CH 19 – Flashcard
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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? a) The client has a nasogastric (NG) tube in place that drained 400 ml. b) The client has been lying on his side for 2 hours with the drain positioned upward. c) There is a moderate amount of dry drainage on the outside of the dressing. d) The Hemovac drain isn't compressed; instead it's fully expanded.
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The Hemovac drain isn't compressed; instead it's fully expanded. Correct Explanation: 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.
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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 gap at the lower end of the incision. The nurse concludes which of the following conditions exists? a) Dehiscence b) Evisceration c) Hemorrhage d) Normal healing by primary intention.
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Dehiscence Correct Explanation: Dehiscence is a disruption of the incision.
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The nurse is preparing the client with an abdominal incision for discharge. Which statement by the client indicates teaching has been ineffective? a) "My incision should become less red and tender." b) "I can resume my usual activities as soon as I get home." c) "I need to keep my follow-up appointment with the physician." d) "I should call my physician if I develop a fever."
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"I can resume my usual activities as soon as I get home." Correct Explanation: By time of discharge, clients should be able to verbalize clinical manifestations of complications, activity and diet restrictions, and specifics regarding follow-up appointments. The client with abdominal incision will need to avoid lifting and driving in the initial discharge period.
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Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? a) Second-intention b) First-intention c) Fourth-intention d) Third-intention
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First-intention Correct Explanation: When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Postoperatively, many of these wound are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing.
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A patient asks why there is a drain pulling fluid from the surgical wound. What is the best response by the nurse?
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"It assists in preventing infection." Correct Explanation: 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.
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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? a) Encouraging the patient to breathe deeply b) Reinforcing dressing or applying pressure if bleeding is frank c) Providing a back rub d) Elevating the head of the bed
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Reinforcing dressing or applying pressure if bleeding is frank Correct Explanation: 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.
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A postoperative patient begins coughing forcefully when eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first? a) Cover the intestines with sterile, moist dressings. b) Place the patient in low Fowler's position. c) Document the event. d) Notify the surgeon.
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Place the patient in low Fowler's position. Correct Explanation: Placing the patient in low Fowler's position decreases further protrusion of the intestines. The nurse should cover the intestines with a sterile, moist dressing; notify the surgeon and document the event; but first and foremost the nurse should minimize further protrusion of the intestines.
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A patient with an abdominal surgical wound sneezes and states, "Something doesn't feel right with my wound." The nurse asses the upper half of the surgical wounds edges are no longer approximated and the lower half remains well approximated. What documentation by the nurse is most appropriate? a) Following a sneeze, the wound eviscerated. b) Following a sneeze, the wound pustulated. c) Following a sneeze, the wound hemorrhaged. d) Following a sneeze, the wound dehisced.
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Following a sneeze, the wound dehisced. Correct Explanation: 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.
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The nurse is attempting to ambulate a patient who underwent shoulder surgery earlier in the day. The patient is refusing to ambulate. What action by the nurse is most appropriate? a) Use multiple staff members to remove the patient from the bed. b) Document the patient's refusal. c) Delegate the task to the unlicensed assistive personnel. d) Reinforce the importance of early mobility in preventing complications.
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Reinforce the importance of early mobility in preventing complications. Correct Explanation: The patient may be refusing to ambulate because of fear or pain. Educating on the importance of mobility in preventing complications may encourage the patient to ambulate. The nurse should try all reasonable measures (pain control, education) before documenting the patient's refusal to ambulate. If the patient is already refusing to ambulate delegating the task to the unlicensed assistive personnel is not an appropriate action. The patient should not be forcefully removed from the bed.
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To prevent thromboembolism in the postoperative client, the nurse should include which of the following in the plan of care? a) Splint the incision when ambulating. b) Assist the client with deep breathing. c) Place a pillow under the knees. d) Assist with oral fluid intake.
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Assist with oral fluid intake. Correct Explanation: Dehydration, immobility, and pressure on leg veins promote venous stasis, which can lead to thromboembolism.
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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? a) Acute incisional pain b) Ineffective airway clearance c) Decreased cardiac output d) Ineffective thermoregulation
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Ineffective thermoregulation Correct Explanation: Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.
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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 pressure is 88/50, pulse is 115, and respirations are 24 and labored. Abdomen is soft and distended. No obvious bleeding noted. What action by the nurse is most appropriate? a) Ambulate the patient to reduce abdominal distention. b) Notify the physician. c) Administer morphine per orders. d) Inform the patient this is the normal progression following abdominal surgery.
