Postoperative Nursing Management

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

First-intention

A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority?

Applying a sterile, moist dressing

A patient with an abdominal surgical wound sneezes and states, "Something doesn't feel right with my wound." The nurse asses the upper half of the surgical wounds edges are no longer approximated and the lower half remains well approximated. What documentation by the nurse is most appropriate?

Following a sneeze, the wound dehisced.

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The nurse recognizes the client is experiencing:

Hypothermia

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

A patient who underwent abdominal surgery 3 hours ago has started to hemorrhage. The nurse would classify this type of hemorrhage has which of the following?

Intermediary Explination: Intermediary hemorrhage occurs during the first few hours after surgery when the rise of blood pressure to its normal level dislodges insecure clots formed in untied vessels. Primary hemorrhage occurs at the time of surgery. Secondary hemorrhage may occur some time after surgery if a suture slips because a blood vessel was not securely tied, became infected, or was eroded by a drainage tube.

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

Maintaining a patent airway

The nurse is attempting to ambulate a patient who underwent shoulder surgery earlier in the day. The patient is refusing to ambulate. What action by the nurse is most appropriate?

Reinforce the importance of early mobility in preventing complications.

When caring for a postsurgical patient, the nurse observes that the client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing dressing or applying pressure if bleeding is frank

When caring for a postsurgical patient, the nurse observes that the client has hemorrhaged and is in hypovolemic shock. Which of the following nursing interventions will manage and minimize hemorrhage and shock?

Reinforcing dressing or applying pressure if bleeding is frank

A postanesthesia care unit (PACU) nurse is preparing to discharge a patient home following ankle surgery. The patient keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate?

Review the instructions with the patient and accompanying adult.

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

Which of the following would be the least important factor affecting wound healing?

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

Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective?

Vital signs within normal limits; absence of chills and cough

The nurse is caring for a client during the immediate postoperative period and is assessing for signs of shock. What signs and symptoms indicate that the client may be in shock?

Weak and rapid pulse rate

You are caring for a client who is an obese diabetic. The client is 48 hours post surgery. What is this client at increased risk for?

Wound dehiscence

Nursing assessment findings reveal a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. The nurse recognizes the client is experiencing:

Wound infection

It is important for the nurse to assist a postsurgical client to sit up and turn his or her head to one side when vomiting in order to

avoid aspiration.

A client with nausea and vomiting is to receive an antiemetic that inhibits the vomiting center in the brain. Which of the following would the nurse expect the physician to order most likely?

Prochlorperazine (Compazine) Prochlorperazine is a phenothiazine that inhibits the chemoreceptor trigger zone (CTZ) and the vomiting center in the brain. Odansetron blocks receptors for 5 HT3, affecting the neural pathways involved in nausea and vomiting. Hydroxyzine and promethazine are antihistamines which block H1 receptors resulting in a decrease in stimulation of the CTZ and vomiting.

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 nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates teaching has been ineffective?

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

A patient asks why there is a drain pulling fluid from the surgical wound. What is the best response by the nurse?

"It assists in preventing infection."

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:

Ambulating the client as soon as possible

A patient is postoperative day 3 for 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

To prevent thromboembolism in the postoperative client, the nurse should include which of the following in the plan of care?

Assist with oral fluid intake.

A PACU nurse receives a postoperative patient who received general anesthesia with a hard plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and an oxygen saturation of 98%. The patient is minimally responsive to painful stimuli. What action by the nurse is most appropriate?

Continue with frequent patient assessments.

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 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 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 3 days 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 at least three times per day.

Which of the following terms refers to a protrusion of abdominal organs through the surgical incision?

Evisceration

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

A postoperative patient, with an open abdominal wound is currently taking corticosteroids. The physician orders a wound culture of the abdominal wound even though there are no signs and symptoms of infection. What action by the nurse is appropriate?

Obtain the wound culture specimen.

The nurse has medicated a postoperative patient for complaints of nausea. Which medication would the nurse document as having been given?

Ondansetron (Zofran)

Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention?

Oxygen saturation of 82%

Postoperative day 2, a patient requires wound 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 with dry dressing

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

Which of the following is a classic sign of hypovolemic shock?

Pallor

In what phase of postanesthesia care (PACU) is the client prepared for self-care or care in the hospital or an extended care setting?

Phase II PACU

A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem?

Pink color

The nurse is caring for a client who develops an evisceration. What nursing intervention is most appropriate when an evisceration occurs in the surgical wound of a client who has undergone surgery?

Place sterile dressings moistened with normal saline over the protruding organs and tissues.

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.

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.

A recently extubated postoperative patient starts to gag and make vomiting sounds. What action should the nurse do first?

Turn patient on her side.

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

dehiscence.

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.

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation.

The PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. Which short-term outcome would be most important for this client? The client:

maintains adequate oxygenation status.

The client complains of weakness and dizziness as the nurse assists the client to sit on the side of the bed. The nurse recognizes the client is experiencing:

orthostatic hypotension

A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to:

place saline-soaked sterile dressings on the wound.

The nurse is reviewing the medications of a postoperative client. Which of the following medications may be of concern to the nurse?

predinisone (Deltasone)

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

The nurse is assessing the client for wound complications following surgery. For which clinical manifestation should the nurse assess? Select all that apply.

• Dehiscence • Hematoma

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

A postanesthesia care unit (PACU) nurse is caring for a patient 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 client who is receiving the maximum levels of 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? Select all that apply.

• Putting on soothing music • Performing guided imagery • Changing the client's position

Which of the following actions should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical patient?

Reinforce the need to perform leg exercises every hour when awake

The nurse is caring for a patient in the postanesthesia care unit (PACU) with the following vital signs, pulse 115, respiration 20, temperature 97.2°F oral, blood pressure 84/50. What should the nurse do first?

Assess for bleeding.

A patient is postoperative day 1 from abdominal surgery. The patient 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 2430 mL. What action by the nurse is most appropriate?

Assess for signs and symptoms of fluid volume deficit.

A patient is postoperative hour 8 following 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. Abdomen is soft and distended. No obvious bleeding noted. What action by the nurse is most appropriate?

Notify the physician.

When the nurse observes that the postoperative patient demonstrates a constant low level of oxygen saturation, although the patient's breathing appears normal, the nurse identifies that the patient may be suffering from which type of hypoxemia?

Subacute

A patient has undergone hernia repair surgery without complications. In the immediate postoperative period, which of the following actions by the nurse is most appropriate?

Monitor vital signs every 15 minutes

Which of the following factors may contribute to rapid and shallow respirations in a postoperative client? Select all that apply.

• Pain • Constricting dressings • Abdominal distention • Obesity