Ch. 15 and 16: Intra-op and Post-op Care (Nurs 309)

On which concern should the nurse focus when caring for a client after abdominal surgery? 1. Identify signs of bleeding. 2. Preventing pressure on the suture site. 3. Encouraging the use of incentive spirometer. 4. Detecting clinical manifestations of inflammation.

1. Identify signs of bleeding.

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure? 1. Keeps the area free of microorganisms. 2. Confines microorganisms to the surgical site. 3. Protects self from microorganisms in the wound. 4. Reduces the risk for growing opportunistic microorganisms.

1. Keeps the area free of microorganisms.

Four days after abdominal surgery a client has not passed flatus and there is no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the MOST likely cause of the ileus? 1. Decreased blood supply. 2. Impaired neural functioning. 3. Perforation of bowel wall. 4. Obstruction of the bowel lumen.

2. Impaired neural functioning.

A client reports severe pain 2 days after surgery. Which INITIAL action should the nurse take after assessing the character of the pain? 1. Encourage rest. 2. Obtain vital signs. 3. Administer the PRN analgesic. 4. Document the client's pain response.

2. Obtain vital signs.

After undergoing a modified radical mastectomy, a client is transferred to the PACU. Which nursing action is best to assign to an experienced LPN/LVN? 1. Monitoring the client's dressing for any signs of bleeding. 2. Documenting the initial assessment on the client's chart. 3. Communicating the client's status report to the charge nurse on the surgical unit. 4. Teaching the client about the importance of using pain medication as needed.

1. Monitoring the client's dressing for any signs of bleeding.

The nurse is responsible for the care of a postoperative patient with a thoracotomy. Which action should the nurse delegate to the UAP? 1. Instructing the patient to alternate rest and activity periods. 2. Encouraging, monitoring, and recording nutritional intake. 3. Monitoring cardiorespiratory response to activity. 4. Planning activities for periods when the patient has the most energy.

2. Encouraging, monitoring, and recording nutritional intake.

While caring for a client with a portable wound drainage system, a nurse observes that the collection container is half full and empties it. What is the NEXT nursing intervention? 1. Encircle the drainage on the dressing. 2. Irrigate the suction tube with sterile saline. 3. Clean the drainage port with an alcohol wipe. 4. Compress the container before closing the port.

4. Compress the container before closing the port.

After abdominal surgery a client reports pain. What action should the nurse take FIRST? 1. Reposition the client. 2. Obtain the client's vital signs. 3. Administer the prescribes analgesic. 4. Determine the characteristics of the pain.

4. Determine the characteristics of the pain.

Immediately after receiving spinal anesthesia a client develops hypotension. To what physiologic change does the nurse attribute the decreased blood pressure? 1. Dilation of blood vessels. 2. Decreased response of chemorecptors. 3. Decreased strength of cardiac contractions. 4. Disruption of cardiac accelerator pathways.

1. Dilation of blood vessels.

A client experiences abdominal distension following surgery. Which nursing actions are appropriate? SELECT ALL THAT APPLY. 1. Encourage ambulation. 2. Giving sips of ginger ale 3. Auscultating bowel sounds. 4. Providing a straw for drinking. 5. Offering the prescribed opioid analgesic.

1. Encourage ambulation. 3. Auscultating bowel sounds.

A client is extubated in the post-anesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? 1. Restlessness. 2. Bradycardia. 3. Constricted pupils. 4. Clubbing of the fingers.

1. Restlessness.

A nurse in the post-anesthesia care unit observes that after an abdominal cholecystectomy a client has serousanguineous drainage on the abdominal dressing. What is the NEXT nursing action? 1. Change the dressing. 2. Reinforce the dressing. 3. Replace the tape with Montgomery ties. 4. Support the incision with an abdominal binder.

2. Reinforce the dressing.

The nurse is caring for an obese postoperative client who underwent a surgery for bowel resection. As the client is moving in bed, he comments, "Something popped open." Upon examination, the nurse notes wound evisceration. Place the steps in order for handling this complication. 1. Cover the intestine with sterile moistened gauze. 2. Stay calm and stay with the client. 3. Check the vital signs, especially blood pressure and pulse. 4. Have a colleague gather sterile supplies and contact the HCP. 5. Put the client into semi-fowlers position with knees slightly flexed. 6. Prepare client for surgery as ordered.

2. Stay calm and stay with the client. 5. Put the client into semi-fowlers position with knees slightly flexed. 3. Check the vital signs, especially blood pressure and pulse. 4. Have a colleague gather sterile supplies and contact the HCP. 1. Cover the intestine with sterile moistened gauze. 6. Prepare client for surgery as ordered.

In the immediate postoperative period after a gastrectomy, the client's nasogastric tube is draining a light red liquid. For how long should the nurse expect this type of drainage? 1. 1-2 hours 2. 2-3 hours 3. 10-12 hours 4. 24-48 hours

3. 10-12 hours

The postoperative care of a morbidly obese client is being planned. Which task best uses the expertise of the LPN/LVN, under the supervision of the RN team leader? 1. Obtaining an oversized blood pressure cuff and large sized bed. 2. Setting up a reinforced trapeze bar. 3. Assisting in the planning of toileting, turning, and ambulation. 4. Assigning tasks the UAP and other ancillary staff.

3. Assisting in the planning of toileting, turning, and ambulation.

What is the PRIORITY nursing intervention for a client during the immediate postoperative period? 1. Monitoring vital signs. 2. Observing for hemorrhage. 3. Maintaining patent airway. 4. Recording the intake and output.

3. Maintaining patent airway.

After an abdominal cholecystectomy, a client has a T-tube attached to a collectible device. On the day of surgery, at 10:30 PM, 300 mL of bile is emptied from the collection bag. At 6:30 AM the next day, the bag contains 60 mL of bile. What should the nurse consider in response to this information? 1. The T-tube may have to be irrigated. 2. The bile is now draining into the duodenum. 3. Mechanical problems may have developed with the T-tube. 4. Suction must be reestablished in the portable drainage system.

3. Mechanical problems may have developed with the T-tube.

A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. What medication does the nurse anticipate will be prescribed for this client? 1. Vitamin A 2. Cyanocobalamin 3. Phytonadione 4. Ascorbic acid

4. Ascorbic acid

A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated? 1. Dialysis. 2. Osmosis. 3. Diffusion. 4. Capillarity.

4. Capillarity.

When assessing an obese client, the nurse observes dehiscence of the abdominal surgical with evisceration. The nurse places the client in the low-fowler's position with the knees slightly bent and encourages the client to lie still. What is the NEXT nursing action? 1. Obtain the vital signs. 2. Notify the health care provider. 3. Reinsert the protruding organs using aseptic technique. 4. Cover the wound with a sterile towel moistened with normal saline.

4. Cover the wound with a sterile towel moistened with normal saline.

A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? 1. Productive cough. 2. Clubbing of the finger tips. 3. Crackles at the height of inhalation. 4. Diminished breath sounds on auscultation.

4. Diminished breath sounds on auscultation.

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent accumulation of secretions? 1. Postural drainage. 2. Cupping the chest. 3. Nasotracheal suctioning. 4. Frequent changed of position.

4. Frequent changed of position.