Post-op DElmar's

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 protrud- ing through the incision. Which interventions should the nurse take? Select all that apply. 1. Contact the surgeon. 2. Instruct the client to remain quiet. 3. Prepare the client for wound closure. 4. Document the findings and actions taken. 5. Place a sterile saline dressing and ice packs over the wound. 6. Place the client in a supine position without a pillow under the head.

1,2,3,4 Rationale: Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken. Test-Taking Strategy: Focus on the subject, that the client is experiencing wound evisceration. Visualizing this occurrence will assist you in determining that the client would not be placed supine and that ice packs would not be placed on the incision.

The nurse receives a telephone call from the post- anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway. 2. Check tubes or drains for patency. 3. Check the dressing to assess for bleeding. 4. Assess the vital signs to compare with preopera- tive measurements.

1. Assess the patency of the airway. Rationale:The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. A pulse of 86 beats/minute 3. Blood pressure of 110/70 mm Hg 4. Hypoactive bowel sounds in all 4 quadrants

1. Increasing restlessness Rationale: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all 4 quadrants are a normal occurrence in the immediate postoperative period.

A nurse notifies a physician after assessing a client 5 days after an exploratory laparotomy and noting a distended abdomen, abdominal pain, absence of flatus, and absent bowel sounds. Which typical complication of abdominal surgery should the nurse conclude may be occurring? 1. Paralytic ileus 2. Silent peritonitis 3. Fluid volume excess 4. Malabsorption syndrome

1. Paralytic ileus Paralytic ileus results from a neuromuscular disturbance and does not involve a physical obstruction in or outside the intestine. Peristalsis is decreased or absent, resulting in a slowing of the movement or a backup of intestinal contents. In addition to the symptoms the client is experiencing, nausea and vomiting may be present. The client would not have any signs or symptoms with silent peritonitis. The distended abdomen could indicate that fluid may have shifted into the abdomen. However, fluid volume deficit would then occur and not excess. There is an interference with absorption of nutrients in malabsorption syndrome. Typical signs and symptoms include weight loss, bloating and flatus, edema, bone pain, anemia, easy bruising, and decreased libido.

A nurse evaluates that a client has achieved an expected outcome for the second postoperative day following abdominal surgery under general anesthesia. Which finding supports the nurse's conclusion? 1. Passing flatus 2. Urine output 680 mL in 24 hours 3. Crackles in bilateral lung bases 4. Rates incisional pain at 4 out of 10 on a 0 to 10 rating scale 60 minutes after analgesic given

1. Passing flatus Passing flatus indicates increased gastrointestinal motility and the return of bowel function. The urine output should be at least 30 mL per hour or at least 720 mL in 24 hours. Crackles indicate atelectasis or fluid accumulation in the lungs. Incisional pain is the most intense in the first 48 hours. An expected outcome should be a pain level of 3 or less.

a client is experiencing confusion in the immediate postoperative period. which of the following assessments is essential to determine the reason for the confusion? 1. airway status 2. cardiac rhythm 3. level of consciousness 4. level of anxiety

1. airway status the nurse must first rule out hypoxemia as being the cause of a client's confusion. a client with an impaired airway may be experiencing confusion due to hypoxemia. cardiac rhythm, level of consciousness, and anxiety are all important assessments in the postoperative period, but are not the initial assessment in a client presenting with confusion.

A nurse assesses that a client on the second postoperative day following abdominal surgery has diminished breath sounds in both lung bases, is taking shallow breaths, is able to achieve only 500 mL on an incentive spirometer, and has been smoking one pack of cigarettes per day prior to surgery. The nurse's best interpretation of these findings is that the client is experiencing: 1. atelectasis. 2. pneumonia. 3. a normal postoperative course. 4. chronic obstructive pulmonary disease (COPD)

1. atelectasis. Atelectasis is a common finding in smokers after abdominal surgery due to the accumulation of secretions. It is caused from collapsed alveoli or mucus that prevents some alveoli from opening and manifests with diminished breath sounds, diminished vital capacity, and decreased oxygen saturation. There is no indication, such as elevated temperature or increased white blood cells, that the client has an infection. It should also be noted that the client is experiencing abnormal findings for the second postoperative day. Smoking can cause COPD, but the diminished lung bases suggest alveoli are not expanding.

the nurse is caring for a client postoperatively. which of the following would indicate that the client has a compromised airway? the client 1. complains of anxiety. 2. complains of pain. 3. has a pulse oximetry reading of 90%. 4. is slightly cool and clammy.

1. complains of anxiety. hypoxemia is often associated with complaints of anxiety. a complaint of pain is a common postoperative complaint but is not associated with airway compromise. normal pulse oximetry levels are above 90%. the assessment finding of coolness and clamminess is a nonspecific assessment finding that may indicate a wide variety of problems.

which of the following is the priority nursing intervention that the nurse should perform for a client in the postoperative period after surgery? 1. establish a patent airway 2. maintain adequate blood pressure 3. establish level of consciousness 4. assess level of pain

1. establish a patent airway the first priority in caring for a client in the postoperative period is the establishment of a patent airway. maintenance of hemodynamic stability, determination of level of consciousness, and assessment of pain are all important aspects in postoperative care, but are not the priorities.

A client is to receive a second dose of oxycodone/ acetaminophen (Percocet®) for postoperative incisional pain. When a nurse brings the medication to the client, the client says, "Why bring this medication again? It makes me feel sick." Which statement is the most appropriate initial nurse response? 1. "I can call the doctor to see what else can be ordered for your pain." 2. "Describe what you feel when you say that the medication makes you feel sick." 3. "The doctor has ordered an antacid. I can give you this along with the medication." 4. "Many people say the same thing. The aspirin in the medication is hard on your stomach."

2. "Describe what you feel when you say that the medication makes you feel sick." The nurse is using the therapeutic communication technique, known as clarifying, to determine the effects of the medication on the client. This focuses on the client's feelings. Simply offering new medication avoids the client's feelings. Also, without questioning the client, the nurse would have insufficient information to give to the physician regarding the client's reaction to the medication. Offering an antacid also avoids the client's concerns and assumes that the client has a gastrointestinal reaction to the medication. Even though option 4 focuses on the client's nausea, incorrect information is provided. Oxycodone/acetaminophen does not contain aspirin.

A physician documents in a client's postoperative progress notes that the client is experiencing a respi- ratory infection with a shift to the left in the white blood cell (WBC) differential count. Which finding by a nurse reviewing the client's laboratory report would support the physician's documentation? 1. Decreased WBC count 2. Increased band cells 3. Decreased hemoglobin 4. Increased C-reactive protein

2. Increased band cells An early indication of infection is an increase in the band cells, which are immature neutrophils in the WBC differential count. The increase is termed a shift to the left. The total WBC count should be elevated, not decreased. However, this does not describe the shift to the left. Decreased hemoglobin in a postoperative client is usually due to blood loss. An increased C-reactive protein indicates nonspecific inflammation and is not part of the WBC differential count.

Which outcome should indicate to a nurse that a post- surgical client's coughing and deep breathing (C&DB) is most effective? 1. Respirations are 16 per minute and unlabored. 2. Lung sounds are audible and clear on auscultation. 3. Coughs include small amount of clear secretions. 4. Cough effort is strong and productive.

2. Lung sounds are audible and clear on auscultation. The purpose of postoperative C&DB is to expel secretions, keep the lungs clear, allow full aeration, and prevent pneumonia and atelectasis. Auscultating for clear and audible lung sounds is a definitive means for evaluating the effectiveness of C&DB. Secretions could still be pres- ent in the lungs with normal respirations and nonlabored breathing. Coughing clear secretions and a productive cough indicates that secretions are still present.

when caring for a client receiving conscious sedation, which of the following should the perioperative nurse routinely monitor? 1. temperature 2. level of consciousness 3. Dermatome level 4. urine output

