Chapter 16 Care of Postoperative Patients PDF

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Chapter16:CareofPostoperativePatients MULTIPLECHOICE 1.Aclienthasarrivedinthepostoperativeunit.Whatactionbythecirculatingnursetakespriority? a.Assessingfluidandbloodoutput b.Checkingthesurgicaldressings c.Ensuringtheclientiswarm d.Participatinginhand-offreport ANS:D Hand-offsareacriticaltimeinclientcare,andpoorcommunicationduringthistimecanleadtoseriouserrors. Thepostoperativenurseandcirculatingnurseparticipateinhand-offreportasthepriority.Assessingfluid lossesanddressingscanbedonetogetheraspartofthereport.Ensuringtheclientiswarmisalowerpriority. DIF:Applying/ApplicationREF:271 KEY:Postoperativenursing|communication|hand-offcommunication|SBAR MSC:IntegratedProcess:CommunicationandDocumentation NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 2.Thepostanesthesiacareunit(PACU)chargenursenotesvitalsignsonfourpostoperativeclients.Which clientshouldthenurseassessfirst? a.Clientwithabloodpressureof100/50mmHg b.Clientwithapulseof118beats/min c.Clientwitharespiratoryrateof6breaths/min d.Clientwithatemperatureof96F(35.6C) ANS:C Therespiratoryrateisthemostcriticalvitalsignforanyclientwhohasundergonegeneralanesthesiaor moderatesedation,orhasreceivedopioidanalgesia.Thisrespiratoryrateistoolowandindicatesrespiratory depression.Thenurseshouldassessthisclientfirst.Abloodpressureof100/50mmHgisslightlylowand maybewithinthatclientsbaseline.Apulseof118beats/minisslightlyfast,whichcouldbeduetoseveral causes,includingpainandanxiety.Atemperatureof96Fisslightlylowandtheclientneedstobewarmed. Butnoneoftheseothervitalsignstakepriorityovertherespiratoryrate. DIF:Applying/ApplicationREF:272 KEY:Postoperativenursing|nursingassessment|sedation|respiratorysystem MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 3.Apostoperativenurseiscaringforaclientwhoseoxygensaturationdroppedfrom98%to95%.Whataction bythenurseismostappropriate? a.Assessotherindicatorsofoxygenation. b.CalltheRapidResponseTeam. c.Notifytheanesthesiaprovider. d.Preparetointubatetheclient. ANS:A Ifapostoperativeclientsoxygensaturation(SaO2)dropsbelow95%(ortheclientsbaseline),thenurseshould notifytheanesthesiaprovider.IftheSaO2dropsby10%ormore,thenurseshouldcalltheRapidResponse Team.Sincethisisapproximatelya3%drop,thenurseshouldfurtherassesstheclient.Intubation(iftheclient isnotintubatedalready)isnotwarranted. DIF:Applying/ApplicationREF:273 KEY:Postoperativenursing|nursingassessment|respiratoryassessment|oxygensaturation MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:PhysiologicalIntegrity:ReductionofRiskPotential 4.Tenhoursaftersurgery,apostoperativeclientreportsthattheantiembolismstockingsandsequential

