The nurse is assigned to care for several patients on the ...

[MirandaLo]

The nurse is assigned to care for several patients on the surgical unit. Which patient need will the nurse address first?
 
  a. A patient who is waiting for discharge teaching before going home
  b. A patient who needs to be ambulated for the first time postoperatively
  c. A patient who has not voided since the catheter was removed 8 hours ago
  d. A patient who requires a daily dressing change to the surgical incision

Question 2

The nurse is caring for a patient who is headed to the operating room for abdominal surgery. Which goal is appropriate for the nursing diagnosis risk for Perioperative positioning injury?
 
  a. Patient will deny numbness or tingling in extremities after surgical procedure.
  b. Patient will maintain urine output of at least 30 mL/hour during and after surgery.
  c. Patient will maintain elastic skin turgor as well as moist tongue and mucus membranes.
  d. Patient will have no emesis and deny nausea following arousal from general anesthesia.

[swimkari]

Answer to Question 1

ANS: C
Urinary retention is common after removal of urinary catheters and must be addressed promptly. The nurse should address the patient with urinary retention first because it is the highest priority. The other patients may wait until later.

Answer to Question 2

ANS: A
Numbness and tingling of extremities may be indicative of injury following improper positioning for surgery. The other goals do not relate to positioning injury but relate to nursing diagnoses of Fluid balance and Nausea.

[MirandaLo]

Thank you!

[swimkari]

Always glad to help...