2. level of consciousness level of consciousness is routinely monitored in the provision of conscious sedation. temperature and urine output are monitored in the postoperative phase. Dermatome level is monitored postoperatively after the provision of regional anesthesia.

the nurse is caring for a client who developed a compromised airway. which of the following interventions is the priority to perform first? 1. reposition the client in a supine position 2. open the airway with a chin lift or jaw thrust 3. prepare for reintubation of the client 4. notify the surgeon

2. open the airway with a chin lift or jaw thrust the initial priority nursing intervention for a client experiencing a compromised airway is the reestablishment of the airway. the client may need to be repositioned but often to a fowler's or lateral position. the client may need to be reintubated and the surgeon should be notified, but these are not the priority interventions.

a client has a pca (patient-controlled analgesia) machine ordered to manage postoperative pain. the pacu (postanesthesia care unit) nurse determines that the best time to initiate the pca machine is 1. when the client complains of pain. 2. when the client arrives at the pacu. 3. just prior to transfer of the client to the floor. 4. when the client shows evidence of nonverbal signs of pain.

2. when the client arrives at the pacu. pca (patient-controlled analgesia) is an effective mechanism for the management of client pain. it is initiated upon arrival to the postanesthesia care unit (pacu) and client education is reinforced during the client's stay in the pacu. a delay in initiation of the pca device may cause an increase in client pain.

which of the following nursing measures should the nurse include in the plan of care to help reduce the clinical manifestations of laryngospasm? 1. administer atropine 2. reposition the client in a supine position 3. administer high-flow oxygen via face mask 4. administer succinylcholine (anectine)

4. administer succinylcholine (anectine) with severe laryngospasm, a client may require the administration of a muscle relaxant such as succinylcholine (anectine) to relax the muscles of the larynx. clients experiencing laryngospasm are often repositioned into a semi-fowler's position. the administration of high-flow oxygen is based upon client's oxygen saturation levels and may be used to treat hypoxia, but will not directly reduce the clinical manifestations of laryngospasm.

the nurse is concerned about a client's risk for impaired gas exchange related to ineffective airway clearance. which of the following would be a priority assessment? 1. number of respirations per minute 2. number of liters of oxygen per minute inspired 3. Decreased air movement 4. capillary refill

3. Decreased air movement Decreased air movement may indicate a significant respiratory compromise. assessing the client's ability to move air is a priority nursing assessment. the number of respirations per minute, number of liters of oxygen inspired, and capillary refill are important assessment data, but are not priority assessments.

A nurse is caring for a postoperative client who re- ports an inability to void. Which initial action by the nurse is most appropriate? 1. Turning on running water 2. Inserting a urinary catheter 3. Palpating the client's bladder 4. Reviewing the client's chart for the time of the last voiding

3. Palpating the client's bladder The bladder should be palpated for distention. The nurse should also observe for other signs of a full bladder such as restlessness or an ele- vated blood pressure. The nurse should first determine the underlying reason for the client's inability to void. Turning on running water as- sumes that the client has a full bladder. A urinary catheter should only be inserted if the client has a full bladder and other measures to initiate void- ing have been unsuccessful. Though reviewing the chart for the time of the last voiding may assist in determining the underlying problem, client as- sessment should be the first action.

A nurse notes redness, swelling, and warmth of and around the incision when assessing a client's leg incision 48 hours after femoral popliteal bypass surgery. The nurse's best analysis should be that the incision is: 1. healing normally for the second postoperative day. 2. showing signs of rejection of the suture materials. 3. inflamed and could indicate the presence of an infection. 4. infected and showing signs of wound dehiscence

3. inflamed and could indicate the presence of an infection. Redness, swelling, and warmth are signs of inflammation and could indicate the presence of an infection. Other signs of an infection in- clude excessive pain or tenderness on palpation and purulent or odor- ous drainage. Slight crusting, a pink color to the incision line, and slight swelling under the sutures or staples are normal findings for the second postoperative day due to inflammation from the surgical procedure. Though these findings could indicate rejection of the sutures, rejection oc- curs less frequently than a wound infection. If the wound is dehiscing, bloody or serosanguineous drainage would also be present.

