Post Operative Nursing Management

The nurse is caring for a client with COPD who needs teaching on pursed lip breathing. Place the steps in order

1. Inhale through your nose 2. Slowly count to 3 3. Exhale slowly through pursed lips 4. . Slowly count to 7

A nurse prepares to suction a client's trache tube. Place the steps in order

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

Adequate hourly urine output for a client with an indwelling urinary catheter is

2.0 ml/kg/hr

The nurse is preparing to discharge a patient from the PACU using PACU room scoring guide. With what score can the patient be transferred out of the recovery room

8

When should the nurse encourage the post op patient to get out of bed

As soon as it is indicated

A client is a post-op day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75ml/h, has a NGT to low wall suction with 200ml every 8 hours of light yellow fluid and a wound drain with 50ml of dark red drainage every 8 hours. The 24 hour urine output total is 2430 ml. What action by the nurse is most appropriate.

Asses for signs and symptoms of fluid volume deficit

The client post-op 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

Following a splenectomy, a client has a HGb level of 7.5g/dL and has a vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that most support the nurse's analysis are

Blood pressure 80/40 mm hg and pulse 130 bpm

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 nurses's priority action

Call the health care provider

The post-op client is being evaluated for discharge and currently has an aldrete score of 8. Which of the following is most likely outcome for this patient

Can be discharged from PACU

The nurse is responsible for monitoring cardiovascular function in a Post-Op patient. What method can the nurse use to measure cardiovascular function

Central venous pressure

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

Changing position watching television listening to music

When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as

Clean contaminated

A client with nausea and vomiting is to receive an antiemetic that inhibits the vomiting center in the brain. Which of the following would the nurse expect the physician to order most likely

Comparing (prochlorperazine)

A physician's admitting note lists a wound as healing by second intention. What does the nurse expect to find

A wound in which the edges were not approximated

The nurse is concerned that a post-op patient may have a paralytic lieus. What assessment data may indicate that the patient does have a paralytic lieu's

Absence of peristalsis

To prevent pneumonia and promote the integrity of pulmonary system, an essential post-op nursing intervention include

Ambulate got the client as soon as possible

Which of the following mobility criteria must a post-op client meet to discharge to home. Select all that apply

Ambulate the length of the clients house Get out of bed without assistance Be able to self toilet

A nurse is reviewing with a client the use of a PCA device and is explaining the benefits. Which of the following would the nurse correctly emphasize. Select all that apply .

Fosters client participation in care Facilities reduction of post-op pulmonary complications

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates teaching has been effective

I can resume my usual activities as soon as I get home

Nursing assessment findings reveal a temperature of 96.2 F, pulse ox 90% , shivering and client complains of chilling. The findings are indicative of which nursing diagnosis

Ineffective thermoregulation

Primary objective in the immediate post-op period is

Maintaining pulmonary ventilation

The PACU nurse is caring for an older adult who presents with clinical manifestation of delirium. Which short term outcome would be most important for this client. The client:

Maintains adequate oxygenation status

The nurse is caring for a client post-op. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery

Encourage the client to move legs frequently and do leg exercises

Which term refers to the protrusion of abdominal organs through surgical incision

Evisceration

A client in post-op hour 8 after appendectomy and is anxious, stating" something is not right. My pain is worse than ever and my stomach is swollen." Blood pressure is 88/50, pulse is 115 and respirators are 24 and labored. The abdomen is soft and distended. No obvious bleeding is noted. What action by the nurse is most appropriate

Notify the physician

Unless contraindicated, how should the nurse position an unconscious patient

On the side with a patient back's and chin extended, to minimize the dangers of aspiration

The client complains of weakness and dizziness as the nurse assists the client to sit on the side of the bed. The nurse recognizes the client is experiencing

Orthostatic hypotension

On post-p day 2, a client requires 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

When vomiting occurs post-op. What is the most important nursing intervention

Turn the patients head completely to one side to prevent aspiration of vomitus into the lungs

Which of the following clinical manifestations increase the risk for evisercation in the post-op client

Valsalva maneuver

The nurse cares for a client who is 3 hour post-op abdominal hysterectomy and begins to develop hiccups. What nursing assessment will the nurse monitor more closely with the client's new symptoms

Wound approximation

You are caring for a client who is an obese diabetic. The client is 48 hours post surgery. What is this client at increased risk for

Wound dehiscence

Nursing assessment findings reveal a temperature of 103.2 F, tachycardia, and client complaints of increased incision pain. The nurse recognizes the client is experiencing

Wound infection

The client is experiencing nausea and vomiting the following surgery. The nurse expects the surgeon to order

Zofran (ondansetron)

Which is a classic sign of hypovolemic shock

Pallor

In what phase PACU is the client prepared for self-care or care in the hospital or an extended care setting

Phase II PACU

A post-op client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem

Pink color

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

What does the nurse recognize as one of the most common post-op respiratory complications in elderly patient

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

Position the client in the side-lying position

The nurse is caring for post-op client in the PACU. Which of the following is the priority nursing action

Position the client to maintain a patent airway

The nurse is reviewing the medications of a post-op client. Which of following medications may be concern to the nurse

Prednisone (deltasone)

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

Pulmonary embolism

The nurse recognizes which symptom as a clinical manifestation of shock

Rapid, weak thready pulse

The nurse is attempting to ambulate a client who underwent shoulder surgery earlier in the day, but the client is refusing to do so. What action by the nurse is most appropriate?

Reinforce the importance of early mobility in preventing complications

The nurse observes that a post surgical client has a hemorrhage and is hypovolemic shock. Which nursing intervention will manage and minimize the hemorrhage and shock

Reinforcing dressings or applying pressure if bleeding is frank

Nursing assessment findings reveal a temperature of 96.2 F, pulse o 90%, shivering and client complains of chilling. Which of the following actions by the nurse would be inappropriate

Restrict oral fluids

The nurse is teaching the client about PCA. Which of following wound be appropriate for the nurse to include in the teaching plan?

Therapeutic drug levels can be maintained more evenly with PCA

You are caring for a client who needs to ambulate. What considerations should be included when planning the post-op ambulatory activities for older adults

Tolerance

A client had a nephew to my 2 days ago and is now complaining of a abdominal pressure and nausea. The first nursing action should be to

Auscultate bowel sounds

A nurse is planning care for a patient schedule to undergo a thoracotomy. After tolerating full liquids, which dietary recommendation will the nurse consider

Small, frequent full fat meals

The nurse is changing the dressing of a client who is a 4 days post-op with an abdominal wound. The nurse has changed this dressing daily since surgery. Today the nurse notes increase serosanguinous drainage, wound edges not approximated and a 1/4 inch gap at the lower end of the incision. The nurse concludes which of the following conditions exists

Dehiscence

A nurse asks a client who had abdominal surgery 3 days 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 at least three times per day

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

First intention

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage

Hemovac drain isn't compressed; instead it is fully expanded

A client asks why a drain is in place to pull fluid from the surgical wound.what is the best response by the nurse

It assists in preventing infection

When abnormal post-op urinary output should the nurse report to the physician for a 2 hour period

Less than 30 ml

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

Moisten sterile gauze with normal saline and place on the protruding organ

A post-op client with an open abdominal wound is currently taking corticosteroids. The physician orders a culture of the abdominal wound even though no signs or symptoms of infection are seen. What action by the nurse is appropriate

Obtain the would culture specimen

What measurement should the nurse report to the physician in the immediate post-op period

Systolic blood pressure lower than 90 mm hg

Select the nutrient that is important for post-op wound healing because is helps form collagen

Vitamin c