N 403 Ch 19 PrepU
The nurse is caring for a client in the postanesthesia care unit (PACU). The client has the following vital signs: pulse 115, respirations 20, oral temperature 97.2°F, blood pressure 84/50. What should the nurse do first? Notify the physician. Assess for bleeding. Increase rate of IV fluids. Review the client's preoperative vital signs.
Correct response: Assess for bleeding. Explanation: The client is tachycardic with low blood pressure; thus assessing for hemorrhage is the priority action. While the physician may need to be notified, the nurse needs to be able to communicate a complete picture of the client, which would include bleeding, when calling the physician. The rate of IV fluid administration should be adjusted according to a physician order. The nurse should review prior vital signs but only after the immediate threat of hemorrhage is assessed.
The nurse recognizes that a traumatic wound with fecal contamination would be classified as - clean. - clean contaminated. - contaminated. - dirty.
Correct response: dirty. Explanation: An example of a dirty wound includes a traumatic wound with delayed repair, devitalized tissue, foreign bodies, or fecal contamination. A clean wound occurs at a nontraumatic site or at an uninfected site. Examples of clean contaminated wounds include appendectomy or a minor break in aseptic technique. An example of a contaminated wound is gross spillage from the gastrointestinal tract.
The nurse is assessing the client for wound complications following surgery. For which clinical manifestation should the nurse assess? Select all that apply. - Atelectasis - Thrombophlebitis - Dehiscence - Hematoma - Paralytic ileus
Correct response: Dehiscence Hematoma Explanation: A hematoma can form within the wound and result in delayed healing. Dehiscence is a disruption of the surgical incision. Atelectasis, thrombophlebitis, and paralytic ileus are potential complications following surgery. Atelectasis is a collapse of the alveoli, which interferes with gas exchange. Thrombophlebitis is the development of a blood clot, usually in the lower extremity. Paralytic ileus is an absence of intestinal peristalsis.
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.
Correct response: Hypoxemia and hypercapnia. Explanation: 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.
When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O2 saturation monitor despite the client's breathing appearing normal, what action should the nurse take first? - Assess the client's heart rhythm and nail beds. - Apply oxygen. - Notify the physician. - Document the findings.
Correct response: Assess the client's heart rhythm and nail beds. Explanation: A client may demonstrate low oxygenation readings because of certain colors of nail polish or may show an irregular heart rate such as atrial fibrillation. These factors should be assessed to ensure the accuracy of the oxygen reading. Once the reading is confirmed as accurate, then the nurse may need to apply oxygen, notify the physician, and document the findings.
Which term refers to the protrusion of abdominal organs through the surgical incision? - Hernia - Dehiscence - Erythema - Evisceration
Correct response: Evisceration Explanation: Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.
The nurse is planning care for a client in the postoperative period. Place the following nursing diagnoses in sequence, from highest to lowest priority. - Fluid Volume Deficit - Anxiety - Risk for Infection - Altered Comfort - Impaired Gas Exchange
Correct response: Impaired Gas Exchange Fluid Volume Deficit Altered Comfort Anxiety Risk for Infection Explanation: According to the Maslow's hierarchy of deeds, airway and gas exchange is of the highest priority. Next would be the deficiency in fluid volume. Altered comfort would be higher than anxiety because decreasing pain may alleviate/reduce anxiety. Lastly, a risk for infection is not a current problem but an important teaching point to reduce the risk.
When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation, although the patient's breathing appears normal, the nurse identifies that the patient may be suffering from which type of hypoxemia? - Subacute - Hypoxic - Episodic - Anemic
Correct response: Subacute Explanation: Supplemental oxygen may be indicated for subacute hypoxemia. Hypoxic hypoxemia results from inadequate breathing. Episodic hypoxemia develops suddenly, and the client may be at risk for myocardial ischemia, cerebral dysfunction, and cardiac arrest. Anemic hypoxemia results from blood loss during surgery.
Using the PACU room scoring guide, a nurse would give a patient an admission cardiovascular score of 2 if the patient's blood pressure is what percentage of his or her preanesthetic level? 20% 30% to 40% 40% to 50% Greater than 50%
Correct response: 20% Explanation: The patient would receive a cardiovascular / circulation score of 2 if the blood pressure is 20% of the preanesthetic level.
To prevent thromboembolism in the postoperative client, the nurse should include which of the following in the plan of care? - Place a pillow under the knees. - Assist the client with deep breathing. - Splint the incision when ambulating. - Assist with oral fluid intake.