A nurse is orienting a new nurse to a postanesthesia care unit (PACU). Which statement by the new nurse indicates further orientation is needed? 1. "Lactated Ringer's (LR) and 5% dextrose with LR are typical IV solutions administered in the PACU." 2. "If a client has an opioid overdose, I should expect to administer naloxone hydrochloride (Narcan®)." 3. "I should monitor vital signs and perform a pain assessment every 15 minutes or more often if necessary." 4. "Once a client responds verbally after a spinal anesthetic, the client can be transferred to the nursing unit."

4. "Once a client responds verbally after a spinal anesthetic, the client can be transferred to the nursing unit." The client receiving a spinal anesthetic should remain in the PACU until feeling and voluntary motor movement of the lower extremities has begun to return. Because the client did not receive a general anesthetic that depressed the central nervous system, the client may be verbally re- sponsive immediately after surgery. Both LR and dextrose with LR solutions are isotonic and are used for fluid replacement in the PACU. After re- turning to the medical-surgical unit, the type and amount of solution are based on client need. Naloxone hydrochloride (Narcan®) is an antagonist for opioids and is used for reversing the respiratory-depressive effects of opioid analgesics. Vital sign observations and pain assessment should be completed every 15 minutes or more frequently based on the client's condition.

A nurse is reviewing a plan of care for a postopera- tive client with a history of sickle cell disease. Which nursing diagnosis, documented on the client's care plan, should the nurse address first? 1. Anxiety 2. Impaired skin integrity 3. Deficient fluid volume 4. Ineffective airway clearance

4. Ineffective airway clearance An open airway is a physiological need that is priority. Ineffective air- way clearance in a postoperative client is often due to an ineffective or absent cough and the accumulation of secretions that compromise the airway. Anxiety is a psychosocial need and is not the priority. Impaired skin integrity is a physiological need, but of lower priority than an open airway. Deficient fluid volume is a physiological problem, but of lower priority than an open airway.

which of the following is a priority in the plan of care for a client who has had abdominal surgery and complains of pain in the immediate postoperative period? 1. monitor the client's blood pressure 2. teach the client to splint the abdomen 3. reposition the client for comfort 4. ask the client to describe the pain

4. ask the client to describe the pain a priority assessment for a client's pain includes a description of the severity and nature of the pain as experienced by the client. monitoring blood pressure, repositioning of the client, and teaching the client to splint the abdomen are all important postoperative nursing interventions, but are not priority interventions in the management of the client's postoperative pain.

the nurse is caring for a client in the immediate postoperative period. which of the following would indicate that the client is becoming hypovolemic? 1. a diastolic blood pressure of 100 mm hg 2. the client complains of excruciating pain 3. the client complains of anxiety 4. blood loss of 500 ml

4. blood loss of 500 ml blood loss and resulting low fluid volume may result in hypovolemia in the postoperative period. anxiety and pain may cause hypertension in the perioperative client, but would not cause hypovolemia. an elevated diastolic blood pressure is not indicative of hypovolemia.

a client admitted to the postanesthesia care unit (pacu) after abdominal surgery complains of "feeling a pop" and a gush of warm fluid at the incision site. the nurse concludes that the client has experienced a wound dehiscence. the priority nursing interventions would be to select all that apply: [ ]1. position the client in a supine position [ ]2. obtain a complete set of vital signs [ ]3. cover the incision with a sterile dressing [ ]4. apply oxygen via nasal cannula at 8 l per minute [ ]5. contact the surgical team [ ]6. increase the iv fluid rate

[ ]1. position the client in a supine position [ ]3. cover the incision with a sterile dressing [ ]5. contact the surgical team the priority nursing interventions include repositioning the client in a supine position to prevent evisceration of abdominal contents, covering the wound with a sterile dressing, and notifying the surgical team immediately. administering oxygen may be applied if the client's oxygen saturation is low. the iv rate may be increased if there is an indication to do so, but is not a priority intervention.

