Ignatavicius Chapter 16: Care of Postoperative Patients

33. The nurse is caring for several postoperative clients on the unit. Which client does the nurse assess first? a. Client with 200 mL dark drainage from the nasogastric tube in an hour b. Client who received oral pain medication 20 minutes ago c. Client who has not yet ambulated after surgery 4 hours ago d. Client requiring discharge teaching and whose family is present

ANS: A 200 mL of dark drainage from the nasogastric tube in an hour should be assessed and communicated to the physician because it may indicate a bleed. Oral pain medication needs more than 20 minutes to be effective, and the nurse should re-assess the client when the pain medication has had time to take effect. Four hours is probably too soon for a client to ambulate after an operation. The nurse should include the family in discharge teaching, but the client with the nasogastric (NG) drainage needs to be seen first.

18. The nurse is changing the client's dressing on the second postoperative day and notes a small amount of serosanguineous drainage. What is the nurse's best action? a. Cleanse the suture line and apply a sterile dressing. b. Culture the drainage and leave the incision open to air. c. Cover the incision with a transparent dressing. d. Notify the surgeon to assess the client.

ANS: A A small amount of serosanguineous drainage is a normal assessment finding on the second postoperative day. The incision should be cleaned and dressed.

5. The nurse reviews the initial postanesthesia care unit (PACU) flow record and notes that the client is alert and oriented 3 when stimulated, pulse is 88 per minute and regular, respirations are 12 per minute and unlabored, and oxygen saturation is 95% on 2 LPM of nasal oxygen. What is the nurse's priority action at this time? a. Examine the surgical site; obtain blood pressure and temperature. b. Suction the client and assess anterior and posterior lung sounds. c. Assess urinary output, the IV site, and the client's pain. d. Turn the client and perform chest physiotherapy.

ANS: A Initial assessment on the client entering the PACU that should be recorded on the flow chart record includes level of consciousness, temperature, pulse, respirations, oxygen saturation, and blood pressure. In addition, the nurse should examine the surgical area for bleeding. These items were missing from the initial assessment.

20. A client reports pain 8 hours after surgery. The client has already received an opioid within the past 2 hours. What is the nurse's best action? a. Assess the pain further. b. Administer naloxone (Narcan). c. Call the surgeon. d. Document the finding.

ANS: A Opioids are short acting. The client may be undermedicated. The nurse should further assess location, intensity, etc., of the pain. If the client has no respiratory depression, it is possible that the dose can be increased. The nurse would not call the surgeon until the pain is further assessed. Narcan is used to reverse opioid effects but would not be appropriate in this case. Documentation is important, but the higher priority is a more complete assessment of the client's pain.

40. A client has received an overdose of a benzodiazepine. What medication does the nurse anticipate an order for? a. Flumazenil (Romazicon) b. Naloxone (Narcan) c. Acetylcysteine (Mucomyst) d. Digoxin immune fab (Digibind)

ANS: A Romazicon is the most commonly used antidote for benzodiazepine overdose. Narcan is used to treat overdoses of narcotics, Mucomyst can be used for acetaminophen overdose, and Digibind is used for digoxin overdoses.

6. A client who has just been transferred to the postanesthesia care unit (PACU) from surgery is very restless and confused. What is the nurse's first action? a. Orient the client and remain with him or her. b. Call the surgeon for an intraoperative report. c. Notify the physician on call. d. Assess the client's level of pain.

ANS: A The client who is not oriented is at risk of falling. The nurse should remain with the client to ensure safety, and should assign another staff member to the client if care has to be given to others. The client should not be left alone.

14. The nurse is caring for clients in the postanesthesia care unit (PACU). Which client does the nurse intervene for first? a. Client with a pulse deficit of 15 b. Client who is reporting leg pain c. Client with dementia who is confused d. Client who is reporting a headache

ANS: A The client with an apical radial pulse deficit could be having dysrhythmias, which may be indicative of volume deficit, acidosis, electrolyte imbalances, or hypothermia. All clients must be assessed and cared for according to their needs, but this client would be the nurse's highest priority.

31. The nurse is assisting a client to ambulate several hours after his surgery. The client coughs and says to the nurse, "I feel like something ripped in my incision." A large amount of blood is suddenly apparent on the client's gown near the incision. What action does the nurse take first? a. Ease the client to the floor and call for assistance. b. Put immediate pressure over the incision with the hands. c. Call the Rapid Response Team to assess the client. d. Lift up the gown and take off the dressing.

