Nokea
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.
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A physically fit 86-year-old is scheduled for right knee replacement. Which factor places the client at increased risk for complications during or after surgery?
- A. Age
- B. Type of surgery
- C. Ability to metabolize medication
- D. Nutritional status
Correct Answer: A
Rationale: General risk factors are related to age, nutritional status; use of alcohol, tobacco, and other substances; and physical condition. In this scenario, the risk to the client is age; the type of surgery, client's ability to metabolize medication, and client's nutritional status are not risk factors for complication in the scenario described.
The nurse has received shift report on a postoperative surgical client. Which medication prescription would indicate that the medication was being administered prophylactically?
- A. A 5% dextrose in 0.5 NSS to infuse at 100 mL/hr
- B. Percocet two tablets every 4 hours as needed for pain
- C. Humulin NPH 12 units at 0800
- D. Cefazolin 1 g IV every 6 hours for 24 hours
Correct Answer: D
Rationale: Cefazolin, an antibiotic, is commonly administered prophylactically to prevent postoperative infections. A 5% dextrose in 0.5 NSS is used for fluid maintenance, Percocet is for pain management, and Humulin NPH is for diabetes management, none of which are primarily prophylactic in this context.
Which nursing statement would best ease a client's anxiety before an emergency operative procedure?
- A. You will be just fine; the operating room nurses will take good care of you.
- B. It is best to take deep breaths and relax before the procedure.
- C. Let me explain to you what will happen next.
- D. We will keep your family informed of your progress.
Correct Answer: C
Rationale: Many clients feel fearful of knowing little about the operative procedure and what to expect. This fear causes anxiety and can lead to a poorer response to surgery and surgical complications. Explanations of what the client is to expect can help to decrease anxiety. False reassurance of being fine does not diminish anxiety. Deep breathing and relaxation techniques can be helpful to the client but addressing the source of the anxiety is more beneficial. Keeping the family informed helps the family and is not client focused.
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 PACU nurse is about to administer pain medication to an older adult client who is recovering from surgery. What does this client's age put them at increased risk for? Select all that apply.
- A. Acute confusion
- B. Respiratory depression
- C. Disorientation
- D. Infection
- E. Greater requirement for pain medication
Correct Answer: A,B,C,D
Rationale: The older adult client requiring pain medication postoperatively is at greater risk for confusion, disorientation, respiratory depression, and infection. The older adult client does not have a greater requirement for pain medication, because even standard doses may cause complications that would not occur in younger clients.