NU144- Chapter 19: Postoperative Nursing Management

A client is beginning highly active antiretroviral therapy (HAART). The client demonstrates an understanding of the need for follow up when scheduling a return visit for viral load testing at which time?

6 weeks

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required?

"I can resume my usual activities as soon as I get home."

The nurse is working with a parent whose child has just been diagnosed with selective immunoglobulin A deficiency. The parent asks the nurse, "Does this mean that my child is going to die?" How should the nurse respond?

"Your child has a mild genetic immune deficiency caused by a lack of immunoglobulin A, a type of antibody that protects against infections of the lining the mouth and digestive tract."

Which is usually the most important consideration in the decision to initiate antiretroviral therapy?

CD4+ counts

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action?

Call the health care provider.

A client with acquired immune deficiency syndrome (AIDS) informs the nurse of difficulty eating and swallowing, and shows the nurse white patches in the mouth. What problem related to AIDS does the nurse understand the client has developed?

Candidiasis

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?

Central venous pressure

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?

Assess for bleeding.

HIV is harbored within which type of cell?

Lymphocyte

What complication is the nurse aware of that is associated with deep venous thrombosis?

Pulmonary embolism

Which client is more at risk of becoming infected with human immunodeficiency virus (HIV)?

A person having casual intercourse with multiple partners

A client with AIDS has become forgetful with a limited attention span, decreased ability to concentrate, and delusional thinking. What condition is represented by these symptoms?

AIDS dementia complex (ADC)

The nurse completes a history and physical assessment on a client with acquired immune deficiency syndrome (AIDS) who was admitted to the hospital with respiratory complications. The nurse knows to assess for what common infection (80% occurrence) in persons with AIDS?

Pneumocystis pneumonia

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing the dressing or applying pressure if bleeding is frank

The client is experiencing intractable hiccups following surgery. What would the nurse expect the surgeon to order?

chlorpromazine

When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as

clean contaminated.

dehiscence

partial or complete separation of wound edges

When should the nurse encourage the postoperative patient to get out of bed?

As soon as it is indicated

A client is to have a hip replacement in 3 months and does not want a blood transfusion from random donors. What option can the nurse discuss with the client?

Bank autologous blood.

Which blood test confirms the presence of antibodies to HIV?

Enzyme-linked immunosorbent assay (ELISA)

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?

Evisceration

During a routine checkup, a nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?

Kaposi's sarcoma

The nurse teaches the client that reducing the viral load will have what effect?

Longer survival

What is the highest priority nursing intervention for a client in the immediate postoperative phase?

Maintaining a patent airway

Corticosteroids have which effect on wound healing?

Mask the presence of infection

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?

Notify the primary care provider immediately.

The nurse is caring for a client who has a diagnosis of human immunodeficiency virus (HIV). Part of this client's teaching plan is educating the client about his or her medications. What is essential for the nurse to include in the teaching of this client regarding medications?

Side effects of drug therapy

A client with suspected exposure to HIV has been tested with the enzyme-linked immunosorbent assay (ELISA) with positive results twice. The next step for the nurse to explain to the client for confirmation of the diagnosis is to perform a:

Western blot test for confirmation of diagnosis.

phase I PACU

area designated for care of surgical patients immediately after surgery and for patients whose condition warrants close monitoring

phase II PACU

area designated for care of surgical patients who have been transferred from a phase I PACU because their condition no longer requires the close monitoring provided in a phase I PACU

post anesthesia care unit (PACU)

area where postoperative patients are monitored as they recover from anesthesia formerly referred to as the recovery room or postanesthesia recovery room

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.

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.

third-intention healing

method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by opposing areas of granulation

evisceration

protrusion of organs through the surgical incision

phase III PACU

setting in which the patient is cared for in the immediate postoperative period and then prepared for discharge from the facility

A female client comes to the clinic and tells the nurse, "I think I have another vaginal infection and I also have some wart-like lesions on my vagina. This is happening quite often." What should the nurse consult with the physician regarding?

testing the client for the presence of HIV

The nurse is preparing to administer the recommended dose of intravenous gamma-globulin for a 60-kg male client. How many grams will the nurse administer?

30 g

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?

Assess for signs and symptoms of fluid volume deficit.

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.

Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis?

Decreased cardiac output

The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists?

Dehiscence

Which of the following is the most common HIV-related malignancy?

Kaposi's sarcoma

Which option should the nurse encourage to replace fluid and electrolyte losses in a client with AIDS?

Liquids

Which is a classic sign of hypovolemic shock?

Pallor

A majority of clients with CVID develop which type of anemia?

Pernicious

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?

Pink to red and soft, bleeding easily

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?

Pink to red and soft, noting that it bleeds easily

A client with acquired immune deficiency syndrome (AIDS) is exhibiting shortness of breath, cough, and fever. What type of infection will the nurse most likely suspect?

Pneumocystis jiroveci

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?

Pneumonia

A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention?

Report early calf pain.

The nurse is reviewing a list of surgical clients. Which clients would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period? Select all that apply.

The 27-year-old client with non-insulin dependent diabetes. The 70-year-old client who takes no routine medications.

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client?

The client can be discharged from the PACU.

A nurse is working in the postanesthesia unit (PACU). What evidence indicates that a client is ready for discharge from the PACU? Select all that apply.

The client is arousable, but falls back to sleep rapidly. The client has a blood pressure within 10 mm Hg of the baseline.

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.

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?

Tolerance

A client vomits postoperatively. What is the most important nursing intervention?

Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?

Urine retention

second-intention healing

method of healing in which wound edges are not surgically approximated and integumentary continuity is restored by the process known as granulation

first-intention healing

method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation