Post-Operative Care Instructions for Various Injuries and Conditions, Exams of Nursing

Download Post-Operative Care Instructions for Various Injuries and Conditions and more Exams Nursing in PDF only on Docsity! NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS Upon admission for an appendectomy, the patient provides the nurse with a document that specifies instructions his healthcare team should follow in the event he is unable to communicate these wishes postoperatively. This document is best known as: A. An informed consent B. An insurance card C. A Patient's Bill of Rights D. An advance directive D) An advance directive, a legal document, allows the patient to specify instructions for his or her healthcare treatment should he or she be unable to communicate these wishes postoperatively. The advance directive allows the patient to discuss his or her wishes with the family members in advance of the surgery. Two common forms of advance directives include living wills and durable powers of attorney for healthcare. When family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a patient, which response by the nurse is best? a. "This type of monitoring system is complex and highly skilled staff are needed." NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS b. "The monitoring system helps show whether blood flow to the brain is adequate." c. "The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure." d. "This monitoring system has multiple benefits including facilitation of cerebrospinal fluid drainage." ANS: B Short and simple explanations should be given to patients and family members. The other explanations are either too complicated to be easily understood or may increase the family member's anxiety. DIF: Cognitive Level: Application REF: 1438  While admitting a patient with a basal skull fracture, the nurse notes clear drainage from the patient's nose. Which of these admission orders should the nurse question? a. Insert nasogastric tube. b. Turn patient every 2 hours. c. Keep the head of bed elevated. d. Apply cold packs for facial bruising. ANS: A Rhinorrhea may indicate a dural tear with cerebrospinal fluid (CSF) leakage, and insertion of a nasogastric tube will increase the risk for infections such as meningitis. Turning the patient, elevating the head, and applying cold pack are appropriate orders. DIF: Cognitive Level: Application REF: 1440 NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient's Glasgow Coma Scale score as a. 9. b. 11. c. 13. d. 15. ANS: B The patient has a score of 3 for eye opening, 3 for best verbal response, and 5 for best motor response. DIF: Cognitive Level: Application REF: 1434  Following a head injury, an unconscious 32-year-old patient is admitted to the emergency department (ED). The patient's spouse and children stay at the patient's side and constantly ask about the treatment being given. NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS What action is best for the nurse to take? a. Ask the family to stay in the waiting room until the initial assessment is completed. b. Allow the family to stay with the patient and briefly explain all procedures to them. c. Call the family's pastor or spiritual advisor to support them while initial care is given. d. Refer the family members to the hospital counseling service to deal with their anxiety. ANS: B The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counseling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety. DIF: Cognitive Level: Application REF: 1438  An unconscious patient has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which nursing intervention will be included in the plan of care? a. Keep the head of the bed elevated to 30 degrees. b. Position the patient with the knees and hips flexed. c. Encourage coughing and deep breathing to improve oxygenation. d. Cluster nursing interventions to provide uninterrupted rest periods. ANS: A NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS The patient with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP. DIF: Cognitive Level: Application REF: 1436-1437  After noting that a patient with a head injury has clear nasal drainage, which action should the nurse take? a. Have the patient blow the nose. b. Check the nasal drainage for glucose. c. Assure the patient that rhinorrhea is normal after a head injury. NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS DIF: Cognitive Level: Application REF: 1440-1441   Which assessment information will the nurse collect to determine whether a patient is developing postconcussion syndrome? a. Muscle resistance b. Short-term memory c. Glasgow coma scale d. Pupil reaction to light ANS: B Decreased short-term memory is one indication of postconcussion syndrome. The other data may be assessed but are not indications of postconcussion syndrome. DIF: Cognitive Level: Application REF: 1440  When admitting a patient who has a tumor of the right frontal lobe, the nurse would expect to find a. judgment changes. b. expressive aphasia. c. right-sided weakness. d. difficulty swallowing. ANS: A The frontal lobes control intellectual activities such as judgment. Speech is controlled in the parietal lobe. NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS Weakness and hemiplegia occur on the contralateral side from the tumor. Swallowing is controlled by the brainstem. DIF: Cognitive Level: Application REF: 1447 | 1448 NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS  Which statement by a patient who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse? a. "I will return if I feel dizzy or nauseated." b. "I am going to drive home and go to bed." c. "I do not even remember