICP may result from hemorrhage or edema.
Option D: CSF leakage may result in meningitis.
Option C: Seizures are another postoperative concern.
Postoperatively Mr. Snyder needs vigilant nursing care including all of the following except:
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Solution
Keeping his head flat
Option A: Postoperatively clients who have undergone craniotomy usually have their heads elevated to decrease local edema and also decrease ICP.
Mr. Snyder is scheduled for surgery in the morning, and you are surprised to find out that there is no order for an enema. You assess the situation and conclude that the reason for this is
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Solution
Straining to evacuate the enema might increase the intracranial pressure
Option B: Any activity that increases ICP could possibly cause brain herniation. Straining to expel an enema is one example of how the increased ICP can be further aggravated.
Whether Mr. Snyder’s tumor is benign or malignant, it will eventually cause increased intracranial pressure. Signs and symptoms of increasing intracranial pressure may include all of the following except:
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Solution
increased pulse rate, drop in blood pressure
Option D: As ICP increases, the pulse rate decreases and the BP rise. However, as ICP continues to rise, vital signs may vary considerably.
Acoustic neuromas produce symptoms of progressive nerve deafness, tinnitus, and vertigo due to pressure and eventual destruction of:
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Solution
CN8
Option C: CN8, the acoustic nerve or vestibulocochlear nerve, is the most commonly affected CN in acoustic neuroma.
Options A and B: As the tumor progresses, CN5 and CN7 can be affected.