Peri-Op Prep U
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?
Review the instructions with the client and an accompanying adult.
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
Corticosteroids have which effect on wound healing?
Mask the presence of infection
A client is transported from the postanesthesia care unit (PACU) to an inpatient care area after receiving intrapleural analgesia for pain control. The nurse knows that this type of anesthesia is used for which surgical procedure?
Nephrectomy
A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention?
Report early calf pain.
Which of the following clinical manifestations increases the risk for evisceration in the postoperative client?
Valsalva maneuver
The nurse is caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock?
Weak and rapid pulse rate
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.
Which of the following clinical manifestations increases the risk for evisceration in the postoperative client?
valsalva maneuver
The nurse recognizes adequate hourly urine output for a client with an indwelling urinary catheter as at least
0.5 mL/kg/hr
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
A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?
Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?
First intention
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.
-Maintain a patent airway. -Frequently monitor neurological status. -Administer blood products per orders. -Apply oxygen per orders.
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 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?
Central venous pressure
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
When should the nurse encourage the postoperative patient to get out of bed?
As soon as it is indicated
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?
Assess for signs and symptoms of fluid volume deficit.
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 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
A patient has a wound that has hemorrhaged. What does the nurse understand is the cause of the patient's increased risk of infection?
dead space and dead cells provide a culture medium
The primary objective in the immediate postoperative period is
maintaining pulmonary ventilation
A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?
Evisceration
Which is a classic sign of hypovolemic shock?
Pallor
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
What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?
Pneumonia
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.
What complication is the nurse aware of that is associated with deep venous thrombosis?
Pulmonary embolism
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
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.
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.
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
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
Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis?
decreased cardiac output
The nurse recognizes that a traumatic wound with fecal contamination would be classified as
dirty
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 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?
have the client lay on back with the head elevated
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."
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?
<30 mL
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
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
A client is transferred from the postanesthesia care unit (PACU) to an inpatient care unit. What will the nurse assess first?
Breathing
What measurement should the nurse report to the physician in the immediate postoperative period?
A systolic blood pressure lower than 90 mm Hg
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
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?
Performing guided imagery Putting on soothing music Changing the client's position
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
A client recovering from surgery asks, "When can I go home?" The nurse responds by stating which of the following activities must be completed before discharging home? Select all that apply.
-Be independent with toileting -Ambulate a functional distance -Get in and out of bed unassisted
The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply.
-Chills -Crackles -Tachypnea
To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:
Ambulating the client as soon as possible
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 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
A client recovering from surgery is at risk for respiratory complications. The nurse knows which action(s) could improve a client's respiratory status? Select all that apply.
-Turn and reposition the client -Instruct the client to yawn frequently -Coach the client to take deep breaths and cough -Remind the client to use the incentive spirometer every 2 hours
The nurse is planning care for a client in the postoperative period. Place the following nursing diagnoses in sequence, from highest to lowest priority.
1-Impaired Gas Exchange 2-Fluid Volume Deficit 3-Altered Comfort 4-Anxiety 5-Risk for Infection
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 health care provider
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
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.
What is the highest priority nursing intervention for a client in the immediate postoperative phase?
Maintaining a patent airway
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.
Which of the following stimulates the wound healing process?
Sufficient oxygenation
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
The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?
ondansetron
A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem?
pink color
A nursing assessment's findings reveal a postoperative client has a temperature of 96.2 °F (35.7 °C), shivering, and reports feeling cold. What does the nurse conclude about the client?
the client is experiencing hypothermia
A client in the postanesthesia care unit (PACU) develops noisy and irregular respirations. Which action will the nurse take?
tilt the head back and lift the lower jaw
