Chapter 19, Nursing Management: Postoperative Care

The nurse is monitoring a patient who is about to be transferred to the clinical unit from the postanesthesia care unit (PACU). Which assessment data require the most immediate attention? Oxygen saturation of 94% Pulse rate 128 beats/minute Respiratory rate of 13/minute Temperature of 99.8° F (37.7° C)

pulse rate 128

While caring for a patient after a colectomy on the first postoperative day, the nurse notes new bright-red drainage about 4 cm in diameter on the surgical dressing. What is the priority nursing action? Take the patient's vital signs. Mark the area on the dressing and document the finding. Recheck the dressing in one hour for increased drainage. Notify the health care provider of a potential hemorrhage.

take vitals

A nurse is caring for an older adult patient, who had a knee replacement the previous day. The patient denies any pain. Which response by the nurse would be most appropriate? "Excellent. You must be able to handle a lot of pain." "Great. It is wise to only take the pain medication if you need it." "It is important that you take pain medication. It will help you recover quicker." "Almost everyone has pain after this surgery. Are you certain that you are not experiencing pain?"

"Almost everyone has pain after this surgery. Are you certain that you are not experiencing pain?"

The patient donated a kidney and early ambulation is included in the plan of care; however, the patient refuses to get up and walk. What explanation should the nurse give to the patient for early ambulation? "Early walking keeps your legs limber and strong." "Early ambulation will help you be ready to go home." "Early ambulation will help you get rid of your syncope and pain." "Early walking is the best way to prevent postoperative complications."

"Early walking is the best way to prevent postoperative complications."

A patient is admitted to the postanesthesia care unit (PACU) after colon surgery. During the initial assessment, the patient tells the nurse they are going to "throw up." Which statement by the nurse reflects a priority nursing intervention? "I need to check your vital signs." "Let me help you turn to your side." "Here is a sip of ginger-ale for you." "I can give you some antinausea medicine."

"Let me help you turn to your side."

A postoperative patient is transferred from the postanesthesia unit to the medical-surgical nursing floor. The nurse notes that the patient has a prescription for D 5½ normal saline (NS) to infuse at 120 mL/hr. The nurse regulates the intravenous (IV) at what flow rate in drops (gtts)/min, noting that the tubing has a drop factor of 10 drops/mL? Fill in the blank using a whole number.

20 120 mL/hr × 10 gtts/mL = 1200 gtts/hr 1200 gtts ÷ 60 min = 20 gtts/min

The nurse is preparing to administer cefazolin 2 gm in 100 mL of normal saline to a postoperative patient. What infusion rate on the infusion pump will infuse this medication over 20 minutes? Record your answer using a whole number.

300 ml/hr ml/hr = 100 ml / 0.33 (20 mins) = 300

The nurse is caring for a group of patients. What patient should the nurse be sure to institute interventions for the prevention of thrombophlebitis? A patient with a 25-year smoking history A female patient in the fifth month of pregnancy An older adult patient taking anticoagulant medications A hospitalized patient who has been on bed rest for 3 days

A hospitalized patient who has been on bed rest for 3 days

The nurse is caring for a postoperative patient. What patient does the nurse determine is at the greatest risk for development of atelectasis? A patient after a hypoxic episode during an acute asthma attack An older adult patient who has undergone cardiothoracic surgery A patient not adherent with the pulmonary regimen after surgery A patient experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD)

A patient not adherent with the pulmonary regimen after surgery

A patient with a history of bipolar disorder underwent an amputation of the left leg. The patient has diabetes and a complicated diabetic foot ulcer. Which factor will best determine the patient's ability to cope? Ability to regain independence Previous diagnosis of depression Anxiety during the discharge process Ability to complete the rehabilitation program

Ability to regain independence

A patient with asthma develops wheezing on the postanesthesia care unit. The nurse finds that the patient is tachypneic, has dyspnea, and has reduced oxygen saturation. How will the nurse prevent further pulmonary complications? Administer bronchodilators. Provide incentive spirometry. Encourage chest physical therapy. Provide nebulization of histamine vapors.

Administer bronchodilators.

The nurse is developing a care plan for the postoperative patient in order to prevent complications and promote ambulation, coughing, deep breathing, and turning. What actions can the nurse provide to achieve desired outcomes? Explain easily the rationale for these activities. Have family in the room for support and encouragement. Warn about pneumonia and clotting if the actions are not completed. Administer enough analgesics to promote relative freedom from pain.

Administer enough analgesics to promote relative freedom from pain.

The nurse finds that a postoperative patient has an oxygen saturation of 85%. On auscultation the patient has decreased breath sounds. Which nursing interventions are appropriate? Select all that apply. Restrict intake of fluid. Administer oxygen therapy. Administer diuretics as advised. Encourage deep breathing exercises. Help the patient to walk around, if tolerated.

