Nokea
The home health nurse is caring for a postoperative patient who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the patients postoperative day 2. During the visit, the nurse will assess for wound infection. For most patients, what is the earliest postoperative day that a wound infection becomes evident?
- A. Day 9
- B. Day 7
- C. Day 5
- D. Day 3
Correct Answer: C
Rationale: Wound infection may not be evident until at least postoperative day 5. This makes the other options incorrect.
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The nursing instructor is talking with a group of medicalsurgical students about deep vein thrombosis (DVT). A student asks what factors contribute to the formation of a DVT. What would be the instructors best response?
- A. There is a genetic link in the formation of deep vein thrombi
- B. Hypervolemia is often present in patients who go on to develop deep vein thrombi
- C. No known factors contribute to the formation of deep vein thrombi; they just occur
- D. Dehydration is a contributory factor to the formation of deep vein thrombi
Correct Answer: D
Rationale: The stress response that is initiated by surgery inhibits the fibrinolytic system, resulting in blood hypercoagulability. Dehydration, low cardiac output, blood pooling in the extremities, and bedrest add to the risk of thrombosis formation. Hypervolemia is not a risk factor and there are no known genetic factors.
The PACU nurse is caring for a male patient who had a hernia repair. The patients blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery?
- A. Dysrhythmias, blood loss, and hyperthermia
- B. Electrolyte imbalances and neurologic changes
- C. A parasympathetic reaction and low blood volumes
- D. Pain, hypoxia, or bladder distention
Correct Answer: D
Rationale: Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Dysrhythmias, blood loss, hyperthermia, electrolyte imbalances, and neurologic changes are not common postoperative reasons for hypertension. A parasympathetic reaction and low blood volumes would cause hypotension.
The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion?
- A. Describe the appearance of the dressing in the electronic health record
- B. Photograph the patients abdomen for later comparison using a smartphone
- C. Trace the outline of the drainage on the dressing for future comparison
- D. Remove and weigh the dressing, reapply it, and then repeat in 8 hours
Correct Answer: C
Rationale: Spots of drainage on a dressing are outlined with a pen, and the date and time of the outline are recorded on the dressing so that increased drainage can be easily seen. A dressing is never removed and then reapplied. Photographs normally require informed consent, so they would not be used for this purpose. Documentation is necessary, but does not confirm or rule out an increase in drainage.
The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication?
- A. Sepsis
- B. Infection
- C. Pulmonary embolism
- D. Hematoma
Correct Answer: C
Rationale: Patients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of an external pneumatic compression stocking significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection or sepsis would not be affected by an external pneumatic compression stocking. A hematoma or bruise would not be affected by the external pneumatic compression stocking unless the stockings were placed directly over the hematoma.
The perioperative nurse is providing care for a patient who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The patient is reluctant to ambulate, citing the need to recover in bed. For what complication is the patient most at risk?
- A. Atelectasis
- B. Anemia
- C. Dehydration
- D. Peripheral edema
Correct Answer: A
Rationale: Atelectasis occurs when the postoperative patient fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia occurs rarely and usually in situations where the patient loses a significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the patient is most at risk for atelectasis.