being in an accident." d. "I can take acetaminophen (Tylenol) for my headache." ANS: B Following a head injury, the patient should avoid operating heavy machinery. Retrograde amnesia is common after a concussion. The patient can take acetaminophen for headache and should return if symptoms of increased intracranial pressure such as dizziness or nausea occur. DIF: Cognitive Level: Application REF: 1444  After having a craniectomy and left anterior fossae incision, a patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. An appropriate nursing intervention is to a. position the bed flat and log roll the patient. b. cluster nursing activities to allow longer rest periods. c. turn and reposition the patient side to side every 2 hours. d. perform range-of-motion (ROM) exercises every 4 hours. ANS: D NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS Haemophilus influenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic. DIF: Cognitive Level: Application REF: 1453-1455  While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The nursing assistant goes into the patient's room without a mask. d. The lights in the patient's room are turned off and the blinds are shut. ANS: C Meningococcal meningitis is spread by respiratory NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the food and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis. DIF: Cognitive Level: Application REF: 1453-1455  When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient has a positive Kernig's sign. b. The patient complains of having a stiff neck. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 86/42 mm Hg. ANS: D Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension. DIF: Cognitive Level: Application REF: 1452-1453  A patient has a systemic BP of 108/51 mm Hg and an NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? a. Elevate the head of the patient's bed to 60 degrees. b. Document the BP and ICP in the patient's record. c. Report the BP and ICP to the health care provider. d. Continue to monitor the patient's vital signs and ICP. ANS: C The patient's cerebral perfusion pressure is 56 mm Hg, below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take. NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS  A patient with possible cerebral edema has a serum sodium level of 115 mEq/L (115 mmol/L) and a decreasing level of consciousness (LOC) and complains of a headache. Which of these prescribed interventions should the nurse implement first? a. Draw blood for arterial blood gases (ABGs). b. Administer 5% hypertonic saline intravenously. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Send patient for computed tomography (CT) of the head. ANS: B The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intra-cranial pressure (ICP). Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly. DIF: Cognitive Level: Application REF: 1452-1455  After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? a. A patient whose cranial x-ray shows a linear skull fracture NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS b. A patient who has an initial Glasgow Coma Scale score of 13 c. A patient who lost consciousness for a few seconds after a fall d. A patient whose right pupil is 10 mm and unresponsive to light ANS: D The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation. DIF: Cognitive Level: Analysis REF: 1432-1433 | 1437-1438  Which assessment finding in a patient who was admitted the previous day with a basilar skull fracture is most important to report to the health care provider? a. Bruising under both eyes NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS b. Complaint of severe headache c. Large ecchymosis behind one ear d. Temperature of 101.5° F (38.6° C) ANS: D Patients who have basilar skull fractures are at risk for meningitis, so the elevated temperature should be reported to the health care provider. The other findings are typical of a patient with a basilar skull fracture. DIF: Cognitive Level: Application REF: 1440  When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to the health care provider? a. Oral temperature 101.6° F b. Apical pulse 102 beats/min c. Intracranial pressure 15 mm Hg d. Mean arterial pressure 90 mm Hg ANS: A Infection is a serious consideration with ICP monitoring, especially with intraventricular catheters. The temperature indicates the need for antibiotics or removal of the monitor. The ICP, arterial pressure, and apical pulse are all borderline high but require only ongoing monitoring at this time. DIF: Cognitive Level: Application REF: 1438-1440 NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS require RN-level education and scope of practice. Although repositioning patients is frequently delegated to NAP, repositioning a patient with a ventriculostomy is complex and should be done by the RN. DIF: Cognitive Level: Application REF: 1442  Which information about a patient who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? a. Intracranial pressure of 15 mm Hg b. Cerebrospinal fluid (CSF) drainage of 15 mL/hour c. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg d. Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/min ANS: C The PbtO2 should be 20 to 40 mm Hg. Lower levels NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20 to 30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO2. DIF: Cognitive Level: Application REF: 1430-1432  When caring for a patient who has had a head injury, which assessment information requires the most rapid action by the nurse? a. The patient is more difficult to arouse. b. The patient's pulse is slightly irregular. c. The patient's blood pressure increases from 120/54 to 136/62 mm Hg. d. The patient complains of a headache at pain level 5 of a 10-point scale. ANS: A The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a patient after a head injury. A slightly irregular apical pulse is not unusual. DIF: Cognitive Level: Application REF: 1431-1433 NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS  The nurse obtains these assessment findings for a patient who has a head injury. Which finding should be reported rapidly to the health care provider? a. Urine output of 800 mL in the last hour b. Intracranial pressure of 16 mm Hg when patient is turned c. Ventriculostomy drains 10 mL of cerebrospinal fluid per hour d. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg ANS: A The high urine output indicates that diabetes insipidus may be developing and interventions to prevent dehydration need to be rapidly implemented. The other data do not indicate a need for any change in therapy. DIF: Cognitive Level: Application REF: 1434-1435  NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS Having trouble? Click here for help.  Common Preoperative Medications: 1) Benzodiazepines and barbiturates: for sedation and amnesia 2) Anticholinergics: to reduce secretions 3) Opioids: to decrease intraoperative anesthetic requirements and pain 4) Additional drugs include antiemetics, antibiotics, eye drops, and regular prescription drugs  Drug Use in Pre-Op setting: Benzodiazepines and barbiturates Drug used in pre-op setting for sedation and amnesia  Drug Use in Pre-Op setting: Anticholinergics Drug used in pre-op setting to reduce secretions.  Drug Use in Pre-Op setting: Opioids Drug used in pre-op setting to decrease intraoperative anesthetic requirements and pain.  Pre-Op patients should be screened for possible critical allergies? NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS Pre-Op pts should be screened for critical allergies: Latex, Iodine, and allergies to anesthesia that may result in Malignant Hyperthermia.  In the surgical setting, where is the center of the sterile field? The center of the sterile field is the site of the surgical incision.  Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks the nurse to get up to go to the bathroom to urinate. Which of the following is the most appropriate action for the nurse to take? A.) Assist patient to bathroom and stay next to door to assist patient back to bed when done. NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS B. Allow patient to go to the bathroom since the onset of the medication will be more than 5 minutes. C. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. D. Ask patient to hold the urine for a short period of time since a urinary catheter will be placed in the operating room. C. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance.  As the nurse is preparing a patient for surgery, the patient refuses to remove a wedding ring. Which of the following is the most appropriate action by the nurse? A. Note the presence of the ring in the nurse's notes of the chart. B. Insist the patient remove the ring. C. Explain that the hospital will not be responsible for the ring. D. Tape the ring securely to the finger. C. Explain that the hospital will not be responsible for the ring. It is customary policy to tape a patient's wedding band to the finger and make a NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS D. Confusion upon arousal from anesthesia B. Muscle rigidity Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles occurring secondary to exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercarbia, and dysrhythmias may also be seen with this disorder.  Before admitting a patient to the operating room, the nurse recognizes that which of the following must be attached to the chart of all patients? A. A functional status evaluation B. Renal and liver function tests C. A physical examination report D. An electrocardiogram NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS C. A physical examination report. It is essential to have a physical examination report attached to the chart of a patient going for surgery. This document explains in detail the overall status of the patient for the surgeon and other members of the surgical team.  Which of the following nursing interventions should receive highest priority when a patient is admitted to the postanesthesia care unit? A. Positioning the patient B. Observing the operative site C. Checking the postoperative orders D. Receiving report from operating room personnel. A. Positioning the patient. A patient is received in the postanesthesia care unit on a bed or stretcher. Proper positioning is necessary to ensure airway patency in a sedated, unconscious, or semiconscious patient. Observation of the operative site, receiving report from operating room personnel, and checking postoperative orders are interventions made after proper positioning of the patient.  Which of the following may be left in place when a patient is sent to the operating room? A. Wig B. Hearing aid C. Engagement ring NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS D. Well-fitting dentures B. Hearing aid If a patient is wearing a hearing aid, the perioperative nurse should be notified. Leaving the hearing aid in place enhances communication in the operating room. The nurse should make certain to record that the appliance is in place. Wigs, engagement rings, and dentures are not necessary items to facilitate quality patient care in the operating room.  In caring for a person receiving an opioid analgesic through an epidural catheter, the nursing responsibility of prime importance is A. assessing for respiratory depression. B. establishing a baseline laboratory profile. NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS anesthesia can precipitate "spinal headache" or nausea related to losses of cerebrospinal fluid or changes in ICP. Elevating the patient's feet or administering oxygen are not necessary interventions unless the patient becomes hypotensive or hypoxic.  A nurse has requested and gotten permission to observe a surgical procedure of interest in the hospital in which the nurse is employed. While the patient is being draped, the nurse notices that a break in sterile technique occurs. Which of the following actions on the nurse's part is most appropriate? A. Tell the surgeon before an incision is made. B. Tell the circulating nurse at the end of the surgery. C. Say nothing because someone else is likely to notice also. D. Point out the observation immediately to the personnel involved. D. Point out the observation immediately to the personnel involved. Any break in sterile technique in the operating room should be immediately pointed out and remedied.  In the operating room, a patient tells a circulating nurse that he is going to have the cataract in his left eye removed. If the nurse notes that the consent form indicates that surgery is to be performed on the right eye, what should be the nurse's first action?  NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS A. Ask the patient his name. B. Notify the surgeon and anesthesiologist. C. Check to see whether the patient has received any preoperative medications. D. Assume that the patient is a little confused because he is older and has received midazolam intramuscularly. A. Ask the patient his name. Ensuring proper identification of a patient is a responsibility of all members of the surgical team. In a specialty surgical setting where many patients undergo the same type of surgery each day, such as cataract removal, it is possible that the patient and the record do not match. Nurses do not assume in the care of their patients. The priority is with the nurse identifying the patient and the patient's consent form before the physicians are notified. NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS When administering low-molecular-weight heparin (LMWH) after an operation, a nurse should A. explain that the drug will help prevent clot formation in the legs. B. check the results of the partial thromboplastin time before administration. C. administer the dose with meals to prevent GI irritation and bleeding. D. inform the patient that blood will be drawn every 6 hours to monitor the prothrombin time. A. explain that the drug will help prevent clot formation in the legs. Unfractionated heparin or LMWH is given as a prophylactic measure for venous thrombosis and pulmonary embolism. These anticoagulants work by inhibiting thrombin-mediated conversion of fibrinogen to fibrin. LMWH is injected subcutaneously with no relationship to meals. It has a more predictable dose response and less risk of bleeding complications. It does not require anticoagulant monitoring and dosage adjustments.  A physician is performing a sterile procedure at a patient's bedside. Near the end of the procedure, the nurse thinks that the physician has contaminated a sterile glove and the sterile field. The nurse should A. report the physician for violating surgical asepsis and endangering the patient. NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS B. Teaching the patient and family. A nurse should determine learning needs preoperatively and teach both the patient and the family before surgery. Using only written instructions does not provide the opportunity for evaluation for learning. Brief verbal instructions are often forgotten. Teaching only the patient limits learning preoperatively because the patient can be anxious and not receptive to new information.  Which of the following preoperative assessment findings should be reported to a surgeon for preoperative treatment? A. Excessive thirst B. Gradual weight gain C. Overwhelming fatigue D. Recurrent blurred vision NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS A. Excessive thirst. The classic clinical manifestations of diabetes mellitus are increased frequency of urination (polyuria); increased thirst and fluid intake (polydipsia); and as the disease progresses, weight loss despite increased hunger and food intake (polyphagia). Weakness, fatigue, and recurrent blurred vision are associated with diabetes mellitus but are not considered priority manifestations because of the generalization of these complaints being applied to other disease processes. Weight loss is the cardinal sign related to the depletion of water, glycogen, and triglyceride stores.  What would be the most effective way for a nurse to validate "informed consent"? A. Ask the family whether the patient understands the procedure. B. Check the chart for a completed and signed consent form. C. Ask the patient what he or she understands regarding the procedure. D. Determine from the physician what was discussed with the patient. C. Ask the patient what he or she understands regarding the procedure. Informed consent in the health care setting is a process whereby a patient is informed of the risks, benefits, and alternatives of a certain procedure, and then gives consent for it to be done. The piece of paper is simply evidence that the informed consent process has been done. NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS  If a 77-year-old patient who is NPO after surgery has dry oral mucous membranes, which of the following is the most appropriate nursing intervention? A. Increase oral fluid intake. B. Perform oral hygiene frequently. C. Swab the inside of the mouth with petroleum. D. Increase the rate of IV fluid administration. B. Perform oral hygiene frequently. Frequent oral hygiene will help alleviate discomfort for a patient who is NPO. IV fluid rate is prescribed by the physician. Petroleum is always inappropriate intraorally. Oral fluid intake is contraindicated in a patient who is NPO.  