Chapter 16: Postoperative Nursing Management
The nurse is preparing discharge instructions to a client who has undergone minor same-day surgery. Which client statement indicates that teaching has been effective? a) "I had some type of surgery on my abdomen." b) "There is no need to call my doctor as the surgery was minor." c) "I am not permitted to drive myself home after surgery." d) "I will read up on how to use my walker at home for safety."
"I am not permitted to drive myself home after surgery." Explanation: There are specific educational points that the nurse needs to provide to the client before discharging after a same-day procedure. After teaching, the client should be able to describe activities that can or cannot be performed, such as limited driving for 2 days. Rather than self-teaching at home, the discharge instructions will educate the client how to identify interventions and strategies for adaptive equipment. The client should be instructed to call the health care provider for a follow-up postsurgical appointment. The client should be able to name the procedure that was performed and not just give a vague statement of something being done in the abdomen. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Preparing the Postoperative Patient for Direct Discharge, p. 444.
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? a) 6 b) 7 c) 5 d) 4
7 Explanation: Many hospitals use a scoring system (e.g., Aldrete score) to determine the patient's general condition and readiness for transfer from the PACU (Aldrete & Wright, 1992). Throughout the recovery period, the patient's physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. This evaluation guide allows an objective assessment of the patient's condition in the PACU. The patient is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The Aldrete score is usually between 7 and 10 before discharge from the PACU. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Patient in the Postanesthesia Care Unit, p. 443.
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? a) Blood pressure of 120/90 mm Hg b) Blood pressure of 110/80 mm Hg c) Blood pressure of 90/50 mm Hg d) Blood pressure of 150/100 mm Hg
Blood pressure of 90/50 mm Hg Explanation: The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis. Orthostatic changes develop from hypovolemia and cause a drop in blood pressure (evidenced by a blood pressure of 80/40 mm Hg) when the client rises from a lying position. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Patient in the Postanesthesia Care Unit, p. 440.
A client is transferred from the postanesthesia care unit (PACU) to an inpatient care unit. What will the nurse assess first? a) Breathing b) Pain level c) Surgical site d) Level of consciousness
Breathing Explanation: The nurse will assess the client being transferred from the PACU to an inpatient care unit. The priority is to assess breathing and administer oxygen if prescribed because this provides a baseline and helps identify for the development of respiratory distress. Pain level is assessed after the surgical site and level of consciousness are assessed. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Patient in the Postanesthesia Care Unit, p. 438.
The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? a) Chest x-ray b) Upper endoscopy c) Complete blood count d) Central venous pressure
Central venous pressure Explanation: 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 are monitored to provide information on the patient's respiratory and cardiovascular status. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Patient in the Postanesthesia Care Unit, p. 440.
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) Evisceration b) Normal healing by primary intention. c) Hemorrhage d) Dehiscence
Dehiscence Explanation: Dehiscence is a disruption of the incision. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Hospitalized Postoperative Patient, pp. 456-457.
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? a) Third intention b) Fourth intention c) First intention d) Second intention
First intention Explanation: When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, GLOSSARY, p. 437.
Corticosteroids have which effect on wound healing? a) May cause protein-calorie depletion b) Mask the presence of infection c) Cause hemorrhage d) Reduce blood supply
Mask the presence of infection Explanation: Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. Edema may reduce blood supply. Corticosteroids do not cause hemorrhage or protein-calorie depletion. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Nursing Management After Surgery > TABLE 16-3 Factors Affecting Wound Healing, p. 451.
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? a) Ambulate the client to reduce abdominal distention. b) Inform the client this is the normal progression after abdominal surgery. c) Notify the physician. d) Administer morphine per orders.
Notify the physician. Explanation: The physician should be notified of the findings. The client may be hemorrhaging internally and may need to return to surgery. The client may be in need of pain medication, but morphine will lower the blood pressure further and may cause further complications. Ambulating the client increases the risk of injury because the client may experience orthostatic hypotension. What the client is experiencing is not the normal progression after abdominal surgery. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Nursing Management After Surgery > Chart 16-6 PATIENT EDUCATION, p. 453.
