Adult Nursing - Chapter 19: Postoperative Nursing Management - PrepU

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for? - Hypotension - Contractures - Phlebitis - Wound dehiscence

- Wound dehiscence

Which is a classic sign of hypovolemic shock? - Bradypnea - Pallor - Dilute urine - High blood pressure

- Pallor

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? - Hypoxemia - Pulmonary edema - Pleurisy - Pneumonia

- Pneumonia

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse? - Obtain an emesis basin. - Administer an anti-emetic. - Position the client in the side-lying position. - Ask the client for more clarification.

- Position the client in the side-lying position.

The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus? - Abdominal tightness - Abdominal distention - Absence of peristalsis - Increased abdominal girth

- Absence of peristalsis

The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by: - Second intention - Granulation - First intention - Third intention

- First intention

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? - First intention - Third intention - Fourth intention - Second intention

- First intention

The nurse observes that a post-surgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? - Reinforcing dressings or applying pressure if bleeding is frank - Encouraging the client to breathe deeply - Rubbing the back - Elevating the head of the bed

- Reinforcing dressings or applying pressure if bleeding is frank

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client? - The client should be transferred to an intensive care area. - The client can be discharged from the PACU. - The client must remain in the PACU. - The client must be put on immediate life support.

- The client can be discharged from the PACU.

A client vomits postoperatively. What is the most important nursing intervention? - Measure the amount of vomitus to estimate fluid loss, in order to accurately monitor fluid balance. - Offer tepid water and juices to replace lost fluids and electrolytes. - Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs. - Support the wound area so that unnecessary strain will not disrupt the integrity of the incision.

- Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what? - Urine retention - Calculus formation - Urinary infection - Requirement of intermittent catheterization

- Urine retention

The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply. - Watching television - Listening to music - Changing position - An On-Q pump - An epidural infusion

- Watching television - Listening to music - Changing position

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: - palpate the abdomen. - auscultate bowel sounds. - insert a rectal tube. - change the client's position.

- auscultate bowel sounds.

When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as - contaminated. - clean contaminated. - dirty. - clean.

- clean contaminated.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: - third intention. - fourth intention. - first intention. - second intention.

- first intention.

The primary objective in the immediate postoperative period is - maintaining pulmonary ventilation. - relieving pain. - controlling nausea and vomiting. - monitoring for hypotension.

- maintaining pulmonary ventilation.

The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order? - omeprazole (Prilosec) - ondansetron (Zofran) - ranitidine (Zantac) - chlorpromazine (Thorazine)

- ondansetron (Zofran)

What measurement should the nurse report to the physician in the immediate postoperative period? - Respirations between 20 and 25 breaths/min - A temperature reading between 97°F and 98°F - A systolic blood pressure lower than 90 mm Hg - A hemoglobin of 13.6

- A systolic blood pressure lower than 90 mm Hg

A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse? - "The drain will remove necrotic tissue." - "Most surgeons use wound drains now." - "It assists in preventing infection." - "It will cut down on the number of dressing changes needed."

- "It assists in preventing infection."

Using the PACU room scoring guide, a nurse would give a patient an admission cardiovascular score of 2 if the patient's blood pressure is what percentage of his or her preanesthetic level? - Greater than 50% - 20% - 30% to 40% - 40% to 50%

- 20%

The nurse is preparing to discharge a patient from the PACU using a PACU room scoring guide. With what score can the patient be transferred out of the recovery room? - 6 - 8 - 5 - 7

- 8

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? - >200 mL - Between 100 and 200 mL - <30 mL - Between 75 and 100 mL

- <30 mL

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates teaching has been ineffective? - "My incision should become less red and tender." - "I need to keep my follow-up appointment with the physician." - "I can resume my usual activities as soon as I get home." - "I should call my physician if I develop a fever."

- "I can resume my usual activities as soon as I get home."

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? - Pale yet able to blanch with digital pressure - White with long, thin areas of scar tissue - Necrotic and hard - Pink to red and soft, bleeding easily

- Pink to red and soft, bleeding easily

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first? - Place a dry, sterile dressing over the protruding organs. - Moisten sterile gauze with normal saline and place on the protruding organ. - Place a pressure dressing over the opening and secure. - Have the client lay quietly on back and call the physician.

- Moisten sterile gauze with normal saline and place on the protruding organ.

Adequate hourly urine output for a client with an indwelling urinary catheter is - 1.0 mL/kg/h. - 0.5 mL/kg/h. - 2.0 mL/kg/h. - 1.5 mL/kg/h.

- 2.0 mL/kg/h.

