CH 16: Postoperative Nursing Management
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? A) Document the findings. B) Apply oxygen. C) Assess the client's heart rhythm and nail beds. D) Notify the physician.
C
The primary objective in the immediate postoperative period is A) maintaining pulmonary ventilation. B) monitoring for hypotension. C) relieving pain. D) controlling nausea and vomiting.
A
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? A) The client is displaying late signs of shock. B) The client is displaying early signs of shock. C) The client is showing signs of a medication reaction. D) The client is showing signs of an anesthesia reaction.
B
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? A) Decreased cardiac output B) Ineffective thermoregulation C) Acute incisional pain D) Ineffective airway clearance
B
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? A) Re-attempt to auscultate bowel sounds. B) Prepare to administer a stool softener. C) Call the health care provider. D) Prepare to insert a nasogastric tube.
C
Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis? A) Urinary retention B) Ineffective airway clearance C) Decreased cardiac output D) Acute pain
C
A client has a patient-controlled analgesia (PCA) pump at the bedside. For which requirement(s) will the nurse assess the client to determine if the PCA pump can be used for pain control? Select all that apply. A) Reports pain at a level of 7 or greater B) Recovers from a major surgical procedure C) Physically able to self-dose D) Experiences signs of atelectasis E) Understands the need to self-dose
C and E
A client is transferred from the postanesthesia care unit (PACU) to an inpatient care unit. What will the nurse assess first? A) Level of consciousness B) Surgical site C) Pain level D) Breathing
D
A patient has a wound that has hemorrhaged. What does the nurse understand is the cause of the patient's increased risk of infection? A) Reduced amounts of oxygen and nutrients are available B) The tissue becomes less resilient C) Retrograde bacterial contamination may occur D) Dead space and dead cells provide a culture medium
D
Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? A) Primary-intention healing B) Third-intention healing C) First-intention healing D) Second-intention healing
D
Which of the following stimulates the wound healing process? A) Hemorrhage B) Immobility C) Nutritional deficiencies D) Sufficient oxygenation
D
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? A) Reinforcing the dressing or applying pressure if bleeding is frank B) Encouraging the client to breathe deeply C) Elevating the head of the bed D) Monitoring vital signs every 15 minutes
A
A nurse asks a client who had abdominal surgery 1 day 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? ' A) Encourage the client to ambulate as soon as possible after surgery. B) Administer a tap water enema. C) Notify the physician. D) Apply moist heat to the client's abdomen.
A
The nurse in the ED is caring for a client who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. The nurse is aware that the wound will now heal by what means? A) Third intention B) Second intention C) Late intention D) First intention
A
Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply. A) Be able to drive to the grocery B) Ambulate the length of the client's house C) Get out of bed without assistance D) Pass a stress test E) Be able to self-toilet
B, C, and E
A client vomits postoperatively. What is the most important nursing intervention? A) Support the wound area so that unnecessary strain will not disrupt the integrity of the incision. B) Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs. C) Offer tepid water and juices to replace lost fluids and electrolytes. D) Measure the amount of vomitus to estimate fluid loss, in order to accurately monitor fluid balance.
B
What complication is the nurse aware of that is associated with deep venous thrombosis? A) Immobility because of calf pain B) Pulmonary embolism C) Marked tenderness over the anteromedial surface of the thigh D) Swelling of the entire leg owing to edema
B
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? A) Obtain vital signs, including pulse oximetry, every 5 minutes. B) Remove the oral airway. C) Continue with frequent client assessments. D) Notify the physician of impaired neurological status.
C
A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client? A) maintains adequate fluid status. B) resumes usual urinary elimination pattern. C) experiences pain within tolerable limits. D) exhibits wound healing without complications.
C
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? A) Ask the client, "Do you understand?" B) Give the written instructions to the client's 16-year-old child. C) Review the instructions with the client and an accompanying adult. D) Continuously repeat the instructions until the client restates them.
