PrepU Postoperative

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

A systolic blood pressure lower than 90 mm Hg

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

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

Maintaining a patent airway

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?

Moisten sterile gauze with normal saline and place on the protruding organ.

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 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

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period?

<30 mL

When should the nurse encourage the postoperative patient to get out of bed?

As soon as it is indicated

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

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

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.

Changing position Listening to music Watching television

Which term refers to the protrusion of abdominal organs through the surgical incision?

Evisceration

A client vomits postoperatively. What is the most important nursing intervention?

Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for?

Wound dehiscence

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.

When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as

clean contaminated.

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

first intention.

The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?

ondansetron

A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to:

place saline-soaked sterile dressings on the wound.

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue?

Pink to red and soft, bleeding easily

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

Pneumonia

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.

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 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.

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.

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

Pulmonary embolism

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 dressings or applying pressure if bleeding is frank

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.

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 can be discharged from the PACU.