NU 310 Adult Health Postop Nx Mgmnt

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order. 1 Position the client in Fowlers position. 2 Don sterile gloves. 3 Apply intermittent suction while withdrawing the catheter. 4 Insert suction catheter into the lumen of the tube. 5 Lubricate the sterile suction catheter.

1, 2, 5, 4, 3

What complication is the nurse aware of that is associated with deep venous thrombosis? A. Immobility because of calf pain B. Marked tenderness over the anteromedial surface of the thigh C. Pulmonary embolism D. Swelling of the entire leg owing to edema

C. Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010).

A physician's admitting note lists a wound as healing by second intention. What does the nurse expect to find? A. A deep, open wound that was previously sutured B. A sutured incision with a little tissue reaction C. A wound with a deep, wide scar that was previously resutured D. A wound in which the edges were not approximated

D. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been approximated.

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

B. The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply and rubbing the back will not help manage and minimize hemorrhage and shock.

! A nurse is planning care for a client scheduled to undergo a thoracotomy. After tolerating full liquids, which dietary recommendation will the nurse consider? A. Small, frequent low-fat meals B. Small, frequent full-fat meals C. Three low-sodium meals D. Three full-fat meals

B. Clients undergoing thoracotomy may have poor nutritional status before surgery due to shortness of breath, increased sputum production, and decreased appetite. It is for these reasons that nutrition is very important for clients undergoing thoracotomy. Small, frequent full-fat meals provide adequate nutrition while also allowing frequent rest periods. Larger, less frequent meals may fatigue the clients more easily. There is no reason for the clients to have low-sodium or low-fat meals.

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? A. Acute incisional pain B. Ineffective thermoregulation C. Decreased cardiac output D. Ineffective airway clearance

B. Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: A. Positioning the client in a supine position B. Assisting with incentive spirometry every 6 hours C. Ambulating the client as soon as possible D. Assessing breath sounds at least every 2 hours

C. The nurse should assist the client to ambulate as soon as the client is able. Incentive spirometry should be performed every 1 to 2 hours. The client should be positioned from side to side and in semi-Fowler's position. While assessing breath sounds is essential, it does not help to prevent pneumonia.

The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract? A. The client is passing flatus. B. The client states being hungry. C. The client is tolerating sips of water. D. The client reports a small bowel movement.

D. A bowel movement demonstrates that the nursing outcome of the return to function of the gastrointestinal track has been met. All of the other options are components of meeting the outcome of functioning.

The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists? A. Dehiscence B. Evisceration C. Hemorrhage D. Normal healing by primary intention.

A. Dehiscence is a disruption of the incision.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? A. First intention B. Second intention C. Third intention D. Fourth intention

A. When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing.

A client develops a hemorrhage one hour post surgery. The nurse knows this is most likely an intermediary hemorrhage from a vein because it occurred: A. within the first few hours, and has darkly colored blood that bubbles out slowly. B. during surgery, and has bright red blood that flows freely. C. at a suture site, and the blood appears intermittently in spurts. D. a few hours after surgery, and the bright red blood appears with each heartbeat.

A. An intermediary hemorrhage appears within the first few hours following surgery. Darkly colored blood that bubbles out quickly indicates a venous hemorrhage. A hemorrhage that occurs during surgery is classified as a primary hemorrhage. A bright red color indicates that a hemorrhage's source is an artery. Secondary hemorrhages occur when sutures slip or drainage tubes dislodge insecure vessels.

The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists? A. Dehiscence B. Evisceration C. Hemorrhage D. Normal healing by primary intention.

A. Dehiscence is a disruption of the incision.

On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing? A. Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing B. Covering the well-approximated wound edges with a dry dressing C. Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive D. Cleaning the wound with soap and water, then leaving it open to the air

A. Postoperative surgical wounds that are allowed to heal using second-intention healing are usually packed with a sterile saline-soaked dressing and covered with a dry dressing. The edges of a wound healing by second intention are not approximated. The wound may be cleaned using sterile saline, but the nurse would not apply a cyanoacrylate tissue adhesive. The wound should not be left open to the air, as it could expose the wound to microorganisms and dry out the wound bed, impairing healing.

