PREP U: Postoperative Management

The PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. Which short-term outcome would be most important for this client? The client:

Maintains adequate oxygenation status. -Acute confusion associated with delirium may be a result of hypoxia, pain, urinary retention, fecal impaction, fever, hypotension, hypoglycemia, fluid loss, and anemia. Hypoxia would be most important for the nurse to address.

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

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.

The primary objective in the immediate postoperative period is maintaining pulmonary ventilation. controlling nausea and vomiting. monitoring for hypotension. relieving pain.

Maintaining pulmonary ventilation. -The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and monitoring for hypotension are important, but they not the primary objectives in the immediate postoperative period.

Which of the following factors may contribute to rapid and shallow respirations in a postoperative client? Select all that apply. Constricting dressings Effects of analgesics and anesthesia Abdominal distention Obesity Pain

Pain Constricting dressings Abdominal distention Obesity -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.

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

Pneumonia -Older patients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Delirium, pneumonia, decline in functional ability, exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and falls are all threats to recovery in the older adult (Tabloski, 2009; Tolson, Morley, Rolland, et al., 2011).

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The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of:

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? Phase I PACU Phase II PACU Phase IV PACU Phase III PACU

Phase II PACU -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.

When caring for a postsurgical patient, the nurse observes that the client has hemorrhaged and is in hypovolemic shock. Which of the following nursing interventions will manage and minimize hemorrhage and shock?

Reinforcing dressing or applying pressure if bleeding is frank -The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the patient to breathe deeply and providing a back rub will not help manage and minimize hemorrhage and shock.

You are caring for a client 6 hours post surgery. You observe that the client voids urine frequently and in small amounts. You know that this most probably indicates what?

Urine retention -Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus.

A patient asks why there is a drain pulling fluid from the surgical wound. What is the best response by the nurse?

"It assists in preventing infection." -A wound drain assists in preventing infection by removing the medium in which bacteria would grow. The purpose of the wound drain is not to remove necrotic tissue or to decrease the number of dressing changes. Stating that most surgeons use wound drains does not answer the patient's question appropriately.

The 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/minute. The nurse calculates the Aldrete score as:

9 -The total Aldrete score is 9.

A physician's admitting note lists a wound as healing by second intention. What does the nurse expect to find? A deep, open wound that was previously sutured A wound in which the edges were not approximated A wound with a deep, wide scar that was previously resutured A sutured incision with a little tissue reaction

A wound in which the edges were not approximated. -Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been approximated.

The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus? Abdominal tightness Absence of peristalsis Increased abdominal girth Abdominal distention

Absence of peristalsis -Paralytic ileus and intestinal obstruction are potential postoperative complications that occur more frequently in patients undergoing intestinal or abdominal surgery. Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for 24 to 48 hours, depending on the type and extent of surgery.

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

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.

To prevent thromboembolism in the postoperative client, the nurse should include which of the following in the plan of care?

Assist with oral fluid intake. -Dehydration, immobility, and pressure on leg veins promote venous stasis, which can lead to thromboembolism.

It is important for the nurse to assist a postsurgical client to sit up and turn his or her head to one side when vomiting in order to

Avoid aspiration -The nurse helps the patient to sit up and turn his or her head to one side when vomiting to avoid aspiration. Sitting up and turning the head to one side when vomiting does not maximize comfort and does not help to avoid dizziness. Encouraging the patient to breathe deeply helps eliminate inhaled anesthetics.

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

Be able to self-toilet Get out of bed without assistance Ambulate the length of the client's house -For a safe discharge to home, clients need to be able to ambulate a functional distance (eg, length of the house or apartment), get in and out of bed unassisted, and be independent with toileting.

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 Urinary retention Ineffective airway clearance Decreased cardiac output

Decreased cardiac output -Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion.

The nurse is assessing the client for wound complications following surgery. For which clinical manifestation should the nurse assess? Select all that apply. Dehiscence Thrombophlebitis Atelecstasis Paralytic ileus Hematoma

Dehiscence Hematoma -A hematoma can form within the wound and result in delayed healing. Dehiscence is a disruption of the surgical incision. Atelecstasis, thromobophlebitis, and paralytic ileus are potential complications following surgery. Atelecstasis is a collapse of the alveoli, which interferes with gas exchange. Thromobophlebitis is the development of a blood clot, usually in the lower extremity. Paralytic ileus is an absence of intestinal peristalsis.

