Obtain a cuff that covers the upper one-third of the client’s arm.
Position the cuff approximately 4 inches above the antecubital arm.
Use a cuff that is wide enough to cover the upper two-thirds of the client’s arm.
Identify the Korotkoff sounds, and take a systolic reading at 10 mmHg after the first sound.
Platelet count of 250,000/cu.mm.
Total cholesterol of 325 mg/dl.
Blood urea nitrogen (BUN)) 17 mg/dl.
Hemoglobin 9.5 mg/dl.
Turn, cough, and deep breathe every 30 minutes around the clock.
Get the client out of bed and ambulate to a bedside chair.
Provide a passive range of motion three times a day.
It is not necessary to worry about complications of immobility on the first postoperative day.
Start administration of oxygen through a nasal cannula.
Call for assistance.
Reposition the head and determine patency of the airway.
Insert an oral airway and suction the nasopharynx.
Remove all jewelry or tape wedding ring.
Verify that all laboratory work is complete.
Inform family or next of kin.
Have all consent forms signed.
1, 2, 3, 4
2, 3, 1, 4
2, 1, 4, 3
4, 3, 2, 1
Full liquid diet
“After surgery, I will need to wear the pneumatic compression device while sitting in the chair.”
“The skin prep area is going to be longer and wider than the anticipated incision.”
“I cannot have anything to drink or eat after midnight on the night before the surgery.”
“To ensure my safety, a ‘time out’ will be conducted in the operating room.”
To prevent malnutrition.
To prevent electrolyte imbalance.
To prevent aspiration pneumonia..
To prevent intestinal obstruction.
Before administration of preoperative medications.
The afternoon or evening prior to surgery.
Several days prior to surgery.
Upon admission of the client in the recovery room.
The patient is of legal age with a proper mental disposition.
If the patient is a child, secure consent from the parents or legal guardian.
The consent is secured before administration of preoperative medications.
If the patient is unable to write, the nurse signs the consent for the patient.
The patient is unconscious.
The patient is awake.
The patient experiences slight pain.
The patient experiences loss of sensation in the lower half of the body.
The obese patient with a long history of smoking who had undergone upper abdominal surgery.
The patient with a normal pulmonary function who had undergone upper abdominal surgery.
An adolescent patient with diabetes mellitus who had undergone cholecystectomy.
A football player who had undergone knee replacement surgery.
Flat on the bed for 6 to 8 hours.
Modified Trendelenburg position.
Assessing the patient’s level of consciousness.
Checking the patient’s vital signs.
Checking the patient’s identification and correct operative permit.
Positioning and performing skin preparation to the patient.
The time of the return of motion and sensation in the patient’s legs and toes.
The character of the patient’s respiration.
The patient’s level of consciousness.
The amount of wound drainage.
To prevent muscle injury.
To prevent sudden drop of blood pressure.
To prevent respiratory distress.
To promote comfort.
The patient pushes out the oral airway with his tongue.
The patient’s urine output has been 20 ml/hr for the past 2 hours.
The patient’s vital signs are as follows: BP = 100/70 mmHg; PR = 95 bpm; RR = 9 minute; T = 36.8°C.
The patient’s wound drainage.
Fast, thready pulse, bradypnea.
Apprehension and restlessness.
Cover the wound with sterile gauze moistened with sterile normal saline.
Cover the wound with sterile dry gauze.
Cover the wound with a water-soaked gauze.
Leave the wound uncovered and pull the skin edges together.
Administer the ordered analgesic.
Instruct the patient to do deep breathing and coughing exercises.
Assess the patient’s pain level and vital signs.
Change the patient’s position.