ANS: A The first action of the nurse should be to ease the client to the floor to reduce tension on the incision. This will help keep organs within the abdominal cavity and will help prevent the client from fainting and falling to the floor. The nursing staff should return the client to bed, and the nurse needs to reinforce the dressing while leaving the original one intact. The surgeon or the Rapid Response Team should be notified.

26. The nurse is working in the postanesthesia care unit (PACU) and receives a client from the operating room (OR). What does the nurse assess first? a. Client's endotracheal tube b. Client's nasogastric tube c. Client's Foley catheter d. Hemovac drain at the incision site

ANS: A The first priority for this client is to assess airway, breathing, and circulation postoperatively. Therefore, the patency of the client's endotracheal (ET) tube should be determined first. All other drains should be assessed, but they are not the priority.

35. The nurse is caring for a client who is reporting severe postoperative pain. The physician's order states that the client is to receive "hydromorphone hydrochloride (Dilaudid) 10-15 mg every 1-2 hours PRN pain." What is the nurse's priority action? a. Call the physician to clarify the order. b. Give the medication as ordered. c. Refuse to give the medication. d. Call the hospital pharmacist.

ANS: A The order must be clarified before the medication is given because the Dilaudid dosage is beyond safe parameters. The nurse can consult the pharmacist, but then would still need to call the physician to determine the specific route of administration and eliminate the "ranges" in the order. Refusing to give the medication will not help the client obtain pain relief.

2. A postoperative client is receiving morphine for pain. For which side effects does the nurse monitor this client? (Select all that apply.) a. Hypotension b. Respiratory depression c. Constipation d. Increased intracranial pressure e. Altered bleeding times

ANS: A, B, C Morphine can cause hypotension, respiratory depression, constipation, and urinary retention. Increased intracranial pressure is a side effect of butorphanol tartrate (Stadol), and altered bleeding times can occur owing to combination drugs that contain aspirin or ibuprofen.

8. The nurse is assessing a client admitted to the postanesthesia care unit (PACU) after abdominal surgery. The client's respiratory rate is 8 breaths/min and breath sounds are decreased in the bases. What is the nurse's priority action? a. Prepare to administer naloxone (Narcan). b. Assess oxygen saturation and level of consciousness. c. Call a code or the Rapid Response Team. d. Turn the client and perform chest physiotherapy.

ANS: B Additional data are needed to determine respiratory status, so the nurse must finish the assessment with an oxygen saturation (SaO2) and check the client's level of consciousness. A respiratory rate of less than 10 could indicate an emergency, especially if the SaO2 drops below 95%. A respiratory rate of less than 10 breaths/min may indicate anesthetic-induced depression. Naloxone should not be administered unless there are clear indications for it, and performing chest physiotherapy may not be warranted. Calling a code or the Rapid Response Team may be needed, but only after a complete assessment.

9. The nurse assesses a client who has just been brought to the postanesthesia care unit (PACU). In the operating room, the client's blood pressure was 136/80 mm Hg; it is now 110/80 mm Hg. Urine output was 40 mL/hr and is now 10 mL/hr. Which action by the nurse is best? a. Awaken the client and encourage oral fluids. b. Increase the IV of 0.9 NS as ordered to 100 mL/hr. c. Put the client in Trendelenburg position. d. Assess the client's levels of consciousness and pain.

ANS: B One of the most sensitive and earliest indicators of vascular volume loss is decreased urine output. The nurse is concerned about urinary output less than 30 mL/hr because this may indicate that the kidneys are not being perfused. The nurse should increase the IV rate. Oral fluids are not an option at this point because the client has not recovered from the anesthesia. Placing the client in Trendelenburg position is not warranted because this puts pressure on the heart and lungs, limiting their effectiveness. Assessing consciousness and pain can wait until later.

39. A client is being discharged after abdominal surgery. What information about the diet does the nurse teach the client? a. "Be sure to monitor your fluid intake." b. "Eat foods high in protein and vitamin C." c. "Call the physician if you develop gas." d. "You will need to limit your carbohydrates."

