Medical-Surgical Nursing Chapter 20 Postoperative Care

3 The formula for determining adequate urine output is 0.5 mL/kg/hr. This patient, weighing 91 kg, needs to have 45 cc per hour or about 365 cc of urine in eight hours. It often takes three to five days for the bowel to begin working postabdominal surgery; therefore, it would be inappropriate at this time to encourage PO fluids. Continuing to monitor the urine output, instead of calling the primary health care provider, would delay identifying and treating the cause for the low urine output. The nurse must obtain a prescription for the normal saline bolus before administration. Text Reference - p. 360

A nurse is caring for a patient, who had a bowel resection 10 hours before. The patient weighs 200 pounds (91 kg) and has a urine output of 240 cc for the past eight hours. What action should the nurse take? 1 Encourage oral (PO) fluids 2 Continue to monitor the urine output 3 Notify the primary health care provider 4 Administer a 500 cc normal saline intravenous (IV) bolus

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. Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early. Text Reference - p. 350

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.

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 because 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. Text Reference - p. 352

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 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. Test-Taking Tip: As you answer each question, write a few words about why you think that answer is correct; in other words, justify why you selected that answer. If an answer you provide is a guess, mark the question to identify it. This will permit you to recognize areas that need further review. It will also help you to see how correct your "guessing" can be. Remember: on the licensure examination you must answer each question before moving on to the next question. Text Reference - p. 360

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 anti-nausea medicine."

4 The first action of the nurse is to identify what the patient's normal blood pressure is. Interventions are dependent on the baseline variation. Rousing the patient is an intervention that can increase the blood pressure, but would be done after determining the baseline blood pressure. Placing the patient in Trendelenburg is not an appropriate action in this situation. Before notifying the anesthesiologist of the blood pressure, the nurse needs to check the baseline blood pressure. Text Reference - p. 355

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure of 100/60 mm Hg. Which action should the nurse take first? 1 Rouse the patient 2 Place the patient in the Trendelenburg position 3 Notify the anesthesiologist of the low blood pressure 4 Check the medical record for the patient's baseline blood pressure

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. Text Reference - p. 359

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 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 the patient's ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase the risk for upper airway edema, causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action. Text Reference - p. 363

A patient is having elective cosmetic surgery performed on the face. The patient will remain at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? 1 Manage patient pain 2 Control the bleeding 3 Maintain fluid balance 4 Manage oxygenation status

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. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action. Text Reference - p. 350

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 The use of skeletal muscle relaxants may paralyze the muscles required for breathing. Administering drugs for reversal of paralysis may make breathing easier. Use of opioids aggravates the condition by causing respiratory depression. Loosening the dressing and repositioning the patient are helpful when the breathing difficulty is caused by mechanical restriction, but may not help in this case. Text Reference - p. 352

A patient on the postoperative unit reports having much difficulty breathing. The nurse discovers that the patient received large doses of skeletal muscle relaxants during surgery. What should the nurse include in the patient's plan of care to promote breathing? 1 Administering opioids 2 Administering drugs for reversal of paralysis 3 Loosening the dressings 4 Repositioning the patient

1 Pain management is essential to postoperative care. Assessing the level of pain and offering an analgesic before performing postoperative breathing exercises or any activities will ease pain and facilitate compliance, thus decreasing the risk of complications. Checking vital signs, assisting the patient into a chair, and reviewing the primary healthcare provider's plan of care are all appropriate after the patient's pain level has been assessed. Text Reference - p. 349

A patient undergoes abdominal surgery. Before asking the patient to perform postoperative breathing exercises, what evaluation or intervention should the nurse perform? 1 Gauging the patient's level of pain 2 Evaluating the patient's vital signs 3 Assisting the patient out of bed and into a chair 4 Reviewing the primary health care provider's plan of care

1, 3, 5 The hypoventilation observed in this patient is due to mechanical restriction caused by the abdominal binder. Therefore, the patient should be repositioned to improve comfort and the binder should be loosened to relieve the constriction. Raising the head end of the bed would promote lung expansion and facilitate breathing. Music therapy may relax the patient, but would not relieve the mechanical restriction. Elevating the foot end of the bed would further aggravate the patient's condition. Text Reference - p. 352

A patient who underwent surgery has a binder snugly around the abdomen. While providing postoperative care, the nurse assesses that the patient has shallow respiration, is hypoxemic, and hypercapnic. How should the nurse promote normal breathing in this patient? Select all that apply. 1 Reposition the patient 2 Provide music therapy 3 Loosen the binder 4 Elevate the foot end of bed 5 Raise the head end of the bed

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. Text Reference - p. 359 Topics

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

1, 3, 4 The patient's laryngeal edema is caused by an anaphylactic reaction to the penicillin injection. Sedatives reduce the emotional disturbance and calm down the patient. Antihistamines and corticosteroids help reduce the allergic manifestation and the laryngeal edema. Suctioning helps in cases of increased secretions in the airways. Chest physical therapy is helpful to drain the secretions in the airway. Text Reference - p. 352

A postoperative patient develops laryngeal edema after receiving a penicillin injection and is distressed. How can the nurse prevent further complications in the patient? Select all that apply. 1 By administering sedatives 2 By suctioning the airway 3 By administering antihistamines 4 By administering corticosteroids 5 By providing chest physical therapy

3 Most patients urinate within 6 to 8 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. Text Reference - p. 360

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, because 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.