While a nurse is caring for a patient who is scheduled to have surgery in 2 hours, the patient states, "My doctor NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS C. decrease anxiety and produce amnesia of the preoperative period. D. induce sleep, so the patient will not be aware during transport to the operating room. B. decrease oral and respiratory secretions, thereby drying the mouth. Atropine, an anticholinergic medication, is frequently used preoperatively to decrease oral and respiratory secretions during surgery, and the addition of morphine will help to relieve discomfort during the preoperative procedures. Antiemetics decrease nausea and vomiting during and after surgery, and scopolamine and some benzodiazepines induce amnesia. An actual sleep state is rarely induced by preoperative medications unless an anesthetic agent is administered before the patient is transported to the operating room.  The primary goal of the circulating nurse during preparation of the operating room, transferring and positioning the patient, and assisting the anesthesia team is A. avoiding any type of injury to the patient. B. maintaining a clean environment for the patient. C. providing for patient comfort and sense of well-being. D. preventing breaks in aseptic technique by the sterile members of the team. A. avoiding any type of injury to the patient. The protection of the patient from injury in the operating room environment is maintained by the circulating nurse by ensuring functioning NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS equipment, preventing falls and injury during transport and transfer, monitoring asepsis, and being with the patient during anesthesia induction.  Conscious sedation is being considered for a patient undergoing a cervical dilation and endometrial biopsy in the health care provider's office. The patient asks the nurse, "What is this conscious sedation?" The nurse's response is based on the knowledge that conscious sedation A. can be administered only by anesthesiologists or nurse anesthetists. B. enables the patient to respond to commands and accept painful procedures. C. is so safe that it can be administered by nurses with direction from health care providers. NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS D. should never be used outside of the OR because of the risk of serious complications. B. enables the patient to respond to commands and accept painful procedures. Conscious sedation is a moderate sedation that allows the patient to manage his or her own airway and respond to commands, and yet the patient can emotionally and physically accept painful procedures. Drugs are used to provide analgesia, relieve anxiety and/or provide amnesia. It can be administered by personnel other than anesthesiologists, but nurses should be specially trained in the techniques of conscious sedation to carry out this procedure because of the high risk of complications resulting in clinical emergencies.  To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, the nurse A. encourages deep breathing. B. elevates the head of the bed. C. administers oxygen per mask. D. positions the patient in a side-lying position. D. positions the patient in a side-lying position. An unconscious or semiconscious patient should be placed in a lateral position to protect the airway from obstruction by the tongue. Deep breathing and elevation of the head of the bed are implemented to facilitate gas exchange when the patient is responsive. Oxygen administration is often used, but the patient must first have a patent airway. NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS D. postoperative pain. E. postoperative infection. A, B, C, D, & E (All of the above) Laser surgery offers the benefits of diminished bleeding, swelling, tissue damage, and postoperative pain and infection.  Select all that apply. A nurse is caring for a surgical patient in the preoperative area. The nurse obtains the patient's informed consent for the surgical procedure. Which statements are true regarding informed consent? A. Informed consent must be signed while the patient is free from mind-altering medications. B. Informed consent must be witnessed. NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS C. Informed consent may be withdrawn at any time. D. Informed consent must be signed by patients age 16 and older. E. Informed consent must be obtained by the physician. F. Informed consent must be obtained from the family even in a life-threatening emergency. A. Informed consent must be signed while the patient is free from mind-altering medications. B. Informed consent must be witnessed. An informed consent must be signed while the patient is free from mind-altering medications and must be witnessed after it has been determined that the patient has received all of the necessary information needed to make an informed decision. An informed consent may be withdrawn at any time before the procedure and must be signed by patients age 18 and older. A parent or guardian's signature is required for minors. The informed consent may be obtained by the physician or the nurse and is not required in the event of a life-threatening emergency.  