ANS: B Postoperatively, a diet high in calories, protein, and vitamin C promotes healing. There is no need to monitor fluid intake, to call the physician for gas, or to limit carbohydrates.

21. A client with diabetes mellitus type 1 underwent surgery 24 hours ago. Which precaution does the nurse take to help prevent postoperative complications for this client? a. Order a high-protein diet. b. Observe the incision frequently. c. Have suction available at the bedside. d. Instruct the client to use an electric razor.

ANS: B The client with diabetes is at higher risk for impaired wound healing and the development of wound infection. The nurse should observe the incision for drainage and changes in appearance. The client does not need a high-protein diet, suction, nor an electric razor owing to diabetes.

27. The nurse is caring for a client whose wound dehisces after vomiting. What is the nurse's first action? a. Prepare the client for emergency surgery. b. Cover the wound with sterile moist dressings. c. Give the client medication for nausea. d. Call the surgeon and the operating room.

ANS: B The dehisced wound should be covered immediately with sterile moist dressings. Then the nurse should call the surgeon.

22. The nurse is providing discharge teaching for a client who will be going home with a Jackson-Pratt (JP) drain. Which statement indicates that the client understands how to care for the drain correctly? a. "I will flush the tubing to make sure that it stays open." b. "I will measure the drainage before I discard it." c. "I will close the drain valve and then compress the bulb to create suction." d. "I will pull it out once the surgeon says I don't need it anymore."

ANS: B The drainage from the JP should be measured before it is discarded. The client does not have to flush the tubing. The tubing is sutured in place, and the client should not pull on it. The bulb should be compressed, then the drain valve closed.

11. A client is brought to the postanesthesia care unit (PACU) after surgery that took place with the client in the lithotomy position. Which action does the nurse take after assessing vital signs? a. Assess for sacral decubiti. b. Assess dorsalis pedis pulses. c. Turn the client on the left side. d. Put the client in the Trendelenburg position.

ANS: B The lithotomy position can compromise the client's peripheral circulation in the lower extremities, leading to weak pedal pulses. The nurse should check dorsalis pedis pulses. The client would not need to be assessed for decubiti, turned on the side, nor placed in the Trendelenburg position.

16. One hour after admission to the postanesthesia care unit (PACU), the postoperative client has become very restless. What is the nurse's first action? a. Assess for bladder distention. b. Assess the oxygen saturation level. c. Call the surgeon to assess the client. d. Administer pain medication as ordered.

ANS: B The most common causes of restlessness in the immediate postoperative period are hypoxemia and pain. Although pain control is very important, determining the adequacy of ventilation in this case has higher priority.

23. The nurse is caring for a client who has had surgery the previous day. The client tells the nurse, "Breathing in using this thing (incentive spirometer) is a ridiculous waste of time." What is the nurse's best response? a. "The spirometer will help you cough effectively." b. "The spirometer will help your lungs expand." c. "The spirometer will help prevent blood clots." d. "The spirometer will improve blood flow in your lungs."

ANS: B The primary purpose of using an incentive spirometer is to promote lung expansion. The incentive spirometer assists the client in seeing how much air he or she can inhale. The nurse can encourage the client by setting a volume and encouraging the client to reach it. Although many clients may cough while using this, it does not help them cough. Clients begin to cough after taking deep breaths. The spirometer will help with airflow into the lungs, not with blood flow.

36. Which instruction does the nurse provide to a client to prevent postoperative venous thromboembolism? a. "Cough and deep-breathe six times every hour after surgery." b. "Use your incentive spirometer hourly." c. "Get up and walk as much as possible." d. "Keep the sterile dressing on your incision."

ANS: C Ambulation will help prevent formation of blood clots in the legs, the most common site for postoperative venous thromboembolism. Coughing and deep breathing will help prevent atelectasis, and sterile dressings will help prevent wound infection.

10. The nurse is caring for a client who has just been brought to the postanesthesia care unit (PACU) after surgery. The client's oxygen saturation is 92% and his hemoglobin is 14 g/dL. What is the nurse's first action? a. Assess the client's pain response. b. Determine whether the client is alert and oriented. c. Increase oxygen and auscultate lung sounds. d. Assess vital signs and temperature.

