Chapter 19: Postoperative Nursing Management (Exam 2)
What complication is the nurse aware of that is associated with deep venous thrombosis? Pulmonary embolism Immobility because of calf pain Swelling of the entire leg owing to edema Marked tenderness over the anteromedial surface of the thigh
Pulmonary embolism Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010).
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? Abdominal tightness Absence of peristalsis Abdominal distention Increased abdominal girth
Absence of peristalsis Paralytic ileus and intestinal obstruction are potential postoperative complications that occur more frequently in patients undergoing intestinal or abdominal surgery. Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for 24 to 48 hours, depending on the type and extent of surgery.
Which term refers to the protrusion of abdominal organs through the surgical incision? Dehiscence Hernia Evisceration Erythema
Evisceration Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.
Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis? Ineffective airway clearance Acute pain Urinary retention Decreased cardiac output
Decreased cardiac output Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion.
A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding? Hernia Dehiscence Erythema Evisceration
Evisceration Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.
The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required? "I need to keep my follow-up appointment with the physician." "My incision should become less red and tender." "I can resume my usual activities as soon as I get home." "I should call my physician if I develop a fever."
"I can resume my usual activities as soon as I get home." By time of discharge, clients should be able to verbalize clinical manifestations of complications, activity and diet restrictions, and specifics regarding follow-up appointments. The client with abdominal incision will need to avoid lifting and driving in the initial discharge period.
The nurse is caring for a postoperative client with an indwelling urinary catheter. The hourly urinary output is 80 mL at 9 am. At 10 am, the nurse assesses the hourly urinary output as 20 mL. What is the priority action by the nurse? Document the findings. Notify the primary care provider immediately. Reassess the output at 11 am. Irrigate the catheter with sterile normal saline.
Notify the primary care provider immediately. If the client has an indwelling urinary catheter, hourly outputs are monitored and rates <30 mL/h are reported. Any urinary output <30 mL/h should be reported to the primary care provider immediately. Though urinary output will be reassessed at 11 am, but waiting to notify the primary care provider puts the patient at risk. The findings should be documented, but this is not the highest priority. A urinary catheter may need to be irrigated, but a postoperative client with a low urinary output is demonstrating a complication of inadequate fluid imbalance that needs to be reported immediately.
The nurse has medicated a postoperative client who reported nausea. Which medication would the nurse document as having been given? Ondansetron Propofol Prednisone Warfarin
Ondansetron Ondansetron is an antiemetic and one of the most commonly prescribed medications for nausea and vomiting. Warfarin is an anticoagulant. Prednisone is a corticosteroid. Propofol is an anesthetic agent.
A recently extubated postoperative client starts to gag and make vomiting sounds. What action should the nurse perform first? Turn the client onto their side. Administer an antiemetic. Provide an emesis basin. Obtain suction equipment.
Turn the client onto their side. The nurse should turn the client on their side to avoid aspiration. The nurse may need to obtain suction equipment, provide an emesis basin, or administer an antiemetic, but the first priority is protecting the client's airway by preventing aspiration.
A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for? Hypotension Contractures Wound dehiscence Phlebitis
Wound dehiscence Risk factors for wound dehiscence include advanced age over 65 years, chronic disease such as diabetes, hypertension, obesity, history of radiation or chemotherapy, malnutrition, particularly insufficient protein and vitamin C, and hypoalbuminemia. This client is not at increased risk for hypotension, contractures, or phlebitis.
Nursing assessment findings reveal a temperature of 39.5 C (103.2°F), tachycardia, and client complaints of increased incisional pain. The nurse recognizes the client is experiencing: Uncontrolled pain Hyperthermia Atelectasis Wound infection
Wound infection Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.
When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as contaminated. clean contaminated. dirty. clean.
clean contaminated. Clean contaminated cases are those with a potential, limited source for infection, the exposure to which can largely be controlled. Clean cases are those with no apparent source of potential infection. Contaminated cases are those that contain an open and obvious source of potential infection. A traumatic wound with foreign bodies, fecal contamination, or purulent drainage would be considered dirty.
The primary objective in the immediate postoperative period is relieving pain. controlling nausea and vomiting. maintaining pulmonary ventilation. monitoring for hypotension.
maintaining pulmonary ventilation. The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and monitoring for hypotension are important, but they are not primary objectives in the immediate postoperative period.
Which is a classic sign of hypovolemic shock? Bradypnea Pallor Dilute urine High blood pressure
Pallor The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing.
A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem? Copious red blood in the sputum Pink color Pieces of vomitus Foul smell
Pink color Flash pulmonary edema that occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation, tachypnea, tachycardia, decreased pulse oximetry readings, frothy, pink sputum, and crackles on auscultation.
Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? Primary-intention healing Third-intention healing Second-intention healing First-intention healing
Second-intention healing When wounds dehisce, they are allowed to heal by secondary intention. Primary or first-intention healing is the method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation. Third-intention healing is a method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by bringing apposing granulations together.
What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? Pulmonary edema Pleurisy Pneumonia Hypoxemia
Pneumonia Older clients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Delirium, pneumonia, decline in functional ability, exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and falls are all threats to recovery in the older adult.
A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: second intention. third intention. fourth intention. first intention.
first intention. Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.
What measurement should the nurse report to the physician in the immediate postoperative period? A temperature reading between 97°F and 98°F Respirations between 20 and 25 breaths/min A systolic blood pressure lower than 90 mm Hg A hemoglobin of 13.6
A systolic blood pressure lower than 90 mm Hg A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal.
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? First intention Third intention Fourth intention Second intention
First intention When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing.
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 First intention Second intention Granulation
First intention First-intention healing is characterized by a closed incision with little tissue reaction and the absence of signs and symptoms of infection.
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? Ineffective thermoregulation Decreased cardiac output Acute incisional pain Ineffective airway clearance
Ineffective thermoregulation Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.
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 Tolerance Respiratory depressive effects
Tolerance Postoperative ambulatory activities are essential but planned according to the older adult's tolerance, which usually is less than that of a younger person. The respiratory depressive effects should be considered when administering certain drugs for the older adults. The convalescent period usually is longer for older adults. Therefore, they may require positive reinforcement throughout the postoperative period as well as extensive discharge planning. The convalescent period of older adults and detailed medication history may not be necessary to consider when planning the postoperative ambulatory activities.
A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse? "The drain will remove necrotic tissue." "It will cut down on the number of dressing changes needed." "Most surgeons use wound drains now." "It assists in preventing infection."
"It assists in preventing infection." A wound drain assists in preventing infection by removing the medium in which bacteria could grow. The purpose of the wound drain is not to remove necrotic tissue or to decrease the number of dressing changes. Stating that most surgeons use wound drains does not answer the client's question appropriately.
In the immediate postoperative period, vital signs are taken at least every 60 minutes. 15 minutes. 30 minutes. 45 minutes.
15 minutes. Pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours.
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? 4 5 6 7
7 Many hospitals use a scoring system (e.g., Aldrete score) to determine the patient's general condition and readiness for transfer from the PACU (Aldrete & Wright, 1992). Throughout the recovery period, the patient's physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. This evaluation guide allows an objective assessment of the patient's condition in the PACU. The patient is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The Aldrete score is usually between 7 and 10 before discharge from the PACU.
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? Between 100 and 200 mL Between 75 and 100 mL <30 mL >200 mL
<30 mL If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL per hour are reported; if the patient is voiding, an output of less than 240 mL per 8-hour shift is reported.
To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: Assisting with incentive spirometry every 6 hours Assessing breath sounds at least every 2 hours Ambulating the client as soon as possible Positioning the client in a supine position
Ambulating the client as soon as possible The nurse should assist the client to ambulate as soon as the client is able. Incentive spirometry should be performed every 1 to 2 hours. The client should be positioned from side to side and in semi-Fowler's position. While assessing breath sounds is essential, it does not help to prevent pneumonia.
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? Primary Secondary Tertiary Intermediary
Intermediary Intermediary hemorrhage occurs during the first few hours after surgery when the rise of blood pressure to its normal level dislodges insecure clots formed in untied vessels. Primary hemorrhage occurs at the time of surgery. Secondary hemorrhage may occur some time after surgery if a suture slips because a blood vessel was not securely tied, became infected, or was eroded by a drainage tube.
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 wound evisceration occurs when the wound completely separates, and the internal organs protrude. The first action by the nurse would be to cover the protruding organs with sterile dressings moistened with normal saline. Once the client is safe, the nurse can notify the physician. The client is positioned in a manner that places the least stress on the organs. Dry or pressure dressings are not placed over the protruding organ.
A client is at postoperative hour 8 after 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. The abdomen is soft and distended. No obvious bleeding is noted. What action by the nurse is most appropriate? Administer morphine per orders. Ambulate the client to reduce abdominal distention. Inform the client this is the normal progression after abdominal surgery. Notify the physician.
Notify the physician. The physician should be notified of the findings. The client may be hemorrhaging internally and may need to return to surgery. The client may be in need of pain medication, but morphine will lower the blood pressure further and may cause further complications. Ambulating the client increases the risk of injury because the client may experience orthostatic hypotension. What the client is experiencing is not the normal progression after abdominal surgery.
