Funds- Perioperative Nursing Care

A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery? 1. patency of the airway 2. dressing for bleeding 3. tubes or drains for patency 4. vital signs to compare with preoperative measurements

1 Rationale: if the airway is not patent, immediate measures must be taken for the survival of the client. after checking the client's airway, the nurse would then check the client's vital signs, and this would be followed by checking the dressings, tubes, and drains

The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem? 1. pneumonia 2. fluid imbalance 3. pulmonary edema 4. carbon dioxide retention

1 Rationale: the most common postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboi. pneumonia is the inflammation of lung tissue that causes a productive cough, dyspnea, and crackles. fluid imbalance can be a deficit or excess related to fluid loss or overload. pulmonary edema usually results from left sided heart failure, and it can be caused by medications, fluid overload, and smoke inhalation. carbon dioxide retention results from the inability to exhale carbon dioxide in clients with conditions such as COPD

The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. have the client void immediately before surgery 2. avoid oral hygiene and rinsing with mouthwash 3. verify that the client has not eaten for the last 24 hours 4. report immediately any slight increase in blood pressure or pulse

1 Rationale: the nurse should assist the client with voiding immediately before surgery so that the bladder will be empty. oral hygiene is allowed, but the client should not swallow any water. the client usually has restrictions of food and fluids for 8 hours before surgery rather than 24 hours. a slight increase in blood pressure and pulse is common during the preoperative period. this is generally the result of anxiety

The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation? 1. a urinary output of 20ml/hr 2. a temp of 37.6 3. a blood pressure of 100/70 4. serous drainage on the surgical dressing

1 Rationale: urine output is maintained at a minimum of at least 30ml for an adult. an output of less than 30ml/hr for each of 2 consecutive hours should be reported to the surgeon. a temp more than 37 or less than 36.1 and a falling systolic blood pressure less than 90 are to be reported. the client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. moderate or light serous drainage from the surgical site is considered normal

The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which nursing action should be performed? 1. shake the client gently to arouse 2. continue to monitor the vital signs 3. call the RN immediately 4. cover the client with a warm blanket

2 Rationale: a slightly lower than normal BP and an increased pulse rate are common after surgery. the LOC can be determined by checking the clients response to light touch and verbal stimuli rather than by shaking the client. warm blankets are applied to maintain the clients body temp. there is no need to contact the RN immediately

The nurse checks the client's surgical incision for signs of infection. Which is indicative of a potential infection? 1. the presence of serous drainage 2. the presence of purulent drainage 3 a temp of 98.8 F 4. the client complaining of feeling cold

2 Rationale: signs and symptoms of a wound infection include warm, red, and tender skin around the incision. the client may have a fever and chills. purulent material may exit from drains or from separated wound edges. infection may be caused by poor aseptic technique or a wound that was contaminated before surgical exploration; it appears 3 to 6 days after surgery. serous drainage is not indicative of a wound infection. a temp of 98.8 F is not an abnormal finding in a postop client. the fact that a client feels cold is not indicative or an infection, although chills and fever are signs of infection

The nurse is checking a clients surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which should be the initial action by the nurse? 1. cover the wound with a betadine-soaked dressing 2. apply a sterile dressing soaked with normal saline to the wound 3. leave the incision open to the air to assist with drying the drainage 4. clean the wound using aseptic technique, and apply a sterile, dry dressing

2 Rationale: wound dehiscence is the separation of the wound edges at the suture line. signs and symptoms include increased drainage and the appearance of underlying tissues. it usually occurs as a complication 60 to 8 days after surgery. the client should be instructed to remain quiet and avoid coughing or straining, and he or she should be positioned to prevent further stress on the wound. sterile dressings soaked with sterile normal saline should be used to cover the wound. the surgeon needs to be notified

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client a history of arthritis and has been taking (Aspirin). The nurse reports the information to the HCP and anticipates that the provider will prescribe which? 1. discontinue the aspirin immediately 2. continue to take the aspirin as prescribed 3. discontinue the aspirin 48 hours before the scheduled surgery 4. decrease the dose of the aspirin to half of what is normally taken

3 Rationale: anticoagulants alter normal clotting factors ad increase the risk of bleeding after surgery. aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery. however, the client should always check with his or her HCP regarding when to stop taking the aspirin when a surgical procedure is scheduled. therefore, the remaining options are incorrect

The nurse is caring for a client who is scheduled for surgery. The client is concerned about the surgical procedure. Which action should alleviate the client's fears and misconceptions about surgery? 1. tell the client that preoperative fear is normal 2. explain all nursing care and possible discomfort that may result 3. ask the client to discuss information known about the planned surgery 4. provide explanations about the procedures involved in the planned surgery

3 Rationale: explanations should begin with the information that the client knows. option 1 is a block to communication, and options 2 and 4 may produce additional anxiety in the client

The nurse is caring for a postoperative client who has a drain inserted into the surgical wound. Which action should the nurse avoid in the care of the drain? 1. check the drain for patency 2. observe for bright red, bloody drainage 3. maintain aseptic technique when emptying 4. secure the drain by curling or folding it and taping it firmly to the body

4 Rationale: aseptic technique must be used when emptying the drainage container or changing the dressing to avoid contamination of the wound. usually drainage from the wound is pale, red, and watery, whereas active bleeding will be bright red in color. the drain should be checked for patency to provide an exit for the fluid or blood to promote healing. the nurse needs to ensure that drainage flows freely and that there are no kinks in the drains. curling or folding the drain prevents the flow of the drainage