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Notify the physician. Correct Explanation: The physician should be notified of the findings. The patient may be hemorrhaging internally and may need to return to surgery. The patient may be in need of pain medication but morphine will lower the blood pressure further and may cause further complications. Ambulating the patient increases the risk of injury because the patient may experience orthostatic hypotension. What the patient is experiencing is not the normal progression following abdominal surgery.
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A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to: a) pull the dehiscence closed. b) place saline-soaked sterile dressings on the wound. c) call the physician. d) take a blood pressure and pulse.
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place saline-soaked sterile dressings on the wound. Correct Explanation: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the client's vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.
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Which of the following terms refers to a protrusion of abdominal organs through the surgical incision? a) Dehiscence b) Evisceration c) Erythema d) Hernia
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Evisceration Correct Explanation: 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.
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The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action? a) Monitor vital signs for early detection of shock. b) Assess the incisional dressing to detect hemorrhage. c) Administer antiemetics to prevent nausea and vomiting. d) Position the client to maintain a patent airway.
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Position the client to maintain a patent airway. Correct Explanation: Maintaining a patent airway is the immediate priority in the PACU.
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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: a) exhibits wound healing without complications. b) maintains adequate oxygenation status. c) resumes usual urinary elimination pattern. d) experiences pain within tolerable limits.
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maintains adequate oxygenation status. Correct Explanation: 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.
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What is the highest priority nursing intervention for a patient in the immediate postoperative phase? a) Monitoring vital signs at least every 15 minutes b) Assessing urinary output every hour c) Maintaining a patent airway d) Assessing for hemorrhage
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Maintaining a patent airway Correct Explanation: All interventions listed are correct. The highest priority intervention is maintaining a patent airway. Without a patent airway, the other interventions of monitoring vital signs and urinary output, along with assessing for hemorrhage, become secondary to the possibility of a lack of oxygen.
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The primary objective in the immediate postoperative period is a) monitoring for hypotension. b) maintaining pulmonary ventilation. c) controlling nausea and vomiting. d) relieving pain.
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maintaining pulmonary ventilation. Correct Explanation: The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and monitoring for hypotension are important, but they not the primary objectives in the immediate postoperative period.
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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: a) First intention b) Second intention c) Third intention d) Granulation
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First intention Correct Explanation: First-intention healing is characterized by a closed incision with little tissue reaction and the absence of signs and symptoms of infection.
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Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis? a) Ineffective airway clearance b) Decreased cardiac output c) Urinary retention d) Acute pain
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Decreased cardiac output Correct Explanation: Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion.
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Which of the following is a classic sign of hypovolemic shock? a) High blood pressure b) Bradypnea c) Dilute urine d) Pallor
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Pallor Correct Explanation: The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing.
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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? a) What was estimated blood loss? b) Does the client have a history of dementia? c) What procedure was performed? d) Are family members available?
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Does the client have a history of dementia? Correct Explanation: Acute confusion is a common side effect of anesthesia in older adults. The nurse needs to know whether any confusion displayed by the client is a result of the surgery and anesthesia or a usual state for the client.
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The client is experiencing nausea and vomiting following surgery. The nurse expects the surgeon to order: a) ranitidine (Zantac) b) chlorpromazine (Thorazine) c) omeprazole (Prilosec) d) ondansetron (Zofran)
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ondansetron (Zofran) Correct Explanation: Ondansetron (Zofran) is used to treat nausea and vomiting.
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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? a) Encourage the client to ambulate at least three times per day. b) Apply moist heat to the client's abdomen. c) Notify the physician. d) Administer a tap water enema.
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Encourage the client to ambulate at least three times per day. Correct Explanation: 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.
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A postanesthesia care unit (PACU) nurse is preparing to discharge a patient home following ankle surgery. The patient keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate? a) Review the instructions with the patient and accompanying adult. b) Give the written instructions to the patient's 16-year-old child. c) Ask the patient, "Do you understand?" d) Continuously repeat the instructions until the patient restates them.
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Review the instructions with the patient and accompanying adult. Correct Explanation: The effects of the anesthesia may impair the memory or concentration of the patient. It is important that the discharge instructions are covered with the patient and an accompanying adult. Giving the instructions to a 16-year-old is not appropriate. Repeating the instruction until the patient restates them does not ensure that the patient will remember them because of how anesthesia can impair the memory. Asking if the patient understands the instructions only elicits an yes or no answer but does not give insight on if the patient comprehending the instructions.
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When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as a) clean. b) contaminated. c) dirty. d) clean-contaminated.
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clean-contaminated. Explanation: 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.
