Postoperative Management Exam (PREP U) | Answered with Rationales

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Postoperative Management Exam (PREP U) | Answered with Rationales 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. -If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort. When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as Clean-contaminated. -Clean-contaminated cases are those with a potential, limited source for infection, the exposure to which, to a large extent, can be controlled. Clean cases are those with no apparent source of potential infection. Contaminated cases are those that contain an open and obvious source of potential infection. A traumatic wound with foreign bodies, fecal contamination, or purulent drainage would be considered a dirty case. 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 -First-intention healing is characterized by a closed incision with little tissue reaction and the absence of signs and symptoms of infection. When should the nurse encourage the postoperative patient to get out of bed? As soon as it's indicated. -Postoperative activity orders are checked before the patient is assisted to get out of bed, in many instances, on the evening following surgery. Sitting up at the edge of the bed for a few minutes may be all that the patient who has undergone a major surgical procedure can tolerate at first. 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. -Any postoperative patient may suffer from distention. Postoperative distention of the abdomen results from the accumulation of gas in the intestinal tract. Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for 24 to 48 hours, depending on the type and extent of surgery. Even though nothing is given by mouth, swallowed air and GI tract secretions enter the stomach and intestines; if not propelled by peristalsis, they collect in the intestines, producing distention and causing the patient to complain of fullness or pain in the abdomen. Most often, the gas collects in the colon. Abdominal distention is further increased by immobility, anesthetic agents, and the use of opioid medications. 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. -The nurse should encourage the client to ambulate at least three times per day. Ambulating stimulates peristalsis, which helps the bowels to move. It isn't appropriate to apply heat to a surgical wound. Moreover, heat application can't be initiated without a physician order. A tap water enema is typically administered as a last resort after other methods fail. A physician's order is needed with a tap water enema as well. Notifying the physician isn't necessary at this point because the client is exhibiting bowel function by passing flatus. Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? First-intention healing Primary-intention healing Third-intention healing Second-intention healing -When wounds dehisce, they will be allowed to heal by secondary intention. Primary or first-intention healing is the method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulating. Third-intention healing is a method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by bringing apposing granulations together. The client is experiencing nausea and vomiting following surgery. The nurse expects the surgeon to order: Propofol (Diprivan) Warfarin (Coumadin) Prednisone (Deltasone) Ondansetron (Zofran) -It's used to treat nausea and vomiting. The nurse is caring for a client who develops an evisceration. What nursing intervention is most appropriate when an evisceration occurs in the surgical wound of a client who has undergone surgery? Place sterile dressings moistened with normal saline over the protruding organs and tissues. -If evisceration occurs, the nurse should place sterile dressings moistened with normal saline over the protruding organs and tissues and should inform the physician. If wound disruption is suspected, the nurse should place the client in a position that puts the least strain on the operative area. Analgesics help reduce pain. Avoiding any movement will not help recover from the wound evisceration. What does the nurse recognize as one of the most common postoperative respiratory complications in elderly patients? Pneumonia -Older patients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Delirium, pneumonia, decline in functional ability, exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and falls are all threats to recovery in the older adult (Tabloski, 2009; Tolson, Morley, Rolland, et al., 2011). 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. third intention. second intention. fourth intention. -Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing. Which of the following terms refers to a protrusion of abdominal organs through the surgical incision? Evisceration -Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue. When caring for a postsurgical patient, the nurse observes that the client has hemorrhaged and is in hypovolemic shock. Which of the following nursing interventions will manage and minimize hemorrhage and shock? Reinforcing dressing or applying pressure if bleeding is frank -The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the patient to breathe deeply and providing a back rub will not help manage and minimize hemorrhage and shock. The nurse recognizes that a traumatic wound with fecal contamination would be classified as Dirty An example of a dirty wound includes a traumatic wound with delayed repair, devitalized tissue, foreign bodies, or fecal contamination. A clean wound is at a nontraumatic site or at an uninfected site. Examples of clean-contaminated wounds include appendectomy or a minor break in aseptic technique. An example of a contaminated wound is gross spillage from the GI tract. 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. -The Aldrete score is usually 8 to 10 before discharge from the PACU. Clients with a score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area, depending on their preoperative baseline score. A nurse is reviewing with a client the use of a patient-controlled anesthesia device and is explaining the benefits. Which of the following would the nurse correctly emphasize? Select all that apply. Fosters client participation in care Facilitates reduction of postoperative pulmonary complications -PCA promotes client participation in care, eliminates delayed administration of analgesics, maintains a therapeutic drug level, and enables the client to move, turn, cough, and take deep breaths with less pain, thus reducing postoperative pulmonary complications. A patient is postoperative day 3 for 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 patient has an increased risk for infection related to the surgical wound classification of dirty. Assessing the WBC count, temperature, and wound appearance will allow the nurse to intervene at the earliest sign of infection. The patient will have special nutritional needs for wound healing and need education on safe transfer procedures but the need to monitor for infection is a higher priority. The patient should receive pain medication as soon as possible after asking but the latest literature suggest that pain medication should be given on a schedule versus "as needed." A postoperative patient, with an open abdominal wound is currently taking corticosteroids. The physician orders a wound culture of the abdominal wound even though there are no signs and symptoms of infection. What action by the nurse is appropriate? Obtain the wound culture specimen. -Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. The culture should be obtained even though the patient is not demonstrating traditional signs and symptoms of infection. The order should not be discontinued or held until purulent drainage is noted because the infection could worsen and the patient will possibly develop sepsis. An antibiotic cleaning agent should not be used before obtaining the specimen because it will alter the growth of the organisms. A patient asks why there is a drain pulling fluid from the surgical wound. What is the best response by the nurse? "It assists in preventing infection." -A wound drain assists in preventing infection by removing the medium in which bacteria would grow. The purpose of the wound drain is not to remove necrotic tissue or to decrease the number of dressing changes. Stating that most surgeons use wound drains does not answer the patient's question appropriately. What measurement should the nurse report to the physician in the immediate postoperative period? A systolic blood pressure lower than 90 mm Hg. -A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal. 