chapter 19 prepU

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."

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

0.5 mL/kg/h.

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

7

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

<30 mL

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

As soon as it is indicated

A nursing measure for evisceration is to:

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

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?

Moisten sterile gauze with normal saline and place on the protruding organ.

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?

Encourage the client to ambulate as soon as possible after surgery.

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

Evisceration

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? Select all that apply.

Facilitates reduction of postoperative pulmonary complications Fosters client participation in care

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

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

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

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.

third intention wound healing

deep wounds not sutured early or break down & re-suture later; pack w/ moist gauze & cover w/ dry sterile dressing

A term used to describe a partial or complete separation of wound edges is

dehiscence

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.

second intention wound healing

granulation occurs in infected wounds or wounds w/ edges not approximated; pack w/ moist sterile dressing & cover w/ dry sterile dressing

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation

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

ondansetron

first intention wound healing

open wounds are closed surgically with sutures or staples

Granulation phase

the second phase of primary intention; lasts from 5 days -3 weeks; forms tissue that includes proliferating fibroblasts, proliferating capillary sprouts, various types of WBCs, exudate, and lose semifluid substances

Evisceration

wound separation with protrusion of organs

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?

Pneumonia

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.

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

Pulmonary embolism

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing the dressing or applying pressure if bleeding is frank

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

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?

Shoulder and upper arm range-of-motion exercises

A nurse is planning care for a client scheduled to undergo a thoracotomy. After tolerating full liquids, which dietary recommendation will the nurse consider?

Small, frequent full-fat meals

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 concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus

Absence of peristalsis

Ondansetron (Zofran)

Antiemetic.

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 Watching television Changing position

What is the highest priority nursing intervention for a client in the immediate postoperative phase?

Maintaining a patent airway

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.

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

Dehiscence

Bursting open of a wound, especially a surgical abdominal wound

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?

Central venous pressure

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?

Pink to red and soft, noting that it bleeds easily

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?

Position the client to maintain a patent airway.

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?

Wound infection