NUR 145 The Point Chapter 19 Postoperative Care

The term used to describe a partial or complete separation of wound edges is: A. erythema B. Evisceration C. Hemorrhage D. Dehiscence

D. Dehiscence

Which is a classic sign of hypovolemic shock? A. Bradycardia B. Dilute urine C. High blood pressure D. Pallor

D. Pallor - pallor, rapid, weak thready pulse, low BP, and rapid breathing

Which is the least important factor affecting wound healing? A. Age of patient B. Nutritional deficiencies C. Hemorrhage D. Sufficient oxygenation

D. Sufficient oxygenation

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? A. First intention B. Third intention C. Second intention D. Fourth intention

A. First intention

The immediate postoperative period, vital signs are taken at least every A. 60 minutes B. 45 minutes C. 15 minutes D. 30 minutes

C. 15 minutes

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 bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply. A. Assess for hypoxia B. Assess urine output C. Ambulate the client D. Apply wrist restraints E. Administer opioid pain medications per orders F. Reorient the client

A. Assess for hypoxia B. Assess urine output F. Reorient the client Do not give pain medications as it may confuse the client more.

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? A. Assessing the WBC count, temp, and wound appearance B. Obtaining dietary consultation for improved wound healing C. Educating the client on safe bed-to-chair transfer procedures D. Administering pain medications within 1 hour of the client's request

A. Assessing the WBC count, temp, and wound appearance - the client is at increased risk for infection to the surgical wound, which is classified as dirty. Assessing the WBC count, temp, and wound appearance allows the nurse to intervene at the earliest sign of infection.

A 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? A. Give the written instructions to the client's 16-year old child B. Continuously repeat the instructions until the client restates them. C. Review the instructions with the client and an accompanying adult D. Ask the client Do you Understand?

C. Review the instructions with the client and an accompanying adult. The effects of anesthesia may impair the client's memory or concentration. It is important that the discharge instructions are covered with the client and an accompanying adult.

When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation, although the patient's breathing appears normal, the nurse identifies that the patient may be suffering from which type of hypoxemia? A. Anemic B. Episodic C. Subacute D. Hypoxic

C. Subacute - supplemental oxygen may be indicated for subacute hypoxemia.

A recent extubated postoperative client starts to gag and making vomiting sounds. What action should the nurse perform first? A. administer an antiemetic B. Obtain suction equipment C. Turn the client onto their side D. Provide an emesis basin

C. Turn the client onto their side

The nurse recognizes which symptoms as a clinical manifestation of shock? A. Increased urine output B. Flushed face C. rapid, weak, thready pulse D. warm, dry skin

C. rapid, weak, thready pulse

A postanesthesia care unit (PACU) nurse is caring for a client with the following assessment data: Pale, cool, moist skin; thready pulse of 122, blood pressure of 78/60, urine output of 25 ml/h temp of 99.2. What intervention by the nurse is appropriate? Select all that apply. A. Frequently monitor neurological status B. Raise the head of the bed 30 degrees C. Maintain a patent airway D. Administer blood products per orders E. Apply a warm blanket F. Apply oxygen per orders.

A. Frequently monitor neurological status C. Maintain a patent airway D. Administer blood products per orders F. Apply oxygen per orders. Client is demonstrating signs and symptoms of shock. A client in shock may lose the ability to protect the airway. Frequent neurological checks can provide info related to a decrease in oxygen to the brain. There is an increased need for oxygen when in shock, so it is appropriate to apply oxygen.

