ch. 19

What measurement should the nurse report to the physician in the immediate postoperative period? A. A systolic blood pressure lower than 90 mm Hg B. Respirations between 20 and 25 breaths/min C. A hemoglobin of 13.6 D. A temperature reading between 97°F and 98°F

A. A systolic blood pressure lower than 90 mm Hg

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. Absence of peristalsis B. Abdominal distention C. Abdominal tightness D. Increased abdominal girth

A. Absence of peristalsis

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? A. Dehiscence B. Hemorrhage C. Normal healing by primary intention. D. Evisceration

A. Dehiscence

Unless contraindicated, how should the nurse position an unconscious patient? A. On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration B. In Fowler's position, which most closely simulates a sitting position, thus facilitating respiratory as well as gastrointestinal functioning C. Flat on the back, without elevation of the head, to facilitate frequent turning and minimize pulmonary complications D. In semi-Fowler's position, to promote respiratory function and reduce the incidence of orthostatic hypotension when the patient can eventually stand

A. On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? A. Pneumonia B. Hypoxemia C. Pleurisy D. Pulmonary edema

A. Pneumonia

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

A. Pulmonary embolism

Which is the of the following factors stimulates the wound healing process? A. Sufficient oxygenation B. Nutritional deficiencies C. Hemorrhage D. Immobility

A. Sufficient oxygenation

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? A. The client can be discharged from the PACU. B. The client must be put on immediate life support. C. The client must remain in the PACU. D. The client should be transferred to an intensive care area.

A. The client can be discharged from the PACU.

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. auscultate bowel sounds. B. change the client's position. C. insert a rectal tube. D. palpate the abdomen.

A. auscultate bowel sounds.

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

A. maintaining pulmonary ventilation.

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 mostlikely cause of the client's change in condition? A. The client is showing signs of an anesthesia reaction. B. The client is displaying early signs of shock. C. The client is showing signs of a medication reaction. D> The client is displaying late signs of shock.

B. The client is displaying early signs of shock.

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

C. Call the health care provider.

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: A. Granulation B. Second intention C. First intention D. Third intention

C. First intention

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? A. Second intention B. Fourth intention C. First intention D. Third intention

C. First intention

What is the highest priority nursing intervention for a client in the immediate postoperative phase? A. Assessing urinary output every hour B. Assessing for hemorrhage C. Maintaining a patent airway D. Monitoring vital signs at least every 15 minutes

C. Maintaining a patent airway

A nurse is caring for a client who is scheduled to have a thoracotomy. When planning care for this client, what mobility teaching will the nurse include in the plan of care? A. Use of a cane on the affected side B. Lower back and rib range of motion exercises C. Shoulder and upper arm range-of-motion exercises D. Use of a cane on the unaffected side

C. Shoulder and upper arm range-of-motion exercises

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

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

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: A. second intention. B. fourth intention. C. first intention. D. third intention.

C. first intention

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

C. ondansetron

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

D. Central venous pressure

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? A. Obtaining dietary consultation for improved wound healing B. Educating the client on safe bed-to-chair transfer procedures C. Administering pain medications within 1 hour of the client's request D. Assessing WBC count, temperature, and wound appearance

D. Assessing WBC count, temperature, and wound appearance

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? A. Elevating the head of the bed B. Encouraging the client to breathe deeply C. Rubbing the back D. Reinforcing dressings or applying pressure if bleeding is frank

D. Reinforcing dressings 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? A. Take off the pneumatic compression devices for sleeping. B. Rely on the IV fluids for hydration. C. Dangle at the bedside. D. Report early calf pain.

D. Report early calf pain.

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?

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

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.

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

The nurse recognizes that a traumatic wound with fecal contamination would be classified as A. dirty. B. contaminated. C. clean. D. clean contaminated.

A. dirty.

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? A. Cleaning the wound with soap and water, then leaving it open to the air B. Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing C. Covering the well-approximated wound edges with a dry dressing D. Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive

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

Which is a classic sign of hypovolemic shock? A. Dilute urine B. Pallor C. High blood pressure D. Bradypnea

B. Pallor

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

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

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

C. 15 minutes

A client has undergone surgery to repair a hernia, with no complications. In the immediate postoperative period, which action by the nurse is most appropriate? A. Assess pupillary response every 5 minutes B. Measure urinary output every 15 minutes C. Monitor vital signs every 15 minutes D. Measure arterial blood gas every 5 minutes

C. Monitor vital signs every 15 minutes

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

C. Pink to red and soft, bleeding easily

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? A. Administer an anti-emetic. B. Ask the client for more clarification. C. Position the client in the side-lying position. D. Obtain an emesis basin.

C. Position the client in the side-lying position.