Chapter 20: Postoperative Care

A patient inadvertently received a large amount of intravenous fluid. On examination, the nurse finds that the patient has reduced oxygen saturation, crackles on auscultation, and infiltrates on chest X-ray. How should the nurse relieve the patient's breathing discomfort and promote oxygen saturation? Select all that apply. 1. Restrict fluids. 2. Administer diuretics. 3. Administer oxygen therapy. 4. Administer bronchodilators. 5. Implement anticoagulant therapy.

1, 2, 3. The breathing difficulty in the patient is due to the development of pulmonary edema caused by the infusion of a large volume of fluids. The patient would be relieved of pulmonary edema by fluid restriction. Use of diuretics would reduce the volume load. Oxygen therapy would help maintain adequate oxygenation saturation levels. Bronchodilators may help patients with constriction of the bronchi, but that is not the case with this patient. Anticoagulant therapy prevents the blood from clotting, but may not be helpful in relieving pulmonary edema.

When administering an analgesic to a postoperative patient, which nursing actions should the nurse take? Select all that apply. 1. Assess the location, quality, and intensity of pain. 2. Assess the patient's sleep/wake cycle and sensory and motor status. 3. Time the analgesic administration for effectiveness during painful activities. 4. Assess the patient's level of orientation and ability to follow commands. 5. Monitor the patient for nausea, vomiting, and respiratory depression.

1, 3, 5. When administering analgesics to a postoperative patient, the nurse should assess the location, quality, and intensity of pain. The time of administration of the analgesic should be adjusted so that the patient is free of pain during activities like ambulation. The nurse should monitor the patient for analgesic side effects, including nausea, vomiting, and respiratory depression. Assessing the sleep/wake cycle, sensory and motor status, level of orientation, and ability to follow instructions are part of a neurological assessment and not part of administering an analgesic.

The nurse finds that a postoperative patient has not voided for 8 hours. Which are the most appropriate early nursing actions? Select all that apply. 1. Reassure the patient regarding the ability to void. 2. Scan the bladder with a portable ultrasound. 3. Obtain a prescription and catheterize the patient. 4. Use techniques like pouring warm water over the perineum. 5. Help the patient to use a bedside commode.

1, 4, 5. It is very important that the patient voids within 6-8 hours postoperatively. The nurse should reassure the patient regarding the ability to void and help the patient using techniques like providing privacy and pouring warm water over the perineum. The patient should be helped to use a bedside commode if comfortable. If these early measures fail, then the nurse should scan the bladder to assess bladder fullness and catheterize the patient as per the prescription.

In teaching a postcoronary bypass patient about the risk of venous thromboembolism (VTE), it is important to stress: 1. Early ambulation 2. Turning every two hours 3. Splinting chest while coughing 4. Importance of taking pain medication

1. Activity has proven vital in helping to prevent postoperative VTEs. Other forms of treatment include anticoagulants and sequential compression devices (SCDs). Splinting the chest while coughing, taking pain medication, and turning every two hours are important for the recovery of the coronary bypass patient, but have little impact on preventing VTE.

The nurse is monitoring a postoperative patient in the Phase I postanesthesia care unit (PACU). Discharge criteria for the Phase I patient include which of the following? Select all that apply. 1. No nausea or vomiting 2. No respiratory depression 3. Oxygen saturation above 90% 4. Written discharge instructions understood 5. Patient reports pain level of 4 on a 1 to 10 scale

2, 3, 5. Discharge criteria from Phase I are listed in Table 20-8 and include: oxygen saturation above 90%; no respiratory depression; and pain controlled or tolerable. Nausea and vomiting should be minimal. Understanding written discharge instructions are part of Phase II discharge criteria.

A postoperative patient develops fever, abdominal pain, and diarrhea despite being on long-term antibiotics. What should the nurse evaluate for? 1. Wound infection 2. Urinary infection 3. Respiratory infection 4. Clostridium difficile infection

4. Prolonged use of antibiotics increases the risk of Clostridium difficile infection by damaging the normal flora of the intestine. The infection is manifested as fever, diarrhea, and abdominal pain. Wound infection, urinary infection, and respiratory infection may present with fever, but these infections rarely present with diarrhea and abdominal pain.

An alcoholic patient who has undergone a hernia operation is restless and irritable. On assessment, the nurse finds that the patient has auditory hallucinations. What is the most appropriate nursing action? 1. Conclude that the patient suffers from a psychotic disorder. 2. Consider the situation normal, due to the anesthetic drugs. 3. Infer that the patient is suffering from pain and suggest using pain killers. 4. Conclude that these effects are due to alcohol withdrawal.