4, 5 Decreased breath sounds and a low oxygen saturation level may indicate atelectasis due to retained secretions. Incentive spirometry helps lung expansion and promotes removal of secretions. Humidified oxygen therapy helps maintain the oxygen saturation levels. Diuretics help remove excess fluid in the body, but do not help in atelectasis. Late ambulation and shallow breathing aggravate atelectasis; therefore, the patient should be mobilized early and deep breathing should be encouraged. Text Reference - p. 352

A postoperative patient has decreased breath sounds and decreased oxygen saturation. The nurse understands that the anesthetic agents may stimulate bronchial secretion. On auscultation the nurse finds an absence of breath sounds on one lung. What interventions should be included in the postoperative care to maintain adequate oxygen saturation? Select all that apply. 1 Administer diuretics. 2 Allow delayed ambulation. 3 Instruct shallow breathing. 4 Encourage incentive spirometry. 5 Provide humidified oxygen therapy.

21 125 mL/hr × 10 gtts/mL = 1250 gtts/hr 1250 gtts ÷ 60 min = 20.83 gtts/min Text Reference - p. 349

A postoperative patient is transferred from the postanesthesia unit to the medical-surgical nursing floor. The nurse notes that the patient has a prescription for D5½ normal saline (NS) to infuse at 125 mL/hr. The nurse regulates the intravenous (IV) at what flow rate in drops (gtts)/min, noting that the tubing has a drop factor of 10 drops/mL? Fill in the blank using a whole number. ___ gtts/min

2, 3, 5 The patient suffers from postoperative cognitive dysfunction, which dissipates over a few weeks. The nurse should provide supportive care during this period, such as bowel and bladder care, adequate nutrition, and fluid and electrolyte monitoring. Early mobilization should be encouraged to prevent pulmonary complications. Sedatives should not be used, because they further add to cognitive dysfunction. Text Reference - p. 357

An elderly postoperative patient has difficulty with memory and the ability to concentrate. What should the nurse do to help this patient? Select all that apply. 1 Encourage delayed mobility. 2 Provide bowel and bladder care. 3 Provide adequate nutrition. 4 Sedate the patient for long durations. 5 Monitor fluid and electrolyte disturbance.

1, 5 The patient's presentation of restlessness, agitation, thrashing, and shouting indicates emergence delirium. It is due to the prolonged action of opioids and benzodiazepines during the surgery. The use of opioid and benzodiazepine antagonists may reverse the effect and alleviate agitation in the patient. Until the patient is fully conscious, the nurse should ensure the patient's safety by raising the side rails of the bed and securing the equipment, such as the IV line. Antianxiety drugs are less helpful in managing emergence delirium. Emergence delirium is not a psychotic condition; therefore antipsychotic drugs are not useful. Narcotic analgesics would further enhance the action of opioids that were used during surgery. Text Reference - p. 357

An elderly postoperative patient wakes up and becomes restless and agitated and starts thrashing and shouting. The nurse finds that the patient was administered benzodiazepines during surgery. What would be important to have on the patient's plan of care? Select all that apply. 1 Use drugs to reverse the benzodiazepines. 2 Administer an antianxiety drug. 3 Administer an antipsychotic drug. 4 Administer a narcotic analgesic. 5 Ensure patient safety.

1, 2, 4, 5 Have the patient take deep breaths; hypoxemia can cause hypotension. Hypotension in the postoperative patient can be due to various reasons, but the nurse should begin by treating hypoxemia. Inspect the surgical site; hypotension can be caused by hemorrhage. Therefore, it is important to inspect the surgical site for evidence of bleeding. Administer IV fluid boluses per protocol; fluid shifts during and after surgery can cause a drop in blood pressure. Fluid boluses often are needed to correct for these shifts. Assess ECG tracing; a change in the heart rhythm can cause a decrease in blood pressure. Some of these rhythms include supraventricular tachycardia, sinus bradycardia, atrial fibrillation, and atrial flutter. Hypertension, not hypotension, is indicative of pain. A side effect of many pain medications is hypotension, which would exacerbate the patient's present hypotensive state. Metoprolol causes a decrease in blood pressure. If the patient is hypotensive, the prudent nurse should hold the metoprolol and notify the primary health care provider. Text Reference - p. 355

In postanesthesia care unit (PACU), a patient's blood pressure drops from 110/60 mm HG to 92/58 mm Hg. What actions should the nurse take? Select all that apply. 1 Assess ECG tracing 2 Inspect the surgical site 3 Administer pain medication 4 Have the patient take deep breaths 5 Administer intravenous (IV) fluid bolus per protocol 6 Administer prescribed metoprolol

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 2 hours are important for the recovery of the coronary bypass patient, but have little impact on preventing VTE. Text Reference - p. 356

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

2 PE in a postoperative patient is due to fluid overload. Therefore, fluid restriction is the most appropriate intervention. In addition, oxygen therapy and diuretics can be administered. The airway is suctioned if there is any secretion retained in the system. Monitoring of mental status is done in the early postoperative period to determine emergence from anesthesia. Lateral recovery position is used in the early postoperative period to keep the airway patent and prevent aspiration in case the patient vomits. Test-Taking Tip: Make educated guesses when necessary. Text Reference - p. 352

The nurse finds that a postoperative patient has pulmonary edema (PE) characterized by low oxygen saturation and crackles on auscultation. Which is an appropriate nursing action? 1 Suction the airway. 2 Restrict fluid intake. 3 Monitor mental status. 4 Place the patient in lateral recovery position.

