Care of Postoperative Patients
After undergoing a modified radical mastectomy, a client is transferred to the PACU. Which nursing action is best to delegate to an experienced LPN/LVN? 1. Monitoring the client's dressing for any signs of bleeding 2. Document the initial assessment on the client's chart 3. Communicating the client's status report to the charge nurse on the surgical unit 4. Teaching the client about the importance of using pain medication as needed
1. Monitoring the client's dressing for any signs of bleeding
When Ms. Jackson arrives on the unit, the nurse notes that her IV is wide open. Review of Ms. Jackson's postoperative prescriptions indicates that 0.9% NS is to infuse at 75 ml/hr, alternating with Lactated Ringer's solution at 75 ml/hr. An infusion pump is not the immediately available, so the nurse notes that the infusion tubing has a drop factor of 10 drops/ml and resets the IV. (HESI) At what rate should the IV infuse?
13 drops/min
While the nurse begins to assess the client, another nurse finds an infusion pump and prepares a prescribed "now" dose of an IV antibiotic. The prescription is for 2 grams of Ancef, which arrives from the pharmacy diluted in 100 ml of NS and is to be administered over 30 minutes. (HESI) At what rate should the infusion pump be set?
200 ml/hour
Ms. Jackson is currently receiving Lactated Ringer's solution IV at a rate of 75 ml/hour. (HESI) In transfusing the 250-ml unit of packed RBC, what action should the nurse implement? A. Stop the IV solution and transfuse the packed cells at 125 ml/hour via tubing connected to a bag of saline solution.. B. Infuse the Lactated Ringer's solution through the IV tubing concurrently with the blood at a combined rate of 75ml/hour. C. Flush the IV tubing with a 5 ml bolus of NS before and after the transfusion, and transfuse the blood within 1 hour. D. Replace the Lactated Ringer's solution with the unit of packed RBC and administer through the tubing at 75 ml/hour.
A. Stop the IV solution and transfuse the packed cells at 125 ml/hour via tubing connected to a bag of saline solution.
The nurse is caring for a patient who has had abdominal surgery. After a hard sneeze, the patient reports pain in the surgical area, and the nurse immediately sees that the patient has a wound evisceration. What priority action must the nurse do first. A. The nurse calls for help and stays with the patient. B. The nurse leaves the patient to immediately call the surgeon. C. The nurse covers the wound with a non adherent dressing moistened with normal saline. D. The nurse takes the patient's vital signs.
A. The nurse calls for help and stays with the patient.
While assessing Ms. Jackson, the nurse observes that the surgical dressing is in place on the left hip, with no visible drainage. (HESI) How should the nurse document this finding? A. No problems with dressing on left hip B. Left hip dressing clean, dry, and intact. C. Dressing present over left hip incision. D. Incision well-approximated with no drainage.
B. Left hip dressing clean, dry, and intact.
While cleansing the incision, the nurse observes that the staples are intact, but a 2-cm gap has opened at the bottom of the incision. (HESI) How should the nurse document this finding? A. Bottom edges of incision approximated. B. Small area of dehiscence at bottom of incision. C. Evisceration of incision noted at bottom edge. D. Wound healing via secondary intention.
B. Small area of dehiscence at bottom of incision.
The PACU nurse is caring for a postoperative patient. The patient's oxygen saturation drops from 98% to 88%. What is the nurse's priority action? A. Call the anesthesia provider. B. Call the surgeon. C. Call the Rapid Response Team. D. Call the respiratory therapist.