C
The client is experiencing intractable hiccups following surgery. What would the nurse expect the surgeon to order? A) metoclopramide B) omeprazole C) chlorpromazine D) nizatidine
C
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? A) Assess for signs and symptoms of fluid volume deficit. B) Assess for edema. C) Document the findings and reassess in 24 hours. D) Discontinue the nasogastric tube suctioning.
A
To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: A) Ambulating the client as soon as possible B) Positioning the client in a supine position C) Assisting with incentive spirometry every 6 hours D) Assessing breath sounds at least every 2 hours
A
What measurement should the nurse report to the physician in the immediate postoperative period? A) A systolic blood pressure lower than 90 mm Hg B) A temperature reading between 97°F and 98°F C) A hemoglobin of 13.6 D) Respirations between 20 and 25 breaths/min
A
Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis? A) Hourly leg exercises B) Use of blanket rolls to elevate the lower extremities C) Prolonged dangling of the legs over the edge of the bed D) Fluid restriction
A
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? A) Wound drainage B) Respiratory rate C) Temperature D) Wound approximation
D
When the nurse observes that a postoperative client 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? A) Episodic B) Anemic C) Hypoxic D) Subacute
D
A novice nurse provides aftercare instructions to a client who has just had sutures removed. Which statement by the novice nurse requires the nurse preceptor to clarify? A) "If the wound edges are red or raised, you should call your doctor." B) "The wound should not be rubbed or scrubbed." C) "If the wound site gets wet, pat the wound dry." D) "The wound will continue to heal for several weeks."
A
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? A) Position the client in the side-lying position. B) Obtain an emesis basin. C) Ask the client for more clarification. D) Administer an anti-emetic.
A
The nurse is preparing discharge instructions to a client who has undergone minor same-day surgery. Which client statement indicates that teaching has been effective? A) "I had some type of surgery on my abdomen." B) "I am not permitted to drive myself home after surgery." C) "There is no need to call my doctor as the surgery was minor." D) "I will read up on how to use my walker at home for safety."
B
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? A) Between 100 and 200 mL B) >200 mL C) Between 75 and 100 mL D) <30 mL
D
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: A) auscultate bowel sounds. B) palpate the abdomen. C) change the client's position. D) insert a rectal tube.
A
A nursing assessment's findings reveal a postoperative client has a temperature of 96.2 °F (35.7 °C), shivering, and reports feeling cold. What does the nurse conclude about the client? A) The client is experiencing hypothermia. B) The client is experiencing atelectasis. C) The client is having pain at the surgical site. D) The client is beginning to develop pneumonia.
A
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dL, and a blood pressure lying in bed of 110/70 mm Hg. The nurse suspects abnormal orthostatic changes when the client gets out of bed and reports vertigo. What vital sign value most supports the client's orthostatic changes? A) Blood pressure of 90/50 mm Hg B) Blood pressure of 120/90 mm Hg C) Blood pressure of 150/100 mm Hg D) Blood pressure of 110/80 mm Hg
A
The nurse is caring for a postoperative client with a Hemovac. The Hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to: A) Empty and measure the drainage and compress the Hemovac. B) Notify the surgeon that the Hemovac is not functioning. C) Assess the client's wound and apply a pressure dressing. D) Remove the Hemovac because it is expanded.
A
The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room? A) 7 B) 5 C) 4 D) 6
A
Using the PACU room scoring guide, a nurse would give a patient an admission cardiovascular score of 2 if the patient's blood pressure is what percentage of his or her preanesthetic level? A) 20% B) 30% to 40% C) 40% to 50% D) Greater than 50%
A
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? A) There are no advantages of patient-controlled analgesia over a PRN dosing schedule. B) Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. C) Family members can be involved in the administration of pain medications with patient-controlled analgesia. D) The client can self-administer oral pain medication as needed with patient-controlled analgesia.
