N120 Ch 19 Postop Care (AQ)

A patient with asthma develops wheezing on the postanesthesia care unit. The nurse finds that the patient is tachypneic, has dyspnea, and has reduced oxygen saturation. How will the nurse prevent further pulmonary complications? 1. Administer bronchodilators. 2. Provide incentive spirometry. 3. Encourage chest physical therapy. 4. Provide nebulization of histamine vapors.

1. Administer bronchodilators. The presence of wheeze, tachypnea, and reduced oxygen saturation indicates bronchospasm. The use of bronchodilators relieves bronchospasm and promotes a patent airway. Incentive spirometry is useful in managing atelectasis when the airway is patent. Chest physical therapy is helpful to clear secretions from the respiratory tract. Histamine vapors aggravate bronchospasm and therefore should be avoided.

A postoperative patient with bronchial obstruction has a pulse oximetry reading of 87%. What does the nurse suspect is occurring with this patient? 1. Atelectasis 2. Bronchospasm 3. Hypoventilation 4. Pulmonary embolism

1. Atelectasis The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.

A patient that is an alcoholic had a hernia operation and is restless and irritable. On assessment, the nurse finds that the patient has auditory hallucinations. What is the most appropriate nursing action? 1. Conclude that these effects are due to alcohol withdrawal. 2. Consider the situation normal, due to the anesthetic drugs. 3. Conclude that the patient suffers from a psychotic disorder. 4. Infer that the patient is suffering from pain and suggest using pain killers

1. Conclude that these effects are due to alcohol withdrawal. The patient is irritable and restless due to loss of the inhibitory effects of alcohol; this is also causing the hallucinations. The patient does not have a history of psychotic illness; therefore, the symptoms cannot be attributed to a psychotic disorder. Anesthetic drugs may cause delirium, but not hallucinations. Pain may cause restlessness and irritability, but not hallucinations.

A patient had an estimated blood loss of 400 mL during abdominal surgery. The patient received 300 mL of 0.9% saline during surgery and now is experiencing hypotension postoperatively. What should the nurse anticipate for this patient? 1. Restoring circulating volume 2. Monitor pulse and blood pressure 3. An ECG to check circulatory status 4. Return to surgery to check for internal bleeding

1. Restoring circulating volume The nurse should anticipate restoring circulating volume with intravenous (IV) infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. The nurse will need to do more than monitor pulse and blood pressure. An ECG may be done if there is no response to the fluid administration or there is a past history of cardiac disease or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if the patient's level of consciousness changes or the abdomen becomes firm and distended.

While caring for a patient after a colectomy on the first postoperative day, the nurse notes new bright-red drainage about 4 cm in diameter on the surgical dressing. What is the priority nursing action? 1. 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. Take the patient's vital signs. 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 priority nursing action. Rechecking the dressing in an hour increases the risk of adverse outcomes by waiting more time to notify the health care provider about a potential bleeding complication. The health care provider should be notified after the nurse assesses the patient.

A patient is admitted to the postanesthesia care unit (PACU) after colon surgery. During the initial assessment, the patient tells the nurse they are 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 antinausea medicine."

2. "Let me help you turn to your side." 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.

A patient is transferred to the postanesthesia care unit (PACU) after surgery. Which nursing intervention is the highest priority initially? 1. Assess intake, output, and fluid balance. 2. Assess airway, breathing, and circulation status. 3. Assess the surgical site and condition of the dressing. 4. Note the presence of all IV lines and drainage catheters.

2. Assess airway, breathing, and circulation status. When the patient is shifted to the PACU after surgery, the nurse should first assess the patient's airway, breathing, and circulation status. Any evidence of respiratory or circulatory compromise needs immediate intervention. Thereafter, the nurse may assess the patient's intake, output, and fluid status and note the presence of IV lines and drainage bags. The nurse should also assess the surgical site and condition of the wound.

A patient on the postoperative unit was given a large dose of opioids during a surgical procedure and is now hypoxemic. What would the nurse expect to be prescribed to manage hypoxemia in this patient? 1. Opioids 2. Naloxone 3. Benzodiazepines 4. Withholding mechanical ventilation

2. Naloxone Shallow respiration associated with hypoxemia and reduced respiratory rate in a patient who received large doses of opioids indicates hypoventilation due to medullary depression. Drugs that reverse the effect of opioids should be administered to stimulate the medullary respiratory center such as naloxone. Opioids and benzodiazepines should be avoided because they further aggravate medullary depression. In severe medullary depression, the patient may need mechanical ventilation.

The nurse is monitoring a patient who is about to be transferred to the clinical unit from the postanesthesia care unit (PACU). Which assessment data require the most immediate attention? 1. Oxygen saturation of 94% 2. Pulse rate 128 beats/minute 3. Respiratory rate of 13/minute 4. Temperature of 99.8° F (37.7° C)

2. Pulse rate 128 beats/minute The most important aspect of the cardiovascular assessment is frequent monitoring of vital signs. They usually are monitored every 15 minutes in Phase I, or more often until stabilized, and then at less frequent intervals in Phase II. Notify the anesthesia care provider (ACP) or the health care provider if the pulse rate is less than 60 beats/minute or greater than 120 beats/minute. The oxygen saturation should be above 90%, so 94% is good. A respiratory rate of 13 is normal. A temperature of 99.8 is expected.

