Chapter 19: Postoperative Nursing Management

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

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 Beginning food intake in the immediate postoperative period Improper body positioning during the recovery period The type of anesthetic administered

A temporary loss of peristalsis and gas accumulation in the intestines

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

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

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? First intention Second intention Third intention Fourth intention

First intention

Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis? Prolonged dangling of the legs over the edge of the bed Hourly leg exercises Use of blanket rolls to elevate the lower extremities Fluid restriction

Hourly leg exercises

The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of: Laryngospasm Hyperventilation Hypoxemia and hypercapnia. Pulmonary edema and embolism.

Hypoxemia and hypercapnia.

When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority. Anxiety Altered comfort Impaired gas exchange Risk for infection Fluid volume deficit

Impaired Gas Exchange Fluid Volume Deficit Altered Comfort Anxiety Risk for Infection

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

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 nurse has medicated a postoperative client who reported nausea. Which medication would the nurse document as having been given? Ondansetron Warfarin Prednisone Propofol

Ondansetron

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.

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

Which is a classic sign of hypovolemic shock? Dilute urine Pallor High blood pressure Bradypnea

Pallor

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

Pink color

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? Necrotic and hard Pale yet able to blanch with digital pressure Pink to red and soft, bleeding easily White with long, thin areas of scar tissue

Pink to red and soft, bleeding easily

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? Pleurisy Pneumonia Hypoxemia Pulmonary edema

Pneumonia

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 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.

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

Prednisone

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

The nurse recognizes which symptom as a clinical manifestation of shock? Flushed face Warm, dry skin Increased urine output Rapid, weak, thready pulse

Rapid, weak, thready pulse

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.

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

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.

It is important for the nurse to assist a postsurgical client to sit up and turn the head to one side when vomiting in order to maximize comfort. avoid dizziness. avoid aspiration. help eliminate inhaled anesthetics.

avoid aspiration

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

chlorpromazine

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

clean contaminated.

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

maintaining pulmonary ventilation.

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

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required? "I should call my physician if I develop a fever." "My incision should become less red and tender." "I can resume my usual activities as soon as I get home." "I need to keep my follow-up appointment with the physician."

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

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

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 site gets wet, pat the wound dry." "The wound will continue to heal for several weeks." "The wound should not be rubbed or scrubbed." "If the wound edges are red or raised, you should call your doctor."

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

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."

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

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% 30% to 40% 40% to 50% Greater than 50%

20%

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? 4 5 6 7

7

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

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

As soon as it is indicated

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? Notify the physician. Assess for bleeding. Increase rate of IV fluids. Review the client's preoperative vital signs.

Assess for bleeding.

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

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. Apply oxygen. Notify the physician. Document the findings.

Assess the client's heart rhythm and nail beds.

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

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

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? Re-attempt to auscultate bowel sounds. Prepare to insert a nasogastric tube. Call the health care provider. Prepare to administer a stool softener.

Call the health care provider.

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? Complete blood count Central venous pressure Upper endoscopy Chest x-ray

Central venous pressure

The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply. Wheezes Chills Crackles Afebrile Tachypnea

Chills Crackles Tachypnea

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.

A nursing measure for evisceration is to: Apply an abdominal binder snugly so that the intestines can be slowly pushed back into the abdominal cavity. Approximate the wound edges with adhesive tape so that the intestines can be gently pushed back into the abdomen. Carefully push the exposed intestines back into the abdominal cavity. Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution.

Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution.

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

A nurse is caring for a client with a chest tube connected to a dry suction water seal drainage system. The nurse notes 2 cm of water and intermittent bubbling in the water seal chamber. Which action will the nurse take? Document the findings. Add water to the water seal chamber. Check for an air leak. Notify the health care provider.

Document the findings.

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.

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? Place pillows under the client's knees or calves. Encourage the client to move legs frequently and do leg exercises. Place pressure on the client's lower extremities. Place the client in a side-lying position.

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

Which term refers to the protrusion of abdominal organs through the surgical incision? Hernia Dehiscence Erythema Evisceration

Evisceration

The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply. Listening to music An On-Q pump Watching television An epidural infusion Changing position

Listening to music Watching television Changing position

A postanesthesia care unit (PACU) nurse is caring for a client with the following assessment data: pale, cool, moist skin; thready pulse of 122; blood pressure 78/60; urine output of 25 mL/h; temperature 99.2°F. What interventions by the nurse are appropriate? Select all that apply. Raise the head of the bed 30 degrees. Maintain a patent airway. Frequently monitor neurological status. Administer blood products per orders. Apply oxygen per orders. Apply a warming blanket.

Maintain a patent airway. Frequently monitor neurological status. Administer blood products per orders. Apply oxygen per orders.

A nurse is receiving a client to the postanesthesia unit. What initial nursing activity is most important in the postoperative recovery area? Maintain patient safety. Administer medications and fluids. Assess pain level. Inspect surgical site.

Maintain patient safety

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

Corticosteroids have which effect on wound healing? Reduce blood supply Mask the presence of infection Cause hemorrhage May cause protein-calorie depletion

Mask the presence of infection

A client is at postoperative hour 8 after an appendectomy and is anxious, stating "Something is not right. My pain is worse than ever and my stomach is swollen." Blood pressure is 88/50, pulse is 115, and respirations are 24 and labored. The abdomen is soft and distended. No obvious bleeding is noted. What action by the nurse is most appropriate? Notify the physician. Administer morphine per orders. Inform the client this is the normal progression after abdominal surgery. Ambulate the client to reduce abdominal distention.

Notify the physician.

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? Position the client on his or her side. Assist the client to intake ample amounts of water. Notify the physician. Instruct the client to take deep breaths.

Notify the physician.

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 Massage the calves or thighs Instruct the client to cross the legs or prop a pillow under the knees Maintain bed rest

Reinforce the need to perform leg exercises every hour when awake

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? Elevating the head of the bed Reinforcing dressings or applying pressure if bleeding is frank Rubbing the back Encouraging the client to breathe deeply

Reinforcing dressings or applying pressure if bleeding is frank

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.

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? Ask the client, "Do you understand?" Continuously repeat the instructions until the client restates them. Give the written instructions to the client's 16-year-old child. Review the instructions with the client and an accompanying adult.

Review the instructions with the client and an accompanying adult.

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? Primary-intention healing First-intention healing Second-intention healing Third-intention healing

Second-intention healing

Which of the following stimulates the wound healing process? Hemorrhage Sufficient oxygenation Nutritional deficiencies Immobility

Sufficient oxygenation

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? The client has been lying on his side for 2 hours with the drain positioned upward. The client has a nasogastric (NG) tube in place that drained 400 ml. The Hemovac drain isn't compressed; instead it's fully expanded. There is a moderate amount of dry drainage on the outside of the dressing.

The Hemovac drain isn't compressed; instead it's fully expanded.

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.

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? The client has an absence of bowel sounds. The client's lungs reveal rales in the bases. The client states a moderate amount of pain at the incisional site. A moderate amount of serous drainage is noted on the operative dressing.

The client has an absence of bowel sounds.

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 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 clinical manifestations increases the risk for evisceration in the postoperative client? Hypovolemia Edema Valsalva maneuver Hypoxia

Valsalva maneuver

Select the nutrient that is important for postoperative wound healing because it helps form collagen. Protein Vitamin C Magnesium Vitamin A

Vitamin C

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

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

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

Wound dehiscence

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 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.

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. second intention. third intention. fourth intention.

first intention

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.