Chapter 19 Postoperative Care

The nurse is educating a patient who had a coronary bypass graft (CABG) about the risk of venous thromboembolism (VTE). Which topic would the nurse include in the education to the patient? 1 Early ambulation 2 Turning every two hours 3 Splinting chest while coughing 4 Importance of taking pain medication

1 Activity has proven vital in helping to prevent postoperative VTE. Other forms of treatment include anticoagulants and sequential compression devices (SCDs). Splinting the chest while coughing, taking pain medication, and turning every two hours are important for the recovery of the coronary bypass patient but have little impact on preventing VTE.

Which condition is the most likely reason for a patient having a partial pressure of arterial oxygen (PaO2) less than 60 mm Hg after surgery? 1 Atelectasis 2 Bronchospasm 3 Pulmonary edema 4 Pulmonary embolism

1 Atelectasis, partial collapse of the small airways, is the most common cause of hypoxemia after surgery and results from alveolar collapse, bronchial obstruction caused by retained secretions, decreased respiratory excursion, or general anesthesia. Bronchospasm, pulmonary edema, and pulmonary embolism are all causes of hypoxemia, but not as common as atelectasis.

Which factor would determine if an older patient who is having problems with concentration and memory after an extensive surgery is experiencing delirium or postoperative cognitive dysfunction? 1 Preexisting cognitive impairment identified before surgery 2 Ability of the patient to state name, location, and date 3 Ability to ambulate in the halls and follow commands 4 An undisturbed sleep/wake cycle in the critical care unit

1 Dementia should be assessed preoperatively so interventions can be established after surgery to help the patient meet outcomes. Preexisting cognitive impairment is a factor that contributes to postoperative cognitive dysfunction (POCD). Orientation of name, location, and date and ability to ambulate in halls and follow commands do not determine if it is dementia or POCD. A disturbed sleep/wake cycle may be a sign of postoperative delirium.

An older adult patient has a complication after a cardiac catheterization and has to remain in the postanesthesia care unit (PACU) for several days. Which complication is the patient most at risk for? 1 Delirium 2 Depression 3 Alcohol withdrawal 4 Aggressive behaviors

1 Older adult patients who spend prolonged amounts of time in the PACU are at risk for delayed emergence, a type of delirium caused by spending a longer amount of time in an ICU-like environment. Aggressive behaviors and depression can also be part of delayed emergence, but this disorder is most often characterized by delirium. There is not enough information in this scenario to determine if the patient is at risk for alcohol withdrawal.

While caring for a patient after surgery on the first postoperative day, the nurse notes new, bright red drainage about 4 cm in diameter on the surgical dressing. Which action would the nurse take first? Correct1 Take the patient's vital signs. 2 Mark the area on the dressing and document the finding. 3 Recheck the dressing in one hour for increased drainage. 4 Notify the health care provider of a potential hemorrhage.

1 The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse then can report the findings to the provider. Marking the area is acceptable, but not the first nursing action. Rechecking the dressing in an hour would be acceptable but only after checking vital signs and notifying the health care provider. The health care provider should be notified after the nurse assesses the patient.

A patient's BP increases from 110/76 mm Hg to 160/90 mm Hg two hours after a surgical procedure. Which action would the nurse take first? 1 Assess pain level. 2 Reassess the BP in 15 minutes. 3 Decrease the IV fluid rate. 4 Restart the patient's antihypertensive medication.

1 Treatment for hypertension focuses on the source of the problem. Pain often causes a rise in BP. If a patient becomes hypertensive, the nurse should begin with assessing and treating the pain. Reassessing the BP in 15 minutes would not be done first but after treating the patient for pain. Per prescription of the health care provider, decreasing the IV fluid and administering an antihypertensive medication may be appropriate but are not the first nursing interventions.

