med/surg ch 16 PrepU quiz
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: First intention Third intention Second intention Granulation
First intention Explanation: First-intention healing is characterized by a closed incision with little tissue reaction and the absence of signs and symptoms of infection. Reference: page 451
A client recovering from abdominal surgery has abdominal distention and nausea. Which action will the nurse take? Maintain nothing by mouth status. Use a pillow to splint the incision when changing position. Encourage deep breathing and coughing. Assist with ambulation.
Assist with ambulation. Explanation: Assessment and management of GI function are important after surgery because the GI tract is subject to uncomfortable or potentially life-threatening complications. Any postoperative client may suffer from distention. Postoperative distention of the abdomen results from the accumulation of gas in the intestinal tract. 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. Even though nothing is given by mouth, swallowed air and GI tract secretions enter the stomach and intestines; if not propelled by peristalsis, they collect in the intestines, producing distention and causing the client to report fullness or pain in the abdomen. After major abdominal surgery, distention may be avoided by having the client ambulate as early as possible.Coughing and deep breathing after surgery is necessary to decrease respiratory complications, not abdominal distension. Maintaining nothing by mouth status may make the distention worse. A pillow to splint the incision during position change prevents wound dehiscence. Reference: page 442
A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate? Continue with frequent client assessments. Obtain vital signs, including pulse oximetry, every 5 minutes. Remove the oral airway. Notify the physician of impaired neurological status.
Continue with frequent client assessments. Explanation: An immediate postoperative client may be transferred to the PACU with a hard, plastic oral airway in place. The airway should not be removed until the client shows signs of gagging or choking. The neurological status is appropriate for a client who received general anesthesia, and the nurse should continue with frequent client assessments. . None of the information provided requires the client to have vital signs measured more frequently than the standard 15 minutes. Reference: page 438
A client recovering from surgery will need wound care at home. Which information will the nurse include when teaching this client? Select all that apply. Contact the health care provider if the area is sore. Cleanse the area gently with sterile normal saline. Use adhesive when securing gauze. Apply a dry cool pack to reduce discomfort. Cover the area with a non-stick gauze pad. Use gauze large enough to cover the wound
Cover the area with a non-stick gauze pad. Cleanse the area gently with sterile normal saline. Use gauze large enough to cover the wound Apply a dry cool pack to reduce discomfort. Explanation: The client with a surgical wound who is being discharged home should be instructed to keep the wound covered with a non-stick gauze pad. The area should be cleansed gently with sterile normal saline. Gauze should be used that is large enought to fully cover the wound area. A dry cool pack can be applied to the area to reduce the discomfort. Adhesive tape is not recommended for affixing postsurgical gauze dressings because it is difficult to remove without possible injury to the incisional site. The health care provider does not need to be contacted if the area is sore. Reference: page 453
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? Hold the order until purulent drainage is noted. Request the order be discontinued without obtaining the specimen. Use an antibiotic cleaning agent before obtaining the specimen. Obtain the wound culture specimen.
Obtain the wound culture specimen. Explanation: Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. The culture should be obtained even though the client is not demonstrating traditional signs and symptoms of infection. The order should not be discontinued or held until purulent drainage is noted because the infection could worsen and the client could develop sepsis. An antibiotic cleaning agent should not be used before obtaining the specimen because it will alter the growth of the organisms. Reference: page 452
A significant mortality rate exists for patients with alcoholism who experience delirium tremens postoperatively. When caring for the patient with alcoholism, the nurse should assess for symptoms of alcoholic withdrawal: 4 days after surgery. About 24 hours postoperatively. Within the first 12 hours. On the second or third day.