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The nurse is caring for a patient in the postanesthesia care unit (PACU) with the following vital signs, pulse 115, respiration 20, temperature 97.2°F oral, blood pressure 84/50. What should the nurse do first? a) Notify the physician. b) Assess for bleeding. c) Increase rate of IV fluids. d) Review the patient's preoperative vital signs.
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Assess for bleeding. Correct Explanation: The patient is tachycardic with a low blood pressure; thus assessing for hemorrhage is the priority action. While the physician may need to be notified, the nurse needs to be able to communicate a complete picture of the patient, which would include bleeding, when calling the physician. The rate of IV fluid administration should be adjusted according to a physician order. The nurse should review prior vital signs but only after the immediate threat of hemorrhage is assessed.
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A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: a) auscultate bowel sounds. b) change the client's position. c) palpate the abdomen. d) insert a rectal tube.
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auscultate bowel sounds. Correct Explanation: 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.
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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? a) Assessing WBC count, temperature, and wound appearance b) Administering pain medications within 1 hour of the patient's request c) Educating patient on safe bed-to-chair transfer procedures d) Obtaining dietary consultation for improved wound healing
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Assessing WBC count, temperature, and wound appearance Correct Explanation: 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."
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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? a) The client must remain in the PACU. b) The client can be discharged from the PACU. c) The client should be transferred to an intensive care area. d) The client must be put on immediate life support.
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The client can be discharged from the PACU. Correct Explanation: 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.
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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: a) Hyperthermia b) Wound infection c) Atelectasis d) Uncontrolled pain
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Wound infection Correct Explanation: Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.
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The nurse is caring for a postoperative patient with an indwelling urinary catheter. The hourly urinary output at 9 am is 80 mL. The nurse assesses the hourly urinary output at 10 am at 20 mL. What is the highest priority action by the nurse? a) Document the findings. b) Irrigate the catheter with sterile normal saline. c) Reassess the output at 11 am. d) Notify the physician.
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Notify the physician. Correct Explanation: If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/h are reported. Any urinary output less than 30 mL/h should be reported to the physician immediately. The urinary output will be reassessed at 11 am but waiting to notify the physician could cause harm to the patient. The findings should be documented but this is not the highest priority. A urinary catheter may need to be irrigated but a postoperative patient with a low urinary output is demonstrating a complication that needs to be reported immediately.
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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: a) blood pressure of 150/100 mm Hg and pulse of 130 beats/minute. b) blood pressure of 80/40 mm Hg and pulse of 50 beats/minute. c) blood pressure of 80/40 mm Hg and pulse of 130 beats/minute. d) blood pressure of 150/100 mm Hg and pulse of 50 beats/minute.
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blood pressure of 80/40 mm Hg and pulse of 130 beats/minute. Correct Explanation: The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis. Orthostatic changes develop from hypovolemia and cause a drop in blood pressure (evidenced by a blood pressure of 80/40 mm Hg) and a compensatory rise in the heart rate (evidenced by a pulse of 130 beats/minute) when the client rises from a lying position.
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A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first? a) Ask the client to drink as much fluid as possible. b) Cover the protruding internal organs with sterile gauze moistened with sterile saline solution. c) Explain to the client what is happening and provide support. d) Push the protruding organs back into the abdominal cavity.
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Cover the protruding internal organs with sterile gauze moistened with sterile saline solution. Correct Explanation: Immediately covering the wound with moistened gauze prevents the organs from drying. The gauze and the saline solution must be sterile to reduce the risk of infection. Although providing support to reduce the client's anxiety is important, it isn't the priority nursing action. The organs shouldn't be pushed back into the abdomen; doing so may tear or damage them. Evisceration requires emergency surgery; therefore, the nurse should put the client on nothing-by-mouth status immediately.
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The client is experiencing intractable hiccups following surgery. The nurse expects the surgeon to order: a) chlorpromazine (Thorazine) b) omeprazole (Prilosec) c) metoclopramide (Reglan) d) ranitidine (Zantac)
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chlorpromazine (Thorazine) Explanation: Chlorpromazine (Thorazine) is used to treat intractable hiccups.
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A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: a) third intention. b) second intention. c) fourth intention. d) first intention.
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first intention. Correct Explanation: 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.
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The nurse is reviewing the medications of a postoperative client. Which of the following medications may be of concern to the nurse? a) digoxin (Lanoxin) b) allopurinol (Zyloprim) c) predinisone (Deltasone) d) furosemide (Lasix)
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predinisone (Deltasone) Correct Explanation: Corticosteroids impair the normal inflammatory process and may mask infection.
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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? a) Place sterile dressings moistened with normal saline over the protruding organs and tissues. b) Administer prescribed analgesics. c) Place the client in a position that puts the least strain on the operative area. d) Instruct the client to avoid any movement.