Select all that apply. A nurse is caring for patients on a medical- surgical unit. The nurse plans the patients' care and instructs the nursing assistant to assist in repositioning patients every 2 hours. Which patients are at the greatest risk for complications if not repositioned properly? A. A 20-year-old unconscious patient B. A 90-year-old frail patient C. A 65-year-old patient who is visually impaired NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS D. A 40-year-old patient who has paraplegia A. A 20-year-old unconscious patient B. A 90-year-old frail patient (&) D. A 40-year-old patient who has paraplegia Patients who are at the greatest risk for complications if not properly repositioned are those who are unconscious, frail, or paralyzed.  What are some common Nursing Interventions to reduce risk/avoid post-op complications? 1. Turn & reposition the pt to promote circulation and reduce the risk of skin breakdown, especially over boney prominences. Initially position pt in a Lateral recumbant position until arousal from anesthesia, then position pt in Semi or Fowler    NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS C. The pt should take prescribed medication as directed. Sudden withdrawl of steroids can precipitate adrenal crisis. An adrenal crisis is characterized by all of the signs and symptoms except: A. weakness and fatigue B. nausea & vomiting C. hypotension D. sodium & fluid retention D. Sodium and fluid retention are characteristics of Cushing's Syndrome. Adrenal crisis causes decreased sodium levels and hypotension. Which statement about diabetes mellitus is false? A. Type 2 diabetes commonly occurs in adults <40 yr. old. B. Type 1 diabetes usually occurs before age 30. C. Type 1 diabetes is treatable with exercise, meal planning, and antidiabetic drugs. D. An increasing number of adolescents are being diagnosed with type 2 diabetes. C. Type 1 diabetes is treated with insulin and dietary management.  NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS Patients may experience which problem 24-48 hrs post- op as a result of anesthetics? A. colitis B. Stomatitis C. Paralytic ileus D. Gastrocolic reflux C. After surgery, pts are clients are at risk for paralytic ileus as a result of anesthesia. What are some common RN interventions to prevent/ minimize paralytic ileus? The nurse can prevent/minimize paralytic ileus after surgery with pt positioning and early ambulation. Evidence of bowel function returning to normal includes NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS auscultation of bowel sounds and passing of flatus and stool.  A pt has returned from surgery with a tracheostomy tube in place. After about 10 minutes in postoperative recovery, the pt begins to have noisy, increased respirations and an elevated heart rate. What action should the RN take immediately? A. Suction the tracheostomy. B. Readjust the tracheostomy tube and tighten the ties. C. Preform a complete respiratory assessment. A. Noisy, increased respiration & increased pulse are signs that the pt needs immediate suctioning to clear the airway of secretions. A complete respiratory assessment may then be completed.  A nurse is assessing a pt with a closed chest tube drainage system connected to suction. Which finding would require additional evaluation in the post-operative period? A. 75ml of bright red drainage in the system. B. A column of water 20cm high in the suction control chamber. C. Constant bubbling in the water seal chamber. D. Constant bubbling in the water seal chamber is indicative of an air leak. The nurse should assess the entire system to the pt to find the sourse of NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS A. Before the pain becomes severe. B. When the patient experiences a pain rating of 10 on a 1-to-10 pain scale. C. After the pain becomes severe and relaxation techniques have failed. D. When there is no pain, but it is time for the medication to be administered. A) The question states that the patient is being instructed on when to "request" pain medication. If a pain medication is ordered PRN, the patient should be instructed to ask for the medication before the pain becomes severe.  The nurse is preparing to send a patient to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the patient's chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS from the patient. The nurse's best action to the physician's request is to: A. Inform the physician that is his responsibility to obtain the signature. B. Obtain the signature and ask another nurse to co-sign the signature. C. Inform the physician that the nurse manager will need to obtain the signature. A) The responsibility for securing informed consent from the patient lies with the person who will perform the procedure. The nurse's best action is to inform the physician that it is his responsibility to obtain the signature.  The PACU has received a semiconscious patient from the operating room and reviews the chart for orders related to positioning of the patient. There are no specific orders on the chart related to specific orders for the patient's position. In this situation, in what position will the nurse place the patient? A. Trendelenburg position B. Prone position C. Side-lying position D. Supine position C) If the patient is not fully conscious, place the patient in the side-lying position, unless there is an ordered position on the patient's chart.  The nurse is preparing a patient for a colonoscopy. The NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS nurse is familiar with the colonoscopy procedures at the hospital and is aware that which type of anesthesia os commonly used for his procedure? A. Spinal anesthesia B. Nerve block C. Conscious sedation D. Epidural anesthesia C) Moderate sedation/analgesia is also known as conscious sedation or procedural sedation and is used for short-term and minimally invasive procedures such as a colonoscopy.  