4. The patient is irritable and restless due to loss of the inhibitory effects of alcohol; this is also causing the hallucinations. The patient does not have a history of psychotic illness; therefore, the symptoms cannot be attributed to a psychotic disorder. Anesthetic drugs may cause delirium, but not hallucinations. Pain may cause restlessness and irritability, but not hallucinations.

A patient is being discharged after laparoscopic cholecystectomy. The nurse should instruct the patient to notify the surgeon immediately if which condition develops? 1. Constipation 2. Right shoulder pain 3. Decreased appetite 4. Temperature of 103° F

4. The primary health care provider should be notified immediately if the patient experiences an increase in temperature higher than 101° F because this may be indicative of an infectious process that will require immediate interventions to resolve. Right shoulder pain is expected after a laparoscopic surgery and is resolved within 48 to 72 hours. Constipation and decreased appetite may occur. If these do not resolve after discharge, the patient should be instructed to contact the primary health care provider.

Phases of post anesthesia care: Phase 2

Ambulatory surgery patients. Goal: Prepare patient for transfer to extended observation, home, or extended care facility.

Postoperative period

Begins immediately after surgery and continues until the patient is discharged from medical care.

Atelectasis (alveolar collapse)

Bronchial obstruction caused by retained secretion or decreased lung volumes.

Phases of post anesthesia care : Phase 1

Care during the immediate post-anesthesia period. ECG and more intense monitoring (BP, mechanical ventilation, etc.) Goal: Prepare patient for transfer to phase 2 or inpatient unit.

Airway Obstruction

Commonly caused by blockage of the airway by the patient's tongue.

Phases of post anesthesia care: Extended Observation

Extended care or observation unit. Goal: Prepare patient for self-care.

Pulmonary Edema

Fluid overload Increased Hydrostatic pressure Decreased interstitial pressure Increased capillary permeability

Bronchospasm

Increased smooth muscle tone with closure of small airways.

Aspiration

Inhalation of gastric contents into lungs

The postanesthesia care unit (PACU) nurse has received a patient and all of the following assessments are included in the initial assessment. In which order should the nurse perform the following actions for the patient with no complications? Correct 1. Airway 2. Breathing 3. Circulation 4. Neurologic 5. Gastrointestinal 6. Output 7. Surgical Site

The airway, breathing, and circulation are evaluated first with vital signs, ECG, and other noninvasive methods. In the patient not experiencing surgical complications, initial neurologic assessment next will focus on level of consciousness, orientation, sensory (touch, temperature, pain) and motor status, and reactivity of pupils. The gastrointestinal system's bowel sounds will be assessed if there is no nausea and vomiting. Then output of urine and blood or wound drainage lost during surgery will be assessed for balance with the intravenous (IV) and irrigation input. The surgical site will be assessed next.

Pulmonary embolism

Thrombus dislodged from peripheral venous system and lodged in pulmonary artery system.

A nurse is monitoring the status of a post-operative client. The nurse would become most concerned with which of the following signs that could indicate an evolving complication? a. increasing restlessness b. a pulse of 86 beats/min c. blood pressure of 110/70 d. hypoactive bowel sounds in all four quadrants

a

A postoperative client asks a nurse why it is so important to deep breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to: a. pneumonia b. fluid imbalance c. pulmonary embolism d. carbon dioxide retention

a

A nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? a. red, hard skin b. serous drainage c. purulent drainage d. warm, tender skin

b

A patient is admitted to the PACU following major abdominal surgery. During the initial assessment, the patient tells the nurse that he thinks he is going to "throw up". A priority nursing intervention would be to: A. obtain vital signs, including O2 saturation B. position the patient in a lateral recovery position C. administer antiemetic medications as ordered D. apply intermittent compression devices (ICDs)

b

Unless contraindicated by the surgical procedure, which of the following positions is preferred for the unconscious patient immediately postoperative? A. Supine B. Lateral C. Semi-Fowler's D. High-Fowler's

b

A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to "throw up." A priority nursing intervention would be to: a. increase the rate of IV fluids b. obtain vital signs, including O2 saturation c. position patient in lateral recovery position d. administer antiemetic medication as ordered

c. position patient in lateral recovery position Rationale: If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs.

A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? a. Manage patient pain. b. Control the bleeding. c. Maintain fluid balance. d. Manage oxygenation status.

d. Manage oxygenation status. The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.