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. STUDY TIP: When forming a study group, carefully select members for your group. Choose students who have abilities and motivation similar to your own. Look for students who have a different learning style than you. Exchange names, email addresses, and phone numbers. Plan a schedule for when and how often you will meet. Plan an agenda for each meeting. You may exchange lecture notes and discuss content for clarity or quiz one another on the material. You could also create your own practice tests or make flash cards that review key vocabulary terms. Text Reference - p. 362

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

4 Atelectasis is a common postoperative complication that is prevented by a pulmonary regimen of interventions such as deep breathing, coughing, turning, and using an incentive spirometer. Patients who have received general anesthesia and are noncompliant with a pulmonary regimen are at highest risk for atelectasis. Patients who have experienced a hypoxic episode during an acute asthma attack or with an acute exacerbation of chronic obstructive pulmonary disease are at lower risk for atelectasis than are postoperative patients. Postoperative older adults who have had cardiothoracic surgery are also at risk for atelectasis if they do not adhere to a pulmonary regimen. Text Reference - p. 351

The nurse recognizes what patient situation as the greatest risk for development of atelectasis? 1 After a hypoxic episode during an acute asthma attack 2 In patients experiencing acute exacerbations of COPD 3 In older adult patients who have undergone cardiothoracic surgery 4 After general anesthesia if the patient is not compliant with the pulmonary regimen

4 The best rationale is that early ambulation will prevent postoperative complications that then can be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and venous thromboembolism (VTE), speeds wound healing, increases vital capacity, and maintains normal respiratory function. These things help the patient to be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management always should occur before walking. Text Reference - p. 356

The patient donated a kidney and early ambulation is included in the plan of care; however, the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? 1 "Early walking keeps your legs limber and strong." 2 "Early ambulation will help you be ready to go home." 3 "Early ambulation will help you get rid of your syncope and pain." 4 "Early walking is the best way to prevent postoperative complications."

5, 7, 2, 3, 6, 4, 1 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. Text Reference - p. 351

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? 1. Surgical site 2. Circulation 3. Neurologic 4. Output 5. Airway 6. Gastrointestinal 7. Breathing

1 Until peristalsis returns to normal after anesthesia, the patient may experience slowed gastric motility, leading to gas pains and abdominal distension. Colectomy does not require a nasogastric tube; the bowel should not be inflamed following surgery unless infection is present. Constipation may occur following surgery; however, with bowel manipulation, slowed gastric emptying is the most common reason for gas pains and abdominal distention because of gas. Text Reference - p. 359

Two days after colectomy for an abdominal mass, the patient reports gas pains and abdominal distension. The nurse plans care for the patient on the basis of the knowledge that these symptoms occur as a result of which condition? 1 Slowed gastric emptying 2 Nasogastric suctioning 3 Constipation 4 Inflammation of the bowel at the anastomosis site

2 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 usually is returned to a supine position with the head of the bed elevated. Supine, semi-Fowler's, and high-Fowler's positions are all supine; they are not as helpful in keeping the airway open and reducing the risk of aspiration. Text Reference - p. 354

Unless contraindicated by the surgical procedure, which position is safest for the unconscious patient immediately after the operation? 1 Supine 2 Lateral 3 Semi-Fowler's 4 High-Fowler's

1 The first priority for a patient being admitted to the PACU is the respiratory status. The cardiac function, pain, and circulation to the distal extremity are all important in the safe recovery of the patient, but are secondary to the patient breathing adequately. Text Reference - p. 354

Which initial nursing diagnosis has the highest priority for the patient, who is being admitted to the postanesthesia care unit (PACU) after undergoing an internal fixation of the femur under general anesthesia? 1 Impaired gas exchange related to hypoventilation 2 Decreased cardiac output related to hypovolemia 3 Acute pain related to surgical incision and manipulation 4 Impaired circulation distal to the surgical site

4 Patients at highest risk for thrombophlebitis are those who stand, sit, or remain on bedrest for prolonged periods. Hypercoagulable states, such as pregnancy, and vessel wall trauma due to the effects of smoking also may place a person at risk for thrombophlebitis. An elderly patient taking anticoagulant medications would be at less risk for thrombophlebitis. Text Reference - p. 356

Which patient does the nurse recognize as being at highest risk for thrombophlebitis? 1 A patient with a 25-year smoking history 2 A female patient in the fifth month of pregnancy 3 An elderly patient taking anticoagulant medications 4 A hospitalized patient who has been on bedrest for 3 days

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. Text Reference - p. 361

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.