MED SURG I Chapter 16: Postoperative Nursing Management

You are caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery? Place the client in a side-lying position. Place pressure on the client's lower extremities. Encourage the client to move legs frequently and do leg exercises. Place pillows under the client's knees or calves.

Encourage the client to move legs frequently and do leg exercises.

Which term refers to the protrusion of abdominal organs through the surgical incision? Dehiscence Evisceration Hernia Erythema

Evisceration

Using the PACU room scoring guide, a nurse would give a patient an admission cardiovascular score of 2 if the patient's blood pressure is what percentage of his or her preanesthetic level? 40% to 50% 30% to 40% Greater than 50% 20%

20%

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 5 6 4

7

A nurse is assessing the client's readiness for discharge from the postanesthesia care unit (PACU). The nurse can rouse the client by calling the client's name. The client can move all extremities and has a blood pressure of 134/82. Baseline preoperative blood pressure was 128/78. The most recent pulse oximetry reading was 94% on room air; the client's respirations are deep and easy at a rate of 12 breaths/minute. What is the calculated Aldrete score? 9 8 7 10

9

What measurement should the nurse report to the physician in the immediate postoperative period? A hemoglobin of 13.6 A temperature reading between 97°F and 98°F Respirations between 20 and 25 breaths/min A systolic blood pressure lower than 90 mm Hg

A systolic blood pressure lower than 90 mm Hg

Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply. Ambulate the length of the client's house Be able to self-toilet Get out of bed without assistance Pass a stress test Be able to drive to the grocery

Ambulate the length of the client's house Be able to self-toilet Get out of bed without assistance

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: Assessing breath sounds at least every 2 hours Ambulating the client as soon as possible Assisting with incentive spirometry every 6 hours Positioning the client in a supine position

Ambulating the client as soon as possible

The nurse is caring for a client in the postanesthesia care unit (PACU). The client has the following vital signs: pulse 115, respirations 20, oral temperature 97.2°F, blood pressure 84/50. What should the nurse do first? Review the client's preoperative vital signs. Increase rate of IV fluids. Assess for bleeding. Notify the physician.

Assess for bleeding.

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? Document the findings and reassess in 24 hours. Assess for edema. Assess for signs and symptoms of fluid volume deficit. Discontinue the nasogastric tube suctioning.

Assess for signs and symptoms of fluid volume deficit.

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? Assess the client's heart rhythm and nail beds. Apply oxygen. Notify the physician. Document the findings.

Assess the client's heart rhythm and nail beds.

Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis? Decreased cardiac output Ineffective airway clearance Acute pain Urinary retention

Decreased cardiac output

A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate? Remove the oral airway. Notify the physician of impaired neurological status. Continue with frequent client assessments. Obtain vital signs, including pulse oximetry, every 5 minutes.

Continue with frequent client assessments.

A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first? Ask the client to drink as much fluid as possible. Explain to the client what is happening and provide support. Cover the protruding internal organs with sterile gauze moistened with sterile saline solution. Push the protruding organs back into the abdominal cavity. SUBMIT ANSWER

Cover the protruding internal organs with sterile gauze moistened with sterile saline solution. Immediately covering the wound with moistened gauze prevents the organs from drying. The gauze and the saline solution must be sterile to reduce the risk of infection. Although providing support to reduce the client's anxiety is important, it isn't the priority nursing action. The organs shouldn't be pushed back into the abdomen; doing so may tear or damage them. Evisceration requires emergency surgery; therefore, the nurse should put the client on nothing-by-mouth status immediately.

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: Second intention Granulation Third intention First intention

First intention

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? Fourth intention Second intention Third intention First intention

First intention

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? Secondary Primary Intermediary Tertiary

Intermediary

The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply. Watching television Changing position An epidural infusion Listening to music An On-Q pump

Listening to music Watching television Changing position

A nurse is receiving a client to the postanesthesia unit. What initial nursing activity is most important in the postoperative recovery area? Administer medications and fluids. Inspect surgical site. Assess pain level. Maintain patient safety.

Maintain patient safety.

Corticosteroids have which effect on wound healing? May cause protein-calorie depletion Mask the presence of infection Cause hemorrhage Reduce blood supply

Mask the 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.

