NURS 301 Postoperative Nursing

The nurse is caring for a postoperative client with an indwelling urinary catheter. The hourly urinary output is 80 mL at 9 am. At 10 am, the nurse assesses the hourly urinary output as 20 mL. What is the priority action by the nurse? Document the findings. Notify the primary care provider immediately. Irrigate the catheter with sterile normal saline. Reassess the output at 11 am

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

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

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

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

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

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

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

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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? Re-attempt to auscultate bowel sounds. Prepare to insert a nasogastric tube. Prepare to administer a stool softener. Call the health care provider.

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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? Abdominal distention Increased abdominal girth Abdominal tightness Absence of peristalsis

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