The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?
1. Urine output of
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The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?
1. Urine output of 20ml/hour
2. Temperature of 37.6 C
3. Blood pressure of 114/70
4. Serous drainage on the surgical dressing - ANSWER 1.
Urine output should be maintained at a minimum of 30mL/hour for an adult. An output of less than that for each of 2 consecutive hours should be reported to the health care provider.
A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition?
1. Pneumonia
2. Hypoxemia
3. Fluid imbalance
4. Pulmonary embolism - ANSWER 1.
Postoperative respiratory problems are atelectasis, pneumonia and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by the retention of pulmonary secretions.
The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?
1. Avoid oral hygiene and rinsing with mouthwash
2. Verify that the client has not eaten for the last 24 hours
3. Have the client void immediately before going into surgery
4. Report immediately any slight increase in BP or pulse - ANSWER 3.
The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A slight increase in BP and pulse is common during the preoperative period due to anxiety.
A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?
1. Obtain a court order for the surgery.
2. Have the charge nurse sign the informed consent immediately
3. Send the client to surgery without the consent form being signed
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