Post-Op PrepU

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

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 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

The nurse is caring for a client during the immediate postoperative period and is assessing for signs of shock. What signs and symptoms indicate that the client may be in shock?

weak, rapid pulse rate

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

1. Position the client in Fowlers position. 2. Don sterile gloves. 3. Lubricate the sterile suction catheter. 4. Insert suction catheter into the lumen of the tube. 5. Apply intermittent suction while withdrawing the catheter.

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

<30 mL less than 30 ml

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 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

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

Evisceration

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

First intention

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

Hypoxemia and hypercapnia

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.

Listening to music Watching television Changing position

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

Pneumonia

Which is the of the following factors stimulates the wound healing process?

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 can be discharged from the PACU.

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 is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus?

absence of peristalsis

When should the nurse encourage the postoperative patient to get out of bed?

as soon as it is indicated

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 q

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 HCP

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?

continue with frequent client assessments

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 CO

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 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?

early signs of shock -anxious, apprehensive, BP 90/56

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

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

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

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?

moisten sterile gauze with normal saline and place on the protruding organ.

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

ondansetron

Which is a classic sign of hypovolemic shock?

pallor

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 has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to:

place saline-soaked sterile dressings on the wound.

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 client in side-lying position

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?

position client to maintain a patent airway

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

pulmonary embolism

A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention?

report early calf pain