Postoperative Care Evolve

A postoperative patient is transferred from the postanesthesia unit to the medical-surgical nursing floor. The nurse notes that the patient has a prescription for D 5½ normal saline (NS) to infuse at 120 mL/hr. The nurse regulates the intravenous (IV) at what flow rate in drops (gtts)/min, noting that the tubing has a drop factor of 10 drops/mL? Fill in the blank using a whole number. gtts/min

20 gtts/min

A patient with a history of bipolar disorder underwent an amputation of the left leg. The patient has diabetes and a complicated diabetic foot ulcer. Which factor will best determine the patient's ability to cope?

Ability to regain independence

A patient with asthma develops wheezing on the postanesthesia care unit. The nurse finds that the patient is tachypneic, has dyspnea, and has reduced oxygen saturation. How will the nurse prevent further pulmonary complications?

Administer bronchodilators.

A patient is suspected of having a pulmonary embolism following a major orthopaedic procedure. How would the nurse relieve the patient of dyspnea?

Administer oxygen therapy. Administer anticoagulant therapy.

A patient who was on mechanical ventilation through an endotracheal tube develops inspiratory stridor and sternal retraction upon removal of the endotracheal tube. How should the nurse manage this patient and ensure oxygenation?

Administer oxygen therapy. Administer muscle relaxants. Provide positive pressure ventilation.

A patient on the postoperative unit reports difficulty breathing. The nurse discovers that the patient received large doses of skeletal muscle relaxants during surgery. What should the nurse include in the patient's plan of care to promote breathing?

Administering drugs for reversal of paralysis

A postoperative patient is delirious, restless, and shouting at the nurse about pain. What does the nurse consider may be a cause of this behavior?

Anesthetic agents used in surgery

A nurse cares for a patient with acute pulmonary edema. What findings would the nurse expect to assess?

Anxiety and distended neck veins

The nurse has received a patient from surgery in the postanesthesia care unit (PACU). What is the best way for the nurse to ensure that this patient has a patent airway?

By putting in an artificial airway By tilting the head and thrusting the jaw

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure of 100/60 mm Hg. Which action should the nurse take first?

Check the medical record for the patient's baseline blood pressure.

A postoperative patient develops fever, abdominal pain, and diarrhea despite being on long-term antibiotics. What should the nurse evaluate for?

Clostridium difficile infection

A patient that is an alcoholic had a hernia operation and is restless and irritable. On assessment, the nurse finds that the patient has auditory hallucinations. What is the most appropriate nursing action?

Conclude that these effects are due to alcohol withdrawal.

An older adult patient has a complication after a cardiac catheterization and has to remain in the intensive care unit (ICU) for an extra three days. For what is the patient most at risk?

Delirium

A patient with a history of deep vein thrombosis is recovering in the postanesthesia care unit (PACU) after an abdominal surgery. Considering that the patient is at risk of developing pulmonary embolism (PE), what signs should the nurse watch out for?

Dyspnea Tachypnea Tachycardia

The nurse is educating a patient that had a coronary bypass graft (CABG) about the risk of venous thromboembolism (VTE). What should the nurse be sure to include in the education to the patient?

Early ambulation

A patient with a history of psychosis has newly developed anxiety and is combative with the nurse. What does the nurse know may be causes of this change in behavior?

Electrolyte imbalances

A postoperative patient has absence of breath sounds on the left lung and an oxygen saturation of 86%. What interventions should be included to maintain adequate oxygen saturation?

Encourage incentive spirometry. Provide humidified oxygen therapy

A nurse is caring for a patient who had a bowel resection 10 hours before. The patient weighs 200 pounds (91 kg) and has a urine output of 240 cc for the past eight hours. What action should the nurse take?

Notify the primary health care provider

A patient underwent a laparoscopic assisted hysterectomy the day before and is now experiencing chills and a temperature of 102.2 °F (39 °C). Which nursing action is priority?

Notify the primary health care provider.

A patient has been admitted to the postanesthesia care unit (PACU). Which of these assessment findings require the nurse's immediate action?

The patient is restless, agitated, and hypotensive.

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge?

Vital signs baseline or stable Minimal nausea and vomiting Responsible adult taking patient home

The patient donated a kidney and early ambulation is included in the plan of care; however, the patient refuses to get up and walk. What explanation should the nurse give to the patient for early ambulation?

"Early walking is the best way to prevent postoperative complications."

A nurse is caring for an older adult patient, who had a knee replacement the previous day. The patient denies any pain. Which response by the nurse would be most appropriate?

"Almost everyone has pain after this surgery. Are you certain that you are not experiencing pain?"

The nurse is preparing to administer cefazolin 2 gm in 100 mL of normal saline to a postoperative patient. What infusion rate on the infusion pump will infuse this medication over 20 minutes? Record your answer using a whole number. mL/hr

300 ml/hr

The nurse is caring for a postoperative patient. What patient does the nurse determine is at the greatest risk for development of atelectasis?

A patient not adherent with the pulmonary regimen after surgery

The nurse is caring for a patient in the postanesthesia care unit (PACU), when the blood pressure drops from 110/60 mm HG to 92/58 mm Hg. What actions should the nurse take?

Assess ECG tracing. Inspect the surgical site. Have the patient take deep breaths. Administer intravenous (IV) fluid bolus per protocol.

