Chapter 19: Postoperative Nursing Management

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?

Position the client to maintain a patent airway. Explanation: Maintaining a patent airway is the immediate priority in the PACU.

A client develops a hemorrhage an hour post surgery while in your care. Which of the following characteristics indicate this is most likely an intermediary hemorrhage from a vein?

It occurred within the first few hours and has darkly colored blood that bubbles out slowly. Explanation: An intermediary hemorrhage appears within the first few hours following surgery. The darkly colored blood bubbles out quickly makes it a venous hemorrhage. A hemorrhage that occurs during surgery is classified as a primary hemorrhage. The blood's color indicates its source is an artery. Secondary hemorrhages occur when sutures slip or drainage tubes dislodge insecure vessels. These characteristics are for a secondary hemorrhage from an artery.

The nurse is caring for a client 24 hours post surgery who is having persistent hiccups. What action is most appropriate for the nurse to take?

Notify the physician. Explanation: Prolonged hiccups may cause pain or discomfort. Prolonged hiccups may also result in wound dehiscence or evisceration, inability to eat, nausea and vomiting, exhaustion, and fluid, electrolyte, and acid-base imbalances. If hiccups continue, the nurse needs to notify the physician. Deep breathing helps minimize pain and will not help in this condition. Positioning the client and ample water intake will not help stop the hiccups.

The PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. Which short-term outcome would be most important for this client? The client:

maintains adequate oxygenation status. Explanation: Acute confusion associated with delirium may be a result of hypoxia, pain, urinary retention, fecal impaction, fever, hypotension, hypoglycemia, fluid loss, and anemia. Hypoxia would be most important for the nurse to address.

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that most support the nurse's analysis are:

blood pressure of 80/40 mm Hg and pulse of 130 beats/minute. Explanation: The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis. Orthostatic changes develop from hypovolemia and cause a drop in blood pressure (evidenced by a blood pressure of 80/40 mm Hg) and a compensatory rise in the heart rate (evidenced by a pulse of 130 beats/minute) when the client rises from a lying position.

The nurse is caring for a patient in the postanesthesia care unit (PACU) with the following vital signs, pulse 115, respiration 20, temperature 97.2°F oral, blood pressure 84/50. What should the nurse do first?

Assess for bleeding. Explanation: The patient is tachycardic with a low blood pressure; thus assessing for hemorrhage is the priority action. While the physician may need to be notified, the nurse needs to be able to communicate a complete picture of the patient, which would include bleeding, when calling the physician. The rate of IV fluid administration should be adjusted according to a physician order. The nurse should review prior vital signs but only after the immediate threat of hemorrhage is assessed.

A nurse is reviewing with a client the use of a patient-controlled anesthesia device and is explaining the benefits. Which of the following would the nurse correctly emphasize? Select all that apply.

Fosters client participation in care Facilitates reduction of postoperative pulmonary complications Explanation: PCA promotes client participation in care, eliminates delayed administration of analgesics, maintains a therapeutic drug level, and enables the client to move, turn, cough, and take deep breaths with less pain, thus reducing postoperative pulmonary complications.

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?

Encourage the client to ambulate at least three times per day. Explanation: The nurse should encourage the client to ambulate at least three times per day. Ambulating stimulates peristalsis, which helps the bowels to move. It isn't appropriate to apply heat to a surgical wound. Moreover, heat application can't be initiated without a physician order. A tap water enema is typically administered as a last resort after other methods fail. A physician's order is needed with a tap water enema as well. Notifying the physician isn't necessary at this point because the client is exhibiting bowel function by passing flatus.

Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention?

Oxygen saturation of 82% Explanation: Normal pulse oximetry is 95% to 100%. An oxygen saturation of 82% indicates respiratory compromise and requires immediate attention.

Select the nutrient that is important for postoperative wound healing because it helps form collagen.

Vitamin C Explanation: Vitamin C is important for capillary formation, tissue synthesis, and wound healing through collagen formation. Vitamin A decreases the inflammatory response in wounds. Magnesium is essential for wound repair, and protein allows collagen deposition.

You are caring for a client who is an obese diabetic. The client is 48 hours post surgery. What is this client at increased risk for?

Wound dehiscence Explanation: Risk factors for wound dehiscence include: Advanced age over 65 years; Chronic disease such as diabetes, hypertension, obesity; History of radiation or chemotherapy; Malnutrition, particularly insufficient protein and vitamin C; Hypoalbuminemia. This client is not at increased risk for hypotension; contractures, or phlebitis.

The client is experiencing nausea and vomiting following surgery. The nurse expects the surgeon to order:

ondansetron (Zofran) Explanation: Ondansetron (Zofran) is used to treat nausea and vomiting.

When caring for a postsurgical patient, the nurse observes that the client has hemorrhaged and is in hypovolemic shock. Which of the following nursing interventions will manage and minimize hemorrhage and shock?

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 patient to breathe deeply and providing a back rub will not help manage and minimize hemorrhage and shock.

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?

Tolerance Explanation: 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.

Corticosteroids have which effect on wound healing?

Mask presence of infection Explanation: Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. Edema may reduce blood supply. Corticosteroids do not cause hemorrhage or protein-calorie depletion.

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 can be discharged from the PACU. Explanation: The Aldrete score is usually 8 to 10 before discharge from the PACU. Clients with a score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area, depending on their preoperative baseline score.

A postoperative patient, with an open abdominal wound is currently taking corticosteroids. The physician orders a wound culture of the abdominal wound even though there are no signs and symptoms of infection. What action by the nurse is appropriate?

Obtain the wound culture specimen. Explanation: Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. The culture should be obtained even though the patient 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 patient will possibly develop sepsis. An antibiotic cleaning agent should not be used before obtaining the specimen because it will alter the growth of the organisms.

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly patients?

Pneumonia Explanation: Older patients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Delirium, pneumonia, decline in functional ability, exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and falls are all threats to recovery in the older adult (Tabloski, 2009; Tolson, Morley, Rolland, et al., 2011).

You are caring for a client 6 hours post surgery. You observe that the client voids urine frequently and in small amounts. You know that this most probably indicates what?

Urine retention Explanation: 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.

A postoperative patient is being discharged home following minor surgery. The PACU nurse is reviewing discharge instructions with the patient and his or her spouse. What action by the nurse is appropriate? Select all that apply.

Educate on activity limitations. Discuss wound care. Have the spouse review when to notify the physician. Provide information on health promotion topics. Explanation: The nurse should provide education on activity limitations, wound care, and review complications that require notification to the physician. The nurse should also provide information regarding health promotion topics, such as, weight management and smoking cessation. The patient should not make any major decisions or sign any legal forms due to the effects of anesthesia.

The nurse is assessing the postoperative client on the second postoperative day. Which assessment finding requires immediate physician notification?

The client has an absence of bowel sounds. Explanation: A nursing assessment finding of concern on the second postoperative day is the absence of bowel sounds, which may indicate a paralytic ileus. Other assessment findings may include abdominal pain and distention as fluids, solids, and gas do not move through the intestinal tract. Rales in the bases are a frequent finding postoperatively, especially if general anesthesia was administered. Encourage the client to cough and deep breathe. Pain is a common symptom following a surgical procedure. Serous drainage on the postoperative dressing needs to monitored and brought to the physician's attention when he or she assesses the client.

When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as

clean-contaminated. Explanation: Clean-contaminated cases are those with a potential, limited source for infection, the exposure to which, to a large extent, can be controlled. Clean cases are those with no apparent source of potential infection. Contaminated cases are those that contain an open and obvious source of potential infection. A traumatic wound with foreign bodies, fecal contamination, or purulent drainage would be considered a dirty case.

Which of the following terms refers to a protrusion of abdominal organs through the surgical incision?

Evisceration Explanation: 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.

A patient asks why there is a drain pulling fluid from the surgical wound. What is the best response by the nurse?

"It assists in preventing infection." Explanation: A wound drain assists in preventing infection by removing the medium in which bacteria would grow. The purpose of the wound drain is not to remove necrotic tissue or to decrease the number of dressing changes. Stating that most surgeons use wound drains does not answer the patient's question appropriately.

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?

(there was a blank answer, but heres the explanation) 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.

What measurement should the nurse report to the physician in the immediate postoperative period?

A systolic blood pressure lower than 90 mm Hg Explanation: 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.

The nurse determines that a patient has postoperative abdominal distention. What does the nurse determine that the distention may be directly related to?

A temporary loss of peristalsis and gas accumulation in the intestines Explanation: Any postoperative patient may suffer from distention. Postoperative distention of the abdomen results from the accumulation of gas in the intestinal tract. Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for 24 to 48 hours, depending on the type and extent of surgery. Even though nothing is given by mouth, swallowed air and GI tract secretions enter the stomach and intestines; if not propelled by peristalsis, they collect in the intestines, producing distention and causing the patient to complain of fullness or pain in the abdomen. Most often, the gas collects in the colon. Abdominal distention is further increased by immobility, anesthetic agents, and the use of opioid medications.

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?

Absence of peristalsis Explanation: Paralytic ileus and intestinal obstruction are potential postoperative complications that occur more frequently in patients undergoing intestinal or abdominal surgery. Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for 24 to 48 hours, depending on the type and extent of surgery.

