POSTOP (CH. 16) PREPU

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

A systolic blood pressure lower than 90 mm Hg RATIONALE: A systolic blood pressure lower than 90 mm Hg

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:

Ambulating the client as soon as possible

A client is transferred from the postanesthesia care unit (PACU) to an inpatient care unit. What will the nurse assess first?

Breathing

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.

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

First intention

The nurse is planning care for a client in the postoperative period. Place the following nursing diagnoses in sequence, from highest to lowest priority.

Impaired Gas Exchange Fluid Volume Deficit Altered Comfort Anxiety Risk for Infection RATIONALE: According to the Maslow's hierarchy of deeds, airway and gas exchange is of the highest priority. Next would be the deficiency in fluid volume. Altered comfort would be higher than anxiety because decreasing pain may alleviate/reduce anxiety. Lastly, a risk for infection is not a current problem but an important teaching point to reduce the risk.

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 RATIONALE: Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.

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

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.

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 dressings or applying pressure if bleeding is frank

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 most likely cause of the client's change in condition?

The client is displaying early signs of shock.

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 client in the postanesthesia care unit (PACU) develops noisy and irregular respirations. Which action will the nurse take?

Tilt the head back and lift the lower jaw.

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

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

Valsalva maneuver

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

Wound dehiscence RATIONALE: Risk factors for wound dehiscence include advanced age over 65 years, chronic disease such as diabetes, hypertension, obesity, history of radiation or chemotherapy, malnutrition, particularly insufficient protein and vitamin C, and hypoalbuminemia. This client is not at increased risk for hypotension, contractures, or phlebitis.

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 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. RATIONALE: Because pain can contribute to postoperative delirium, adequate pain control without oversedation is essential. Nursing assessment of mental status and of all physiologic factors influencing mental status helps the nurse plan for care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult client.

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 RATIONALE: Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation.

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 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. RATIONALE: The client's 24-hour intake is 1800 mL (75 x 24). The client's 24-hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Because the output is significantly higher than the intake, the client is at risk for fluid volume deficit. The nurse should not discontinue the nasogastric suctioning without a physician's order. The findings should be documented and reassessed, but the nurse needs to take more action to prevent complication. Edema is usually associated with fluid volume excess.

Which is a classic sign of hypovolemic shock?

Pallor RATIONALE: The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing.

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 RATIONALE: In second-intention healing, necrotic material gradually disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue.

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

"I'll eat plenty of fruits and vegetables." RATIONALE: Optimal nutritional status is important for wound healing; the client should eat plenty of fruits and vegetables and not reduce protein intake. To avoid impeding circulation to the area, the bandage should be secure but not tight. If the client's foot feels cold, circulation is impaired, which inhibits wound healing.

The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply.)

- Assisting the patient with leg exercises - Encouraging early ambulation - Avoiding placement of pillows or blanket rolls under the patient's knees RATIONALE: The benefits of early ambulation and leg exercises in preventing deep vein thrombosis cannot be overemphasized, and these activities are recommended for all patients, regardless of their risk. It is important to avoid the use of blanket rolls, pillow rolls, or any form of elevation that can constrict vessels under the knees. Compression stockings should be worn all the time, not just at night. Massage would be contraindicated due to the risk of dislodging a clot.

The nurse is caring for a postoperative client with an indwelling urinary catheter. The hourly urinary output is 80 mL at 9 am. At 10 am, the nurse assesses the hourly urinary output as 20 mL. What is the priority action by the nurse?

Notify the primary care provider immediately. RATIONALE: If the client has an indwelling urinary catheter, hourly outputs are monitored and rates <30 mL/h are reported. Any urinary output <30 mL/h should be reported to the primary care provider immediately. Though urinary output will be reassessed at 11 am, but waiting to notify the primary care provider puts the patient at risk. The findings should be documented, but this is not the highest priority. A urinary catheter may need to be irrigated, but a postoperative client with a low urinary output is demonstrating a complication of inadequate fluid imbalance that needs to be reported immediately.

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. RATIONALE: The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.

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.