Post Operative Nursing Management
The nurse is caring for a client with COPD who needs teaching on pursed lip breathing. Place the steps in order
1. Inhale through your nose 2. Slowly count to 3 3. Exhale slowly through pursed lips 4. . Slowly count to 7
A nurse prepares to suction a client's trache tube. Place the steps in order
1. Position the client in Fowler's position 2. Don sterile gloves 3. Lubricate sterile suction Cather 4. Insert suction catheter into the lumen of the tube 5. Apply intermittent suction while withdrawing the catheter
Adequate hourly urine output for a client with an indwelling urinary catheter is
2.0 ml/kg/hr
The nurse is preparing to discharge a patient from the PACU using PACU room scoring guide. With what score can the patient be transferred out of the recovery room
8
When should the nurse encourage the post op patient to get out of bed
As soon as it is indicated
A client is a post-op day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75ml/h, has a NGT to low wall suction with 200ml every 8 hours of light yellow fluid and a wound drain with 50ml of dark red drainage every 8 hours. The 24 hour urine output total is 2430 ml. What action by the nurse is most appropriate.
Asses for signs and symptoms of fluid volume deficit
The client post-op day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention
Assessing WBC count, temperature and wound appearance
Following a splenectomy, a client has a HGb level of 7.5g/dL and has a vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that most support the nurse's analysis are
Blood pressure 80/40 mm hg and pulse 130 bpm
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 nurses's priority action
Call the health care provider
The post-op client is being evaluated for discharge and currently has an aldrete score of 8. Which of the following is most likely outcome for this patient
Can be discharged from PACU
The nurse is responsible for monitoring cardiovascular function in a Post-Op patient. What method can the nurse use to measure cardiovascular function
Central venous pressure
The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client. Select all that apply
Changing position watching television listening to music
When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as
Clean contaminated
A client with nausea and vomiting is to receive an antiemetic that inhibits the vomiting center in the brain. Which of the following would the nurse expect the physician to order most likely
Comparing (prochlorperazine)
A physician's admitting note lists a wound as healing by second intention. What does the nurse expect to find
A wound in which the edges were not approximated
The nurse is concerned that a post-op patient may have a paralytic lieus. What assessment data may indicate that the patient does have a paralytic lieu's
Absence of peristalsis
To prevent pneumonia and promote the integrity of pulmonary system, an essential post-op nursing intervention include
Ambulate got the client as soon as possible
Which of the following mobility criteria must a post-op client meet to discharge to home. Select all that apply
Ambulate the length of the clients house Get out of bed without assistance Be able to self toilet
A nurse is reviewing with a client the use of a PCA device and is explaining the benefits. Which of the following would the nurse correctly emphasize. Select all that apply .
Fosters client participation in care Facilities reduction of post-op pulmonary complications
The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates teaching has been effective
I can resume my usual activities as soon as I get home
Nursing assessment findings reveal a temperature of 96.2 F, pulse ox 90% , shivering and client complains of chilling. The findings are indicative of which nursing diagnosis
Ineffective thermoregulation
Primary objective in the immediate post-op period is
Maintaining pulmonary ventilation
The PACU nurse is caring for an older adult who presents with clinical manifestation of delirium. Which short term outcome would be most important for this client. The client:
Maintains adequate oxygenation status
The nurse is caring for a client post-op. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery
Encourage the client to move legs frequently and do leg exercises
Which term refers to the protrusion of abdominal organs through surgical incision
Evisceration
A client in post-op hour 8 after appendectomy and is anxious, stating" something is not right. My pain is worse than ever and my stomach is swollen." Blood pressure is 88/50, pulse is 115 and respirators are 24 and labored. The abdomen is soft and distended. No obvious bleeding is noted. What action by the nurse is most appropriate
Notify the physician
Unless contraindicated, how should the nurse position an unconscious patient
On the side with a patient back's and chin extended, to minimize the dangers of aspiration
The client complains of weakness and dizziness as the nurse assists the client to sit on the side of the bed. The nurse recognizes the client is experiencing
Orthostatic hypotension
On post-p day 2, a client requires for a surgical wound using second intention healing. What type of dressing change should the nurse anticipate doing
Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing
When vomiting occurs post-op. What is the most important nursing intervention
Turn the patients head completely to one side to prevent aspiration of vomitus into the lungs
Which of the following clinical manifestations increase the risk for evisercation in the post-op client
Valsalva maneuver
The nurse cares for a client who is 3 hour post-op abdominal hysterectomy and begins to develop hiccups. What nursing assessment will the nurse monitor more closely with the client's new symptoms
Wound approximation
You are caring for a client who is an obese diabetic. The client is 48 hours post surgery. What is this client at increased risk for
Wound dehiscence
Nursing assessment findings reveal a temperature of 103.2 F, tachycardia, and client complaints of increased incision pain. The nurse recognizes the client is experiencing
Wound infection
The client is experiencing nausea and vomiting the following surgery. The nurse expects the surgeon to order
Zofran (ondansetron)
Which is a classic sign of hypovolemic shock
Pallor
In what phase PACU is the client prepared for self-care or care in the hospital or an extended care setting
Phase II PACU
A post-op client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem
Pink color
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
What does the nurse recognize as one of the most common post-op respiratory complications in elderly patient
Pneumonia
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
The nurse is caring for post-op client in the PACU. Which of the following is the priority nursing action
Position the client to maintain a patent airway
The nurse is reviewing the medications of a post-op client. Which of following medications may be concern to the nurse
Prednisone (deltasone)
What complication is the nurse aware of that is associated with deep venous thrombosis
Pulmonary embolism
The nurse recognizes which symptom as a clinical manifestation of shock
Rapid, weak thready pulse
The nurse is attempting to ambulate a client who underwent shoulder surgery earlier in the day, but the client is refusing to do so. What action by the nurse is most appropriate?
Reinforce the importance of early mobility in preventing complications
The nurse observes that a post surgical client has a hemorrhage and is hypovolemic shock. Which nursing intervention will manage and minimize the hemorrhage and shock
Reinforcing dressings or applying pressure if bleeding is frank
Nursing assessment findings reveal a temperature of 96.2 F, pulse o 90%, shivering and client complains of chilling. Which of the following actions by the nurse would be inappropriate
Restrict oral fluids
The nurse is teaching the client about PCA. Which of following wound be appropriate for the nurse to include in the teaching plan?
Therapeutic drug levels can be maintained more evenly with PCA
You are caring for a client who needs to ambulate. What considerations should be included when planning the post-op ambulatory activities for older adults
Tolerance
A client had a nephew to my 2 days ago and is now complaining of a abdominal pressure and nausea. The first nursing action should be to
Auscultate bowel sounds
A nurse is planning care for a patient schedule to undergo a thoracotomy. After tolerating full liquids, which dietary recommendation will the nurse consider
Small, frequent full fat meals
The nurse is changing the dressing of a client who is a 4 days post-op with an abdominal wound. The nurse has changed this dressing daily since surgery. Today the nurse notes increase serosanguinous drainage, wound edges not approximated and a 1/4 inch gap at the lower end of the incision. The nurse concludes which of the following conditions exists
Dehiscence
A nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The client states "i haven't moved my bowels, but i am passing gas" how should the nurse intervene
Encourage the client to ambulate at least three times per day
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal
First intention
A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage
Hemovac drain isn't compressed; instead it is fully expanded
A client asks why a drain is in place to pull fluid from the surgical wound.what is the best response by the nurse
It assists in preventing infection
When abnormal post-op urinary output should the nurse report to the physician for a 2 hour period
Less than 30 ml
A post-op client is moving from bed to a chair when blood drips from the dressing. The nurse assess the incision and notes evisceration. What does the nurse do first?
Moisten sterile gauze with normal saline and place on the protruding organ
A post-op client with an open abdominal wound is currently taking corticosteroids. The physician orders a culture of the abdominal wound even though no signs or symptoms of infection are seen. What action by the nurse is appropriate
Obtain the would culture specimen
What measurement should the nurse report to the physician in the immediate post-op period
Systolic blood pressure lower than 90 mm hg
Select the nutrient that is important for post-op wound healing because is helps form collagen
Vitamin c