Brunner Ch 20
The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?
Position the patient to maintain a patent airway
The client is experiencing nausea and vomiting following surgery. The nurse expects the surgeon to order:
ondansetron (Zofran)
A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to:
place saline-soaked sterile dressings on the wound.
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.
Protrusion of organs through the surgical incision
Evisceration
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
Method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation
First-intention healing
Corticosteroids have which effect on wound healing?
Mask the presence of infection
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?
Notify the physician
Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?
Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis?
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?
Outline the drainage with a pen and record the date and time next to the drainage.
A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem?
Pink color
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.
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.
A client just entered the post-anesthesia care unit following abdominal surgery. The client is showing frank, increased bleeding; his blood pressure is plummeting. Which of the following interventions will the nurse perform to manage and minimize hemorrhage and shock?
Reinforce dressing and applying pressure
A client just entered the post-anesthesia care unit following abdominal surgery. The client is showing frank, increased bleeding; his blood pressure is plummeting. Which of the following interventions will the nurse perform to manage and minimize hemorrhage and shock?
Reinforcing dressing and applying pressure
Method of healing in which wound edges are not surgically approximated and integumentary continuity is restored by the process known as granulation
Second-intention healing
Which of the following clinical manifestations increase the risk for evisceration in the postoperative client?
Valsalva maneuver
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.
You selected: • Putting on soothing music • Changing the client's position • Performing guided imagery
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
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 80/40 mm Hg and pulse of 130 beats/minute.
Which findings would be indicative of a nursing diagnosis of decreased cardiac output?
tachycardia; hemoglobin 10.9 gm/dL; BP 88/56
Partial or complete separation or wound edges
Dehiscence
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
You are caring for a client who is an obese diabetic. The client is 48 hours post surgery. What is this client at increased risk for?
Wound dehiscence
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
Method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by the process known as granulation
Third-intention healing
You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult?
Tolerance