You are a PACU nurse caring for an older adult client who is recovering from surgery. The client tells you they are in pain. You know older adults react to medications differently than younger clients. What does this client's age put them at increased risk for? Overdose of pain medication Anxiety Longer recovery time Acute agitation

Overdose of pain medication

Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention? Blood pressure of 94/62 mm Hg Urine output of 60 ml/hr Oxygen saturation of 82% Respiratory rate of 12 breaths per minute

Oxygen saturation of 82%

On postoperative day 2, a client requires 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 it with a dry dressing Cleaning the wound with soap and water, then leaving it open to the air Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive Covering the well-approximated wound edges with a dry dressing

Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing

Which is a classic sign of hypovolemic shock? Pallor High blood pressure Dilute urine Bradypnea

Pallor

A client who is receiving the maximum levels of pain 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. Massaging the client's legs Applying hot cloths to the client's face Changing the client's position Putting on soothing music Performing guided imagery

Performing guided imagery Putting on soothing music Changing the client's position

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? Pneumonia Pleurisy Hypoxemia Pulmonary edema

Pneumonia

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? Administer an anti-emetic. Obtain an emesis basin. Position the client in the side-lying position. Ask the client for more clarification.

Position the client in the side-lying position.

What complication is the nurse aware of that is associated with deep venous thrombosis? Pulmonary embolism Swelling of the entire leg owing to edema Marked tenderness over the anteromedial surface of the thigh Immobility because of calf pain

Pulmonary embolism

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? Continuously repeat the instructions until the client restates them. Ask the client, "Do you understand?" Give the written instructions to the client's 16-year-old child. Review the instructions with the client and an accompanying adult.

Review the instructions with the client and an accompanying adult.

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 Third-intention healing First-intention healing Primary-intention healing

Second-intention healing

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? Anemic Episodic Hypoxic Subacute

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

Which of the following stimulates the wound healing process? Sufficient oxygenation Immobility Nutritional deficiencies Hemorrhage

Sufficient oxygenation

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 should be transferred to an intensive care area. The client must be put on immediate life support. The client must remain in the PACU. The client can be discharged from the PACU.

The client can be discharged from the PACU. Aldrete score = assesses the readiness of patients recovering from anesthesia in the PACU Higher score = more ready Scores range from 0-10

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 late signs of shock. The client is showing signs of an anesthesia reaction. The client is displaying early signs of shock. The client is showing signs of a medication reaction.

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. Family members can be involved in the administration of pain medications with patient-controlled analgesia. The client can self-administer oral pain medication as needed with patient-controlled analgesia. There are no advantages of patient-controlled analgesia over a PRN dosing schedule.

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

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? Convalescent period Respiratory depressive effects Detailed medication history Tolerance

Tolerance

Which of the following clinical manifestations increases the risk for evisceration in the postoperative client? Edema Hypoxia Valsalva maneuver Hypovolemia

Valsalva maneuver the action of attempting to exhale with the nostrils and mouth, or the glottis, closed. This increases pressure in the middle ear and the chest, as when bracing to lift heavy objects, and is used as a means of equalizing pressure in the ears.

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

Wound dehiscence

Nursing assessment findings reveal a temperature of 39.5 C (103.2°F), tachycardia, and client complaints of increased incisional pain. The nurse recognizes the client is experiencing: Atelectasis Uncontrolled pain Wound infection Hyperthermia

Wound infection

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. palpate the abdomen. change the client's position. insert a rectal tube.

auscultate bowel sounds.

It is important for the nurse to assist a postsurgical client to sit up and turn the head to one side when vomiting in order to avoid dizziness. help eliminate inhaled anesthetics. avoid aspiration. maximize comfort.

avoid aspiration.

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 eviscerated. dehisced. hemorrhaged. pustulated.

dehisced. Dehisced: organs do not protrude out of the wound Eviscerated: organs protrude out of the wound

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? Normal healing by primary intention. Dehiscence Evisceration Hemorrhage

dehiscence

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? exhibits wound healing without complications. resumes usual urinary elimination pattern. maintains adequate fluid status. experiences pain within tolerable limits.

experiences pain within tolerable limits.