NLN-MedSurg II - Chapter 19 Postop Management

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates teaching has been ineffective? a) "My incision should become less red and tender." b) "I can resume my usual activities as soon as I get home." c) "I should call my physician if I develop a fever." d) "I need to keep my follow-up appointment with the physician."

"I can resume my usual activities as soon as I get home."

A patient asks why there is a drain pulling fluid from the surgical wound. What is the best response by the nurse? a) "It assists in preventing infection." b) "The drain will remove the necrotic tissue." c) "Most surgeons use wound drains now." d) "It will cut down on the number of dressing changes needed."

"It assists in preventing infection."

Using the PACU room scoring guide, a nurse would give a patient an admission cardiovascular score of 2 if the patient's blood pressure is what percentage of his or her preanesthetic level? a) 20% b) Greater than 50% c) 30% to 40% d) 40% to 50%

20%

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? a) Between 100 and 200 mL b) <30 mL c) Between 75 and 100 mL d) >200 mL

<30 mL

What measurement should the nurse report to the physician in the immediate postoperative period? a) A temperature reading between 97°F and 98°F b) Respirations between 20 and 25 breaths/min c) A hemoglobin of 13.6 d) A systolic blood pressure lower than 90 mm Hg

A systolic blood pressure lower than 90 mm Hg

The nurse determines that a patient has postoperative abdominal distention. What does the nurse determine that the distention may be directly related to? a) Improper body positioning during the recovery period b) The type of anesthetic administered c) Beginning food intake in the immediate postoperative period d) A temporary loss of peristalsis and gas accumulation in the intestines

A temporary loss of peristalsis and gas accumulation in the intestines

A physician's admitting note lists a wound as healing by second intention. What does the nurse expect to find? a) A sutured incision with a little tissue reaction b) A wound in which the edges were not approximated c) A wound with a deep, wide scar that was previously resutured d) A deep, open wound that was previously sutured

A wound in which the edges were not approximated

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? a) Increased abdominal girth b) Absence of peristalsis c) Abdominal tightness d) Abdominal distention

Absence of peristalsis

When should the nurse encourage the postoperative patient to get out of bed? a) Between 10 and 12 hours after surgery b) Within 6 to 8 hours after surgery c) On the second postoperative day d) As soon as it is indicated

As soon as it is indicated

A patient is postoperative day 1 from abdominal surgery. The patient 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 2430 mL. What action by the nurse is most appropriate? a) Assess for edema. b) Assess for signs and symptoms of fluid volume deficit. c) Document the findings and reassess in 24 hours. d) Discontinue the nasogastric tube suctioning.

Assess for signs and symptoms of fluid volume deficit.

A patient is postoperative day 3 for 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? a) Assessing WBC count, temperature, and wound appearance b) Administering pain medications within 1 hour of the patient's request c) Educating patient on safe bed-to-chair transfer procedures d) Obtaining dietary consultation for improved wound healing

Assessing WBC count, temperature, and wound appearance

To prevent thromboembolism in the postoperative client, the nurse should include which of the following in the plan of care? a) Splint the incision when ambulating. b) Assist the client with deep breathing. c) Assist with oral fluid intake. d) Place a pillow under the knees.

Assist with oral fluid intake.

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? a) Central venous pressure b) Complete blood count c) Upper endoscopy d) Chest x-ray

Central venous pressure

A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first? a) Cover the protruding internal organs with sterile gauze moistened with sterile saline solution. b) Explain to the client what is happening and provide support. c) Ask the client to drink as much fluid as possible. d) Push the protruding organs back into the abdominal cavity.

Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.

Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis? a) Urinary retention b) Acute pain c) Ineffective airway clearance d) Decreased cardiac output

Decreased cardiac output

A nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene? a) Administer a tap water enema. b) Notify the physician. c) Encourage the client to ambulate at least three times per day. d) Apply moist heat to the client's abdomen.

Encourage the client to ambulate at least three times per day.

