Chapter 19 prepu

The nurse is preparing to discharge a patient from the PACU using a PACU room scoring guide. With what score can the patient be transferred out of the recovery room? 5 8 7 6

8

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: Ambulating the client as soon as possible Assisting with incentive spirometry every 6 hours Assessing breath sounds at least every 2 hours Positioning the client in a supine position

Ambulating the client as soon as possible The nurse should assist the client to ambulate as soon as the client is able. Incentive spirometry should be performed every 1 to 2 hours. The client should be positioned from side to side and in semi-Fowler's position. While assessing breath sounds is essential, it does not help to prevent pneumonia

Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis? Urinary retention Ineffective airway clearance Acute pain Decreased cardiac output

Decreased cardiac output

The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of: Laryngospasm Hyperventilation Hypoxemia and hypercapnia. Pulmonary edema and embolism.

Hypoxemia and hypercapnia The primary objective in the immediate postoperative period is to maintain pulmonary ventilation and thus prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. Besides checking the health care provider's orders for and administering supplemental oxygen, the nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds.

In what phase of postanesthesia care (PACU) is the client prepared for self-care or care in the hospital or an extended care setting?

In some hospitals and ambulatory surgical centers, postanesthesia care is divided into three phases. In the phase I PACU, used during the immediate recovery phase, intensive nursing care is provided. In the phase II PACU, the patient is prepared for self-care or care in the hospital or an extended care setting. In phase III PACU, the patient is prepared for discharge. There is no phase IV PACU.

What evidence does the nurse understand indicates that a patient is ready for discharge from the recovery room or PACU? (Select all that apply.) The patient has sonorous respirations and occasionally requires chin lift. The patient rates pain a 9 out of 10 on a 0-10 scale after receiving morphine sulfate. The patient has been extubated but still has an oropharyngeal airway in. The patient has a blood pressure within 10 mm Hg of the baseline. The patient is arousable but falls back to sleep rapidly.

The patient has sonorous respirations and occasionally requires chin lift. patient has a blood pressure within 10 mm Hg of the baseline The patient is arousable but falls back to sleep rapidly. A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline.

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

dehiscence

Corticosteroids have which effect on wound healing? Cause hemorrhage May cause protein-calorie depletion Mask presence of infection Reduce blood supply

Mask presence of infection Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. Edema may reduce blood supply. Corticosteroids do not cause hemorrhage or protein-calorie depletion.

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: Ambulating the client as soon as possible Assisting with incentive spirometry every 6 hours Assessing breath sounds at least every 2 hours Positioning the client in a supine position

Ambulating the client as soon as possible The nurse should assist the client to ambulate as soon as the client is able. Incentive spirometry should be performed every 1 to 2 hours. The client should be positioned from side to side and in semi-Fowler's position. While assessing breath sounds is essential, it does not help to prevent pneumonia.

Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply. Be able to self-toilet Ambulate the length of the client's house Get out of bed without assistance Be able to drive to the grocery Pass a stress test

Be able to self-toilet Ambulate the length of the client's house Get out of bed without assistance

Postoperative day 2, a patient requires wound care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing? Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive Packing the wound bed with sterile saline-soaked dressing and covering with dry dressing Cleaning the wound with soap and water, then leaving open to air Covering the well approximated wound edges with a dry dressing

Packing the wound bed with sterile saline-soaked dressing and covering with dry dressing

Which of the following is a classic sign of hypovolemic shock? High blood pressure Dilute urine Bradypnea Pallor

Pallor

Which of the following would be the least important factor affecting wound healing? Hemorrhage Nutritional deficiencies Sufficient oxygenation Age of patient

Sufficient oxygenation Oxygen deficit is a factor in wound healing. Hemorrhage. nutritional deficiencies, such as protein-calorie depletion, and the age of the patient are factors affecting wound healing. The older the patient, the less resilient are his or her tissues.

Which of the following clinical manifestations increase the risk for evisceration in the postoperative client? Valsalva maneuver Edema Hypoxia Hypovolemia

Valsalva maneuver The Valsalva maneuver produces tension on abdominal wounds, which increases the risk for evisceration.

The client is experiencing intractable hiccups following surgery. The nurse expects the surgeon to order: omeprazole (Prilosec) ranitidine (Zantac) metoclopramide (Reglan) chlorpromazine (Thorazine)

Chlorpromazine (Thorazine) is used to treat intractable hiccups.

Corticosteroids have which effect on wound healing? Cause hemorrhage May cause protein-calorie depletion Mask presence of infection Reduce blood supply

Mask presence of infection Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. Edema may reduce blood supply. Corticosteroids do not cause hemorrhage or protein-calorie depletion.

postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first? Place a pressure dressing over the opening and secure. Have the client lay quietly on back and call the physician. Place a dry, sterile dressing over the protruding organs. Moisten sterile gauze with normal saline and place on the protruding organ.

Moisten sterile gauze with normal saline and place on the protruding organ.

Question 1 of 5 When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as dirty. clean-contaminated. clean. contaminated.

clean-contaminated. Clean-contaminated cases are those with a potential, limited source for infection, the exposure to which, to a large extent, can be controlled. Clean cases are those with no apparent source of potential infection. Contaminated cases are those that contain an open and obvious source of potential infection. A traumatic wound with foreign bodies, fecal contamination, or purulent drainage would be considered a dirty case.

Question 7 of 10 The nurse is assessing the postoperative client on the second postoperative day. Which assessment finding requires immediate physician notification? The client has an absence of bowel sounds. The client's lungs reveal rales in the bases. The client states a moderate amount of pain at the incisional site. A moderate amount of serous drainage is noted on the operative dressing.

The client has an absence of bowel sounds. nursing assessment finding of concern on the second postoperative day is the absence of bowel sounds, which may indicate a paralytic ileus. Other assessment findings may include abdominal pain and distention as fluids, solids, and gas do not move through the intestinal tract. Rales in the bases are a frequent finding postoperatively, especially if general anesthesia was administered. Encourage the client to cough and deep breathe. Pain is a common symptom following a surgical procedure. Serous drainage on the postoperative dressing needs to monitored and brought to the physician's attention when he or she assesses the client.

Question 6 of 10 A client develops a hemorrhage an hour post surgery while in your care. Which of the following characteristics indicate this is most likely an intermediary hemorrhage from a vein? It occurred within the first few hours and has darkly colored blood that bubbles out slowly. It occurred during surgery and has bright red blood that flows freely. It occurred at a suture site, and the blood appears intermittently in spurts. It occurred a few hours after surgery, and the bright red blood appears with each heartbeat.

It occurred within the first few hours and has darkly colored blood that bubbles out slowly. An intermediary hemorrhage appears within the first few hours following surgery. The darkly colored blood bubbles out quickly makes it a venous hemorrhage. A hemorrhage that occurs during surgery is classified as a primary hemorrhage. The blood's color indicates its source is an artery. Secondary hemorrhages occur when sutures slip or drainage tubes dislodge insecure vessels. These characteristics are for a secondary hemorrhage from an artery.