Which statement should a nurse include when teach- ing a client prior to discharge following abdominal surgery? 1. "Return to work in about 4 weeks because working increases your physical activity gradually." 2. "The ordered iron and vitamins tablets will promote wound healing and red blood cell growth." 3. "Daily walking carrying 10-pound weights will help to strengthen your incision." 4. "Home-care nursing service is usually paid by insurance if you need help around the house."

2. "The ordered iron and vitamins tablets will promote wound healing and red blood cell growth." In addition to vitamins and iron, supplemental vitamin C and a diet high in protein and calories will promote wound healing.

In reviewing a physician's orders for a postoperative client who underwent gynecological surgery, which order should a nurse determine is specifically written with the intent to prevent postoperative thrombophlebitis and pulmonary embolism? 1. Have the client dangle the legs the evening of surgery 2. Administer enoxaparin (Lovenox®) 40 mg subcutaneously daily 3. Administer hydromorphone (Dilaudid®) 1 to 4 mg IV every 3 to 4 hours as needed (prn) 4. Encourage coughing and deep breathing (C&DB) every hour while awake

2. Administer enoxaparin (Lovenox®) 40 mg subcutaneously daily Enoxaparin is an anticoagulant that potentiates the inhibitory effect of antithrombin on factor Xa and thrombin. Early postoperative ambula- tion instead of dangling is a major preventive technique for throm- bophlebitis. Hydromorphone is a narcotic analgesic for pain control. Coughing and deep breathing promote lung expansion and prevent atelectasis and pneumonia.

A nurse is planning the discharge of a client following recovery from an exploratory laparotomy. The client has a history of chronic back pain and limited ability to ambulate. The nurse plans for further discharge teaching when the client states: 1. "I can leave my elastic antiembolic (TEDS®) stockings off once I get home." 2. "I should be eating a diet high in protein, calories, and vitamin C now and when I get home." 3. "An alternative method to control pain and reduce swelling is applying ice to my incision." 4. "I use my incentive spirometer every 2 hours so I can reach my volume goal before discharge."

1. "I can leave my elastic antiembolic (TEDS®) stockings off once I get home." Because the client has limited ability to ambulate, the client should continue to wear the TED stockings at home to prevent deep vein thrombosis until the client increases ambulation. The TEDS should be removed one to two times daily for skin care and inspection. Clients provided with preoperative teaching pamphlets learn proper exercise tech- niques or skills faster than those provided the information postadmission. A diet high in protein, calories, and vitamin C will promote wound healing. A nonpharmacological method to reduce postoperative pain and promote comfort includes ice application. Specific volume goals are usu- ally set based on the client's ability and the type of incentive spirometer. Achievement of the volume goal is an expected postoperative outcome that should be met prior to discharge.

A postoperative client who received a spinal anesthetic is experiencing a headache, photophobia, and double vision. A nurse's initial intervention should be to: 1. immediately notify the surgeon. 2. position the client flat in bed. 3. limit the client's fluid intake. 4. administer steroid medications.

2. position the client flat in bed. The client is experiencing a postdural puncture headache caused by leakage of cerebrospinal fluid (CSF) from the needle insertion made in the dura for the spinal anesthetic. Placing the client in the flat position minimizes the leakage of CSF. The surgeon should be notified of the development as well as the anesthesiologist if the headache persists despite interventions or there is noticeable leakage of CSF. Fluids should be increased to hydrate the client and replace fluids lost from the CSF leakage. If the headache persists, steroids may be ordered to decrease inflammation, but this is not an initial intervention.

A nurse evaluates that the drainage from a client's na- sogastric (NG) tube, inserted for gastric decompres- sion during emergency surgery, would be normal if it: 1. returns brown-liquid in color. 2. returns greenish-yellow in color. 3. has an alkalotic hydrogen level (pH). 4. measures less than 25 mL in volume.

