Chapter 19 post operative

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

The nurse is caring for a client during the immediate postoperative period and is assessing for signs of shock. What signs and symptoms indicate that the client may be in shock? Weak and rapid pulse rate Warm, dry skin Pooling of secretions in the lungs Obstructed airway

Weak and rapid pulse rate Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock.

What is the highest priority nursing intervention for a client in the immediate postoperative phase? Maintaining a patent airway Monitoring vital signs at least every 15 minutes Assessing urinary output every hour Assessing for hemorrhage

Maintaining a patent airway All interventions listed are correct. The highest priority intervention, however, 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.

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 flows quickly. 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 flows quickly. An intermediary hemorrhage appears within the first few hours following surgery. Darkly colored blood that flows 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 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

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

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

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

ondansetron Ondansetron (Zofran) is used to treat nausea and vomiting.

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.

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.

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? Blood pressure of 150/100 mm Hg Blood pressure of 120/90 mm Hg Blood pressure of 110/80 mm Hg Blood pressure of 90/50 mm Hg

Blood pressure of 90/50 mm Hg

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

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.

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 sterile normal saline and place on the protruding organ.

Moisten sterile gauze with sterile normal saline and place on 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 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.

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 teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention? Dangle at the bedside. Report early calf pain. Take off the pneumatic compression devices for sleeping. Rely on the IV fluids for hydration.

Report early calf pain. The client needs to report calf pain or cramping for the nurse to investigate any swelling or potential DVT. Blanket rolls or prolonged dangling should be avoided to reduce impediment of circulation behind the knee. Prevention of DVT includes early ambulation, use of antiembolism or pneumatic compression devices, and low-molecular-weight or low-dose heparin and low-dose warfarin for clients postoperatively. Adequate fluids need to be offered to avoid dehydration.

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.

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 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.

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what? Requirement of intermittent catheterization Calculus formation Urine retention Urinary infection

Urine retention

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 (e.g., length of the house or apartment), get in and out of bed unassisted, and be independent with toileting.

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

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.

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."

The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists? Dehiscence Evisceration Hemorrhage Normal healing by primary intention.

Dehiscence

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-like symptoms?

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

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? Apply moist heat to the client's abdomen. Encourage the client to ambulate as soon as possible after surgery. Administer a tap water enema. Notify the physician.

Encourage the client to ambulate as soon as possible after surgery. The nurse should encourage the client to ambulate as soon as possible after surgery. 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 health care provider's order. A tap water enema is typically administered as a last resort after other methods fail. A health care provider's order is needed with a tap water enema as well. Notifying the health care provider isn't necessary at this point because the client is exhibiting bowel function by passing flatus.

What complication in the immediate postoperative period should the nurse understand requires early intervention to prevent? Laryngospasm Hyperventilation Hypoxemia and hypercapnia Pulmonary edema and embolism

Hypoxemia and hypercapnia The primary objective in the immediate postoperative period is to maintain ventilation and thus prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Both can occur if the airway is obstructed and ventilation is reduced (hypoventilation). Besides administering supplemental oxygen (as prescribed), the nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds.

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? Acute incisional pain Ineffective thermoregulation Decreased cardiac output Ineffective airway clearance

Ineffective thermoregulation Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.

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.

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.

Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client? Reinforce the need to perform leg exercises every hour when awake. Administer prophylactic high-dose heparin. Instruct the client to prop a pillow under the knees. Maintain bed rest.

Reinforce the need to perform leg exercises every hour when awake. The nurse should reinforce the need to perform leg exercises every hour when awake. Maintaining bed rest increases the pooling of blood in the lower extremities, increasing the risk for deep vein thrombosis. The client may be given low-dose heparin for prophylactic treatment, but not high-dose heparin. The nurse should instruct the client not to prop a pillow under the knees because it can constrict the blood vessels.

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.

A client who is receiving the maximum levels of pain 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 Massaging the client's legs

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.

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.

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 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 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.

Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective? Vital signs within normal limits; absence of chills and cough Alert and oriented; peripheral pulses present and strong Bladder non—distended; Foley catheter draining clear, yellow urine Bowel sounds present and active; denies nausea and vomiting

Vital signs within normal limits; absence of chills and cough

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.

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

experiences pain within tolerable limits. Because pain can contribute to postoperative delirium, adequate pain control without oversedation is essential. Nursing assessment of mental status and of all physiologic factors influencing mental status helps the nurse plan for care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult client.

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.