C. Call the Rapid Response Team.
A patient arrives in the PACU. Which action does the nurse perform first? a. Assess for a patent airway and adequate gas exchange b. Rate the patient's pain using the 0-10 pain assessment scale c. Position the patient in a supine position to prevent aspiration d. Calculate the patient-controlled analgesia (PCA) pump maximum dose per hour to avoid an overdose
a. Assess for a patent airway and adequate gas exchange
A patient cared for in the PACU has had a colostomy placed for treatment of Crohn's disease. The nurse assesses that an abdominal dressing is 25% saturated with serosanguineous drainage and notes that the incision is intact. An IV is infusing with D5/lactated ringer's at 100 mL/hr through a 20-g peripheral IV access. Auscultation of abdomen reveals hypoactive sounds in all 4 quadrants, abdomen soft, and no distention. Foley catheter is in place and draining yellow urine with sediment, 375 mL output in Foley bag. Which body systems have been assessed by the nurse? (select all that apply) a. Renal/urinary b. Gastrointestinal c. Respiratory d. Musculoskeletal e. Integumentary
a. Renal/urinary b. Gastrointestinal e. Integumentary
A postoperative patient in the PACU has had an open reduction internal fixation of a left fractured femur. Vital signs are blood pressure 87/49 mm Hg, heart rate 100/min sinus rhythm, respiration 22/min temperature 98.3 degrees F. The Foley catheter has a total amount of 110 mL of clear, yellow urine in the last 4 hours. Which body systems have been assessed by the nurse? (select all that apply) a. Respiratory b. Cardiovascular c. Neurovascular d. Integumentary e. Renal/urinary
a. Respiratory b. Cardiovascular e. Renal/urinary
The PACU nurse is assessing a patient transferred in from the OR. Which assessment findings apply to assessment of the cardiovascular system? (select all that apply) a. Opens eyes on command b. Absent dorsalis pedis pulse left foot c. Foley catheter in place with clear yellow drainage d. Monitor shows normal sinus rhythm e. States name correctly when asked f. Apical pulse 85 beats/min
b. Absent dorsalis pedis pulse left foot d. Monitor shows normal sinus rhythm f. Apical pulse 85 beats/min
In the PACU, the nurse assesses that a patient is bleeding profusely from an abdominal incision. What is the nurse's best first action? a. Notify the surgeon b. Apply pressure to the wound dressing c. Instruct the UAP to get additional dressing supplies d. Request and draw a complete blood count
b. Apply pressure to the wound dressing
A 49-year-old patient is in the PACU following a frontal crainotomy for repair of a ruptured cerebral aneurysm. The nurse assesses hat the patients eyes open on verbal stimulation. Pupils are equal, reactive to light, and diameter is 3 mm. The patient's hand grasps are equal and strong. When the nurse asks the patient to state name, the patient states name correctly. The patient has had one episode of nausea and vomiting. Incision edges are dry and approximated with sutures. Lung sounds are slightly diminished per auscultation and the nurse observed the patient is using abdominal accessory muscles to breathe. Which body systems has the nurse assessed? (select all that apply) a. Cardiovascular b. Gastrointestinal c. Neurologic d. Integumentary e. Respiratory
b. Gastrointestinal c. Neurologic d. Integumentary e. Respiratory
What is the primary purpose of a PACU? a. Follow-through on the surgeon's postoperative orders b. Ongoing critical evaluation and stabilizing of the patient c. Prevention of lengthened hospital stay d. Arousal of patient following the use if conscious sedation
b. Ongoing critical evaluation and stabilizing of the patient
The nurse is teaching incisional care to a patient who has been discharged after abdominal surgery. Which priority instruction must the nurse include? a. Do not rub or touch the incision site b. Practice proper hand washing c. Clean the incision site two times a day with soap and water d. Splint the incision site as often as needed for comfort
b. Practice proper hand washing
A patient who is 2 days postoperative fr abdominal surgery states, "I coughed and I heard something pop." The nurse's immediate assessment reveals an opened incision with a portion of large intestine protruding. Which statements apply to this clinical situation? (select all that apply) a. Incision dehiscence has occurred b. This is an emergency situation c. The wound must be kept moist with normal saline-soaked sterile dressings d. This is an urgent situation e. Incision evisceration has occurred
b. This is an emergency situation c. The wound must be kept moist with normal saline-soaked sterile dressings e. Incision evisceration has occurred
