Chapter 19
The nurse observed that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?
Reinforcing the dressing or applying pressure if bleeding is frank
A postanesthesia care unit (PACU) nurse is preparing to discharge a client home following ankle surgery. The client keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate?
Review the instructions with the client and an accompanying adult
When should the nurse encourage the postoperative patient to get out of bed?
As soon as it is indicated
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 client has undergone surgery to repair a hernia, with no complications. In the immediate postoperative period, which action by the nurse is most appropriate?
Monitor vital signs every 15 minutes
The client complains of weakness and dizziness as the nurse assists the client to sit on the side of the bed. The nurse recognizes the client is experiencing:
Orthostatic hypotension
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?
Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing
To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:
Ambulating the client as soon as possible
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?
7
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?
<30 mL
What measurement should the nurse report to the physician in the immediate postoperative period?
A systolic blood pressure lower than 90 mm Hg
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?
Blood pressure of 90/50 mm Hg
A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate?
Continue with frequent client assessments
What is the highest priority nursing intervention for a client in the immediate postoperative phase?
Maintaining a patent airway
The primary objective in the immediate postoperative period is
Maintaining pulmonary ventilation
A nurse is caring for a client with a chest tube connected to a dry suction water seal drainage system. The nurse notes 2 cm of water and intermittent bubbling in the water seal chamber. Which action will the nurse take?
Document the findings
A nurse asks a client who had abdominal surgery 1 day 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?
Encourage the client to ambulate as soon as possible after surgery
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?
Experiences pain within tolerable limits
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
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:
First intention
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?
First intention
The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of:
Hypoxia and hypercapnia
A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?
Pink to red and soft, noting that it bleeds easily
What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?
Pneumonia
A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.
Position the client in Fowlers position, Don sterile gloves, Lubricate the sterile suction catheter, Insert suction catheter into the lumen of the tube, Apply intermittent suction while withdrawing the catheter
A nurse is caring for a client in the PACU after the 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?
Position the client in the side-lying position
The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?
Position the client to maintain a patent airway
A nurse is reviewing the medications of a postoperative client. What medication related to the recent surgery may be of concern to the nurse?
Prednisone
What complication is the nurse aware of that is associated with deep venous thrombosis?
Pulmonary embolism
Which action should a nurse preform to prevent deep vein thrombosis when caring for a postsurgical client?
Reinforce the need to perform leg exercises every hour when awake
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?
Shoulder and arm range-of-motion exercises
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 finished 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
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
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?
The client is displaying early signs of shock
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?
Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia
A client vomits postoperatively. What is the most important nursing intervention?
Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.
The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?
Urine retention
A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for?
Wound dehiscence
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?
Wound infection