B
What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? A) Hypoxemia B) Pneumonia C) Pulmonary edema D) Pleurisy
B
A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem? A) Pieces of vomitus B) Foul smell C) Pink color D) Copious red blood in the sputum
C
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: A) 4 days after surgery. B) About 24 hours postoperatively. C) Within the first 12 hours. D) On the second or third day.
D
The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order? A) nizatidine B) chlorpromazine C) omeprazole D) ondansetron
D
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? A) Convalescent period B) Respiratory depressive effects C) Detailed medication history D) Tolerance
D
A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to: A) pull the dehiscence closed. B) place saline-soaked sterile dressings on the wound. C) call the physician. D) take a blood pressure and pulse.
B
Corticosteroids have which effect on wound healing? A) May cause protein-calorie depletion B) Mask the presence of infection C) Cause hemorrhage D) Reduce blood supply
B
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? A) Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive B) Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing C) Covering the well-approximated wound edges with a dry dressing D) Cleaning the wound with soap and water, then leaving it open to the air
B
What complication in the immediate postoperative period should the nurse understand requires early intervention to prevent? A) Hyperventilation B) Hypoxemia and hypercapnia C) Laryngospasm D) Pulmonary edema and embolism
B
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? A) Third intention B) First intention C) Fourth intention D) Second intention
B
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? A) Place the client in a side-lying position. B) Encourage the client to move legs frequently and do leg exercises. C) Place pressure on the client's lower extremities. D) Place pillows under the client's knees or calves.
B
A nurse is assessing the postoperative client on the second postoperative day. What assessment finding requires the nurse to immediately notify the health care provider? A) The client states a moderate amount of pain at the incisional site. B) The client's lungs reveal rales in the bases. C) A moderate amount of serous drainage is noted on the operative dressing. D) The client has an absence of bowel sounds.
D
A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: A) second intention. B) fourth intention. C) third intention. D) first intention.
D
A postoperative client with an open abdominal wound is currently taking corticosteroids. The physician orders a culture of the abdominal wound even though no signs or symptoms of infection are seen. What action by the nurse is appropriate? A) Request the order be discontinued without obtaining the specimen. B) Use an antibiotic cleaning agent before obtaining the specimen. C) Hold the order until purulent drainage is noted. D) Obtain the wound culture specimen.
D
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? A) Review the client's preoperative vital signs. B) Notify the physician. C) Increase rate of IV fluids. D) Assess for bleeding.
D
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: A) Second intention B) Granulation C) Third intention D) First intention
D
Which findings would be indicative of a nursing diagnosis of decreased cardiac output? A) bradycardia; urinary output < 30 ml; confusion B) confusion; tachypnea; hemoglobin 14.2 gm/dL C) urinary output > 60 ml; BP 90/60; tachypnea D) tachycardia; hemoglobin 10.9 gm/dL; BP 88/56
D
Which is a classic sign of hypovolemic shock? A) Dilute urine B) Bradypnea C) High blood pressure D) Pallor
D
The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action? A) Administer antiemetics to prevent nausea and vomiting. B) Monitor vital signs for early detection of shock. C) Assess the incisional dressing to detect hemorrhage. D) Position the client to maintain a patent airway.
D
The nurse is providing teaching about tissue repair and wound healing to a client who has a leg ulcer. Which of the following statements by the client indicates that teaching has been effective? A) "I'll make sure to limit my intake of protein." B) "I'll make sure that the bandage is wrapped tightly." C) "My foot should feel cool or cold while my leg's healing." D) "I'll eat plenty of fruits and vegetables."
D
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? A) Remove the dressing, assess the wound, and apply a new sterile dressing. B) Make the client NPO and order a stat hemoglobin and hematocrit. C) Take the client's vital signs and call the surgeon. D) Outline the drainage with a pen and record the date and time next to the drainage.
D
A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? A) Pink to red and soft, noting that it bleeds easily B) Necrotic and hard C) White with long, thin areas of scar tissue D) Pale yet able to blanch with digital pressure
A