When should the nurse encourage the postoperative patient to get out of bed?

As soon as it is indicated Explanation: 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.

The nurse is caring for a female postoperative client who is having difficulty voiding. Which nursing action is most helpful to promote normal voiding?

Assist to the bathroom. Explanation: The nurse encourages the client to void within 4 hours of surgery to minimize the risk of a urinary tract infection. Ambulating the client to the bathroom promotes normal body positioning for urination. Running water is a common psychological strategy to cause urination, but positioning is a better option. Encouraging water will help fill the bladder but not urination. Offering to catheterize is a last option.

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 Explanation: 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.

The nurse is assessing the client for wound complications following surgery. For which clinical manifestation should the nurse assess? Select all that apply.

Dehiscence Hematoma Explanation: A hematoma can form within the wound and result in delayed healing. Dehiscence is a disruption of the surgical incision. Atelecstasis, thromobophlebitis, and paralytic ileus are potential complications following surgery. Atelecstasis is a collapse of the alveoli, which interferes with gas exchange. Thromobophlebitis is the development of a blood clot, usually in the lower extremity. Paralytic ileus is an absence of intestinal 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:

First intention Explanation: First-intention healing is characterized by a closed incision with little tissue reaction and the absence of signs and symptoms of infection.

What complication in the immediate postoperative period should the nurse understand requires early intervention to prevent?

Hypoxemia and hypercapnia Explanation: The primary objective in the immediate postoperative period is to maintain ventilation and thus prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Both can occur if the airway is obstructed and ventilation is reduced (hypoventilation). Besides administering supplemental oxygen (as prescribed), the nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds.

A patient who underwent abdominal surgery 3 hours ago has started to hemorrhage. The nurse would classify this type of hemorrhage has which of the following?

Intermediary Explanation: Intermediary hemorrhage occurs during the first few hours after surgery when the rise of blood pressure to its normal level dislodges insecure clots formed in untied vessels. Primary hemorrhage occurs at the time of surgery. Secondary hemorrhage may occur some time after surgery if a suture slips because a blood vessel was not securely tied, became infected, or was eroded by a drainage tube.

The nurse is caring for a postoperative patient with an indwelling urinary catheter. The hourly urinary output at 9 am is 80 mL. The nurse assesses the hourly urinary output at 10 am at 20 mL. What is the highest priority action by the nurse?

Notify the physician. Explanation: If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/h are reported. Any urinary output less than 30 mL/h should be reported to the physician immediately. The urinary output will be reassessed at 11 am but waiting to notify the physician could cause harm to the patient. The findings should be documented but this is not the highest priority. A urinary catheter may need to be irrigated but a postoperative patient with a low urinary output is demonstrating a complication that needs to be reported immediately.

A significant mortality rate exists for patients with alcoholism who experience delirium tremens postoperatively. When caring for the patient with alcoholism, the nurse should assess for symptoms of alcoholic withdrawal:

On the second or third day. Explanation: The person with a history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase surgical risk. Alcohol withdrawal syndrome or delirium tremens may be anticipated between 48 and 72 hours after alcohol withdrawal and is associated with a significant mortality rate when it occurs postoperatively.

A client who is receiving the maximum levels of medication for postoperative recovery asks the nurse if there are other measures that the nurse can employ to ease pain. Which of the following strategies might the nurse employ? Select all that apply.

Performing guided imagery Putting on soothing music Changing the client's position Explanation: Guided imagery, music, and application of heat or cold (if prescribed) have been successful in decreasing pain. Changing the client's position, using distraction, applying cool washcloths to the face, and providing back massage may be useful in relieving general discomfort temporarily.

A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem?

Pink color Explanation: Flash pulmonary edema that occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation, tachypnea, tachycardia, decreased pulse oximetry readings, frothy, pink sputum, and crackles on auscultation.

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?

Pink to red and soft, bleeding easily Explanation: 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.

A client with nausea and vomiting is to receive an antiemetic that inhibits the vomiting center in the brain. Which of the following would the nurse expect the physician to order most likely?

Prochlorperazine (Compazine) Explanation: Prochlorperazine is a phenothiazine that inhibits the chemoreceptor trigger zone (CTZ) and the vomiting center in the brain. Odansetron blocks receptors for 5 HT3, affecting the neural pathways involved in nausea and vomiting. Hydroxyzine and promethazine are antihistamines which block H1 receptors resulting in a decrease in stimulation of the CTZ and vomiting.

The nurse recognizes which of the following as clinical manifestations of shock?

Rapid, weak, thready pulse Explanation: The patient's pulse increases as the body tries to compensate for the effects of shock. Pallor is an indicator of shock. The skin is generally cool and moist in shock. Usually, a low blood pressure and concentrated urine are observed in the patient who is in shock.

