Postoperative

A nurse is providing postoperative care for a patient who has undergone exploratory abdominal surgery. To prevent the complication of atelectasis, what interventions should the nurse perform?

Encouraging the use of an incentive spirometer at least every hour

A patient is admitted to the postanesthesia care unit (PACU) after colon surgery. During the initial assessment, the patient tells the nurse they are going to "throw up." Which statement by the nurse reflects a priority nursing intervention?

"Let me help you turn to your side."

A patient with asthma develops wheezing on the postanesthesia care unit. The nurse finds that the patient is tachypneic, has dyspnea, and has reduced oxygen saturation. How will the nurse prevent further pulmonary complications?

Administer bronchodilators

The nurse is developing a care plan for the postoperative patient in order to prevent complications and promote ambulation, coughing, deep breathing, and turning. What actions can the nurse provide to achieve desired outcomes?

Administer enough analgesics to promote relative freedom from pain.

A patient on the postoperative unit reports 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?

Administering drugs for reversal of paralysis

A patient is transferred to the postanesthesia care unit (PACU) after surgery. Which nursing intervention is the highest priority initially?

Assess airway, breathing, and circulation status.

A postoperative patient with bronchial obstruction has a pulse oximetry reading of 87%. What does the nurse suspect is occurring with this patient?

Atelectasis

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?

Check the medical record for the patient's baseline blood pressure.

A postoperative patient develops fever, abdominal pain, and diarrhea despite being on long-term antibiotics. What should the nurse evaluate for?

Clostridium difficile infection

A patient that is an alcoholic had a hernia operation and is restless and irritable. On assessment, the nurse finds that the patient has auditory hallucinations. What is the most appropriate nursing action?

Conclude that these effects are due to alcohol withdrawal.

A patient with a history of psychosis has newly developed anxiety and is combative with the nurse. What does the nurse know may be causes of this change in behavior?

Electrolyte imbalances

A patient on the postoperative unit was given a large dose of opioids during a surgical procedure and is now hypoxemic. What would the nurse expect to be prescribed to manage hypoxemia in this patient?

Naloxone

The nurse is monitoring a patient who is about to be transferred to the clinical unit from the postanesthesia care unit (PACU). Which assessment data require the most immediate attention?

Pulse rate 128 beats/minute

A patient had an estimated blood loss of 400 mL during abdominal surgery. The patient received 300 mL of 0.9% saline during surgery and now is experiencing hypotension postoperatively. What should the nurse anticipate for this patient?

Restoring circulating volume

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?

Slowed gastric emptying

A patient transferred to the medical-surgical unit from the postanesthesia care unit (PACU) has regained consciousness. In which position should the nurse place the patient in order to prevent respiratory problems?

Supine position with head elevated

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?

Take the patient's vital signs

What is the priority nursing action when a patient is transferred from the postanesthesia care unit (PACU) to the surgical unit after a lobectomy?

Take the patient's vital signs.

A patient has been admitted to the postanesthesia care unit (PACU). Which of these assessment findings require the nurse's immediate action?

The patient is restless, agitated, and hypotensive.

The nurse caring for a postoperative patient assesses clinical manifestations of early pulmonary edema secondary to heart failure. What manifestations does the nurse determine correlates with this disorder?

paroxysmal nocturnal dyspnea