A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to: a. perform a straight catheterization to measure the amount of urine in the bladder b. notify the physician and anticipate obtaining blood work to evaluate renal function c. continue to monitor the patient because this is a normal finding during this time period d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound

d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound Rationale: Because of the possibility of infection associated with catheterization, the nurse should first try to validate that the bladder is full. The nurse should consider fluid intake during and after surgery and should determine bladder fullness by percussion, by palpation, or by a portable bladder ultrasound study to assess the volume of urine in the bladder and avoid unnecessary catheterization.

A nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which of the following parameters most carefully during the next hour? a. urinary output of 20 ml/hr b. temperature of 37.6°C (99.6°F) c. blood pressure of 100/70 d. serous drainage on the surgical dressing

a, minimum is 30ml/hr

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, the nurse should do which of the following? A. Recheck in 1 hour for increased drainage. B. Notify the surgeon of a potential hemorrhage. C. Assess the patient's blood pressure and heart rate. D. Remove the dressing and assess the surgical incision.

c

A patient who has been admitted to the postoperative unit following a major abdominal surgery develops noisy respirations. On auscultation, the nurse finds coarse crackles in the lungs. How should the nurse prevent pulmonary complications in this patient? Select all that apply. 1. By suctioning the airways 2. By providing IV hydration 3. By administering sedatives 4. By abdominal exercises 5. By administering cough suppressants

1, 2. Coarse crackles and noisy respiration are caused by increased respiratory secretions due to use of irritant anesthetic drugs. Suctioning helps clear the airway of secretions. IV hydration helps keep the secretions in liquid form, allowing them to be easily suctioned. Sedatives and cough suppressants would hinder clearing the secretions in the airways; therefore, they should not be used. Chest physical therapy, rather than abdominal exercises, would be helpful to clear secretions.

A postoperative patient who has been transferred from surgery to the postanesthesia care unit is cold and shivering. The patient's plan of care includes a prescription for morphine (Evinza) to be administered for pain relief. When managing this patient, which interventions should the nurse perform?Select all that apply. 1. Give warm IV fluids. 2. Withhold opioids. 3. Use forced air warmers. 4. Use warmed cotton blankets. 5. Administer oxygen therapy.

1, 3, 4, 5. Administering warm liquids and using forced air warmers are active warming methods. Using warmed cotton blankets is a passive warming measure. Oxygen therapy is needed to meet the increased oxygen demand during shivering. Opioids are used to treat shivering in the immediate postoperative period, so the nurse should not withhold the morphine dose.

While caring for a patient after a colectomy on the first postoperative day, the nurse notes new bright-red drainage about 4 cm in diameter on the surgical dressing. What is the priority nursing action? 1. Take the patient's vital signs. 2. Mark the area on the dressing and document the finding. 3. Recheck the dressing in one hour for increased drainage. 4. Notify the health care provider of a potential hemorrhage.

1. The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse then can report the findings to the provider. Marking the area is acceptable, but not the priority nursing action. Rechecking the dressing in an hour increases the risk of adverse outcomes by waiting more time to notify the health care provider about a potential bleeding complication. The health care provider should be notified after the nurse assesses the patient.

The nurse is teaching deep breathing and coughing techniques to a postoperative patient with abdominal incision. Which important instruction should the nurse include in her teaching regarding safe use of this technique? 1. Splint the abdominal incision with a pillow. 2. Perform the technique two times every waking hour. 3. Encourage deep breathing and coughing if the patient is in pain or feels the urge to clear secretions. 4. Limit fluid intake to thicken the secretions and membranes.

1. When performing deep breathing and coughing exercises, the patient should splint the abdominal incision site with a pillow or folded blankets to support the incision. The patient may be instructed to perform the technique 10 times every hour if the condition allows. The nurse should assure the patient that the breathing and coughing techniques will not harm the incision site and are essential to mobilizing secretions. The patient should be instructed to drink sufficient water to keep the secretions thin.

A patient is admitted to the postanesthesia care unit (PACU) after major colon surgery. During the initial assessment the patient tells the nurse he or she thinks he or she is going to "throw up." Which statement by the nurse reflects a priority nursing intervention? 1. "I need to check your vital signs." 2. "Let me help you turn to your side." 3. "Here is a sip of ginger-ale for you." 4. "I can give you some antinausea medicine."

2. If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs. Checking vital signs does not address the nausea. It may not be appropriate to give the patient oral fluids immediately following bowel surgery. Administering an antiemetic may be appropriate after turning the patient to the side.

A patient has undergone a major orthopedic surgery and is immobilized. On the third postoperative day, the patient reports dyspnea. On examination, the nurse finds that the patient has tachypnea, tachycardia, hypotension, and reduced oxygen saturation. How would the nurse relieve the patient of dyspnea? Select all that apply. 1. Administer lidocaine. 2. Administer oxygen therapy. 3. Administer anticoagulant therapy. 4. Administer bronchodilators. 5. Administer skeletal muscle relaxant.