Correct response: Assist with oral fluid intake. Explanation: Dehydration, immobility, and pressure on leg veins promote venous stasis, which can lead to thromboembolism.
Aldrete Scoring System
1 Consciousness - Fully awake (2 points) - Arousable (1 point) - Not responding (0 points) 2 Mobility - Able to move four extremities on command (2 points) - Able to move two extremities on command (1 point) - Able to move 0 extremities on command (0 points) 3 Breathing - Able to breathe deeply (2 points) - Dyspnea (1 point) - Apnea (0 points) 4 Circulation Systemic BP ≠ 20% of the preanesthetic level (2 points) - Systemic BP between 20% and 49% of the preanesthetic level (1 point) - Systemic BP ≠ 50% of the preanesthetic level (0 points) 5Color - Normal (2 points) - Pale, jaundiced, blotchy (1 point) - Cyanotic (0 points)
A nurse is assessing the client's readiness for discharge from the postanesthesia care unit (PACU). The nurse can rouse the client by calling the client's name. The client can move all extremities and has a blood pressure of 134/82. Baseline preoperative blood pressure was 128/78. The most recent pulse oximetry reading was 94% on room air; the client's respirations are deep and easy at a rate of 12 breaths/minute. What is the calculated Aldrete score? - 7 - 8 - 9 - 10
Correct response: 9 Explanation: The Aldrete score is used 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 client's condition in the PACU. The client's total Aldrete score is 9 because the client is aroused when name is called (1), moves all extremities (2), is able to breath deeply and cough (2), exhibits circulation (blood pressure) 20% or more above the preanesthesia level (2), and is able to maintain a oxygen saturation level >92% on room air (2).
The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply. - Wheezes - Chills - Crackles - Afebrile - Tachypnea
Correct response: Chills Crackles Tachypnea Explanation: Pneumonia is characterized by fever, chills, tachycardia, tachypnea, and crackles. Cough may or may not be present. Wheezing is not an expected finding of 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? - Acute pain - Ineffective airway clearance - Decreased cardiac output - Urinary retention
Correct response: Decreased cardiac output Explanation: Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion.
The nurse is admitting the older adult to the PACU. Which information about this client would be most important for the PACU nurse to obtain? - What procedure was performed? - What was estimated blood loss? - Are family members available? - Does the client have a history of dementia-like symptoms?
Correct response: Does the client have a history of dementia-like symptoms? Explanation: Acute confusion is a common side effect of anesthesia in older adults. The nurse needs to know whether any confusion displayed by the client is a result of the surgery and anesthesia or a usual state for the client.
A postoperative client is being discharged home after minor surgery. The PACU nurse is reviewing discharge instructions with the client and the client's spouse. What actions by the nurse are appropriate? Select all that apply. - Educate on activity limitations. - Discuss wound care. - Have the spouse review when to notify the physician. - Have the client sign his or her advance directive form. - Provide information on health promotion topics.
Correct response: Educate on activity limitations. Discuss wound care. Have the spouse review when to notify the physician. Provide information on health promotion topics. Explanation: The nurse should provide education on activity limitations and wound care, and should review complications that require notification to the physician. The nurse should also provide information regarding health promotion topics, such as weight management and smoking cessation. The client should not make any major decisions or sign any legal forms because of the effects of anesthesia.
The nurse is caring for a postoperative client with a Hemovac. The Hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to: - Assess the client's wound and apply a pressure dressing. - Notify the surgeon that the Hemovac is not functioning. - Remove the Hemovac because it is expanded. - Empty and measure the drainage and compress the Hemovac.
Correct response: Empty and measure the drainage and compress the Hemovac. Explanation: A Hemovac needs to be recompressed periodically, because it operates with the use of gentle, constant suction. The amount of drainage is not excessive.
During the first 24 hours after surgery, how often will the nurse evaluate the client's temperature? - Every 15 minutes - Every 2 hours - Every 4 hours - Every 8 hours
Correct response: Every 4 hours Explanation: The pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours. Thereafter, they are measured less frequently if they remain stable. The temperature is monitored every 4 hours for the first 24 hours.