ANS: C Oxygen saturation is the most definitive assessment finding for whether or not the client is adequately oxygenated. However, because oxygen saturation is based on the amount of hemoglobin in the blood, this indicator needs to be evaluated, in addition to the saturation. If a client has low hemoglobin, even if the percentage of saturation is high, the client is still underoxygenated. Oxygen should be increased and further respiratory assessment performed.

1. The nurse is caring for a client who had surgery 24 hours ago. He is alert and oriented when awakened and reports pain, but goes back to sleep when not being stimulated. He is on patient-controlled analgesia (PCA). What is the nurse's next action? a. Push the PCA control for the client. b. Discontinue the PCA immediately. c. Assess the client's respiratory status. d. Keep the client awake as much as possible.

ANS: C The client should be assessed further before action is taken. If the client cannot stay awake 24 hours after surgery, there may be other problems. The nurse should assess respiratory rate and depth and lung sounds, as well as oxygen status. The nurse should never push the PCA for the client, and pain should be assessed before decisions are made and interventions taken.

4. The nurse is performing a hand-off report in the PACU. What is the best action for the nurse to perform during the hand-off report? a. Write all information on a chart and hand it to the nurse who will assume care of the client. b. Follow the nurse assigned to the new client and give a verbal report that does not interrupt care. c. Focus on the report and sit with the nurse receiving the client to give a detailed report. d. Finish the report quickly so the nurse can assume care of the client.

ANS: C The hand-off report is a time when errors can potentially occur. The nurse should sit with the receiving nurse to give report. That way, both nurses will be focused on the report. Simply handing the information to the new nurse does not ensure that he or she will read or understand it. Following the accepting nurse around and giving report while he or she provides care for other clients would be distracting. The hand-off nurse should not hurry through this report and should provide a report that allows for two-way communication between nurses.

29. The nurse is preparing a client for discharge. The client has a large draining wound. What is the nurse's best action? a. Arrange a nurse to come to the house to change the dressing after discharge. b. Have the client come back to the clinic daily to have the dressing changed. c. Teach the client and family how to change the dressing. d. Apply a hydrocolloid dressing and change once a week.

ANS: C The nurse should teach the client and family members to change the dressing as necessary. If they are not able to perform this task, a referral can be made for home health nursing. A daily trip to the clinic would be inconvenient; this would increase the chance of noncompliance. A hydrocolloid dressing is not indicated for this wound.

1. Which clients are at increased risk for postoperative nausea and vomiting? (Select all that apply.) a. Older adult with a history of hypertension b. Client who was in the lateral position during surgery c. Middle aged client with a body mass index (BMI) of 46 d. Woman who has undergone a cholecystectomy e. Young adult who received 3 L of IV fluid during surgery f. Man who has a history of seasickness g. Man who has a nasogastric tube to suction

ANS: C, D, F Obesity, motion sickness, and general anesthesia carry increased risk for postoperative nausea and vomiting.

17. The nurse is caring for a client in the postanesthesia care unit (PACU) 2 hours after abdominal surgery. The nurse auscultates the client's abdomen and notes that there are no bowel sounds. What action does the nurse take? a. Position the client on the left side with the bed flat. b. Insert a nasogastric tube to low intermittent suction. c. Palpate the bladder and measure abdominal girth. d. Document the finding and continue to monitor.

ANS: D Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that should be documented. No intervention specific to this finding is needed at this time.

3. A client has been transferred to the postanesthesia care unit (PACU). Which action does the receiving nurse perform first? a. Complete a nursing assessment sheet. b. Change the client's arm band. c. Enter client data into the computer. d. Participate in a hand-off report.

ANS: D After the surgery is completed, the circulating nurse and the anesthesia provider accompany the client to the PACU. A hand-off report that meets National Patient Safety Goal 2 requires effective communication between health care professionals.

19. The nurse is caring for a client who had abdominal surgery 3 days ago. He tells the nurse, "I felt something 'give way' when I coughed." What is the nurse's best response? a. "It is good that you are coughing and deep-breathing to prevent pneumonia." b. "That is a normal feeling in the incision whenever you are moving." c. "Be sure to splint the incision with a pillow or your hands when you cough." d. "Lie down flat on the bed with your knees up and let me examine your incision."

ANS: D Although wound dehiscence is not a common complication after surgery, it is usually painless and the client feels as if something has split or given way. This frequently occurs after coughing. Any client report of such a sensation should be assessed immediately.