2, 3. Dyspnea associated with tachypnea, tachycardia, hypotension, and reduced oxygen saturation following a major orthopedic surgery indicates a pulmonary embolism. A pulmonary embolism could be a result of dislodgement of thrombus from the peripheral veins. Oxygen therapy helps improve oxygen saturation. Anticoagulant therapy prevents the blood from clotting further. Lidocaine, a local anesthetic, helps relieve laryngospasm, but may not relieve pulmonary embolism. Bronchodilators help to dilate the airways, but have no effect on embolism as it is associated with the compromised pulmonary circulation. IV skeletal muscle relaxants help relax the muscles to relieve laryngeal spasm, but do not help relieve pulmonary embolism.

A patient is transferred to the postanesthesia care unit (PACU) after surgery. Which nursing intervention is the highest priority initially? 1. Assess intake, output, and fluid balance. 2. Assess airway, breathing, and circulation status. 3. Note the presence of all IV lines and drainage catheters. 4. Assess the surgical site and condition of the dressing.

2. When the patient is shifted to the PACU after surgery, the nurse should first assess the patient's airway, breathing, and circulation status. Any evidence of respiratory or circulatory compromise needs immediate intervention. Thereafter, the nurse may assess the patient's intake, output, and fluid status and note the presence of IV lines and drainage bags. The nurse should also assess the surgical site and condition of the wound.

A patient on the postoperative unit develops an airway obstruction due to the tongue falling back. How should the nurse ensure a patent airway? Select all that apply. 1. By suctioning the airway 2. By administering oxygen therapy 3. By tilting the head and thrusting the jaw 4. By administering sedatives 5. By putting in an artificial airway

3, 5. The physical repositioning of a patient to reestablish the patency of the airway involves tilting the head and thrusting the jaw. If the physical repositioning does not help, the patient may need an artificial airway to assist in breathing. Suctioning is helpful for patients with increased secretions; it may not help a patient with an airway obstruction. Oxygen therapy does not help unless the airway is patent. Sedatives would worsen the airway prolapse.

A patient has been admitted to the postanesthesia care unit (PACU). Which of these assessment findings require the nurse's immediate action? 1. The patient indicates that he or she is in pain. 2. The patient is groggy but arouses to voice. 3. The patient is restless, agitated, and hypotensive. 4. The Jackson-Pratt is draining serosanguinous fluid.

3. Assessment in the PACU begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Restlessness, agitation, and hypotension are clinical manifestations of inadequate oxygenation. Identification of inadequate oxygenation and ventilation or respiratory compromise requires prompt intervention. Pain, sedation, and draining serosanguinous fluid are expected findings.

A postoperative patient had his or her Foley catheter removed at 1200. At 2100, the patient still has not voided. The priority nursing intervention for this assessment would be to 1. Perform a straight catheterization 2. Continue to monitor the patient as this is an expected finding 3. Assess for bladder fullness by percussion, palpation, or portable bladder scanner 4. Notify the health care provider and anticipate obtaining blood work to evaluate renal function

3. Most patients urinate within six to eight hours after surgery. If no voiding occurs, the nurse should consider fluid intake during and after surgery and should determine bladder fullness by percussion, palpation, or by a portable bladder ultrasound to assess the volume of urine in the bladder and avoid unnecessary catheterization. Inability to void is not an expected finding. It is not necessary to assess renal function.

The nurse recalls that the earliest symptom of pulmonary edema is: 1. Early-morning cough 2. Increased urine output 3. Paroxysmal nocturnal dyspnea 4. Crackles heard on auscultation

3. The most common cause of pulmonary edema is left-sided congestive heart failure, which commonly manifests as shortness of breath and crackles in the lungs. Between the two, shortness of breath in the form of paroxysmal nocturnal dyspnea is the earlier symptom, although crackles is more common. An early-morning cough may be seen with respiratory infection or chronic obstructive pulmonary disease but is not usually a symptom of pulmonary edema. In pulmonary edema, urine output is typically decreased due to fluid retention. Crackles heard on auscultation of the lungs is one of the more common symptoms of pulmonary edema, along with coughing of frothy pink-tinged sputum.