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Place sterile dressings moistened with normal saline over the protruding organs and tissues. Correct Explanation: 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.
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To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes: a) Positioning the client in a supine position b) Assessing breath sounds at least every 2 hours c) Assisting with incentive spirometry every 6 hours d) Ambulating the client as soon as possible
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Ambulating the client as soon as possible Correct Explanation: The nurse should assist the client to ambulate as soon as the client is able. Incentive spirometry should be performed every 1 to 2 hours. The client should be positioned from side to side and in semi-Fowler's position. While assessing breath sounds is essential, it does not help to prevent pneumonia.
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Adequate hourly urine output for a patient with an indwelling urinary catheter is a) 30 mL/hr. b) 20 mL/hr. c) 15 mL/hr. d) 25 mL/hr.
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30 mL/hr. Correct Explanation: If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/hr are reported.
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Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. Which of the following actions by the nurse would be inappropriate? a) Administer oxygen. b) Monitor for cardiac dysrhythmias. c) Restrict oral fluids. d) Provide a blanket.
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Restrict oral fluids. Correct Explanation: The client exhibits clinical manifestations of hypothermia. The nurse should maintain adequate hydration of the client rather than restrict fluids.
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A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem? a) Pieces of vomitus b) Foul smell c) Copious red blood in the sputum d) Pink color
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Pink color Correct Explanation: Flash pulmonary edema that occurs when protein and fluid accumulate in the alveoli unrelated to elevated pulmonary artery occlusive pressure. Signs and symptoms include agitation, tachypnea, tachycardia, decreased pulse oximetry readings, frothy, pink sputum, and crackles on auscultation.
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The nurse is caring for a postoperative client with a hemovac. The hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to: a) Empty and measure the drainage and compress the hemovac. b) Remove the hemovac because it is expanded. c) Notify the surgeon that the hemovac is not functioning. d) Assess the client's wound and apply a pressure dressing.
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Empty and measure the drainage and compress the hemovac. Correct Explanation: A hemovac needs to be recompressed periodically, because it operates with the use of gentle, constant suction. The amount of drainage is not excessive.
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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. a) Fosters client participation in care b) Allows drug levels to fluctuate with the client's vital signs c) Delays administration of analgesics d) Facilitates reduction of postoperative pulmonary complications e) Prevents drowsiness
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• Fosters client participation in care • Facilitates reduction of postoperative pulmonary complications Correct Explanation: 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.
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The nurse is caring for a client 24 hours post surgery who is having persistent hiccups. What action is most appropriate for the nurse to take? a) Notify the physician. b) Position the client on his or her side. c) Instruct the client to take deep breaths. d) Assist the client to intake ample amounts of water.
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Notify the physician. Correct Explanation: Prolonged hiccups may cause pain or discomfort. Prolonged hiccups may also result in wound dehiscence or evisceration, inability to eat, nausea and vomiting, exhaustion, and fluid, electrolyte, and acid-base imbalances. If hiccups continue, the nurse needs to notify the physician. Deep breathing helps minimize pain and will not help in this condition. Positioning the client and ample water intake will not help stop the hiccups.
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In what phase of postanesthesia care (PACU) is the client prepared for self-care or care in the hospital or an extended care setting? a) Phase IV PACU b) Phase II PACU c) Phase III PACU d) Phase I PACU
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Phase II PACU Correct Explanation: In some hospitals and ambulatory surgical centers, postanesthesia care is divided into three phases. In the phase I PACU, used during the immediate recovery phase, intensive nursing care is provided. In the phase II PACU, the patient is prepared for self-care or care in the hospital or an extended care setting. In phase III PACU, the patient is prepared for discharge. There is no phase IV PACU.
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During the first 24 hours after surgery, how often will the nurse evaluate the client's temperature? a) Every 2 hours b) Every 15 minutes c) Every 4 hours d) Every 8 hours
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Every 4 hours Correct Explanation: The pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours. Thereafter, they are measured less frequently if they remain stable. The temperature is monitored every 4 hours for the first 24 hours.
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A recently extubated postoperative patient starts to gag and make vomiting sounds. What action should the nurse do first? a) Turn patient on her side. b) Obtain suction equipment. c) Provide emesis basin. d) Administer antiemetic.
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Turn patient on her side. Correct Explanation: The nurse should turn the patient on her side to avoid aspiration. The nurse may need to obtain suction equipment, provide an emesis basin, or administer and antiemetic but the first priority is protecting the patient's airway by preventing aspiration.
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In the immediate postoperative period, vital signs are taken at least every: a) 15 minutes. b) 60 minutes. c) 30 minutes. d) 45 minutes.