A postoperative client with an open abdominal wound is currently taking corticosteroids. The physician orders a culture of the abdominal wound even though no signs or symptoms of infection are seen. What action by the nurse is appropriate? a) Hold the order until purulent drainage is noted. b) Request the order be discontinued without obtaining the specimen. c) Obtain the wound culture specimen. d) Use an antibiotic cleaning agent before obtaining the specimen.
Obtain the wound culture specimen. Explanation: Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. The culture should be obtained even though the client is not demonstrating traditional signs and symptoms of infection. The order should not be discontinued or held until purulent drainage is noted because the infection could worsen and the client could develop sepsis. An antibiotic cleaning agent should not be used before obtaining the specimen because it will alter the growth of the organisms. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Nursing Management After Surgery > Caring for Surgical Drains, p. 452.
Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention? a) Respiratory rate of 12 breaths per minute b) Blood pressure of 94/62 mm Hg c) Urine output of 60 ml/hr d) Oxygen saturation of 82%
Oxygen saturation of 82% Explanation: Normal pulse oximetry is 95% to 100%. An oxygen saturation of 82% indicates respiratory compromise and requires immediate attention. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Hospitalized Postoperative Patient, p. 447.
Which is a classic sign of hypovolemic shock? a) Bradypnea b) Pallor c) High blood pressure d) Dilute urine
Pallor Explanation: The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Nursing Management in the Postanesthesia Care Unit > Hypotension and Shock, p. 440.
A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? a) Pale yet able to blanch with digital pressure b) Pink to red and soft, noting that it bleeds easily c) White with long, thin areas of scar tissue d) Necrotic and hard
Pink to red and soft, noting that it bleeds easily Explanation: Second-intention healing (granulation) occurs in infected wounds or in wounds in which the edges have not been approximated. Gradually, the necrotic material disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue. Healing is complete when skin cells grow over these granulations. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Hospitalized Postoperative Patient, p. 452.
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
Pneumonia Explanation: Older clients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Delirium, pneumonia, decline in functional ability, exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and falls are all threats to recovery in the older adult. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Hospitalized Postoperative Patient, p. 447.
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) Obtain an emesis basin. b) Position the client in the side-lying position. c) Ask the client for more clarification. d) Administer an anti-emetic.
Position the client in the side-lying position. Explanation: The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits. The nurse may also obtain an emesis basin and administered an anti-emetic if one is ordered; however, these will be done after the client is repositioned. There is no need for the nurse to ask the client for more clarification. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Patient in the Postanesthesia Care Unit, p. 442.
The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action? a) Assess the incisional dressing to detect hemorrhage. b) Monitor vital signs for early detection of shock. c) Position the client to maintain a patent airway. d) Administer antiemetics to prevent nausea and vomiting.
Position the client to maintain a patent airway. Explanation: Maintaining a patent airway is the immediate priority in the PACU. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Patient in the Postanesthesia Care Unit, pp. 438-439.
What complication is the nurse aware of that is associated with deep venous thrombosis? a) Pulmonary embolism b) Immobility because of calf pain c) Marked tenderness over the anteromedial surface of the thigh d) Swelling of the entire leg owing to edema
Pulmonary embolism Explanation: Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Hospitalized Postoperative Patient, p. 455.
Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client? a) Reinforce the need to perform leg exercises every hour when awake. b) Instruct the client to prop a pillow under the knees. c) Administer prophylactic high-dose heparin. d) Maintain bed rest.
Reinforce the need to perform leg exercises every hour when awake. Explanation: The nurse should reinforce the need to perform leg exercises every hour when awake. Maintaining bed rest increases the pooling of blood in the lower extremities, increasing the risk for deep vein thrombosis. The client may be given low-dose heparin for prophylactic treatment, but not high-dose heparin. The nurse should instruct the client not to prop a pillow under the knees because it can constrict the blood vessels. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Nursing Management After Surgery> Managing Potential Complications, p. 455.
