Prep U ch 16

What measurement should the nurse report to the physician in the immediate postoperative period?

A systolic blood pressure lower than 90 mm Hg

A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse?

"It assists in preventing infection."

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?

Position the client to maintain a patent airway.

The nurse recognizes which symptom as a clinical manifestation of shock?

Rapid, weak, thready pulse

The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room?

7 The Aldrete score is usually between 7 and 10 before discharge from the PACU.

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

<30 mL

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:

Ambulating the client as soon as possible

Which of the following clinical manifestations increases the risk for evisceration in the postoperative client?

Valsalva maneuverExplanation:The Valsalva maneuver produces tension on abdominal wounds, which increases the risk for evisceration.

The nurse cares for a client who is three hours post op abdominal hysterectomy and begins to develop hiccups. What nursing assessment will the nurse monitor more closely with the client's new symptoms?

Wound approximation

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: within the first few hours, and has darkly colored blood that flows quickly. during surgery, and has bright red blood that flows freely. at a suture site, and the blood appears intermittently in spurts. a few hours after surgery, and the bright red blood appears with each heartbeat.

within the first few hours, and has darkly colored blood that flows quickly.

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?

Have the client lay on the back with the head elevated A wound evisceration occurs when the wound completely separates, and the internal organs protrude. If disruption of a wound occurs, the patient is placed in the low Fowler's position and instructed to lie quietly. These actions minimize the protrusion of body tissues. The protruding coils of the intestine are covered with sterile dressings moistened with sterile saline solution, and the surgeon is notified at once.

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing the dressing or applying pressure if bleeding is frank 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 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. An epidural infusion Listening to music An On-Q pump Changing position Watching television

Listening to music Watching television Changing position

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?

Pneumonia

A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority? Inserting a nasogastric (NG) tube Applying a sterile, moist dressing Putting the client on nothing-by-mouth (NPO) status Monitoring vital signs

Applying a sterile, moist dressing

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dL, and a blood pressure lying in bed of 110/70 mm Hg. The nurse suspects abnormal orthostatic changes when the client gets out of bed and reports vertigo. What vital sign value most supports the client's orthostatic changes?

Blood pressure of 90/50 mm Hg

A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem? Pink color Foul smell Pieces of vomitus Copious red blood in the sputum

Pink color

The nurse is reviewing a list of surgical clients. Which clients would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period? Select all that apply.

The 27-year-old client with non-insulin dependent diabetes. The 70-year-old client who takes no routine medications.

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?

Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.

The nurse is providing teaching about tissue repair and wound healing to a client who has a leg ulcer. Which of the following statements by the client indicates that teaching has been effective?

"I'll eat plenty of fruits and vegetables."

A novice nurse provides aftercare instructions to a client who has just had sutures removed. Which statement by the novice nurse requires the nurse preceptor to clarify?

"If the wound edges are red or raised, you should call your doctor."

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? - Acute incisional pain - Decreased cardiac output - Ineffective airway clearance- Ineffective thermoregulation - Ineffective thermoregulation

- Ineffective thermoregulation

The client diagnosed with acute respiratory distress syndrome (ARDS) is having increased difficulty breathing. The arterial blood gas indicates an arterial oxygen level of 54% on O2 at 10 LPM. Which intervention should the intensive care unit nurse implement first?1. Prepare the client for intubation.2. Bag the client with a bag/mask device.3. Call a Code Blue and initiate cardiopulmonary resuscitation (CPR).4. Start an IV with an 18-gauge catheter.

1. Prepare the client for intubation.

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?

Absence of peristalsis

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? Fever Absence of peristalsis Abdominal flatness Nosebleed

Absence of peristalsis

Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply.

Ambulate the length of the client's house Get out of bed without assistance Be able to self-toilet

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

Ambulating the client as soon as possible

When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O2 saturation monitor despite the client's breathing appearing normal, what action should the nurse take first?

Assess the client's heart rhythm and nail beds.

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: First intention Granulation Second intention Third intention

Assess the client's heart rhythm and nail beds. Rationale: A client may demonstrate low oxygenation readings because of certain colors of nail polish or may show an irregular heart rate such as atrial fibrillation. These factors should be assessed to ensure the accuracy of the oxygen reading. Once the reading is confirmed as accurate, then the nurse may need to apply oxygen, notify the physician, and document the findings.

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?

Call the health care provider. Rationale: 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 nursing measure for evisceration is to: Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution. Carefully push the exposed intestines back into the abdominal cavity. Apply an abdominal binder snugly so that the intestines can be slowly pushed back into the abdominal cavity. Approximate the wound edges with adhesive tape so that the intestines can be gently pushed back into the abdomen.

Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution.

A nurse asks a client who had abdominal surgery 1 day 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?

Encourage the client to ambulate as soon as possible after surgery.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?

First intention

The primary nursing goal in the immediate postoperative period is the maintenance of pulmonary function and prevention of:

Hypoxemia and hypercapnia.