On the second or third day. Explanation: The person with a history of chronic alcoholism often suffers from malnutrition and other systemic problems that increase surgical risk. Alcohol withdrawal syndrome or delirium tremens may be anticipated between 48 and 72 hours after alcohol withdrawal and is associated with a significant mortality rate when it occurs postoperatively. Reference: page 457
Unless contraindicated, how should the nurse position an unconscious client? On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration In Fowler's position, which most closely simulates a sitting position, thus facilitating respiratory as well as gastrointestinal functioning In semi-Fowler's position, to promote respiratory function and reduce the incidence of orthostatic hypotension when the patient can eventually stand Flat on the back, without elevation of the head, to facilitate frequent turning and minimize pulmonary complications
On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration Explanation: The head of the bed is elevated 15 to 30 degrees unless contraindicated, and the patient is closely monitored to maintain the airway as well as to minimize the risk of aspiration. If vomiting occurs, the patient is turned to the side to prevent aspiration and the vomitus is collected in the emesis basin. Reference: page 439
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 Covering the well-approximated wound edges with a dry dressing Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive 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 Explanation: 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. Reference: page 457
A client who is receiving the maximum levels of pain medication for postoperative recovery asks the nurse if there are other measures that the nurse can employ to ease pain. Which of the following strategies might the nurse employ? Select all that apply. Putting on soothing music Massaging the client's legs Applying hot cloths to the client's face Changing the client's position Performing guided imagery
Performing guided imagery Putting on soothing music Changing the client's position Explanation: Guided imagery, music, and application of heat or cold (if prescribed) have been successful in decreasing pain. Changing the client's position, using distraction, applying cool washcloths to the face, and providing back massage may be useful in relieving general discomfort temporarily. Reference: page 441
A postoperative client begins coughing forcefully while eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first? Place the client in the low Fowler's position. Notify the surgeon. Document the event. Cover the intestines with sterile, moist dressings.
Place the client in the low Fowler's position. Explanation: Placing the client in the low Fowler's position decreases further protrusion of the intestines. The nurse should cover the intestines with a sterile, moist dressing; notify the surgeon and document the event; but first the nurse should minimize further protrusion of the intestines. Reference: page 457
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. Obtain an emesis basin. Ask the client for more clarification. Administer an anti-emetic.
Position the client in the side-lying position. Explanation: 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. Reference: page 442
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 Second-intention healing First-intention healing Third-intention healing
Second-intention healing Explanation: 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. Reference: page 449-450
A nurse is assessing the postoperative client on the second postoperative day. What assessment finding requires the nurse to immediately notify the health care provider? The client states a moderate amount of pain at the incisional site. The client's lungs reveal rales in the bases. A moderate amount of serous drainage is noted on the operative dressing. The client has an absence of bowel sounds.
The client has an absence of bowel sounds. Explanation: A nursing assessment finding of concern on the second postoperative day is the absence of bowel sounds, which may indicate a paralytic ileus. Other assessment findings may include abdominal pain and distention as fluids, solids, and gas do not move through the intestinal tract. Rales in the bases are a frequent finding postoperatively, especially if general anesthesia was administered. Encourage the client to cough and breathe deep. Pain is a common symptom following a surgical procedure. Serous drainage on the postoperative dressing needs to monitored and brought to the physician's attention when assessing the client. Reference: page 454
When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as clean. clean contaminated. dirty. contaminated.
clean contaminated. Explanation: 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. Reference: page 456
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 should be transferred to an intensive care area. The client must remain in the PACU. The client can be discharged from the PACU.
The client can be discharged from the PACU. Explanation: The Aldrete score is usually 8 to 10 before discharge from the PACU. Clients with a score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area, depending on their preoperative baseline score. Reference: page 443
The nurse is preparing discharge instructions to a client who has undergone minor same-day surgery. Which client statement indicates that teaching has been effective? "I had some type of surgery on my abdomen." "I am not permitted to drive myself home after surgery." "There is no need to call my doctor as the surgery was minor." "I will read up on how to use my walker at home for safety."
"I am not permitted to drive myself home after surgery." Explanation: There are specific educational points that the nurse needs to provide to the client before discharging after a same-day procedure. After teaching, the client should be able to describe activities that can or cannot be performed, such as limited driving for 2 days. Rather than self-teaching at home, the discharge instructions will educate the client how to identify interventions and strategies for adaptive equipment. The client should be instructed to call the health care provider for a follow-up postsurgical appointment. The client should be able to name the procedure that was performed and not just give a vague statement of something being done in the abdomen. Reference: page 444
The nurse is providing teaching about tissue repair and wound healing to a client who has a leg ulcer. Which of the following statements by the client indicates that teaching has been effective? "I'll eat plenty of fruits and vegetables." "I'll make sure that the bandage is wrapped tightly." "I'll make sure to limit my intake of protein." "My foot should feel cool or cold while my leg's healing."
