Nurs 309, Ch 16 Post op

What is the priority nursing intervention for a client during the immediate post-op period?

maintaining a patent airway

Which signs and symptoms are considered post- op complications? SATA

PE, Hypothermia, Wound evisceration, Postoperative ileus

The nurse is assessing a post op pt's GI system. What is the best indicator the peristaltic activity has resumed?

Passing flatus or stool

Which statement describes phase 1 of care?

Phase 1 care occurs immediately after surgery, most often in PACU

The post-op pt has a pen-rose drain in place. Which action does the nurse take to prevent skin irritation, wound contamination and infection?

Place absorbent pads under and around the exposed drain

The nurse on the med- surg unit is caring for a post-op pt. which assessment criteria indicates to the nurse that the pt is experiencing respiratory difficulty? sata

- The pt is using assessory muscles to breath -The pt makes high pitch crowning sounds when breathing - the pt RR is 29

The health care provider removed a pt's original surgical dressing 2 days after surgery and is discharged home with daily dressing changes. Which actions will the nurse take for this pt's discharge teaching? SATA

- Ask the pt's family or significant other to observe the dressing change -Have the case manager arrange for a home health nurse to ensure that dressing changes are done and there are no complications or infections -Teach the pt and family the s/s of infection

The PACU nurse is receiving the handoff report for a pt transferred in from the OR. Which statements about this report are accurate? SATA

-A handoff report requires clear concise language -A handoff report is a two-way verbal interaction between the healthcare professional giving the report and the nurse receiving it -The receiving nurse take time to restate( report back) the information to verify what was said -The receiving nurse take time to respond to questions and the reporting professional must respond to questions until common understanding is established

What are interventions for the medical-surgical nurse to use to prevent hypoxemia for the post-op pt? SATA

-Encourage pt to cough and deep breath -Get pt ambulating as soon as possible -Remind the pt to use incentive spirometry every hour while awake

When assessing the hydration status of an older adult post-op pt, where must the nurse assess fro tenting of the skin? SATA

-On the forehead -On the sternum

Which are criteria used by the health care team to determine when a pt is ready to be discharged from PACU? SATA

-Stable vital signs with normal body temp -intact cough and swallow reflexes -Adequate urine output -Return of gag reflex

What information should be included in the hand-off report when a pt is transferred from OR to PACU staff? SATA

-Type and extent of surgical procedure -Intra-op complication and how they were handled -Type and amount of iv fluids and blood products given -Location and type of incision, dressings, catheters, tubes, drains or packing

The nursing is caring for an obese post-op client who underwent surgery for bowel resection. As the client is moving in bed, he comments, "Something popped open." Upon examination, the nurse notes wound evisceration. Place the steps in order for handling this complication.

1) Stay calm and stay with the patient 2) Put the client into semi-fowler position with knees slightly flexed. 3) Check VS, esp. BP and pulse 4)Have a colleague gather sterile supplies and contact HCP 5) Cover the intestine with sterile moistened gauze 6) Prepare the client for surgery

In the immediate post-op period after a gastrectomy, the client's NG tube is draining a light-red liquid. For how long should the nurse expect this type of drainage?

10-12 hrs

The health care team determines a pt readiness for discharge from PACu by noting a post-anesthesia score of at least 10. After determining that all criteria have been met, the pt is discharged to the hospital unit or home. Which pt should the nurse expect to be discharged from PACU first?

42 y.o. F, Colonoscopy, Iv conscious sedation, Awake and alert, Up to bathroom to void, IV dc, resting quietly in chair VS are within normal limits

While caring for a client with a portable wound drainage system a nurse observes that the collection container is half full and empties it. What is the next nursing intervention?

Compress the container before closing the port

The PACU nurse is assessing a pt transferred in from the OR. Which assessment findings apply to assessment of the cardiovascular system? SATA

Absent pedal pulses in left foot Monitor show sinus rhythm Apical pulse 85 beats/min

Which members of the surgical team usually accompany post-op pt to the PACU?

Anesthesia provider and circulating nurse

In the PACU the nurse assesses that a pt is bleeding profusely from an abdominal incision. What is the nurses best first action?

Apply pressure to wound dressing

A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication will be prescribed because of its major role in wound healing?

Ascorbic acid

A pt arrives in the PACU. Which action does the nurse preform first?

Asses for patent airway and adequate gas exchange

A post-op care of a morbidly obese client is being planned. Which task best uses the expertise of the LPN/LVN, under the supervision of the RN team leader?

Assisting in the planning of toileting, turning, and ambulation

The nurse transfers a pt to the PACU........ Using SBAR which information should be included in the assessment?

BP 80/47, HR 117, RR 28, SPO2 93%, temp 101.3,Jackson pratt drain with 70ml cream colored output

The nurse is caring for a pt who has had abdominal surgery. After a hard sneeze the pt reports pain in the surgical area and the nurse immediately sees that the pt has a wound evisceration. What priority action must the nurse do first?

Call fro help and stay with pt

The PACU nurse is caring for a post op pt. The pt o2 stat drops from 98% to 88%. What is the nurses priority action?

Call the Rapid response team

A nurse if applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated?

Capillarity

A pt develops respiratory distress after having a total left hip replacement. The pt develops labored breathing, and spo2 is 83% on 2L via nasal cannula. Which intervention is appropriate for the nurse to delegate to a UAP?

