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In the post-operative period following the repair of a cleft palate, the nurse places the client in the side-lying position. The mother questions why. The nurse’s response is based on the know that this position:
a. Allows for observation of the suture line
b. Will allow the client to relax
c. Will allow for drainage
d. Allows for the best method for fluid intake
- Correct: C
- Rationale: In the initial period following a cleft palate repair, the nurse should anticipateincreased salivation, which can increase the client’s risk for aspiration. Placing a client in theside-lying position, will maintain an open airway and allow for drainage of oral secretions.
While performing the pre-operative check list on a client, the nurse notes that theclient is having difficulty paying attention, increased heart rate and respirations andhas sweaty palms with trembling hands. The client states, “All I can think about isthe surgery and I keep wondering if everything will go alright.” Based on theinformation provided the nurse should classify the client’s anxiety at:
- Correct: C
- Rationale: The client in this scenario is displaying obvious signs of sympathetic nervous systemstimulation. With the addition of client statements regarding the surgical procedure, the nurseshould classify their anxiety as severe.
While preforming the discharge assessment on the client 2 day post opencholecystectomy, the nurse notes tachypnea, restlessness and hemoptysis. The nurseshould:
a. Evaluate the clients white blood cell count
b. Check client’s records for a positive TB test
c. Document findings, as physician assess client 45 minutes prior and determined the client was ready for discharge
d. Contact primary health care provider and report findings
- Correct: D
- Rationale: The client in the scenario is exhibiting potential signs of pulmonary embolism, apotential post-operative complication. It is possible that the client was not exhibiting theseclinical manifestations previously and therefore the physician should be notified.
Discuss the degree of risk of surgery.
- 1.Major – involves a high degree of risk for a variety reasons; It may be complicated or prolonged, large losses of blood may occur, vital organs may be involved, or postoperative complications are possible.
- 2.Minor – normally involves little risk, produces few complications, and is often performed in an outpatient setting.