If a patient experiences a wound dehiscence, which description illustrates what is happening with the wound? a. Purulent drainage is present at incision site because of infection b. Extreme pain is present at incision site c. A partial or complete separation of outer layers is present at incision site d. The inner and outer layers of the incision are separated
c. A partial or complete separation of outer layers is present at incision site
The nurse transfers a patient to the PACU with an incision and drainage of an abscess in the right groin under general anesthesia. Blood pressure is 80/47 mm Hg, heart rate 117/min in sinus tachycardia, respiratory rate 28/min, pulse oximetry reading 93% on oxygen at 3 L nasal cannula, temp is 38.5 degrees Celsius. The Jackson-Pratt drain has 70 mL of a cream-colored output. Normal saline is infusing at 150 mL/hr. The surgeon orders a bolus of 500 mL IV over 1 hour of normal saline, two sets of blood cultures, and culture drainage from the Jackson-Pratt drain. The patient's history includes includes vulvar cancer with a needle biopsy of the right groin, hypertension treated with lisinopril (zestril) 5 mg PO daily, and no known drug allergies. The patient is a full code. Using the SBAR charting format, which information should be included in assessment? a. Nurse transfers patient to the PACU with an incision and drainage of an abscess in the right groin with general anesthesia. b. Surgeon sending orders to bolus the patient with 500 mL normal saline over an hour, draw two sets of blood cultures and send a culture of drainage from the Jackson-Pratt drain. c. Blood pressure 80/47 mm Hg, heart rate 117/min, sinus tachycardia, respirations 28/min, pulse oximetry 93% on o2 at 3 L nasal cannula, temp 38.5 degrees C, Jackson-Pratt drain with 70 mL cream-colored output. d. Patient had a right groin abscess. History of vulvar cancer. Needle biopsy or right groin completed 1 week ago. History of hypertension treated with lisinopril (zestril) 5 mg. No known drug allergies. Full code.
c. Blood pressure 80/47 mm Hg, heart rate 117/min, sinus tachycardia, respirations 28/min, pulse oximetry 93% on o2 at 3 L nasal cannula, temp 38.5 degrees C, Jackson-Pratt drain with 70 mL cream-colored output.
Which signs/symptoms are considered postoperative complications? (select all that apply) a. Sedation b. Pain at the surgical site c. Pulmonary embolism d. Hypothermia e. Wound evisceration
c. Pulmonary embolism d. Hypothermia e. Wound evisceration
The health care team determines a patient's readiness for discharge from the PACU by noting a post anesthesia recovery score of at least 10. After determining that all criteria have been met, the patient is discharged to the hospital unit or home. Review the patient profiles after 1 hour in the PACU listed below. Which patient should the nurse expect to be discharged from the PACU first? a. 10-year-old girl, tonsillectomy, general anesthesia. Duration of surgery 30 minutes. Immediate response to voice. Alert to place and person. Able to move all extremities. Respiration even, deep, rate of 20. Vital signs are within normal limits. IV solution is D5RL. Has voided on bedpan. Eating ice chips. Complaining of sore throat. b. 55-year-old man, repair of fractured lower left leg. General anesthesia. Duration of surgery 1 hour, 30 minutes. Drowsy, but responds to voice. Nausea and vomiting twice in PACU. No urge to void at this time. IV infusion D5NS. Pedal pulses noted in both lower extremities. VS: temp 98.6 degrees F; Pulse 130 beats/min; respiratory rate 24/min; BP 124/76 mm Hg c. 24-year-old man, reconstruction of facial scar. General anesthesia. Duration of surgery 2 hours. Sleeping, groans to voice command. VS are WDL. Respirations 10 breaths/min. No urge to void. IV of D5RL infusing. Complains of pain in surgical area d. 42-year-old woman, colonoscopy. IV conscious sedation. Awake and alert. Up to bathroom to void. IV disconnected. Resting quietly in chair. VS are within normal limits
d. 42-year-old woman, colonoscopy. IV conscious sedation. Awake and alert. Up to bathroom to void. IV disconnected. Resting quietly in chair. VS are within normal limits
A patient develops respiratory distress after having a total left hip replacement. The patient develops labored breathing and a pulse oximetry reading is 83% on 2 L oxygen via nasal cannula. Which intervention is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Assess change in patient's respiratory status b. Order necessary medication to be administered c. Intubate the patient for maintenance of airway and assisted breathing d. Check the patient's vital signs
d. Check the patient's vital signs
Which description illustrates the beginning of the postoperative period? a. Completion of the surgical procedure and arousal of the patient from anesthesia in the OR. b. Discharge planning initiated in the preoperative setting. c. Closure of the patient's surgical incision with sutures. d. Completion of the surgical procedure and transfer of the patient to the PACU.