The telemetry unit nurse is reviewing laboratory results for a patient who is scheduled for an operative procedure later in the day. The nurse notes on the laboratory report that the patient has a serum potassium level of 6.5 mEq/L, indicative of hyperkalemia. The nurse informs the Please allow access to your computer’s microphone to use Voice Recording. Having trouble? for help.  NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS position: supine *avoids hip flexion *hip flexion can compress arterial flow  position: dorsal recumbent *supine + hips flexed *more comfortable (e.g. lower back pain)  position: prone     NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS *promotes hip joint extension *NOT WELL-TOLERATED w/resp. or CV problems POTENTIAL PROBLEMS: plantar flexion of foot (foot drop) and pressure points on toes place pillow under lower legs to allow for dorsiflexion of ankle+foot and to keep pressure off toes position: side lateral/ side- lying allows draining of oral secretions POTENTIAL PROBLEMS: hip joints that are internally rotated, adducted, and unsupported upper leg should be mildly flexed and rest on a pillow from groin to feet AVOID upper leg being extended and upper leg directly resting on the mattress position: knee-chest maximal visualization of rectal area position: side w/upper leg bent (Sim's) *↓ abdominal tension *allows drainage of oral secretions      NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS position: HOB elevation (Fowler's) *maximal lung expansion *↑venous return position: Fowler's 45-60 degrees position: High- Fowler's 60-90 degrees position: Semi- Fowler's 30-45 degrees position: Low- Fowler's 15-30 degrees reduces abd. pressure [except for appendectomy apparently]      NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS sterile dressing applied Renal Biopsy prone w/pillow under abdomen and shoulders during epidural puncture/ epidural patch side-lying position *epidural blood patch... An injection of a patient's own blood over the dura to repair a cerebrospinal fluid leak that may be caused by a lumbar puncture, esp. one performed with a large-bore needle. It is used to treat post-lumbar puncture headache. lower back pain -HOB = 45 -hips & knees moderately flexed -flexing knees relieves pain on sciatic nerve and disk -knees should be higher than hips for comfort -prone position should be avoided to maintain good posture orthopnea -HOB = 60 -arms resting on overhead table [from kaplan question]   NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS amputation: above-the-knee (AKA) or below-the- knee (BKA) elevated for 1st 24hrs prone 2x/day: prevents hip flexion, contractures, abduction; stretches flexor muscles promotion of mobility: ROM exercises; trapeze w/overhead frame; firm mattress; prone position q3 hrs for 20-30 minutes casted arm elevate at or above level of heart to minimize swelling delayed prosthesis fitting elevate foot of bed to elevate residual limb hasten venous return, prevent edema NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS residual limb covered with dressing with figure-eight wrapping and elastic bandage or residual limb sock; reapply bandages q4-6 hrs note if penrose drain is inserted TURNING: turn pt to prone position for short time 1st day post-op then 30 min TID to prevent hip contracture have pt roll from side to side hyperextension of residual limb active ROM (remaining leg) observe dressings for signs of excessive bleeding; keep large tourniquet on hand to apply around residual limb in event of hemorrhage; dressings changed daily until sutures removed; wrap with elastic bandage to shape, reduce  immediate prosthesis fitting *elevate residual limb for 24 hrs *rigid cast acts to control swelling residual limb covered with dressing and rigid plastic dressing Penrose drain usually not inserted rigid dressing helps prevent bleeding by compressing residual limb    NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS hiatal hernia upright position after meals (prevent reflux) hypophysectomy (pituitary gland) elevate HOB (↓ ICP) spina bifida (infant) prone; so sac doesn't rupture laminectomy (vertebral bone) *maintain body allignment *support neck (cervical laminectomy) *keep back as straight as possible *AVOID twisting of the spine & prone position *log-roll q2h w/pillow btwn legs *assess: sensation & circulatory status (esp. lower extremities) *ambulation: straight back      NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS lumbar laminectomy + spinal fusion: from supine to standing entire spine must be kept straight during the transfer NO spinal twisting, no rocking bending knees, swinging legs, using side rails will cause spine to twist laryngectomy *HOB = 30-45 degrees *to maintain airway & ↓edema lobectomy HOB = 30-45 degrees lumbar puncture (LP) **shrimp or fetal position (maximize spine flexion) **AFTER: flat (prevent headache & CSF leakage) for 4- 12hrs **sterile dressing **frequent neuro checks **headache represents excessive loss of CSF, resulting in brain settling while in upright position  NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS mastectomy *HOB ≥ 30 degrees *elevate affected arm (lymphatic return) *turn pt only on back and on unaffected side myelogram (oil-based dye) POST-OP: *flat in bed for 6-8 hrs (prevent CSF leakage) neuro checks q 2-4 hrs assess for distended bladder, encourage PO fluids oral analgesics for h/a inspect site PRE-OP: table will be moved to various positions during test npo 4-6 hrs allergy Hx