NUR307 Periop PrepU

A patient was admitted 2 hours ago to the postsurgical unit from PACU following a Hartmann's resection (bowel surgery). During the nurse's most recent assessment of the patient, significant bleeding was noted on the patient's abdominal dressing, which was previously dry and intact. What action should the nurse perform first? -Apply a transparent dressing over the existing bandage and position the patient side-lying. -Remove the patient's dressing and insert gauze packing if dehiscence is apparent. -Check the results of the patient's preoperative blood group and screen -Apply a sterile gauze and hold it in place while applying moderate pressure.

Apply a sterile gauze and hold it in place while applying moderate pressure. If bleeding is evident at a surgical site, a sterile gauze pad and a pressure dressing are applied, and the site of the bleeding is elevated to heart level if possible. The patient is placed in the shock position (flat on back, legs elevated at a 20-degree angle, knees kept straight). It would be inappropriate to remove the dressing or insert packing.

The nurse observes bloody drainage on the surgical dressing of the client who has just arrived on the nursing unit. Which intervention should the nurse plan to do next? Make the client NPO and order a stat hemoglobin and hematocrit. Remove the dressing, assess the wound, and apply a new sterile dressing. Outline the drainage with a pen and record the date and time next to the drainage. Take the client's vital signs and call the surgeon.

Areas of drainage on the dressing should be outlined with a pen, and the date and time should be recorded next to the drainage. Blood drainage from the incision is a normal expected finding in the immediate postoperative period; however, excessive amounts should be reported to the surgeon.

A nurse who works in the operating room is required to assess the client continuously and protect the client from potential complications. Which symptoms would the nurse watch for as indicative of malignant hyperthermia? Select all that apply. Cyanosis Cardiac arrest Increased urine output Mottled skin

Cyanosis Cardiac arrest Mottled skin Symptoms of malignant hyperthermia include tachycardia, tachypnea, cyanosis, fever, muscle rigidity, diaphoresis, mottled skin, hypotension, irregular heart rate, decreased urine output, and cardiac arrest.

Sudden withdrawal of which of the following may result in seizures? Tranquilizers Steroids Monoamine-oxidase inhibitors Thiazide diuretics

Abrupt withdrawal of tranquilizers may result in anxiety, tension, and even seizures if withdrawn suddenly. Abrupt withdrawal of steroids may precipitate cardiovascular collapse. Monoamine oxidase inhibitors increase the hypotensive effects of anesthetics. Thiazide diuretics may cause excessive respiratory depression during anesthesia due to an associated electrolyte imbalance.

The potential effects of prior medication therapy must be evaluated before surgery. Which of the following drug classifications may cause respiratory depression from an associated electrolyte imbalance during anesthesia? Corticosteroids Diuretics Insulin Anticoagulants

Diuretics

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? Low heart rate Elevated blood pressure Rapid respiration Subnormal temperature

Elevated BP Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess volume in the system. Respirations are not typically affected unless there is fluid accumulation in the lungs. Temperature is not generally affected.

The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of: Laryngospasm Hyperventilation Hypoxemia and hypercapnia. Pulmonary edema and embolism.

Hypoxemia and hypercapnia. Explanation: The primary objective in the immediate postoperative period is to maintain pulmonary ventilation and thus prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. Besides checking the health care provider's orders for and administering supplemental oxygen, the nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds.

The nurse recognizes that the client most at risk for mortality associated with surgery is the: Client who is obese Client with chronic alcoholism Client with controlled diabetes Client with controlled hypertension

The client with chronic alcoholism who experiences alcohol withdrawal symptoms is at significant risk for mortality, which can be attributed to cardiac dysrthymias, cardiomyopathy, and bleeding tendencies.