An oncology patient has just returned from the postanesthesia care unit after an open hemicolectomy. This patient's plan of nursing care should prioritize which of the following?
A) Assess the patient hourly for signs of compartment syndrome.
B) Assess the patient's fine motor skills once per shift.
C) Assess the patient's wound for dehiscence every 4 hours.
D) Maintain the patient's head of bed at 45 degrees or more at all times.
Ans: C
Feedback:
Postoperatively, the nurse assesses the patient's responses to the surgery and monitors the patient for possible complications, such as infection, bleeding, thrombophlebitis, wound dehiscence, fluid and electrolyte imbalance, and organ dysfunction. Fine motor skills are unlikely to be affected by surgery and compartment syndrome is a complication of fracture casting, not abdominal surgery. There is no need to maintain a high head of bed.
You might also like to view...
A woman is not progressing in her labor. She is to be administered oxytocin. What is the goal of oxytocin therapy?
A) Prevent postpartum bleeding B) Decrease fetal hyperactivity C) 3–4 contractions every 10 minutes D) Diminished periods of relaxation
Which statement about the biomedical health belief system is true?
a. Life processes can be manipulated by human beings by mechanical interventions. b. Life processes cannot be manipulated by human beings by mechanical interventions. c. Disease has a nonspecific cause, onset, course, and treatment. d. Disease is only caused by failure of body parts and chemical imbalances.
Which of the following represents a major philosophy of the hospice concept?
A. Improving the quality of life for a client with a terminal illness B. Assisting the family of a terminally ill client to grieve more efficiently C. Ensuring that a terminally ill client is never alone D. Removing the stigma of death
The community health nurse is caring for a client who is living in persistent poverty. Which of the following best describes this client?
a. Severe mental illness b. Transient homelessness c. Victim of domestic violence d. Temporary housing