A patient, who is eight hours postappendectomy, has not voided since surgery. What action should the nurse take? 1. Encourage oral (PO) fluid intake 2. Insert an in and out catheter to assess for retention 3. Palpate the suprapubic area for bladder distention 4. Check the medical record to determine the type of anesthetic given

3. The nurse needs to know first if there is urine in the bladder. The assessment can be done by palpating or scanning the suprapubic area. Encouraging PO fluid intake is appropriate if the patient can tolerate PO fluids and there is no bladder distention. Because of the risk of infection, an in and out catheter is not used for assessment purposes but to relieve known urine retention. No matter what type of anesthetic was administered, the nurse needs to determine if the patient has not voided because of a lack of urine output or if the issue is an alteration in micturition

Which nursing intervention is important to prevent syncope in a postoperative patient? 1. Administer oxygen therapy. 2. Administer analgesics before ambulation. 3. Make changes in the patient's position slowly. 4. Encourage deep breathing and coughing exercises.

3. To prevent syncope in a postoperative patient, the nurse should slowly change the patient's position. Progression to ambulation can be achieved by first raising the head of the patient's bed for 1 to 2 minutes and then assisting the patient to sit, with legs dangling, while monitoring the pulse rate. If no changes or complaints are noted, start ambulation with ongoing monitoring of the pulse. Oxygen therapy and deep breathing and coughing exercises are interventions to improve pulmonary function and not to prevent syncope. Administering analgesics before ambulation makes the activity painless and encourages the patient to become more active.

A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Increase the IV infusion rate. b. Assess the patient's dressing. c. Increase the oxygen flow rate. d. Check the patient's temperature.

ANS: A, C, B, D The first nursing action should be to increase the IV infusion rate. Because the most common cause of hypotension is volume loss, the IV rate should be increased. The next action should be to increase the oxygen flow rate to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient's temperature should be assessed to determine the effects of vasodilation caused by rewarming.

While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities? (Put a comma and a space between each answer choice [A, B, C, D].) a. Have the patient sit down in a chair. b. Give the patient something to drink. c. Take the patient's blood pressure (BP). d. Notify the patient's health care provider.

ANS: A, C, B, D The first priority for the patient with syncope is to prevent a fall, so the patient should be assisted to a chair. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the fluid intake will help prevent orthostatic dizziness. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no urgent need to notify the health care provider.

A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first? a. Assess the patient's pain. b. Orient the patient to the unit. c. Take the patient's vital signs. d. Read the postoperative orders.

ANS: C Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer.

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8° F. Which action should the nurse take first? a. Have the patient use the incentive spirometer. b. Assess the surgical incision for redness and swelling. c. Administer the ordered PRN acetaminophen (Tylenol). d. Ask the health care provider to prescribe a different antibiotic.

ANS: A A temperature of 100.8° F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because a wound infection does not usually occur before the third postoperative day, a wound infection is not a likely source of the elevated temperature.

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider? a. The right calf is swollen, warm, and painful. b. The patient's temperature is 100.3° F (37.9° C). c. The 24-hour oral intake is 600 mL greater than the total output. d. The patient complains of abdominal pain at level 6 (0 to 10 scale) when ambulating.

ANS: A The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require the health care provider to order diagnostic tests and/or anticoagulants. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3° F on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities.

A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first? a. Perform a bladder scan. b. Encourage increased oral fluid intake. c. Assist the patient to ambulate to the bathroom. d. Insert a straight catheter as indicated on the PRN order.

ANS: A The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Because of the risk for urinary tract infection, catheterization should only be done after other measures have been tried without success. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful.

The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take? a. Cover the patient with a warm blanket and put on socks. b. Notify the anesthesia care provider about the temperature. c. Avoid the use of opioid analgesics until the patient is warmer. d. Administer acetaminophen (Tylenol) 650 mg suppository rectally.

ANS: A The patient assessment indicates the need for active rewarming. There is no indication of a need for acetaminophen. Opioid analgesics may help reduce shivering. Because hypothermia is common in the immediate postoperative period, there is no need to notify the anesthesia care provider, unless the patient continues to be hypothermic after active rewarming.

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery c. Patient who has bibasilar crackles and a temperature of 100°F (37.8°C) on the first postoperative day after chest surgery d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) administration

ANS: A The patient's history and assessment suggests possible wound dehiscence, which should be reported immediately to the surgeon. Although the information about the other patients indicates a need for ongoing assessment and/or possible intervention, the data do not suggest any acute complications. Small amounts of red drainage are common in the first postoperative hours. Bibasilar crackles and a slightly elevated temperature are common after surgery, although the nurse will need to have the patient cough and deep breathe. Oral medications typically take more than 15 minutes for effective pain relief.