d. Completion of the surgical procedure and transfer of the patient to the PACU.
A patient arrives at the PACU and the nurse notes a respiratory rate of 10 with sternal retractions. The report from anesthesia personnel indicates that the patient had received fentanyl during surgery. What is the nurse's best priority first action? a. Monitor the patient for effects of anesthetic for at least one hour b. Closely monitor vital signs and pulse ox readings until the patient is responsive c. Administer oxygen as ordered, monitoring pulse ox d. Maintain an open airway through positioning and suction if needed
d. Maintain an open airway through positioning and suction if needed
You are caring for an obese postoperative client who underwent surgery for bowel resection. As the client is moving in bed, he comments, "Something popped open. " Upon the examination you note wound evisceration. Place in order the steps for handling this complication. 1. Cover the intestine with sterile moistened gauze. 2. Stay calm and stay with the client 3. Check the vital signs, especially blood pressure and pulse 4. Have a colleague gather sterile supplies and contact the physician 5. Put the client into semi-fowler position with knees slightly flexed 6. Prepare the client for surgery as ordered.
2. Stay calm and stay with the client 5. Put the client into semi-fowler position with knees slightly flexed 3. Check the vital signs, especially blood pressure and pulse 4. Have a colleague gather sterile supplies and contact the physician 1. Cover the intestine with sterile moistened gauze. 6. Prepare the client for surgery as ordered.
The health care provider removed a patient's original surgical dressing 2 days after surgery and is discharging the patient home on daily dressing changes. Which actions does the nurse take for this patient's discharge teaching? (select all that apply)? A. Ask the patient's family or significant other to observe the dressing change. B. Ask the UAP to get dressing supplies for the patient C. Instruct that the drainage will appear serosanguineous. D. Instruct the patient to go to the emergency department (ED) for problems related to dressing changes. E. Have the case manager arrange for a home health nurse to ensure that dressing changes are done and there are no complications of infection.
A. Ask the patient's family or significant other to observe the dressing change. C. Instruct that the drainage will appear serosanguineous. E. Have the case manager arrange for a home health nurse to ensure that dressing changes are done and there are no complications of infection.
The nurse continues the postoperative assessment. What action should the nurse take to assess for atelectasis? (HESI) A. Auscultate the client's breath sounds B. Observe the appearance of the sputum. C. Determine the client's temperature D. Measure the client's blood pressure
A. Auscultate the client's breath sounds
The nurse determines that Ms. Jackson's bowel sounds are hypoactive. What action should the nurse implement in response to this finding? (HESI) A. Document the assessment finding in the chart. B. Notify the surgeon of the assessment finding. C. Review the client's serum electrolyte values. D. Administer a laxative prescribed for PRN use.
A. Document the assessment finding in the chart.
A client experiences abdominal distention following surgery. Which nursing actions are appropriate? (select all that apply) A. Encouraging ambulation B. Giving sips of ginger ale C. Auscultating bowel sounds D. Providing a straw for drinking E. Offering the prescribed opioid analgesic
A. Encouraging ambulation C. Auscultating bowel sounds
On which concern should the nurse focus when caring for a client after abdominal surgery? A. Identifying signs of bleeding B. Preventing pressure on the suture site C. Encouraging use of an incentive spirometer D. Detecting clinical manifestations of inflammation
A. Identifying signs of bleeding
What criteria guide the handoff report when a patient is transferred from the OR to the PACU? (Select all that apply). A. It is a two-way verbal interaction. B. The language is clear. C. Reporting nurse asks questions about PACU procedures. D. Standardized reports help avoid omissions. E. Receiving nurse repeats information to verify what was said.