The nurse observes bloody drainage on the surgical dressing of the client who has just arrived on the nursing unit. Which intervention should the nurse plan to do next?

Outline the drainage with a pen and record the date and time next to the drainage.

A postoperative client begins coughing forcefully while eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first?

Place the client in the low Fowler's position. Rationale: decreases further protrusion of the intestines. The nurse should cover the intestines with a sterile, moist dressing; notify the surgeon and document the event; but first the nurse should minimize further protrusion of the intestines.

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

Position the client in Fowlers position.- Don sterile gloves.- Lubricate the sterile suction catheter.- Insert suction catheter into the lumen of the tube.- Apply intermittent suction while withdrawing the catheter.

A postanesthesia care unit (PACU) nurse is preparing to discharge a client home following ankle surgery. The client keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate?

Review the instructions with the client and an accompanying adult.

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation?

Second-intention healing

When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation, although the patient's breathing appears normal, the nurse identifies that the patient may be suffering from which type of hypoxemia?

Subacute Rationale: Supplemental oxygen may be indicated for subacute hypoxemia. Hypoxic hypoxemia results from inadequate breathing. Episodic hypoxemia develops suddenly, and the client may be at risk for myocardial ischemia, cerebral dysfunction, and cardiac arrest. Anemic hypoxemia results from blood loss during surgery

A nurse is assessing the postoperative client on the second postoperative day. What assessment finding requires the nurse to immediately notify the health care provider? A moderate amount of serous drainage is noted on the operative dressing. The client states a moderate amount of pain at the incisional site. The client's lungs reveal rales in the bases. The client has an absence of bowel sounds.

The client has an absence of bowel sounds.

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 displaying early signs of shock.

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what?

Urine retention

The nurse cares for a client who is three hours post op abdominal hysterectomy and begins to develop hiccups. What nursing assessment will the nurse monitor more closely with the client's new symptoms? Temperature Wound drainage Respiratory rate Wound approximation

Wound approximation SUBMIT ANSWER

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

auscultate bowel sounds.

The client is experiencing intractable hiccups following surgery. What would the nurse expect the surgeon to order?

chlorpromazine

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 hemorrhaged. pustulated. dehisced. eviscerated.

dehisced

A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client?

experiences pain within tolerable limits.

A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client? experiences pain within tolerable limits. resumes usual urinary elimination pattern. exhibits wound healing without complications. maintains adequate fluid status.

experiences pain within tolerable limits.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by:

first intention.

A client in the postanesthesia care unit (PACU) develops a blood pressure of 180/90 mm Hg. Which assessment will the nurse complete to determine the cause of the blood pressure findings? Select all that apply.

Reasons for an increase in blood pressure in the PACU include pain, hypoxia, or bladder distention

Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis?

Decreased cardiac output

Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis? Ineffective airway clearance Urinary retention Acute pain Decreased cardiac output

Decreased cardiac output

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? Normal healing by primary intention. Dehiscence Hemorrhage Evisceration

Dehiscence

What is the highest priority nursing intervention for a client in the immediate postoperative phase? Monitoring vital signs at least every 15 minutes Maintaining a patent airway Assessing urinary output every hour Assessing for hemorrhage

Maintaining a patent airway Rationale: All interventions listed are correct. The highest priority intervention, however, is maintaining a patent airway. Without a patent airway, the other interventions—monitoring vital signs, assessing urinary output, and assessing for hemorrhage—become secondary to the possibility of a lack of oxygen.

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? Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive Covering the well-approximated wound edges with a dry dressing Cleaning the wound with soap and water, then leaving it open to the air Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing

Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing

A client in the postanesthesia care unit (PACU) develops a blood pressure of 180/90 mm Hg. Which assessment will the nurse complete to determine the cause of the blood pressure findings? Select all that apply. Bowel obstruction Bladder distention Hypoxia Pain Nausea

Pain Hypoxia Bladder distention

Which is a classic sign of hypovolemic shock?

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

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

auscultate bowel sounds.

What is the highest priority nursing intervention for a client in the immediate postoperative phase?

Maintaining a patent airway Rationale: The highest priority intervention, however, is maintaining a patent airway. Without a patent airway, the other interventions—monitoring vital signs, assessing urinary output, and assessing for hemorrhage—become secondary to the possibility of a lack of oxygen.

A client who is receiving the maximum levels of pain medication for postoperative recovery asks the nurse if there are other measures that the nurse can employ to ease pain. Which of the following strategies might the nurse employ? Select all that apply.

Performing guided imagery Putting on soothing music Changing the client's position Guided imagery, music, and application of heat or cold (if prescribed) have been successful in decreasing pain. Changing the client's position, using distraction, applying cool washcloths to the face, and providing back massage may be useful in relieving general discomfort temporarily.