Administer oxygen therapy. Encourage deep breathing exercises. Help the patient to walk around, if tolerated.

A patient is suspected of having a pulmonary embolism following a major orthopaedic procedure. How would the nurse relieve the patient of dyspnea? Select all that apply. Administer lidocaine. Administer oxygen therapy. Administer bronchodilators. Administer anticoagulant therapy. Administer skeletal muscle relaxant.

Administer oxygen therapy. Administer anticoagulant therapy.

A patient who was on mechanical ventilation through an endotracheal tube develops inspiratory stridor and sternal retraction upon removal of the endotracheal tube. How should the nurse manage this patient and ensure oxygenation? Select all that apply. Suction the airway. Administer oxygen therapy. Administer muscle relaxants. Tilt the head and thrust the jaw. Provide positive pressure ventilation.

Administer oxygen therapy. Administer muscle relaxants. Provide positive pressure ventilation.

A patient reports abdominal distention and gas pains after abdominal surgery. What nursing action(s) will help to treat the problem? Select all that apply. Ambulate the patient Reposition frequently Administer bisacodyl Turn patient onto left side Administer morphine sulfate Discontinue the nasal gastric tube (NGT)

Ambulate the patient Reposition frequently Administer bisacodyl

A postoperative patient is delirious, restless, and shouting at the nurse about pain. What does the nurse consider may be a cause of this behavior? A new diagnosis of psychosis Increased ability to tolerate pain Anesthetic agents used in surgery Inadequately timed administration of pain medication

Anesthetic agents used in surgery

A nurse cares for a patient with acute pulmonary edema. What findings would the nurse expect to assess? Vertigo and headache Palpitations and nausea Anxiety and distended neck veins Dry, hacking cough and chest pain

Anxiety and distended neck veins

The nurse is caring for a patient in the postanesthesia care unit (PACU), when the blood pressure drops from 110/60 mm HG to 92/58 mm Hg. What actions should the nurse take? Select all that apply. Assess ECG tracing. Inspect the surgical site. Administer pain medication. Administer prescribed metoprolol. Have the patient take deep breaths. Administer intravenous (IV) fluid bolus per protocol.

Assess ECG tracing. Inspect the surgical site. Have the patient take deep breaths. Administer intravenous (IV) fluid bolus per protocol.

The nurse is preparing to administer an analgesic to a postoperative patient. What actions taken by the nurse would be appropriate? Select all that apply. Assess the location, quality, and intensity of pain. Monitor the patient for nausea, vomiting, and respiratory depression. Assess the patient's sleep/wake cycle and sensory and motor status. Assess the patient's level of orientation and ability to follow commands. Time the analgesic administration for effectiveness during painful activities.

Assess the location, quality, and intensity of pain. Monitor the patient for nausea, vomiting, and respiratory depression. Time the analgesic administration for effectiveness during painful activities.

In caring for the postoperative patient on the clinical unit after transfer from the postanesthesia care unit (PACU), which care can be delegated to the unlicensed assistive personnel (UAP)? Monitor the patient's pain Do the admission vital signs Assist the patient to take deep breaths and cough Change the dressing when there is excess drainage

Assist the patient to take deep breaths and cough

A postoperative patient with bronchial obstruction has a pulse oximetry reading of 87%. What does the nurse suspect is occurring with this patient? Atelectasis Bronchospasm Hypoventilation Pulmonary embolism

Atelectasis

A postoperative patient develops laryngeal edema after receiving a penicillin injection. How can the nurse prevent further complications in the patient? Select all that apply. By suctioning the airway By administering sedatives By administering antihistamines By administering corticosteroids By providing chest physical therapy

By administering sedatives By administering antihistamines By administering corticosteroids

A patient who has been admitted to the postanesthesia care unit following major abdominal surgery develops coarse crackles. How should the nurse prevent pulmonary complications in this patient? Select all that apply. By abdominal exercises By providing IV hydration By suctioning the airways By administering sedatives By administering cough suppressants

By providing IV hydration By suctioning the airways

The nurse has received a patient from surgery in the postanesthesia care unit (PACU). What is the best way for the nurse to ensure that this patient has a patent airway? Select all that apply. By suctioning the airway By administering sedatives By putting in an artificial airway By administering oxygen therapy By tilting the head and thrusting the jaw

By putting in an artificial airway By tilting the head and thrusting the jaw

An older adult patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this patient? Check the chart for intraoperative complications. Check the effectiveness of the analgesics received. Check which medications were used for anesthesia. Check the preoperative assessment for previous delirium or dementia.

Check the preoperative assessment for previous delirium or dementia.