The nurse recognizes that a traumatic wound with fecal contamination would be classified as

Dirty An example of a dirty wound includes a traumatic wound with delayed repair, devitalized tissue, foreign bodies, or fecal contamination. A clean wound is 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 GI tract.

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. second intention. fourth intention.

First intention -Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.

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

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.

A patient is postoperative hour 8 following an 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 respirations are 24 and labored. Abdomen is soft and distended. No obvious bleeding noted. What action by the nurse is most appropriate?

Notify the physician -The physician should be notified of the findings. The patient may be hemorrhaging internally and may need to return to surgery. The patient may be in need of pain medication but morphine will lower the blood pressure further and may cause further complications. Ambulating the patient increases the risk of injury because the patient may experience orthostatic hypotension. What the patient is experiencing is not the normal progression following abdominal surgery.

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? Instruct the client to take deep breaths. Position the client on his or her side. Notify the physician. Assist the client to intake ample amounts of water.

Notify the physician. -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.

A significant mortality rate exists for patients with alcoholism who experience delirium tremens postoperatively. When caring for the patient with alcoholism, the nurse should assess for symptoms of alcoholic withdrawal: On the second or third day. About 24 hours postoperatively. Within the first 12 hours. 4 days after surgery.

On the second or third day. -The person with a history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase surgical risk. Alcohol withdrawal syndrome or delirium tremens may be anticipated between 48 and 72 hours after alcohol withdrawal and is associated with a significant mortality rate when it occurs postoperatively.

The client is experiencing nausea and vomiting following surgery. The nurse expects the surgeon to order: Propofol (Diprivan) Warfarin (Coumadin) Prednisone (Deltasone) Ondansetron (Zofran)

Ondansetron (Zofran) -It's used to treat nausea and vomiting.

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

Pallor -The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing.

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?

Position the client to maintain a patent airway. -Maintaining a patent airway is the immediate priority in the PACU.

What complication is the nurse aware of that is associated with deep venous thrombosis? Pulmonary embolism Immobility because of calf pain Marked tenderness over the anteromedial surface of the thigh Swelling of the entire leg owing to edema

Pulmonary embolism -Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010).

Which actions should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical patient? Instruct the patient to cross the legs or prop pillow under the knees Reinforce the need to perform leg exercises every hour when awake Massage the calves or thighs Maintain bed rest

Reinforce the need to perform leg exercises every hour when awake. -The nurse should reinforce the need to perform leg exercises every hour when awake. Maintaining bed rest increases the pooling of blood in the lower extremities, increasing the risk for deep vein thrombosis. The patient may be given low-dose heparin for prophylaxis treatment but not a high-dose heparin. The nurse should instruct the patient not to prop a pillow under the knees because the patient can constrict the blood vessels.

A postanesthesia care unit (PACU) nurse is preparing to discharge a patient home following ankle surgery. The patient keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate? Continuously repeat the instructions until the patient restates them. Review the instructions with the patient and accompanying adult. Ask the patient, "Do you understand?" Give the written instructions to the patient's 16-year-old child.

Review the instructions with the patient and accompanying adult. -The effects of the anesthesia may impair the memory or concentration of the patient. It is important that the discharge instructions are covered with the patient and an accompanying adult. Giving the instructions to a 16-year-old is not appropriate. Repeating the instruction until the patient restates them does not ensure that the patient will remember them because of how anesthesia can impair the memory. Asking if the patient understands the instructions only elicits an yes or no answer but does not give insight on if the patient comprehending the instructions.

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. -The Aldrete score is usually 8 to 10 before discharge from the PACU. Clients with a score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area, depending on their preoperative baseline score.

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. -A 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.

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? Convalescent period Tolerance Detailed medication history Respiratory depressive effects

Tolerance -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.

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

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

Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective?

Vital signs within normal limits; absence of chills and cough -Pneumonia is characterized by chills, fever, tachypnea, tachycardia, and sometimes cough.

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.

Watching television Changing position Listening to music -Nonpharmacological management of pain includes listening to music, watching television, and changing position. Pharmacological pain management strategies include epidural infusions and On-Q pumps. An epidural infusion delivers a local opioid with or without a local anesthetic agent directly into the epidural space of the spine. An On-Q pump delivers a local anesthetic agent subcutaneously to the incisional area.

What measurement should the nurse report to the physician in the immediate postoperative period?

A systolic blood pressure lower than 90 mm Hg. -A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal.