During the first 24 hours after surgery, how often will the nurse evaluate the client's temperature? a) Every 15 minutes b) Every 8 hours c) Every 2 hours d) Every 4 hours

Every 4 hours

Which of the following terms refers to a protrusion of abdominal organs through the surgical incision? a) Hernia b) Dehiscence c) Evisceration d) Erythema

Evisceration

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: a) Granulation b) First intention c) Third intention d) Second intention

First intention First-intention healing is characterized by a closed incision with little tissue reaction and the absence of signs and symptoms of infection.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? a) Third-intention b) Second-intention c) First-intention d) Fourth-intention

First-intention When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. 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.

A patient with an abdominal surgical wound sneezes and states, "Something doesn't feel right with my wound." The nurse asses the upper half of the surgical wounds edges are no longer approximated and the lower half remains well approximated. What documentation by the nurse is most appropriate? a) Following a sneeze, the wound eviscerated. b) Following a sneeze, the wound pustulated. c) Following a sneeze, the wound dehisced. d) Following a sneeze, the wound hemorrhaged.

Following a sneeze, the wound dehisced.

Which of the following should be incorporated into the patient teaching plan to prevent deep vein thrombosis? a) Use of blanket rolls for elevation of the lower extremities b) Hourly leg exercises c) Fluid restriction d) Prolonged dangling at the edge of the bed

Hourly leg exercises

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? a) Ineffective thermoregulation b) Acute incisional pain c) Ineffective airway clearance d) Decreased cardiac output

Ineffective thermoregulation

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

Maintaining a patent airway

A patient is postoperative hour 8 following 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. Abdomen is soft and distended. No obvious bleeding noted. What action by the nurse is most appropriate? a) Notify the physician. b) Administer morphine per orders. c) Ambulate the patient to reduce abdominal distention. d) Inform the patient this is the normal progression following abdominal surgery.

Notify the physician.

Unless contraindicated, how should the nurse position an unconscious patient? a) In Fowler's position, which most closely simulates a sitting position, thus facilitating respiratory as well as gastrointestinal functioning b) In semi-Fowler's position, to promote respiratory function and reduce the incidence of orthostatic hypotension when the patient can eventually stand c) On the side with a pillow at the patient's back and the chin extended, to minimize the dangers of aspiration d) 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

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? a) Take the client's vital signs and call the surgeon. b) Remove the dressing, assess the wound, and apply a new sterile dressing. c) Make the client NPO and order a stat hemoglobin and hematocrit. d) 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.

Postoperative day 2, a patient requires wound care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing? a) Covering the well approximated wound edges with a dry dressing b) Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive c) Cleaning the wound with soap and water, then leaving open to air d) Packing the wound bed with sterile saline-soaked dressing and covering with dry dressing

Packing the wound bed with sterile saline-soaked dressing and covering with dry dressing

Which of the following is a classic sign of hypovolemic shock? a) Bradypnea b) High blood pressure c) Pallor d) Dilute urine

Pallor

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? a) Necrotic and hard b) White with long, thin areas of scar tissue c) Pink to red and soft, bleeding easily d) 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.

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? a) Place the client in a position that puts the least strain on the operative area. b) Administer prescribed analgesics. c) Place sterile dressings moistened with normal saline over the protruding organs and tissues. d) Instruct the client to avoid any movement.

Place sterile dressings moistened with normal saline over the protruding organs and tissues.

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

Pneumonia

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? a) Hydroxyzine (Vistaril) b) Odansetron (Zofran) c) Promethazine (Phenergan) d) Prochlorperazine (Compazine)

Prochlorperazine (Compazine) Explanation: Prochlorperazine is a phenothiazine that inhibits the chemoreceptor trigger zone (CTZ) and the vomiting center in the brain. Odansetron 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.

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

Proper hand-washing techniques

What complication is the nurse aware of that is associated with deep venous thrombosis? a) Pulmonary embolism b) Marked tenderness over the anteromedial surface of the thigh c) Immobility because of calf pain d) Swelling of the entire leg owing to edema

Pulmonary embolism

The nurse is attempting to ambulate a patient who underwent shoulder surgery earlier in the day. The patient is refusing to ambulate. What action by the nurse is most appropriate? a) Document the patient's refusal. b) Delegate the task to the unlicensed assistive personnel. c) Use multiple staff members to remove the patient from the bed. d) Reinforce the importance of early mobility in preventing complications.

Reinforce the importance of early mobility in preventing complications.

When caring for a postsurgical patient, the nurse observes that the client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? a) Monitoring vital signs every 15 minutes b) Elevating the head of the bed c) Encouraging the patient to breathe deeply d) Reinforcing dressing or applying pressure if bleeding is frank

Reinforcing dressing or applying pressure if bleeding is frank

Which of the following would be the least important factor affecting wound healing? a) Sufficient oxygenation b) Age of patient c) Hemorrhage d) Nutritional deficiencies

Sufficient oxygenation

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

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

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

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? a) Family members can be involved in the administration of pain medications with patient-controlled analgesia. b) The client can self-administer oral pain medication as needed with patient-controlled analgesia. c) There are no advantages of patient-controlled analgesia over a PRN dosing schedule. d) Therapeutic drug levels can be maintained more evenly 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? a) Measure the amount of vomitus to estimate fluid loss, in order to accurately monitor fluid balance. b) Offer tepid water and juices to replace lost fluids and electrolytes. c) Support the wound area so that unnecessary strain will not disrupt the integrity of the incision. d) Turn the patient's head completely to one side to prevent aspiration of vomitus into the lungs.

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

Which of the following clinical manifestations increase the risk for evisceration in the postoperative client? a) Hypoxia b) Edema c) Hypovolemia d) Valsalva maneuver

Valsalva maneuver Explanation: The Valsalva maneuver produces tension on abdominal wounds, which increases the risk for evisceration.

Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective? a) Bladder non—distended; Foley catheter draining clear, yellow urine b) Bowel sounds present and active; denies nausea and vomiting c) Vital signs within normal limits; absence of chills and cough d) Alert and oriented; peripheral pulses present and strong

Vital signs within normal limits; absence of chills and cough

You are caring for a client who is an obese diabetic. The client is 48 hours post surgery. What is this client at increased risk for? a) Phlebitis b) Contractures c) Hypotension d) Wound dehiscence

Wound dehiscence

Nursing assessment findings reveal a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. The nurse recognizes the client is experiencing: a) Wound infection b) Uncontrolled pain c) Atelectasis d) Hyperthermia

Wound infection

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: a) palpate the abdomen. b) insert a rectal tube. c) change the client's position. d) auscultate bowel sounds.

auscultate bowel sounds.

The nurse recognizes that a traumatic wound with fecal contamination would be classified as a) dirty. b) contaminated. c) clean-contaminated. d) clean.

dirty

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: a) third intention. b) first intention. c) second intention. d) fourth intention.

first intention

The primary objective in the immediate postoperative period is a) monitoring for hypotension. b) relieving pain. c) maintaining pulmonary ventilation. d) controlling nausea and vomiting.

maintaining pulmonary ventilation.

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: a) experiences pain within tolerable limits. b) resumes usual urinary elimination pattern. c) exhibits wound healing without complications. d) maintains adequate oxygenation status.

maintains adequate oxygenation status.

The client is experiencing nausea and vomiting following surgery. The nurse expects the surgeon to order: a) ranitidine (Zantac) b) omeprazole (Prilosec) c) chlorpromazine (Thorazine) d) ondansetron (Zofran)

ondansetron (Zofran)

The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply. a) Wheezes b) Crackles c) Afebrile d) Tachypnea e) Chills

• Chills • Crackles • Tachypnea

A postoperative patient is being discharged home following minor surgery. The PACU nurse is reviewing discharge instructions with the patient and his or her spouse. What action by the nurse is appropriate? Select all that apply. a) Have the patient sign his or her advance directive form. b) Provide information on health promotion topics. c) Have the spouse review when to notify the physician. d) Discuss wound care. e) Educate on activity limitations.

• Educate on activity limitations. • Discuss wound care. • Have the spouse review when to notify the physician. • Provide information on health promotion topics.