PrepU Med-Surg Chaper 19

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? a) Notify the physician. b) Assess the patient's heart rhythm and nail beds. c) Document the findings. d) Apply oxygen.

Assess the client's heart rhythm and nail beds. 448 Explanation: A patient may demonstrate low oxygenation readings due to wearing certain colors of nail polish or irregular heart rate such as atrial fibrillation. These items should be assessed to ensure the accuracy of the oxygen reading. Once the reading is confirmed as accurate, then the nurse may need to apply oxygen, notify the physician, and document the findings.

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 452 Explanation: First-intention healing is characterized by a closed incision with little tissue reaction and the absence of signs and symptoms of infection.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

First intention. 452 Explanation: Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.

The primary objective in the immediate postoperative period is

Maintaining pulmonary ventilation. 441

When vomiting occurs postoperatively what is the most important nursing intervention?

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

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 nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?

Pink to red and soft, noting that it bleeds easily 452

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 preparing the client with an abdominal incision for discharge. Which statement by the client indicates teaching has been ineffective? a) "My incision should become less red and tender." b) "I can resume my usual activities as soon as I get home." c) "I need to keep my follow-up appointment with the physician." d) "I should call my physician if I develop a fever."

"I can resume my usual activities as soon as I get home." Explanation: By time of discharge, clients should be able to verbalize clinical manifestations of complications, activity and diet restrictions, and specifics regarding follow-up appointments. The client with abdominal incision will need to avoid lifting and driving in the initial discharge period.

The nurse determines that a patient is at risk for the develop meant of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply)

- Assisting the patient with leg exercises - Encouraging early ambulation - Avoiding placement of pillows or blanket rolls under the patients knees

Adequate hourly urine output for a patient with an indwelling urinary catheter is a) 30 mL/hr. b) 20 mL/hr. c) 15 mL/hr. d) 25 mL/hr.

30 mL/hr. Explanation: If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/hr are reported.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: a) auscultate bowel sounds. b) change the client's position. c) palpate the abdomen. d) insert a rectal tube.

Auscultate bowel sounds. 455 Explanation: If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.

A term used to describe a partial or complete separation of the wound edges is a) evisceration. b) erythema. c) dehiscence. d) hemorrhage.

Dehiscence. Explanation: Evisceration is the protrusion of organs through the surgical incision. Dehiscence is the partial or complete separation of wound edges. Erythema refers to redness of the skin. Hemorrhage is excessive bleeding.

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. 455 Explanation: The nurse should encourage the client to ambulate at least three times per day. Ambulating stimulates peristalsis, which helps the bowels to move. It isn't appropriate to apply heat to a surgical wound. Moreover, heat application can't be initiated without a physician order. A tap water enema is typically administered as a last resort after other methods fail. A physician's order is needed with a tap water enema as well. Notifying the physician isn't necessary at this point because the client is exhibiting bowel function by passing flatus.

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

Encourage the client to move their legs frequently and do leg exercises. 450

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding? a) Dehiscence b) Evisceration c) Erythema d) Hernia

Evisceration 458 Explanation: Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.

A patient with an abdominal surgical wound sneezes and states, "Something doesn't feel right with my wound." The nurse asses the upper half of the surgical wounds edges are no longer approximated and the lower half remains well approximated. What documentation by the nurse is most appropriate? a) Following a sneeze, the wound eviscerated. b) Following a sneeze, the wound pustulated. c) Following a sneeze, the wound hemorrhaged. d) Following a sneeze, the wound dehisced.

Following a sneeze, the wound dehisced. Explanation: Dehiscence is the partial or complete separation of wound edges. Evisceration is the protrusion of organs through the surgical incision. Pustulated refers to the formation of pustules Hemorrhage is excessive bleeding.

Which of the following should be incorporated into the patient teaching plan to prevent deep vein thrombosis? a) Fluid restriction b) Use of blanket rolls for elevation of the lower extremities c) Hourly leg exercises d) Prolonged dangling at the edge of the bed

Hourly leg exercises Explanation: The benefits of early ambulation and hourly leg exercises in preventing deep vein thrombosis cannot be overemphasized. It is important to avoid the use of blanket rolls, pillow rolls, or any form of elevation that constricts vessels under the knees. Prolonged dangling can be dangerous and is not recommended in susceptible patients because the pressure under the knees can impede circulation. Dehydration adds to the risk of thrombosis formation.

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order. Don sterile gloves. Insert suction catheter into the lumen of the tube. Lubricate the sterile suction catheter. Apply intermittent suction while withdrawing the catheter. Position the client in Fowlers position.

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

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action? a) Monitor vital signs for early detection of shock. b) Assess the incisional dressing to detect hemorrhage. c) Administer antiemetics to prevent nausea and vomiting. d) Position the client to maintain a patent airway.

Position the client to maintain a patent airway. Explanation: Maintaining a patent airway is the immediate priority in the PACU.

Which actions should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical patient? a) Maintain bed rest. b) Reinforce the need to perform leg exercises every hour when awake. c) Instruct the patient to prop pillow under the knees. d) Administer prophylaxis high-dose heparin. Reinforce the need to perform leg exercises every hour when awake.

Reinforce the need to perform leg exercises every hour when awake. Explanation: The nurse should reinforce the need to perform leg exercises every hour when awake. Maintaining bed rest increases the pooling of blood in the lower extremities, increasing the risk for deep vein thrombosis. The patient may be given low-dose heparin for prophylaxis treatment but not a high-dose heparin. The nurse should instruct the patient not to prop a pillow under the knees because the patient can constrict the blood vessels.

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? a) Hypoxic b) Anemic c) Episodic d) Subacute

Subacute hypoxia 449 Explanation: For subacute hypoxemia supplemental oxygen may be indicated. Hypoxic hypoxemia results from inadequate breathing. Episodic hypoxemia develops suddenly, and the patient may be at risk for myocardial ischemia, cerebral dysfunction, and cardiac arrest. Anemic hypoxemia results from blood loss during surgery.

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

<30 mL

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 455

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing the dressing or applying pressure if bleeding is frank 433

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? a) Contractures b) Phlebitis c) Hypotension d) Wound dehiscence

Wound dehiscence 458 Explanation: Risk factors for wound dehiscence include: Advanced age over 65 years; Chronic disease such as diabetes, hypertension, obesity; History of radiation or chemotherapy; Malnutrition, particularly insufficient protein and vitamin C; Hypoalbuminemia. This client is not at increased risk for hypotension; contractures, or phlebitis.

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

avoid aspiration. Explanation: The nurse helps the patient to sit up and turn his or her head to one side when vomiting to avoid aspiration. Sitting up and turning the head to one side when vomiting does not maximize comfort and does not help to avoid dizziness. Encouraging the patient to breathe deeply helps eliminate inhaled anesthetics.