AH Exam 1: Chapter 19

A patient is postoperative day 1 from abdominal surgery. The patient 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 2430 mL. What action by the nurse is most appropriate?

Assess for signs and symptoms of fluid volume deficit.

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

Continue with frequent patient assessments

A nurse is caring for a client who underwent a skin biopsy and has 3stitches in place. This wound is healing

First intention

Which findings would be indicative of a nursing diagnosis of decreased cardiac output?

Tachycardia; hemoglobin 10.9 gm/dL; BP 88/56

On the Aldrete checklist, a pt would get a cardiovascular/circulation score of __ if the BP is 20% of the preanesthetic level.

2

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

The nurse is caring for a client who develops an evisceration. What nursing intervention is most appropriate when an evisceration occurs in the surgical wound of a client who has undergone surgery?

Place sterile dressings moistened with normal saline over the protruding organs and tissues and inform the physician

The nurse determines that a patient has postoperative abdominal distention. What does the nurse determine that the distention may be directly related to?

A temporary loss of peristalsis and gas accumulation in the intestines

Which of the following would be the least important factor affecting wound healing? Age of patient, sufficient oxygenation, Hemorrhage, or Nutritional Deficiency

Sufficient oxygenation

As a circulating nurse, what task are you solely responsible for?

Keeping records

Anxiety is?

increases the amount of anesthetic medication needed, the level of postoperative pain, and overall recovery time.

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

Pneumonia

The Hemovac?

Must be compressed to establish function

A patient is postoperative hour 8 following 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. Abdomen is soft and distended. No obvious bleeding noted. What action by the nurse is most appropriate?

Notify the physician

The nurse is caring for a postoperative patient with an indwelling urinary catheter. The hourly urinary output at 9 am is 80 mL. The nurse assesses the hourly urinary output at 10 am at 20 mL. What is the highest priority action by the nurse?

Notify the physician

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; (48 to 72 hours after alcohol withdrawal)

Postoperative day 2, a patient requires wound care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing?

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

Which of the following factors may contribute to rapid + shallow respirations in a postoperative client? Select all that apply

Pain Constricting dressings Abdominal distention Obesity Gastric dilation

In what phase of postanesthesia care (PACU) is the client prepared for self-care or care in the hospital or an extended care setting?

Phase II PACU

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. Which of the following actions by the nurse would be inappropriate?

Restrict oral fluids

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

When vomiting occurs postoperatively, what is the most important nursing intervention?

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

Select the nutrient that is important for postoperative wound healing because it helps form collagen.

Vitamin C

To prevent thromboembolism in the postoperative client, the nurse should include which of the following in the plan of care?

Assist with oral fluid intake

The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply.)

Assisting the patient with leg exercises Encouraging early ambulation Avoiding placement of pillows or blanket rolls under the patient's knees

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.

A pt has a wound that hemorrhaged. What does the nurse understand is the cause of the pts increased risk of infection?

Dead space and dead cells provide a culture medium

The nurse is assessing the client for wound complications following surgery. For which clinical manifestation should the nurse assess? Select all that apply.

Dehiscence Hematoma

A postoperative patient is being discharged home following minor surgery. The PACU nurse is reviewing discharge instructions with the patient and his or her spouse. What action by the nurse is appropriate? Select all that apply.

Educate on activity limitations. Discuss wound care. Have the spouse review when to notify the physician. Provide information on health promotion topics.

A nurse is reviewing with a client the use of a patient-controlled anesthesia device and is explaining the benefits. Which of the following would the nurse correctly emphasize? Select all that apply.

Fosters client participation in care Facilitates reduction of postoperative pulmonary complications

What complication in the immediate postoperative period should the nurse understand requires early intervention to prevent?

Hypoxemia and hypercapnia

Which statement by the client indicates further teaching about epidural anesthesia is necessary?

I will become unconscious

A postoperative client is experiencing a flash pulmonary edema. What finding in the pts sputum is consistent with this?

Pink color

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

Review the instructions with the patient and 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

Nonpharmacological management of pain includes:

listening to music, watching television, and changing position

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

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

Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention?

Oxygen saturation of 82%; Normal pulse oximetry is 95% to 100%