2. Postoperatively, a client has a heart rate of 120 beats/min, with dysrhythmias noted on the ECG monitor and a respiratory rate of 34 breaths/min, and is very difficult to arouse. Which action by the nurse is most appropriate? a. Accompany the client to the postanesthesia care unit (PACU). b. Keep the client in the surgical suite. c. Call a code or the Rapid Response Team. d. Transfer the client to the intensive care unit (ICU).

ANS: D Clients in critical condition are transferred from the operating room directly to the ICU. This client is not stable with elevated heart and respiratory rates, dysrhythmias, and difficulty in arousal.

15. The nurse is caring for several clients on the postoperative unit. Which client does the nurse determine has the highest risk of respiratory complications after general anesthesia? a. Older woman taking a calcium channel blocker for hypertension b. Middle-aged man with a deviated nasal septum c. Middle-aged woman taking St. John's wort daily for depression d. Young adult with a body mass index of 40

ANS: D Clients who are extremely obese have heavy chest walls that make it difficult to expand the lungs fully. The other clients would not have an elevated risk of respiratory complications.

25. The nurse is caring for clients in the postanesthesia care unit (PACU). Which client is ready to be extubated? a. Client with an oxygen saturation of 90% b. Client with a respiratory rate of 14 breaths/min c. Client who is alert and oriented d. Client who is coughing and gagging

ANS: D Coughing and gagging on the endotracheal (ET) tube indicates readiness for extubation; the client should be further assessed to see whether he or she meets other extubation criteria. Often these criteria include ability to raise and hold the head up and evidence of thoracic breathing. An oxygen saturation of 90% is abnormal. Respiratory rate and orientation status are not sufficient criteria for extubation.

37. The nurse is assessing clients in the postanesthesia care unit (PACU). A client is shivering and has a temperature of 95.4° F (35.2° C). What is the nurse's best action? a. Get the client warm blankets. b. Elevate the head of the bed. c. Auscultate the client's lungs. d. Assess the client's oxygen saturation.

ANS: D Hypothermia can cause shivering and hypoxemia. The nurse first should assess the client's oxygen saturation, then should apply warm blankets to bring the client's temperature up to a normal level. The other two actions may be needed but not as a priority.

7. A client had surgical repair of a fractured ankle under local anesthesia and is being transferred from the postanesthesia care unit (PACU) to the surgical floor. Once admitted, what is the nurse's priority action? a. Assess pressure points for breakdown. b. Assess the client's pain. c. Insert an IV for antibiotic therapy. d. Assess a full set of vital signs.

ANS: D On admission to the surgical floor from the PACU, the nurse should assess vital signs every 15 minutes 4, then every 30 minutes 4 and every 2 hours 4. After vital signs, the nurse would continue with assessments, including the surgical site and pain. An IV should already be inserted before arrival to the surgical unit.

24. After discharge from the postanesthesia care unit (PACU), the client returned to the surgical nursing unit at 10 AM. It is now 6 PM, and the client is not experiencing any complications. How often does the nurse assess the client's vital signs? a. Every 15 minutes b. Every 30 minutes c. Every hour d. Every 4 hours

ANS: D Once the client leaves the PACU, the nurse should monitor vital signs every 15 minutes 4, every 30 minutes 4, every hour 4, then every 4 to 8 hours for the next 24 to 48 hours. It has been 8 hours since the client returned to the surgical nursing unit, so vital signs should be monitored every 4 hours at this point.

32. A client is scheduled for an operation. What does the nurse teach the client about postoperative pain control? a. "You should not ask for IV pain medication more than once every 4 or 5 hours." b. "You should not take the pain medication if you are nauseated." c. "You will not get pain medication until you are transferred to the floor." d. "You should ask for pain medication before the pain becomes severe."

ANS: D Pain medications are most effective when they are administered before the pain becomes severe. IV pain medications often are given every 1 to 2 hours. If the client is nauseated, the IV route can be used. The client will receive pain medication as needed in the postanesthesia care unit (PACU).