A patient that is an alcoholic had a hernia operation and is restless and irritable. On assessment, the nurse finds that the patient has auditory hallucinations. What is the most appropriate nursing action? Conclude that these effects are due to alcohol withdrawal. Consider the situation normal, due to the anesthetic drugs. Conclude that the patient suffers from a psychotic disorder. Infer that the patient is suffering from pain and suggest using pain killers.

Conclude that these effects are due to alcohol withdrawal.

A patient with a history of deep vein thrombosis is recovering in the postanesthesia care unit (PACU) after an abdominal surgery. Considering that the patient is at risk of developing pulmonary embolism (PE), what signs should the nurse watch out for? Select all that apply. Dyspnea Tachypnea Tachycardia Coarse crackles Noisy respirations

Dyspnea Tachypnea Tachycardia

A patient with a history of psychosis has newly developed anxiety and is combative with the nurse. What does the nurse know may be causes of this change in behavior? Delirium Excessive sleep Hyperoxygenation Electrolyte imbalances

Electrolyte imbalances

A postoperative patient has absence of breath sounds on the left lung and an oxygen saturation of 86%. What interventions should be included to maintain adequate oxygen saturation? Select all that apply. Administer diuretics. Allow delayed ambulation. Instruct shallow breathing. Encourage incentive spirometry. Provide humidified oxygen therapy.

Encourage incentive spirometry. Provide humidified oxygen therapy.

An older adult postoperative patient wakes up and becomes restless and agitated and starts thrashing and shouting. The nurse finds that the patient was administered benzodiazepines during surgery. What would be important to have on the patient's plan of care? Select all that apply. Ensure patient safety. Administer an antianxiety drug. Administer a narcotic analgesic. Administer an antipsychotic drug. Use drugs to reverse the benzodiazepines.

Ensure patient safety. Use drugs to reverse the benzodiazepines.

A patient undergoes abdominal surgery. Before asking the patient to perform postoperative breathing exercises, what evaluation or intervention should the nurse perform? Gauging the patient's level of pain Evaluating the patient's vital signs Assisting the patient out of bed and into a chair Reviewing the primary health care provider's plan of care

Gauging the patient's level of pain

The nurse determines that a postoperative patient has not voided for 8 hours. What appropriate action should the nurse take? Select all that apply. Scan the bladder with a portable ultrasound. Help the patient to use a bedside commode. Reassure the patient regarding the ability to void. Obtain a prescription and catheterize the patient. Use techniques like pouring warm water over the perineum.

Help the patient to use a bedside commode. Reassure the patient regarding the ability to void. Use techniques like pouring warm water over the perineum.

The nurse receives an unconscious postoperative patient in the post anesthesia care unit (PACU). What position would be the safest to place this patient immediately after the operation? Supine Lateral Semi-Fowler's High Fowler's

Lateral

The nurse places an abdominal binder on a patient after colon surgery. After approximately an hour, the nurse assesses the patient has shallow respirations, is hypoxemic, and hypercapnic. How should the nurse promote optimal breathing in this patient? Select all that apply. Loosen the binder Reposition the patient Provide music therapy Elevate the foot end of bed Raise the head end of the bed

Loosen the binder Reposition the patient Raise the head end of the bed

The nurse is caring for a patient at risk for developing syncope. Which nursing intervention is important to prevent this occurrence in this postoperative patient? Administer oxygen therapy. Administer analgesics before ambulation. Make changes in the patient's position slowly. Encourage deep breathing and coughing exercises.

Make changes in the patient's position slowly.

The nurse is monitoring a postoperative patient in the Phase I postanesthesia care unit (PACU). What criteria must the patient meet in order to be discharged from this phase? Select all that apply. No nausea or vomiting No respiratory depression Oxygen saturation above 90% Written discharge instructions understood Patient reports pain level of 4 on a 1 to 10 scale

No respiratory depression Oxygen saturation above 90% Patient reports pain level of 4 on a 1 to 10 scale

A nurse is caring for a patient who had a bowel resection 10 hours before. The patient weighs 200 pounds (91 kg) and has a urine output of 240 cc for the past eight hours. What action should the nurse take? Encourage oral (PO) fluids Continue to monitor the urine output Notify the primary health care provider Administer a 500 cc normal saline intravenous (IV) bolus

Notify the primary health care provider The formula for determining adequate urine output is 0.5 mL/kg/hr. This patient, weighing 91 kg, needs to have 45 cc per hour or about 365 cc of urine in eight hours.

A patient, who is eight hours postappendectomy, has not voided since surgery. What action should the nurse take? Encourage oral (PO) fluid intake. Palpate the suprapubic area for bladder distention. Insert an in and out catheter to assess for retention. Check the medical record to determine the type of anesthetic given.