A. It is a two-way verbal interaction. B. The language is clear. D. Standardized reports help avoid omissions. E. Receiving nurse repeats information to verify what was said.
A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure? A. Keeps the area free of microorganisms B. Confines microorganisms to the surgical site. C. Protects self from microorganisms in the wound D. Reduces the risk for growing opportunistic microorganisms
A. Keeps the area free of microorganisms
Which are interventions for the medical-surgical nurse to use in preventing hypoxemia for the postoperative patient? (select all that apply)? A. Monitor the patient's oxygen saturation. B. Position the patient supine C. Encourage the patient to cough and breathe deeply D. Get the patient up ambulating as soon as possible E. Instruct the patient to rest as much as possible.
A. Monitor the patient's oxygen saturation. C. Encourage the patient to cough and breathe deeply D. Get the patient up ambulating as soon as possible
The surgery is successfully completed without complications. Following surgery, Ms Jackson is admitted to the Post Anesthesia Care Unit. The operative report indicates that Ms. Jackson had a left hip replacement under general anesthesia. The initial nursing assessment reveals that Ms. Jackson is not responding to verbal stimuli. Her vital signs are T 97.6 F, P 88, R14, and BP 130/70. (HESI) What action should the nurse implement first? A. Postion the client on her side. B. Observe the surgical dressing. C. Place the call bell within reach D. Remove the oral airway.
A. Position the client on her side.
A client is extubated in the post anesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? A. Restlessness B. Bradycardia C. Constricted pupils D. Clubbing of the fingers
A. Restlessness
The PACU nurse is assessing an older adult postoperative patient for pain. Which nonverbal manifestations by the patient suggest pain to the nurse? (select all that apply)? A. Restlessness B. Profuse sweating C. Difficult to arouse D. Confusion E. Increased blood pressure
A. Restlessness B. Profuse sweating D. Confusion E. Increased blood pressure
Which patient is most risk for postoperative nausea and vomiting (PONV)? A. The patient with a history of motion sickness B. The patient with a nasogastric tube C. The patient who recently experienced a weight loss of 50 pounds D. The patient who had minimally invasive surgery (MIS)
A. The patient with a history of motion sickness
The nurse observes that the Hemovac drain is full of sanguineous drainage. (HESI) What action should the nurse implement first? A. Compress the drain and re-establish suction. B. Empty the drain and measure the amount of drainage. C. Page the surgeon to report finding. D. Document the appearance of the drainage.
B. Empty the drain and measure the amount of drainage.
You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given the nursing diagnosis of Activity Intolerance. Which action should you delegate to the UAP? A. Instructing the patient to alternate rest and activity periods B. Encouraging, monitoring, and recording nutritional intake C. Monitoring cardiorespiratory response to activity. D. Planning activities for periods when the patient has the most energy.
B. Encouraging, monitoring, and recording nutritional
Based on the lab data provided by the nurse, the healthcare provider prescribes the transfusion of 2 units of packed RBC ASAP. Once the first unit of packed RBC is ready, the nurse obtains the blood from the blood bank. When the nurse enters Ms. Jackson's room to begin the transfusion, the UAP is giving Ms. Jackson a partial bath. (HESI) What action should the nurse take? A. Place the unit of blood in the medication fridge until the client's cares are completed. B. Hang the transfusion of packed cells while the UAP continues to complete the client's cares. C. Lock the unit of blood in the computerized medication care and assist the UAP in completing the personal care. D. Return the blood to the blood bank and sent the UAP to obtain the blood when the personal care is completed.