2. returns greenish-yellow in color. Normal NG drainage fluid is greenish yellow in color. Brown liquid or drainage with a "coffee-ground" appearance indicates old bleeding. The pH of gastric secretions would be acidic. In emergency surgery, large amounts of output would be expected because the client's stomach was unlikely to be empty.

the nurse is caring for a client postoperatively who has become hypothermic. the nurse's best action would be to 1. position the client in a left lateral position. 2. administer an analgesic. 3. remove clothing saturated with blood. 4. monitor the intake and output.

3. remove clothing saturated with blood. the nurse removes clothing saturated with blood and reapplies clean and dry clothing in order to maintain a client's body temperature. repositioning a client, medicating a client for pain, or monitoring intake and output do not treat a client's low body temperature.

Which information is most important for a postanesthesia care unit nurse to include in a report on a post- operative client to a surgical unit nurse? 1. Location of the relatives 2. Review of the surgical consent 3. Placement of client belongings 4. Last dose and type of pain medication

4. Last dose and type of pain medication Pain is the fifth vital sign. Time and dose is the reference for imple- menting the pain protocol or developing a plan for the client's pain control. The hand-off of the client to another area is the ideal time to insure the continuation of care, as well as the transfer of responsibility. The nurse should check for the presence of family or significant others. However, this is not the most important. Reviewing the consent is unneces- sary postoperatively. If the client needs a blood transfusion, the nurse may need to review the consent for a blood transfusion prior to administering blood or blood products. This may be a part of the surgical consent but varies by institution. The nurse should note where the client's belongings are placed if the client was not previously on the surgical unit. However, this is not the most important.

A nurse is caring for a client who received conscious sedation during a surgical procedure. Which assessment of this client is most important for a nurse to make postoperatively? 1. Lung sounds 2. Amount of urine output 3. Ability to swallow liquids 4. Rate and depth of breathing

4. Rate and depth of breathing The rate and depth of breathing should be assessed to determine the adequacy of air exchange. A respiratory rate of less than 10 breaths per minute indicates drug-induced respiratory depression. The primary concern with conscious sedation is the effect of the medications on the central nervous system (CNS). Lung sounds are assessed to determine the adequacy of ventilation of all lung lobes or the presence of fluid or secre- tions in the airways and lung tissue. Though assessing the lung sounds is important postoperatively, assessing the rate and depth of breathing is most important with conscious sedation. Though urine output should be at least 30 mL/hr and medications administered can potentially be nephrotoxic, it is more important to assess the rate and depth of respirations with con- scious sedation. The client swallowing ability should be assessed prior to administering liquids. However, it is more important to assess the rate and depth of respirations with conscious sedation.

the nurse is caring for a client postoperatively who develops sinus tachycardia. which of the following interventions should the nurse perform? 1. apply warmed blankets 2. administer atropine sulfate 3. position the client in a left lateral position 4. manage the client's anxiety

4. manage the client's anxiety treatment of sinus tachycardia involves treating the underlying cause. sinus tachycardia is a common dysrhythmia often caused by anxiety. atropine is a drug commonly used to treat sinus bradycardia. applying warmed blankets and positioning a client in the left lateral position would not be performed for sinus tachycardia.

the nurse is caring for a postoperative client who has received a general anesthetic. which of the following observations is the priority to be immediately reported? 1. complaints of nausea 2. mild hypertension 3. Decreased urine output 4. rising body temperature

4. rising body temperature a rising body temperature can indicate malignant hyperthermia, a rare but life- threatening complication of general anesthesia. complaints of nausea, mild hypertension, and decreased urine output would need to be conveyed to the anesthesia or surgical team, but are not emergent complaints.

which of the following should the perioperative nurse monitor when evaluating the presence of ineffective thermoregulation in a client? 1. cardiac rhythm 2. blood pressure 3. oxygen saturation level 4. temperature

4. temperature body temperature is the primary method of assessment utilized by nurses to determine the client's thermoregulation. cardiac rhythm, blood pressure, and oxygen saturation levels are all monitored, but give little indication of the client's risk for altered body temperature.