Prep U- Chap.19: Postoperative Nursing Management

The nurse is caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock? -Warm, dry skin -Obstructed airway -Pooling of secretions in the lungs -Weak and rapid pulse rate

Weak and rapid pulse rate

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

auscultate bowel sounds.

Which findings would be indicative of a nursing diagnosis of decreased cardiac output? -tachycardia; hemoglobin 10.9 gm/dL; BP 88/56 -bradycardia; urinary output < 30 ml; confusion -confusion; tachypnea; hemoglobin 14.2 gm/dL -urinary output > 60 ml; BP 90/60; tachypnea

tachycardia; hemoglobin 10.9 gm/dL; BP 88/56

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 -Upper endoscopy -Chest x-ray -Complete blood count

Central venous pressure

A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.

-Position the client in Fowlers position. -Don sterile gloves. -Lubricate tauscultate bowel sounds.he sterile suction catheter. -Insert suction catheter into the lumen of the tube. -Apply intermittent suction while withdrawing the catheter.

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 -Hemorrhage -Evisceration -Normal healing by primary intention.

Dehiscence

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? -Encourage the client to ambulate as soon as possible after surgery. -Notify the physician. -Apply moist heat to the client's abdomen. -Administer a tap water enema.

Encourage the client to ambulate as soon as possible after surgery.

You are caring for a client postoperatively. What nursing interventions help prevent venous stasis and other circulatory complications in a client who has undergone surgery? -Place pillows under the client's knees or calves. -Place the client in a side-lying position. -Encourage the client to move legs frequently and do leg exercises. -Place pressure on the client's lower extremities.

Encourage the client to move legs frequently and do leg exercises.

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: -Granulation -Third intention -Second intention -First intention

First intention

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

First intention

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? -Pleurisy -Hypoxemia -Pulmonary edema -Pneumonia

Pneumonia

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. -Monitor vital signs for early detection of shock. -Administer antiemetics to prevent nausea and vomiting. -Assess the incisional dressing to detect hemorrhage.

Position the client to maintain a patent airway.

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

Reinforcing the dressing or applying pressure if bleeding is frank

Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis? -Prolonged dangling of the legs over the edge of the bed -Hourly leg exercises -Use of blanket rolls to elevate the lower extremities -Fluid restriction

Hourly leg exercises

A patient who underwent abdominal surgery 3 hours ago has started to hemorrhage. The nurse would classify this type of hemorrhage has which of the following? -Primary -Tertiary -Intermediary -Secondary

Intermediary -Intermediary hemorrhage occurs during the first few hours after surgery when the rise of blood pressure to its normal level dislodges insecure clots formed in untied vessels. Primary hemorrhage occurs at the time of surgery. Secondary hemorrhage may occur some time after surgery if a suture slips because a blood vessel was not securely tied, became infected, or was eroded by a drainage tube.

Which is a classic sign of hypovolemic shock? -Dilute urine -Pallor -Bradypnea -High blood pressure

Pallor

The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? -Pale yet able to blanch with digital pressure -White with long, thin areas of scar tissue -Necrotic and hard -Pink to red and soft, bleeding easily

Pink to red and soft, bleeding easily

The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order? -ranitidine -chlorpromazine -omeprazole -ondansetron

ondansetron -Ondansetron (Zofran) is used to treat nausea and vomiting.

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

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

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

A systolic blood pressure lower than 90 mm Hg

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

As soon as it is indicated

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? -Call the health care provider. -Prepare to administer a stool softener. -Re-attempt to auscultate bowel sounds. -Prepare to insert a nasogastric tube.

Call the health care provider.

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 a nasogastric (NG) tube in place that drained 400 ml. -The client has been lying on his side for 2 hours with the drain positioned upward. -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.

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

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 -Uncontrolled pain -Hyperthermia -Atelectasis

Wound infection

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 -hemorrhaged. -eviscerated. -dehisced. -pustulated.

dehisced. -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.