Ch. 19: Postoperative Nursing Management Prep U

The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of: Hyperventilation Laryngospasm Pulmonary edema and embolism. Hypoxemia and hypercapnia.

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? Remove the dressing, assess the wound, and apply a new sterile dressing. Take the client's vital signs and call the surgeon. Make the client NPO and order a stat hemoglobin and hematocrit. Outline the drainage with a pen and record the date and time next to the drainage.

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

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

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

Decreased cardiac output

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 Ineffective thermoregulation Decreased cardiac output Ineffective airway clearance

Ineffective thermoregulation

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: Third intention Granulation First intention Second intention

First intention

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? Obtain vital signs, including pulse oximetry, every 5 minutes. Remove the oral airway. Notify the physician of impaired neurological status. Continue with frequent client assessments.

Continue with frequent client assessments.

A patient has a wound that has hemorrhaged. What does the nurse understand is the cause of the patient's increased risk of infection? Retrograde bacterial contamination may occur Dead space and dead cells provide a culture medium The tissue becomes less resilient Reduced amounts of oxygen and nutrients are available

Dead space and dead cells provide a culture medium

The nurse is caring for a postoperative client with a Hemovac. The Hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to: Assess the client's wound and apply a pressure dressing. Empty and measure the drainage and compress the Hemovac. Notify the surgeon that the Hemovac is not functioning. Remove the Hemovac because it is expanded.

Empty and measure the drainage and compress the Hemovac.

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? Apply moist heat to the client's abdomen. Administer a tap water enema. Encourage the client to ambulate as soon as possible after surgery. Notify the physician.

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

You are caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery? Place pressure on the client's lower extremities. Encourage the client to move legs frequently and do leg exercises. Place the client in a side-lying position. Place pillows under the client's knees or calves.

Encourage the client to move legs frequently and do leg exercises.

During the first 24 hours after surgery, how often will the nurse evaluate the client's temperature? Every 2 hours Every 15 minutes Every 8 hours Every 4 hours

Every 4 hours

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

First intention

Which is a classic sign of hypovolemic shock? Dilute urine High blood pressure Pallor Bradypnea

Pallor

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

Pink color

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 White with long, thin areas of scar tissue Necrotic and hard Pale yet able to blanch with digital pressure

Pink to red and soft, bleeding easily

A nurse is reviewing the medications of a postoperative client. What medication related to the recent surgery may be of concern to the nurse? Prednisone Digoxin Allopurinol Furosemide

Prednisone

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 drainage Respiratory rate Wound approximation Temperature

Wound approximation

A client asks why a drain is in place to pull fluid from the surgical wound. What is the bestresponse by the nurse? "It will cut down on the number of dressing changes needed." "Most surgeons use wound drains now." "The drain will remove necrotic tissue." "It assists in preventing infection."

"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? 5 6 4 7

7

The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply. Wheezes Chills Crackles Tachypnea Afebrile

Chills Crackles Tachypnea

Question 4 of 20 To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: Ambulating the client as soon as possible Assessing breath sounds at least every 2 hours Positioning the client in a supine position Assisting with incentive spirometry every 6 hours

Ambulating the client as soon as possible

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. Prepare to administer a stool softener. Prepare to insert a nasogastric tube. Re-attempt to auscultate bowel sounds.

Call the health care provider

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Insert suction catheter into the lumen of the tube. 2Apply intermittent suction while withdrawing the catheter. 3Position the client in Fowlers position. 4Don sterile gloves. 5Lubricate the sterile suction catheter.

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.

What complication is the nurse aware of that is associated with deep venous thrombosis? Swelling of the entire leg owing to edema Immobility because of calf pain Marked tenderness over the anteromedial surface of the thigh Pulmonary embolism

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 the dressing or applying pressure if bleeding is frank Encouraging the client to breathe deeply Elevating the head of the bed Monitoring vital signs every 15 minutes

Reinforcing the dressing or applying pressure if bleeding is frank

A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention? Rely on the IV fluids for hydration. Dangle at the bedside. Report early calf pain. Take off the pneumatic compression devices for sleeping.