A client has undergone surgery to repair a hernia, with no complications. In the immediate postoperative period, which action by the nurse is most appropriate? A. Monitor vital signs every 15 minutes B. Measure arterial blood gas every 5 minutes C. Assess pupillary response every 5 minutes D. Measure urinary output every 15 minutes

A. Pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours immediately after surgery. Obtaining an arterial blood gas measurement every 5 minutes would be painful to the client unless a special device is inserted to obtain arterial blood samples. With no complications, this is not indicated for this client. Urinary output is monitored frequently, usually hourly. While it may be necessary to assess pupillary response during the immediate postoperative phase, it does not need to be done every 5 minutes.

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client? A. The client can be discharged from the PACU. B. The client must remain in the PACU. C. The client should be transferred to an intensive care area. D. The client must be put on immediate life support.

A. The Aldrete score is usually 8 to 10 before discharge from the PACU. Clients with a score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area, depending on their preoperative baseline score.

! The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan? A. The client can self-administer oral pain medication as needed with patient-controlled analgesia. B. Family members can be involved in the administration of pain medications with patient-controlled analgesia. C. Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. D. There are no advantages of patient-controlled analgesia over a PRN dosing schedule.

C. Advantages of patient-controlled analgesia include participation of the client in care, elimination of delayed administration of analgesics, and maintenance of therapeutic drug levels. The client must have the cognitive and physical abilities to self-dose.

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates teaching has been ineffective? A. "I should call my physician if I develop a fever." B. "My incision should become less red and tender." C. "I can resume my usual activities as soon as I get home." D. "I need to keep my follow-up appointment with the physician."

C. By time of discharge, clients should be able to verbalize clinical manifestations of complications, activity and diet restrictions, and specifics regarding follow-up appointments. The client with abdominal incision will need to avoid lifting and driving in the initial discharge period.

A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first? A. Place a dry, sterile dressing over the protruding organs. B. Place a pressure dressing over the opening and secure. C. Have the client lay quietly on back and call the physician. D. Moisten sterile gauze with normal saline and place on the protruding organ.

D. A wound evisceration occurs when the wound completely separates, and the internal organs protrude. The first action by the nurse would be to cover the protruding organs with sterile dressings moistened with normal saline. Once the client is safe, the nurse can notify the physician. The client is positioned in a manner that places the least stress on the organs. Dry or pressure dressings are not placed over the protruding organ.

Nursing assessment findings reveal a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. The nurse recognizes the client is experiencing: A. Hyperthermia B. Uncontrolled pain C. Atelectasis D. Wound infection

D. Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? A. Between 75 and 100 mL B. Between 100 and 200 mL C. >200 mL D. <30 mL

D. If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL per hour are reported; if the patient is voiding, an output of less than 240 mL per 8-hour shift is reported.

You are caring for a client who is an obese diabetic. The client is 48 hours post surgery. What is this client at increased risk for? A. Phlebitis B. Hypotension C. Contractures D. Wound dehiscence

D. Risk factors for wound dehiscence include: Advanced age over 65 years; Chronic disease such as diabetes, hypertension, obesity; History of radiation or chemotherapy; Malnutrition, particularly insufficient protein and vitamin C; Hypoalbuminemia. This client is not at increased risk for hypotension; contractures, or phlebitis.

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 A. dehisced. B. eviscerated. C. pustulated. D. hemorrhaged.

A. Dehiscence is the partial or complete separation of wound edges. Evisceration is the protrusion of organs through the surgical incision. Pustulated refers to the formation of pustules. Hemorrhage is excessive bleeding.

The nurse has medicated a postoperative client who reported nausea. Which medication would the nurse document as having been given? A. Ondansetron B. Warfarin C. Prednisone D. Propofol

A. Odansetron is an antiemetic and one of the most commonly prescribed medications for nausea and vomiting. Warfarin is an anticoagulant. Prednisone is a corticosteroid. Propofol is an anesthetic agent.

