CH: 16 POST- OP NURSING MANAGEMENT SET 2-MED SURG I

A client recovering from abdominal surgery has abdominal distention and nausea. Which action will the nurse take?

Assist with ambulation.

A novice nurse provides aftercare instructions to a client who has just had sutures removed. Which statement by the novice nurse requires the nurse preceptor to clarify?

"If the wound edges are red or raised, you should call your doctor." Explanation: Wound edges that are slightly red or raised are normal and do not require the client to report these findings to the health care provider. All other statements are true.

Which is a classic sign of hypovolemic shock?

Pallor Explanation: The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing.

What measurement should the nurse report to the physician in the immediate postoperative period?

A systolic blood pressure lower than 90 mm Hg Explanation: A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal.

On postoperative day 2, a client requires care 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 Explanation: Postoperative surgical wounds that are allowed to heal using second-intention healing are usually packed with a sterile saline-soaked dressing and covered with a dry dressing. The edges of a wound healing by second intention are not approximated. The wound may be cleaned using sterile saline, but the nurse would not apply a cyanoacrylate tissue adhesive. The wound should not be left open to the air, as it could expose the wound to microorganisms and dry out the wound bed, impairing healing.

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

Pink color Explanation: Flash pulmonary edema that occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation, tachypnea, tachycardia, decreased pulse oximetry readings, frothy, pink sputum, and crackles on auscultation.

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. Explanation: The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits. The nurse may also obtain an emesis basin and administered an anti-emetic if one is ordered; however, these will be done after the client is repositioned. There is no need for the nurse to ask the client for more clarification.

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 Explanation: Many hospitals use a scoring system (e.g., Aldrete score) to determine the patient's general condition and readiness for transfer from the PACU (Aldrete & Wright, 1992). Throughout the recovery period, the patient's physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. This evaluation guide allows an objective assessment of the patient's condition in the PACU. The patient is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The Aldrete score is usually between 7 and 10 before discharge from the PACU.

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.

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. Explanation: The client may be refusing to ambulate because of fear or pain. Educating the client on the importance of mobility in preventing complications may encourage the client to ambulate. The nurse should try all reasonable measures (e.g., pain control, education) before documenting the client's refusal to ambulate. If the client is already refusing to ambulate, delegating the task to the unlicensed assistive personnel is not an appropriate action. The client should not be forcefully removed from the bed.

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?

The client is displaying early signs of shock. Explanation: The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated. Medication or anesthesia reactions may cause client symptoms similar to these; however, these causes are not as likely as early shock.

A client recovering from surgery reports pain as 9 on a scale from 0 to 10. Which goal for pain control will the nurse identify as realistic for this client?

The client will be able to tolerate pain experienced Explanation: A realistic goal for postoperative pain management is toleration rather than the elimination of pain. In the postoperative setting, the intravenous route is the first route of administration for analgesics as it acts the most quickly. A preventative approach should be used for pain medication. With this approach, the medication is given at prescribed intervals rather that when the pain becomes severe or unbearable.

Which of the following clinical manifestations increases the risk for evisceration in the postoperative client?

Valsalva maneuver Explanation: Wound dehiscence (disruption of surgical incision or wound) and evisceration (protrusion of wound contents) are serious surgical complications, especially when they occur with abdominal wounds. The Valsalva maneuver involves trying to exhale while blocking the airways and produces tension on abdominal wounds, increasing the risk for evisceration.

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. 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.

A client develops a hemorrhage one hour post surgery. The nurse knows this is most likely an intermediary hemorrhage from a vein because it occurred:

within the first few hours, and has darkly colored blood that flows quickly. Explanation: An intermediary hemorrhage appears within the first few hours following surgery. Darkly colored blood that flows out quickly indicates a venous hemorrhage. A hemorrhage that occurs during surgery is classified as a primary hemorrhage. A bright red color indicates that a hemorrhage's source is an artery. Secondary hemorrhages occur when sutures slip or drainage tubes dislodge insecure vessels.