What measurement should the nurse report to the physician in the immediate postoperative period? - A systolic blood pressure lower than 90 mm Hg - A temperature reading between 97°F and 98°F - Respirations between 20 and 25 breaths/min - A hemoglobin of 13.6

- A systolic blood pressure lower than 90 mm Hg

When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O₂ saturation monitor despite the client's breathing appearing normal, what action should the nurse take first? - Assess the client's heart rhythm and nail beds. - Notify the physician. - Document the findings. - Apply oxygen.

- Assess the client's heart rhythm and nail beds.

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action? - Call the health care provider. - Re-attempt to auscultate bowel sounds. - Prepare to administer a stool softener. - Prepare to insert a nasogastric tube.

- Call the health care provider.

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action? - Re-attempt to auscultate bowel sounds. - Prepare to insert a nasogastric tube. - Call the health care provider. - Prepare to administer a stool softener.

- Call the health care provider.

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? - Central venous pressure - Chest x-ray - Upper endoscopy - Complete blood count

- Central venous pressure

The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists? - Evisceration - Dehiscence - Hemorrhage - Normal healing by primary intention.

- Dehiscence

A nurse is caring for a client with a chest tube connected to a dry suction water seal drainage system. The nurse notes 2cm of water and intermittent bubbling in the water seal chamber. Which action will the nurse take? - Add water to the water seal chamber. - Check for an air leak. - Notify the health care provider. - Document the findings.

- Document the findings.

A nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene? - Administer a tap water enema. - Apply moist heat to the client's abdomen. - Notify the physician. - Encourage the client to ambulate as soon as possible after surgery.

- Encourage the client to ambulate as soon as possible after surgery.

Which term refers to the protrusion of abdominal organs through the surgical incision? - Dehiscence - Evisceration - Erythema - Hernia

- Evisceration

When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority? - Fluid Volume Deficit - Altered Comfort - Impaired Gas Exchange - Anxiety - Risk for Infection

- Impaired Gas Exchange - Fluid Volume Deficit - Altered Comfort - Anxiety - Risk for Infection

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis? - Acute incisional pain - Decreased cardiac output - Ineffective airway clearance - Ineffective thermoregulation

- Ineffective thermoregulation

What is the highest priority nursing intervention for a client in the immediate postoperative phase? - Assessing for hemorrhage - Assessing urinary output every hour - Maintaining a patent airway - Monitoring vital signs at least every 15 minutes

- Maintaining a patent airway

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order. - Don sterile gloves - Apply intermittent suction while withdrawing the catheter - Lubricate the sterile suction catheter - Insert suction catheter into the lumen of the tube - Position the client in Fowlers position

- Position the client in Fowlers position - Don sterile gloves - Lubricate the sterile suction catheter - Insert suction catheter into the lumen of the tube - Apply intermittent suction while withdrawing the catheter

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order. - Don sterile gloves. - Lubricate the sterile suction catheter. - Apply intermittent suction while withdrawing the catheter. - Insert suction catheter into the lumen of the tube. - Position the client in Fowlers position.

- Position the client in Fowlers position. - Don sterile gloves. - Lubricate the sterile suction catheter. - Insert suction catheter into the lumen of the tube. - Apply intermittent suction while withdrawing the catheter.

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action? - Assess the incisional dressing to detect hemorrhage. - Administer antiemetics to prevent nausea and vomiting. - Monitor vital signs for early detection of shock. - Position the client to maintain a patent airway.

- Position the client to maintain a patent airway.

What complication is the nurse aware of that is associated with deep venous thrombosis? - Immobility because of calf pain - Marked tenderness over the anteromedial surface of the thigh - Pulmonary embolism - Swelling of the entire leg owing to edema

- Pulmonary embolism

A post-anesthesia care unit (PACU) nurse is preparing to discharge a client home following ankle surgery. The client keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate? - Continuously repeat the instructions until the client restates them. - Give the written instructions to the client's 16-year-old child. - Review the instructions with the client and an accompanying adult. - Ask the client, "Do you understand?"

- Review the instructions with the client and an accompanying adult.

The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan? - Family members can be involved in the administration of pain medications with patient-controlled analgesia. - The client can self-administer oral pain medication as needed with patient-controlled analgesia. - There are no advantages of patient-controlled analgesia over a PRN dosing schedule. - Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.

- Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.

The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan? - The client can self-administer oral pain medication as needed with patient-controlled analgesia. - Family members can be involved in the administration of pain medications with patient-controlled analgesia. - Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. - There are no advantages of patient-controlled analgesia over a PRN dosing schedule.

- Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.

The nurse's assessment of a post-op client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing? - Atelectasis - Wound infection - Hyperthermia - Uncontrolled pain

- Wound infection

A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client? - maintains adequate fluid status. - exhibits wound healing without complications. - experiences pain within tolerable limits. - resumes usual urinary elimination pattern.

- experiences pain within tolerable limits.