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) Reinforcing the dressing or applying pressure if bleeding is frank c) Monitoring vital signs every 15 minutes d) Encouraging the client to breathe deeply
Reinforcing the dressing or applying pressure if bleeding is frank Explanation: The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply will not help manage and minimize hemorrhage and shock. Monitoring vital signs every 15 minutes is an appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to determine the extent and progression of the problem. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Nursing Management After Surgery > Changing the Dressing, p. 452.
A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention? a) Rely on the IV fluids for hydration. b) Report early calf pain. c) Dangle at the bedside. d) Take off the pneumatic compression devices for sleeping.
Report early calf pain. Explanation: The client needs to report calf pain or cramping for the nurse to investigate any swelling or potential DVT. Blanket rolls or prolonged dangling should be avoided to reduce impediment of circulation behind the knee. Prevention of DVT includes early ambulation, use of antiembolism or pneumatic compression devices, and low-molecular-weight or low-dose heparin and low-dose warfarin for clients postoperatively. Adequate fluids need to be offered to avoid dehydration. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Hospitalized Postoperative Patient, p. 455.
Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? a) Third-intention healing b) Second-intention healing c) First-intention healing d) Primary-intention healing
Second-intention healing Explanation: When wounds dehisce, they are allowed to heal by secondary intention. Primary or first-intention healing is the method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation. Third-intention healing is a method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by bringing apposing granulations together. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Nursing Management After Surgery > Caring for Wounds, pp. 449-450.
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? a) The client is displaying early signs of shock. b) The client is showing signs of an anesthesia reaction. c) The client is showing signs of a medication reaction. d) The client is displaying late signs of shock.
The client is displaying early signs of shock. Explanation: The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated. Medication or anesthesia reactions may cause client symptoms similar to these; however, these causes are not as likely as early shock. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Patient in the Postanesthesia Care Unit, p. 440.
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) Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. b) Family members can be involved in the administration of pain medications with patient-controlled analgesia. c) There are no advantages of patient-controlled analgesia over a PRN dosing schedule. d) The client can self-administer oral pain medication as needed with patient-controlled analgesia.
Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. Explanation: Advantages of patient-controlled analgesia include participation of the client in care, elimination of delayed administration of analgesics, and maintenance of therapeutic drug levels. The client must have the cognitive and physical abilities to self-dose. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Hospitalized Postoperative Patient, pp. 447-448.
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? a) Weak and rapid pulse rate b) Obstructed airway c) Warm, dry skin d) Pooling of secretions in the lungs
Weak and rapid pulse rate Explanation: Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Patient in the Postanesthesia Care Unit, p. 440.
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? a) Wound infection b) Uncontrolled pain c) Hyperthermia d) Atelectasis
Wound infection Explanation: Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Hospitalized Postoperative Patient, p. 456.
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? a) resumes usual urinary elimination pattern. b) exhibits wound healing without complications. c) experiences pain within tolerable limits. d) maintains adequate fluid status.
experiences pain within tolerable limits. Explanation: Because pain can contribute to postoperative delirium, adequate pain control without oversedation is essential. Nursing assessment of mental status and of all physiologic factors influencing mental status helps the nurse plan for care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult client. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Hospitalized Postoperative Patient, p. 457.
A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: a) fourth intention. b) first intention. c) second intention. d) third intention.
first intention. Explanation: Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care of the Hospitalized Postoperative Patient, pp. 449-451.
The primary objective in the immediate postoperative period is a) monitoring for hypotension. b) relieving pain. c) maintaining pulmonary ventilation. d) controlling nausea and vomiting.
maintaining pulmonary ventilation. Explanation: The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and monitoring for hypotension are important, but they are not primary objectives in the immediate postoperative period. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Nursing Management in the Postanesthesia Care Unit > Maintaining a Patent Airway, p. 438.