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compressiondevicesitchandaretoohot.Theclientasksthenursetoremovethem.Whatresponsebythe nurseisbest? a.Letmecallthesurgeontoseeifyoureallyneedthem. b.No,youhavetousethosefor24hoursaftersurgery. c.OK,wecanremovethemsinceyouarestablenow. d.Topreventbloodclotsyouneedthemafewmorehours. ANS:D AccordingtotheSurgicalCareImprovementProject(SCIP),anyprophylacticmeasurestoprevent thromboemboliceventsduringsurgeryarecontinuedfor24hoursafterward.Thenurseshouldexplainthisto theclient.Callingthesurgeonisnotwarranted.Simplytellingtheclientheorshehastowearthehoseand compressiondevicesdoesnoteducatetheclient.Thenurseshouldnotremovethedevices. DIF:Understanding/ComprehensionREF:274 KEY:Postoperativenursing|SurgicalCareImprovementProject(SCIP)|venousthromboembolismprevention thromboembolicevents|coremeasures|qualityimprovement MSC:IntegratedProcess:Teaching/Learning NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 5.Aclienthadasurgicalprocedurewithspinalanesthesia.Thenurseraisestheheadoftheclientsbed.The clientsbloodpressurechangesfrom122/78mmHgto102/50mmHg.Whatactionbythenurseisbest? a.CalltheRapidResponseTeam. b.IncreasetheIVfluidrate. c.Lowertheheadofthebed. d.Nothing;thisisexpected. ANS:C Aclientwhohadepiduralorspinalanesthesiamaybecomehypotensivewhentheheadofthebedisraised.If thisoccurs,thenurseshouldlowertheheadofthebedtoitsoriginalposition.TheRapidResponseTeamisno needed,norisanincreaseinIVrate. DIF:Applying/ApplicationREF:275 KEY:Postoperativenursing|neurologicsystem MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation 6.Apostoperativeclientvomited.Aftercleaningandcomfortingtheclient,whichactionbythenurseismost important? a.Allowtheclienttorest. b.Auscultatelungsounds. c.Documenttheepisode. d.Encouragetheclienttoeatdrytoast. ANS:B Vomitingaftersurgeryhasseveralcomplications,includingaspiration.Thenurseshouldlistentotheclients lungsounds.Theclientshouldbeallowedtorestafteranassessment.Documentingisimportant,butthenurse needstobeabletodocumentfully,includinganassessment.Theclientshouldnoteatuntilnauseahas subsided. DIF:Applying/ApplicationREF:276 KEY:Postoperativenursing|nauseaandvomiting|respiratoryassessment|nursingassessmentMSC:Integrated Process:NursingProcess:Assessment NOT:ClientNeedsCategory:PhysiologicalIntegrity:ReductionofRiskPotential 7.Apostoperativeclienthasjustbeenadmittedtothepostanesthesiacareunit(PACU).Whatassessmentby thePACUnursetakespriority? a.Airway b.Bleeding c.Breathing

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d.Cardiacrhythm ANS:A Assessingtheairwayalwaystakespriority,followedbybreathingandcirculation.Bleedingispartofthe circulationassessment,asiscardiacrhythm. DIF:Applying/ApplicationREF:280 KEY:Postoperativenursing|nursingassessment|respiratoryassessment|respiratorysystem|postanesthesia careunit(PACU)|airway MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 8.Apostoperativeclienthasrespiratorydepressionafterreceivingmidazolam(Versed)forsedation.Which IV-pushmedicationanddosedoesthenursepreparetoadminister? a.Flumazenil(Romazicon)0.2to1mg b.Flumazenil(Romazicon)2to10mg c.Naloxone(Narcan)0.4to2mg d.Naloxone(Narcan)4to20mg ANS:A Flumazenilisabenzodiazepineantagonistandwouldbethecorrectdrugtouseinthissituation.Thecorrect doseis0.2to1mg.Naloxoneisanopioidantagonist. DIF:Remembering/KnowledgeREF:280 KEY:Postoperativenursing|nursingintervention|benzodiazepineantagonist|criticalrescueMSC:Integrated Process:NursingProcess:Implementation NOT:ClientNeedsCategory:PhysiologicalIntegrity:PharmacologicalandParenteralTherapies 9.Anurseiscaringforapostoperativeclientwhoreportsdiscomfort,butdeniesseriouspainanddoesnot wantmedication.Whatactionbythenurseisbesttopromotecomfort? a.Assesstheclientspainona0-to-10scale. b.Assisttheclientintoapositionofcomfort. c.Havetheclientsitupinarecliner. d.Telltheclientwhenpainmedicationisdue. ANS:B Severalnonpharmacologiccomfortmeasurescanhelppostoperativeclientswiththeirpain,including distraction,music,massage,guidedimagery,andpositioning.Thenurseshouldhelpthisclientintoaposition ofcomfortconsideringthesurgicalprocedureandpositionofanytubesordrains.Assessingtheclientspainis importantbutdoesnotimprovecomfort.Theclientmaybemoreuncomfortableinarecliner.Lettingtheclient knowwhenpainmedicationcanbegivennextisimportantbutdoesnotimprovecomfort. DIF:Applying/ApplicationREF:283 KEY:Postoperativenursing|pain|nonpharmacologicpainmanagement MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:PhysiologicalIntegrity:BasicCareandComfort 10.Anurseispreparingaclientfordischargeaftersurgery.Theclientneedstochangealargedressingand manageadrainathome.Whatinstructionbythenurseismostimportant? a.Besureyoukeepallyourpostoperativeappointments. b.Callyoursurgeonifyouhaveanyquestionsathome. c.Eatadiethighinprotein,iron,zinc,andvitaminC. d.Washyourhandsbeforetouchingthedrainordressing. ANS:D Alloptionsareappropriatefortheclientbeingdischargedaftersurgery.However,forthisclientwhois changingadressingandmanagingadrain,infectioncontrolisthepriority.Thenurseshouldinstructtheclient towashhandsoften,includingbeforeandaftertouchingthedressingordrain.