Report early calf pain.

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? 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. Family members can be involved in the administration of pain medications with patient-controlled analgesia. The client can self-administer oral pain medication as needed with patient-controlled analgesia.

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

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 site gets wet, pat the wound dry." "The wound should not be rubbed or scrubbed." "If the wound edges are red or raised, you should call your doctor." "The wound will continue to heal for several weeks."

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

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

Assessing WBC count, temperature, and wound appearance

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required? "I should call my physician if I develop a fever." "My incision should become less red and tender." "I can resume my usual activities as soon as I get home." "I need to keep my follow-up appointment with the physician."

"I can resume my usual activities as soon as I get home."

What measurement should the nurse report to the physician in the immediate postoperative period? A temperature reading between 97°F and 98°F A systolic blood pressure lower than 90 mm Hg A hemoglobin of 13.6 Respirations between 20 and 25 breaths/min

A systolic blood pressure lower than 90 mm Hg

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 Abdominal distention Abdominal tightness Increased abdominal girth

Absence of peristalsis

Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply. Be able to drive to the grocery Pass a stress test Ambulate the length of the client's house Get out of bed without assistance Be able to self-toilet

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

Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply. Pass a stress test Be able to self-toilet Get out of bed without assistance Be able to drive to the grocery Ambulate the length of the client's house

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: Assisting with incentive spirometry every 6 hours Ambulating the client as soon as possible Assessing breath sounds at least every 2 hours Positioning the client in a supine position

Ambulating the client as soon as possible

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? Assess for signs and symptoms of fluid volume deficit. Discontinue the nasogastric tube suctioning. Document the findings and reassess in 24 hours. Assess for edema.

Assess for signs and symptoms of fluid volume deficit.

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. Document the findings. Apply oxygen. Notify the physician.

Assess the client's heart rhythm and nail beds.

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

First intention

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 On-Q pump Watching television An epidural infusion Listening to music Changing position

Listening to music Watching television Changing position

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. Place a dry, sterile dressing over the protruding organs. Have the client lay quietly on back and call the physician. Place a pressure dressing over the opening and secure.

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

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. Massaging the client's legs Performing guided imagery Applying hot cloths to the client's face Changing the client's position Putting on soothing music

Performing guided imagery Putting on soothing music Changing the client's position

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. Massaging the client's legs Putting on soothing music Applying hot cloths to the client's face Changing the client's position Performing guided imagery

Performing guided imagery Putting on soothing music Changing the client's position

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? Pulmonary edema Pneumonia Hypoxemia Pleurisy

Pneumonia

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? Administer an anti-emetic. Ask the client for more clarification. Obtain an emesis basin. Position the client in the side-lying position.

Position the client in the side-lying position.

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? Third-intention healing First-intention healing Second-intention healing Primary-intention healing

Second-intention healing

A nurse is caring for a client who is scheduled to have a thoracotomy. When planning care for this client, what mobility teaching will the nurse include in the plan of care? Use of a cane on the affected side Shoulder and upper arm range-of-motion exercises Lower back and rib range of motion exercises Use of a cane on the unaffected side

Shoulder and upper arm range-of-motion exercises

Which is the of the following factors stimulates the wound healing process? Hemorrhage Nutritional deficiencies Immobility Sufficient oxygenation

Sufficient oxygenation

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

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. The client should be transferred to an intensive care area. The client must remain in the PACU. The client must be put on immediate life support.

The client can be discharged from the PACU.

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing? Atelectasis Wound infection Uncontrolled pain Hyperthermia

Wound infection

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. change the client's position. palpate the abdomen. insert a rectal tube.

auscultate bowel sounds.

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

chlorpromazine

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

first intention.

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? "The wound will continue to heal for several weeks." "If the wound edges are red or raised, you should call your doctor." "If the wound site gets wet, pat the wound dry." "The wound should not be rubbed or scrubbed."