A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse? A. It assists in preventing infection B. It will cut down on the number of dressing changes needed C. The drain will remove necrotic tissue D. Most surgeons use wound drains now

A. It assists in preventing infection

A client has undergone surgery to repair a hernia, with no complications. In the immediate postoperative period, which action by the nurse is most appropriate? A. Monitor vital signs every 15 minutes B. Assess pupillary response every 5 minutes C. Measure urinary output every 15 minutes D. Measure arterial blood gas every 5 minutes

A. Monitor vital signs every 15 minutes

The nurse is caring for a postoperative client with an indwelling urinary catheter. The hourly urinary output is 80 mL at 9AM. At 10AM, the nurse assess the hourly urinary output as 20 mL. What is the priority action by the nurse? A. Notify the physician B. Irrigate the catheter with sterile normal saline C. Document the findings D. Reassess the output at 11AM

A. Notify the physician

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? A. Reinforce the importance of early mobility in preventing complications. B. Document the client's refusal C. Delegate the task to a UAP D. Use multiple staff members to remove the client from the bed.

A. Reinforce the importance of early mobility in preventing complications.

Which action should a nurse perform to prevent DVT when caring for a postsurgical patient? A. Reinforce the need to perform leg exercises every hour when awake B. Administer prophylactic high-dose heparin C. Instruct the client to prop a pillow under the knees D. Maintain bed rest

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

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? A. Reinforcing dressings or applying pressure if bleeding is frank B. Encouraging the client to breath deeply C. Rubbing the back D. Elevating the head of the bed

A. Reinforcing dressings or applying pressure if bleeding is frank

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? A. Second-intention healing B. First- intention healing C. Third - intention healing D. Primary intention healing

A. Second-intention healing - when wounds dehisce, they are allowed to heal by secondary intention.

The primary objective in the immediate postoperative period is A. maintain pulmonary ventilation B. Relieving pain C. Monitoring for hypotension D. Controlling nausea and vomiting

A. maintain pulmonary ventilation

A postoperative client begins coughing forcefully while eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first? A. Document the event B. Cover the intestines with sterile, moist dressings. C. Place the client in the low Fowler's position D. Notify the surgeon

C. Place the client in the low Fowler's position To prevent further protrusion on the intestines

A postoperative client is being discharged home after minor surgery. The PACU nurse is reviewing discharge instructions with the client and the clients spouse. What actions by the nurse are appropriate? Select all that apply. A. Have the spouse review when to notify the physician B. Have the client sign his or her advance directive form C. Discuss wound care D. Provide information on health promotion topics E. Educate on activity limitations

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

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 first? A. Notify the physician B. Assess the client's heart rhythm and nail beds C. Document the findings D. Apply oxygen

B. Assess the client's heart rhythm and nail beds - A client may demonstrate low oxygenation readings because of certain colors of nail polish or may show an irregular heart rate such as A-fib. These factors should be assessed to ensure the accuracy of the oxygen findings. Once the reading is confirmed as accurate, then the nurse may need to apply oxygen, notify the provider, and document the findings.

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding? A. Hernia B. Evisceration C. Erythema D. Dehiscence

B. Evisceration

What is the highest priority nursing intervention for a client in the immediate postoperative phase? A Assessing urinary output every hour B. Maintaining a patent airway C. Assessing for hemorrhage D. Monitoring vital signs at least every 15 minutes

Maintaining a patent airway

Which term refers to the protrusion of abdominal organs through the surgical incision? A. Hernia B. Evisceration C. Dehiscence D. Erythema

B. Evisceration

Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis? A. Fluid restriction B. Hourly leg exercises C. Prolonged dangling of the legs over the edge of the bed D. Use the blanket rolls to elevate the lower extremities

B. Hourly leg exercises

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? A. Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive B. Packing the wound bed with sterile saline-soaking dressing and covering it with a dry dressing C. Cleaning the wound with soap and water, then leaving it open to the air D. Covering the well- approximated wound edges with a dry dressing

B. Packing the wound bed with sterile saline-soaking dressing and covering it with a dry dressing

Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client? A. Maintain bed rest B. Reinforce the need to perform leg exercises every hour when awake C. Instruct the client to cross the legs or prop a pillow under the knees D. Massage the calves or thighs

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

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 200mL every 8 hours of light yellow fluid, and a wound drain with 50mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430mL. What action by the nurse is most appropriate? A. Assess for edema B. Discontinue the nasogastric tube suctioning C. Assess for signs and symptoms of fluid volume deficit D. Document the findings and reassess in 24 hours

C. Assess for signs and symptoms of fluid volume deficit The client's 24- hour intake is 1800 mL (75x24). The client's 24 hour output is 3180 mL [ (200x3) + (50x3) + 2430]. Because the output is significantly higher than the intake, the client is at risk for fluid volume deficit.

