Ch. 16
What is the PRIORITY nursing intervention for a client during the immediate postoperative period?
Maintaining a 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?
Mechanical problems may have developed with the T-tube.
Which are interventions for the med-surg nurse to use in preventing hypoxemia for the post-op pt? SATA
Monitor the patient's oxygen saturation Encourage the patient to cough and breathe deeply Get the patient ambulating as soon as possible Remind the patient to use incentive spirometry every hour while awake
A patient who is 2 days postoperative for abdominal surgery states, "I coughed and heard something pop". The nurse's immediate assessment reveals an opened incision with a portion of large intestine protruding.Which statements apply to this clinical situation? SATA
This is an emergency The wound must be kept moist with normal saline-soaked sterile dressing. Incision evisceration has occurred A nasogastric tube may be ordered to decompress the stomach
The nurse on the medical-surgical unit is caring for a postoperative patient. Which assessment criteria indicate to the nurse that the patient is experiencing respiratory difficulty?
The patient is using accessory muscles to breathe The patient makes a high-pitched crowing sound when breathing The patient's respiratory rate is 29/min
Which patient is most at risk for postoperative nausea and vomiting (PONV)?
The patient with a history of motion sickness
If a patient experiences a wound dehiscence, which description best characterizes what is happening with the wound?
A partial or complete separation of outer layers is present at incision site
The patient who received moderate sedation with midalozam appears to be overly sedated and has respiratory depression. Which drug does the nurse prepare to administer to the pt?
Flumazenil
A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress?
Restlessness
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
10-12 hours
Which description illustrates the beginning of the postoperative period?
Completion of the surgical procedure and transfer of the patient to the postanesthesia care unit (PACU).
A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis
Diminished breath sounds on auscultation
Which indicator of return to consciousness occurs first as a patient recovers from general anesthesia?
Muscular irritability
What information should be included in the handoff report when a patient is transferred from the OR to the postanesthesia care unit (PACU) staff?
Type and extent of surgical procedure Intraoperative complications and how they were handled Type and amount of IV fluids and blood products given Location and type of incisions, dressing, catheters, tubes, drains, or packing
A client experiences abdominal distension following surgery. Which nursing actions are appropriate? SELECT ALL THAT APPLY.
Encouraging ambulation Auscultating bowel sounds
Which intervention by the nurse will help a post op pt with compliance in getting up to ambulate?
Offer the patient pain medication 30-45 minutes before ambulation
Which signs/ symptoms are considered postoperative complications?
Pulmonary embolism Hypothermia Wound evisceration Postoperative ileus
Which interventions for postsurgical care of a patient is correct?
Teach the patient to splint the surgical wound for support and comfort when getting out of bed
The health care team determines a patient's readiness for discharge from the postanesthesia care unit (PACU) by noting a postanesthesia recovery score of at least 10. After determining that all criteria have been met, the patient is discharged to the hospital unit or home. Review the patient profiles after 1 hour in the PACU listed below. Which patient should the nurse expect to be discharged from the PACU first?
42 year old female, colonoscopy. IV conscious sedation. Awake and alert. Up to bathroom to void. IV discontinued. Resting quietly in chair. VS are within normal limits
The postanesthesia care unit nurse is assessing a patient transferred in from the OR. Which assessment findings apply to assessment of the cardiovascular system?
Absent dorsalis pedis pulse in left foot Monitor shows normal sinus rhythm Apical pulse 85 beats/minute
In the postanesthesia care unit (PACU), the nurse assesses that a patient is bleeding profusely from an abdominal incision. What is the nurse's best first action?
Apply pressure to the wound dressing
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?
Ascorbic acid (Ascorbicap)
A patient arrives in the postanesthesia care unit (PACU). Which action does the nurse perform first?
Assess for a patent airway and adequate gas exchange
The patient is recovering in a postanesthesia care unit (PACU) environment that advances the patient quickly from a Phase 1 care level to a phase III care level, preparing for discharge at home. What type of surgery is this patient most likely having?