"I'll eat plenty of fruits and vegetables." Explanation: Optimal nutritional status is important for wound healing; the client should eat plenty of fruits and vegetables and not reduce protein intake. To avoid impeding circulation to the area, the bandage should be secure but not tight. If the client's foot feels cold, circulation is impaired, which inhibits wound healing. Reference: page 455
A novice nurse provides aftercare instructions to a client who has just had sutures removed. Which statement by the novice nurse requires the nurse preceptor to clarify? "The wound should not be rubbed or scrubbed." "If the wound site gets wet, pat the wound dry." "The wound will continue to heal for several weeks." "If the wound edges are red or raised, you should call your doctor."
"If the wound edges are red or raised, you should call your doctor." Explanation: Wound edges that are slightly red or raised are normal and do not require the client to report these findings to the health care provider. All other statements are true. Reference: page 453
Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply. Pass a stress test Ambulate the length of the client's house Be able to self-toilet Be able to drive to the grocery Get out of bed without assistance
Ambulate the length of the client's house Get out of bed without assistance Be able to self-toilet Explanation: For a safe discharge to home, clients need to be able to ambulate a functional distance (e.g., length of the house or apartment), get in and out of bed unassisted, and be independent with toileting. Reference: page 454
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dL, and a blood pressure lying in bed of 110/70 mm Hg. The nurse suspects abnormal orthostatic changes when the client gets out of bed and reports vertigo. What vital sign value most supports the client's orthostatic changes? Blood pressure of 90/50 mm Hg Blood pressure of 120/90 mm Hg Blood pressure of 150/100 mm Hg Blood pressure of 110/80 mm Hg
Blood pressure of 90/50 mm Hg Explanation: The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis. Orthostatic changes develop from hypovolemia and cause a drop in blood pressure (evidenced by a blood pressure of 80/40 mm Hg) when the client rises from a lying position. Reference: 440
A client is transferred from the postanesthesia care unit (PACU) to an inpatient care unit. What will the nurse assess first? Level of consciousness Breathing Surgical site Pain level
Breathing Explanation: The nurse will assess the client being transferred from the PACU to an inpatient care unit. The priority is to assess breathing and administer oxygen if prescribed because this provides a baseline and helps identify for the development of respiratory distress. Pain level is assessed after the surgical site and level of consciousness are assessed. Reference: page 438
The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? Central venous pressure Complete blood count Chest x-ray Upper endoscopy
Central venous pressure Explanation: 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. Reference: page 440
Which is a classic sign of hypovolemic shock? Dilute urine Bradypnea Pallor High blood pressure
Pallor Explanation: The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing. Reference: page 440
A postanesthesia care unit (PACU) nurse is preparing to discharge a client home following ankle surgery. The client keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate? Review the instructions with the client and an accompanying adult. Give the written instructions to the client's 16-year-old child. Continuously repeat the instructions until the client restates them. Ask the client, "Do you understand?"
Review the instructions with the client and an accompanying adult. Explanation: The effects of anesthesia may impair a client's memory or concentration. It is important that the discharge instructions are covered with the client and an accompanying adult. Giving the instructions to a 16-year-old is not appropriate. Repeating the instructions until the client restates them does not ensure that the client will remember them, because anesthesia can impair memory. Asking whether the client understands the instructions only elicits an yes or no answer; it does not give insight into whether the client comprehends the instructions. Reference: page 438
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 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 displaying early signs of shock. Explanation: 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. Reference: page 440
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: auscultate bowel sounds. insert a rectal tube. change the client's position. palpate the abdomen.
auscultate bowel sounds. Explanation: 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. Reference: page 454
The client is experiencing intractable hiccups following surgery. What would the nurse expect the surgeon to order? nizatidine metoclopramide chlorpromazine omeprazole
chlorpromazine Explanation: Chlorpromazine (Thorazine) is used to treat intractable hiccups. Reference: page 454
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? experiences pain within tolerable limits. maintains adequate fluid status. exhibits wound healing without complications. resumes usual urinary elimination pattern.
experiences pain within tolerable limits. Explanation: 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. Reference: page 457
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." "Most surgeons use wound drains now." "It will cut down on the number of dressing changes needed." "It assists in preventing infection."