A patient is postoperative day 1 from abdominal surgery. The patient 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 2430 mL. What action by the nurse is most appropriate? Discontinue the nasogastric tube suctioning. Assess for signs and symptoms of fluid volume deficit. Document the findings and reassess in 24 hours. Assess for edema.

Assess for signs and symptoms of fluid volume deficit. -The patient's 24 hour intake is 1,800 mL (75x24). The patient's 24 hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Since the output is significantly higher than the intake the patient is at risk for fluid volume deficit. The nurse should not discontinue the nasogastric suctioning without a physician's order. The findings should be documented and reassessed but the nurse needs to take more action to prevent complication. Edema is usually associated with fluid volume excess.

In the immediate postoperative period, vital signs are taken at least every:

Every 15 minutes. -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.

The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by:

First intention -First-intention healing is characterized by a closed incision with little tissue reaction and the absence of signs and symptoms of infection.

A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem? Pieces of vomitus Foul smell Copious red blood in the sputum Pink color

Pink color -Flash pulmonary edema that occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation, tachypnea, tachycardia, decreased pulse oximetry readings, frothy, pink sputum, and crackles on auscultation.

When the nurse observes that the postoperative patient 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 -For subacute hypoxemia supplemental oxygen may be indicated. Hypoxic hypoxemia results from inadequate breathing. Episodic hypoxemia develops suddenly, and the patient may be at risk for myocardial ischemia, cerebral dysfunction, and cardiac arrest. Anemic hypoxemia results from blood loss during surgery.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

Auscultate bowel sounds. -If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.

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 Complete blood count Upper endoscopy Chest x-ray

Central Venous Pressure -Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, level of consciousness, central venous pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output are monitored to provide information on the patient's respiratory and cardiovascular status.

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? 8 5 7 6

8 -Many hospitals use a scoring system (e.g., Aldrete score) 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 patient's condition in the PACU (Fig. 19-3). The patient is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The Aldrete score is usually between 8 and 10 before discharge from the PACU.

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?

<30 mL -If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL per hour are reported; if the patient is voiding, an output of less than 240 mL per 8-hour shift is reported.

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

As soon as it's indicated. -Postoperative activity orders are checked before the patient is assisted to get out of bed, in many instances, on the evening following surgery. Sitting up at the edge of the bed for a few minutes may be all that the patient who has undergone a major surgical procedure can tolerate at first.

During the first 24 hours after surgery, how often will the nurse evaluate the client's temperature?

Every 4 hours -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.

Which of the following terms refers to a protrusion of abdominal organs through the surgical incision?

Evisceration -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.

Which of the following is the most important initial nursing activity in the postoperative recovery area?

Maintain patient safety (airway and circulation) -The most important postoperative nursing function is maintenance of a patent airway and circulation

A recently extubated postoperative patient starts to gag and make vomiting sounds. What action should the nurse do first? Administer antiemetic. Turn patient on her side. Provide emesis basin. Obtain suction equipment.

Turn patient on her side. -The nurse should turn the patient on her side to avoid aspiration. The nurse may need to obtain suction equipment, provide an emesis basin, or administer and antiemetic but the first priority is protecting the patient's airway by preventing aspiration.

The nurse determines that a patient has postoperative abdominal distention. What does the nurse determine that the distention may be directly related to?

A temporary loss of peristalsis and gas accumulation in the intestines. -Any postoperative patient may suffer from distention. Postoperative distention of the abdomen results from the accumulation of gas in the intestinal tract. Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for 24 to 48 hours, depending on the type and extent of surgery. Even though nothing is given by mouth, swallowed air and GI tract secretions enter the stomach and intestines; if not propelled by peristalsis, they collect in the intestines, producing distention and causing the patient to complain of fullness or pain in the abdomen. Most often, the gas collects in the colon. Abdominal distention is further increased by immobility, anesthetic agents, and the use of opioid medications.

The nurse is caring for a patient in the postanesthesia care unit (PACU) with the following vital signs, pulse 115, respiration 20, temperature 97.2°F oral, blood pressure 84/50. What should the nurse do first? Assess for bleeding. Increase rate of IV fluids. Notify the physician. Review the patient's preoperative vital signs.

Assess for bleeding. -The patient is tachycardic with a 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 patient, 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.

When the nurse observes that the postoperative patient demonstrates a constant low level of oxygen saturation via the O2 saturation monitor, although the patient's breathing appears normal what action should the nurse take first? Document the findings. Apply oxygen. Assess the patient's heart rhythm and nail beds. Notify the physician.