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DIF:Applying/ApplicationREF:286 KEY:Postoperativenursing|dischargeplanning/teaching|clienteducation|infectioncontrol|handhygiene MSC:IntegratedProcess:Teaching/Learning NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:SafetyandInfectionControl 11.Anolderadulthasbeentransferredtothepostoperativeinpatientunitaftersurgery.Thefamilyis concernedthattheclientisnotwakingupquicklyandstatesSheneedstogetbacktoheroldself!What responsebythenurseisbest? a.Everyonecomesoutofsurgerydifferently. b.Letsjustgivehersomemoretime,okay? c.Shemayhavehadastrokeduringsurgery. d.Sometimesolderpeopletakelongertowakeup. ANS:D Duetoage-relatedchanges,itmaytakelongerforanolderadulttometabolizeanestheticagentsandpain medications,makingitappearthattheyaretakingtoolongtowakeupandreturntotheirnormalbaseline cognitivestatus.Thenurseshouldeducatethefamilyonthispossibility.Whileeveryonedoesreactdifferently thisdoesnotgivethefamilyanyobjectiveinformation.SayingLetsjustgivehermoretime,okay?sounds patronizingandagaindoesnotprovideinformation.Whileanintraoperativestrokeisapossibility,thenurse shouldconcentrateonthemorecommonoccurrenceofolderclientstakinglongertofullyarouseandawake. DIF:Understanding/ComprehensionREF:275 KEY:Postoperativenursing|olderadult|sedation|neurologicsystem MSC:IntegratedProcess:CommunicationandDocumentation NOT:ClientNeedsCategory:HealthPromotionandMaintenance 12.Anurseanswersacalllightonthepostoperativenursingunit.Theclientstatestherewasasuddengushof bloodfromtheincision,andthenurseseesabloodspotonthesheet.Whatactionshouldthenursetakefirst? a.Assesstheclientsbloodpressure. b.Performhandhygieneandapplygloves. c.Reinforcethedressingwithacleanone. d.Removethedressingtoassessthewound. ANS:B Priortoassessingortreatingthedrainagefromthewound,thenurseperformshandhygieneanddonsglovesto protectboththeclientandnursefrominfection. DIF:Applying/ApplicationREF:282 KEY:Postoperativenursing|StandardPrecautions|infectioncontrol MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:SafetyandInfectionControl 13.Aclientonthepostoperativenursingunithasabloodpressureof156/98mmHg,pulse140beats/min,and respirationsof24breaths/min.Theclientdeniespain,hasnormalhemoglobin,hematocrit,andoxygen saturation,andshowsnosignsofinfection.Whatshouldthenurseassessnext? a.Cognitivestatus b.Familystress c.Nutritionstatus d.Psychosocialstatus ANS:D Afterensuringtheclientsphysiologicstatusisstable,thesemanifestationsshouldleadthenursetoassessthe clientspsychosocialstatus.Anxietyespeciallycanbedemonstratedwithelevationsinvitalsigns.Cognitive andnutritionstatusarenotrelated.Familystressisacomponentofpsychosocialstatus. DIF:Remembering/KnowledgeREF:279 KEY:Postoperativenursing|support|psychosocialresponse|anxiety MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:PsychosocialIntegrity

