Chapter 20 - Postoperative Care

b

A 70-kg postoperative patient has an average urine output of 25ml?hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to: A. place in indwelling urinary catheter and assess urine characteristics B. evaluate the patient's fluid volume status and obtain a bladder ultrasound C. notify the physician and anticipate the patient returning to the operating room D. continue to monitor the patient as this is a normal, expected finding after surgery

b

A nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? a. red, hard skin b. serous drainage c. purulent drainage d. warm, tender skin

a

Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which of the following health problems is the patient experiencing? A. Atelectasis B. Bronchospasm C. Hypoventilation D. Pulmonary embolism

b, c, d

Discharge criteria for the phase II patient includes (select all that apply): A. ability to drive self home B. no respiratory depression C. minimal nausea and vomiting D. written discharge instruction

c

During the patient's admission to the PACU, what are the primary interventions the nurse performs? A. assess the surgical site, noting the presence and character of drainage B. assess the amount of urinary output and the presence of bladder distention C. assess the airway for patency and quality of respirations and obtain vital signs D. review the results of intraoperative laboratory values and medications received

a

Following admission of a postoperative patient to the clinical unit, which of the following assessment data requires the most immediate attention? A. oxygen saturation of 85% B. respiratory rate of 13/min C. temperature of 100.4°F (38°C) D. blood pressure of 90/60mmHg

a

In planning postoperative interventions to promote ambulation, coughing, deep breathing, and turning, the nurse recognizes that which of the following actions will best enable the patient to achieve the desired outcomes? A. Administering adequate analgesics to promote relief or control of pain B. Asking the patient to demonstrate the postoperative exercises every 1 hour C. Giving the patient positive feedback when the activities are performed correctly D. Warning the patient about possible complications if the activities are not performed

d

The nurse is preparing to administer cefazolin (Ancef) 2 gm in 100 ml of normal saline to a postoperative patient. Which of the following IV rates will infuse this medication over 20 minutes? A. 100 ml/hr B. 150 ml/hr C. 200 ml/hr D. 300 ml/hr

b

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia unit. Which of the following should be the nurse's initial action upon the patient's arrival? A. Assess the patient's pain. B. Assess the patient's vital signs. C. Check the rate of the IV infusion. D. Check the physician's postoperative orders.

b

Unless contraindicated by the surgical procedure, which of the following positions is preferred for the unconscious patient immediately postoperative? A. Supine B. Lateral C. Semi-Fowler's D. High-Fowler's

c

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, the nurse should do which of the following? A. Recheck in 1 hour for increased drainage. B. Notify the surgeon of a potential hemorrhage. C. Assess the patient's blood pressure and heart rate. D. Remove the dressing and assess the surgical incision.

a, b, c, d

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply: a. contact the surgeon b. instruct the client to remain quiet c. prepare the client for wound closure d. document the findings and actions taken e. place a sterile saline dressing and ice packs over the wound f. place the client in a supine position without a pillow under the head

a, minimum is 30ml/hr

A nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which of the following parameters most carefully during the next hour? a. urinary output of 20 ml/hr b. temperature of 37.6°C (99.6°F) c. blood pressure of 100/70 d. serous drainage on the surgical dressing

a

A nurse is monitoring the status of a post-operative client. The nurse would become most concerned with which of the following signs that could indicate an evolving complication? a. increasing restlessness b. a pulse of 86 beats/min c. blood pressure of 110/70 d. hypoactive bowel sounds in all four quadrants

b

A patient is admitted to the PACU following major abdominal surgery. During the initial assessment, the patient tells the nurse that he thinks he is going to "throw up". A priority nursing intervention would be to: A. obtain vital signs, including O2 saturation B. position the patient in a lateral recovery position C. administer antiemetic medications as ordered D. apply intermittent compression devices (ICDs)

a

A postoperative client asks a nurse why it is so important to deep breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to: a. pneumonia b. fluid imbalance c. pulmonary embolism d. carbon dioxide retention

d

A postoperative patient is transferred from the postanesthesia unit to the medical-surgical nursing floor. The nurse notes that the patient has an order for D5½ NS to infuse at 125 ml/hr. Until an IV pump is available, the nurse regulates the IV flow rate at which of the following drops (gtts)/min, noting that the tubing has a drop factor of 10 drops/ml? A. 13 gtts/min B. 31 gtts/min C. 25 gtts/min D. 21 gtts/min

d, the ability to whistle tests for the postoperative complication of facial nerve paralysis

A pt undergoes mastoidectomy. When the pt returns to the floor postoperatively, the pt has difficulty drinking without drooling. It is most important for the nurse to take which of the following actions? a. reassure the pt that this will disappear in a few days b. tell the pt that she is understandably tired and should rest c. loosen the dressing on the affected ear d. check the pt's ability to whistle