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? 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 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. -The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage. The nurse is assessing the client's readiness for discharge from the postanesthesia care unit (PACU). The nurse can rouse the client by calling the client's name. The client can move all extremities and has a blood pressure of 134/82. Baseline preoperative blood pressure was 128/78. The most recent pulse oximetry reading was 94% on room air; the client's respirations are deep and easy at a rate of 12/minute. The nurse calculates the Aldrete score as: 9 -The total Aldrete score is 9. 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. -Acute confusion associated with delirium may be a result of hypoxia, pain, urinary retention, fecal impaction, fever, hypotension, hypoglycemia, fluid loss, and anemia. Hypoxia would be most important for the nurse to address. 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 -Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain. 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. The client can self-administer oral pain medication as needed with patient-controlled analgesia. Family members can be involved in the administration of pain medications with patient-controlled analgesia. There are no advantages of patient-controlled analgesia over a PRN dosing schedule. -Advantages of patient-controlled analgesia include participation of the client in care, elimination of delayed administration of analgesics, and maintenance of therapeutic drug levels. The client must have the cognitive and physical abilities to self-dose. What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? <30 mL -If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL per hour are reported; if the patient is voiding, an output of less than 240 mL per 8-hour shift is reported. 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 Pale yet able to blanch with digital pressure Necrotic and hard White with long, thin areas of scar tissue -In second-intention healing, necrotic material gradually disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue. What complication is the nurse aware of that is associated with deep venous thrombosis? Pulmonary embolism Immobility because of calf pain Marked tenderness over the anteromedial surface of the thigh Swelling of the entire leg owing to edema -Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010). What intervention by the nurse is most effective for reducing hospital-acquired infections? Proper hand-washing technique -Efforts to prevent wound infection are directed at reducing risks, such as thorough hand washing. (Preoperative and intraoperative risks and interventions are discussed in Chapters 17 and 18.) Postoperative care of the wound centers on assessing the wound, preventing contamination and infection before wound edges have sealed, and enhancing healing. You are caring for a client 6 hours post surgery. You observe that the client voids urine frequently and in small amounts. You know that this most probably indicates what? Urine retention -Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus. 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 Complete blood count Upper endoscopy Chest x-ray -Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, level of consciousness, central venous pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output are monitored to provide information on the patient's respiratory and cardiovascular status. The nurse is preparing to discharge a patient from the PACU using a PACU room scoring guide. With what score can the patient be transferred out of the recovery room? 8 5 7 6 -Many hospitals use a scoring system (e.g., Aldrete score) to determine the patient's general condition and readiness for transfer from the PACU (Aldrete & Wright, 1992). Throughout the recovery period, the patient's physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. This evaluation guide allows an objective assessment of the patient's condition in the PACU (Fig. 19-3). The patient is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The Aldrete score is usually between 8 and 10 before discharge from the PACU. 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? Abdominal tightness Absence of peristalsis Increased abdominal girth Abdominal distention -Paralytic ileus and intestinal obstruction are potential postoperative complications that occur more frequently in patients undergoing intestinal or abdominal surgery. Manipulation of the abdominal organs during surgery may produce a loss of normal peristalsis for 24 to 48 hours, depending on the type and extent of surgery. To prevent thromboembolism in the postoperative client, the nurse should include which of the following in the plan of care? Assist with oral fluid intake. -Dehydration, immobility, and pressure on leg veins promote venous stasis, which can lead to thromboembolism. Which of the following is a classic sign of hypovolemic shock? High blood pressure Dilute urine Pallor Bradypnea -The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing. How do you survive nursing school? By not giving up. YOU GOT THIS. A client with nausea and vomiting is to receive an antiemetic that inhibits the vomiting center in the brain. Which of the following would the nurse expect the physician to order most likely? Prochlorperazine (Compazine) -Prochlorperazine is a phenothiazine that inhibits the chemoreceptor trigger zone (CTZ) and the vomiting center in the brain. Odansetron blocks receptors for 5 HT3, affecting the neural pathways involved in nausea and vomiting. Hydroxyzine and promethazine are antihistamines which block H1 receptors resulting in a decrease in stimulation of the CTZ and vomiting. You are 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 -Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock. 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. -A nursing assessment finding of concern on the second postoperative day is the absence of bowel sounds, which may indicate a paralytic ileus. Other assessment findings may include abdominal pain and distention as fluids, solids, and gas do not move through the intestinal tract. Rales in the bases are a frequent finding postoperatively, especially if general anesthesia was administered. Encourage the client to cough and deep breathe. Pain is a common symptom following a surgical procedure. Serous drainage on the postoperative dressing needs to monitored and brought to the physician's attention when he or she assesses the client. Postoperative day 2, a patient requires wound 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 with dry dressing Covering the well approximated wound edges with a dry dressing Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive Cleaning the wound with soap and water, then leaving open to air -Postoperative surgical wounds that are allowed to heal using second-intention healing are usually packed with a sterile saline dressing and covered with a dry dressing. The edges of a second-intention healing wound are not approximated. The wound may be cleaned using sterile saline but the nurse would not apply a cyanoacrylate tissue adhesive. The wound should not be left open to the air, as it could expose the wound to microorganisms and dry out the wound bed impairing healing. A patient is postoperative hour 8 following an appendectomy and is anxious stating, "Something is not right. My pain is worse than ever and my stomach is swollen." Blood [Show More]

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