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15 minutes. Correct Explanation: The pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours.
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The nurse has medicated a postoperative patient for complaints of nausea. Which medication would the nurse document as having been given? a) Propofol (Diprivan) b) Prednisone (Deltasone) c) Ondansetron (Zofran) d) Warfarin (Coumadin)
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Ondansetron (Zofran) Correct Explanation: Odansetron (Zofran) is an antiemetic and one of the most commonly prescribed medications for nausea and vomiting. Warfarin (Coumadin) is an anticoagulant. Prednisone (Deltasone) is a corticosteroid. Propofol (Diprivan) is an anesthetic agent.
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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: a) Atelectasis b) Sepsis c) Pain d) Hypothermia
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Hypothermia Correct Explanation: Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.
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Which findings would be indicative of a nursing diagnosis of decreased cardiac output? a) urinary output > 60 ml; BP 90/60; tachypnea b) bradycardia; urinary output < 30 ml; confusion c) confusion; tachypnea; hemoglobin 14.2 gm/dL d) tachycardia; hemoglobin 10.9 gm/dL; BP 88/56
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tachycardia; hemoglobin 10.9 gm/dL; BP 88/56 Correct Explanation: Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion.
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It is important for the nurse to assist a postsurgical client to sit up and turn his or her head to one side when vomiting in order to a) help eliminate inhaled anesthetics. b) avoid aspiration. c) avoid dizziness. d) maximize comfort.
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avoid aspiration. Correct Explanation: The nurse helps the patient to sit up and turn his or her head to one side when vomiting to avoid aspiration. Sitting up and turning the head to one side when vomiting does not maximize comfort and does not help to avoid dizziness. Encouraging the patient to breathe deeply helps eliminate inhaled anesthetics.
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On the second postoperative day, nursing assessment reveals that the client has a temperature of 103°F (39.5°C). The nurse recognizes that the client is most likely exhibiting a sign of: a) Lung atelectasis b) Urinary tract infection c) Wound infection d) The normal surgical stress response
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Lung atelectasis Correct Explanation: Respiratory complications occur early in the postoperative period.
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Which of the following factors may contribute to rapid and shallow respirations in a postoperative client? Select all that apply. a) Pain b) Obesity c) Effects of analgesics and anesthesia d) Constricting dressings e) Abdominal distention
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• Pain • Obesity • Constricting dressings • Abdominal distention Correct Explanation: Often, because of the effects of analgesic and anesthetic medications, respirations are slow. Shallow and rapid respirations may be caused by pain, constricting dressings, gastric dilation, abdominal distention, or obesity.
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A PACU nurse receives a postoperative patient who received general anesthesia with a hard plastic oral airway in place. The patient has clear lung sounds, even and unlabored respirations of 16, and an oxygen saturation of 98%. The patient is minimally responsive to painful stimuli. What action by the nurse is most appropriate? a) Notify the physician of impaired neurological status. b) Obtain vital signs, including pulse oximetry, every 5 minutes. c) Continue with frequent patient assessments. d) Remove the oral airway.
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Continue with frequent patient assessments. Correct Explanation: An immediate postoperative patient may be transferred to the PACU with a hard plastic oral airway. The airway should not be removed until the patient is showing signs of gagging or choking. The neurological status is appropriate for a patient that received general anesthesia. There is no information provided that requires the patient to have vitals taken more frequently than the standard 15 minutes. The nurse should continue with frequent patient assessments.
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A nurse assesses a postoperative patient to have the protrusion of abdominal organs through the surgical incision. Which term, documented by the nurse, best describes the assessment findings? a) Dehiscence b) Evisceration c) Erythema d) Hernia
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Evisceration Correct Explanation: 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.
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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. a) Changing the client's position b) Massaging the client's legs c) Applying hot cloths to the client's face d) Putting on soothing music e) Performing guided imagery
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• Changing the client's position • Putting on soothing music • Performing guided imagery Correct Explanation: Guided imagery, music, and application of heat or cold (if prescribed) have been successful in decreasing pain. Changing the client's position, using distraction, applying cool washcloths to the face, and providing back massage may be useful in relieving general discomfort temporarily.
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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? a) Secondary b) Intermediary c) Primary d) Tertiary
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Intermediary Correct Explanation: 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.
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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? a) Hold the order until purulent drainage is noted. b) Use an antibiotic cleaning agent before obtaining the specimen. c) Obtain the wound culture specimen. d) Request the order be discontinued without obtaining the specimen.
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Obtain the wound culture specimen. Correct Explanation: 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.