"It assists in preventing infection." Explanation: 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. Reference: page 448
The nurse is caring for a postoperative client with a Hemovac. The Hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to: Notify the surgeon that the Hemovac is not functioning. Empty and measure the drainage and compress the Hemovac. Remove the Hemovac because it is expanded. Assess the client's wound and apply a pressure dressing.
Empty and measure the drainage and compress the Hemovac. Explanation: A Hemovac needs to be recompressed periodically, because it operates with the use of gentle, constant suction. The amount of drainage is not excessive. Reference: page 452
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 Watching television An epidural infusion Listening to music Changing position
Listening to music Watching television Changing position Explanation: 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. Reference: page 448
The nurse has medicated a postoperative client who reported nausea. Which medication would the nurse document as having been given? Prednisone Propofol Ondansetron Warfarin
Ondansetron Explanation: 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. Reference: page 441
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. 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. 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. Explanation: 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. Reference: page 447-448
Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis? Decreased cardiac output Ineffective airway clearance Urinary retention Acute pain
Decreased cardiac output Explanation: Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion. Reference: page 446
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 Decreased cardiac output Acute pain Urinary retention
Decreased cardiac output Explanation: Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion. Reference: page 446
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 Prolonged dangling of the legs over the edge of the bed Hourly leg exercises
Hourly leg exercises Explanation: 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. Reference: page 445
What is the highest priority nursing intervention for a client in the immediate postoperative phase? Monitoring vital signs at least every 15 minutes Maintaining a patent airway Assessing urinary output every hour Assessing for hemorrhage
Maintaining a patent airway Explanation: All interventions listed are correct. The highest priority intervention, however, is maintaining a patent airway. Without a patent airway, the other interventions—monitoring vital signs, assessing urinary output, and assessing for hemorrhage—become secondary to the possibility of a lack of oxygen. Reference: page 438
Corticosteroids have which effect on wound healing? Reduce blood supply May cause protein-calorie depletion Mask the presence of infection Cause hemorrhage
Mask the presence of infection Explanation: Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. Edema may reduce blood supply. Corticosteroids do not cause hemorrhage or protein-calorie depletion. Reference: page 451
The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? Necrotic and hard Pink to red and soft, bleeding easily White with long, thin areas of scar tissue Pale yet able to blanch with digital pressure
Pink to red and soft, bleeding easily Explanation: In second-intention healing, necrotic material gradually 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. Reference: page 450
What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? Pneumonia Hypoxemia Pulmonary edema Pleurisy
Pneumonia Explanation: 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. Reference: page 447
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? Encouraging the client to breathe deeply Reinforcing the dressing or applying pressure if bleeding is frank Monitoring vital signs every 15 minutes Elevating the head of the bed
Reinforcing the dressing or applying pressure if bleeding is frank Explanation: 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 will not help manage and minimize hemorrhage and shock. Monitoring vital signs every 15 minutes is an appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to determine the extent and progression of the problem. Reference: page 452
The primary objective in the immediate postoperative period is relieving pain. maintaining pulmonary ventilation. controlling nausea and vomiting. monitoring for hypotension.
maintaining pulmonary ventilation. Explanation: 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. Reference: page 438
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? 6 4 5 7
7 Explanation: 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. Reference: page 443
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? Between 75 and 100 mL <30 mL Between 100 and 200 mL >200 mL
<30 mL Explanation: 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. Reference: page 448
To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: Assisting with incentive spirometry every 6 hours Ambulating the client as soon as possible Positioning the client in a supine position Assessing breath sounds at least every 2 hours
Ambulating the client as soon as possible Explanation: 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. Reference: page 446-447
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? Document the findings and reassess in 24 hours. Assess for edema. Discontinue the nasogastric tube suctioning. Assess for signs and symptoms of fluid volume deficit.
Assess for signs and symptoms of fluid volume deficit. Explanation: 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. Reference: page 448
When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O2 saturation monitor despite the client's breathing appearing normal, what action should the nurse take first? Assess the client's heart rhythm and nail beds. Document the findings. Notify the physician. Apply oxygen.
Assess the client's heart rhythm and nail beds. Explanation: A client may demonstrate low oxygenation readings because of certain colors of nail polish or may show an irregular heart rate such as atrial fibrillation. These factors should be assessed to ensure the accuracy of the oxygen reading. Once the reading is confirmed as accurate, then the nurse may need to apply oxygen, notify the physician, and document the findings. Reference: page439
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. Re-attempt to auscultate bowel sounds. Call the health care provider. Prepare to administer a stool softener.
