Med Surg: Ch 19 thePoint

3

A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention? 1) Administering pain medications within 1 hour of the client's request 2) Obtaining dietary consultation for improved wound healing 3) Assessing WBC count, temperature, and wound appearance 4) Educating the client on safe bed-to-chair transfer procedures

4

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound 1) hemorrhaged. 2) pustulated. 3) eviscerated. 4) dehisced.

3

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for? 1) Contractures 2) Phlebitis 3) Wound dehiscence 4) Hypotension

1

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage? 1) The Hemovac drain isn't compressed; instead it's fully expanded. 2) There is a moderate amount of dry drainage on the outside of the dressing. 3) The client has a nasogastric (NG) tube in place that drained 400 ml. 4) The client has been lying on his side for 2 hours with the drain positioned upward.

3

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? 1) Request the order be discontinued without obtaining the specimen. 2) Use an antibiotic cleaning agent before obtaining the specimen. 3) Obtain the wound culture specimen. 4) Hold the order until purulent drainage is noted.

2

A recently extubated postoperative client starts to gag and make vomiting sounds. What action should the nurse perform first? 1) Administer an antiemetic. 2) Turn the client onto their side. 3) Provide an emesis basin. 4) Obtain suction equipment.

2

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? 1) Pulmonary edema 2) Pneumonia 3) Pleurisy 4) Hypoxemia

4

What measurement should the nurse report to the physician in the immediate postoperative period? 1) A hemoglobin of 13.6 2) A temperature reading between 97°F and 98°F 3) Respirations between 20 and 25 breaths/min 4) A systolic blood pressure lower than 90 mm Hg

2

Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client? 1) Instruct the client to prop a pillow under the knees. 2) Reinforce the need to perform leg exercises every hour when awake. 3) Administer prophylactic high-dose heparin. 4) Maintain bed rest.

3

Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective? 1) Bladder non-distended; Foley catheter draining clear, yellow urine 2) Bowel sounds present and active; denies nausea and vomiting 3) Vital signs within normal limits; absence of chills and cough 4) Alert and oriented; peripheral pulses present and strong

3

Which term refers to the protrusion of abdominal organs through the surgical incision? 1) Hernia 2) Dehiscence 3) Evisceration 4) Erythema

2

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis? 1) Decreased cardiac output 2) Ineffective thermoregulation 3) Acute incisional pain 4) Ineffective airway clearance

5

The client asks the nurse about ways to control pain other than taking pain medication. Which strategy should the nurse include when responding to the client? Select all that apply. 1) Watching television 2) Listening to music 3) An On-Q pump 4) An epidural infusion 5) Changing position

1

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? 1) Pink to red and soft, bleeding easily 2) White with long, thin areas of scar tissue 3) Necrotic and hard 4) Pale yet able to blanch with digital pressure

1

The nurse has medicated a postoperative client who reported nausea. Which medication would the nurse document as having been given? 1) Ondansetron 2) Propofol 3) Prednisone 4) Warfarin

4

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? 1) Normal healing by primary intention. 2) Hemorrhage 3) Evisceration 4) Dehiscence

2

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required? 1) "I should call my physician if I develop a fever." 2) "I can resume my usual activities as soon as I get home." 3) "My incision should become less red and tender." 4) "I need to keep my follow-up appointment with the physician."

1

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? 1) 7 2) 6 3) 4 4) 5

1

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? 1) Reinforcing dressings or applying pressure if bleeding is frank 2) Encouraging the client to breathe deeply 3) Elevating the head of the bed 4) Rubbing the back

4

The nurse recognizes which symptom as a clinical manifestation of shock? 1) Warm, dry skin 2) Increased urine output 3) Flushed face 4) Rapid, weak, thready pulse