B. Hang the transfusion of packed cells while the UAP continues to complete the client's personal care.
The nurse notifies the surgeon of the wound drainage. (HESI) What lab data is important of the nurse to report to the surgeon? A. WBC B. Hemoglobin and hematocrit C. Culture and sensitivity D. Type and cross match
B. Hemoglobin and hematocrit
Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus. A. Decreased blood supply B. Impaired neural functioning C. Perforation of the bowel wall D. Obstruction of the bowel lumen
B. Impaired neural functioning
A client reports severe pain 2 days after surgery. Which initial action should the nurse take after assessing the character of the pain? A. Encourage rest B. Obtain the vital signs C. Administer the pen analgesic D. Document the client's pain response
B. Obtain the vital signs
When assessing the older postoperative patient for hydration status, where must the nurse assess for tenting of the skin? (select all that apply.) A. On the back of the hand. B. On the forehead. C. On the forearm D. On the sternum E. On the abdomen
B. On the forehead. D. On the sternum
A nurse in the post anesthesia care unit (PACU) observes that after an abdominal cholecystectomy a client has serosanguineous drainage on the abdominal dressing. What is the next nursing action? A. Change the dressing B. Reinforce the dressing C. Replace the tape with Montgomery ties. D. Support the incision with an abdominal binder
B. Reinforce the dressing
The morning after a patient's lower leg surgery, the nurse notes that the dressing is wet from drainage. The surgeon has not yet been in to see the patient on rounds. What does the nurse do about the dressing? A. Removes the dressing and puts on a dry, sterile dressing. B. Reinforces the dressing by adding dry, sterile dressing material on top of the existing dressing. C. Applies dry, sterile dressing material directly to the wound, then retakes the original dressing. D. Does nothing to the dressing but calls the surgeon to evaluate the patient immediately.
B. Reinforces the dressing by adding dry, sterile dressing material on top of the existing dressing.
The nurse is assisting Ms. Jackson to the bedside commode no the second postoperative day. Ms Jackson states "I have never had to depend on anyone before. I like to take care of myself. I feel so helpless." (HESI) In response to these remarks, the nurse plans care for Ms. Jackson based on the identification of which nursing diagnosis? A. Disturbed body image B. Situational low self-esteem C. Anticipatory grieving D. Impaired physical mobility
B. Situational low self-esteem
The nurse on the medical-surgical unit is caring for a postoperative patient. Which assessment criteria indicate to the nurse that the patient is experiencing respiratory difficulty? (Select all that apply). A. The patient's oxygen saturation drops from 98% to 94%. B. The patient is using accessory muscles to breathe. C. The patient makes a high-pitched crowing sound when breathing. D. The patient's blood pressure drops from 120/80 to 110/78mm Hg. E. The patient's respiratory rate is 26/min.
B. The patient is using accessory muscles to breathe. C. The patient makes a high-pitched crowing sound when breathing. E. The patient's respiratory rate is 26/min.
In the immediate postoperative period after a gastrectomy the client's nasogastric tube is draining a light-red liquid. For how long should the nurse expect this type of drainage? A. 1 to 2 hours B. 3 to 4 hours C. 10 to 12 hours D. 24 to 48 hours
C. 10 to 12 hours
The postoperative care of a morbidly obese client is being planned. Which task best utilizes the expertise of the LPN/LVN? A. Obtaining an oversized blood pressure cuff and a large-size bed. B. Setting up a reinforced trapeze bar C. Assisting in the planning of toileting, turing, and ambulation D. Assigning tasks to UAP's and other ancillary staff.
C. Assisting in the planning of toileting, turing, and ambulation
After Ms. Jackson ambulates with the physical therapist, the nurse prepares to change the surgical dressing. While obtaining supplies, the nurse reviews the sterile procedure to be followed. (HESI) At what step in the procedure should the nurse don sterile gloves? A. Prior to removing the dressing on the client's hip. B. Before opening the new sterile dressing package. C. Before cleansing the client's hip incision. D. After cleansing the client's hip incision.
