Chapter 19 Med Surg - Post-op

The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what means?

C) Third intention

A surgical patient has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). The nurse should know that the requirements for safe and effective use of PCA include what?

A) A clear understanding of the need to self-dose

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.

The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurse's first response?

B) Place saline-soaked sterile dressings on the wound.

A postoperative patient rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be the nurse's first action?

B) Quickly attempt to determine the cause of hemorrhage.

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?

B) Notify the physician and continue to monitor the hourly urine output closely.

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

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) Hemorrhage and shock

The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect is the problem with the patient?

A) Postoperative delirium

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) The patient should not drive herself home.

The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply

ABC A) Provide all discharge instructions in writing. B) Provide the nurse's or surgeon's contact information. C) Give prescriptions to the patient.

The PACU nurse is caring for a 45-year-old male patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply.

ADE A) Hypotension D) Dysrhythmias E) Hypertension

The nurse is preparing to change a patient's abdominal dressing. The nurse recognizes the first step is to provide the patient with information regarding the procedure. Which of the following explanations should the nurse provide to the patient?

B) "During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to."

The nursing instructor is discussing the difference between ambulatory surgical centers and hospital-based surgical units. A student asks why some patients have surgery in the hospital and others are sent to ambulatory surgery centers. What is the instructor's best response?

B) "Patients admitted to the hospital for surgery usually have multiple health needs."

The nursing instructor is discussing postoperative care with a group of nursing students. A student nurse asks, "Why does the patient go to the PACU instead of just going straight up to the postsurgical unit?" What is the nursing instructor's best response?

B) "The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications."

The nurse is creating the plan of care for a patient who is status postsurgery for reduction of a femur fracture. What is the most important short-term goal for this patient?

B) Adequate respiratory function

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?

B) Encourage early ambulation.

The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the patient's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the patient's skin is cold, moist, and pale. Of what is the patient showing signs?

B) Hypovolemic shock

The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority?

B) Maintaining a patent airway

A patient underwent an open bowel resection 2 days ago and the nurse's most recent assessment of the patient's abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have caused the dehiscence?

B) The patient has vomited three times in the past 12 hours.

The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patient's skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention?

B) Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw.

The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patient's possible readiness to learn how to change her dressing? Select all that apply

BCE B) The patient expresses interest in the dressing change. C) The patient is willing to look at the incision during a dressing change. E) The patient assists in opening the packages of dressing material for the nurse.

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.

BDE B) Stable blood pressure D) Sufficient oxygen saturation E) Adequate respiratory function

The nurse just received a postoperative patient from the PACU to the medical-surgical unit. The patient is an 84-year-old woman who had surgery for a left hip replacement. Which of the following concerns should the nurse prioritize for this patient in the first few hours on the unit?

C) Close monitoring of neurologic status

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?

C) Day 5

You are caring for a 71-year-old patient who is 4 days postoperative for bilateral inguinal hernias. The patient has a history of congestive heart failure and peptic ulcer disease. The patient is highly reluctant to ambulate and will not drink fluids except for hot tea with her meals. The nurse's aide reports to you that this patient's vital signs are slightly elevated and that she has a nonproductive cough. When you assess the patient, you auscultate crackles at the base of the lungs. What would you suspect is wrong with your patient?

C) Hypostatic pulmonary congestion

The intraoperative nurse is transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year-old woman. The nurse should prioritize which of the following actions?

C) Keeping the patient warm

The nurse is caring for an 82-year-old female patient in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurse's subsequent assessment?

C) Postoperative confusion is common in the older adult patent, but it could also indicate a significant blood loss.

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?

C) Pulmonary embolism

The nurse is caring for a patient on the medical-surgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?

C) Red, warm, tender incision

The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do?

C) Stand upright for 2 to 3 minutes prior to ambulating.

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?

C) The patient is in pain.

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?

C) Trace the outline of the drainage on the dressing for future comparison.

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?

D) "Dehydration is a contributory factor to the formation of deep vein thrombi."

The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer. Which of the following statements by the patient indicates that teaching has been effective?

D) "I'll eat plenty of fruits and vegetables."

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?

D) Airway patency

The nurse is admitting a patient to the medical-surgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia?

D) Encourage the patient to use the incentive spirometer every 2 hours.

The nurse's aide notifies the nurse that a patient has decreased oxygen saturation levels. The nurse assesses the patient and finds that he is tachypnic, has crackles on auscultation, and his sputum is frothy and pink. The nurse should suspect what complication?

D) Flash pulmonary edema

The PACU nurse is caring for a male patient who had a hernia repair. The patient's blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery?

D) Pain, hypoxia, or bladder distention

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?

D) Turn the patient completely to one side.