Ch 16: Postoperative Nursing Management
c) Place the client in the low Fowler's position Pg. 457 Placing the client in the low Fowler's position decreases further protrusion of the intestines. The nurse should cover the intestines with a sterile, moist dressing; notify the surgeon and document the event; but first the nurse should minimize further protrusion of the intestines.
13. A postoperative client begins coughing forcefully while eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first? a) Cover the intestines with sterile, moist dressings b) Document the event c) Place the client in the low Fowler's position d) Notify the surgeon
d) Auscultate bowel sounds Pg. 454 If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.
16. A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: a) Change the client's position b) Insert a rectal tube c) Palpate the abdomen d) Auscultate bowel sounds
b) Pink to red and soft, bleeding easily Pg. 450 In second-intention healing, necrotic material gradually disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue.
18. The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? a) White with long, thin areas of scar tissue b) Pink to red and soft, bleeding easily c) Pale yet able to blanch with digital pressure d) Necrotic and hard
a) Reinforcing dressings or applying pressure if bleeding is frank Pg. 439 The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply and rubbing the back will not help manage and minimize hemorrhage and shock.
19. The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? a) Reinforcing dressings or applying pressure if bleeding is frank b) Encouraging the client to breathe deeply c) Elevating the head of the bed d) Rubbing the back
a) A systolic blood pressure lower than 90 mm Hg Pg. 440 A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal.
20. What measurement should the nurse report to the physician in the immediate postoperative period? a) A systolic blood pressure lower than 90 mm Hg b) A temperature reading between 97°F and 98°F c) A hemoglobin of 13.6 d) Respirations between 20 and 25 breaths/min
a) Evisceration Pg. 456 Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.
8. A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding? a) Evisceration b) Erythema c) Dehiscence d) Hernia
b) Ineffective thermoregulation Pg. 441-442 Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.
11. 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? a) Ineffective airway clearance b) Ineffective thermoregulation c) Decreased cardiac output d) Acute incisional pain
c) <30 mL Pg. 448 If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL per hour are reported; if the patient is voiding, an output of less than 240 mL per 8-hour shift is reported.
12. What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? a) Between 75 and 100 mL b) >200 mL c) <30 mL d) Between 100 and 200 mL
b) Call the health care provider Pg. 454 The client presents with a possible paralytic ileus, a serious condition where the intestines are paralyzed and peristalsis is absent. This may occur as a result of surgery, especially abdominal surgery. If the nurse is unable to auscultate bowel sounds and the client has pain and a rigid abdomen, the nurse will suspect an ileus and immediately call the health care provider. Re-attempting auscultation may occur, but only after the health care provider has been notified. The health care provider may order the placement of an NG tube, however, the nurse cannot do this without the provider's order. Administering a stool softener will not help the client and may make the condition worse.
1. 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? a) Prepare to administer a stool softener b) Call the health care provider c) Re-attempt to auscultate bowel sounds d) Prepare to insert a nasogastric tube
b) As soon as it is indicated Pg. 449 Postoperative activity orders are checked before the patient is assisted to get out of bed, in many instances, on the evening following surgery. Sitting up at the edge of the bed for a few minutes may be all that the patient who has undergone a major surgical procedure can tolerate at first.
10. When should the nurse encourage the postoperative patient to get out of bed? a) Within 6 to 8 hours after surgery b) As soon as it is indicated c) Between 10 and 12 hours after surgery d) On the second postoperative day
b) First intention Pg. 437 When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing.
2. Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? a) Fourth intention b) First intention c) Third intention d) Second intention
b) Assess the client's heart rhythm and nail beds Pg. 439 A client may demonstrate low oxygenation readings because of certain colors of nail polish or may show an irregular heart rate such as atrial fibrillation. These factors should be assessed to ensure the accuracy of the oxygen reading. Once the reading is confirmed as accurate, then the nurse may need to apply oxygen, notify the physician, and document the findings.
39. 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? a) Document the findings b) Assess the client's heart rhythm and nail beds c) Notify the physician d) Apply oxygen
b) Maintaining pulmonary ventilation Pg. 438 The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and monitoring for hypotension are important, but they are not primary objectives in the immediate postoperative period.
