Preop Prep U

The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists? Dehiscence Evisceration Hemorrhage Normal healing by primary intention.

Dehiscence

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? Acute incisional pain Ineffective thermoregulation Decreased cardiac output Ineffective airway clearance

Ineffective thermoregulation

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 An On-Q pump Watching television An epidural infusion Changing position

Listening to music Watching television Changing position

Which is a classic sign of hypovolemic shock? Dilute urine Pallor High blood pressure Bradypnea

Pallor

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action? Monitor vital signs for early detection of shock. Assess the incisional dressing to detect hemorrhage. Position the client to maintain a patent airway. Administer antiemetics to prevent nausea and vomiting.

Position the client to maintain a patent airway.

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 client is showing signs of a medication reaction. The client is displaying late signs of shock. The client is showing signs of an anesthesia reaction.

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? Respiratory depressive effects Tolerance Convalescent period Detailed medication history

Tolerance

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? Document the findings and reassess in 24 hours. Assess for signs and symptoms of fluid volume deficit. Assess for edema. Discontinue the nasogastric tube suctioning.

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 A temperature reading between 97°F and 98°F Respirations between 20 and 25 breaths/min A hemoglobin of 13.6

A systolic blood pressure lower than 90 mm Hg

What intervention by the nurse is most effective for reducing hospital-acquired infections? Administration of prophylactic antibiotics Aseptic wound care Control of upper respiratory tract infections Proper hand-washing techniques

Proper hand-washing techniques

What complication is the nurse aware of that is associated with deep venous thrombosis? Pulmonary embolism Immobility because of calf pain Marked tenderness over the anteromedial surface of the thigh Swelling of the entire leg owing to edema

Pulmonary embolism

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 client has been lying on his side for 2 hours with the drain positioned upward. The client has a nasogastric (NG) tube in place that drained 400 ml. The Hemovac drain isn't compressed; instead it's fully expanded. There is a moderate amount of dry drainage on the outside of the dressing.

The Hemovac drain isn't compressed; instead it's fully expanded.

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. palpate the abdomen. change the client's position. insert a rectal tube.

auscultate bowel sounds.

The client is experiencing intractable hiccups following surgery. What would the nurse expect the surgeon to order? chlorpromazine metoclopramide omeprazole nizatidine

chlorpromazine

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required? "I should call my physician if I develop a fever." "My incision should become less red and tender." "I can resume my usual activities as soon as I get home." "I need to keep my follow-up appointment with the physician."

"I can resume my usual activities as soon as I get home."

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? <30 mL Between 75 and 100 mL Between 100 and 200 mL >200 mL

<30 mL

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

"It assists in preventing infection."

In the immediate postoperative period, vital signs are taken at least every 15 minutes. 30 minutes. 45 minutes. 60 minutes.

15 minutes.

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? 4 5 6 7

7 (should be between 7-10)

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? Complete blood count Central venous pressure Upper endoscopy Chest x-ray

Central venous pressure

When should the nurse encourage the postoperative patient to get out of bed? Within 6 to 8 hours after surgery Between 10 and 12 hours after surgery As soon as it is indicated On the second postoperative day

As soon as it is indicated

The nurse is caring for a client in the postanesthesia care unit (PACU). The client has the following vital signs: pulse 115, respirations 20, oral temperature 97.2°F, blood pressure 84/50. What should the nurse do first? Notify the physician. Assess for bleeding. Increase rate of IV fluids. Review the client's preoperative vital signs.

Assess for bleeding.

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 Obtaining dietary consultation for improved wound healing Educating the client on safe bed-to-chair transfer procedures Administering pain medications within 1 hour of the client's request

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? Re-attempt to auscultate bowel sounds. Prepare to insert a nasogastric tube. Call the health care provider. Prepare to administer a stool softener.

Call the health care provider.

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? Place a dry, sterile dressing over the protruding organs. Place a pressure dressing over the opening and secure. Have the client lay quietly on back and call the physician. Moisten sterile gauze with sterile normal saline and place on the protruding organ.

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

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

Evisceration

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 Covering the well-approximated wound edges with a dry dressing Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive Cleaning the wound with soap and water, then leaving it open to the air

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

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? Requirement of intermittent catheterization Calculus formation Urine retention Urinary infection

Urine retention

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. exhibits wound healing without complications. resumes usual urinary elimination pattern. maintains adequate fluid status.

experiences pain within tolerable limits.

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. second intention. third intention. fourth intention.

first intention.

The primary objective in the immediate postoperative period is controlling nausea and vomiting. relieving pain. maintaining pulmonary ventilation. monitoring for hypotension.

maintaining pulmonary ventilation.

The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order? chlorpromazine omeprazole ondansetron nizatidine

ondansetron

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? Necrotic and hard Pale yet able to blanch with digital pressure Pink to red and soft, bleeding easily White with long, thin areas of scar tissue

Pink to red and soft, bleeding easily

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

Reinforcing the dressing or applying pressure if bleeding is frank

A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention? Dangle at the bedside. Report early calf pain. Take off the pneumatic compression devices for sleeping. Rely on the IV fluids for hydration.

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? Primary-intention healing First-intention healing Second-intention healing Third-intention healing

Second-intention healing

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order. Apply intermittent suction while withdrawing the catheter. Position the client in Fowlers position. Don sterile gloves. Lubricate the sterile suction catheter. Insert suction catheter into the lumen of the tube.

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

The nurse is caring for a client 24 hours post surgery who is having persistent hiccups. What action is most appropriate for the nurse to take? Position the client on his or her side. Assist the client to intake ample amounts of water. Notify the physician. Instruct the client to take deep breaths.

Notify the physician.

A client who is receiving the maximum levels of pain medication for postoperative recovery asks the nurse if there are other measures that the nurse can employ to ease pain. Which of the following strategies might the nurse employ? Select all that apply. Performing guided imagery Putting on soothing music Changing the client's position Applying hot cloths to the client's face Massaging the client's legs

Performing guided imagery Putting on soothing music Changing the client's position

A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem? Pink color Copious red blood in the sputum Foul smell Pieces of vomitus

Pink Flash pulmonary edema that occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation, tachypnea, tachycardia, decreased pulse oximetry readings, frothy, pink sputum, and crackles on auscultation.

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? The client can self-administer oral pain medication as needed with patient-controlled analgesia. Family members can be involved in the administration of pain medications with patient-controlled analgesia. Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. There are no advantages of patient-controlled analgesia over a PRN dosing schedule.

Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.

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

Hourly leg exercises