Chapter 19: Postoperative Nursing Management

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 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?

assess for bleeding

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?

call the provider

The client is experiencing intractable hiccups following surgery. What would the nurse expect the surgeon to order?

chlorpromazine

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

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.

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

A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem?

pink color

What complication is the nurse aware of that is associated with deep venous thrombosis?

pulmonary embolism

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

vitamin c

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?

less than 30 mL

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

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required?

"I can resume my usual activities as soon as I get home."

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."

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.

- 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.

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

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

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?

Encourage the client to move legs frequently and do leg exercises.

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?

Ineffective thermoregulation

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

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.

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?

Pink to red and soft, bleeding easily

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 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?

Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.

A client vomits postoperatively. What is the most important nursing intervention?

Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.

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?

Urine retention

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

as soon as it is indicated

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

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

first intention

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

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 90/50 mm Hg

What measurement should the nurse report to the physician in the immediate postoperative period?

A systolic blood pressure lower than 90 mm Hg

The nurse determines that a patient has postoperative abdominal distention. What does the nurse determine that the distention may be directly related to?

A temporary loss of peristalsis and gas accumulation in the intestines

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?

Evisceration