NUR 256 PrepU Ch 16 Post Operative Nursing Management

A nurse asks a client who had abdominal surgery 1 day 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?

Encourage the client to ambulate as soon as possible after surgery

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?

Have the client lay on the back with the head elevated Explanation: A wound evisceration occurs when the wound completely separates, and the internal organs protrude. If disruption of a wound occurs, the patient is placed in the low Fowler's position and instructed to lie quietly. These actions minimize the protrusion of body tissues. The protruding coils of the intestine are covered with sterile dressings moistened with sterile saline solution, and the surgeon is notified at once

In the immediate postoperative period, vital signs are taken at least every

15 minutes. Explanation: 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.

What measurement should the nurse report to the physician in the immediate postoperative period?

A systolic blood pressure lower than 90 mm Hg Explanation: 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

When should the nurse encourage the postoperative patient to get out of bed?

As soon as it is indicated Explanation: Postoperative activity orders are checked before the patient is assisted to get out of bed, in many instances, on the evening following surgery. Sitting up at the edge of the bed for a few minutes may be all that the patient who has undergone a major surgical procedure can tolerate at first

The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists?

Dehiscence Explanation: Dehiscence is a disruption of the incision.

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 Explanation: 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?

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.

The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of:

Hypoxemia and hypercapnia. Explanation: The primary objective in the immediate postoperative period is to maintain pulmonary ventilation and thus prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. Besides checking the health care provider's orders for and administering supplemental oxygen, the nurse assesses respiratory rate and depth, ease of respirations, oxygen saturation, and breath sounds

When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority.

Impaired Gas Exchange Fluid Volume Deficit Altered Comfort Anxiety Risk for 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 Explanation: Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?

Position the client to maintain a patent airway. Explanation: Maintaining a patent airway is the immediate priority in the PACU

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock?

Reinforcing dressings 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 and rubbing the back will not help manage and minimize hemorrhage and shock

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. 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.

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. 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.

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. 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

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. 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.

The primary objective in the immediate postoperative period is

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

A postanesthesia care unit (PACU) nurse is caring for a client with the following assessment data: pale, cool, moist skin; thready pulse of 122; blood pressure 78/60; urine output of 25 mL/h; temperature 99.2°F. What interventions by the nurse are appropriate? Select all that apply.

Maintain a patent airway. Frequently monitor neurological status. Administer blood products per orders. Apply oxygen per orders.

What is the highest priority nursing intervention for a client in the immediate postoperative phase?

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.

Which term refers to the protrusion of abdominal organs through the surgical incision?

Evisceration Explanation: 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 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?

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

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?

Evisceration Explanation: 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.

Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis?

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.

A nurse is receiving a client to the postanesthesia unit. What initial nursing activity is most important in the postoperative recovery area?

Maintain patient safety. Explanation: The most important postoperative nursing function is maintenance of patent safety, with airway and circulation as priorities. Administering medications and fluids, assessing pain, and inspecting the surgical site are important nursing activities, but are not the priorities of client care

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue?

Pink to red and soft, noting that it bleeds easily Explanation: 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.

A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention?

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.

The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates that further teaching is required?

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

A nursing measure for evisceration is to:

Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution. Explanation: If evisceration occurs, the nurse aseptically covers the abdominal contents with moist saline dressings to prevent drying of the bowel, notifies the surgical team immediately, and assesses the patient's vital signs including oxygen saturation. The patient remains in bed with knees bent to reduce abdominal muscle tension.

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 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

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. Explanation: 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 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?

Assessing WBC count, temperature, and wound appearance Explanation: The client has an increased risk for infection related to the surgical wound, which is classified as dirty. Assessing the WBC count, temperature, and wound appearance allows the nurse to intervene at the earliest sign of infection. The client will have special nutritional needs during wound healing and needs education on safe transfer procedures, but the need to monitor for infection is a higher priority. The client should receive pain medication as soon as possible after asking, but the latest literature suggests that pain medication should be given on a schedule versus "as needed."

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 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.

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 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

A client in the postanesthesia care unit (PACU) develops noisy and irregular respirations. Which action will the nurse take?

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.

A client vomits postoperatively. What is the most important nursing intervention?

Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs. Explanation: When a client vomits, the nurse should turn the client's head to the side to prevent aspiration; the vomitus is collected in the emesis basin. Measuring the vomitus is not helpful to the client. Offering fluids is not advised with vomiting. Supporting the wound is important, but not a priority with vomiting.

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?

Urine retention Explanation: 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

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for?

Wound dehiscence Explanation: 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.

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?

Wound infection Explanation: Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain