Prepu Chapt19 MedSurg

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.

1 Position the client in Fowlers position. 2 Don sterile gloves. 3 Lubricate the sterile suction catheter. 4 Insert suction catheter into the lumen of the tube. 5 Apply intermittent suction while withdrawing the catheter.

Review the instructions with the client and an accompanying adult.

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

Nursing interventions: postoperative signs of abdominal distention.

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 planning care for a client in the postoperative period. Place the following nursing diagnoses in sequence, from highest to lowest priority.

Impaired Gas Exchange Fluid Volume Deficit Altered Comfort Anxiety Risk for Infection

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

Maintaining a patent airway Monitoring vital signs at least every 15 minutes Assessing urinary output every hour Assessing for hemorrhage

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.

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? Re-attempt to auscultate bowel sounds. Prepare to insert a nasogastric tube. Call the health care provider. Prepare to administer a stool softener.

Call the health care provider.

Mask the presence of infection

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

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

ondansetron

The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order? chlorpromazine omeprazole ondansetron ranitidine

Ambulate the length of the client's house Get out of bed without assistance Be able to self-toilet

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

First-intention healing

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

The most important postoperative nursing function

is maintenance of a patent airway and circulation

Pink color

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

Moisten sterile gauze with normal saline and place on the protruding organ.

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

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.

Ondansetron (Zofran)

- Ondansetron is a seratonin blocker and antiemetic. Zofran) is used to treat nausea and vomiting. - Side effects = dizzy, headache, diarrhea. -Admin 30 minutes before chemo & 4-8 hours later. -Infuse over 15 minutes.

If the client has an indwelling urinary catheter, what output is monitored hourly and rate are reportable?

<0.5 mL/kg/h

"It assists in preventing infection."

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." "It will cut down on the number of dressing changes needed." "The drain will remove necrotic tissue." "Most surgeons use wound drains now."

A client with abdominal incision :

By time of discharge, clients should be able to verbalize clinical manifestations of complications, activity and diet restrictions, and specifics regarding follow-up appointments. avoid lifting and driving in the initial discharge period.

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

Edema

Abnormal accumulation of fluid in interstitial spaces of tissues.

Result of hypoxia

Acute confusion associated with delirium may be a, pain, urinary retention, fecal impaction, fever, hypotension, hypoglycemia, fluid loss, and anemia.

2.0 mL/kg/h.

Adequate hourly urine output for a client with an indwelling urinary catheter is 0.5 mL/kg/h. 1.0 mL/kg/h. 1.5 mL/kg/h. 2.0 mL/kg/h.

Risk factors for wound dehiscence include:

Advanced age over 65 years; Chronic disease such as diabetes, hypertension, obesity; History of radiation or chemotherapy; Malnutrition, particularly insufficient protein and vitamin C; Hypoalbuminemia.

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.

Postoperative factors, which can lead to thromboembolism?

Dehydration, immobility, and pressure on leg veins that promote venous stasis.

Decreased cardiac output

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

As soon as it is indicated

When should the nurse encourage the postoperative patient to get out of bed? Within 6 to 8 hours after surgery Between 10 and 12 hours after surgery As soon as it is indicated On the second postoperative day

Maintain patient safety (airway and circulation)

Which of the following is the most important initial nursing activity in the postoperative recovery area? Maintain patient safety (airway and circulation) Administer medications and fluids Assess pain level Inspect surgical site

Evisceration

Which term refers to the protrusion of abdominal organs through the surgical incision? Hernia Dehiscence Erythema Evisceration

second intention are not approximated edges.

Wound healing by

Wound dehiscence

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? Hypotension Contracture's Phlebitis Wound dehiscence

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.

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.

Paralytic ileus and intestinal obstruction:

are potential postoperative complications that occur more frequently in patients undergoing intestinal or abdominal surgery.

A wound drain purpose

assists in preventing infection by removing the medium in which bacteria could grow.

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.

Clinical manifestations of a wound infection include

fever, tachycardia, an elevated white blood cell count, and increased incisional pain.

Second-intention healing

granulation occurs in infected wounds or in wounds in which the edges have not been approximated. Gradually, the necrotic material 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. Healing is complete when skin cells grow over these granulations.

Postoperative interventions:

highest priority is maintaining a patent airway. Without a patent airway, the other interventions—monitoring vital signs, assessing urinary output, and assessing for hemorrhage—become secondary to the possibility of a lack of oxygen.

effects of anesthesia may

impair a client's memory or concentration. . Giving the instructions to a 16-year-old is not appropriate. Repeating the instructions until the client restates them does not ensure that the client will remember them, because anesthesia can impair memory. Asking whether the client understands the instructions only elicits an yes or no answer; it does not give insight into whether the client comprehends the instructions.

discharge instructions are

important they can be covered with the client and an accompanying adult.

Clinical manifestations of decreased cardiac output

include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion.

Evisceration

is a surgical emergency

hernia

is a weakness in the abdominal wall

Corticosteroids:

may mask the presence of infection by impairing the normal inflammatory response.

When vomiting occurs postoperatively, what is the most important nursing intervention?

patient is turned to the side to prevent aspiration and the vomitus is collected in the emesis basin.

Flash pulmonary edema that occurs when

protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. agitation, tachypnea, tachycardia, decreased Reference:

Flash pulmonary edema Signs and symptoms include:

pulse oximetry readings, frothy, pink sputum, and crackles on auscultation.

Dehiscence

refers to the partial or complete separation of wound edges

Erythema

refers to the redness of tissue.

Suctioning a tracheostomy is a:

sterile procedure. The nurse should first position the client in Fowler's position then don sterile gloves. Next, the nurse will lubricate the sterile suction catheter and insert the catheter into the lumen of the tube. Finally, the nurse will apply intermittent suction while withdrawing the catheter.

Aldrete score of 8: Aldrete score is usually 8 to 10 before discharge from

the PACU.

Hypoxia :

would be most important for the nurse to address postoperatively.

Continue with frequent client assessments.

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

Wound healing postoperative Day 2

Postoperative surgical wounds that are allowed to heal using second-intention healing are usually packed with a sterile saline-soaked dressing and covered with a dry dressing.

What's monitored to provide information on the patient's respiratory and cardiovascular status?

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.

Wound infection

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing? Hyperthermia Atelectasis Wound infection Uncontrolled pain

First intention

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: Granulation First intention Second intention Third intention

The client presents with a possible paralytic ileus, a serious condition where the intestines are paralyzed and peristalsis is absent.

This may occur as a result of surgery, especially abdominal surgery. If the nurse is unable to auscultate bowel sounds and the client has pain and a rigid abdomen, the nurse will suspect an ileus and immediately call the health care provider. Re-attempting auscultation may occur, but only after the health care provider has been notified. The health care provider may order the placement of an NG tube, however, the nurse cannot do this without the provider's order. Administering a stool softener will not help the client and may make the condition worse.

Assist with oral fluid intake.

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.

maintains adequate oxygenation status

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: experiences pain within tolerable limits. exhibits wound healing without complications. resumes usual urinary elimination pattern. maintains adequate oxygenation status.

Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing .

On postoperative day 2, a client requires 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 it with a dry dressing Covering the well-approximated wound edges with a dry dressing Cleaning the wound with soap and water, then leaving it open to the air Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive

Absence of peristalsis

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 Abdominal distention Absence of peristalsis Increased abdominal girth

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

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates teaching has been ineffective? "I should call my physician if I develop a fever." "My incision should become less red and tender." "I can resume my usual activities as soon as I get home." "I need to keep my follow-up appointment with the physician."