Which nursing actions will help to treat the problem of abdominal distention and gas pains after abdominal surgery? Select all that apply. 1 Ambulate the patient. 2 Reposition frequently. 3 Administer bisacodyl. 4 Turn patient onto left side. 5 Administer morphine sulfate. 6 Discontinue the nasal gastric tube (NGT).

1,2,3 Ambulating, repositioning the patient, and administering bisacodyl (Dulcolax) suppositories all help to relieve gas after surgery. Turning the patient onto the right side, not left side, helps the gas to move into the transverse colon and then into the rectum. Morphine sulfate tends to cause constipation and may increase abdominal pain because of distention. Discontinuing the NGT too early can increase abdominal distention.

A patient with a history of deep vein thrombosis is recovering in the postanesthesia care unit (PACU) after surgery. Which symptoms would the nurse assess if this patient develops a pulmonary embolism (PE)? Select all that apply. 1 Dyspnea 2 Tachypnea 3 Tachycardia 4 Coarse crackles 5 Noisy respirations

1,2,3 PE can be recognized by the presence of tachycardia, tachypnea, and dyspnea, especially if the patient is already receiving oxygen therapy. PE may occur in a postoperative patient who already has a history of deep vein thrombosis and is an older adult. Other symptoms of PE may include agitation, chest pain, hypotension, hemoptysis, dysrhythmias, and heart failure. Coarse crackles and noisy respirations may happen if thick secretions are present in the airway.

A postoperative patient who has been transferred from surgery to the postanesthesia care unit is cold and shivering. The patient's plan of care includes a prescription for morphine to be administered for pain relief. When managing this patient, which interventions would the nurse perform? Select all that apply. 1 Use forced air warmers. 2 Administer oxygen therapy. 3 Administer warmed IV fluids. 4 Use warmed cotton blankets. 5 Withhold morphine until shivering stops.

1,2,3,4 Administering warm liquids and using forced air warmers are active warming methods. Using warmed cotton blankets is a passive warming measure. Oxygen therapy is needed to meet the increased oxygen demand during shivering. Opioids are used to treat shivering in the immediate postoperative period, so the nurse should not withhold the morphine dose.

Which action would the nurse take for a postoperative patient who has not voided for eight hours? Select all that apply. 1 Scan the bladder with a portable ultrasound. 2 Help the patient to use a bedside commode. 3 Reassure the patient regarding the ability to void. 4 Obtain a prescription and insert an indwelling catheter 5 Use techniques like pouring warm water over the perineum.

1,2,3,5 It is very important that the patient voids within six to eight hours postoperatively. The nurse should scan the bladder to assess bladder fullness. The nurse should reassure the patient regarding the ability to void and help the patient using techniques like providing privacy and pouring warm water over the perineum. The patient should be helped to use a bedside commode if comfortable. A straight catheterization as compared to an indwelling catheter is preferred, to limit the risk for catheter-associated urinary tract infection (CAUTI).

The nurse is caring for a patient in the postanesthesia care unit (PACU), when the BP drops from 110/60 mm Hg to 92/58 mm Hg. Which actions would the nurse take? Select all that apply. 1 Assess electrocardiogram (ECG) tracing. 2 Inspect the surgical site. 3 Administer pain medication. 4 Elevate the head of the bed. 5 Have the patient take deep breaths. 6 Administer IV fluid bolus per protocol.

1,2,4,5 Assess ECG tracing; a change in the heart rhythm can cause a decrease in BP. Some of these rhythms include supraventricular tachycardia, sinus bradycardia, atrial fibrillation, and atrial flutter. Inspect the surgical site; hypotension can be caused by hemorrhage. Therefore it is important to inspect the surgical site for evidence of bleeding. Have the patient take deep breaths; hypoxemia can cause hypotension. Administer IV fluid boluses per protocol; fluid shifts during and after surgery can cause a drop in BP. Fluid boluses often are needed to correct for these shifts. Hypertension, not hypotension, is indicative of pain. A side effect of many pain medications is hypotension, which would exacerbate the patient's present hypotensive state. The head of the bed should be lowered to increase blood flow to the cerebrum.

