Ch19 PrepU AH1

A nurse is reviewing with a client the use of a patient-controlled anesthesia device and is explaining the benefits. Which of the following would the nurse correctly emphasize? Select all that apply.

Fosters client participation in care Facilitates reduction of postoperative pulmonary complications

When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority?

Impaired Gas Exchange Fluid Volume Deficit Altered Comfort Anxiety Risk for Infection

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? Select all that apply.

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

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. Which of the following actions by the nurse would be inappropriate?

Restrict oral fluids

When vomiting occurs postoperatively, what is the most important nursing intervention?

Turn the patient's head completely to one side to prevent aspiration of vomitus into the lungs.

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation.

The nurse is preparing to discharge a patient from the PACU using a PACU room scoring guide. With what score can the patient be transferred out of the recovery room?

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

Assess for bleedingd

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

Dehisence Hematoma

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 nurse is caring for a postoperative client with an indwelling urinary catheter. The hourly urinary output is 80 mL at 9 am. At 10 am, the nurse assesses the hourly urinary output as 20 mL. What is the priority action by the nurse?

Notify the primary care provider immediately.

The nurse observes bloody drainage on the surgical dressing of the client who has just arrived on the nursing unit. Which intervention should the nurse plan to do next?

Outline the drainage with a pen and record the date/time next to it

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

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 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.

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.

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that most support the nurse's analysis are:

blood pressure of 80/40 mm Hg and pulse of 130 beats/minute.

Select the nutrient that is important for postoperative wound healing because it helps form collagen.

Vitamin C

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 is assessing the client's readiness for discharge from the postanesthesia care unit (PACU). The nurse can rouse the client by calling the client's name. The client can move all extremities and has a blood pressure of 134/82. Baseline preoperative blood pressure was 128/78. The most recent pulse oximetry reading was 94% on room air; the client's respirations are deep and easy at a rate of 12/minute. The nurse calculates the Aldrete score as:

9

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

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 caring for a client 24 hours post surgery who is having persistent hiccups. What action is most appropriate for the nurse to take?

Notify the physician

A 76-year-old client had surgery for an abdominal hernia. The PACU nurse observes that the client is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply.

Reorient the client. Assess for hypoxia. Assess urine output

A nurse is caring for a client with a chest tube connected to a dry suction water seal drainage system. The nurse notes 2cm of water and intermittent bubbling in the water seal chamber. Which action will the nurse take?

Document the findings

The nurse is admitting the older adult to the PACU. Which information about this client would be most important for the PACU nurse to obtain?

Does the client have a history of dementia-like symptoms?

A postoperative client is being discharged home after minor surgery. The PACU nurse is reviewing discharge instructions with the client and the client's spouse. What actions by the nurse are appropriate? Select all that apply.

Educate on activity limitations. Discuss wound care. Have the spouse review when to notify the physician. Provide information on health promotion topics.

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.