4. The primary objective in the immediate postoperative period is a) Relieving pain b) Maintaining pulmonary ventilation c) Controlling nausea and vomiting d) Monitoring for hypotension
a) Breathing Pg. 438 The nurse will assess the client being transferred from the PACU to an inpatient care unit. The priority is to assess breathing and administer oxygen if prescribed because this provides a baseline and helps identify for the development of respiratory distress. Pain level is assessed after the surgical site and level of consciousness are assessed.
5. A client is transferred from the postanesthesia care unit (PACU) to an inpatient care unit. What will the nurse assess first? a) Breathing b) Level of consciousness c) Surgical site d) Pain level
a) Encouraging early ambulation b) Assisting the patient with leg exercises e) Avoiding placement of pillows or blanket rolls under the patient's knees Pg. 449 The benefits of early ambulation and leg exercises in preventing deep vein thrombosis cannot be overemphasized, and these activities are recommended for all patients, regardless of their risk. It is important to avoid the use of blanket rolls, pillow rolls, or any form of elevation that can constrict vessels under the knees. Compression stockings should be worn all the time, not just at night. Massage would be contraindicated due to the risk of dislodging a clot.
6. The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply.) a) Encouraging early ambulation b) Assisting the patient with leg exercises c) Applying compression stockings only at night d) Massaging the legs every 4 hours e) Avoiding placement of pillows or blanket rolls under the patient's knees
c) 7 Pg. 443 Many hospitals use a scoring system (e.g., Aldrete score) to determine the patient's general condition and readiness for transfer from the PACU (Aldrete & Wright, 1992). Throughout the recovery period, the patient's physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. This evaluation guide allows an objective assessment of the patient's condition in the PACU. The patient is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The Aldrete score is usually between 7 and 10 before discharge from the PACU.
14. The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room? a) 5 b) 6 c) 7 d) 4
b) Obtain the wound culture specimen Pg. 452 Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. The culture should be obtained even though the client is not demonstrating traditional signs and symptoms of infection. The order should not be discontinued or held until purulent drainage is noted because the infection could worsen and the client could develop sepsis. An antibiotic cleaning agent should not be used before obtaining the specimen because it will alter the growth of the organisms.
15. A postoperative client with an open abdominal wound is currently taking corticosteroids. The physician orders a culture of the abdominal wound even though no signs or symptoms of infection are seen. What action by the nurse is appropriate? a) Hold the order until purulent drainage is noted b) Obtain the wound culture specimen c) Use an antibiotic cleaning agent before obtaining the specimen d) Request the order be discontinued without obtaining the specimen
a) Be independent with toileting c) Get in and out of bed unassisted d) Ambulate a functional distance Pg. 449 For a safe discharge to home, clients need to be independent with toileting, able to ambulate a functional distance (e.g., length of the house or apartment), and get in and out of bed unassisted. The client does not need to be able to complete total self-care or perform instrumental activities of daily living before being discharged after surgery.
17. A client recovering from surgery asks, "When can I go home?" The nurse responds by stating which of the following activities must be completed before discharging home? Select all that apply. a) Be independent with toileting b) Perform instrumental activities of daily living c) Get in and out of bed unassisted d) Ambulate a functional distance e) Complete total self-care
a) Urinary retention Pg. 455 Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus.
21. 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? a) Urine retention b) Urinary infection c) Calculus formation d) Requirement of intermittent catheterization
b) Assessing WBC count, temperature, and wound appearance Pg. 456 The client has an increased risk for infection related to the surgical wound, which is classified as dirty. Assessing the WBC count, temperature, and wound appearance allows the nurse to intervene at the earliest sign of infection. The client will have special nutritional needs during wound healing and needs education on safe transfer procedures, but the need to monitor for infection is a higher priority. The client should receive pain medication as soon as possible after asking, but the latest literature suggests that pain medication should be given on a schedule versus "as needed."