Assess the patient's heart rhythm and nail beds. -A patient may demonstrate low oxygenation readings due to wearing certain colors of nail polish or irregular heart rate such as atrial fibrillation. These items 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.

A patient is postoperative day 3 for 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 -The patient has an increased risk for infection related to the surgical wound classification of dirty. Assessing the WBC count, temperature, and wound appearance will allow the nurse to intervene at the earliest sign of infection. The patient will have special nutritional needs for wound healing and need education on safe transfer procedures but the need to monitor for infection is a higher priority. The patient should receive pain medication as soon as possible after asking but the latest literature suggest that pain medication should be given on a schedule versus "as needed."

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has 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 of 150/100 mm Hg and pulse of 50 beats/minute. blood pressure of 80/40 mm Hg and pulse of 130 beats/minute. blood pressure of 80/40 mm Hg and pulse of 50 beats/minute. blood pressure of 150/100 mm Hg and pulse of 130 beats/minute.

Blood pressure of 80/40 mm Hg and pulse of 130 beats/minute. -The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis. Orthostatic changes develop from hypovolemia and cause a drop in blood pressure (evidenced by a blood pressure of 80/40 mm Hg) and a compensatory rise in the heart rate (evidenced by a pulse of 130 beats/minute) when the client rises from a lying position.

A PACU nurse receives a postoperative patient who received general anesthesia with a hard plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and an oxygen saturation of 98%. The patient is minimally responsive to painful stimuli. What action by the nurse is most appropriate? Remove the oral airway. Notify the physician of impaired neurological status. Continue with frequent patient assessments. Obtain vital signs, including pulse oximetry, every 5 minutes.

Continue with frequent patient assessments. -An immediate postoperative patient may be transferred to the PACU with a hard plastic oral airway. The airway should not be removed until the patient is showing signs of gagging or choking. The neurological status is appropriate for a patient that received general anesthesia. There is no information provided that requires the patient to have vitals taken more frequently than the standard 15 minutes. The nurse should continue with frequent patient assessments.

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. -The nurse should encourage the client to ambulate at least three times per day. Ambulating stimulates peristalsis, which helps the bowels to move. It isn't appropriate to apply heat to a surgical wound. Moreover, heat application can't be initiated without a physician order. A tap water enema is typically administered as a last resort after other methods fail. A physician's order is needed with a tap water enema as well. Notifying the physician isn't necessary at this point because the client is exhibiting bowel function by passing flatus.

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 Facilitates reduction of postoperative pulmonary complications -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 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 dry, sterile dressing over the protruding organs. Place a pressure dressing over the opening and secure. Moisten sterile gauze with normal saline and place on the protruding organ. Have the client lay quietly on back and call the physician.

Moisten sterile gauze with normal saline and place on the protruding organ. -A wound evisceration occurs when the wound completely separates, and the internal organs protrude. The first action by the nurse would be to cover the protruding organs with sterile dressings moistened with normal saline. Once the client is safe, the nurse can notify the physician. The client is positioned in a manner that places the least stress on the organs. Dry or pressure dressings are not placed over the protruding organ.

A patient has undergone hernia repair surgery without complications. In the immediate postoperative period, which of the following actions by the nurse is most appropriate? Assessing pupillary response every 5 minutes Monitor vital signs every 15 minutes Measuring urinary output every 15 minutes Obtaining arterial blood gas every 5 minutes

Monitor vital signs every 15 minutes. -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. Obtaining an arterial blood gas every 5 minutes is painful to the patient unless a special device is inserted to obtain arterial blood samples. Without complications, this is not indicated for the patient. Urinary output is monitored frequently but usually measured hourly. While it may be necessary to assess pupillary response during the immediate postoperative phase, it does not need to be done every 5 minutes.

A postoperative patient, with an open abdominal wound is currently taking corticosteroids. The physician orders a wound culture of the abdominal wound even though there are no signs and symptoms of infection. What action by the nurse is appropriate?

Obtain the wound culture specimen. -Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. The culture should be obtained even though the patient is not demonstrating traditional signs and symptoms of infection. The order should not be discontinued or held until purulent drainage is noted because the infection could worsen and the patient will possibly develop sepsis. An antibiotic cleaning agent should not be used before obtaining the specimen because it will alter the growth of the organisms.

Unless contraindicated, how should the nurse position an unconscious patient? 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 Flat on the back, without elevation of the head, to facilitate frequent turning and minimize pulmonary complications On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration

On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration -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.

