AH Chp 19 Prep U

Episodic hypoxemia

-develops suddenly -pt @ risk for MI, cerebral dysfunction, and cardiac arrest

aldrete score of discharge

8 to 10 before discharge from the PACU

A physician's admitting note lists a wound as healing by second intention. What does the nurse expect to find?

A wound in which the edges were not approximated

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? a. does the pt have a history of dementia b. med history c. family histor d. does the pt use any assistive devices

Does the client have a history of dementia?

Which of the following terms refers to a protrusion of abdominal organs through the surgical incision?

Evisceration

Postoperative day 2, a patient requires wound 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 with dry dressing

A client who is receiving the maximum levels of 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

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

A patient is postoperative hour 8 following 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. Abdomen is soft and distended. No obvious bleeding noted. What action by the nurse is most appropriate? a. administer pain med b. ambulate pt to decrease pain c. reposition pt d. notify HCP

d. notify HCP

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

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

first intention

stitches are an ex. of what type of wound healing

first intention

A patient asks why there is a drain pulling fluid from the surgical wound. What is the best response by the nurse?

it prevents infection

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. Which of the following actions by the nurse would be appropriate?

maintain adequate hydration

When vomiting occurs postoperatively, what is the most important nursing intervention? a. notify HCP b. administer anti-emetic c. raise pt up in bed d. turn pt on side

Turn the patient's head completely to one side to prevent aspiration of vomitus into the lungs.

What measurement should the nurse report to the physician in the immediate postoperative period? a. RR: 20-25 b. systolic BP less than 90 c. HR: 62 d. pulse ox: 94

b. systolic BP less than 90

phase III PACU

the patient is prepared for discharge

bringing together two apposing granulation surfaces

third intention healing

Ondansetron (Zofran)

treats nausea and vomiting

hernia

weakness in the abdominal wall

Nursing assessment findings reveal a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. The nurse recognizes the client is experiencing:

wound infection

The nurse is attempting to ambulate a patient who underwent shoulder surgery earlier in the day. The patient is refusing to ambulate. What action by the nurse is most appropriate? a. document pt refusal b. reinforce importance of early mobility c. delegate ambulation to UAP d. force pt out of bed

Reinforce the importance of early mobility in preventing complications.

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. a.Listening to music b. Watching television c. Changing position d. Epidural infusion e. On-Q pump

a.Listening to music b. Watching television c. Changing position

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? a. white, soft, pus filled b. pink to red and soft, bleeding easily c. pink, hard, scabbing d. white, soft, bleeding easily

b. pink to red and soft, bleeding easily

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that most support the nurse's analysis are: a. normal BP, fast pulse b. high BP, fast pulse c. low BP, fast pulse c. high BP, slow pulse

c. low BP, fast pulse

second intention healing

-infected wounds or wounds with edges that aren't approximated -usually packed with moist dressings

phase I PACU

-used during the immediate recovery phase -intensive nursing care is provide

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 : hypothermia

The PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. Which short-term outcome would be most important for this client? The client:

maintain adequate O2 status Acute confusion associated with delirium may be a result of hypoxia, pain, urinary retention, fecal impaction, fever, hypotension, hypoglycemia, fluid loss, and anemia. Hypoxia would be most important for the nurse to address.

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: a. asucultate bowel sounds b. palpate ab c. administer anti emetic d. change clients position

a. asucultate bowel sounds

You are caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery? a. move legs frequently b. place pillow underneath knees c. place client in side lying position

a. move legs frequently

When the nurse observes that the postoperative patient 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. subacute b. hypoxic hypoxemia c. episodic hypoxemia d. anemic hypoxemia

a. subacute

The nurse is preparing to discharge a patient from the PACU using a PACU room scoring guide. With what score can the patient be transferred out of the recovery room?

