Chapter 16 Post Op

A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a. Airway b. Bleeding c. Breathing d. Cardiac rhythm

ANS: A a. Airway Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of the circulation assessment, as is cardiac rhythm.

The nurse assesses a client who has just been brought to the postanesthesia care unit (PACU). Which assessment finding is the best indicator that the client's circulatory status may be compromised? a. The blood pressure decreased from 136/80 to 122/80 mm Hg. b. The urine output decreased from 40 to 10 mL/hr. c. The client's respirations are irregular. d. The client's temperature has risen from 99.4° to 99.8° F.

ANS: B b. The urine output decreased from 40 to 10 mL/hr. One of the most sensitive and earliest indicators of vascular volume loss is a decreased urine output. The nurse is concerned about urinary outputs less than 30 mL/hr because this may indicate that the kidneys are not being perfused.

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.) a. All phases require the client to be in the hospital. b. Phase I care may last for several days in some clients. c. Phase I requires intensive care unit monitoring. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III.

ANS: B, D, E b. Phase I care may last for several days in some clients. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III. There are three phases of postoperative care. Phase I is the most intense, with clients coming right from surgery until they are completely awake and hemodynamically stable. This may take hours or days and can occur in the intensive care unit or the postoperative care unit. Phase II ends when the client is at a presurgical level of consciousness and baseline oxygen saturation, and vital signs are stable. Phase III involves the extended care environment and may continue at home or in an extended care facility if needed.

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96° F (35.6° C)

ANS: C c. Client with a respiratory rate of 6 breaths/min The respiratory rate is the most critical vital sign for any client who has undergone general anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low and indicates respiratory depression. The nurse should assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may be within that client's baseline. A pulse of 118 beats/min is slightly fast, which could be due to several causes, including pain and anxiety. A temperature of 96° F is slightly low and the client needs to be warmed. But none of these other vital signs take priority over the respiratory rate.

The nurse is caring for an older adult client who has just returned to the medical-surgical unit from the postanesthesia recovery unit. The client does not remember that he just had surgery. What is the nurse's best action? a. Notifying the surgeon immediately b. Documenting the observation as the only action c. Reorienting the client as needed and check the client frequently d. Holding all the client's narcotic pain medications

ANS: C c. Reorienting the client as needed and check the client frequently Many older adult clients experience temporary changes in mental status immediately after surgery as a result of the anesthetic and hospital environment. This is common, and the best action is to reorient the client frequently.

An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states "She needs to get back to her old self!" What response by the nurse is best? a. "Everyone comes out of surgery differently." b. "Let's just give her some more time, okay?" c. "She may have had a stroke during surgery." d. "Sometimes older people take longer to wake up."

ANS: D d. "Sometimes older people take longer to wake up." Due to age-related changes, it may take longer for an older adult to metabolize anesthetic agents and pain medications, making it appear that they are taking too long to wake up and return to their normal baseline cognitive status. The nurse should educate the family on this possibility. While everyone does react differently, this does not give the family any objective information. Saying "Let's just give her more time, okay?" sounds patronizing and again does not provide information. While an intraoperative stroke is a possibility, the nurse should concentrate on the more common occurrence of older clients taking longer to fully arouse and awake.

A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the client's plan of care to minimize the potential for this occurring? (Select all that apply.) a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. d. Place the client in a room secluded at the end of the hall. e. Provide the client with uninterrupted periods of sleep.

ANS: A, B, C, E a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. e. Provide the client with uninterrupted periods of sleep Older clients may have difficulty adjusting to the stress of the hospital environment and illness or surgery. Techniques that are helpful include allowing liberal visitation, assisting the client to use successful coping techniques, and keeping the client bathed and groomed. Sleep deprivation can contribute to confusion, so the nurse ensures the client receives adequate sleep. Secluding the client at the end of the hall may lead to sensory deprivation and loneliness.