Which factors contribute to a patient's risk for constipation postoperatively? Select all that apply. 1 Anesthesia 2 Opioid analgesics 3 IV fluids 4 Decreased mobility 5 Diminished peristalsis

1,2,4,5 Causes of constipation in a patient who underwent surgery would be the anesthesia, opioid analgesics, decreased mobility, and diminished peristalsis. IV fluids could cause fluid volume excess.

Which actions would the nurse take when administering an analgesic to a postoperative patient? Select all that apply. 1 Assess the location, quality, and intensity of pain. 2 Monitor the patient for nausea, vomiting, and respiratory depression. 3 Assess the patient's sleep/wake cycle and sensory and motor status. 4 Assess the patient's level of orientation and ability to follow commands. 5 Time the analgesic administration for effectiveness during painful activities.

1,2,5 When administering analgesics to a postoperative patient, the nurse should assess the location, quality, and intensity of pain. The time of administration of the analgesic should be adjusted so that the patient is free of pain during activities like ambulation. The nurse should monitor the patient for analgesic side effects, including nausea, vomiting, and respiratory depression. Assessing the sleep/wake cycle, sensory and motor status, level of orientation, and ability to follow commands are part of a neurologic assessment and not a part of administering an analgesic.

Which nursing care measures are useful in the prevention of postoperative respiratory complications? Select all that apply. 1 Monitor oxygen saturation. 2 Measure intake and output. 3 Assess bilateral lung sounds. 4 Ambulate the halls with patient. 5 Instruct on incentive spirometer use.

1,3,4,5 The nurse assesses oxygen saturation levels and lung sounds to monitor for atelectasis and respiratory complications. Ambulation and incentive spirometry promote lung expansion and reduce the risk for postoperative atelectasis and pneumonia. Measuring intake and output is useful in assessing for and preventing renal or cardiac complications.Test-Taking Tip: Be alert for grammatical inconsistencies. If the response is intended to complete the stem (an incomplete sentence) but makes no grammatical sense to you, it might be a distractor rather than the correct response. Question writers typically try to eliminate these inconsistencies.

The nurse is assessing a patient's surgical dressing on the first postoperative day and notes new, bright red drainage about 5 cm in diameter. Which action would the nurse implement first? 1 Recheck in one hour for increased drainage. Correct2 Assess the patient's BP and heart rate. 3 Check agency policy to determine if the nurse can change the first dressing. 4 Notify the health care provider of a potential hemorrhage.

2 The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The priority assessment is to check BP and heart rate to determine possibility of significant blood loss/internal hemorrhaging. Following this, the nurse will contact the provider to report findings and can inquire at that time about a dressing change. Typically, the surgeon changes the first dressing postoperatively; the nurse reinforces it as needed until that first change has been done. Continued reassessment will be done on an ongoing basis.

Which actions would the nurse take for a postoperative patient who has an oxygen saturation of 85% and decreased breath sounds? Select all that apply. 1 Restrict intake of fluid. 2 Administer humidified oxygen therapy. 3 Administer diuretics as advised. 4 Encourage deep-breathing exercises. 5 Assist the patient to walk around, if tolerated.

2,4,5 Low oxygen saturation and decreased breath sounds may indicate atelectasis. Therefore the nurse should administer humidified oxygen therapy and encourage deep-breathing exercises. Deep breathing and coughing techniques help prevent alveolar collapse and move respiratory secretions to larger airway passages for expectoration. Assisting the patient to walk around will also help, because lying down will only settle secretions into the respiratory system. Fluid restriction and diuretics may not be required; these are therapies best used for pulmonary edema (PE).