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Which actions should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical patient? a) Maintain bed rest. b) Reinforce the need to perform leg exercises every hour when awake. c) Instruct the patient to prop pillow under the knees. d) Administer prophylaxis high-dose heparin.
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Reinforce the need to perform leg exercises every hour when awake. Correct Explanation: The nurse should reinforce the need to perform leg exercises every hour when awake. Maintaining bed rest increases the pooling of blood in the lower extremities, increasing the risk for deep vein thrombosis. The patient may be given low-dose heparin for prophylaxis treatment but not a high-dose heparin. The nurse should instruct the patient not to prop a pillow under the knees because the patient can constrict the blood vessels.
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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? a) Contractures b) Phlebitis c) Hypotension d) Wound dehiscence
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Wound dehiscence Correct Explanation: Risk factors for wound dehiscence include: Advanced age over 65 years; Chronic disease such as diabetes, hypertension, obesity; History of radiation or chemotherapy; Malnutrition, particularly insufficient protein and vitamin C; Hypoalbuminemia. This client is not at increased risk for hypotension; contractures, or phlebitis.
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The nurse is assessing the client for wound complications following surgery. For which clinical manifestation should the nurse assess? Select all that apply. a) Paralytic ileus b) Dehiscence c) Hematoma d) Atelecstasis e) Thrombophlebitis
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• Dehiscence • Hematoma Correct Explanation: A hematoma can form within the wound and result in delayed healing. Dehiscence is a disruption of the surgical incision. Atelecstasis, thromobophlebitis, and paralytic ileus are potential complications following surgery. Atelecstasis is a collapse of the alveoli, which interferes with gas exchange. Thromobophlebitis is the development of a blood clot, usually in the lower extremity. Paralytic ileus is an absence of intestinal peristalsis.
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When the nurse observes that the postoperative patient demonstrates a constant low level of oxygen saturation, although the patient's breathing appears normal, the nurse identifies that the patient may be suffering from which type of hypoxemia? a) Hypoxic b) Anemic c) Episodic d) Subacute
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Subacute Correct Explanation: For subacute hypoxemia supplemental oxygen may be indicated. Hypoxic hypoxemia results from inadequate breathing. Episodic hypoxemia develops suddenly, and the patient may be at risk for myocardial ischemia, cerebral dysfunction, and cardiac arrest. Anemic hypoxemia results from blood loss during surgery.
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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? a) Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. b) The client can self-administer oral pain medication as needed with patient-controlled analgesia. c) Family members can be involved in the administration of pain medications with patient-controlled analgesia. d) There are no advantages of patient-controlled analgesia over a PRN dosing schedule.
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Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. Correct Explanation: 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.
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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. a) An On-Q pump b) Listening to music c) Changing position d) An epidural infusion e) Watching television
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• Listening to music • Changing position • Watching television Correct Explanation: Nonpharmacological management of pain includes listening to music, watching television, and changing position. Pharmacological pain management strategies include epidural infusions and On-Q pumps. An epidural infusion delivers a local opioid with or without a local anesthetic agent directly into the epidural space of the spine. An On-Q pump delivers a local anesthetic agent subcutaneously to the incisional area.
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Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? a) Primary-intention healing b) First-intention healing c) Third-intention healing d) Second-intention healing
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Second-intention healing Correct Explanation: 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.
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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? a) Respiratory depressive effects b) Tolerance c) Detailed medication history d) Convalescent period
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Tolerance Correct Explanation: Postoperative ambulatory activities are essential but planned according to the older adult's tolerance, which usually is less than that of a younger person. The respiratory depressive effects should be considered when administering certain drugs for the older adults. The convalescent period usually is longer for older adults. Therefore, they may require positive reinforcement throughout the postoperative period as well as extensive discharge planning. The convalescent period of older adults and detailed medication history may not be necessary to consider when planning the postoperative ambulatory activities.
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When the nurse observes that the postoperative patient demonstrates a constant low level of oxygen saturation via the O2 saturation monitor, although the patient's breathing appears normal what action should the nurse take first? a) Notify the physician. b) Assess the patient's heart rhythm and nail beds. c) Document the findings. d) Apply oxygen.
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Assess the patient's heart rhythm and nail beds. Correct Explanation: A patient may demonstrate low oxygenation readings due to wearing certain colors of nail polish or irregular heart rate such as atrial fibrillation. These items should be assessed to ensure the accuracy of the oxygen reading. Once the reading is confirmed as accurate, then the nurse may need to apply oxygen, notify the physician, and document the findings.
