Ch. 19 PrepU

A nurse is working in the postanesthesia unit (PACU). What evidence indicates that a client is ready for discharge from the PACU?

The client is arousable, but falls back to sleep rapidly The client has a blood pressure within 10 mm Hg of the baseline

Select the nutrient that is important for postoperative wound healing because it helps form collagen.

Vitamin C

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?

Wound approximation

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

clean contaminated

The nurse recognizes adequate hourly urine output for a client with an indwelling urinary catheter as at least

0.5 mL/kg/h

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

15 minutes

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?

20%

The nurse is reviewing a list of surgical clients. Which clients would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period?

27-year-old client with non-insulin dependent diabetes 70-year-old client who takes no routine medications

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

As soon as it is indicated

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?

Assess for signs and symptoms of fluid volume deficit

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

A patient has a wound that has hemorrhaged. What does the nurse understand is the cause of the patient's increased risk of infection?

Dead space and dead cells provide a culture medium

The nurse is assessing the client for wound complications following surgery. For which clinical manifestation should the nurse assess?

Dehiscence, hematoma

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?

Does the client have a history of dementia-like symptoms?

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

Every 4 hours

A nurse is reviewing with a client the use of a patient-controlled anesthesia device and is explaining the benefits. Which of the following would the nurse correctly emphasize?

Fosters client participation in care Facilitates reduction of postoperative pulmonary complications

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?

If the wound edges are red or raised, you should call your doctor

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

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

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

The nurse is caring for a postoperative client with an indwelling urinary catheter. The hourly urinary output is 80 mL at 9 am. At 10 am, the nurse assesses the hourly urinary output as 20 mL. What is the priority action by the nurse?

Notify the primary care provider immediately

Unless contraindicated, how should the nurse position an unconscious patient?

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

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

Which of the following factors may contribute to rapid and shallow respirations in a postoperative client?

Pain Constricting dressings Abdominal distention Obesity

In what phase of postanesthesia care (PACU) is the client prepared for self-care or care in the hospital or an extended care setting?

Phase II PACU

A postoperative client begins coughing forcefully while eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first?

Place the client in the low Fowler's position

A client with nausea and vomiting is to receive an antiemetic that inhibits the vomiting center in the brain. Which of the following would the nurse expect the physician to order most likely?

Prochlorperazine (compazine)

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation?

Second-intention healing

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?

Subacute

The nurse is caring for a female postoperative client who is having difficulty voiding. Which nursing action is most helpful to promote normal voiding?

Assist to the bathroom

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

The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this?

Assisting the patient with leg exercises Encouraging early ambulation Avoiding placement of pillows or blanket rolls under the patient's knees

What complication in the immediate postoperative period should the nurse understand requires early intervention to prevent?

hypoxemia and hypercapnia