Check pt vital signs

Which description illustrates the beginning of the postoperative period?

Completion of surgical procedure and transfer of the pt to the PACU

When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action?

Cover the wound with a sterile towel moistened with normal saline

After abdominal surgery a client reports pain. What action should the nurse take first?

Determine the characteristics of the pain

A post-op client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis?

Diminished breath sounds on auscultation

A client experiences abdominal distention following surgery. Which nursing actions are appropriate? SATA

Encouraging ambulation; auscultating bowel sounds

The nurse is responsible for the care of a post-op client with a thoracotomy. Which action should the nurse delegate to the UAP?

Encouraging, monitoring, and recording nutritional intake

The pt who received moderate sedation with midazolam appears overly sedated and has respiratory depression. Which drug does the nurse prepare to administer to this pt?

Flumazenil

A 49 y.o. Pt is in the PACU following a frontal craniotomy for repair of a ruptured cerebral aneurysm. The nurse assesses the pt eyes. the pt grasps hands. pt able to state name correctly. One episode of n/v. Incision edges are dry and approximated with sutures. Lung sound are slightly diminished on auscultation and nurse observes use of accessory muscles to breath. Which body systems has the nurse assessed? SATA

GI, Neuro, Integumentary, Respiratory

On which concern should the nurse focus when caring for a client after abdominal surgery?

Identifying signs of bleeding

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus?

Impaired neural functioning

A nurse if preparing to change a client's dressing. What is the reason for using surgical asepsis during the procedure?

Keeps the area free of microorganisms

A pt arrives in the PACU and the nurse notes a RR of 10 with sternal retractions. The report from the anesthesia provider indicates that the pt received fetanyl during surgery. What is the nurses best first action?

Maintain an open airway through positioning and suctioning if necessary

After undergoing a modified radical mastectomy, a client is transferred to the PACU. Which nursing action if best to assign to an experienced LPN/LVN?

Monitoring the client's dressing for any signs of bleeding

Which indicator of return of consciousness occurs first as a pt recovers from general anesthesia?

Muscular irritability

A client reports severe pain 2 days after surgery. Which initial action should the nurse take after assessing the character of pain?

Obtain the vital signs

What is the primary purpose of the PACU?

Ongoing critical evaluation and stabilization of the patient

The nurse is teaching incisional care to a pt who is being discharged after abdominal surgery. Which priority instructions must the nurse include?

Practice proper hand washing

A nurse in the PACU observes that after an abdominal cholecystectomy a client has serosanguineous drainage on the abdominal dressing. What is the next nursing action?

Reinforce the dressing

The morning after a pt lower leg surgery the nurse notes that the dressing is wet from drainage. The surgeon has not yet been in to see the pt on rounds. What does the nurse do about the dressing?

Reinforces the dressing by adding dry, sterile dressing material on top of the existing dressing

A pt cared for in PACU had a colostomy placed fro tx of chrohn's disease. The nurse assesses that the abdominal dressing is 25% saturated with seroanguieous drainage and the incision is intact. An IV is infusing with D%/lactate ringers at 100mls/hr through a 20 g peripheral IV. Auscultation of abd reveals hypo-active bowel sounds in all 4 quadrants, abd soft with no distention. Foley catheter in pace and draining yellow urine with sediment, 375ml output in foley bag. Which body systems have been assessed by the nurse? SATA

Renal urinary, GI, Integumentary

A post-op pt in the PACU has an open reduction internal fixation of left fractured femur. Vital signs are BP 87/49,HR 100 sinus rhythm, rr 22, temp 98.3, The Foley catheter has a total of 110ml of clear urine in last 4 hrs. Which body systems have been assessed by the nurse? SATA

Respiratory, Cardiovascular, Renal/Urinary

A client is extubated in the PACU after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress?

Restlessness

The PACU nurse is assessing an older adult pt for post op pain. Which nonverbal manifestation by the pt would suggest pain to the nurse? SATA

Restlessness, Profuse sweating, Confusion, Increased BP

The pt is recovering in PACU environment that advances the pt quickly from phase 1 care level to phase 3, preparing for discharge to home. What type of surgery is this pt most likely having?

Same-day surgery

WHich intervention for post surgical care of a pt is correct?

Teach the pt to splint the surgical wound for support and comfort when getting out of bed

The med-surg nurse is caring for a post-op pt whose lab values reveal an increase in band cells. What is the nurses best interpretation of this value?

The pt is developing an infection

A pt who is 2 days post-op for abd surgery states, " i coughed and heard something pop". the nurse immediate assessment reveals an opened incision with the intestines protruding. Which statement apply to this clinical situation?

This is an emergency The wound must be kept moist with NS-soaked sterile dressings Incisional evisceration has occurred A NG tube may be ordered to decompress stomach

If a pt experiences a wound dehiscense, which description best characterizes what is happening to the wound?

a partial or complete separation of outer layers is present at incision site

The nurse is caring for a post-op client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions?

frequent changes of position

Which intervention by the nurse will help a post-op pt with compliance in getting up to ambulate?

offer pt pain medication 30-45 mins before ambulation

Which pt is most at risk fro post-op N/V?

the pt with a hx of motion sickness