Call the health care provider. Explanation: 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. Reference: page 454
The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? Chest x-ray Upper endoscopy Complete blood count Central venous pressure
Central venous pressure Explanation: 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. Reference: page 440
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? Second intention Fourth intention First intention Third intention
First intention Explanation: 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. Reference: page 437
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 airway clearance Ineffective thermoregulation
Ineffective thermoregulation Explanation: Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia. Reference: page 441-442
An older adult recovering from anesthesia for a surgical procedure develops delirium. Which action(s) will the nurse take to help this client? Select all that apply.
Limit unfamiliar noises. Engage in conversation. Keep lights on in the room. Ensure adequate pain control. Explanation: Older adults recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Recognizing postoperative delirium and identifying and treating its underlying cause are the goals of care. Supportive interventions for delirium after surgery include limiting unfamiliar noises. Engaging the client in conversation may improve cognitive function. Keeping the client in a well-lit room helps reduce sensory deprivation. Because pain can contribute to postoperative delirium, adequate pain control without oversedation is essential. Physical activity should not be neglected while the client is confused because physical deterioration can worsen delirium and place the client at increased risk for other complications Reference: page 457
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 III PACU Phase I PACU Phase IV PACU Phase II PACU
Phase II PACU Explanation: In some hospitals and ambulatory surgical centers, postanesthesia care is divided into three phases. In the phase I PACU, used during the immediate recovery phase, intensive nursing care is provided. In the phase II PACU, the patient is prepared for self-care or care in the hospital or an extended care setting. In phase III PACU, the patient is prepared for discharge. There is no phase IV PACU. Reference: page 437
A client with nausea and vomiting is to receive an antiemetic that inhibits the vomiting center in the brain. Which of the following would the nurse expect the physician to order most likely? Ondansetron (Zofran) Hydroxyzine (Vistaril) Promethazine (Phenergan) Prochlorperazine (Compazine)
Prochlorperazine (Compazine) Explanation: Prochlorperazine is a phenothiazine that inhibits the chemoreceptor trigger zone (CTZ) and the vomiting center in the brain. Ondansetron blocks receptors for 5 HT3, affecting the neural pathways involved in nausea and vomiting. Hydroxyzine and promethazine are antihistamines which block H1 receptors resulting in a decrease in stimulation of the CTZ and vomiting. Reference: page 441
What complication is the nurse aware of that is associated with deep venous thrombosis? Immobility because of calf pain Marked tenderness over the anteromedial surface of the thigh Pulmonary embolism Swelling of the entire leg owing to edema
Pulmonary embolism Explanation: Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010). Reference: page 455
A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention? Take off the pneumatic compression devices for sleeping. Rely on the IV fluids for hydration. Dangle at the bedside. Report early calf pain.
Report early calf pain. Explanation: The client needs to report calf pain or cramping for the nurse to investigate any swelling or potential DVT. Blanket rolls or prolonged dangling should be avoided to reduce impediment of circulation behind the knee. Prevention of DVT includes early ambulation, use of antiembolism or pneumatic compression devices, and low-molecular-weight or low-dose heparin and low-dose warfarin for clients postoperatively. Adequate fluids need to be offered to avoid dehydration. Reference: page 455
When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation, although the patient's breathing appears normal, the nurse identifies that the patient may be suffering from which type of hypoxemia? Episodic Subacute Anemic Hypoxic
Subacute Explanation: Supplemental oxygen may be indicated for subacute hypoxemia. Hypoxic hypoxemia results from inadequate breathing. Episodic hypoxemia develops suddenly, and the client may be at risk for myocardial ischemia, cerebral dysfunction, and cardiac arrest. Anemic hypoxemia results from blood loss during surgery. Reference: page 447
Which of the following stimulates the wound healing process? Sufficient oxygenation Hemorrhage Nutritional deficiencies Immobility
Sufficient oxygenation Explanation: Oxygenation is needed to increase tissue perfusion and circulation to stimulate the healing process . Hemorrhage is bleeding and is not a factor that stimulates wound healing., Nutritional deficiencies such as protein-calorie depletion decrease wound healing. Immobility leads to thrombosis formation causing tissue necrosis, not healing. Reference: page 451
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? The client has been lying on his side for 2 hours with the drain positioned upward. The Hemovac drain isn't compressed; instead it's fully expanded. The client has a nasogastric (NG) tube in place that drained 400 ml. There is a moderate amount of dry drainage on the outside of the dressing.
