306 test 4

A nurse is providing preoperative teaching to a client scheduled for a cholecystectomy. Which intervention would be of highest priority in the preoperative teaching plan?

Teaching coughing and deep breathing exercises

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply 1.Contact the surgeon. 2. Instruct the client to remain quiet. 3. Prepare the client for wound closure. 4. Document the findings and actions taken 5.Place a sterile saline dressing and ice packs over the wound. 6. Place the client in a supine position without a pillow under the head.

1.Contact the surgeon. 2. Instruct the client to remain quiet. 3. Prepare the client for wound closure. 4. Document the findings and actions taken Rationale: Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. -If wound dehiscence or evisceration occurs, -the nurse should call for help, -stay with the client, -and ask another nurse to contact the surgeon and -obtain needed supplies to care for the client. -The nurse places the client in a low Fowler's position, -and the client is kept quiet, and instructed not to cough. -- Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client

Assess the patency of the airway Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? A)"If it's any help, everyone is nervous before surgery." B)"I will be happy to explain the entire surgical procedure to you." C)"Can you share with me what you've been told about your surgery?" D)"Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

C) Rationale: Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the entire surgical procedure may increase the client's anxiety. Option 4 avoids the client's anxiety and is focused on postoperative care.

The nurse in a surgical unit receives a postoperative client from the postanesthesia care unit. After the initial assessment of the client, the nurse should plan to continue with postoperative assessment activities how often?

Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed

A preoperative client has received a dose of scopolamine as prescribed by the anesthesiologist. The nurse should assess the client for which anticipated side effect of this medication?

Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils.

When a client is transferred from the post-anesthesia care unit (PACU) and arrives on the surgical unit, which should be the first action taken by the nurse?

When a client arrives on the nursing unit from the PACU, the nurse receives the client and immediately checks the client's airway status. The nurse next performs an initial assessment consisting of vital signs. The results must be compared with the vital signs last obtained in the PACU. Once this has been done, the intravenous infusion is checked and a pain, respiratory, neurological, wound, urinary, and safety assessment is performed. Oxygen is not needed for every postoperative client but may be administered to those who may have a compromised respiratory status. The nurse documents the findings including the time that the client arrived from the PACU.

a temperature of what in postoperative nursing should be of concern?

a temp of 37.7(100F) or 36.1(97F)

what urine output in postop surgery should be of concern and be reported to the HCP?

output for urine at minimum is 30ml/hr thats alarming but anything less should be immediately reported

For optimal lung expansion with the incentive spirometer, the client should assume the..

semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

before going into surgery what should the nurse have the patient do?

void

what are postoperative pulmonary issues that can happen?

atelectasis, pneumonia(retained pulmonary secretions so cough and deep breathe helps), and pulmonary emboli.

Signs and symptoms of infection include

warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. serous drainage after surgery is normal

The nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which sign that could indicate an evolving complication? A)Increasing restlessness B)A pulse of 86 beats/minute C)Blood pressure of 110/70 mm Hg D)Hypoactive bowel sounds in all four quadrants

A) increasing restlessness Rationale: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all four quadrants are a normal occurrence.

Wound dehiscence is partial or complete separation of the outer layers of the wound, sometimes described as splitting open of the wound. If this is noted, the nurse applies a?

sterile nonadherent dressing, such as a Telfa dressing or a saline dressing, to the wound and notifies the health care provider. The nurse would document the findings, but this would not be the initial action.