A patient who had knee surgery received intramuscular ketorolac (Toradol) 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is best for the nurse to take at this time? a. Administer the prescribed PRN IV morphine sulfate. b. Notify the health care provider about the ongoing knee pain. c. Reassure the patient that postoperative pain is expected after knee surgery. d. Teach the patient that the effects of ketorolac typically last about 6 to 8 hours.

ANS: A The priority at this time is pain relief. Concomitant use of opioids and nonsteroidal antiinflammatory drugs (NSAIDs) improves pain control in postoperative patients. Patient teaching and reassurance are appropriate, but should be done after the patient's pain is relieved. If the patient continues to have pain after the morphine is administered, the health care provider should be notified.

On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Continue to take vital signs every 15 minutes. c. Administer oxygen therapy at 100% per mask. d. Notify the anesthesia care provider (ACP) immediately.

ANS: B A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration.

The nasogastric (NG) tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. What action by the nurse is the most appropriate? a. Reinsert the NG tube. b. Give the PRN IV opioid. c. Assist the patient to ambulate. d. Place the patient on NPO status.

ANS: C Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient's discomfort. If distention persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains.

A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. Which action by the nurse is most helpful? a. Teach the patient to fully exhale into the incentive spirometer. b. Administer ordered analgesic medications before these activities. c. Ask the patient to state two possible complications of immobility. d. Encourage the patient to state the purpose of splinting the incision.

ANS: B An important nursing action to encourage these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities. When using an incentive spirometer, the patient should be taught to inhale deeply, rather than exhale into the spirometer to promote lung expansion and prevent atelectasis.

The nurse reviews the laboratory results for a patient on the first postoperative day after a hiatal hernia repair. Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing? a. Potassium 3.5 mEq/L b. Albumin level 2.2 g/dL c. Hemoglobin 11.2 g/dL d. White blood cells 11,900/µL

ANS: B Because proteins are needed for an appropriate inflammatory response and wound healing, the low serum albumin level (normal level 3.5 to 5.0 g/dL) indicates a risk for poor wound healing. The potassium level is normal. Because a small amount of blood loss is expected with surgery, the hemoglobin level is not indicative of an increased risk for wound healing. WBC count is expected to increase after surgery as a part of the normal inflammatory response.

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Assess for bladder distention. c. Notify the anesthesia care provider (ACP). d. Demonstrate the use of the nurse call bell button.

ANS: B Because the patient's assessment indicates physiologic stability, the most likely cause of the patient's agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should look for a cause such as bladder distention. Although hypoxemia is the most common cause, the patient's oxygen saturation is 96%. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify the ACP. Orientation of the patient to bed controls is needed, but is not likely to be effective until the effects of anesthesia have resolved more completely.

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? a. Administer the ordered opioid. b. Check the oxygen (O2) saturation. c. Take the blood pressure and pulse. d. Apply wrist restraints to secure IV lines.

ANS: B Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action.

An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I do not know if I can take care of myself with this patch over my eye." Which action by the nurse is most appropriate? a. Refer the patient for home health care services. b. Discuss the specific concerns regarding self-care. c. Give the patient written instructions regarding care. d. Assess the patient's support system for care at home.

ANS: B The nurse's initial action should be to assess exactly the patient's concerns about self-care. Referral to home health care and assessment of the patient's support system may be appropriate actions but will be based on further assessment of the patient's concerns. Written instructions should be given to the patient, but these are unlikely to address the patient's stated concern about self-care.

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient? a. Potential complication: hypovolemic shock b. Potential complication: venous thromboembolism c. Potential complication: fluid and electrolyte imbalance d. Potential complication: impaired surgical wound healing

ANS: B The patient is older and relatively immobile, which are two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient.

In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient to a clinical unit. d. Increase the rate of the postoperative IV fluids.

ANS: B The patient's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable blood pressure and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU to a clinical unit is not appropriate.

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit? a. Clarify the postoperative orders with the surgeon. b. Help with the transfer of the patient onto a stretcher. c. Document the appearance of the patient's incision in the chart. d. Provide hand off communication to the surgical unit charge nurse.

ANS: B The scope of practice of UAP includes repositioning and moving patients under the supervision of a nurse. Providing report to another nurse, assessing and documenting the wound appearance, and clarifying physician orders with another nurse require registered-nurse (RN) level education and scope of practice.

A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate? a. Notify the patient's surgeon. b. Place the patient on bed rest. c. Document the color and amount of drainage. d. Irrigate the T-tube with sterile normal saline.

ANS: C A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary.

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first? a. Reinforce the dressing. b. Apply an abdominal binder. c. Take the patient's vital signs. d. Recheck the dressing in 1 hour for increased drainage.