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. Areas of drainage on the dressing should be outlined with a pen, and the date and time should be recorded next to the drainage. Blood drainage from the incision is a normal expected finding in the immediate postoperative period; however, excessive amounts should be reported to the surgeon.
A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order. Insert suction catheter into the lumen of the tube. Apply intermittent suction while withdrawing the catheter. Position the client in Fowlers position. Don sterile gloves. Lubricate 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. Suctioning a tracheostomy is a sterile procedure. The nurse should first position the client in Fowler's position then don sterile gloves. Next, the nurse will lubricate the sterile suction catheter and insert the catheter into the lumen of the tube. Finally, the nurse will apply intermittent suction while withdrawing the catheter.
Which is the of the following factors stimulates the wound healing process? Sufficient oxygenation Nutritional deficiencies Hemorrhage Immobility
Sufficient oxygenation Oxygen deficit is a factor in wound healing, oxygenation is needed to increase tissue perfusion and circulation to stimulate the healing process . Hemorrhage nutritional deficiencies such as protein-calorie depletion, and the immobility are factors that decrease wound healing. Immobility leads to thrombosis formation causing tissue necrosis, not healing.
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? exhibits wound healing without complications. resumes usual urinary elimination pattern. maintains adequate fluid status. experiences pain within tolerable limits.
experiences pain within tolerable limits. Because pain can contribute to postoperative delirium, adequate pain control without oversedation is essential. Nursing assessment of mental status and of all physiologic factors influencing mental status helps the nurse plan for care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult client.
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 edema. Document the findings and reassess in 24 hours. Assess for signs and symptoms of fluid volume deficit. Discontinue the nasogastric tube suctioning.
Assess for signs and symptoms of fluid volume deficit. The client's 24-hour intake is 1800 mL (75 x 24). The client's 24-hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Because the output is significantly higher than the intake, the client is at risk for fluid volume deficit. The nurse should not discontinue the nasogastric suctioning without a physician's order. The findings should be documented and reassessed, but the nurse needs to take more action to prevent complication. Edema is usually associated with fluid volume excess.
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? Prepare to insert a nasogastric tube. Call the health care provider. Re-attempt to auscultate bowel sounds. Prepare to administer a stool softener.
Call the health care provider. The client presents with a possible paralytic ileus, a serious condition where the intestines are paralyzed and peristalsis is absent. This may occur as a result of surgery, especially abdominal surgery. If the nurse is unable to auscultate bowel sounds and the client has pain and a rigid abdomen, the nurse will suspect an ileus and immediately call the health care provider. Re-attempting auscultation may occur, but only after the health care provider has been notified. The health care provider may order the placement of an NG tube, however, the nurse cannot do this without the provider's order. Administering a stool softener will not help the client and may make the condition worse.
The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? Upper endoscopy Chest x-ray Central venous pressure Complete blood count
Central venous pressure Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, level of consciousness, central venous pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output are monitored to provide information on the patient's respiratory and cardiovascular status.
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 An epidural infusion An On-Q pump Watching television
Changing position Listening to music Watching television Nonpharmacological management of pain includes listening to music, watching television, and changing position. Pharmacological pain management strategies include epidural infusions and On-Q pumps. An epidural infusion delivers a local opioid with or without a local anesthetic agent directly into the epidural space of the spine. An On-Q pump delivers a local anesthetic agent subcutaneously to the incisional area.
The nurse is caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery? Encourage the client to move legs frequently and do leg exercises. Apply pressure on the client's lower extremities. Maintain 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. The nurse should encourage the client to move legs frequently and do leg exercises to prevent venous stasis and other circulatory complications. The nurse should not place pillows under the client's knees or calves unless ordered and should avoid placing pressure on the client's lower extremities. Placing the client in a side-lying position will not help prevent venous stasis and other circulatory complications in a client who has undergone surgery.
Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis? Fluid restriction Use of blanket rolls to elevate the lower extremities Hourly leg exercises Prolonged dangling of the legs over the edge of the bed
Hourly leg exercises The benefits of early ambulation and hourly leg exercises in preventing deep vein thrombosis cannot be overemphasized. It is important to avoid the use of blanket rolls, pillow rolls, or any form of elevation that constricts vessels under the knees. Prolonged dangling can be dangerous and is not recommended in susceptible clients because the pressure under the knees can impede circulation. Dehydration adds to the risk of thrombosis formation.
Nursing assessment findings reveal a temperature of 35.6 C (96.2°F), pulse oximetry 90%, shivering, and client complains of chilling. The nurse recognizes the client is experiencing: Pain Atelectasis Hypothermia Sepsis
Hypothermia Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.