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Which of the following actions should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical patient? a) Reinforce the need to perform leg exercises every hour when awake b) Massage the calves or thighs c) Maintain bed rest d) Instruct the patient to cross the legs or prop pillow under the knees
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First-intention Correct Explanation: When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Postoperatively, many of these wound are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing.
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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? a) Inserting a nasogastric (NG) tube b) Applying a sterile, moist dressing c) Monitoring vital signs d) Putting the client on nothing-by-mouth (NPO) status
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Applying a sterile, moist dressing Correct Explanation: Evisceration involves separation of all layers of the abdominal wall, resulting in protrusion of abdominal contents. The nurse's first priority should be to protect the client's abdominal contents. She should apply warm, sterile saline dressings over the protruding viscera. Next, the nurse should institute NPO status because the client will ultimately need surgery. The client is at risk for shock, so the nurse should monitor vital signs frequently after applying the sterile, moist dressing. The nurse doesn't need to make inserting an NG tube an immediate priority, especially because the physician may not order one.
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A postanesthesia care unit (PACU) nurse is caring for a patient with the following assessment data: pale, cool, moist skin; thready pulse of 122; blood pressure 78/60; urine output of 25 mL/h; temperature 99.2°F. What interventions by the nurse are appropriate? Select all that apply. a) Administer blood products per orders. b) Raise the head of the bed 30 degrees. c) Apply a warming blanket. d) Apply oxygen per orders. e) Frequently monitor neurological status. f) Maintain a patent airway.
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• Administer blood products per orders. • Apply oxygen per orders. • Frequently monitor neurological status. • Maintain a patent airway. Correct Explanation: The patient is demonstrating signs and symptoms of shock. The patient in shock may lose the ability to protect his or her airway. Frequently neurological assessment can provide information related to decrease oxygen to the brain. Administering the blood products may reverse the signs and symptoms of shock. There is an increased need for oxygen when in shock, so it is appropriate to apply oxygen. The head of the bed should not be elevated. The patient should be lying flat or in the Trendelenburg position. Applying a warming blanket when the patient is not hypothermic may cause vasodilation, which could further decrease blood pressure and perfusion to vital organs.
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A patient has undergone hernia repair surgery without complications. In the immediate postoperative period, which of the following actions by the nurse is most appropriate? a) Assessing pupillary response every 5 minutes b) Measuring urinary output every 15 minutes c) Monitor vital signs every 15 minutes d) Obtaining arterial blood gas every 5 minutes
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Monitor vital signs every 15 minutes Correct Explanation: The pulse rate, blood pressure, and respiration rate are recorded at least every 15 minutes for the first hour and every 30 minutes for the next 2 hours. Obtaining an arterial blood gas every 5 minutes is painful to the patient unless a special device is inserted to obtain arterial blood samples. Without complications, this is not indicated for the patient. Urinary output is monitored frequently but usually measured hourly. While it may be necessary to assess pupillary response during the immediate postoperative phase, it does not need to be done every 5 minutes.
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Which of the following should be incorporated into the patient teaching plan to prevent deep vein thrombosis? a) Fluid restriction b) Use of blanket rolls for elevation of the lower extremities c) Hourly leg exercises d) Prolonged dangling at the edge of the bed
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Hourly leg exercises Correct Explanation: The benefits of early ambulation and hourly leg exercises in preventing deep vein thrombosis cannot be overemphasized. It is important to avoid the use of blanket rolls, pillow rolls, or any form of elevation that constricts vessels under the knees. Prolonged dangling can be dangerous and is not recommended in susceptible patients because the pressure under the knees can impede circulation. Dehydration adds to the risk of thrombosis formation.
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A patient is postoperative day 1 from abdominal surgery. The patient 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 2430 mL. What action by the nurse is most appropriate? a) Document the findings and reassess in 24 hours. b) Discontinue the nasogastric tube suctioning. c) Assess for signs and symptoms of fluid volume deficit. d) Assess for edema.
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Assess for signs and symptoms of fluid volume deficit. Correct Explanation: The patient's 24 hour intake is 1,800 mL (75x24). The patient's 24 hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Since the output is significantly higher than the intake the patient is at risk for fluid volume deficit. The nurse should not discontinue the nasogastric suctioning without a physician's order. The findings should be documented and reassessed but the nurse needs to take more action to prevent complication. Edema is usually associated with fluid volume excess.
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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? a) Packing the wound bed with sterile saline-soaked dressing and covering with dry dressing b) Cleaning the wound with soap and water, then leaving open to air c) Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive d) Covering the well approximated wound edges with a dry dressing
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Packing the wound bed with sterile saline-soaked dressing and covering with dry dressing Correct Explanation: 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.
