Scalpels & Safety
Your client has diminished breath sounds after abdominal surgery. What should the nurse educate the patient on?
Encourage use of the incentive spirometer and ambulation to prevent atelectasis.
This type of skin cancer is often asymmetrical, irregularly shaped, and may ulcerate or bleed
Asymmetry, irregular borders, varied pigmentation, and potential ulceration or bleeding characterize melanoma.
The recommended compression depth for adults during CPR.
At least 2 inches (5 cm)
Identify three priority assessments during the postoperative phase.
Airway and Breathing
Anesthesia can depress respiratory drive and compromise airway patency. Monitoring for airway obstruction (e.g., due to the tongue falling back), respiratory rate, and oxygen saturation ensures adequate ventilation and prevents hypoxia.
Circulation
Postoperative patients are at risk for hemorrhage, hypovolemia, and shock. Monitoring blood pressure, heart rate, skin color, and capillary refill helps detect early signs of circulatory compromise and ensures tissue perfusion.
Neurological Status
Assessing level of consciousness and orientation helps determine the patient’s recovery from anesthesia and detect potential complications such as stroke, delayed emergence, or over-sedation.
Urinary Output
Urinary retention is a common postoperative issue due to anesthesia, immobility, or pain. Monitoring for spontaneous voiding and measuring urine output helps assess renal perfusion, fluid balance, and detect complications like retention or acute kidney injury.
A patient presents with fatigue and constipation, a calcium level of 12.2 mg/dL, and ECG findings of a shortened QT interval. What electrolyte imbalance is occurring, and identify at least two appropriate interventions to support this patient?
Hypercalcemia
Administer IV normal saline to promote hydration and increase calcium excretion.
Give a loop diuretic (e.g., furosemide) to enhance renal calcium excretion.
Calcitonin inhibits bone resorption and increases renal calcium excretion.
Bisphosphonates inhibit osteoclast activity to prevent further calcium release from bone.
Cardiac Monitoring is important to assess for potential complications of shortened QT intervals, dysrhythmias, and heart block.
A post-operative patient requires CPR with compressions and ventilations, but no advanced airway is in place. What is the recommended rate for chest compressions?
100–120 compressions per minute
Maintaining this body parameter during surgery helps prevent infection and bleeding.
Normothermia
A patient tests positive for a BRCA1 mutation. What types of cancer this patient is at increased risk for.
Breast cancer, prostate cancer, pancreatic cancer
In a client with an advanced airway in place during CPR, what is the correct compression-to-ventilation ratio?
Continuous compressions with 1 breath every 6 seconds. With an advanced airway, compressions should be uninterrupted while ventilations are delivered every 6 seconds.
During the time-out, the nurse notices the consent says 'left knee,' but the surgeon marked the right knee. What should the nurse do?
Stop the procedure until the discrepancy is resolved.
A patient with pancreatic cancer is scheduled to start radiation therapy. Identify three key education points the nurse should include to prepare the patient.
Skin care at the treatment site: keep the area clean and avoid irritants.
Managing fatigue: plan for rest periods and energy conservation.
Monitoring for side effects: such as nausea, vomiting, diarrhea, or changes in appetite, and when to notify the healthcare provider.
What is the priority nursing action for a patient presenting with snoring and cyanosis?
Perform the Head tilt–chin lift to restore airway patency.
This type of sedation depresses the patient’s consciousness but allows them to maintain their own airway and respond to verbal commands, commonly used for endoscopy.
Moderate (conscious) sedation
During surgery, a patient under general anesthesia develops rapidly rising body temperature, muscle rigidity, tachycardia, and dark urine. The perioperative nurse suspects a rare but life-threatening condition triggered by certain anesthetic agents.
Malignant hyperthermia
The recommended compression-to-ventilation ratio for single-rescuer adult CPR.
30:2