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.
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