He nurse is caring for a patient who is about to have surgery. ...

[ashley]

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.

Question 2

The nurse is caring for a patient who has pain following abdominal surgery. Which of the following are independent nursing interventions that can be used to make the patient more comfortable? (Select all that apply.)
 
  a. Encourage the patient to relax and imagine that he is resting on a tropical beach.
  b. Provide headphones so that the patient can listen to his favorite music.
  c. Increase pain medication dosage if prescribed regimen is ineffective to manage pain.
  d. Teach the patient to take pain medication before discomfort becomes severe.
  e. Switch the patient from IV to oral pain medication when bowel sounds return.
  f.
  Demonstrate the use of relaxation breathing before painful procedures.

[jjorrostieta]

Answer to Question 1

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.

Answer to Question 2

ANS: A, B, D, F
Independent nursing interventions may be carried out without an order from the physician. Changing medication orders must be done by the physician; increasing pain medication dosage and switching the patient to PO pain medications are not independent nursing interventions.