A postanesthesia care unit (PACU) nurse is preparing to discharge a client home following ankle surgery. The client keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate? Ask the client, "Do you understand?" Give the written instructions to the client's 16-year-old child. Continuously repeat the instructions until the client restates them. Review the instructions with the client and an accompanying adult.

Review the instructions with the client and an accompanying adult.

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

Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs. Rationale: When a client vomits, the nurse should turn the client's head to the side to prevent aspiration; the vomitus is collected in the emesis basin. Measuring the vomitus is not helpful to the client. Offering fluids is not advised with vomiting. Supporting the wound is important, but not a priority with vomiting.

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:

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

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

First intention 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 patient who underwent abdominal surgery 3 hours ago has started to hemorrhage. The nurse would classify this type of hemorrhage has which of the following?

Intermediary

A significant mortality rate exists for patients with alcoholism who experience delirium tremens postoperatively. When caring for the patient with alcoholism, the nurse should assess for symptoms of alcoholic withdrawal:

On the second or third day. Explanation: The person with a history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase surgical risk. Alcohol withdrawal syndrome or delirium tremens may be anticipated between 48 and 72 hours after alcohol withdrawal and is associated with a significant mortality rate when it occurs postoperatively.

A client in the postanesthesia care unit (PACU) develops noisy and irregular respirations. Which action will the nurse take?

Tilt the head back and lift the lower jaw.

To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:

intermediate

The primary objective in the immediate postoperative period is

maintaining pulmonary ventilation.

A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate?

Continue with frequent client assessments.

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

Reinforcing the dressing or applying pressure if bleeding is frank

The nurse is reviewing a list of surgical clients. Which clients would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period? Select all that apply. The 27-year-old client with non-insulin dependent diabetes. The 47-year-old client who stopped smoking 4 years ago. The 25-year-old client who occasionally smoked marijuana in high school. The 70-year-old client who takes no routine medications. The 43-year-old client with past surgeries.

The 27-year-old client with non-insulin dependent diabetes. The 70-year-old client who takes no routine medications.

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

Assessing WBC count, temperature, and wound appearance

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function?

Central venous pressure

A client is at postoperative hour 8 after an appendectomy and is anxious, stating "Something is not right. My pain is worse than ever and my stomach is swollen." Blood pressure is 88/50, pulse is 115, and respirations are 24 and labored. The abdomen is soft and distended. No obvious bleeding is noted. What action by the nurse is most appropriate?

Notify the physician. Explanation: The physician should be notified of the findings. The client may be hemorrhaging internally and may need to return to surgery. The client may be in need of pain medication, but morphine will lower the blood pressure further and may cause further complications. Ambulating the client increases the risk of injury because the client may experience orthostatic hypotension. What the client is experiencing is not the normal progression after abdominal surgery.

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?

Notify the primary care provider immediately. Rationale: Though urinary output will be reassessed at 11 am, but waiting to notify the primary care provider puts the patient at risk. The findings should be documented, but this is not the highest priority. A urinary catheter may need to be irrigated, but a postoperative client with a low urinary output is demonstrating a complication of inadequate fluid imbalance that needs to be reported immediately.

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?

Pink to red and soft, noting that it bleeds easily

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 Hemovac drain isn't compressed; instead it's fully expanded. The client has a nasogastric (NG) tube in place that drained 400 ml. 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.

The Hemovac drain isn't compressed; instead it's fully expanded.

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? Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. The client can self-administer oral pain medication as needed with patient-controlled analgesia. Family members can be involved in the administration of pain medications with patient-controlled analgesia. There are no advantages of patient-controlled analgesia over a PRN dosing schedule.

Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia.

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?

Tolerance

Corticosteroids have which effect on wound healing?

Mask the presence of infection Explanation: Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. Edema may reduce blood supply. Corticosteroids do not cause hemorrhage or protein-calorie depletion

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:

within the first few hours, and has darkly colored blood that flows quickly.

What complication is the nurse aware of that is associated with deep venous thrombosis?

Pulmonary embolism

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate? Discontinue the nasogastric tube suctioning. Assess for signs and symptoms of fluid volume deficit. Document the findings and reassess in 24 hours. Assess for edema.

Assess for signs and symptoms of fluid volume deficit.

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?

Position the client in the side-lying position.

A nurse is assessing the postoperative client on the second postoperative day. What assessment finding requires the nurse to immediately notify the health care provider?

The client has an absence of bowel sounds. Explanation: A nursing assessment finding of concern on the second postoperative day is the absence of bowel sounds, which may indicate a paralytic ileus. Other assessment findings may include abdominal pain and distention as fluids, solids, and gas do not move through the intestinal tract. Rales in the bases are a frequent finding postoperatively, especially if general anesthesia was administered. Encourage the client to cough and breathe deep. Pain is a common symptom following a surgical procedure. Serous drainage on the postoperative dressing needs to monitored and brought to the physician's attention when assessing the client.