Elective surgery
A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent accumulation of secretions?
Frequent changes of position
A 49 year old patient is in the postanesthesia care unit (PACU) following a frontal craniotomy for repair of a ruptured cerebral aneurysm. The nurse assesses that the patient's eyes open on verbal stimulation. Pupils are equal and reactive to light, and diameter is 3mm. The patient's hand grasps are equal and strong. The patient is able to state name correctly. The patient has had one episode of nausea and vomiting. Incision edges are dry and approximated with sutures. Lung sounds are slightly diminished on auscultation, and the nurse observes the patient is using abdominal accessory muscles to breathe. Which body systems has the nurse assessed? SATA
Gastrointestinal Neurologic Integumentary Respiratory
A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure?
Keeps the area free of microorganisms
A patient arrives at the postanesthesia care unit (PACU), and the nurse notes a respiratory rate of 10 with sternal retractions. The report from the anesthesia provider indicates that the patient received fentanyl during surgery. What is the nurse's best first action?
Maintain an open airway through positioning and suction if needed
A client reports severe pain 2 days after surgery. Which INITIAL action should the nurse take after assessing the character of the pain?
Obtain vital signs
When assessing the hydration of an older postoperative patient, where must the nurse assess for tenting of the skin? SATA
On the forehead On the sternum
What is the primary purpose of a PACU?
Ongoing critical evaluation and stabilization of the patient.
The nurse is assessing a postoperative patient's gastrointestinal system. What is the best indicator that peristaltic activity has resumed?
Passing flatus or stool
The nurse is teaching incisional care to a patient who is being discharged after abdominal surgery. Which priority instruction must the nurse include?
Practice proper handwashing
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?
Reinforce the dressing
A postoperative patient in the postanesthesia care unit (PACU) has had an open reduction internal fixation of a left fractured femur. Vital signs are blood pressure 87/49 mmHg, heart rate 100/min sinus rhythm, respirations 22/min and temperature 98.3F (36.8C). The Foley catheter has a total of 110mL of clear yellow urine in the last 4 hours. Which body systems have been assessed by the nurse?
Respiratory Cardiovascular Gastrointestinal
The postnesthesia care unit (PACU) nurse is assessing an older adult patient for postoperative pain. Which nonverbal manifestations suggest pain to the nurse? SATA
Restlessness Profuse sweating Confusion Increased BP
A patient develops respiratory distress after having a left total knee replacement. The patient develops labored breathing and a pulse oximetry reading is 83% on 2 L oxygen via nasal cannula. Which intervention is appropriate for the nurse to delegate to unlicensed assistive personnel?
Check the patient's vital signs
The postanesthesia care unit (PACU) nurse is receiving the "handoff" report for a patient transferred in from the OR. Which statements about this report are accurate?
A handoff report requires clear, concise language A handoff report is a two-way verbal interaction between the health care professional giving the report and the nurse receiving it The receiving nurse takes time to restate (report back) the information to verify what was said. The receiving nurse takes the time to ask questions, and the reporting professional must respond to the questions until a common understanding is established.
The HCP removed a pt's original surgical dressing 2 days after surgery and is discharging the patient home with daily dressing changes. Which actions will the nurse take for this pt's discharge teaching? SATA
Ask the patient's family or SO to observe the dressing change Ask the UAP to get dressing supplies for the pt Have the case manager arrange for a home health nurse to ensure that dressing changes are done and there are no complications or infection Teach the patient and family the signs and symptoms of infection
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?
Capillarity
Which member to the surgical team usually accompany a postoperative patient to the postanesthesia care unit (PACU)?
Anesthesia provider and circulating nurse
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?
Assisting in the planning of toileting, turning, and ambulation.
