Surg 1 TEST NUMBER 3 Postoperative care/supplemental oxygen

How should the administration of analgesics be scheduled to provide a uniform level of pain relief to a client?

Administering the analgesics on a regular basis

The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client?

Airway patency

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

As soon as it is indicated

When assessing the client postoperatively, which nursing consideration is essential before offering oral fluids?

Assess ability to swallow.

A patient who is postoperative day 1 following a discectomy has lit his call light and requested a dose of hydromorphone, which he receives on a p.r.n. basis for breakthrough pain. What should the nurse first do in response to the patient's request?

Assess the characteristics of the patient's pain.

A client is receiving postoperative morphine through a patient-controlled analgesia (PCA) pump and the client's prescriptions specify an initial bolus dose. What is the nurse's priority assessment?

Assessment for respiratory depression

A client with a history of alcoholism is scheduled for urgent surgery. The client asks the nurse, "Why is everyone so concerned about how much I drink?" What is the best response by the nurse?

"It is important for us to know how much and how often you drink to help prevent surgical complications."

A presurgical client asks, "Why will I go to the PACU instead of just going straight up to the postsurgical unit?" What is the nurse's best response?

"The PACU allows you to recover from the effects of anesthesia, and you'll stay in the PACU until you're oriented, have stable vital signs, and are without complications."

What is the average stay in the PACU for a postop patient?

2-6 hours

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

<30 mL

Neurovascular checks

A systematic method of monitoring the function and status of nerves and blood vessels, as well as the movement of muscles that could be damages, circulation, motion, sensation.

The nurse determines that a patient has postoperative abdominal distention. What does the nurse determine that the distention may be directly related to?

A temporary loss of peristalsis and gas accumulation in the intestines

A nurse is receiving a client to the post anesthesia unit. What initial nursing activity is most important in the postoperative recovery area?

Maintain patient safety.

A client has undergone surgery to repair a hernia, with no complications. In the immediate postoperative period, which action by the nurse is most appropriate?

Monitor vital signs every 15 minutes

A postoperative 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 wound culture specimen.

Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention?

Oxygen saturation of 82%

What is paralytic ileus?

Paralysis of the bowel due to surgery (common --especially in abdominal surgery)

The nurse is caring for an 88-year-old client who is recovering from an ileac-femoral bypass graft. The client is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the client, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What complication should the nurse suspect?

Postoperative delirium

A client is being taught to self-administer a narcotic analgesic by means of an intravenous pump system. Which of the following functions is designed to help prevent the client from unintentionally overdosing?

Programming the dosage and time interval into the device

What intervention by the nurse is most effective for reducing hospital-acquired infections?

Proper hand-washing techniques

An elderly client has a fractured hip and is in Buck's traction. The client is disoriented and cannot express herself. At 0730 the client was calm. Now, at 0930, the client is restless and agitated. The nurse reviews the medication administration record. The last dose of opioid was at 0330. The nurse assesses the client's agitation may be from

Recurring pain

A new surgical patient has been prescribed an opioid analgesic intravenously for pain control. The nurse should be aware of which most serious adverse effect of this medication?

Respiratory depression

The nurse is monitoring a client who is in the hospital and has a fentanyl patch in place for the control of breakthrough pain for breast cancer. What would be a concern for the nurse when she obtains vital signs for this client?

Respiratory rate of 10 breaths/minute

What has the highest priority in an assessment after sugery

THE ABC's -airway -breathing -circulation

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 perioperative nurse is preparing to discharge a female client home from day surgery performed under general anesthetic. What instruction should the nurse give the client prior to the client leaving the hospital?

The client should not drive herself home.

When completing a teaching plan for a client receiving patient-controlled analgesia (PCA), which component would be important for the nurse to stress?

The pump will deliver a preset amount of medication.

A recently extubated postoperative client starts to gag and make vomiting sounds. What action should the nurse perform first?

Turn the client onto their side.

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

Weak and rapid pulse rate

Penrose drain

a flat, thin, rubber tube inserted into a wound to allow for fluid to flow from the wound; it has an open end that drains onto a dressing

During the postoperative period, a client starts gagging and retching. The nurse immediately sits the client up and turns the client's head to one side in order to:

avoid aspiration.

Which post op patients vital signs might be showing signs of shock?

bp 90/60, HR 105, RR 22, pain 2

What is the first priority when receiving a post op patient?

check airway

Vacuum-Assisted Closure

device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together

A Jackson Pratt Drain

drainage system that uses a compressed bulb, applies slight suction within the wound

In advance of a client's scheduled appendectomy, the nurse spends significant time explaining to the client what will happen, both before the procedure and after the procedure is complete. The primary reason the nurse puts so much effort into preoperative teaching is to:

increase the likelihood of a successful recovery.

Glasgow Coma Scale

is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. The scale assesses patients according to three aspects of responsiveness - eye opening, motor, and verbal responses.

According to The Joint Commission's pain assessment and management standards, which of the following are essential components of a comprehensive pain assessment?

location, onset, alleviating factors, and aggravating factors

What happens in the PACU

ongoing evaluation and stabilization of patients to anticipate, prevent, and manage complications after surgery

A hemovac drain

placed under your skin during surgery. This drain removes any blood or other fluids that might build up in the area.

What do you check on a neurovascular check

pulses, capillary refills, skin color, temperature, sensation, and motor function

A nurse administers hydromorphone to a client. What serious side effect should the nurse carefully monitor for?

respiratory depression

An client in the ambulatory surgery clinic is having difficulty undressing and putting clothing away. The client arrived via taxi, lives alone, and has few friends. The client will be unaccompanied before surgery and the client's children all live in different parts of the country. This client may not be a suitable candidate for ambulatory surgery because:

the client's postoperative care is questionable.

Evisceration

wound separation with protrusion of organs

What is included in a post op assessment?

· Airway patency · Effectiveness of respirations · Presence of artificial airways · Mechanical ventilation or supplemental oxygen · Assess circulatory status (bleeding) · Vital signs · Wound condition (dressing and drains) · Fluid balance including IV fluids · Output from blood loss or catheter drains · Ability to void · Level of consciousness · Pain

Post Op discharge instructions

· Discharge planning and teaching is done throughout the entire perioperative process · Assess need for home care · Assess need for equipment: Oxygen, raised toilet, adaptive equipment · Education on wound care/incision care, showering, bathing · Any precautions · Diet, activity and medication changes · Instructions for follow up · Family should be involved in education, planning and teaching

The nurse is assessing a postoperative patient's abdominal wound and observes a portion of intestines protruding through the wound. What is the priority intervention for the nurse to provide?

Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution.

A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.

A client's physician prescribes opiate pain medication to manage post-surgical pain. Which contraindication applies to opiate analgesics?

Do not administer if respirations are less than 12 breaths/minute.

At which time does the nurse realize that it is best to begin teaching about care needed during the postoperative period?

During the preoperative period

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 legs frequently and do leg exercises.

An adult client has just been admitted to the PACU following abdominal surgery. As the client begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the client may be at risk for what?

Hemorrhage and shock

When is an NG tube used?

If vomiting, nausea, or abdominal distention occurs after surgery/or if the patient had certain surgeries. This is used to allow air to escape the stomach (since the patient's intestines are not working, air becomes trapped) the NG tube allows air to escape causing less distress.

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

A client with appendicitis has had an appendectomy. After surgery, what type of pain does the nurse anticipate the client will have?

Acute pain

When the nurse is performing an assessment and finds no physical cause for a patient's pain, what should the nurse do when the patient continues to complain of pain?

Believe a patient when he or she states that pain is present.

Dehiscence

Bursting open of a wound, especially a surgical abdominal wound

Glasgow Coma Scale scoring

Comatose Patient - 8 or less Totally unresponsive - 3 or less

The nurse is assessing a patient complaining of severe pain. What physiologic indicator does the nurse recognize as significant of acute pain?

Diaphoresis