The Hemovac drain isn't compressed; instead it's fully expanded. Explanation: The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage. Reference: page 452
A client in the postanesthesia care unit (PACU) develops noisy and irregular respirations. Which action will the nurse take? Place the client in a prone position. Increase the percentage of supplemental oxygen. Tilt the head back and lift the lower jaw. Allow the client to come to consciousness naturally.
Tilt the head back and lift the lower jaw. Explanation: Clients who have experienced prolonged anesthesia usually are unconscious, with all muscles relaxed. This relaxation extends to the muscles of the pharynx. When the client lies on the back, the lower jaw and the tongue fall backward and the air passages become obstructed. This is called hypopharyngeal obstruction. Signs of occlusion include choking; noisy and irregular respirations. The treatment of hypopharyngeal obstruction involves tilting the head back and pushing forward on the angle of the lower jaw, as if to push the lower teeth in front of the upper teeth. This maneuver pulls the tongue forward and opens the air passages. Allowing the client to come to consciousness naturally will not address the noisy and irregular respirations. The prone position will not open the airway. Increasing the percentage of supplemental oxygen will not improve the hypopharyngeal obstruction. Reference: page 439
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? Tolerance Convalescent period Respiratory depressive effects Detailed medication history
Tolerance Explanation: 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. Reference: page 446-447
Which of the following clinical manifestations increases the risk for evisceration in the postoperative client? Hypoxia Hypovolemia Edema Valsalva maneuver
Valsalva maneuver Explanation: Wound dehiscence (disruption of surgical incision or wound) and evisceration (protrusion of wound contents) are serious surgical complications, especially when they occur with abdominal wounds. The Valsalva maneuver involves trying to exhale while blocking the airways and produces tension on abdominal wounds, increasing the risk for evisceration. Reference: page 451
The nurse cares for a client who is three hours post op abdominal hysterectomy and begins to develop hiccups. What nursing assessment will the nurse monitor more closely with the client's new symptoms? Respiratory rate Wound drainage Temperature Wound approximation
Wound approximation Explanation: Hiccups are produced by intermittent spasms of the diaphragm, secondary to irritation of the phrenic nerve. Hiccups may be caused by surgery and are usually not problematic. However, persistent or forceful spasms may lead to wound dehiscence, or wound separation at the surgical incision. The other answer choices are things the nurse will monitor; however, the approximation of wound edges will be monitored more closely. Reference: page 451
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 Uncontrolled pain Hyperthermia Wound infection
Wound infection Explanation: Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain. Reference: page 456
A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound dehisced. eviscerated. hemorrhaged. pustulated.
dehisced. Explanation: Dehiscence is the partial or complete separation of wound edges. Evisceration is the protrusion of organs through the surgical incision. Pustulated refers to the formation of pustules. Hemorrhage is excessive bleeding. Reference: page 456
A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: first intention. fourth intention. second intention. third intention.
first intention. Explanation: 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. Reference: page 449-451
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. first intention. second intention. third intention.
first intention. Explanation: 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. Reference: page 449-451
The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order? chlorpromazine omeprazole nizatidine ondansetron
ondansetron Explanation: Ondansetron (Zofran) is used to treat nausea and vomiting. Reference: page 441
A client develops a hemorrhage one hour post surgery. The nurse knows this is most likely an intermediary hemorrhage from a vein because it occurred: at a suture site, and the blood appears intermittently in spurts. during surgery, and has bright red blood that flows freely. within the first few hours, and has darkly colored blood that flows quickly. a few hours after surgery, and the bright red blood appears with each heartbeat.
within the first few hours, and has darkly colored blood that flows quickly. Explanation: An intermediary hemorrhage appears within the first few hours following surgery. Darkly colored blood that flows out quickly indicates a venous hemorrhage. A hemorrhage that occurs during surgery is classified as a primary hemorrhage. A bright red color indicates that a hemorrhage's source is an artery. Secondary hemorrhages occur when sutures slip or drainage tubes dislodge insecure vessels. Reference: page 440