Palpate the suprapubic area for bladder distention.

The nurse caring for a postoperative patient assesses clinical manifestations of early pulmonary edema secondary to heart failure. What manifestations does the nurse determine correlates with this disorder? Early-morning cough Increased urine output Paroxysmal nocturnal dyspnea Crackles heard on auscultation

Paroxysmal nocturnal dyspnea

A patient has difficulty passing urine after surgery for the correction of rectal prolapse. How should the nurse help this patient void? Select all that apply. Perform early catheterization. Pour warm water over perineum. Encourage immobility and bed rest. Reassure the patient of the ability to void. Help the patient to attain a normal voiding position.

Pour warm water over perineum. Reassure the patient of the ability to void. Help the patient to attain a normal voiding position.

An older patient is having problems with concentration and memory after extensive surgery to repair an abdominal aortic aneurysm. What determines if this is a factor of delirium or postoperative cognitive dysfunction? Preexisting dementia identified before surgery Ability of the patient to state name, location, and date Ability to ambulate in the halls and follow commands An undisturbed sleep-wake cycle in the critical care unit

Preexisting dementia identified before surgery

An older adult postoperative patient has difficulty with memory and the ability to concentrate. What should the nurse do to help this patient? Select all that apply. Provide adequate nutrition. Encourage delayed mobility. Provide bowel and bladder care. Sedate the patient for long durations. Monitor fluid and electrolyte disturbance.

Provide adequate nutrition. Provide bowel and bladder care. Monitor fluid and electrolyte disturbance.

The nurse is caring for a patient in the postanesthesia care unit (PACU) when they become agitated. What is the priority action by the nurse? Select all that apply. Put the side rails up. Evaluate respiratory status. Monitor fluid intake and output. Use clocks to orient the patient if needed. Sedate the patient, if the patient is not hypoxemic.

Put the side rails up. Evaluate respiratory status. Use clocks to orient the patient if needed. Sedate the patient, if the patient is not hypoxemic.

A patient had an estimated blood loss of 400 mL during abdominal surgery. The patient received 300 mL of 0.9% saline during surgery and now is experiencing hypotension postoperatively. What should the nurse anticipate for this patient? Restoring circulating volume Monitor pulse and blood pressure An ECG to check circulatory status Return to surgery to check for internal bleeding

Restoring circulating volume

The nurse finds that a postoperative patient has low oxygen saturation and crackles on auscultation. Which is an appropriate nursing action? Suction the airway. Restrict fluid intake. Monitor mental status. Place the patient in lateral recovery position.

Restrict fluid intake.

A patient inadvertently received a large amount of intravenous fluid. The nurse assesses that the patient has reduced oxygen saturation, crackles on auscultation, and infiltrates on chest x-ray. How should the nurse relieve the patient's breathing discomfort and promote oxygen saturation? Select all that apply. Restrict fluids. Administer diuretics. Administer oxygen therapy. Administer bronchodilators. Implement anticoagulant therapy.

Restrict fluids. Administer diuretics. Administer oxygen therapy.

Two days after colectomy for an abdominal mass, the patient reports gas pains and abdominal distension. The nurse plans care for the patient on the basis of the knowledge that these symptoms occur as a result of which condition? Constipation Nasogastric suctioning Slowed gastric emptying Inflammation of the bowel at the anastomosis site

Slowed gastric emptying

A patient transferred to the medical-surgical unit from the postanesthesia care unit (PACU) has regained consciousness. In which position should the nurse place the patient in order to prevent respiratory problems? Lithotomy position Lateral recovery position Prone position with extra pillows Supine position with head elevated

Supine position with head elevated

What is the priority nursing action when a patient is transferred from the postanesthesia care unit (PACU) to the surgical unit after a lobectomy? Assess the patient's pain. Take the patient's vital signs. Check the rate of the intravenous (IV) infusion. Check the health care provider's postoperative prescriptions.

Take the patient's vital signs.

A postoperative patient who has been transferred from surgery to the postanesthesia care unit is cold and shivering. The patient's plan of care includes a prescription for morphine to be administered for pain relief. When managing this patient, which interventions should the nurse perform? Select all that apply. Use forced air warmers. Administer oxygen therapy. Administer warmed IV fluids. Use warmed cotton blankets. Withhold morphine until shivering stops.

Use forced air warmers. Administer oxygen therapy. Administer warmed IV fluids. Use warmed cotton blankets.

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge? Select all that apply. Vital signs baseline or stable Minimal nausea and vomiting Wants to go to the bathroom at home Responsible adult taking patient home Comfortable after intravenous (IV) opioid 15 minutes ago

Vital signs baseline or stable Minimal nausea and vomiting Responsible adult taking patient home