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? A. Assessing WBC count, temperature, and wound appearance B. Obtaining dietary consultation for improved wound healing C. Educating the client on safe bed-to-chair transfer procedures D. Administering pain medications within 1 hour of the client's request

A. The client has an increased risk for infection related to the surgical wound, which is classified as dirty. Assessing the WBC count, temperature, and wound appearance allows the nurse to intervene at the earliest sign of infection. The client will have special nutritional needs during wound healing and needs education on safe transfer procedures, but the need to monitor for infection is a higher priority. The client should receive pain medication as soon as possible after asking, but the latest literature suggests that pain medication should be given on a schedule versus "as needed."

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition? A. The client is displaying early signs of shock. B. The client is showing signs of a medication reaction. C. The client is displaying late signs of shock. D. The client is showing signs of an anesthesia reaction.

A. The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated. Medication or anesthesia reactions may cause client symptoms similar to these; however, these causes are not as likely as early shock.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: A. first intention. B. second intention. C. third intention. D. fourth intention.

A. Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: A. change the client's position. B. insert a rectal tube. C. palpate the abdomen. D. auscultate bowel sounds.

D.

What intervention by the nurse is most effective for reducing hospital-acquired infections? A. Administration of prophylactic antibiotics B. Aseptic wound care C. Control of upper respiratory tract infections D. Proper hand-washing techniques

D.

The nurse is admitting the older adult to the PACU. Which information about this client would be most important for the PACU nurse to obtain? A. Are family members available? B. What procedure was performed? C. What was estimated blood loss? D. Does the client have a history of dementia?

D. Acute confusion is a common side effect of anesthesia in older adults. The nurse needs to know whether any confusion displayed by the client is a result of the surgery and anesthesia or a usual state for the client.

When vomiting occurs postoperatively, what is the most important nursing intervention? A. Measure the amount of vomitus to estimate fluid loss, in order to accurately monitor fluid balance. B. Offer tepid water and juices to replace lost fluids and electrolytes. C. Support the wound area so that unnecessary strain will not disrupt the integrity of the incision. D. Turn the patient's head completely to one side to prevent aspiration of vomitus into the lungs.

D. If vomiting occurs, the patient is turned to the side to prevent aspiration and the vomitus is collected in the emesis basin.

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action? A. Administer antiemetics to prevent nausea and vomiting. B. Assess the incisional dressing to detect hemorrhage. C. Monitor vital signs for early detection of shock. D. Position the client to maintain a patent airway.

D. Maintaining a patent airway is the immediate priority in the PACU.

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action? A. Prepare to insert a nasogastric tube. B. Prepare to administer a stool softener. C. Re-attempt to auscultate bowel sounds. D. Call the health care provider.

D. The client presents with a possible paralytic ileus, a serious condition where the intestines are paralyzed and peristalsis is absent. This may occur as a result of surgery, especially abdominal surgery. If the nurse is unable to auscultate bowel sounds and the client has pain and a rigid abdomen, the nurse will suspect an ileus and immediately call the health care provider. Re-attempting auscultation may occur, but only after the health care provider has been notified. The health care provider may order the placement of an NG tube, however, the nurse cannot do this without the provider's order. Administering a stool softener will not help the client and may make the condition worse.

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse? A. Obtain an emesis basin. B. Ask the client for more clarification. C. Administer an anti-emetic. D. Position the client in the side-lying position.

D. The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits. The nurse may also obtain an emesis basin and administered an anti-emetic if one is ordered; however, these will be done after the client is repositioned. There is no need for the nurse to ask the client for more clarification.

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. Listening to music 2. An On-Q pump 3. Watching television 4. An epidural infusion 5. Changing position

1, 3, 5 Nonpharmacological management of pain includes listening to music, watching television, and changing position. Pharmacological pain management strategies include epidural infusions and On-Q pumps. An epidural infusion delivers a local opioid with or without a local anesthetic agent directly into the epidural space of the spine. An On-Q pump delivers a local anesthetic agent subcutaneously to the incisional area.

The nursing assessment of the postoperative client reveals an incision that is well-approximated with sutures intact, minimal redness and edema, and absence of drainage. The nurse recognizes the wound is healing by: A. Granulation B. First intention C. Second intention D. Third intention

B. First-intention healing is characterized by a closed incision with little tissue reaction and the absence of signs and symptoms of infection.

