Chapter 19 Prep U

The nurse is assessing the client's readiness for discharge from the postanesthesia care unit (PACU). The nurse can rouse the client by calling the client's name. The client can move all extremities and has a blood pressure of 134/82. Baseline preoperative blood pressure was 128/78. The most recent pulse oximetry reading was 94% on room air; the client's respirations are deep and easy at a rate of 12/minute. The nurse calculates the Aldrete score as: 9 8 7 10

9

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 BP lower than 90 mm Hg

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: Second intention First intention Third intention Granulation

First Intention

What is the highest priority nursing intervention for a client in the immediate postoperative phase? Monitoring vital signs at least every 15 minutes Assessing for hemorrhage Assessing urinary output every hour Maintaining a patent airway

Maintain a patent airway

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

Pneumonia

What intervention by the nurse is most effective for reducing hospital-acquired infections? Aseptic wound care Control of upper respiratory tract infections Administration of prophylactic antibiotics Proper hand-washing techniques

Proper hand-washing techniques

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

Second-intention healing

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? There is a moderate amount of dry drainage on the outside of the dressing. The client has been lying on his side for 2 hours with the drain positioned upward. The client has a nasogastric (NG) tube in place that drained 400 ml. The Hemovac drain isn't compressed; instead it's fully expanded.

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

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 An epidural infusion Watching television Listening to music Changing position

Watching television Listening to music Changing position

The PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. Which short-term outcome would be most important for this client? The client: maintains adequate oxygenation status. experiences pain within tolerable limits. exhibits wound healing without complications. resumes usual urinary elimination pattern.

maintains adequate oxygenation status.

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 Tolerance Convalescent period Respiratory depressive effects

tolerance

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

Pallor

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

Phase II PACU

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

"It assists in preventing infection."

A postoperative client with an open abdominal wound is currently taking corticosteroids. The physician orders a culture of the abdominal wound even though no signs or symptoms of infection are seen. What action by the nurse is appropriate? Request the order be discontinued without obtaining the specimen. Obtain the wound culture specimen. Use an antibiotic cleaning agent before obtaining the specimen. Hold the order until purulent drainage is noted.

Obtain the wound culture specimen

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

PE

Adequate hourly urine output for a client with an indwelling urinary catheter is 2.0 mL/kg/h. 1.5 mL/kg/h. 1.0 mL/kg/h. 0.5 mL/kg/h.

2.0 mL/kg/h

The nurse is preparing to discharge a patient from the PACU using a PACU room scoring guide. With what score can the patient be transferred out of the recovery room? 7 5 8 6

8

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 tightness Abdominal distention Increased abdominal girth

Absence of peristalsis

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

Assessing WBC count, temperature, and wound appearance

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? Decreased cardiac output Acute incisional pain Ineffective thermoregulation Ineffective airway clearance

ineffective thermoregulation

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? Pale yet able to blanch with digital pressure White with long, thin areas of scar tissue Pink to red and soft, noting that it bleeds easily Necrotic and hard

Pink to red and soft, noting that it bleeds easily

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. Ask the client for more clarification. Administer an anti-emetic. Obtain an emesis basin.

Position the client in the side-lying position.

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

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

The client is displaying early signs of 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? The client can self-administer oral pain medication as needed with patient-controlled analgesia. 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.

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

When vomiting occurs postoperatively, what is the most important nursing intervention? Turn the patient's head completely to one side to prevent aspiration of vomitus into the lungs. Offer tepid water and juices to replace lost fluids and electrolytes. Support the wound area so that unnecessary strain will not disrupt the integrity of the incision. Measure the amount of vomitus to estimate fluid loss, in order to accurately monitor fluid balance.

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

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.

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. third intention. first intention. second intention.

first intention

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

first intention