PostOp Chapter 19

The nursing instructor is talking with a group of medical-surgical students about deep vein thrombosis (DVT). A student asks what factors contribute to the formation of a DVT. What would be the instructor's best response? A. hypervolemia B. dehydration C. genetics D. ambulation

Ans: "Dehydration is a contributory factor to the formation of deep vein thrombi." Feedback: The stress response that is initiated by surgery inhibits the fibrinolytic system, resulting in blood hypercoagulability. Dehydration, low cardiac output, blood pooling in the extremities, and bedrest add to the risk of thrombosis formation. Hypervolemia is not a risk factor and there are no known genetic factors.

The recovery room nurse is admitting a patient from the OR following the patient's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted patient? A. airway patency B. blood pressure C. temperature D. skin integrity

Ans: Airway patency Feedback: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).

The nurse is performing the shift assessment of a postsurgical patient. The nurse finds his mental status, level of consciousness, speech, and orientation are intact and at baseline, but the patient tells you he is very anxious. What should the nurse do next? A. assess the patient's oxygen levels B. administer an antianxiolytic C. notify the physician D. request a social work consult

Ans: Assess the patient's oxygen levels. Feedback: The nurse assesses the patient's mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage. Antianxiety medications are not given until the cause of the anxiety is known. The physician is notified only if the reason for the anxiety is serious or if an order for medication is needed. A social work consult is inappropriate at this time.

The perioperative nurse is providing care for a patient who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The patient is reluctant to ambulate, citing the need to recover in bed. For what complication is the patient most at risk? A. atelectasis B. dehydration C. peripheral edema D. anemia

Ans: Atelectasis Feedback: Atelectasis occurs when the postoperative patient fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia occurs rarely and usually in situations where the patient loses a significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the patient is most at risk for atelectasis.

The home health nurse is caring for a postoperative patient who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the patient's postoperatative day 2. During the visit, the nurse will assess for wound infection. For most patients, what is the earliest postoperative day that a wound infection becomes evident? A. day one B. day three C. day five D. day seven

Ans: Day 5 Feedback: Wound infection may not be evident until at least postoperative day 5. This makes the other options incorrect.

The surgeon's preoperative assessment of a patient has identified that the patient is at a high risk for venous thromboembolism. Once the patient is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the patient's risk of developing this complication? A. passive range-of-motion exercises B. encourage early ambulation C. increase fluid intake D. elevate the head of the bed

Ans: Encourage early ambulation. Feedback: The benefits of early ambulation and leg exercises in preventing DVT cannot be overemphasized, and these activities are recommended for all patients, regardless of their risk. Increasing the head of the bed is not effective. Ambulation is superior to passive range-of-motion exercises. Fluid intake is important, but is less protective than early ambulation.

An adult patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the patient may be at risk for what? A. aspiration B. hypertension and dysrhythmia C. hemorrhage and shock D. infection

Ans: Hemorrhage and shock Feedback: The patient with a hemorrhage presents with hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin. Aspiration would manifest in airway disturbance. Hypertension or dysrhythmias would be less likely to cause pallor and cool skin. An infection would not be present at this early postoperative stage.

The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority? A. maintaining a patent airway B. assess for hemorrhage C. monitor vital signs D. assess the patient's pain

Ans: Maintaining a patent airway Feedback: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Assessing for hemorrhage and assessing vital sign are also important, but constitute second and third priorities. Pain management is important but only after the patient has been stabilized.

A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do? A. document the output B. notify the physician and monitor the urine output hourly C. irrigate the catheter

Ans: Notify the physician and continue to monitor the hourly urine output closely. Feedback: If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/hr are reported. The urine output should continue to be monitored hourly by the nurse. Irrigation would not be warranted.

The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication? A. pulmonary embolism B. hematoma C. infection D. sepsis

Ans: Pulmonary embolism Feedback: Patients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of an external pneumatic compression stocking significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection or sepsis would not be affected by an external pneumatic compression stocking. A hematoma or bruise would not be affected by the external pneumatic compression stocking unless the stockings were placed directly over the hematoma.

A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? Select all that apply. A. stable blood pressure B. oral intake resumed C. sufficient oxygen saturation D. adequate respiratory function E. lack of pain

Ans: Stable blood pressure, Sufficient oxygen saturation, Adequate respiratory function Feedback: A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. Patients can be released from PACU before resuming oral intake. Pain is often present at discharge from the PACU and can be addressed in other inpatient settings.

The nurse is caring for a patient after abdominal surgery in the PACU. The patient's blood pressure has increased and the patient is restless. The patient's oxygen saturation is 97%. What cause for this change in status should the nurse first suspect? A. hypothermia B. hypoxia C. pain D. shock

Ans: The patient is in pain. Feedback: An increase in blood pressure and restlessness are symptoms of pain. The patient's oxygen saturation is 97%, so hypothermia, hypoxia, and shock are not likely causes of the patient's restlessness.

The perioperative nurse is preparing to discharge a female patient home from day surgery performed under general anesthetic. What instruction should the nurse give the patient prior to the patient leaving the hospital? A. purchase an OTC hypnotic B. stay on complete bed rest C. eat three big meals a day D. don't drive yourself home

Ans: The patient should not drive herself home. Feedback: Although recovery time varies, depending on the type and extent of surgery and the patient's overall condition, instructions usually advise limited activity for 24 to 48 hours. Complete bedrest is contraindicated in most cases, however. During this time, the patient should not drive a vehicle and should eat only as tolerated. The nurse does not normally make OTC recommendations for hypnotics.

The dressing surrounding a mastectomy patient's Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion? A. remove the dressing, check the wound, and reapply the dressing B. take a photograph of the dressing C. document his/her suspicion D. trace the outline of the drainage on the dressing for future comparison

Ans: Trace the outline of the drainage on the dressing for future comparison. Feedback: Spots of drainage on a dressing are outlined with a pen, and the date and time of the outline are recorded on the dressing so that increased drainage can be easily seen. A dressing is never removed and then reapplied. Photographs normally require informed consent, so they would not be used for this purpose. Documentation is necessary, but does not confirm or rule out an increase in drainage.

An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patient's vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next? A. offer a cool cloth B. administer an analgesic C. turn the pt. to one side D. give the pt. ice chips

Ans: Turn the patient completely to one side. Feedback: Turning the patient completely to one side allows collected fluid to escape from the side of the mouth if the patient vomits. After turning the patient to the side, the nurse can offer a cool cloth to the patient's forehead. Ice chips can increase feelings of nausea. An analgesic is not administered for nausea and vomiting.