Chapter 19

Which patient would be at highest risk for hypothermia after surgery? A 42-yr-old patient who had a laparoscopic appendectomy A 38-yr-old patient who had a lumpectomy for breast cancer A 20-yr-old patient with an open reduction of a fractured radius. A 75-yr-old patient with repair of a femoral neck fracture after a fall.

A 75-yr-old patient with repair of a femoral neck fracture after a fall. Patients at highest risk for hypothermia are those who are older, debilitated, or intoxicated. Also, long surgical procedures and prolonged anesthetic administration increase the patient's risk for hypothermia.

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, the nurse recognizes which action will best enable the patient to achieve the desired outcomes? * Administering adequate analgesics to promote relief or control of pain * Asking the patient to demonstrate the postoperative exercises every 1 hour * Giving the patient positive feedback when the activities are performed correctly * Warning the patient about possible complications if the activities are not performed

Administering adequate analgesics to promote relief or control of pain Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. What is the priority action by the nurse? Recheck in 1 hour for increased drainage. Notify the surgeon of a potential hemorrhage. Assess the patient's blood pressure and heart rate. Remove the dressing and assess the surgical incision.

Assess the patient's blood pressure and heart rate. The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

In caring for the postoperative patient on the clinical unit after transfer from the postanesthesia care unit (PACU), which care can the nurse delegate to the unlicensed assistive personnel (UAP)? Monitor the patient's pain. Obtain the admission vital signs. Assist the patient to take deep breaths and cough. Change the dressing when there is excess drainage.

Assist the patient to take deep breaths and cough. The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the postanesthesia care unit (PACU). The RN will monitor and treat the patient's pain and change the dressings.

The nurse determines a postoperative patient has a bronchial obstruction from retained secretions and an oxygen saturation of 87%. What condition does the nurse suspect is occurring? Atelectasis Bronchospasm Hypoventilation Pulmonary embolism

Atelectasis The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.

An older adult patient who had surgery has signs of delirium. What priority action would benefit this patient? Review the chart for intraoperative complications. Check which medications were used for anesthesia. Assess the effectiveness of the analgesics received. Check the preoperative assessment for previous delirium or dementia.

Check the preoperative assessment for previous delirium or dementia. If the patient's ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications and pain will be assessed as these can all contribute to delirium.

A patient having abdominal surgery had an estimated blood loss of 400 mL and received 300 mL of 0.9% normal saline. Postoperatively, the patient's blood pressure is 70/48 mm Hg. What priority treatment does the nurse anticipate administering? Blood administration IV fluid administration An ECG to check circulatory status Return to surgery to check for internal bleeding

IV fluid administration The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, there is a history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient's level of consciousness changes or the abdomen becomes firm and distended.

The nurse is caring for a Native American patient 2 days after a thoracotomy for a tumor resection. What would be the most appropriate action if the patient does not report any pain? Contact the health care provider. Identify possible reasons for denying pain. Administer the prescribed pain medication. Assess the renal and liver function test results.

Identify possible reasons for denying pain. Encourage older adults to report pain, especially those who are reluctant to discuss pain or deny pain when it is likely present, such as after surgery. Older patients may be hesitant to request pain medication, believe pain is an inevitable consequence of surgery, and may not understand how to use patient-controlled machines. Some cultures discourage the expression of pain. The nurse should encourage the use of analgesics, explaining to the patient that untreated pain has a negative effect on recovery. Assessment of pain and administration of medications are within the scope of practice of a nurse. An older patient may have decreased renal and liver function that may lead to drug toxicity. However, this would not be a reason for denial of pain. Administration of pain medication must be based on the patient assessment.

A patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression? Increased respiratory rate Decreased oxygen saturation Increased carbon dioxide pressure Frequent premature ventricular contractions (PVCs)

Increased carbon dioxide pressure Transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a sensitive indicator of respiratory depression. Increased CO2 pressures would indicate respiratory depression. Clinical manifestations of inadequate oxygenation include increased respiratory rate, dysrhythmias (e.g., premature ventricular contractions), and decreased oxygen saturation.

The nurse is positioning a patient after a surgical procedure. What is the best position unless contraindicated, for this patient to be placed in to prevent respiratory complications? Supine Lateral Semi-Fowler's High-Fowler's

Lateral Unless contraindicated by the surgical procedure, an unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated.

A nurse is caring for an unconscious patient who has just been admitted to the postanesthesia care unit (PACU) after an abdominal hysterectomy. How should the nurse position the patient? Left lateral position with head supported on a pillow Prone position with a pillow supporting the abdomen Supine position with head of bed elevated 30 degrees Semi-Fowler's position with the head turned to the right

Left lateral position with head supported on a pillow An unconscious patient should be placed in the lateral "recovery" position to keep the airway open and reduce the risk of aspiration. When conscious, the patient is usually returned to a supine position with the head of the bed elevated to maximize expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.

A patient is having elective facial cosmetic surgery and will be staying in the facility for 24 hours after surgery. What is the nurse's postoperative priority for this patient? Manage patient pain. Control the bleeding. Maintain fluid balance. Manage oxygenation status.

Manage oxygenation status. The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? Assess the patient's pain. Obtain the patient's vital signs. Check the rate of the IV infusion. Review the surgeon's postoperative orders.

Obtain the patient's vital signs. The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence.

Early ambulation is ordered in the postoperative plan of care, but the patient refuses to get up and walk. What teaching should the nurse provide to the patient about the reason for early ambulation? "Early walking keeps your legs limber and strong." "Early ambulation will help you be ready to go home." "Early ambulation will help you get rid of your syncope and pain." "Early walking is the best way to prevent postoperative complications."

"Early walking is the best way to prevent postoperative complications." The best reason is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and venous thromboembolism, speeds wound healing, and increases vital capacity and maintains normal respiratory function. These things help the patient be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management should always occur before walking.

The nurse is providing discharge teaching to a patient who has had a laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the patient, indicates an understanding of the discharge instructions? "I will have someone stay with me for 24 hours in case I feel dizzy." "I should wait for the pain to be severe before taking the medication." "Because I did not have general anesthesia, I will be able to drive home." "It is expected after this surgery to have a temperature up to 102.4° F."

"I will have someone stay with me for 24 hours in case I feel dizzy." The nurse must assess understanding of discharge instructions and the ability of the patient and caregiver to provide for home care needs. A responsible adult caregiver must accompany the patient. The patient may not drive after receiving anesthetics or sedatives. The patient should understand how to manage pain, and pain medication should be taken before the pain becomes severe. The patient should understand symptoms to be reported, such as a fever.

A patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge? (Select all that apply.) Vital signs baseline or stable Minimal nausea and vomiting Wants to wait to void at home Responsible adult taking patient home Comfortable after IV opioid 15 minutes ago

Vital signs baseline or stable Minimal nausea and vomiting Responsible adult taking patient home Ambulatory surgery discharge criteria include meeting phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria include a responsible adult driving patient, no IV opioid drugs for the past 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.