The nurse is preparing to discharge a patient from the PACU using a PACU room scoring guide. With what score can the patient be transferred out of the recovery room? A. 6 B. 8 C. 7 D. 5

B. Many hospitals use a scoring system (e.g., Aldrete score) to determine the patient's general condition and readiness for transfer from the PACU (Aldrete & Wright, 1992). Throughout the recovery period, the patient's physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. This evaluation guide allows an objective assessment of the patient's condition in the PACU (Fig. 19-3). The patient is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The Aldrete score is usually between 8 and 10 before discharge from the PACU.

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly patients? A. Pleurisy B. Pneumonia C. Hypoxemia D. Pulmonary edema

B. Older patients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Delirium, pneumonia, decline in functional ability, exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and falls are all threats to recovery in the older adult.

You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult? A. Respiratory depressive effects B. Tolerance C. Convalescent period D. Detailed medication history

B. Postoperative ambulatory activities are essential but planned according to the older adult's tolerance, which usually is less than that of a younger person. The respiratory depressive effects should be considered when administering certain drugs for the older adults. The convalescent period usually is longer for older adults. Therefore, they may require positive reinforcement throughout the postoperative period as well as extensive discharge planning. The convalescent period of older adults and detailed medication history may not be necessary to consider when planning the postoperative ambulatory activities.

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? A. Complete blood count B. Central venous pressure C. Upper endoscopy D. Chest x-ray

B. Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, level of consciousness, central venous pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output are monitored to provide information on the patient's respiratory and cardiovascular status.

A nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene? A. Apply moist heat to the client's abdomen. B. Encourage the client to ambulate at least three times per day. C. Administer a tap water enema. D. Notify the physician.

B. The nurse should encourage the client to ambulate at least three times per day. Ambulating stimulates peristalsis, which helps the bowels to move. It isn't appropriate to apply heat to a surgical wound. Moreover, heat application can't be initiated without a physician order. A tap water enema is typically administered as a last resort after other methods fail. A physician's order is needed with a tap water enema as well. Notifying the physician isn't necessary at this point because the client is exhibiting bowel function by passing flatus.

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

C. In second-intention healing, necrotic material gradually disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue.

The nurse is concerned that a postoperative patient may have a paralytic ileus. What assessment data may indicate that the patient does have a paralytic ileus? A. Abdominal tightness B. Abdominal distention C. Absence of peristalsis D. Increased abdominal girth

C. Paralytic ileus and intestinal obstruction are potential postoperative complications that occur more frequently in patients undergoing intestinal or abdominal surgery. Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for 24 to 48 hours, depending on the type and extent of surgery.

When should the nurse encourage the postoperative patient to get out of bed? A. Within 6 to 8 hours after surgery B. Between 10 and 12 hours after surgery C. As soon as it is indicated D. On the second postoperative day

C. Postoperative activity orders are checked before the patient is assisted to get out of bed, in many instances, on the evening following surgery. Sitting up at the edge of the bed for a few minutes may be all that the patient who has undergone a major surgical procedure can tolerate at first.

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? A. The client has been lying on his side for 2 hours with the drain positioned upward. B. The client has a nasogastric (NG) tube in place that drained 400 ml. C. The Hemovac drain isn't compressed; instead it's fully expanded. D. There is a moderate amount of dry drainage on the outside of the dressing.

C. The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.

Which is a classic sign of hypovolemic shock? A. Bradypnea B. High blood pressure C. Pallor D. Dilute urine

C. The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing.

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? A. Monitoring vital signs every 15 minutes B. Elevating the head of the bed C. Reinforcing the dressing or applying pressure if bleeding is frank D. Encouraging the client to breathe deeply

C. The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply will not help manage and minimize hemorrhage and shock. Monitoring vital signs every 15 minutes is an appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to determine the extent and progression of the problem.

The primary objective in the immediate postoperative period is A. controlling nausea and vomiting. B. relieving pain. C. maintaining pulmonary ventilation. D. monitoring for hypotension.

C. The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and monitoring for hypotension are important, but they are not primary objectives in the immediate postoperative period.

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? A. Primary-intention healing B. First-intention healing C. Second-intention healing D. Third-intention healing

C. When wounds dehisce, they are allowed to heal by secondary intention. Primary or first-intention healing is the method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation. Third-intention healing is a method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by bringing apposing granulations together.