8 or better

first intention healing

-Wounds with a small amount of tissue damage -result of procedures that use sterile technique and that are properly closed -ex. stitches

third intention healing

-deep wounds that aren't sutured together -result in deep, wide scar

A nursing measure for evisceration is to:

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

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: a. prescribing an antibiotic b. isolating client from other pt c. ambulating client asap

c. ambulating client asap

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

You are caring for a client 6 hours post surgery. You observe that the client voids urine frequently and in small amounts. You know that this most probably indicates what? a. urine retention b. urinary infection c. calculus formation

a. urine retention Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow.

s/s of flash pulmonary edema

agitation, tachypnea, tachycardia, decreased pulse oximetry readings, frothy, pink sputum, and crackles on auscultation

When caring for a postsurgical patient, the nurse observes that the client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? a. Reinforcing dressing or applying pressure if bleeding is frank b. remove dressing c. raise head of bed d. monitor vital signs every 15 min

a. Reinforcing dressing or applying pressure if bleeding is frank -keep the head of the bed flat unless it is contraindicated

A nurse asks a client who had abdominal surgery 3 days 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? a. encourage ambulation at least 3 times a day b. pt should be on bedrest c. apply heat to ab d. administer enema e. notify HCP

a. encourage ambulation at least 3 times a day

The client is experiencing nausea and vomiting following surgery. The nurse expects the surgeon to order: a. ondansetron (Zofran)

a. ondansetron (Zofran)

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? a. PCA can increase the potential risk of addiction b. Therapeutic drug levels can be maintained more evenly c. PCA increases adminision time of analgesics

b. Therapeutic drug levels can be maintained more evenly

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? a. abdominal distention b. absence of peristalisis c. hyperactive bowel sounds d. decreased urinary output

b. absence of peristalisis

You are caring for a client who is an obese diabetic. The client is 48 hours post surgery. What is this client at increased risk for? a. hernia b. dehiscence c. evisceration d. hypotension

b. dehiscence

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? a. 75-100 ml b. less than 30 c. about 50 ml d. more than 120 ml

b. less than 30 indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL per hour are reported if the patient is voiding, an output of less than 240 mL per 8-hour shift is reported.

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly patients? a. Hypoxemia b. pneumonia c. delirium d. decreased oral intake

b. pneumonia

risk factors for wound dehiscence

-over 65 yrs -chronic disease (DM, HTN) -obesity -malnutrition (esp. protein, vit C deficiency) -history of radiation

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.

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

Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, level of consciousness, central venous pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output A: central venous pressure

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.

When should the nurse encourage the postoperative patient to get out of bed? a. second post op day b. pt should stay in bed until rehab c. as soon as indicated d. no sooner than 72 hr after surgery

c. as soon as indicated

A recently extubated postoperative patient starts to gag and make vomiting sounds. What action should the nurse do first? a. call for help b. raise head of bed c. turn pt on their side

c. turn pt on their side

Anemic hypoxemia

caused by blood loss during surgery

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? a. move pt to floor b. notify HCP c. apply dry dressing and return to bed d. apply moist sterile guaze

d. apply moist sterile guaze first action by the nurse would be to cover the protruding organs with sterile dressings moistened with normal saline

A patient is postoperative day 1 from abdominal surgery. The patient 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 2430 mL. What action by the nurse is most appropriate? a. notify HCP b. assess for signs of fluid overload c. this is a normal finding d. assess for s/s of fluid volume deficit

d. assess for s/s of fluid volume deficit

The nurse is caring for a postoperative patient with an indwelling urinary catheter. The hourly urinary output at 9 am is 80 mL. The nurse assesses the hourly urinary output at 10 am at 20 mL. What is the highest priority action by the nurse? a. assess urinary catheter b. document urinary output in pt chart c. monitor I + O d. notify HCP

d. notify HCP

cause of flash pulmonary edema

occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure

s/s of hypovolemic shock

pallor rapid, weak thready puls low bp tachypnea

phase II PACU

patient is prepared for self-care or care in the hospital or an extended care setting

In what phase of postanesthesia care (PACU) is the client prepared for self-care or care in the hospital or an extended care setting?

phase II PACU

What intervention by the nurse is most effective for reducing hospital-acquired infections?

proper handwashing

Dehiscence

refers to the partial or complete separation of wound edge

Hypoxic hypoxemia

results from inadequate breathing

aldrete score less than 7

score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area, depending on their preoperative baseline score

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation?

second intention

subacute hypoxemia

supplemental oxygen may be indicated