A nurse is caring for a patient who had a bowel resection 10 hours before. The patient weighs 200 pounds (91 kg) and has a urine output of 240 cc for the past eight hours. Which action would the nurse take? 1 Encourage oral (PO) fluids. 2 Continue to monitor the urine output. 3 Notify the health care provider. 4 Administer a 500 cc normal saline IV bolus.

3 The formula for determining adequate urine output is 0.5 mL/kg/hr. This patient, weighing 91 kg, needs to have 45 cc per hour or about 365 cc of urine in eight hours. It often takes three to five days for the bowel to begin working post-abdominal surgery; therefore it would be inappropriate at this time to encourage PO fluids. Continuing to monitor the urine output, instead of calling the health care provider, would delay identifying and treating the cause for the low urine output. The nurse must obtain a prescription for the normal saline bolus before administration.

Which assessment data requires the notification of the health care provider? 1 A widened pulse pressure 2 Systolic BP of 95 mm Hg 3 Systolic BP of 170 mm Hg 4 A pulse of 80 beats/minute

3 The nurse would notify the health care provider if the patient's systolic BP is higher than 170 mm Hg. It is a narrowed pulse pressure, rather than a widened one, that might necessitate a call to the health care provider. A systolic BP of 95 mm Hg is perfectly acceptable; one that is less than 90 or greater than 160 indicates a problem. A pulse of 80 beats/minute is also acceptable; a pulse that is less than 60 or over 120 can be problematic.

Two days after abdominal surgery, the patient reports gas pains and abdominal distention. The nurse plans care for the patient on the basis of the knowledge that these symptoms occur as a result of which condition? 1 Constipation 2 Hiccups 3 Slowed gastric emptying 4 Inflammation of the bowel at the anastomosis site

3 Until peristalsis returns to normal after anesthesia, the patient may experience slowed gastric motility, leading to gas pains and abdominal distention. Hiccups are intermittent spasms of the diaphragm caused by irritation of the phrenic nerve, which may be irritated after surgery by gastric distention but does not cause gas pains. The bowel should not be inflamed following surgery unless infection is present. Constipation may occur following surgery; however, with bowel manipulation, slowed gastric emptying is the most common reason for gas pains and abdominal distention because of gas.

Which nursing intervention would help prevent postoperative atelectasis? 1 Medicating the patient with a narcotic analgesic as prescribed 2 Providing an abdominal binder to help the patient in ambulation 3 Encouraging frequent use of an incentive spirometer 4 Turning the patient from one side to the other at least every two to four hours

3 Use of an incentive spirometer after surgery encourages the patient to take deep, slow breaths, which facilitates the opening of terminal airways, mobilizes secretions, and prevents postoperative atelectasis. The patient should be instructed to perform 10 repetitions every hour. Narcotic analgesics, use of an abdominal binder for ambulation, and frequent turning in bed may indirectly support recovery and prevention of complications postoperatively. However, these interventions do not specifically address the prevention of atelectasis and pneumonia in the way that the use of an incentive spirometer does.

Which actions would the nurse take for a patient in the postanesthesia care unit (PACU) to ensure that this patient has a patent airway? Select all that apply. 1 Suctioning the airway 2 Administering sedatives 3 Putting in an artificial airway 4 Administering oxygen therapy 5 Tilting the head and thrusting the jaw

3,5 The physical repositioning of a patient to reestablish the patency of the airway involves tilting the head and thrusting the jaw. If the physical repositioning does not help, the patient may need an artificial airway to assist in breathing. Suctioning is helpful for patients with increased secretions; it may not help a patient with an airway obstruction. Oxygen therapy does not help unless the airway is patent. Sedatives would worsen the airway prolapse.