ANS: C New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing.

A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed? a. Patient drinks 2 to 3 L of fluid in 24 hours. b. Patient uses the spirometer 10 times every hour. c. Patient's breath sounds are clear to auscultation. d. Patient's temperature is less than 100.4° F orally.

ANS: C One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or crackles, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems.

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful? a. The new nurse assists a nauseated patient to a supine position. b. The new nurse positions an unconscious patient supine with the head elevated. c. The new nurse turns an unconscious patient to the side upon arrival in the PACU. d. The new nurse places a patient in the Trendelenburg position when the blood pressure drops.

ANS: C The patient should initially be positioned in the lateral "recovery" position to keep the airway open and avoid aspiration. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness.

The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first? a. Elevate the patient's head. b. Suction the patient's mouth. c. Increase the oxygen flow rate. d. Perform the jaw-thrust maneuver.

ANS: D In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient's head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake.

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon? a. Tympanic temperature 99.2° F (37.3° C) b. Fine crackles audible at both lung bases c. Redness and swelling along the suture line d. 200 mL sanguineous fluid in the wound drain

ANS: D Wound drainage should decrease and change in color from sanguineous to serosanguineous by the second postoperative day. The color and amount of drainage for this patient are abnormal and should be reported. Redness and swelling along the suture line and a slightly elevated temperature are normal signs of postoperative inflammation. Atelectasis is common after surgery. The nurse should have the patient cough and deep breathe, but there is no urgent need to notify the surgeon.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply: a. contact the surgeon b. instruct the client to remain quiet c. prepare the client for wound closure d. document the findings and actions taken e. place a sterile saline dressing and ice packs over the wound f. place the client in a supine position without a pillow under the head

a, b, c, d

Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which of the following health problems is the patient experiencing? A. Atelectasis B. Bronchospasm C. Hypoventilation D. Pulmonary embolism

a

Following admission of a postoperative patient to the clinical unit, which of the following assessment data requires the most immediate attention? A. oxygen saturation of 85% B. respiratory rate of 13/min C. temperature of 100.4°F (38°C) D. blood pressure of 90/60mmHg

a

In planning postoperative interventions to promote ambulation, coughing, deep breathing, and turning, the nurse recognizes that which of the following actions will best enable the patient to achieve the desired outcomes? A. Administering adequate analgesics to promote relief or control of pain B. Asking the patient to demonstrate the postoperative exercises every 1 hour C. Giving the patient positive feedback when the activities are performed correctly D. Warning the patient about possible complications if the activities are not performed

a

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)? a. Vital signs baseline or stable b. Minimal nausea and vomiting c. Wants to go to the bathroom at home d. Responsible adult taking patient home e. Comfortable after IV opioid 15 minutes ago

a, b, & d Ambulatory surgery discharge criteria includes meeting Phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria includes a responsible adult driving patient, no IV opioid drugs for last 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes? a. Administering adequate analgesics to promote relief or control of pain b. Asking the patient to demonstrate the postoperative exercises every 1 hour c. Giving the patient positive feedback when the activities are performed correctly d. Warning the patient about possible complications if the activities are not performed

a. Administering adequate analgesics to promote relief or control of pain Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.

Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing? a. Atelectasis b. Bronchospasm c. Hypoventilation d. Pulmonary embolism

a. Atelectasis The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.

After admission of the postoperative patient to the clinical unit, which assessment data require the most immediate attention? a. Oxygen saturation of 85% b. Respiratory rate of 13/min c. Temperature of 100.4F d. Blood pressure of 90/60 mmHg

a. Oxygen saturation of 85% Rationale: During the initial assessment, identify signs of inadequate oxygenation and ventilation. Pulse oximetry monitoring is initiated because it provides a noninvasive means of assessing the adequacy of oxygenation. Pulse oximetry may indicate low oxygen saturation (<90% to 92%) with respiratory compromise. This necessitates prompt intervention.

A 70-kg postoperative patient has an average urine output of 25ml?hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to: A. place in indwelling urinary catheter and assess urine characteristics B. evaluate the patient's fluid volume status and obtain a bladder ultrasound C. notify the physician and anticipate the patient returning to the operating room D. continue to monitor the patient as this is a normal, expected finding after surgery

b

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia unit. Which of the following should be the nurse's initial action upon the patient's arrival? A. Assess the patient's pain. B. Assess the patient's vital signs. C. Check the rate of the IV infusion. D. Check the physician's postoperative orders.

b

Discharge criteria for the phase II patient includes (select all that apply): A. ability to drive self home B. no respiratory depression C. minimal nausea and vomiting D. written discharge instruction

b, c, d

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? a. Assess the patient's pain. b. Assess the patient's vital signs. c. Check the rate of the IV infusion. d. Check the physician's postoperative orders.

b. Assess the patient's vital signs. The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence.

Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately postoperative? a. Supine b. Lateral c. Semi-Fowler's d. High-Fowler's

b. Lateral Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated.

The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient? a. Blood administration b. Restoring circulating volume c. An ECG to check circulatory status d. Return to surgery to check for internal bleeding

b. Restoring circulating volume The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, or there is a past history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient's level of consciousness changes or the abdomen becomes firm and distended.

During the patient's admission to the PACU, what are the primary interventions the nurse performs? A. assess the surgical site, noting the presence and character of drainage B. assess the amount of urinary output and the presence of bladder distention C. assess the airway for patency and quality of respirations and obtain vital signs D. review the results of intraoperative laboratory values and medications received

c

Discharge criteria for the Phsae II patient include (select all that apply): a. no nausea or vomiting b. ability to drive self home c. no respiratory depression d. written discharge instructions understood e. opioid pain medication given 45 minutes ago

c, d, & e Rationale: Phase II discharge criteria that must be met include the following: all PACU discharge criteria (Phase I) met; no intravenous opioid drugs administered for the past 30 minutes; patient's ability to void (if appropriate with regard to surgical procedure or orders); patient's ability to ambulate if it is not contraindicated; presence of a responsible adult to accompany or drive patient home; and written discharge instructions given and understood.

When a patient is admitted to the PACU, what are the priority interventions the nurse performs? a. Assess the surgical site, no tine presence and character of drainage b. Assess the amount of urine output and the presence of bladder distention c. Assess for airway potency and quality of expirations, and obtain vital signs. d. Review results of intraoperative laboratory values and medications received.

c. Assess for airway potency and quality of expirations, and obtain vital signs. Rationale: Assessment in the postanesthesia care unit (PACU) begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Identification of inadequate oxygenation and ventilation or respiratory compromise necessitates prompt intervention.

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first? a. Recheck in 1 hour for increased drainage. b. Notify the surgeon of a potential hemorrhage. c. Assess the patient's blood pressure and heart rate. d. Remove the dressing and assess the surgical incision.

c. Assess the patient's blood pressure and heart rate. The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)? a. Monitor the patient's pain. b. Do the admission vital signs. c. Assist the patient to take deep breaths and cough. d. Change the dressing when there is excess drainage.

c. Assist the patient to take deep breaths and cough. The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The LPN or RN will monitor and treat the patient's pain and change the dressings.

A postoperative patient is transferred from the postanesthesia unit to the medical-surgical nursing floor. The nurse notes that the patient has an order for D5½ NS to infuse at 125 ml/hr. Until an IV pump is available, the nurse regulates the IV flow rate at which of the following drops (gtts)/min, noting that the tubing has a drop factor of 10 drops/ml? A. 13 gtts/min B. 31 gtts/min C. 25 gtts/min D. 21 gtts/min

d

The nurse is preparing to administer cefazolin (Ancef) 2 gm in 100 ml of normal saline to a postoperative patient. Which of the following IV rates will infuse this medication over 20 minutes? A. 100 ml/hr B. 150 ml/hr C. 200 ml/hr D. 300 ml/hr

d

A pt undergoes mastoidectomy. When the pt returns to the floor postoperatively, the pt has difficulty drinking without drooling. It is most important for the nurse to take which of the following actions? a. reassure the pt that this will disappear in a few days b. tell the pt that she is understandably tired and should rest c. loosen the dressing on the affected ear d. check the pt's ability to whistle

d, the ability to whistle tests for the postoperative complication of facial nerve paralysis

The patient donated a kidney, and early ambulation is included in her plan of care. But the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? a. "Early walking keeps your legs limber and strong." b. "Early ambulation will help you be ready to go home." c. "Early ambulation will help you get rid of your syncope and pain." d. "Early walking is the best way to prevent postoperative complications."

d. "Early walking is the best way to prevent postoperative complications." The best rationale is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and VTE, speeds wound healing, and increases vital capacity and maintains normal respiratory function. These things help the patient be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management should always occur before walking.

An older patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this new patient? a. Check his chart for intraoperative complications. b. Check which medications were used for anesthesia. c. Check the effectiveness of the analgesics he has received. d. Check his preoperative assessment for previous delirium or dementia.

d. Check his preoperative assessment for previous delirium or dementia. If the patient's ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed as these can all contribute to delirium.