PrepU Chapter 19: Postop Care (Exam 1)

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? -5 -6 -7 -8

-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.

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

-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.

The client is experiencing intractable hiccups following surgery. The nurse expects the surgeon to order: -chlorpromazine (Thorazine) -metoclopramide (Reglan) -omeprazole (Prilosec) -ranitidine (Zantac)

-chlorpromazine (Thorazine) Chlorpromazine (Thorazine) is used to treat intractable hiccups.

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? -<30 mL -Between 75 and 100 mL -Between 100 and 200 mL ->200 mL

-<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.

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

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

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

-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 action should be incorporated into the client teaching plan to prevent deep vein thrombosis? -Prolonged dangling of the legs over the edge of the bed -Hourly leg exercises -Use of blanket rolls to elevate the lower extremities -Fluid restriction

-Hourly leg exercises The benefits of early ambulation and hourly leg exercises in preventing deep vein thrombosis cannot be overemphasized. It is important to avoid the use of blanket rolls, pillow rolls, or any form of elevation that constricts vessels under the knees. Prolonged dangling can be dangerous and is not recommended in susceptible clients because the pressure under the knees can impede circulation. Dehydration adds to the risk of thrombosis formation.

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).

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. -The client is showing signs of a medication reaction. -The client is displaying late signs of shock. -The client is showing signs of an anesthesia reaction.

-The client is displaying early signs of shock. The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated. Medication or anesthesia reactions may cause client symptoms similar to these; however, these causes are not as likely as early shock.

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? -Complete blood count -Central venous pressure -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 admitting the older adult to the PACU. Which information about this client would be most important for the PACU nurse to obtain? -What procedure was performed? -What was estimated blood loss? -Are family members available? -Does the client have a history of dementia?

-Does the client have a history of dementia? Acute confusion is a common side effect of anesthesia in older adults. The nurse needs to know whether any confusion displayed by the client is a result of the surgery and anesthesia or a usual state for the client.

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action? -Monitor vital signs for early detection of shock. -Assess the incisional dressing to detect hemorrhage. -Position the client to maintain a patent airway. -Administer antiemetics to prevent nausea and vomiting.

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

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 client must remain in the PACU. -The client should be transferred to an intensive care area. -The client must be put on immediate life support.

-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 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? -Notify the physician. -Assess for bleeding. -Increase rate of IV fluids. -Review the client's preoperative vital signs.

-Assess for bleeding. The client is tachycardic with 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 client, 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.

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? -Document the findings and reassess in 24 hours. -Assess for signs and symptoms of fluid volume deficit. -Assess for edema. -Discontinue the nasogastric tube suctioning

-Assess for signs and symptoms of fluid volume deficit. The client's 24-hour intake is 1800 mL (75 x 24). The client's 24-hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Because the output is significantly higher than the intake, the client 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.

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? -Document the findings and reassess in 24 hours. -Assess for signs and symptoms of fluid volume deficit. -Assess for edema. -Discontinue the nasogastric tube suctioning.

-Assess for signs and symptoms of fluid volume deficit. The client's 24-hour intake is 1800 mL (75 x 24). The client's 24-hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Because the output is significantly higher than the intake, the client 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.

A client is postoperative 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 -Obtaining dietary consultation for improved wound healing -Educating the client on safe bed-to-chair transfer procedures -Administering pain medications within 1 hour of the client's request

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

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. 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.

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.

-Continue with frequent client assessments. An immediate postoperative client may be transferred to the PACU with a hard, plastic oral airway in place. The airway should not be removed until the client shows signs of gagging or choking. The neurological status is appropriate for a client who received general anesthesia, and the nurse should continue with frequent client assessments. . None of the information provided requires the client to have vital signs measured more frequently than the standard 15 minutes.

A postoperative client is being discharged home after minor surgery. The PACU nurse is reviewing discharge instructions with the client and the client's spouse. What actions by the nurse are appropriate? Select all that apply. -Educate on activity limitations. -Discuss wound care. -Have the spouse review when to notify the physician. -Have the client sign his or her advance directive form. -Provide information on health promotion topics.

-Educate on activity limitations. -Discuss wound care. -Have the spouse review when to notify the physician. -Provide information on health promotion topics. The nurse should provide education on activity limitations and wound care, and should review complications that require notification to the physician. The nurse should also provide information regarding health promotion topics, such as weight management and smoking cessation. The client should not make any major decisions or sign any legal forms because of the effects of anesthesia.

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? -Apply moist heat to the client's abdomen. -Encourage the client to ambulate at least three times per day. -Administer a tap water enema. -Notify the physician.

-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.

The nurse is caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery? -Place pillows under the client's knees or calves. -Encourage the client to move legs frequently and do leg exercises. -Apply pressure on the client's lower extremities. -Maintain the client in a side-lying position.

-Encourage the client to move legs frequently and do leg exercises. The nurse should encourage the client to move legs frequently and do leg exercises to prevent venous stasis and other circulatory complications. The nurse should not place pillows under the client's knees or calves unless ordered and should avoid placing pressure on the client's lower extremities. Placing the client in a side-lying position will not help prevent venous stasis and other circulatory complications in a client who has undergone surgery.

You are caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery? -Place pillows under the client's knees or calves. -Encourage the client to move legs frequently and do leg exercises. -Place pressure on the client's lower extremities. -Place the client in a side-lying position.

-Encourage the client to move legs frequently and do leg exercises. The nurse should encourage the client to move legs frequently and do leg exercises to prevent venous stasis and other circulatory complications. The nurse should not place pillows under the client's knees or calves unless ordered and should avoid placing pressure on the client's lower extremities. Placing the client in a side-lying position will not help prevent venous stasis and other circulatory complications in a client who has undergone surgery.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? -First intention -Second intention -Third intention -Fourth intention

-First intention When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing.

The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of: -Laryngospasm -Hyperventilation -Hypoxemia and hypercapnia. -Pulmonary edema and embolism.

-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.

A patient who underwent abdominal surgery 3 hours ago has started to hemorrhage. The nurse would classify this type of hemorrhage has which of the following? -Intermediary -Primary -Secondary -Tertiary

-Intermediary Intermediary hemorrhage occurs during the first few hours after surgery when the rise of blood pressure to its normal level dislodges insecure clots formed in untied vessels. Primary hemorrhage occurs at the time of surgery. Secondary hemorrhage may occur some time after surgery if a suture slips because a blood vessel was not securely tied, became infected, or was eroded by a drainage tube.

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. -Have the client lay quietly on back and call the physician. -Moisten sterile gauze with normal saline and place on the protruding organ

-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 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. -Have the client lay quietly on back and call the physician. -Moisten sterile gauze with normal saline and place on the protruding organ.

-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 client has undergone surgery to repair a hernia, with no complications. In the immediate postoperative period, which action by the nurse is most appropriate? -Monitor vital signs every 15 minutes -Measure arterial blood gas every 5 minutes -Measure urinary output every 15 minutes -Assess pupillary response every 5 minutes

-Monitor vital signs every 15 minutes 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 immediately after surgery. Obtaining an arterial blood gas measurement every 5 minutes would be painful to the client unless a special device is inserted to obtain arterial blood samples. With no complications, this is not indicated for this client. Urinary output is monitored frequently, usually 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 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: -Within the first 12 hours. -About 24 hours postoperatively. -On the second or third day. -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 nurse observes bloody drainage on the surgical dressing of the client who has just arrived on the nursing unit. Which intervention should the nurse plan to do next? -Make the client NPO and order a stat hemoglobin and hematocrit. -Remove the dressing, assess the wound, and apply a new sterile dressing. -Outline the drainage with a pen and record the date and time next to the drainage. -Take the client's vital signs and call the surgeon.

-Outline the drainage with a pen and record the date and time next to the drainage. Areas of drainage on the dressing should be outlined with a pen, and the date and time should be recorded next to the drainage. Blood drainage from the incision is a normal expected finding in the immediate postoperative period; however, excessive amounts should be reported to the surgeon.

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 sterile saline and applying cyanoacrylate tissue adhesive -Cleaning the wound with soap and water, then leaving it open to the air

-Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing 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. The edges of a wound healing by second intention 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. -Performing guided imagery -Putting on soothing music -Changing the client's position -Applying hot cloths to the client's face - Performing guided imagery

-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.

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

-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.

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? -Necrotic and hard -Pale yet able to blanch with digital pressure -Pink to red and soft, bleeding easily -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.

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly patients? -Pleurisy -Pneumonia -Hypoxemia -Pulmonary edema

-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).

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order. -Insert suction catheter into the lumen of the tube. -Apply intermittent suction while withdrawing the catheter. -Lubricate the sterile suction catheter. -Don sterile gloves. -Position the client in Fowlers position.