22. A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention? a) Obtaining dietary consultation for improved wound healing b) Assessing WBC count, temperature, and wound appearance c) Administering pain medications within 1 hour of the client's request d) Educating the client on safe bed-to-chair transfer procedures
b) The client reports a small bowel movement and flatus Pg. 454 A bowel movement demonstrates that the nursing outcome of the return to function of the gastrointestinal track has been met. All of the other options are components of meeting the outcome of functioning.
23. The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract? a) The client states being hungry b) The client reports a small bowel movement and flatus c) The client is breathing calmly d) The client is tolerating sips of water
c) The client is displaying early signs of shock Pg. 440 The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated. Medication or anesthesia reactions may cause client symptoms similar to these; however, these causes are not as likely as early shock.
24. A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition? a) The client is showing signs of an anesthesia reaction b) The client is showing signs of a medication reaction c) The client is displaying early signs of shock d) The client is displaying late signs of shock
b) Experiences pain within tolerable limits Pg. 457 Because pain can contribute to postoperative delirium, adequate pain control without oversedation is essential. Nursing assessment of mental status and of all physiologic factors influencing mental status helps the nurse plan for care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult client.
25. 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? a) Resumes usual urinary elimination pattern b) Experiences pain within tolerable limits c) Exhibits wound healing without complications d) Maintains adequate fluid status
b) Impaired gas exchange a) Fluid volume deficit c) Altered comfort d) Anxiety e) Risk for infection Pg. 448-452 According to the Maslow's hierarchy of deeds, airway and gas exchange is of the highest priority. Next would be the deficiency in fluid volume. Altered comfort would be higher than anxiety because decreasing pain may alleviate/reduce anxiety. Lastly, a risk for infection is not a current problem but it is still important to reduce the risk.
26. When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority. a) Fluid volume deficit b) Impaired gas exchange c) Altered comfort d) Anxiety e) Risk for infection
b) Ondansetron Pg. 441 Ondansetron (Zofran) is used to treat nausea and vomiting.
27. The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order? a) Omeprazole b) Ondansetron c) Nizatidine d) Chlorpromazine
c) Wound infection Pg. 456 Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.
28. The nurse's assessment of a postop 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? a) Hyperthermia b) Atelectasis c) Wound infection d) Uncontrolled pain
a) Dead space and dead cells provide a culture medium Pg. 451 In hemorrhage, accumulation of blood creates dead spaces as well as dead cells that must be removed. The area becomes a growth medium for organisms.
29. A patient has a wound that has hemorrhaged. What does the nurse understand is the cause of the patient's increased risk of infection? a) Dead space and dead cells provide a culture medium b) The tissue becomes less resilient c) Reduced amounts of oxygen and nutrients are available d) Retrograde bacterial contamination may occur
d) Central venous pressure Pg. 440 Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, level of consciousness, central venous pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output are monitored to provide information on the patient's respiratory and cardiovascular status.
3. The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? a) Complete blood count b) Chest x-ray c) Upper endoscopy d) Central venous pressure
c) Position the client in the side-lying position Pg. 442 The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits. The nurse may also obtain an emesis basin and administered an anti-emetic if one is ordered; however, these will be done after the client is repositioned. There is no need for the nurse to ask the client for more clarification.
30. 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? a) Administer an anti-emetic b) Ask the client for more clarification c) Position the client in the side-lying position d) Obtain an emesis basin
b) The Hemovac drain isn't compressed; instead it's fully expanded Pg. 452 The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.
31. A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage? a) The client has been lying on his side for 2 hours with the drain positioned upward b) The Hemovac drain isn't compressed; instead it's fully expanded c) The client has a nasogastric (NG) tube in place that drained 400 ml d) There is a moderate amount of dry drainage on the outside of the dressing
a) Hypoxia b) Pain c) Bladder distention Pg. 440 Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation. Reasons for an increase in blood pressure in the PACU include pain, hypoxia, or bladder distention. This assessment finding is managed by treating the underlying cause. Nausea and bowel obstruction are not identified as causing hypertension in clients during the PACU period.
