Postoperative Nursing Management (NC1)
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 the dressing or applying pressure if bleeding is frank
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
The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply.
tachypnea chills crackles
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
To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes:
ambulating the patient as soon as possible
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?
assess for signs and symptoms of fluid volume deficit
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
The nurse is caring for a female postoperative client who is having difficulty voiding. Which nursing action is most helpful to promote normal voiding?
assist to the bathroom
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
What complication is the nurse aware of that is associated with deep venous thrombosis?
pulmonary embolism
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
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
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
Which term refers to the protrusion of abdominal organs through the surgical incision?
evisceration
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
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
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?
first intention
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
The primary objective in the immediate postoperative period is
maintaining pulmonary ventilation
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?
moisten sterile gauze with sterile normal saline on protruding organ
Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention?
oxygen saturation 82%
Which is a classic sign of hypovolemic shock?
pallor
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 displaying early signs of shock
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?
therapeutic drug levels can be maintained more evenly with PCA
A client vomits postoperatively. What is the most important nursing intervention?
turn the clients head completely to one side to prevent aspiration of vomitus into the lungs
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?
urinary retention
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.
watching television changing position listening to music
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