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 soap and water, then leaving it open to the air Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive Covering the well-approximated wound edges with a dry dressing 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 Postoperative surgical wounds that are allowed to heal using second-intention healing are usually packed with a sterile saline-soaked dressing and covered with a dry dressing. The edges of a wound healing by second intention are not approximated. The wound may be cleaned using sterile saline, but the nurse would not apply a cyanoacrylate tissue adhesive. The wound should not be left open to the air, as it could expose the wound to microorganisms and dry out the wound bed, impairing healing.
A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? White with long, thin areas of scar tissue Pale yet able to blanch with digital pressure Necrotic and hard Pink to red and soft, noting that it bleeds easily
Pink to red and soft, noting that it bleeds easily Second-intention healing (granulation) occurs in infected wounds or in wounds in which the edges have not been approximated. Gradually, the necrotic material disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue. Healing is complete when skin cells grow over these granulations.
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 the client in a position that puts the least strain on the operative area. Administer prescribed analgesics. Instruct the client to avoid any movement. Place sterile dressings moistened with normal saline over the protruding organs and tissues.
Place sterile dressings moistened with normal saline over the protruding organs and tissues. If evisceration occurs, the nurse should place sterile dressings moistened with normal saline over the protruding organs and tissues and should inform the physician. If wound disruption is suspected, the nurse should place the client in a position that puts the least strain on the operative area. Analgesics help reduce pain. Avoiding any movement will not help recover from the wound evisceration.
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. Administer an anti-emetic. Ask the client for more clarification. Obtain an emesis basin.
Position the client in the side-lying position. The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits. The nurse may also obtain an emesis basin and administered an anti-emetic if one is ordered; however, these will be done after the client is repositioned. There is no need for the nurse to ask the client for more clarification.
The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action? Assess the incisional dressing to detect hemorrhage. Position the client to maintain a patent airway. Monitor vital signs for early detection of shock. Administer antiemetics to prevent nausea and vomiting.
Position the client to maintain a patent airway. Maintaining a patent airway is the immediate priority in the PACU.
The nurse recognizes which symptom as a clinical manifestation of shock? Warm, dry skin Increased urine output Flushed face Rapid, weak, thready pulse
Rapid, weak, thready pulse The client's pulse increases as the body tries to compensate for the effects of shock. Pallor is an indicator of shock. The skin is generally cool and moist in shock. Usually, a low blood pressure and concentrated urine are observed in clients who are in shock.
Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client? Administer prophylactic high-dose heparin. Maintain bed rest. Instruct the client to prop a pillow under the knees. Reinforce the need to perform leg exercises every hour when awake.
Reinforce the need to perform leg exercises every hour when awake. The nurse should reinforce the need to perform leg exercises every hour when awake. Maintaining bed rest increases the pooling of blood in the lower extremities, increasing the risk for deep vein thrombosis. The client may be given low-dose heparin for prophylactic treatment, but not high-dose heparin. The nurse should instruct the client not to prop a pillow under the knees because it can constrict the blood vessels.
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? Rubbing the back Elevating the head of the bed Encouraging the client to breathe deeply Reinforcing dressings or applying pressure if bleeding is frank
Reinforcing dressings or applying pressure if bleeding is frank The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply and rubbing the back will not help manage and minimize hemorrhage and shock.
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 most likely cause of the client's change in condition? The client is displaying late signs of shock. The client is showing signs of a medication reaction. The client is displaying early signs of shock. The client is showing signs of an anesthesia reaction.
The client is displaying early signs of shock. The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated. Medication or anesthesia reactions may cause client symptoms similar to these; however, these causes are not as likely as early shock.
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. Family members can be involved in the administration of pain medications with patient-controlled analgesia. There are no advantages of patient-controlled analgesia over a PRN dosing schedule. 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. Advantages of patient-controlled analgesia include participation of the client in care, elimination of delayed administration of analgesics, and maintenance of therapeutic drug levels. The client must have the cognitive and physical abilities to self-dose.
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? Urinary infection Urine retention Calculus formation Requirement of intermittent catheterization
Urine retention Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus.
Which of the following clinical manifestations increase the risk for evisceration in the postoperative client? Hypoxia Valsalva maneuver Edema Hypovolemia
Valsalva maneuver The Valsalva maneuver produces tension on abdominal wounds, which increases the risk for evisceration.
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 Hyperthermia Uncontrolled pain
Wound infection Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: change the client's position. palpate the abdomen. insert a rectal tube. auscultate bowel sounds.
auscultate bowel sounds. If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.
The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order? chlorpromazine omeprazole nizatidine ondansetron
ondansetron Ondansetron (Zofran) is used to treat nausea and vomiting.