-Position the client in Fowlers position. -Don sterile gloves. -Lubricate the sterile suction catheter. -Insert suction catheter into the lumen of the tube. -Apply intermittent suction while withdrawing the catheter. 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.

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order. -Insert suction catheter into the lumen of the tube. -Position the client in Fowlers position. -Apply intermittent suction while withdrawing the catheter. -Lubricate the sterile suction catheter. -Don sterile gloves.

-Position the client in Fowlers position. -Don sterile gloves. -Lubricate the sterile suction catheter. -Insert suction catheter into the lumen of the tube. -Apply intermittent suction while withdrawing the catheter. 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.

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order. -Position the client in Fowlers position. -Insert suction catheter into the lumen of the tube. -Apply intermittent suction while withdrawing the catheter. -Don sterile gloves. -Lubricate the sterile suction catheter.

-Position the client in Fowlers position. -Don sterile gloves. -Lubricate the sterile suction catheter. -Insert suction catheter into the lumen of the tube. -Apply intermittent suction while withdrawing the catheter. 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.

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. -Administer an anti-emetic. -Obtain an emesis basin. -Ask the client for more clarification.

-Position the client in the side-lying position. The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits. The nurse may also obtain an emesis basin and administered an anti-emetic if one is ordered; however, these will be done after the client is repositioned. There is no need for the nurse to ask the client for more clarification.

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? -Document the client's refusal. -Delegate the task to the unlicensed assistive personnel. -Reinforce the importance of early mobility in preventing complications. -Use multiple staff members to remove the client from the bed.

-Reinforce the importance of early mobility in preventing complications. The client may be refusing to ambulate because of fear or pain. Educating the client on the importance of mobility in preventing complications may encourage the client to ambulate. The nurse should try all reasonable measures (e.g., pain control, education) before documenting the client's refusal to ambulate. If the client is already refusing to ambulate, delegating the task to the unlicensed assistive personnel is not an appropriate action. The client should not be forcefully removed from the bed.

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? -Elevating the head of the bed -Reinforcing dressings or applying pressure if bleeding is frank -Rubbing the back -Encouraging the client to breathe deeply

-Reinforcing dressings 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 client to breathe deeply and rubbing the back will not help manage and minimize hemorrhage and shock.

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. Which of the following actions by the nurse would be inappropriate? -Administer oxygen. -Restrict oral fluids. -Provide a blanket. -Monitor for cardiac dysrhythmias.

-Restrict oral fluids. The client exhibits clinical manifestations of hypothermia. The nurse should maintain adequate hydration of the client rather than restrict fluids.

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

-Second-intention healing When wounds dehisce, they are 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 granulation. 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 nurse is caring for a client who is scheduled to have a thoracotomy. When planning care for this client, what mobility teaching will the nurse include in the plan of care? -Lower back and rib range of motion exercises -Use of a cane on the unaffected side -Use of a cane on the affected side -Shoulder and upper arm range-of-motion exercises

-Shoulder and upper arm range-of-motion exercises Because large shoulder girdle muscles are transected during a thoracotomy, the arm and shoulder needs mobilization with range-of-motion exercises. Lower back and rib cage exercises are not a standard therapy for those recovering from a thoracotomy. The use of a cane is not a standard assistive device necessary after a thoracotomy.

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

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. -The client's lungs reveal rales in the bases. -The client states a moderate amount of pain at the incisional site. -A moderate amount of serous drainage is noted on the operative dressing.

-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.

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? -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. -Therapeutic drug levels can be maintained more evenly 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 who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult? -Respiratory depressive effects -Tolerance -Convalescent period -Detailed medication history

-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.

When vomiting occurs postoperatively, what is the most important nursing intervention? -Measure the amount of vomitus to estimate fluid loss, in order to accurately monitor fluid balance. -Offer tepid water and juices to replace lost fluids and electrolytes. -Support the wound area so that unnecessary strain will not disrupt the integrity of the incision. -Turn the patient's head completely to one side to prevent aspiration of vomitus into the lungs.

-Turn the patient's head completely to one side to prevent aspiration of vomitus into the lungs. If vomiting occurs, the patient is turned to the side to prevent aspiration and the vomitus is collected in the emesis basin.