A nurse is reviewing with a client the use of a patient-controlled anesthesia device and is explaining the benefits. Which of the following would the nurse correctly emphasize? Select all that apply. - Fosters client participation in care - Delays administration of analgesics - Facilitates reduction of postoperative pulmonary complications - Prevents drowsiness - Allows drug levels to fluctuate with the client's vital signs
Correct response: Fosters client participation in care Facilitates reduction of postoperative pulmonary complications Explanation: PCA promotes client participation in care, eliminates delayed administration of analgesics, maintains a therapeutic drug level, and enables the client to move, turn, cough, and take deep breaths with less pain, thus reducing postoperative pulmonary complications.
A patient who underwent abdominal surgery 3 hours ago has started to hemorrhage. The nurse would classify this type of hemorrhage has which of the following? - Intermediary - Primary - Secondary - Tertiary
Correct response: Intermediary Explanation: Intermediary hemorrhage occurs during the first few hours after surgery when the rise of blood pressure to its normal level dislodges insecure clots formed in untied vessels. Primary hemorrhage occurs at the time of surgery. Secondary hemorrhage may occur some time after surgery if a suture slips because a blood vessel was not securely tied, became infected, or was eroded by a drainage tube.
A postanesthesia care unit (PACU) nurse is caring for a client with the following assessment data: pale, cool, moist skin; thready pulse of 122; blood pressure 78/60; urine output of 25 mL/h; temperature 99.2°F. What interventions by the nurse are appropriate? Select all that apply. - Raise the head of the bed 30 degrees. - Maintain a patent airway. - Frequently monitor neurological status. - Administer blood products per orders. - Apply oxygen per orders. - Apply a warming blanket.
Correct response: Maintain a patent airway. Frequently monitor neurological status. Administer blood products per orders. Apply oxygen per orders. Explanation: The client is demonstrating signs and symptoms of shock. A client in shock may lose the ability to protect the airway. Frequent neurological assessment can provide information related to a decrease in oxygen to the brain. Administering blood products may reverse the signs and symptoms of shock. There is an increased need for oxygen when in shock, so it is appropriate to apply oxygen. The head of the bed should not be elevated. The client should be lying flat or in the Trendelenburg position.
The nurse is caring for a client 24 hours post surgery who is having persistent hiccups. What action is most appropriate for the nurse to take? - Position the client on his or her side. - Assist the client to intake ample amounts of water. - Notify the physician. - Instruct the client to take deep breaths.
Correct response: Notify the physician. Explanation: Prolonged hiccups may cause pain or discomfort. Prolonged hiccups may also result in wound dehiscence or evisceration, inability to eat, nausea and vomiting, exhaustion, and fluid, electrolyte, and acid-base imbalances. If hiccups continue, the nurse needs to notify the physician. Deep breathing helps minimize pain and will not help in this condition. Positioning the client and ample water intake will not help stop the hiccups.
The nurse is caring for a postoperative client with an indwelling urinary catheter. The hourly urinary output is 80 mL at 9 am. At 10 am, the nurse assesses the hourly urinary output as 20 mL. What is the priority action by the nurse? - Irrigate the catheter with sterile normal saline. - Document the findings. - Reassess the output at 11 am. - Notify the primary care provider immediately.
Correct response: Notify the primary care provider immediately. Explanation: If the client has an indwelling urinary catheter, hourly outputs are monitored and rates <30 mL/h are reported. Any urinary output <30 mL/h should be reported to the primary care provider immediately. Though urinary output will be reassessed at 11 am, but waiting to notify the primary care provider puts the patient at risk. The findings should be documented, but this is not the highest priority. A urinary catheter may need to be irrigated, but a postoperative client with a low urinary output is demonstrating a complication of inadequate fluid imbalance that needs to be reported immediately.
Unless contraindicated, how should the nurse position an unconscious patient? - Flat on the back, without elevation of the head, to facilitate frequent turning and minimize pulmonary complications - In semi-Fowler's position, to promote respiratory function and reduce the incidence of orthostatic hypotension when the patient can eventually stand - In Fowler's position, which most closely simulates a sitting position, thus facilitating respiratory as well as gastrointestinal functioning - On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration
Correct response: On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration Explanation: The head of the bed is elevated 15 to 30 degrees unless contraindicated, and the patient is closely monitored to maintain the airway as well as to minimize the risk of aspiration. If vomiting occurs, the patient is turned to the side to prevent aspiration and the vomitus is collected in the emesis basin.
The nurse observes bloody drainage on the surgical dressing of the client who has just arrived on the nursing unit. Which intervention should the nurse plan to do next? - Make the client NPO and order a stat hemoglobin and hematocrit. - Remove the dressing, assess the wound, and apply a new sterile dressing. - Outline the drainage with a pen and record the date and time next to the drainage. - Take the client's vital signs and call the surgeon.