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14.Aregisterednurse(RN)iswatchinganursingstudentchangeadressingandperformcarearoundaPenrose drain.WhatactionbythestudentwarrantsinterventionbytheRN? a.Cleaningaroundthedrainperagencyprotocol b.Placinganewsterilegauzeunderthedrain c.Securingthedrainssafetypintothesheets d.Usingsteriletechniquetoemptythedrain ANS:C Thesafetypinthatpreventsthedrainfromslippingbackintotheclientsbodyshouldbepinnedtotheclients gown,notthebedding.Pinningittothesheetswillcauseittopulloutwhentheclientturns.Theotheractions areappropriate. DIF:Applying/ApplicationREF:282 KEY:Postoperativenursing|drains|infectioncontrol MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:SafetyandInfectionControl MULTIPLERESPONSE 1.Anurseorientingtothepostoperativearealearnswhichprinciplesaboutthepostoperativeperiod?(Select allthatapply.) a.Allphasesrequiretheclienttobeinthehospital. b.PhaseIcaremaylastforseveraldaysinsomeclients. c.PhaseIrequiresintensivecareunitmonitoring. d.PhaseIIendswhentheclientisstableandawake. e.VitalsignsmaybetakenonlyonceadayinphaseIII. ANS:B,D,E Therearethreephasesofpostoperativecare.PhaseIisthemostintense,withclientscomingrightfrom surgeryuntiltheyarecompletelyawakeandhemodynamicallystable.Thismaytakehoursordaysandcan occurintheintensivecareunitorthepostoperativecareunit.PhaseIIendswhentheclientisatapresurgical levelofconsciousnessandbaselineoxygensaturation,andvitalsignsarestable.PhaseIIIinvolvesthe extendedcareenvironmentandmaycontinueathomeorinanextendedcarefacilityifneeded. DIF:Remembering/KnowledgeREF:270 KEY:Postoperativenursing|nursingassessment|surgicalprocedures MSC:IntegratedProcess:Teaching/Learning NOT:ClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation 2.Apostanesthesiacareunit(PACU)nurseisassessingapostoperativeclientwithanasogastric(NG)tube. Whatlaboratoryvalueswouldwarrantinterventionbythenurse?(Selectallthatapply.) a.Bloodglucose:120mg/dL b.Hemoglobin:7.8mg/dL c.pH:7.68 d.Potassium:2.9mEq/L e.Sodium:142mEq/L ANS:B,C,D Fluidandelectrolytebalanceareassessedcarefullyinthepostoperativeclientbecausemanyimbalancescan occur.Thelowhemoglobinmaybefrombloodlossinsurgery.ThehigherpHlevelindicatesalkalosis, possiblyfromlossesthroughtheNGtube.Thepotassiumisverylow.Thebloodglucoseiswithinnormal limitsforapostsurgicalclientwhohasbeenfasting.Thesodiumlevelisnormal. DIF:Applying/ApplicationREF:276 KEY:Postoperativenursing|nasogastrictube|fluidandelectrolytebalance|nursingassessment|laboratory values MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:PhysiologicalIntegrity:ReductionofRiskPotential

TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

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3.Anurseisadmittinganolderclientforsurgerytotheinpatientsurgicalunit.Theclientrelatesapriorhistory ofacuteconfusionafterapreviousoperation.Whatinterventionsdoesthenurseincludeontheclientsplanof caretominimizethepotentialforthisoccurring?(Selectallthatapply.) a.Allowfamilyandfriendstovisitastheclientdesires. b.Asktheclientaboutcopingtechniquesfrequentlyused. c.Instructthenursingassistanttoensuretheclientisbathed. d.Placetheclientinaroomsecludedattheendofthehall. e.Providetheclientwithuninterruptedperiodsofsleep. ANS:A,B,C,E Olderclientsmayhavedifficultyadjustingtothestressofthehospitalenvironmentandillnessorsurgery. Techniquesthatarehelpfulincludeallowingliberalvisitation,assistingtheclienttousesuccessfulcoping techniques,andkeepingtheclientbathedandgroomed.Sleepdeprivationcancontributetoconfusion,sothe nurseensurestheclientreceivesadequatesleep.Secludingtheclientattheendofthehallmayleadtosensory deprivationandloneliness. DIF:Remembering/KnowledgeREF:281 KEY:Postoperativenursing|coping|psychosocialresponse|olderadult MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:HealthPromotionandMaintenance 4.Apostoperativeclientisbeingdischargedwithaprescriptionforoxycodonehydrochloridewith acetaminophen(Percocet).Whatinstructionsdoesthenursegivetheclient?(Selectallthatapply.) a.Checkallover-the-countermedicationsforacetaminophen. b.Donottakemorepillseachdaythanyouareprescribed. c.Eatadietthatishighinfiberanddrinklotsofwater. d.Ifthisgivesyoudiarrhea,loperamide(Imodium)canhelp. e.Youshouldntdrivewhileyouaretakingthismedication. ANS:A,B,C,E Percocetisacommonopioidanalgesicthatcontainsacetaminophen.Theclientshouldbetaughttocheckall over-the-countermedicationsforacetaminophenandtonottakemorethantheprescribedamountofPercocet, asthemaximumdailydoseofacetaminophenis3000mg.Percocet,likeallopioidanalgesics,cancause constipation,andtheclientcanminimizethisbyeatingahigh-fiberdietanddrinkingplentyofwater.Since Percocetcancausedrowsiness,theclienttakingitshouldnotdriveoroperatemachinery.Themedicationis morelikelytocauseconstipationthandiarrhea. DIF:Applying/ApplicationREF:283 KEY:Postoperativenursing|dischargeplanning/teaching|opioidanalgesics|acetaminophen|constipation MSC:IntegratedProcess:Teaching/Learning NOT:ClientNeedsCategory:PhysiologicalIntegrity:PharmacologicalandParenteralTherapies 5.Aclientisexperiencingpainafterlegsurgerybutcannotyethavemorepainmedication.Whatcomfort interventionscanthenurseprovide?(Selectallthatapply.) a.Applystimulationtothecontralateralleg. b.Assesstheclientswillingnesstotrymeditation. c.Elevatetheclientsoperativelegandapplyice. d.Reducethenoiselevelintheclientsenvironment. e.TurntheTVonloudlytodistracttheclient. ANS:A,B,C,D Therearemanynonpharmacologiccomfortmeasuresforpain,includingapplyingstimulationtotheopposite leg,providingopportunitiesformeditation,elevationoftheleg,applyingice,andreducingnoxiousstimuliin theenvironment.Participatingindiversionalactivitiesisanotherapproach,butsimplyturningtheTVon loudlydoesnotprovideagooddiversion. DIF:Remembering/KnowledgeREF:285 KEY:Postoperativenursing|pain|nonpharmacologicpainmanagement|nursingintervention|physical modalities|ice

TestBank-Medical-SurgicalNursing:ConceptsforInterprofessionalCollaborativeCare9e

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MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:PhysiologicalIntegrity:BasicCareandComfort 6.Anurseonthepostoperativenursingunitprovidescaretoreducetheincidenceofsurgicalwoundinfection. Whatactionsarebesttoachievethisgoal?(Selectallthatapply.) a.Administeringantibioticsfor72...