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A term used to describe a partial or complete separation of the wound edges is a) evisceration. b) erythema. c) dehiscence. d) hemorrhage.
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dehiscence. Correct Explanation: Evisceration is the protrusion of organs through the surgical incision. Dehiscence is the partial or complete separation of wound edges. Erythema refers to redness of the skin. Hemorrhage is excessive bleeding.
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Which of the following sets of clinical data would allow the nurse to conclude that the nursing actions taken to prevent postoperative pneumonia have been effective? a) Bowel sounds present and active; denies nausea and vomiting b) Bladder non—distended; Foley catheter draining clear, yellow urine c) Alert and oriented; peripheral pulses present and strong d) Vital signs within normal limits; absence of chills and cough
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Vital signs within normal limits; absence of chills and cough Correct Explanation: Pneumonia is characterized by chills, fever, tachypnea, tachycardia, and sometimes cough.
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A 76-year-old patient had surgery for an abdominal hernia. The PACU nurse assesses that the patient is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply. a) Assess for hypoxia. b) Administer opioid pain medication per orders. c) Apply wrist restraints. d) Ambulate the patient. e) Assess for urine output. f) Reorient the patient.
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• Assess for hypoxia. • Assess for urine output. • Reorient the patient. Correct Explanation: The nurse should provide reassurance and reorient the patient as needed. Hypoxia and urinary retention may cause acute confusion in the older adult postoperative patient, so it would be appropriate for the nurse to assess for hypoxia and urine output. Opioid pain medications may cause further confusion; consultation with the physician about the type and dosage of the pain medication should occur. Ambulating the patient may be a safety issue, especially if the patient is bleeding or hypoxic. Applying wrist restraints should only be used as a last resort.
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Which of the following would be the least important factor affecting wound healing? a) Hemorrhage b) Nutritional deficiencies c) Sufficient oxygenation d) Age of patient
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Sufficient oxygenation Correct Explanation: Oxygen deficit is a factor in wound healing. Hemorrhage. nutritional deficiencies, such as protein-calorie depletion, and the age of the patient are factors affecting wound healing. The older the patient, the less resilient are his or her tissues.
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Corticosteroids have which effect on wound healing? a) Cause hemorrhage b) Mask presence of infection c) Reduce blood supply d) May cause protein-calorie depletion
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Mask presence of infection Correct Explanation: Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. Edema may reduce blood supply. Corticosteroids do not cause hemorrhage or protein-calorie depletion.
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Which of the following mobility criteria must a postoperative client meet to be discharged to home? Select all that apply. a) Be able to self-toilet b) Get out of bed without assistance c) Ambulate the length of the client's house d) Be able to drive to the grocery e) Pass a stress test
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• Be able to self-toilet • Get out of bed without assistance • Ambulate the length of the client's house Correct Explanation: For a safe discharge to home, clients need to be able to ambulate a functional distance (eg, length of the house or apartment), get in and out of bed unassisted, and be independent with toileting.
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The nurse recognizes which of the following as clinical manifestations of shock? a) Flushed face b) Warm, dry skin c) Rapid, weak, thready pulse d) Increased urine output
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Rapid, weak, thready pulse Correct Explanation: The patient's pulse increases as the body tries to compensate for the effects of shock. Pallor is an indicator of shock. The skin is generally cool and moist in shock. Usually, a low blood pressure and concentrated urine are observed in the patient who is in shock.
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The nurse suspects the client is developing postoperative pneumonia. Which clinical manifestation would support the nurse's conclusion? Select all that apply. a) Wheezes b) Afebrile c) Tachypnea d) Chills e) Crackles
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• Tachypnea • Chills • Crackles Correct Explanation: Pneumonia is characterized by fever, chills, tachycardia, tachypnea, and crackles. Cough may or may not be present. Wheezing is not an expected finding of pneumonia.
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Which of the following clinical manifestations increase the risk for evisceration in the postoperative client? a) Valsalva maneuver b) Edema c) Hypovolemia d) Hypoxia
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Valsalva maneuver Correct Explanation: The Valsalva maneuver produces tension on abdominal wounds, which increases the risk for evisceration.
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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? a) Make the client NPO and order a stat hemoglobin and hematocrit. b) Outline the drainage with a pen and record the date and time next to the drainage. c) Take the client's vital signs and call the surgeon. d) Remove the dressing, assess the wound, and apply a new sterile dressing.
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Outline the drainage with a pen and record the date and time next to the drainage. Explanation: Areas of drainage on the dressing should be outlined with a pen, and the date and time should be recorded next to the drainage. Blood drainage from the incision is a normal expected finding in the immediate postoperative period; however, excessive amounts should be reported to the surgeon.