The nurse is developing a care plan for the postoperative patient in order to prevent complications and promote ambulation, coughing, deep breathing, and turning. Which action is the most important for the nurse to provide to achieve these desired outcomes? 1 Explain easily the rationale for these activities. 2 Have family in the room for support and encouragement. 3 Warn about pneumonia and clotting if the actions are not completed. 4 Administer enough analgesics to promote relative freedom from pain

4 Even when a patient understands the importance of postoperative activities, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate. Warning the patient about pneumonia and clotting will not enhance proper activities if pain is not managed. Family encouragement and understanding of the rationale for completing these actions are important; however, pain control is the most helpful way to ensure that ambulation, coughing, deep breathing, and turning can be performed.

An older adult patient who had surgery is displaying manifestations of delirium. Which action would the nurse take first to provide the best care for this patient? 1 Check the chart for intraoperative complications. 2 Check the effectiveness of the analgesics received. 3 Check which medications were used for anesthesia. 4 Check the preoperative assessment for previous delirium or dementia.

4 If the patient's airway, breathing, and circulation are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed, because these can all contribute to delirium.

Alteration in which electrolyte level may be associated with occurrence of postoperative dysrhythmia? 1 Blood urea nitrogen 2 Sodium 3 Chloride 4 Potassium

4 Potassium is an electrolyte that maintains electrical conductivity of the heart. Hypokalemia (low serum potassium) from urinary and gastrointestinal fluid losses during and after surgery may result in cardiac dysrhythmia. Alterations in blood urea nitrogen, sodium, and chloride will be assessed for, but are not linked to cardiac dysrhythmias.

Which action would the nurse take first for a patient is admitted to the postanesthesia care unit (PACU) with a BP of 100/60 mm Hg? 1 Rouse the patient. 2 Assess the patient's pulse and skin color. 3 Notify the anesthesiologist of the low BP. 4 Check the medical record for the patient's baseline BP.

4 The first action of the nurse is to identify what the patient's normal BP is. Interventions are dependent on the baseline variation. Rousing the patient is an intervention that can increase the BP, but would be done after determining the baseline BP. Hypotension accompanied by a normal pulse and warm, dry skin is usually from the residual vasodilating effects of anesthesia and suggests only a need for continued observation, but assessing the pulse and skin would not be done first. Before notifying the anesthesiologist of the BP, the nurse needs to check the baseline BP.

Which clinical manifestation of pulmonary edema secondary to heart failure would the nurse assess in a postoperative patient? 1 Early-morning cough 2 Increased urine output 3 Inspiratory stridor 4 Crackles heard on auscultation

4 The most common cause of pulmonary edema is left-sided congestive heart failure, which commonly manifests as shortness of breath and crackles in the lungs. An early-morning cough may be seen with respiratory infection or chronic obstructive pulmonary disease but is not usually a symptom of pulmonary edema. In pulmonary edema, urine output is typically decreased due to fluid retention. Inspiratory stridor is typically due to laryngospasm.

A patient on the postoperative unit reports difficulty breathing. The nurse discovers that the patient received large doses of benzodiazepines during surgery. Which action would the nurse include in the patient's plan of care to promote breathing? 1 Administer opioids 2 Loosen the dressings 3 Reposition the patient 4 Administer drugs for reversal of benzodiazepines

4 The use of benzodiazepines may depress the muscles required for breathing. Administering drugs for reversal of this may make breathing easier. Use of opioids aggravates the condition by causing respiratory depression. Loosening the dressing and repositioning the patient are helpful when the breathing difficulty is caused by mechanical restriction but may not help in this case.

Which occurrence might cause secondary heart dysfunction? 1 Cardiac tamponade 2 Certain medications 3 Pulmonary embolism 4 Myocardial infarction

2 Certain medications, including β-adrenergic blockers, digoxin, or opioids, can cause secondary heart dysfunction. Cardiac tamponade, pulmonary embolism, and myocardial infarction are causes of primary heart dysfunction.

Which surgery requires a sensory level L2-L3 anesthesia? 1 Hip surgery 2 Foot surgery 3 Appendectomy 4 Hemorrhoidectomy

2 Foot surgery would require sensory level L2-L3 anesthesia. Hip surgery would require T10 level, an appendectomy necessitates T6-T7, and a hemorrhoidectomy calls for sensory level S2-S3 anesthesia.