What is the priority nursing action when a patient is transferred from the postanesthesia care unit (PACU) to the surgical unit after a lobectomy? 1. Assess the patient's pain. 2. Take the patient's vital signs. 3. Check the rate of the intravenous (IV) infusion. 4. Check the health care provider's postoperative prescriptions.

2. Take the patient's vital signs. The highest priority action by the nurse is to assess the physiologic stability of the patient. This is in part accomplished by taking the patient's vital signs. Assessing the patient's pain, checking the prescriptions, and checking the rate of IV infusion can take place in a rapid sequence after taking the vital signs.

The nurse caring for a postoperative patient assesses clinical manifestations of early pulmonary edema. What manifestations does the nurse determine correlates with this disorder? 1. Early-morning cough 2. Increased urine output 3. Paroxysmal nocturnal dyspnea 4. Crackles heard on auscultation

3. Paroxysmal nocturnal dyspnea 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. Between the two, shortness of breath in the form of paroxysmal nocturnal dyspnea is the earlier symptom, although crackles are more common. 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. Crackles heard on auscultation of the lungs are one of the more common symptoms of pulmonary edema, along with coughing of frothy pink-tinged sputum.

Two days after colectomy for an abdominal mass, the patient reports gas pains and abdominal distension. 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. Nasogastric suctioning 3. Slowed gastric emptying 4. Inflammation of the bowel at the anastomosis site

3. Slowed gastric emptying Until peristalsis returns to normal after anesthesia, the patient may experience slowed gastric motility, leading to gas pains and abdominal distension. Colectomy does not require a nasogastric tube; 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.

A patient has been admitted to the postanesthesia care unit (PACU). Which of these assessment findings require the nurse's immediate action? 1. The patient is groggy but arouses to voice. 2. The patient indicates that he or she is in pain. 3. The patient is restless, agitated, and hypotensive. 4. The Jackson-Pratt is draining serosanguinous fluid.

3. The patient is restless, agitated, and hypotensive. Assessment in the PACU begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Restlessness, agitation, and hypotension are clinical manifestations of inadequate oxygenation. Identification of inadequate oxygenation and ventilation or respiratory compromise requires prompt intervention. Pain, sedation, and draining serosanguinous fluid are expected findings.

The nurse is developing a care plan for the postoperative patient in order to prevent complications and promote ambulation, coughing, deep breathing, and turning. What actions can the nurse provide to achieve 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. Administer enough analgesics to promote relative freedom from pain. 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 ambulation, coughing, deep breathing, and turning can be performed.

A patient on the postoperative unit reports difficulty breathing. The nurse discovers that the patient received large doses of skeletal muscle relaxants during surgery. What should the nurse include in the patient's plan of care to promote breathing? 1. Administering opioids 2. Loosening the dressings 3. Repositioning the patient 4. Administering drugs for reversal of paralysis

4. Administering drugs for reversal of paralysis The use of skeletal muscle relaxants may paralyze the muscles required for breathing. Administering drugs for reversal of paralysis 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.

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure of 100/60 mm Hg. Which action should the nurse take first? 1. Rouse the patient. 2. Place the patient in the Trendelenburg position. 3. Notify the anesthesiologist of the low blood pressure. 4. Check the medical record for the patient's baseline blood pressure.

4. Check the medical record for the patient's baseline blood pressure. The first action of the nurse is to identify what the patient's normal blood pressure is. Interventions are dependent on the baseline variation. Rousing the patient is an intervention that can increase the blood pressure, but would be done after determining the baseline blood pressure. Placing the patient in Trendelenburg is not an appropriate action in this situation. Before notifying the anesthesiologist of the blood pressure, the nurse needs to check the baseline blood pressure.

A postoperative patient develops fever, abdominal pain, and diarrhea despite being on long-term antibiotics. What should the nurse evaluate for? 1. Wound infection 2. Urinary infection 3. Respiratory infection 4. Clostridium difficile infection

4. Clostridium difficile infection Prolonged use of antibiotics increases the risk of Clostridium difficile infection by damaging the normal flora of the intestine. The infection is manifested as fever, diarrhea, and abdominal pain. Wound infection, urinary infection, and respiratory infection may present with fever, but these infections rarely present with diarrhea and abdominal pain.

A patient with a history of psychosis has newly developed anxiety and is combative with the nurse. What does the nurse know may be causes of this change in behavior? 1. Delirium 2. Excessive sleep 3. Hyperoxygenation 4. Electrolyte imbalances

4. Electrolyte imbalances The nurse knows electrolyte imbalances can cause an acute change in a patient's behavior. A new onset of anxiety and combativeness may cause delirium rather than the other way around. Sleep deprivation, not excessive sleep, would cause anxiety and aggression. Hyperoxygenation would not cause such behavior changes; hypoxemia does.

A patient transferred to the medical-surgical unit from the postanesthesia care unit (PACU) has regained consciousness. In which position should the nurse place the patient in order to prevent respiratory problems? 1. Lithotomy position 2. Lateral recovery position 3. Prone position with extra pillows 4. Supine position with head elevated

4. Supine position with head elevated If the patient is conscious, the patient should be positioned in supine position with the head elevated. This position helps to maximize the expansion of the thorax by decreasing the pressure of abdominal contents on the diaphragm. Lateral recovery position is usually used in unconscious patients to keep the airway open and reduce the risk of aspiration if vomiting occurs. Prone and lithotomy positions are not used in postsurgery patients.