Nokea
A nurse is assessing the postoperative client on the second postoperative day. What assessment finding requires the nurse to immediately notify the health care provider?
- A. The client has an absence of bowel sounds.
- B. The client's lungs reveal rales in the bases.
- C. The client states a moderate amount of pain at the incisional site.
- D. A moderate amount of serous drainage is noted on the operative dressing.
Correct Answer: A
Rationale: 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 breathe deep. Pain is a common symptom following a surgical procedure. Serous drainage on the postoperative dressing needs to be monitored and brought to the physician's attention when assessing the client.
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The surgical unit nurse is developing a postoperative plan of care. In which client's plan of care would the nurse document interventions of deep breathing, gastrointestinal assessment, and effective regulation of temperature?
- A. A client with gastrointestinal surgery and general anesthesia
- B. A client having a knee replacement and regional anesthesia
- C. A client having lower extremity muscle repair and spinal anesthesia
- D. A client with spinal stenosis and a regional nerve blockade
Correct Answer: A
Rationale: General anesthesia acts on the central nervous system to produce a loss of sensation, reflexes, and consciousness. The anesthesiologist monitors the vital functions of breathing, circulation, and temperature. Following general anesthesia, nurses must closely monitor for effective breathing and oxygenation, temperature regulation, and adequate fluid balance. Nursing interventions for those clients with regional anesthesia, spinal anesthesia, and regional nerve blockades focus on assessing for allergic reactions, neurovascular assessments to specific body regions, and side effects of the medication.
A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?
- A. Place a dry, sterile dressing over the protruding organs.
- B. Place a pressure dressing over the opening and secure.
- C. Have the client lay quietly on back and call the physician.
- D. Moisten sterile gauze with sterile normal saline and place on the protruding organ.
Correct Answer: D
Rationale: A wound evisceration occurs when the wound completely separates, and the internal organs protrude. The first action by the nurse would be to cover the protruding organs with sterile dressings moistened with sterile normal saline. Once the client is safe, the nurse can notify the physician. The client is positioned in a manner that places the least stress on the organs. Dry or pressure dressings are not placed over the protruding organ.
The nurse is reviewing a postoperative client's chart prior to a physician's office visit. Lab reports reveal a prior WBC of 40,000/mm3 (40*10s/L), a current WBC count of 8,000/mms (8*10s/L), and a current wound culture negative, following a Staphylococcus aureus infection. Tertiary intention of wound healing is documented at the last visit. Which current assessment of wound healing is anticipated?
- A. Wound edges well approximated. No redness/swelling noted.
- B. Edges of incision well approximated with the center of incision open. Green purulent drainage noted.
- C. Wound edges sutured. Scant amount of drainage noted. No foul odor.
- D. Wound packed with 0.5-in (1.25-cm) sterile packing material; interior pink.
Correct Answer: C
Rationale: The scenario stated a previous wound infection that has resolved. Sutured wound edges are present once the wound has been cleaned of infection as noted in tertiary intention of wound healing. Well-approximated edges are healing without infection. Wound packing is noted in secondary intention. Green purulent drainage is noted with a wound infection.
The nurse is caring for a client needing emergency surgery. Which preoperative teaching can be omitted when preparing a client for surgery?
- A. Effective coughing and deep breathing
- B. Types of postoperative pain medication
- C. Post-discharge diet
- D. Knowledge of surgical procedure
Correct Answer: C
Rationale: The preoperative teaching that could be omitted due to the need to obtain emergency surgery is explaining the post-discharge diet. This is not essential information to improve client participation in the postoperative recovery. Coughing and deep breathing are essential in the immediate postoperative period. Clients are often concerned about postoperative pain so instruction on pain medication can decrease anxiety. Knowledge of the surgical procedure must be explained by a physician when signing a surgical consent.
The nurse is caring for a client during the immediate postoperative period. What signs and symptoms indicate that the client may be in shock?
- A. Weak and rapid pulse rate
- B. Warm, dry skin
- C. Pooling of secretions in the lungs
- D. Obstructed airway
Correct Answer: A
Rationale: 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.