The nurse transfers a patient to the postanesthesia care unit (PACU) with an incision and damage of an abcess in the right groin under general anesthesia. Blood pressure is 80/47 mmHG, heart rate 117/min in sinus tachycardia, respiratory rate 28/min, pulse oximetry reading 93% on oxygen at 3L per nasal cannula and temp 101.3F(38.5C). The Jackson-Pratt drain has 70 mL of a cream colored output. Normal saline is infusing at 150 ml/hr. The surgeon orders a bolus of 500mL IV normal saline over 1 hour, two sets of blood cultures, and culture drainage from the Jackson Pratt drain. The patient's history includes vulvar cancer with a needle biopsy of the right groin, hypertension treated with lisinopril 5mg PO daily, and no known drug allergies. The patient is designated as a full code. Using the Situation, Background, Assessment, Recommendation (SBAR) charting format, which information should be included in assessment?
Blood pressure is 80/47 mmHg, heart rate 117/min in sinus tachycardia, respirations 28/min, pulse oximetry 93% on O2 at 3L nasal cannula, and temp 101.3F (38.5C); Jackson-Pratt drain with 70mL cream-colored output.
The postanesthesia care unit (PACU) nurse is caring for a postoperative patient. The patient's oxygen saturation drops from 98% to 88%. What is the nurse's priority action?
Call Rapid Response Team
The nurse is caring for a patient who has had abdominal surgery. After a hard sneeze, the patient reports pain in the surgical area, and the nurse immediately sees that the patient has a wound evisceration. What priority action must the nurse do first?
Call for help and stay with the patient
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?
Compress the container before closing the port.
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?
Cover the wound with a sterile towel moistened with normal saline.
After abdominal surgery a client reports pain. What action should the nurse take FIRST?
Determine the characteristics of the pain
The nurse is responsible for the care of a postoperative patient with a thoracotomy. Which action should the nurse delegate to the UAP?
Encouraging, monitoring, and recording nutritional intake.
On which concern should the nurse focus when caring for a client after abdominal surgery?
Identifying signs of bleeding
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?
Impaired neural functioning
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?
Monitoring the client's dressing of any signs of bleeding
Which statement best describes phase I care after surgery?
Phase I care occurs immediately after surgery, most often in post anesthesia care unit
The postoperative pt has a Penrose drain in place. Which action does the nurse take to prevent skin irritation, wound contamination, and infection?
Places absorbent pads under and around the exposed drain
The morning after a patient's lower leg surgery, the nurse notes that the dressing is wet from drainage. The surgeon has not yet been in to see the patient on rounds. What does the nurse do about the dressing?
Reinforces the dressing by adding dry, sterile dressing material on top of the existing dressing
A patient cared for in the postanesthesia care unit(PACU) had a colostomy placed for treatment of Crohn's disease. The nurse assesses that an abdominal dressing is 25% saturated with serosanguineous drainage and the incision is intact. An IV is infusing with D5/ lactated Ringer's at 100 mL/hr through a 20-g peripheral IV access. Auscultation of abdomen reveals hypoactive bowel sounds in all four quadrants, abdomen soft, and no distention. Foley catheter is in place and draining yellow urine with sediment. 375 mL output in the Foley bag. Which body systems have been assessed by the nurse?
Renal/urinary Gastrintestinal Integumentary
Which are criteria used by the health care team to determine when a pt is ready to be discharged from PACU? SATA
Stable vital signs with normal body temp Intact cough and swallow reflexes Adequate urine output Return of gag reflex
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.
Stay calm and stay with the client Put the client into semi-fowlers position with knees slightly flexed Check the vital signs, especially blood pressure and pulse Have a colleague gather sterile supplies and contact the HCP Cover the intestine with sterile moistened gauze Prepare client for surgery as ordered.
The med-surg nurse is caring for a postop pt whose lab values reveal an increase in band cells (immature neutrophils). What is the nurse's best interpretation of this value?
The patient is developing an infection