When the nurse observes that the postoperative patient demonstrates a constant low level of oxygen saturation, although the patient's breathing appears normal, the nurse identifies that the patient may be suffering from which type of hypoxemia?

Subacute Explanation: For subacute hypoxemia supplemental oxygen may be indicated. Hypoxic hypoxemia results from inadequate breathing. Episodic hypoxemia develops suddenly, and the patient may be at risk for myocardial ischemia, cerebral dysfunction, and cardiac arrest. Anemic hypoxemia results from blood loss during surgery.

Which of the following would be the least important factor affecting wound healing?

Sufficient oxygenation Explanation: Oxygen deficit is a factor in wound healing. Hemorrhage. nutritional deficiencies, such as protein-calorie depletion, and the age of the patient are factors affecting wound healing. The older the patient, the less resilient are his or her tissues.

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?

The Hemovac drain isn't compressed; instead it's fully expanded. Explanation: 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.

The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?

The client reports a small bowel movement. Explanation: 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.

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?

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

The nurse is caring for a client during the immediate postoperative period and is assessing for signs of shock. What signs and symptoms indicate that the client may be in shock?

Weak and rapid pulse rate Explanation: Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock.

Nursing assessment findings reveal a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. The nurse recognizes the client is experiencing:

Wound infection Explanation: Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

auscultate bowel sounds. Explanation: 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.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

first intention. Explanation: 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.

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation. Explanation: 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 not the primary objectives in the immediate postoperative period.

A patient is postoperative day 1 from abdominal surgery. The patient is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total 2430 mL. What action by the nurse is most appropriate?

ssess for signs and symptoms of fluid volume deficit. Explanation: The patient's 24 hour intake is 1,800 mL (75x24). The patient's 24 hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Since the output is significantly higher than the intake the patient is at risk for fluid volume deficit. The nurse should not discontinue the nasogastric suctioning without a physician's order. The findings should be documented and reassessed but the nurse needs to take more action to prevent complication. Edema is usually associated with fluid volume excess.

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:

Ambulating the client as soon as possible Explanation: The nurse should assist the client to ambulate as soon as the client is able. Incentive spirometry should be performed every 1 to 2 hours. The client should be positioned from side to side and in semi-Fowler's position. While assessing breath sounds is essential, it does not help to prevent pneumonia.

A patient is postoperative day 3 for 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?

Assessing WBC count, temperature, and wound appearance Explanation: The patient has an increased risk for infection related to the surgical wound classification of dirty. Assessing the WBC count, temperature, and wound appearance will allow the nurse to intervene at the earliest sign of infection. The patient will have special nutritional needs for wound healing and need education on safe transfer procedures but the need to monitor for infection is a higher priority. The patient should receive pain medication as soon as possible after asking but the latest literature suggest that pain medication should be given on a schedule versus "as needed."

Postoperative day 2, a patient requires wound care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing?

Packing the wound bed with sterile saline-soaked dressing and covering with dry dressing Explanation: Postoperative surgical wounds that are allowed to heal using second-intention healing are usually packed with a sterile saline dressing and covered with a dry dressing. The edges of a second-intention healing wound are not approximated. The wound may be cleaned using sterile saline but the nurse would not apply a cyanoacrylate tissue adhesive. The wound should not be left open to the air, as it could expose the wound to microorganisms and dry out the wound bed impairing healing.

Which of the following factors may contribute to rapid and shallow respirations in a postoperative client? Select all that apply.

Pain Constricting dressings Abdominal distention Obesity Explanation: Often, because of the effects of analgesic and anesthetic medications, respirations are slow. Shallow and rapid respirations may be caused by pain, constricting dressings, gastric dilation, abdominal distention, or obesity.

Which of the following actions should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical patient?

Reinforce the need to perform leg exercises every hour when awake Explanation: The nurse should reinforce the need to perform leg exercises every hour when awake. If signs and symptoms of thrombophlebitis appear, the patient should maintain bed rest. The nurse should not massage calves or thighs. The nurse should instruct the patient not to cross the legs or prop pillow under the knees.

When caring for a postsurgical patient, the nurse observes that the client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing dressing or applying pressure if bleeding is frank Explanation: 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 patient to breathe deeply will not help manage and minimize hemorrhage and shock. Monitoring the vital signs every 15 minutes is an appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to determine the extent and progression of the problem.

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. Which of the following actions by the nurse would be inappropriate?

Restrict oral fluids. Explanation: The client exhibits clinical manifestations of hypothermia. The nurse should maintain adequate hydration of the client rather than restrict fluids.