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

Using the PACU room scoring guide, a nurse would give a patient an admission cardiovascular score of 2 if the patient's blood pressure is what percentage of his or her preanesthetic level? Greater than 50% 20% 30% to 40% 40% to 50%

20%

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? Monitoring vital signs Inserting a nasogastric (NG) tube Applying a sterile, moist dressing Putting the client on nothing-by-mouth (NPO) status

Applying a sterile, moist dressing

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? Putting the client on nothing-by-mouth (NPO) status Monitoring vital signs Inserting a nasogastric (NG) tube Applying a sterile, moist dressing

Applying a sterile, moist dressing

What complication is the nurse aware of that is associated with deep venous thrombosis? Immobility because of calf pain Swelling of the entire leg owing to edema Marked tenderness over the anteromedial surface of the thigh Pulmonary embolism

Pulmonary embolism

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? Give the written instructions to the client's 16-year-old child. Ask the client, "Do you understand?" Review the instructions with the client and an accompanying adult. Continuously repeat the instructions until the client restates them.

Review the instructions with the client and an accompanying adult.

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 must remain in the PACU. The client should be transferred to an intensive care area. The client can be discharged from the PACU. The client must be put on immediate life support.

The client can be discharged from the PACU.

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 mostlikely cause of the client's change in condition? The client is displaying late signs of shock. The client is displaying early signs of shock. The client is showing signs of a medication reaction. The client is showing signs of an anesthesia reaction.

The client is displaying early signs of shock.

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? Convalescent period Detailed medication history Respiratory depressive effects Tolerance

Tolerance

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? Detailed medication history Respiratory depressive effects Tolerance Convalescent period

Tolerance

A recently extubated postoperative client starts to gag and make vomiting sounds. What action should the nurse perform first? Provide an emesis basin. Obtain suction equipment. Turn the client onto their side. Administer an antiemetic.

Turn the client onto their side.

Which findings would be indicative of a nursing diagnosis of decreased cardiac output? tachycardia; hemoglobin 10.9 gm/dL; BP 88/56 bradycardia; urinary output < 30 ml; confusion urinary output > 60 ml; BP 90/60; tachypnea confusion; tachypnea; hemoglobin 14.2 gm/dL

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

Which term refers to the protrusion of abdominal organs through the surgical incision? Dehiscence Erythema Hernia Evisceration

Evisceration

Corticosteroids have which effect on wound healing? Cause hemorrhage Mask the presence of infection May cause protein-calorie depletion Reduce blood supply

Mask the presence of infection

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? Place a dry, sterile dressing over the protruding organs. Place a pressure dressing over the opening and secure. Have the client lay quietly on back and call the physician. Moisten sterile gauze with normal saline and place on the protruding organ.

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

Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client? Reinforce the need to perform leg exercises every hour when awake. Maintain bed rest. Administer prophylactic high-dose heparin. Instruct the client to prop a pillow under the knees.

Reinforce the need to perform leg exercises every hour when awake.

The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract? The client states being hungry. The client is passing flatus. The client is tolerating sips of water. The client reports a small bowel movement.

The client reports a small bowel movement.

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

clean contaminated.

Which of the following clinical manifestations increase the risk for evisceration in the postoperative client? Edema Hypoxia Valsalva maneuver Hypovolemia

Valsalva maneuver

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 110/80 mm Hg Blood pressure of 90/50 mm Hg Blood pressure of 150/100 mm Hg Blood pressure of 120/90 mm Hg

Blood pressure of 90/50 mm Hg

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: About 24 hours postoperatively. On the second or third day. Within the first 12 hours. 4 days after surgery. SUBMIT ANSWER

On the second or third day.

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? Encouraging the client to breathe deeply Reinforcing dressings or applying pressure if bleeding is frank Elevating the head of the bed Rubbing the back

Reinforcing dressings or applying pressure if bleeding is frank

The primary objective in the immediate postoperative period is relieving pain. maintaining pulmonary ventilation. controlling nausea and vomiting. monitoring for hypotension.

maintaining pulmonary ventilation.

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

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

Reinforcing the dressing or applying pressure if bleeding is frank

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? Requirement of intermittent catheterization Calculus formation Urinary infection Urine retention

Urine retention