Author Question: The nurse is concerned about the skin integrity of the patient in the intraoperative phase of ... (Read 90 times)

cmoore54 · **on:** Jul 22, 2018

The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which of the following actions helps to minimize skin breakdown?

a. Encouraging the patient to bathe before surgery
b. Securing attachments to the operating table with foam padding
c. Periodically adjusting the patient during the surgical procedure
d. Measuring the time a patient is in one position during surgery

Question 2

The client appears to be breathing faster than before. Which of the following actions should the nurse take first?

a. Ask the client if there have been any stressful visitors.
b. Have the client lie down.
c. Count the rate of respirations.
d. Take the radial pulse.

stanleka1 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
Although it may be necessary to place a patient in an unusual position, try to maintain correct alignment and protect the patient from pressure, abrasion, and other injuries. Special mattresses, use of foam padding, and attachments to the operating suite table provide protection for the extremities and bony prominences. Bathing before surgery helps to decrease the number of microbes on the skin. Periodically adjusting the patient during the surgical procedure is impractical and can present a safety issue with regard to maintaining sterility of the field and maintaining an airway. Measuring the time the patient is in one position may help with monitoring the situation but does not prevent skin breakdown.

Answer to Question 2

C
The first action the nurse should take is to assess the client's respiratory rate. The nurse can then determine if it is within normal limits, and will be able to compare it with the previous measure-ment to determine if the client is breathing faster than before.
Stress may increase an individual's respiratory depth and rate as a result of sympathetic stimula-tion.
Lying flat prevents full chest expansion.
The nurse should count the respirations. Based on these findings, the nurse may or may not need to take the client's pulse. Assessing the pulse will not verify whether the client is breathing faster than before.