phenothiazines, cns depressants, and stimulants withheld 48 hrs prior     NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS If the cord is prolapsed, cover it with sterile saline gauze to prevent drying of the cord and to minimize infection. heat stroke *UNSTABLE CONDITION* *flat, legs elevated *maintains blood flow to head *admin. O2 *air-conditioned room pulmonary edema *HOB = 30-45 degrees *promotes ventilation, relieves dyspnea pyloric stenosis *R side-lying position after meal *facilitates entry of stomach contents into intestines rectal enemas/ irrigations *L Sim's position *allows gravity to work in direction of colon *places descending colon @ lowest point    NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS irrigation set should be 12-18" above pt's rectum (too high causes rapid distention and pressure in intestine causing rapid expulsion of solution, poor defecation, and damage to mucous membranes) irrigation tube should be inserted 3-4" into pt's rectum warmth of solution should be slightly higher than body temperature (e.g. 105F [40C]) retinal detachment affected side toward bed (dependent position) to help the detached retina fall into place seizure side-lying to promote secretion drainage & prevent aspiration shock   NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS bedrest extremities elevated 20 degrees knees straight head slightly elevated (modified Trendelenburg) to promote venous return thoracentesis -position pt sitting on edge of bed -leaning over bedside table, w/feet supported -arms on pillow on over bed table -no more than 1000cc at a one time or -lying in bed on unaffected side with HOB elevated to Fowler's -prevents fluid leakage in the thoracic cavity BEFORE: vitals, shave area around needle insertion AFTER: listen for bilateral breath sounds, vitals, check leakage, sterile dressing paracentesi s semi- Fowler or sitting upright on side of bed w/feet supported (empty bladder) POST-OP:    NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS fiber diet small frequent meals total parenteral nutrition (TPN) trendelenberg during tube insertion to prevent air embolism tracheoesophageal fistula HOB = 30-45 degrees tube feeding w/ decreased LOC -R side-lying with HOB elevated -promotes emptying of stomach -prevents aspiration varicose veins elevate legs above heart to prevent pooling of blood in the legs     NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS avoid prolonged standing or sitting herniated intervertebral disk (pre-op) -HOB = 45-60 degrees -moderate hip & knee flexion -isometric exercises -traction: separates vetebrae to relieve pressure on nerve -transcutaneous electrical nerve stimulation (TENS) developmental dysplasia of the hip (p. 336) maintain abduction [via Pavlik harness] s/s limited abduction of hip w/ pain, unequal knee height w/thigh flexion uneven gluteal folds & thigh creases (deeper on affected side) shortened limb on affected side (older infants) scoliosis teach isometric exercises to strengthen abdominal muscles (functional scoliosis) osteomylitis  NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS support affected extremity w/pillows, splints to maintain proper body alignment AVOID exercise and heat application to the affected area ventriculoperitoneal shunt/ hydrocephalus Tx AFTER SHUNT PLACEMENT: position on unoperated side in FLAT position DO NOT hold infant w/head elevated (so fluid doesn't reduce too rapidly) HOB raised 15-30 degrees (if increased ICP) MONITOR FOR: abd. distention d/t fluid draining into the peritoneum increased ICP (infant)  NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS fractured hip; s/p open-reduction and internal fixation of hip affected extremity needs to be abducted @ all times (use splints, wedge pillow, or 2 or 3 pillows btwn legs) overbed trapeze to lift self onto fracture bedpan initial ambulation w/ walker; crutch walking (3- point gait); chair w/arms, wheelchair, semi- reclining toilet seat DO NOT sleep on operated side; flex hips >90 degrees; cross legs AVOID stooping; flexion position during sex; overexertion r/t walking or exercise flex hip only to 1/4 circle, can resume ADL's within 3 months of surgery (no strenuous sports) contact MD: increased pain; redness, heat, or drainage r/t hip Hip Replacement on unaffected side; maintain Abduction when in supine position w/pillow btw legs    NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS AVOID extreme internal/external rotation, aDDuction, and flexion >60 degrees of the hips, HOB >45 degrees phantom limb pain residual limb desensitization with kneading massage transcutaneous electrical nerve stimulation (TENS), ultrasound, local anesthetic s/p cataract surgery position on back in semi-Fowler's or unaffected side to prevent trauma to surgical eye *avoid water * pt will sleep on unaffected side with a night shield for 1-4 weeks squatting, knee-chest position     NCLEX CARE OF PATIENTS POST CRANIOTOMY QUIZLET QUESTIONS AND ANSWERS 2023/2024 BEST EXAM SOLUTION GRADED A+ FOR SUCCESS -for cyanotic spells (congenital heart anomalies) -mostly seen with kids -enhances systemic venous return -dilates R ventricle -↓ the obstruction ear irrigation tilt head toward affected ear (procedure) lie on affected side for drainage (after) **water that is too cool can illicit dizziness when it comes into contact w/the tympanic membrane; warm the irrigant if needed ear drops position affected ear uppermost lie on unaffected ear for absorption *pull outer ear upward & back (adult) *pull outer ear upward & down (child) eye irrigation tilt head back and toward side of affected eye allow irrigated fluid to flow from inner to outer canthus