Chapter 19 Postoperative Nursing Management

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? A.) First intention B.) Second intention C.) Third intention D.) Fourth intention

Answer: A.) First intention

What complication is the nurse aware of that is associated with deep venous thrombosis? A.) Pulmonary embolism B.) Immobility because of calf pain C.) Marked tenderness over the anteromedial surface of the thigh D.) Swelling of the entire leg owing to edema

Answer: A.) Pulmonary embolism Rationale: Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010).

Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client? A.) Reinforce the need to perform leg exercises every hour when awake B.) Massage the calves or thighs C.) Instruct the client to cross the legs or prop a pillow under the knees D>) Maintain bed rest

Answer: A.) Reinforce the need to perform leg exercises every hour when awake

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.

Answer: A.) 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? A.) experiences pain within tolerable limits. B.) exhibits wound healing without complications. C.) resumes usual urinary elimination pattern. D.) maintains adequate fluid status.

Answer: A.) experiences pain within tolerable limits. Rationale: 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.

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.) Document the findings and reassess in 24 hours. B.) Assess for signs and symptoms of fluid volume deficit. C.) Assess for edema. D.) Discontinue the nasogastric tube suctioning.

Answer: B.) Assess for signs and symptoms of fluid volume deficit. Rationale: The client's 24-hour intake is 1800 mL (75 x 24). The client's 24-hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Because the output is significantly higher than the intake, the client is at risk for fluid volume deficit. The nurse should not discontinue the nasogastric suctioning without a physician's order. The findings should be documented and reassessed, but the nurse needs to take more action to prevent complication. Edema is usually associated with fluid volume excess.

A nurse is reviewing the medications of a postoperative client. What medication related to the recent surgery may be of concern to the nurse? A.) Furosemide B.) Prednisone C.) Digoxin D.) Allopurinol

Answer: B.) Prednisone Rationale: Corticosteroids such as prednisone (Deltasone) may impair the normal inflammatory process and may mask infection. Furosemide (Lasix), digoxin (Lanoxin), and allopurinol (Zyloprim) should not be of concern postoperatively.

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.) Elevating the head of the bed B.) Reinforcing dressings or applying pressure if bleeding is frank C.) Rubbing the back D.) Encouraging the client to breathe deeply

Answer: B.) Reinforcing dressings or applying pressure if bleeding is frank

When should the nurse encourage the postoperative patient to get out of bed? A.) Within 6 to 8 hours after surgery B.) Between 10 and 12 hours after surgery C.) As soon as it is indicated D.) On the second postoperative day

Answer: C.) As soon as it is indicated

A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem? A.) Copious red blood in the sputum B.) Foul smell C.) Pink color D.) Pieces of vomitus

Answer: C.) Pink color Rationale: Flash pulmonary edema that occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation, tachypnea, tachycardia, decreased pulse oximetry readings, frothy, pink sputum, and crackles on auscultation.

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? A.) Necrotic and hard B.) Pale yet able to blanch with digital pressure C.) Pink to red and soft, noting that it bleeds easily D.) White with long, thin areas of scar tissue

Answer: C.) Pink to red and soft, noting that it bleeds easily

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? A.) Dehiscence B.) Evisceration C.) Hemorrhage D.) Normal healing by primary intention.

Answer: A.) Dehiscence

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.) Administer an anti-emetic. C.) Obtain an emesis basin. D.) Ask the client for more clarification.

Answer: A.) Position the client in the side-lying position.

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.) First-intention healing C.) Second-intention healing D.) Third-intention healing

Answer: C.) Second-intention healing Rationale: When wounds dehisce, they are allowed to heal by secondary intention. Primary or first-intention healing is the method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation. Third-intention healing is a method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by bringing apposing granulations together.

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

Answer: - Performing guided imagery - Putting on soothing music - Changing the client's position

A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse? A.) "It assists in preventing infection." B.) "It will cut down on the number of dressing changes needed." C.) "The drain will remove necrotic tissue." D.) "Most surgeons use wound drains now."

Answer: A.) "It assists in preventing infection." Rationale: 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.

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? A.) <30 mL B.) Between 75 and 100 mL C.) Between 100 and 200 mL D.) >200 mL

Answer: A.) <30 mL

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: A.) first intention. B.) second intention. C.) third intention. D.) fourth intention.

Answer: A.) first intention.

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.) Acute incisional pain B.) Ineffective thermoregulation C.) Decreased cardiac output D.) Ineffective airway clearance

Answer: B.) Ineffective thermoregulation

The primary objective in the immediate postoperative period is A.) controlling nausea and vomiting. B.) relieving pain. C.) maintaining pulmonary ventilation. D.) monitoring for hypotension.

Answer: C.) maintaining pulmonary ventilation.

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.) Respirations between 20 and 25 breaths/min D.) A hemoglobin of 13.6

Answer: A.) A systolic blood pressure lower than 90 mm Hg

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.) The client can self-administer oral pain medication as needed with patient-controlled analgesia. B.) Family members can be involved in the administration of pain medications with patient-controlled analgesia. C.) Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. D.) There are no advantages of patient-controlled analgesia over a PRN dosing schedule.

Answer: C.) Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.

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? A.) Requirement of intermittent catheterization B.) Calculus formation C.) Urine retention D.) Urinary infection

Answer: C.) Urine retention

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? A.) Hyperthermia B.) Atelectasis C.) Wound infection D.) Uncontrolled pain

Answer: C.) Wound infection

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

Answer: C.) ondansetron

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage? A.) The client has been lying on his side for 2 hours with the drain positioned upward. B.) The client has a nasogastric (NG) tube in place that drained 400 ml. C.) The Hemovac drain isn't compressed; instead it's fully expanded. D.) There is a moderate amount of dry drainage on the outside of the dressing.

Answer: C.) The Hemovac drain isn't compressed; instead it's fully expanded. Rationale: The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.

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 showing signs of a medication reaction. B.) The client is displaying late signs of shock. C.) The client is displaying early signs of shock. D.) The client is showing signs of an anesthesia reaction.

Answer: C.) The client is displaying early signs of shock. Rationale: 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.

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 150/100 mm Hg B.) Blood pressure of 120/90 mm Hg C.) Blood pressure of 110/80 mm Hg D.) Blood pressure of 90/50 mm Hg

Answer: D.) Blood pressure of 90/50 mm Hg

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

Answer: D.) Dead space and dead cells provide a culture medium

A nurse is caring for a client who is scheduled to have a thoracotomy. When planning care for this client, what mobility teaching will the nurse include in the plan of care? A.) Lower back and rib range of motion exercises B.) Use of a cane on the unaffected side C.) Use of a cane on the affected side D.) Shoulder and upper arm range-of-motion exercises

Answer: D.) Shoulder and upper arm range-of-motion exercises Rationale: Because large shoulder girdle muscles are transected during a thoracotomy, the arm and shoulder needs mobilization with range-of-motion exercises. Lower back and rib cage exercises are not a standard therapy for those recovering from a thoracotomy. The use of a cane is not a standard assistive device necessary after a thoracotomy.

A client vomits postoperatively. What is the most important nursing intervention? A.) Measure the amount of vomitus to estimate fluid loss, in order to accurately monitor fluid balance. B.) Offer tepid water and juices to replace lost fluids and electrolytes. C.) Support the wound area so that unnecessary strain will not disrupt the integrity of the incision. D.) Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.

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

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for? A.) Hypotension B.) Contractures C.) Phlebitis D.) Wound dehiscence

Answer: D.) Wound dehiscence