Med Surg CH.19 Prep U

A client develops a hemorrhage one hour post surgery. The nurse knows this is most likely an intermediary hemorrhage from a vein because it occurred:

within the first few hours, and has darkly colored blood that flows quickly.

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

A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?

Assessing WBC count, temperature, and wound appearance

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action?

Call the health care provider

What is the highest priority nursing intervention for a client in the immediate postoperative phase?

Maintaining a patent airway

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse?

Position the client in the side-lying position.

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?

Position the client to maintain a patent airway.

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.

1) Position the client in Fowlers position. 2) Don sterile gloves. 3) Lubricate the sterile suction catheter. 4) Insert suction catheter into the lumen of the tube. 5) Apply intermittent suction while withdrawing the catheter.

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

<30 mL

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

Which term refers to the protrusion of abdominal organs through the surgical incision?

Evisceration

The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by:

First intention

The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of:

Hypoxemia and hypercapnia.

The nurse is caring for a client who develops an evisceration. What nursing intervention is most appropriate when an evisceration occurs in the surgical wound of a client who has undergone surgery?

Place sterile dressings moistened with normal saline over the protruding organs and tissues.

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

Pneumonia

The nurse is attempting to ambulate a client who underwent shoulder surgery earlier in the day, but the client is refusing to do so. What action by the nurse is most appropriate?

Reinforce the importance of early mobility in preventing complications.

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing the dressing or applying pressure if bleeding is frank

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing?

Wound infection

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

auscultate bowel sounds.

When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as

clean contaminated.

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound

dehisced.

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 client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply.

Listening to music Watching television Changing position

Corticosteroids have which effect on wound healing?

Mask the presence of infection

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

A nurse asks a client who had abdominal surgery 1 day ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?

Encourage the client to ambulate as soon as possible after surgery.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

First intention

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

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?

Moisten sterile gauze with normal saline and place on the protruding organ.

On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing?

Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing

A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem?

Pink color

What complication is the nurse aware of that is associated with deep venous thrombosis?

Pulmonary embolism

Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client?

Reinforce the need to perform leg exercises every hour when awake.

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.

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 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.

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client?

The client can be discharged from the PACU.

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.

A recently extubated postoperative client starts to gag and make vomiting sounds. What action should the nurse perform first?

Turn the client onto their side.

Which of the following clinical manifestations increase the risk for evisceration in the postoperative client?

Valsalva maneuver

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

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

Wound dehiscence

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.

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?

Assess for signs and symptoms of fluid volume deficit.

What measurement should the nurse report to the physician in the immediate postoperative period?

A systolic blood pressure lower than 90 mm Hg

The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?

The client reports a small bowel movement.

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?

Pink to red and soft, bleeding easily

Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective?

Vital signs within normal limits; absence of chills and cough

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 mostlikely cause of the client's change in condition?

The client is displaying early signs of shock.

You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult?

Tolerance

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

When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O2 saturation monitor despite the client's breathing appearing normal, what action should the nurse take first?

Assess the client's heart rhythm and nail beds.