9. A client in the postanesthesia care unit (PACU) develops a blood pressure of 180/90 mm Hg. Which assessment will the nurse complete to determine the cause of the blood pressure findings? Select all that apply. a) Hypoxia b) Pain c) Bladder distention d) Nausea e) Bowel obstruction
a) Reinforce the importance of early mobility in preventing complications Pg. 449 The client may be refusing to ambulate because of fear or pain. Educating the client on the importance of mobility in preventing complications may encourage the client to ambulate. The nurse should try all reasonable measures (e.g., pain control, education) before documenting the client's refusal to ambulate. If the client is already refusing to ambulate, delegating the task to the unlicensed assistive personnel is not an appropriate action. The client should not be forcefully removed from the bed.
32. The nurse is attempting to ambulate a client who underwent shoulder surgery earlier in the day, but the client is refusing to do so. What action by the nurse is most appropriate? a) Reinforce the importance of early mobility in preventing complications b) Document the client's refusal c) Delegate the task to the unlicensed assistive personnel d) Use multiple staff members to remove the client from the bed
b) Pallor Pg. 440 The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing.
33. Which is a classic sign of hypovolemic shock? a) High blood pressure b) Pallor c) Dilute urine d) Bradypnea
c) Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia Pg. 447-448 Advantages of patient-controlled analgesia include participation of the client in care, elimination of delayed administration of analgesics, and maintenance of therapeutic drug levels. The client must have the cognitive and physical abilities to self-dose.
34. 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? a) There are no advantages of patient-controlled analgesia over a PRN dosing schedule b) The client can self-administer oral pain medication as needed with patient-controlled analgesia c) Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia d) Family members can be involved in the administration of pain medications with patient-controlled analgesia
a) First intention Pg. 449-451 Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.
35. A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: a) First intention b) Fourth intention c) Second intention d) Third intention
b) Review the instructions with the client and an accompanying adult Pg. 438 The effects of anesthesia may impair a client's memory or concentration. It is important that the discharge instructions are covered with the client and an accompanying adult. Giving the instructions to a 16-year-old is not appropriate. Repeating the instructions until the client restates them does not ensure that the client will remember them, because anesthesia can impair memory. Asking whether the client understands the instructions only elicits an yes or no answer; it does not give insight into whether the client comprehends the instructions.
36. A postanesthesia 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? a) Ask the client, "Do you understand?" b) Review the instructions with the client and an accompanying adult c) Continuously repeat the instructions until the client restates them d) Give the written instructions to the client's 16-year-old child
b) Pulmonary embolism Pg. 455 Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism .
37. What complication is the nurse aware of that is associated with deep venous thrombosis? a) Immobility because of calf pain b) Pulmonary embolism c) Swelling of the entire leg owing to edema d) Marked tenderness over the anteromedial surface of the thigh
c) Empty and measure the drainage and compress the Hemovac Pg. 452 A Hemovac needs to be recompressed periodically, because it operates with the use of gentle, constant suction. The amount of drainage is not excessive.
38. The nurse is caring for a postoperative client with a Hemovac. The Hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to: a) Notify the surgeon that the Hemovac is not functioning b) Remove the Hemovac because it is expanded c) Empty and measure the drainage and compress the Hemovac d) Assess the client's wound and apply a pressure dressing
d) Tolerance Pg. 446-447 Postoperative ambulatory activities are essential but planned according to the older adult's tolerance, which usually is less than that of a younger person. The respiratory depressive effects should be considered when administering certain drugs for the older adults. The convalescent period usually is longer for older adults. Therefore, they may require positive reinforcement throughout the postoperative period as well as extensive discharge planning. The convalescent period of older adults and detailed medication history may not be necessary to consider when planning the postoperative ambulatory activities.
40. You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult? a) Convalescent period b) Detailed medication history c) Respiratory depressive effects d) Tolerance
b) Dehisced Pg. 456 Dehiscence is the partial or complete separation of wound edges. Evisceration is the protrusion of organs through the surgical incision. Pustulated refers to the formation of pustules. Hemorrhage is excessive bleeding.
7. A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound a) Hemorrhaged b) Dehisced c) Pustulated d) Eviscerated