Chapter 19

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?

Dehiscence

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

The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of:

Hypoxemia and hypercapnia.

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?

Wound 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?

Ineffective thermoregulation

Which is a classic sign of hypovolemic shock?

Pallor

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?

Pink to red and soft, noting that it bleeds easily

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation?

Second-intention healing

A nurse is planning care for a client scheduled to undergo a thoracotomy. After tolerating full liquids, which dietary recommendation will the nurse consider?

Small, frequent full-fat meals

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?

Evisceration

When the nurse observes that a postoperative client 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

Which of the following stimulates the wound healing process?

Sufficient oxygenation

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

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required?

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

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation.

The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?

ondansetron

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.

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.

What is the highest priority nursing intervention for a client in the immediate postoperative phase?

Maintaining a patent airway

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

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.

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

dehisced.

A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse?

"It assists in preventing infection."

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?

7

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

A systolic blood pressure lower than 90 mm Hg

A client is at postoperative day 1 after abdominal surgery. The client 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 is 2430 mL. What action by the nurse is most appropriate?

Assess for signs and symptoms of fluid volume deficit.

A client is at postoperative hour 8 after an appendectomy and is anxious, stating "Something is not right. My pain is worse than ever and my stomach is swollen." Blood pressure is 88/50, pulse is 115, and respirations are 24 and labored. The abdomen is soft and distended. No obvious bleeding is noted. What action by the nurse is most appropriate?

Notify the physician.

Unless contraindicated, how should the nurse position an unconscious client?

On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration

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?

Position the client in the side-lying position.

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?

experiences pain within tolerable limits.

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

<30 mL

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

Pneumonia

What complication is the nurse aware of that is associated with deep venous thrombosis?

Pulmonary embolism

A client vomits postoperatively. What is the most important nursing intervention?

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

The nurse is admitting the older adult to the PACU. Which information about this client would be most important for the PACU nurse to obtain?

Does the client have a history of dementia-like symptoms?

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:

Empty and measure the drainage and compress the Hemovac.

A nurse asks a client who had abdominal surgery 1 day 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 as soon as possible after surgery.

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

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?

Assessing WBC count, temperature, and wound appearance

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dL, and a blood pressure lying in bed of 110/70 mm Hg. The nurse suspects abnormal orthostatic changes when the client gets out of bed and reports vertigo. What vital sign value most supports the client's orthostatic changes?

Blood pressure of 90/50 mm Hg

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.

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

A nursing measure for evisceration is to:

Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

First intention

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

Hypoxemia and hypercapnia

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.

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 observes that a postsurgical 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

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.

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?

The client is displaying early signs of shock.

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.

The nurse cares for a client who is three hours post op abdominal hysterectomy and begins to develop hiccups. What nursing assessment will the nurse monitor more closely with the client's new symptoms?

Wound approximation

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for?

Wound dehiscence

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.