It is important for the nurse to assist a post-surgical client to sit up and turn the head to one side when vomiting in order to? A. Avoid dizziness B.Maximize comfort C. Avoid aspiration D. Help eliminate inhaled anes

C. Avoid aspiration

A PACU nurse is caring for a postoperative patient who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate? A. Notify the physician of impaired neurological status. B. Obtain vital signs, including pulse oximetry, every 5 minutes C. Continue with frequent client assessments D. Remove the oral airway

C. Continue with frequent client assessments - Should not be removed until the client is showing signs of chocking or gagging.

A client is at postoperative hour 8 after an appy and is anxious, stating, "Something is not right. My pain is worse than ever and my stomach is swollen". Blood pressure is 88/50, pulse is 115, and respirations are 24 and labored. The abdomen is soft and distended. No obvious bleeding is noted. What action by the nurse is most appropriate? A. Inform the client this is the normal progression after abdominal surgery B Administer morphine per orders C. Notify the physician D. Ambulate the client to reduce abdominal distention

C. Notify the physician

A postoperative patient with an open abdominal wound is currently taking corticosteroids. The physician orders a culture of the abdominal wound even though no signs or symptoms of infection are seen. What action by the nurse is appropriate? A. Request the order be discontinued without obtaining the specimen B. Hold the order until purulent drainage is noted C. Obtain the wound culture specimen D. Use an antibiotic cleaning agent before obtaining the specimen.

C. Obtain the wound culture specimen

Adequate hourly output for a client with an indwelling urinary catheter is A. 1.5 mL/kg/h B. 0.5 mL/kg/h C. 1.0mL/kg/h D. 2.0mL/kg/h

D. 2.0mL/kg/h - < 0.5 ml/kg/h should be reported

The nurse is caring for a client in the post anesthesia care unit. The client has the following vital signs: HR 115, Resp 20, Temp 92.7, BP 84/50. What should the nurse do first? A. Increase rate of IV fluids B. Review the client's preoperative vital signs C. Notify the physician D. Assess for bleeding.

D. Assess for bleeding. The client is tachycardia with low blood pressure, thus assessing for hemorrhage is the priority action.

When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as: A. Contaminated B. Dirty C. Clean D. Clean contaminated

D. Clean contaminated - those with a potential, limited source for infection, the exposure to which can largely be controlled.

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound". The nurse assess 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: A. Eviscerated B. Hemorrhaged C. Pustulated D. Dehisced

D. Dehisced

The nurse recognizes that a traumatic wound with fecal contamination would be classified as A. Contamination B. Clean contamination C. Clean D. Dirty

D. Dirty - includes a traumatic wound with delayed repair, devitalized tissue, foreign bodies, and fecal contaimination.

Corticosteroids have which effect on wound healing? A. May cause protein-calorie depletion B. Reduce blood supply C. Cause hemorrhage D. Mask the presence of infection

D. Mask the presence of infection - impair normal inflammatory response

The nurse has medicated a postoperative patient who reported nausea. Which medication would the nurse document as having been given? A. Warfarin B. Prednisone C. Propofol D. Ondansetron

D. Ondansetron Most commonly prescribed for N/V

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? A. Encouraging the client to breath deeply B. Elevating the head of the bed C. Monitoring vital signs every 15 minutes D. Reinforcing the dressing or applying pressure if bleeding is frank

D. Reinforcing the dressing or applying pressure if bleeding is frank