Saunders Pain/Perioperative
A nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates that he or she will take which action?
After maximal inspiration, hold the breath for 10 seconds and then exhale. For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should hold the breath for 2 or 3 seconds and then exhale slowly.
A client has received atropine sulfate intravenously during a surgical procedure. The nurse should monitor the client for which side effect of the medication in the immediate postoperative period?
Urinary retention Atropine sulfate is an anticholinergic medication that causes tachycardia, drowsiness, blurred vision, dry mouth, constipation, and urinary retention. The nurse monitors the client for any of these effects in the immediate postoperative period.
A client is admitted to the ambulatory surgery center for elective surgery. The nurse asks the client whether any food, fluid, or medication was taken today. Which medication, if taken by the client, should indicate to the nurse the need to contact the health care provider (HCP)?
An anticoagulant An anticoagulant suppresses coagulation by inhibiting clotting factors. A client admitted for elective surgery should have been instructed to discontinue the anticoagulant 7 to 10 days preoperatively. Even if this were unscheduled surgery, the nurse should notify the HCP. Vitamin K can be given for reversal of its action, but the client may still have an increased risk of bleeding. The other medications listed are commonly taken and do not constitute an increased risk for the client.
The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?
Assess the patency of the airway. The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.
The nurse has a prescription to remove the nasogastric (NG) tube from a client on the first postoperative day after cardiac surgery. The nurse should question the prescription if which finding was noted on assessment of the client?
Bowel sounds are absent. The NG tube should remain in place until the client has bowel sounds. If bowel sounds do not return, the client could have a paralytic ileus, which could result in distention and vomiting if the NG tube is discontinued. It is likely that the client may be drowsy after experiencing a stressor such as cardiac surgery. The abdomen is likely to be slightly distended after surgery, and it is normal for NG tube drainage to be Hematest negative.
A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action?
Continue to monitor the drainage Following gastrectomy, drainage from the nasogastric tube is normally bloody for 24 hours postoperatively, changes to brown-tinged, and is then yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. The nurse does not need to notify the HCP at this time. Measuring abdominal girth is performed to detect the development of distention. Following gastrectomy, a nasogastric tube should not be irrigated unless there are specific HCP prescriptions to do so.
The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?
Have the client void immediately before going into surgery. The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.
A client who has undergone radical neck dissection is experiencing problems with verbal communication related to postoperative hoarseness. The nurse should formulate which outcome as the most appropriate goal for this client problem?
Incorporates nonverbal forms of communication as needed The client may experience temporary hoarseness after neck dissection. Goals for the client include using nonverbal forms of communication as needed, expressing willingness to ring the call bell for assistance, and using the services of a speech pathologist if prescribed. Options 1, 2, and 3 are incorrect.
The nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which sign that could indicate an evolving complication?
Increasing restlessness Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all four quadrants are a normal occurrence.
An 85-year-old client is hospitalized for a fractured right hip. During the postoperative period, the client's appetite is poor and the client refuses to get out of bed. Which nursing statement would be most appropriate to make to the client?
It is important for you to get out of bed so that calcium will go back into the bone." Early ambulation in the postoperative period is important because if a client does not increase activity, the bones will suffer from loss of calcium. Iron, not iodine, is recommended for hemoglobin synthesis because oxygen is necessary for wound healing. Increasing calcium intake would cause elevated amounts of calcium in the blood, which could lead to kidney stones. Clients who are not turned in bed will develop pressure ulcers. An 85-year-old who is immobile needs to be turned every 2 hours by the nursing staff; clients should not be expected to turn themselves.
The nurse has instructed a preoperative client using an incentive spirometer to sustain the inhaled breath for 3 seconds. When the client asks about the rationale for this action, the nurse explains that this action achieves which function?
Maintains inflation of the alveoli Sustained inhalation helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices, such as an incentive spirometer, can help prevent atelectasis and pneumonia in clients at risk for these conditions. Options 1, 2, and 4 are incorrect.
The nurse plans care for an older client admitted with a fractured hip. Which analgesic, prescribed by the health care provider at standard doses and frequencies, would the nurse question?
Meperidine hydrochloride (Demerol) by intramuscular route Ibuprofen, morphine sulfate, tramadol, and meperidine are all analgesics. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) and is acceptable for use in the older client. Tramadol hydrochloride is a centrally acting nonopioid analgesic used for moderate to moderately severe pain and is a suitable option in this situation. Morphine sulfate and meperidine hydrochloride are both opioid analgesics, and both are effective in treating acute pain. Because meperidine hydrochloride produces a neurotoxic metabolite, it should be used only short term and is not recommended for use in older clients.
A nurse is caring for a client who is receiving morphine sulfate by the intravenous route for acute pain. The nurse ensures that which medication is available in the event that the client's respiratory status and level of consciousness deteriorate?
Naloxone (Narcan) Naloxone is an opioid antagonist that is used to treat opioid overdose. Atropine sulfate is an anticholinergic. Promethazine is an antiemetic medication, and protamine sulfate is the antidote for heparin.
The nurse is assessing the status of pain in a cognitively impaired older adult. The nurse understands which information about pain in the older adult?
Pain in the cognitively impaired older adult may require more frequent assessments than in clients who are not impaired. Cognitive impairment in the older adult acts as a barrier to pain assessment, and pain may be more accurately reported at the moment when it occurs than when prompted by the nurse. The prevalence of pain among older clients is greater than among clients younger than 60 years. Clients in this age group are not less sensitive to pain and do not necessarily have a greater pain tolerance. Visual representations of pain are more effective than mental images for evaluating the degree of pain.
A client has returned to the nursing unit after an abdominal hysterectomy. The client is lying supine. To thoroughly assess the client for postoperative bleeding what is the primary nursing action
Roll the client to one side and check her perineal pad. The nurse should roll the client to one side after checking the perineal pad and the abdominal dressing. This client position allows the nurse to check the rectal area, where blood may pool by gravity if the client is lying supine. Asking the client about a sensation of moistness is not a complete assessment. Vital signs will change with hemorrhage however; they are a compensatory mechanism of change. Assess for external or most likely signs of bleeding first.
A nurse is providing preoperative teaching to a client scheduled for a cholecystectomy. Which intervention would be of highest priority in the preoperative teaching plan?
Teaching coughing and deep breathing exercises After cholecystectomy, respirations tend to be shallow because deep breathing is painful as a result of the location for the surgical procedure. Although all the options are correct, teaching coughing and deep breathing exercises is the highest priority.
The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment?
The client's pain rating The client's self-report is a critical component of pain assessment. The nurse should ask the client to describe the pain and listen carefully to the words the client uses to describe the pain. Nonverbal cues from the client are important but are not the most appropriate pain assessment measure. The nurse's impression of the client's pain is not appropriate in determining the client's level of pain. Assessing pain relief is an important measure, but this option is not related to the subject of the question.
The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?
The passage of flatus Following abdominal perineal resection, the nurse would expect the colostomy to begin to function within 72 hours after surgery, although it may take up to 5 days. The nurse should assess for a return of peristalsis, listen for bowel sounds, and check for the passage of flatus. Absent bowel sounds would not indicate the return of peristalsis. The client would remain NPO until bowel sounds return and the colostomy is functioning. Bloody drainage is not expected from a colostomy.
A postoperative client with a large abdominal wound requiring frequent dressing changes is starting to develop skin irritation in the area where the dressing tape is applied to the skin. The nurse determines that the client would benefit most from which measure?
The use of Montgomery straps The use of Montgomery straps is recommended to prevent skin breakdown with frequent dressing changes. They limit the friction and shear that could irritate skin with frequent removal and reapplication of tape. Hypoallergenic tape is used on clients with thin, fragile skin; clients whose skin is sensitive to standard tape; and clients who require less frequent dressing changes. Cleansing with povidone-iodine and obtaining a wound culture are not indicated.
The nurse is caring for a 25-year-old client who will undergo bilateral orchidectomy for testicular cancer. Which statement by the nurse would be helpful in exploring the client's concerns about loss of reproductive ability?
"Can you share with me any concerns about how this surgery will affect you in the future?" One of the most helpful approaches in exploring client concerns is to use open-ended questions. These tend to elicit more descriptive responses on the part of the client. Option 1 imposes the nurse's opinion on the client and does not value the client's perspective. Options 2 and 4 are closed-ended questions that may be answered with a "yes" or "no" response.
A preoperative client has received a dose of scopolamine as prescribed by the anesthesiologist. The nurse should assess the client for which anticipated side effect of this medication?
Dry oral mucous membranes Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. The other options are incorrect.
A nurse is preparing the client for transfer to the operating room. The nurse should take which action first?
Ensure that the client has voided. The nurse's first action is to ensure that the client has voided, if a Foley catheter is not in place. The nurse does not administer all daily medications just prior to sending a client to the operating room. Rather, the health care provider (HCP) writes a specific prescription outlining which medications may be given with a sip of water. The client has nothing by mouth for 8 hours before surgery, not 24. The time of transfer to the operating room is not the time to teach and practice breathing exercises. This should have been accomplished earlier.
A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed?
Hemoglobin, 8.0 g/dL Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.
Parenteral meperidine hydrochloride (Demerol) is prescribed postoperatively for an older adult who has just had a right hip repair. The nurse questions the prescription before administering the medication because of which factor?
It may accumulate with repeated dosing, leading to seizures. Older adults should not take meperidine hydrochloride because of the prolonged half-life of its metabolite, normeperidine. Normeperidine, an excitotoxin, accumulates with repeated dosing, which can lead to life-threatening seizures. Because of the physical changes of aging, older clients excrete this medication slowly, leading to a risk for cerebral irritation and seizures.
The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?
The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.
The nurse is setting up a transcutaneous electrical nerve stimulation (TENS) unit on a client with chronic pain. As the nurse turns up the level of stimulation, the client complains of discomfort. Based on this finding, the nurse should make which interpretation?
The maximal stimulation has been reached, and it should be decreased slightly. Use of a TENS unit involves applying two electrodes to the skin from the machine and adjusting the level of stimulation to one lead at a time. The amount of stimulation is increased until the client feels discomfort, which indicates that the maximal stimulation necessary to block pain stimuli has been reached. The volume is then reduced by a small amount until no further muscle discomfort or contractions occur. The other options are incorrect.
A nurse has provided discharge instructions to a client after radical vulvectomy. Which statement by the client indicates a need for further instruction
"It is all right to ride in a car as much as I want, as long as I am not driving the car." The client should avoid activities such as sitting for long periods of time and doing heavy housework until approved by the HCP because of pressure and trauma at the surgical site. The client should be instructed to avoid sexual activity for 4 to 6 weeks or as indicated by the HCP. The client should keep the perineal area as clean and dry as possible and should wash the perineum with solutions such as peroxide and water or as prescribed after each urination or defecation to prevent infection. The client should be instructed to report any redness, swelling, drainage, odor, or increased soreness along the suture line because these are signs of infection.
The home care nurse visits a client to perform a dressing change on a leg ulcer. The client has diabetes mellitus and a history of cardiac disease and is taking one aspirin daily in addition to other medications as prescribed. The client tells the nurse that dental surgery is scheduled and asks the nurse whether the aspirin should be discontinued. The nurse should most appropriately make which statement to the client?
"Dental surgery can safely be done usually 10 days after stopping the aspirin, depending on the health care provider's (HCP) preference." Aspirin is an antiplatelet agent that affects the platelet for its life, which is 7 to 10 days. For an elective procedure such as dental surgery, aspirin therapy should be stopped approximately 10 days before the procedure (or as prescribed by the HCP) to prevent bleeding complications. Option 1 is not an appropriate response and places the client's issue on hold. Options 2 and 3 are incorrect.
The nurse is caring for a client who is postoperative following a pelvic exenteration and the health care provider changes the client's diet from NPO status to clear liquids. The nurse should check which priority item before administering the diet?
Bowel sounds The client is kept NPO until peristalsis returns, usually in 4 to 6 days. When signs of bowel function return, clear fluids are given to the client. If no distention occurs, the diet is advanced as tolerated. The most important assessment is to assess bowel sounds before feeding the client. Options 2, 3, and 4 are unrelated to the data in the question.
A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?
Can you share with me what you've been told about your surgery? Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Option 1 does not focus on the client's anxiety. Explaining the entire surgical procedure may increase the client's anxiety. Option 4 avoids the client's anxiety and is focused on postoperative care.
A client who had abdominal surgery is receiving epidural analgesia. The nurse monitors the client closely, knowing that which is a potential complication of this therapy?
Dislodgement of the epidural catheter because the catheter is not sutured in place Epidural analgesia (also known as peridural or extradural analgesia) refers to the instillation of a pain-blocking agent into the epidural space. Complications that occur with epidural analgesia are directly related to catheter placement, catheter maintenance, and the type of analgesia. Epidural catheters are not sutured in position and must be taped in place to help prevent dislodgement. Low concentrations of medications are used to avoid any sensory and motor deficits that can accompany epidural analgesia. Constipation and chronic addiction are not specific complications of epidural analgesia.
A client scheduled for surgery receives a dose of scopolamine. The nurse expects to note which side effects of the medication? Select all that apply.
Dry mouth Pupillary dilation Scopolamine is an anticholinergic medication that causes frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. The other options are incorrect and are not side effects of this medication.
The nurse is reviewing a health care provider's (HCP's) prescription sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the HCP to clarify that which medication should be given to the client and not withheld?
Prednisone Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant. Conjugated estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women. These last three medications may be withheld before surgery without undue effects on the client.
A client is recovering well 24 hours after cranial surgery but is fatigued. The neurosurgeon advances the client from NPO status to clear liquids. The nurse knows that which information is least reliable in determining the client's readiness to take in fluids?
Appetite To begin to tolerate oral intake after cranial or any other type of surgery, the client must have bowel sounds. The client also must have intact swallow and gag reflexes and should be free of nausea and vomiting. The client is likely to be easily fatigued, which may decrease appetite. Thus, appetite is the least reliable indicator regarding when intake should be started.
The nurse is developing a plan of care for a preoperative client who has a latex allergy. Which intervention should be included in the plan?
Apply a cloth barrier to the client's arm under a blood pressure cuff when taking the blood pressure. If a client has a latex allergy, a cloth barrier should be applied to his or her arm under a blood pressure cuff to prevent skin contact with the cuff. Medications from glass ampules are safe to use, and medications from ampules with rubber stoppers are unsafe to use. Latex-safe intravenous tubing made of polyvinyl chloride should be used for a client with a latex allergy. Additionally, agency procedures should be followed for a client with a latex allergy; usually, a latex allergy cart containing latex-free supplies is kept in the client's room.
A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply.
Contact the surgeon. Instruct the client to remain quiet. Prepare the client for wound closure. Document the findings and actions taken Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low Fowler's position, and the client is kept quiet, and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.
To prevent postoperative atelectasis in a client recovering from an open cholecystectomy, what should the nurse do first?
Ensure that the client is experiencing adequate pain control. Coughing is one of the protective reflexes. Its purpose is to move mucus that is in the airways upward toward the mouth and nose. Coughing is needed in the postoperative client to mobilize secretions and expel them from the airways and prevent atelectasis. The client with an abdominal incision is hesitant to cough unless pain control is adequate. The incision in an open cholecystectomy is just under the diaphragm in the right upper quadrant of the abdomen, making coughing and deep breathing painful. The nurse should first assure that pain control is adequate so that pulmonary hygiene measures are maximally effective. A cardiopulmonary consult is requested for clients with preexisting risk caused by lung pathology or for clients already experiencing postoperative respiratory complications. Splinting the incision is an effective postoperative strategy for assisting with effective coughing and deep breathing, but it should follow pain control. Huff coughing, although it can be used in the postoperative client, is an effective coughing strategy that is most often recommended for clients with chronic obstructive airway disorders.
A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?
Obtain a telephone consent from a family member, following agency policy. Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but in this case it is not an emergency. Options 1 and 3 are not appropriate in this situation. Also, agency policies regarding informed consent should always be followed.
The nurse is providing discharge instructions to the client who has had a pneumonectomy and prepares a list of postoperative instructions for the client. Which intervention should the nurse include in the list?
Report any signs of respiratory infection to the health care provider (HCP). After a pneumonectomy, if any signs of respiratory infection occur, the HCP should be notified. The client is instructed to perform breathing exercises for the first 3 weeks at home and to space activities to allow for frequent rest periods. The client also should be instructed to avoid heavy lifting of any objects more than 20 pounds until the muscles of the chest wall have healed completely, which takes about 3 to 6 months. The client should be told to expect feelings of weakness and fatigue for the first 3 weeks after surgery.
The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?
Urinary output of 20 mL/hour Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less than 30 mL for each of 2 consecutive hours should be reported to the health care provider. A temperature higher than 37.7° C (100° F) or lower than 36.1° C (97° F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.
A nurse is reviewing the health care provider's prescription sheet for a preoperative client, which states that the client must be NPO after midnight. Which medication should the nurse clarify to be given and not withheld?
Atenolol (Tenormin) Atenolol is a beta blocker. Beta blockers should not be stopped abruptly, and the health care provider (HCP) should be contacted about the administration of this medication before surgery. If a beta blocker is stopped abruptly, the myocardial need for oxygen is increased. Atorvastatin (Lipitor) is a cholesterol lowering medication used to treat high cholesterol. Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant. Conjugated estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women. The other three medications may be withheld before surgery without undue effects on the client.
A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions should the nurse take in the care of the drain? Select all that apply.
Check the drain for patency. Observe for bright red bloody drainage. Maintain aseptic technique when emptying the drain. The nurse should check the tube or drain for patency to provide an exit for the fluid or blood to promote healing. The nurse should monitor the drainage characteristics. Usually the drainage from the wound is pale, red, and watery. Active bleeding will be bright red. The nurse must use aseptic technique for emptying the drainage container or changing the dressing to avoid contamination of the wound. A postoperative drain should not be curled tightly or obstructed in any way, such as with clamping. This could prevent the drain from functioning properly.
A nurse is making initial rounds on the nursing unit to check the condition of assigned clients. The client complains of discomfort at the intravenous (IV) and the nurse notes that the site is cool, pale, and swollen, and the solution is not infusing. What IV therapy complication has the client most likely experienced?
Infiltration An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The discomfort, pallor, coolness, and swelling are the result of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to clamp the IV tubing, remove the catheter, and prepare to start a new IV line. The other three options are likely to be accompanied by warmth at the site, not coolness.
The nurse in a surgical unit receives a postoperative client from the postanesthesia care unit. After the initial assessment of the client, the nurse should plan to continue with postoperative assessment activities how often?
Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed When the postoperative client arrives from the postanesthesia care unit, the nurse performs an initial assessment. Common time frames for continuing postoperative assessment activities are every 15 minutes the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed. However, agency policies should always be followed. Options 1 and 2 identify time frames that are too infrequent and that will not provide adequate assessment of the postoperative client. Option 4 identifies close time frames that are unnecessary.
A client arrives at the surgical unit after nasal surgery. The client has nasal packing in place. The nurse reviews the health care provider's prescriptions and understands that it is essential that the client be placed in which position to reduce swelling?
Semi-Fowler's position To reduce swelling the client would be placed in the semi-Fowler's position. This position should be maintained for at least 24 to 48 hours to minimize postoperative edema. The Sims, prone, and supine positions would not decrease swelling
A client is being started on tramadol (Ultram) therapy for pain management after a back injury. When educating this client on tramadol therapy, what is the priority?
The client cannot drink alcohol while taking tramadol. The client taking tramadol should not consume alcoholic beverages while taking this medication because it further depresses the central nervous system (CNS). Cigarette smoking does not adversely affect tramadol; however, the client should be discouraged from smoking and encouraged to join a smoking-cessation program for general healthy reasons. The client may need increased calcium, but this is not because of tramadol. The client can take cough syrup with this medication.
The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?
Serous drainage Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.