A patient is admitted to the postanesthesia care unit (PACU) after bowel surgery and tells the nurse that he or she is going to "throw up." Which statement by the nurse reflects a priority nursing intervention? 1 "I need to check your vital signs." 2 "Let me help you turn to your side." 3 "Here is a sip of ginger ale for you." 4 "I can give you some anti-nausea medicine."

2 If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs. Checking vital signs does not address the nausea. It may not be appropriate to give the patient oral fluids immediately following bowel surgery. Administering an antiemetic may be appropriate after turning the patient to the side.

Which symptom indicates that a patient may have a pulmonary embolism? 1 Lethargy 2 Tachypnea 3 Bradycardia 4 Hypertension

2 Tachypnea indicates a potential pulmonary embolism. Agitation, rather than lethargy, is a symptom of pulmonary embolism. A patient with a pulmonary embolism would be more likely to present with tachycardia and hypotension rather than bradycardia and hypertension.

Which interventions would the nurse take to prevent pulmonary complications in a patient who has just been admitted to the postanesthesia care unit and develops coarse crackles? Select all that apply. 1 Teach abdominal exercises. 2 Provide IV hydration. 3 Suction the airways. 4 Administer sedatives. 5 Administer cough suppressants.

2,3

Which action would the nurse take to ensure oxygenation in a patient who develops inspiratory stridor and sternal retraction upon removal of the endotracheal tube? Select all that apply. 1 Suction the airway. 2 Administer oxygen therapy. 3 Administer muscle relaxants. 4 Tilt the head and thrust the jaw. 5 Provide positive-pressure ventilation.

2,3,5 Inspiratory stridor and sternal retraction are due to laryngospasm associated with removal of the endotracheal tube. Oxygen therapy helps maintain the perfusion levels in the patient. Skeletal muscle relaxants help relax the muscles and relieve laryngospasm. Positive-pressure ventilation helps keep the patient oxygenated. Suctioning may increase laryngospasm. Tilting the head and thrusting the jaw does not help relieve laryngospasm.

Which factor is associated with the highest risk for respiratory complication following surgery? 1 General anesthesia used during surgery 2 Hydromorphone patient-controlled analgesia (PCA) for pain control 3 History of obstructive sleep apnea 4 Endotracheal intubation for surgery

3 A history of obstructive sleep apnea would be associated with the highest risk for postoperative respiratory complication. General anesthesia, a PCA with hydromorphone, and endotracheal intubation are also risk factors, but sleep apnea poses the highest risk.

A patient in the postanesthesia care unit (PACU) becomes delirious and restless and shouts at the nurse about pain. Which factor would the nurse consider may be a cause of this behavior? 1 A new diagnosis of psychosis 2 Decreased ability to tolerate pain 3 Anesthetic agents used in surgery 4 Overdose of analgesics

3 Anesthetic agents used in surgery can cause short-term psychotic-type behaviors that are relieved after the anesthetic drugs have cleared the body. A new diagnosis of psychosis is not warranted in the acute phase following surgery. The patient may not be tolerating the pain, but the delirium, yelling, and restlessness denote short-term psychotic-like behavior caused by the anesthetic agents and postoperative pain. An overdose of pain medications would present as increased sedation and decreased respiratory rate.

Which position would the nurse place a patient who is still drowsy from anesthesia and has been vomiting? 1 High Fowler's 2 Prone 3 Supine 4 Lateral recovery position

4 Aspiration of the vomitus is a concern in the drowsy patient and can be prevented by placing the patient in the lateral recovery position. This position helps the vomitus escape through the mouth. Supine and prone positions are less helpful in preventing aspiration than the lateral recovery position. High Fowler's position would not be recommended for a drowsy patient and would not be helpful in preventing aspiration.