Correct response: Outline the drainage with a pen and record the date and time next to the drainage. Explanation: Areas of drainage on the dressing should be outlined with a pen, and the date and time should be recorded next to the drainage. Blood drainage from the incision is a normal expected finding in the immediate postoperative period; however, excessive amounts should be reported to the surgeon.
Which of the following factors may contribute to rapid and shallow respirations in a postoperative client? Select all that apply. - Pain - Constricting dressings - Abdominal distention - Obesity - Effects of analgesics and anesthesia
Correct response: Pain Constricting dressings Abdominal distention Obesity Explanation: Often, because of the effects of analgesic and anesthetic medications, respirations are slow. Shallow and rapid respirations may be caused by pain, constricting dressings, gastric dilation, abdominal distention, or obesity.
In what phase of postanesthesia care (PACU) is the client prepared for self-care or care in the hospital or an extended care setting? - Phase I PACU - Phase II PACU - Phase III PACU - Phase IV PACU
Correct response: Phase II PACU Explanation: 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.
The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? - Necrotic and hard - Pale yet able to blanch with digital pressure - Pink to red and soft, bleeding easily - White with long, thin areas of scar tissue
Correct response: Pink to red and soft, bleeding easily Explanation: In second-intention healing, necrotic material gradually disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue.
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. - Administer an anti-emetic. - Obtain an emesis basin. - Ask the client for more clarification.
Correct response: 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.
A nurse is reviewing the medications of a postoperative client. What medication related to the recent surgery may be of concern to the nurse? - Furosemide - Prednisone - Digoxin - Allopurinol
Correct response: Prednisone Explanation: Corticosteroids such as prednisone (Deltasone) may impair the normal inflammatory process and may mask infection. Furosemide (Lasix), digoxin (Lanoxin), and allopurinol (Zyloprim) should not be of concern postoperatively.
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. - The client is showing signs of a medication reaction. - The client is displaying late signs of shock. - The client is showing signs of an anesthesia reaction.
Correct response: 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.
You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult? - Respiratory depressive effects - Tolerance - Convalescent period - Detailed medication history
Correct response: Tolerance Explanation: Postoperative ambulatory activities are essential but planned according to the older adult's tolerance, which usually is less than that of a younger person. The respiratory depressive effects should be considered when administering certain drugs for the older adults. The convalescent period usually is longer for older adults. Therefore, they may require positive reinforcement throughout the postoperative period as well as extensive discharge planning. The convalescent period of older adults and detailed medication history may not be necessary to consider when planning the postoperative ambulatory activities.
Select the nutrient that is important for postoperative wound healing because it helps form collagen. - Protein - Vitamin C - Magnesium - Vitamin A
Correct response: Vitamin C Explanation: Vitamin C is important for capillary formation, tissue synthesis, and wound healing through collagen formation. Vitamin A decreases the inflammatory response in wounds. Magnesium is essential for wound repair, and protein allows collagen deposition.
The client is experiencing intractable hiccups following surgery. What would the nurse expect the surgeon to order? - chlorpromazine - metoclopramide - omeprazole - nizatidine
Correct response: chlorpromazine Explanation: Chlorpromazine (Thorazine) is used to treat intractable hiccups.
When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as - clean. - contaminated. - clean contaminated. - dirty.
Correct response: clean contaminated. Explanation: Clean contaminated cases are those with a potential, limited source for infection, the exposure to which can largely 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 dirty.
A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client? - experiences pain within tolerable limits. - exhibits wound healing without complications. - resumes usual urinary elimination pattern. - maintains adequate fluid status.
Correct response: experiences pain within tolerable limits. Explanation: Because pain can contribute to postoperative delirium, adequate pain control without oversedation is essential. Nursing assessment of mental status and of all physiologic factors influencing mental status helps the nurse plan for care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult client.
Which findings would be indicative of a nursing diagnosis of decreased cardiac output? - urinary output > 60 ml; BP 90/60; tachypnea - bradycardia; urinary output < 30 ml; confusion - tachycardia; hemoglobin 10.9 gm/dL; BP 88/56 - confusion; tachypnea; hemoglobin 14.2 gm/dL
Correct response: tachycardia; hemoglobin 10.9 gm/dL; BP 88/56 Explanation: Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion.
