PrepU - Chapter 19: Postoperative Nursing Management

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

<30 mL

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.

A client is at postoperative hour 8 after an appendectomy 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?

Notify the physician.

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

Pink color

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 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

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

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.

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

chlorpromazine

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

Ambulating the client as soon as possible

When should the nurse encourage the postoperative patient to get out of bed?

As soon as it is indicated

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

Hypoxemia and hypercapnia.

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

Maintaining a patent airway

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.

The nurse observes bloody drainage on the surgical dressing of the client who has just arrived on the nursing unit. Which intervention should the nurse plan to do next?

Outline the drainage with a pen and record the date and time next to the drainage.

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

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

Pneumonia

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

Pulmonary embolism

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 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 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.

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

Which of the following factors may contribute to rapid and shallow respirations in a postoperative client? Select all that apply.

- Pain - Constricting dressings - Abdominal distention - Obesity

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 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.

A nurse is receiving a client to the postanesthesia unit. What initial nursing activity is most important in the postoperative recovery area?

Maintain patient safety.

Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply.

- Ambulate the length of the client's house - Get out of bed without assistance - Be able to self-toilet

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

A systolic blood pressure lower than 90 mm Hg

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.

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 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 action should be incorporated into the client teaching plan to prevent deep vein thrombosis?

Hourly leg exercises

Corticosteroids have which effect on wound healing?

Mask the presence of infection

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

Which is a classic sign of hypovolemic shock?

Pallor

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

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

ondansetron

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

The nurse is admitting the older adult to the PACU. Which information about this client would be most important for the PACU nurse to obtain?

Does the client have a history of dementia-like symptoms?

The nurse is caring for a postoperative client with a Hemovac. The Hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to:

Empty and measure the drainage and compress the Hemovac.

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

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dL, and a blood pressure lying in bed of 110/70 mm Hg. The nurse suspects abnormal orthostatic changes when the client gets out of bed and reports vertigo. What vital sign value most supports the client's orthostatic changes?

Blood pressure of 90/50 mm Hg

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?

Central venous pressure

A PACU nurse is caring for a postoperative client 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?

Continue with frequent client assessments.

A nursing measure for evisceration is to:

Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution.

A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.

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

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

First intention

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.

A postanesthesia care unit (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?

Review the instructions 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?

Subacute

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.

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

Valsalva maneuver

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

The nurse is caring for a client during the immediate postoperative period and is assessing for signs of shock. What signs and symptoms indicate that the client may be in shock?

Weak and rapid pulse rate

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