A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.)
a. All phases require the client to be in the hospital.
b. Phase I care may last for several days in some clients.
c. Phase I requires intensive care unit monitoring.
d. Phase II ends when the client is stable and awake.
e. Vital signs may be taken only once a day in phase III.
ANS: B, D, E
There are three phases of postoperative care. Phase I is the most intense, with clients coming right from surgery until they are completely awake and hemodynamically stable. This may take hours or days and can occur in the intensive care unit or the postoperative care unit. Phase II ends when the client is at a presurgical level of consciousness and baseline oxygen saturation, and vital signs are stable. Phase III involves the extended care environment and may continue at home or in an extended care facility if needed.
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a. This is inappropriate delegation; the nurse should always take the vital signs. b. Have the NAP repeat the measurement if vital signs appear abnormal. c. The nurse should review and interpret the vital sign measurements. d. This task has been delegated so the nurse is not responsible.
Which is the best position to place the patient in to assess the lungs?
1) Supine 2) Prone 3) Fowler's 4) Side-lying
When a new patient is hospitalized, a nurse takes the patient on a tour, explains the rules of the unit, and discusses the daily schedule. The nurse is engaged in:
a. counseling. b. health teaching. c. milieu management. d. psychobiologic intervention.
To assess a client's blood pressure by auscultation, the nurse:
a. Records the pressure at the second Korotkoff sound as the diastolic blood pressure. b. Inflates the cuff until the radial pulse is felt faintly with the fingertips. c. Records the pressure of the first Korotkoff sound as the systolic pressure. d. Records the number of pulsations heard between the first and fifth Korotkoff sounds.