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? Packing the wound bed with sterile saline-soaked dressing and covering with dry dressing Covering the well approximated wound edges with a dry dressing Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive Cleaning the wound with soap and water, then leaving open to air

Packing the wound bed with sterile saline-soaked dressing and covering with dry dressing -Postoperative surgical wounds that are allowed to heal using second-intention healing are usually packed with a sterile saline dressing and covered with a dry dressing. The edges of a second-intention healing wound are not approximated. The wound may be cleaned using sterile saline but the nurse would not apply a cyanoacrylate tissue adhesive. The wound should not be left open to the air, as it could expose the wound to microorganisms and dry out the wound bed impairing healing.

A client who is receiving the maximum levels of medication for postoperative recovery asks the nurse if there are other measures that the nurse can employ to ease pain. Which of the following strategies might the nurse employ? Select all that apply. Putting on soothing music Applying hot cloths to the client's face Massaging the client's legs Performing guided imagery Changing the client's position

Performing guided imagery Putting on soothing music Changing the client's position -Guided imagery, music, and application of heat or cold (if prescribed) have been successful in decreasing pain. Changing the client's position, using distraction, applying cool washcloths to the face, and providing back massage may be useful in relieving general discomfort temporarily.

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 Pale yet able to blanch with digital pressure Necrotic and hard White with long, thin areas of scar tissue

Pink to red and soft, bleeding easily -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.

The nurse is caring for a client who develops an evisceration. What nursing intervention is most appropriate when an evisceration occurs in the surgical wound of a client who has undergone surgery?

Place sterile dressings moistened with normal saline over the protruding organs and tissues. -If evisceration occurs, the nurse should place sterile dressings moistened with normal saline over the protruding organs and tissues and should inform the physician. If wound disruption is suspected, the nurse should place the client in a position that puts the least strain on the operative area. Analgesics help reduce pain. Avoiding any movement will not help recover from the wound evisceration.

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?

Prochlorperazine (Compazine) -Prochlorperazine is a phenothiazine that inhibits the chemoreceptor trigger zone (CTZ) and the vomiting center in the brain. Odansetron blocks receptors for 5 HT3, affecting the neural pathways involved in nausea and vomiting. Hydroxyzine and promethazine are antihistamines which block H1 receptors resulting in a decrease in stimulation of the CTZ and vomiting.

What intervention by the nurse is most effective for reducing hospital-acquired infections?

Proper hand-washing technique -Efforts to prevent wound infection are directed at reducing risks, such as thorough hand washing. (Preoperative and intraoperative risks and interventions are discussed in Chapters 17 and 18.) Postoperative care of the wound centers on assessing the wound, preventing contamination and infection before wound edges have sealed, and enhancing healing.

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? First-intention healing Primary-intention healing Third-intention healing Second-intention healing

Second-intention healing -When wounds dehisce, they will be allowed to heal by secondary intention. Primary or first-intention healing is the method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulating. Third-intention healing is a method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by bringing apposing granulations together.

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? There is a moderate amount of dry drainage on the outside of the dressing. The Hemovac drain isn't compressed; instead it's fully expanded. The client has a nasogastric (NG) tube in place that drained 400 ml. The client has been lying on his side for 2 hours with the drain positioned upward.

The Hemovac drain isn't compressed; instead it's fully expanded. -The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.

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 has been extubated but still has an oropharyngeal airway in. The patient rates pain a 9 out of 10 on a 0-10 scale after receiving morphine sulfate. 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 is arousable but falls back to sleep rapidly. The patient has a blood pressure within 10 mm Hg of the baseline. The patient has sonorous respirations and occasionally requires chin lift. -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.

The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan? Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. The client can self-administer oral pain medication as needed with patient-controlled analgesia. Family members can be involved in the administration of pain medications with patient-controlled analgesia. There are no advantages of patient-controlled analgesia over a PRN dosing schedule.

Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. -Advantages of patient-controlled analgesia include participation of the client in care, elimination of delayed administration of analgesics, and maintenance of therapeutic drug levels. The client must have the cognitive and physical abilities to self-dose.

You are caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock? Warm, dry skin Obstructed airway Pooling of secretions in the lungs Weak and rapid pulse rate

Weak and rapid pulse rate -Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock.

Nursing assessment findings reveal a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. The nurse recognizes the client is experiencing:

Wound infection -Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.