Hinkle Chap. 19 Post Op Nursing Management

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.

In the PACU, after the initial assessment, vital signs are monitored and the patient's general physical status is assessed and documented at least every ___ minutes.

15

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

7

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?

<30 mL

The patient is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The ________ score is usually between 7 and 10 before discharge from the PACU.

Aldrete

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

experiences pain within tolerable limits.

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

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?

Urine retention

The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion?

Crackles Tachypnea Chills

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

When wounds heal by _____________ healing, granulation tissue is not visible and scar formation is minimal

First-intention (primary)

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?

Pink to red and soft, noting that it bleeds easily

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?

Pneumonia

A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention?

Report early calf pain.

______________ healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been approximated

Second-intention (Secondary)

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.

________________ healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two opposing granulation surfaces. This results in a deeper and wider scar.

Third-intention (Tertiary)

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for?

Wound dehiscence