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

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

The nurse cares for a client who is three hours post op abdominal hysterectomy and begins to develop hiccups. What nursing assessment will the nurse monitor more closely with the client's new symptoms? -Temperature -Respiratory rate -Wound approximation -Wound drainage

-Wound approximation Hiccups are produced by intermittent spasms of the diaphragm, secondary to irritation of the phrenic nerve. Hiccups may be caused by surgery and are usually not problematic. However, persistent or forceful spasms may lead to wound dehiscence, or wound separation at the surgical incision. The other answer choices are things the nurse will monitor; however, the approximation of wound edges will be monitored more closely.

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. -palpate the abdomen. -change the client's position. -insert a rectal tube.

-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.

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 130 beats/minute. -blood pressure of 150/100 mm Hg and pulse of 50 beats/minute. -blood pressure of 80/40 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 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.

When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as -clean. -contaminated. -clean contaminated. -dirty.

-clean contaminated. Clean contaminated cases are those with a potential, limited source for infection, the exposure to which can largely 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 dirty.

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound -dehisced. -eviscerated. -pustulated. -hemorrhaged.

-dehisced. Dehiscence is the partial or complete separation of wound edges. Evisceration is the protrusion of organs through the surgical incision. Pustulated refers to the formation of pustules. Hemorrhage is excessive bleeding.

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. -second intention. -third 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.

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.

-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.

Which findings would be indicative of a nursing diagnosis of decreased cardiac output? -urinary output > 60 ml; BP 90/60; tachypnea -bradycardia; urinary output < 30 ml; confusion -tachycardia; hemoglobin 10.9 gm/dL; BP 88/56 -confusion; tachypnea; hemoglobin 14.2 gm/dL

-tachycardia; hemoglobin 10.9 gm/dL; BP 88/56 Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion.

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

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

-As soon as it is 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.

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. -Apply oxygen. -Notify the physician. -Document the findings.

-Assess the client's heart rhythm and nail beds. A client may demonstrate low oxygenation readings because of certain colors of nail polish or may show an irregular heart rate such as atrial fibrillation. These factors 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.

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

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

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? -Elevating the head of the bed -Reinforcing the dressing or applying pressure if bleeding is frank -Monitoring vital signs every 15 minutes -Encouraging the client to breathe deeply

-Reinforcing the 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 client to breathe deeply will not help manage and minimize hemorrhage and shock. Monitoring vital signs every 15 minutes is an appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to determine the extent and progression of the problem.

The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract? -The client is tolerating sips of water. -The client reports a small bowel movement. -The client is passing flatus. -The client states being hungry.

-The client reports a small bowel movement. A bowel movement demonstrates that the nursing outcome of the return to function of the gastrointestinal track has been met. All of the other options are components of meeting the outcome of functioning.

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: -Hyperthermia -Atelectasis -Wound infection -Uncontrolled pain

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

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."

-"It assists in preventing infection." A wound drain assists in preventing infection by removing the medium in which bacteria could 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 client's question appropriately.

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.

-2.0 mL/kg/h. If the client has an indwelling urinary catheter, output is monitored hourly and rates <0.5 mL/kg/h are reported.

A client develops a hemorrhage one hour post surgery. The nurse knows this is most likely an intermediary hemorrhage from a vein because it occurred: -within the first few hours, and has darkly colored blood that bubbles out slowly. -during surgery, and has bright red blood that flows freely. -at a suture site, and the blood appears intermittently in spurts. -a few hours after surgery, and the bright red blood appears with each heartbeat.

-within the first few hours, and has darkly colored blood that bubbles out slowly. An intermediary hemorrhage appears within the first few hours following surgery. Darkly colored blood that bubbles out quickly indicates a venous hemorrhage. A hemorrhage that occurs during surgery is classified as a primary hemorrhage. A bright red color indicates that a hemorrhage's source is an artery. Secondary hemorrhages occur when sutures slip or drainage tubes dislodge insecure vessels.

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? -5 -6 -7 -8

-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.

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: -7 -8 -9 -10

-9

What measurement should the nurse report to the physician in the immediate postoperative period? -A systolic blood pressure lower than 90 mm Hg -A temperature reading between 97°F and 98°F -Respirations between 20 and 25 breaths/min -A hemoglobin of 13.6

-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 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 sutured incision with a little tissue reaction -A wound with a deep, wide scar that was previously resutured -A wound in which the edges were not approximated

-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.

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

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

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

-Mask the 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.

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

-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.

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 -Contractures -Phlebitis -Wound dehiscence

-Wound dehiscence 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. This client is not at increased risk for hypotension; contractures, or phlebitis.

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

-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 are not primary objectives in the immediate postoperative period.