28. The nurse is changing the dressing on a postoperative client's abdominal incision. A Jackson-Pratt (JP) drain is present, along with a moderate amount of serosanguineous drainage. What is the best product for the nurse to use in performing wound care? a. Half hydrogen peroxide and half sterile saline b. Sterile water and antibacterial ointment c. Betadine swabs or alcohol wipes d. Sterile normal saline

ANS: D Sterile saline should be used to clean wounds because it is not harmful to granulating tissues. Hydrogen peroxide, Betadine, and alcohol are all harmful to new tissue. Sterile water is not isotonic so is not recommended. The incision should be cleaned from the least contaminated area to the most contaminated area, from inside the incision toward the surrounding skin.

38. The nurse assesses clients in the postanesthesia care unit (PACU). Which client does the nurse intervene for first? a. Client with a respiratory rate of 12 breaths/min b. Client with an oxygen saturation of 92% c. Client who is reporting pain (5 out of 10) d. Client with audible stridor

ANS: D Stridor, a high-pitched crowing sound, indicates airway obstruction resulting from tracheal or laryngeal spasms or edema or other airway blockage. Opening the airway is the highest priority. The other clients are stable, although the client with pain may need pain medication. However, this does not take priority over caring for the client with stridor.

12. A client is being transferred to the postanesthesia care unit (PACU) after surgery. The client has an endotracheal tube (ET) in place. On assessment, the client has oxygen saturation of 95%, respiratory rate of 14 breaths/min, and asymmetric chest wall expansion. What is the nurse's best action? a. Attempt to awaken the client. b. "Bag" the client with a resuscitation bag. c. Increase the client's fraction of inspired oxygen (FIO2). d. Auscultate lung sounds bilaterally.

ANS: D The ET tube could have slipped into the right mainstem bronchus. Auscultating the lungs will help to confirm this; then the nurse should call the health care provider because the tube will need to be pulled back. Attempting to awaken the client will not change the asymmetric chest wall expansion, neither will "bagging" the client or increasing the fraction of inspired oxygen (FIO2). Because the client's oxygen saturation is still within an acceptable range, this is not warranted.

34. The nurse is reviewing postoperative medication orders. Which order can the nurse implement? a. Acetaminophen orally PRN pain b. Meperidine (Demerol) 75-100 mg every 3-4 hours PRN pain c. MS .5 mg subcutaneously every 1-3 hours PRN pain d. Hydromorphone hydrochloride (Dilaudid) 1 mg orally every 4 hours PRN pain

ANS: D The acetaminophen order does not have a frequency (PRN is not sufficient). The Demerol order does not have a route. MS must be spelled out (morphine sulfate), and the dosage must be written as 0.5 mg. The Dilaudid order includes the drug name, dosage, route, and frequency—all correctly written out.

30. A postsurgical client's urinary output via the Foley catheter is 30 mL in 3 hours. What is the nurse's first action? a. Increase the IV infusion rate. b. Assess the client's skin turgor. c. Weigh the client. d. Check the patency of the catheter.

ANS: D The nurse should check to ensure that the client's catheter tubing is patent. If the catheter is patent, the nurse should increase the IV flow rate if there are orders to do so, or should call the surgeon to report the information and request more fluids. Assessing the skin turgor would give information on hydration status, but this would not be the first intervention. Weighing the client probably would not give relevant information related to this client because the concern has arisen in the last 3 hours.

13. A client who is being admitted to the postanesthesia care unit (PACU) has weak hand grasps on assessment and is unable to lift his head off the bed. During hand-off report, the nurse notes that the client has received a neuromuscular-blocking agent. What is the nurse's best action? a. Document the finding. b. Check the client's pulses. c. Place the client in Fowler's position. d. Auscultate the lungs.

ANS: D When neuromuscular blocking agents are used, the client is at risk that these agents could be retained. The primary concern is the client's airway owing to muscular weakness. Because the client cannot raise the head and has a weak hand grasp, this may be a potential problem. The nurse should document all assessment findings. Placing the client in Fowler's position and checking the pulses is not warranted.

1. A surgical procedure has just been concluded for a client who received a general anesthetic. Place the interventions in order of implementation. (Select in order of priority.) a. Determining pain response b. Assessing the IV c. Taking the client's vital signs d. Applying warmed blankets

ANS: d, c, a, b First, warm blankets are applied for client comfort, because the client will start shivering as an effect of the general anesthesia. Next, vital signs should be taken, then pain assessed. Finally, the nurse can assess the IV.