Med-Surg Chapter 19: Postoperative Nursing Management

Med-Surg Chapter 19: Postoperative Nursing Management Question A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse? • “It assists in preventing infection.” Question A client develops a hemorrhage one-hour post-surgery. The nurse knows this is most likely an intermediary hemorrhage from a vein because it occurred: • within the first few hours and has darkly colored blood that bubbles out slowly. Question 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. Question 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. Question A client is at postoperative hour 8 after 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. The abdomen is soft and distended. No obvious bleeding is noted. What action by the nurse is most appropriate? • Notify the physician. Question 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 Question A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority? • Applying a sterile, moist dressing Question A client who is receiving the maximum levels of medication for postoperative recovery asks the nurse if there are other measures that the nurse can employ to ease pain. Which of the following strategies might the nurse employ? Select all that apply. • Performing guided imagery • Putting on soothing music • Changing the client’s position Question 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 at least three times per day. Question 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. Question A nurse is caring for a client with a chest tube connected to a dry suction water seal drainage system. The nurse notes 2cm of water and intermittent bubbling in the water seal chamber. Which action will the nurse take? • Document the findings. Question A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first? • Cover the protruding internal organs with sterile gauze moistened with sterile saline solution. Question 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. Question 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. Question A nurse is planning care for a client scheduled to undergo a thoracotomy. After tolerating full liquids, which dietary recommendation will the nurse consider? • Small, frequent full-fat meals Question 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 the sterile suction catheter. • Insert suction catheter into the lumen of the tube. • Apply intermittent suction while withdrawing the catheter. Question A PACU nurse is caring for a postoperative client who received general anesthesia and has a hard, plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and 98% oxygen saturation. The client is minimally responsive to painful stimuli. What action by the nurse is most appropriate? • Continue with frequent client assessments. Question 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? • Intermediary Question 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. Question A physician’s admitting note lists a wound as healing by second intention. What does the nurse expect to find? • A wound in which the edges were not approximated Question A postanesthesia care unit (PACU) nurse is preparing to discharge a client home following ankle surgery. The client keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate? • Review the instructions with the client and an accompanying adult. Question A postoperative client begins coughing forcefully while eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first? • Place the client in the low Fowler’s position. Question 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. Question A postoperative client is experiencing a flash pulmonary edema. What finding in the client’s sputum is consistent with this problem? • Pink color Question 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 normal saline and place on the protruding organ. Question 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. Question A significant mortality rate exists for patients with alcoholism who experience delirium tremens postoperatively. When caring for the patient with alcoholism, the nurse should assess for symptoms of alcoholic withdrawal: • On the second or third day. Question Adequate hourly urine output for a client with an indwelling urinary catheter is • 2.0 mL/kg/h. Question Corticosteroids have which effect on wound healing? • Mask the presence of infection Question During the first 24 hours after surgery, how often will the nurse evaluate the client’s temperature? • Every 4 hours Question Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that most support the nurse's analysis are: • blood pressure of 80/40 mm Hg and pulse of 130 beats/minute. Question Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention? • Oxygen saturation of 82% Question 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: • Wound infection Question Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The nurse recognizes the client is experiencing: • Hypothermia Question 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 Question On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing? • Packing the wound bed with sterile saline–soaked dressing and covering it with a dry dressing Question The client is experiencing intractable hiccups following surgery. The nurse expects the surgeon to order: • chlorpromazine (Thorazine) Question The nurse cares for a client who is three hours post op abdominal hysterectomy and begins to develop hiccups. What nursing assessment will the nurse monitor more closely with the client’s new symptoms? • Wound approximation Question The nurse determines that a patient has postoperative abdominal distention. What does the nurse determine that the distention may be directly related to? • A temporary loss of peristalsis and gas accumulation in the intestines Question The nurse documents the presence of granulation tissue in a healing wound. How should the nurse describe the tissue? • Pink to red and soft, bleeding easily Question The nurse is admitting the older adult to the PACU. Which information about this client would be most important for the PACU nurse to obtain? • Does the client have a history of dementia? Question The nurse is assessing the postoperative client on the second postoperative day. Which assessment finding requires immediate physician notification? • The client has an absence of bowel sounds. Question The nurse is caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock? • Weak and rapid pulse rate Question The nurse is caring for the postoperative client in the post anesthesia care unit. Which of the following is the priority nursing action? • Position the client to maintain a patent airway. Question The nurse is caring for a client 24-hour post-surgery who is having persistent hiccups. What action is most appropriate for the nurse to take? • Notify the physician. Question 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? • Absence of peristalsis Question The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract? • The client reports a small bowel movement. Question 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 Question 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 patient-controlled analgesia. Question 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? • Outline the drainage with a pen and record the date and time next to the drainage. Question 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 Question The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse’s conclusion? Select all that apply. • Chills • Crackles • Tachypnea Question 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 Question 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: • maintains adequate oxygenation status. Question The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of: • Hypoxemia and hypercapnia. Question The primary objective in the immediate postoperative period is • maintaining pulmonary ventilation. Question To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: • Ambulating the client as soon as possible Question What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? • 30 mL Question What complication is the nurse aware of that is associated with deep venous thrombosis? • Pulmonary embolism Question What does the nurse recognize as one of the most common postoperative respiratory complications in elderly patients? • Pneumonia Question What is the highest priority nursing intervention for a client in the immediate postoperative phase? • Maintaining a patent airway Question What measurement should the nurse report to the physician in the immediate postoperative period? • A systolic blood pressure lower than 90 mm Hg Question When should the nurse encourage the postoperative patient to get out of bed? • As soon as it is indicated Question When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O2 saturation monitor despite the client’s breathing appearing normal, what action should the nurse take first? • Assess the client’s heart rhythm and nail beds. Question When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as • clean contaminated. Question When vomiting occurs postoperatively, what is the most important nursing intervention? • Turn the patient’s head completely to one side to prevent aspiration of vomitus into the lungs. Question Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client? • Reinforce the need to perform leg exercises every hour when awake Question Which action should be incorporated into the client teaching plan to prevent deep vein thrombosis? • Hourly leg exercises Question Which is a classic sign of hypovolemic shock? • Pallor Question Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? • Second-intention healing Question Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply. • Ambulate the length of the client’s house • Get out of bed without assistance • Be able to self-toilet Question Which of the following clinical manifestations increase the risk for evisceration in the postoperative client? • Valsalva maneuver Question Which of the following factors may contribute to rapid and shallow respirations in a postoperative client? Select all that apply. • Pain • Constricting dressings • Abdominal distention • Obesity Question Which term refers to the protrusion of abdominal organs through the surgical incision? • Evisceration Question Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? • First intention Question 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? • Wound dehiscence Question You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult? • Tolerance