A patient is transferred to the postanesthesia care unit (PACU) after surgery. Which nursing intervention is the highest priority initially?

Assess airway, breathing, and circulation status.

A patient's blood pressure increases from 110/76 mm Hg to 160/90 mm Hg two hours after a cholecystectomy. What action should the nurse take first?

Assess pain level.

The nurse is preparing to administer an analgesic to a postoperative patient. What actions taken by the nurse would be appropriate?

Assess the location, quality, and intensity of pain. Monitor the patient for nausea, vomiting, and respiratory depression. Time the analgesic administration for effectiveness during painful activities.

The nurse is assessing a patient's surgical dressing on the first postoperative day and notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first?

Assess the patient's blood pressure and heart rate

A postoperative patient with bronchial obstruction has a pulse oximetry reading of 87%. What does the nurse suspect is occurring with this patient?

Atelectasis

A postoperative patient develops laryngeal edema after receiving a penicillin injection. How can the nurse prevent further complications in the patient?

By administering sedatives By administering antihistamines By administering corticosteroids

A patient who has been admitted to the postanesthesia care unit following major abdominal surgery develops coarse crackles. How should the nurse prevent pulmonary complications in this patient?

By providing IV hydration By suctioning the airways

A nurse is providing postoperative care for a patient who has undergone exploratory abdominal surgery. To prevent the complication of atelectasis, what interventions should the nurse perform?

Encouraging the use of an incentive spirometer at least every hour

A patient, who is eight hours postappendectomy, has not voided since surgery. What action should the nurse take?

Palpate the suprapubic area for bladder distention.

The nurse receives an unconscious postoperative patient in the post anesthesia care unit (PACU). What position would be the safest to place this patient immediately after the operation?

Lateral

The nurse places an abdominal binder on a patient after colon surgery. After approximately an hour, the nurse assesses the patient has shallow respirations, is hypoxemic, and hypercapnic. How should the nurse promote optimal breathing in this patient?

Loosen the binder Reposition the patient Raise the head end of the bed

The nurse is caring for a patient at risk for developing syncope. Which nursing intervention is important to prevent this occurrence in this postoperative patient?

Make changes in the patient's position slowly.

A patient is having elective cosmetic surgery performed on the face. The patient will remain at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient?

Manage oxygenation status

A patient on the postoperative unit was given a large dose of opioids during a surgical procedure and is now hypoxemic. What would the nurse expect to be prescribed to manage hypoxemia in this patient?

Naloxone

The nurse is monitoring a postoperative patient in the Phase I postanesthesia care unit (PACU). What criteria must the patient meet in order to be discharged from this phase?

No respiratory depression Oxygen saturation above 90% Patient reports pain level of 4 on a 1 to 10 scale

An older patient is having problems with concentration and memory after extensive surgery to repair an abdominal aortic aneurysm. What determines if this is a factor of delirium or postoperative cognitive dysfunction?

Preexisting dementia identified before surgery

A patient has difficulty passing urine after surgery for the correction of rectal prolapse. How should the nurse help this patient void?

Reassure the patient of the ability to void. Help the patient to attain a normal voiding position. Pour warm water over perineum.

A patient had an estimated blood loss of 400 mL during abdominal surgery. The patient received 300 mL of 0.9% saline during surgery and now is experiencing hypotension postoperatively. What should the nurse anticipate for this patient?

Restoring circulating volume

The nurse finds that a postoperative patient has low oxygen saturation and crackles on auscultation. Which is an appropriate nursing action?

Restrict fluid intake.

A patient inadvertently received a large amount of intravenous fluid. The nurse assesses that the patient has reduced oxygen saturation, crackles on auscultation, and infiltrates on chest x-ray. How should the nurse relieve the patient's breathing discomfort and promote oxygen saturation?

Restrict fluids. Administer diuretics. Administer oxygen therapy.

A patient with a history of venous thrombosis had major abdominal surgery. Which nursing interventions are helpful in preventing the development of venous thrombosis?

Sequential compression devices Use of dalteparin

Two days after colectomy for an abdominal mass, the patient reports gas pains and abdominal distension. The nurse plans care for the patient on the basis of the knowledge that these symptoms occur as a result of which condition?

Slowed gastric emptying

What is the priority nursing action when a patient is transferred from the postanesthesia care unit (PACU) to the surgical unit after a lobectomy?

Take the patient's vital signs.

While caring for a patient after a colectomy on the first postoperative day, the nurse notes new bright-red drainage about 4 cm in diameter on the surgical dressing. What is the priority nursing action?

Take the patient's vital signs.

A patient is being discharged after having a laparoscopic cholecystectomy. The nurse should instruct the patient to notify the surgeon immediately if which condition develops?

Temperature of 103° F

An older adult postoperative patient wakes up and becomes restless and agitated and starts thrashing and shouting. The nurse finds that the patient was administered benzodiazepines during surgery. What would be important to have on the patient's plan of care?

Use drugs to reverse the benzodiazepines. Ensure patient safety.

A postoperative patient who has been transferred from surgery to the postanesthesia care unit is cold and shivering. The patient's plan of care includes a prescription for morphine to be administered for pain relief. When managing this patient, which interventions should the nurse perform?

Use forced air warmers. Administer oxygen therapy. Administer warmed IV fluids. Use warmed cotton blankets.