C. Before cleansing the client's hip incision.
What is the priority nursing intervention for a client during the immediate postoperative period? A. Monitoring vital signs B. Observing for hemorrhage C. Maintaining a patent airway D. Recording the intake and output
C. Maintaining a patent airway
After an abdominal cholecystectomy, a client has a T-tube attached to a collection device. On the day of surgery, at 10:30 PM, 300 mL of bile is emptied from the collection bag. At 6:30 AM the next day, the bag contains 60 ml of bile. What should the nurse consider in response to this information? A. The T-tube may have to be irrigated. B. The bile is now draining into the duodenum. C. Mechanical problems may have developed with the T-tube D. Suction must be reestablished in the portable drainage system.
C. Mechanical problems may have developed with the T-tube
During the postoperative assessment, the nurse observes Ms. Jackson's surgical site. The left hip dressing has a moderate amount of sanguineous drainage. (HESI) What actions should the nurse implement? (Select all that apply). A. Apply pressure to the site B. Elevate the leg on a pillow C. Observe the linens under the hip D. Use sterile technique to replace the dressing E. Mark the amount of drainage on the dressing.
C. Observe the linens under the hip E. Mark the amount of drainage on the dressing
The nurse is assessing a postoperative patient's gastrointestinal system. What is the best indicator that peristaltic activity has resumed? A. Presence of bowel sounds B. Patient states he is hungry C. Passing of flatus or stool D. Presence of abdominal cramping
C. Passing of flatus or stool
The medical-surgical nurse is caring for a postoperative patient whose lab values reveal an increase in band cells (immature neutrophils). What is the nurse's best interpretation of this value? A. The patient may need a transfusion B. The patient is using up clotting factors C. The patient is developing an infection D. The patient's result is expected postoperatively
C. The patient is developing an infection
A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. What medication does the nurse anticipate will be prescribed for this client? A. Vitamin A (Aquasol A) B. Cyanocobalamin (Cobex) C. Phytonadione (Mephyton) D. Ascorbic acid (Ascorbicap)
D. Ascorbic acid (Ascorbicap)
A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated? A. Dialysis B. Osmosis C. Diffusion D. Capillarity
D. Capillarity
While caring for a client with a portable wound drainage system, a nurse observes that the collection container is half full and empties it. What is the next nursing intervention? A. Encircle the drainage on the dressing. B. Irrigate the suction C. Clean the drainage port with an alcohol wipe. D. Compress the container before closing the port.
D. Compress the container before closing the port.
When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action? A. Obtain the vital signs B. Notify the health care provider C. Reinsert the protruding organs using aseptic technique D. Cover the wound with a sterile towel moistened with normal saline.
D. Cover the wound with a sterile towel moistened with normal saline.
After abdominal surgery a client reports pain. What action should the nurse take first? A. Reposition the client B. Obtain the client's vital signs C. Administer the prescribed analgesic D. Determine the characteristics of the pain
D. Determine the characteristics of the pain
A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? A. Productive cough B. Clubbing of the fingertips C. Crackles at the height of inhalation D. Diminished breath sounds on auscultation
D. Diminished breath sounds on auscultation
A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? A. Postural drainage B. Cupping the chest C. Nasotracheal suctioning D. Frequent changes of position
D. Frequent changes of position
The nurse teaches Ms. Jackson safe transfer techniques and consults with the physical therapist to begin ambulation activities as soon as possible. (HESI) What is the rationale for the inclusion of these actions in Ms. Jackson's plan of care? A. Frequent activity will distract the client from her concerns. B. Maintaining a safe environment reduces client depression. C. The client should depend on the therapist rather than the nurse. D. Increased mobility will promote and improved sense of control.
D. Increased mobility will promote an improved sense of control.
Which intervention for post surgical care of a patient is correct? A. When positioning the patient, use the knee watch of the bed to bend the knees and relieve pressure. B. Gentle massage on the lower legs and calves helps promote venous blood return to the heart. C. Encourage bedrest for 3 days after surgery to prevent complications. D. The patient should splint the surgical wound for support and comfort when getting out of bed.
D. The patient should splint the surgical wound for support and comfort when getting out of bed.