Nokea
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.
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The client required reversal drugs after surgery. What nursing intervention is required when caring for a client who is treated with reversal drugs?
- A. Instruct the client to lie flat.
- B. Observe the client for an extended period.
- C. Help the client slowly move to an upright or standing position.
- D. Emphasize the dietary restriction.
Correct Answer: B
Rationale: If reversal drugs are required, the nurse must observe the client for an extended period because the reversal effects nearly always are shorter than the effects of the drugs being reversed. This may result in sedation. The client need not lie flat and may not require assistance for ambulation. There is no specific dietary restriction required when treated with reversal drugs.
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.
The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract?
- A. The client is tolerating sips of water.
- B. The client reports a small bowel movement and flatus.
- C. The client is breathing calmly.
- D. The client states being hungry.
Correct Answer: B
Rationale: A bowel movement demonstrates that the nursing outcome of the return to function of the gastrointestinal track has been met. Tolerating sips of water, breathing calmly, and reports of hunger are components of meeting the outcome of functioning.
The nurse is caring for a client during an intraoperative procedure. When assessing vital signs, which result indicates a need to alert the anesthesiologist immediately?
- A. Pulse rate of 110 beats/min
- B. Respiratory rate of 18 breaths/min
- C. Blood pressure of 104/62 mm Hg
- D. Temperature of 102.5?°F (39?°C)
Correct Answer: D
Rationale: Intraoperative hyperthermia can indicate a life-threatening condition called malignant hyperthermia. The circulating nurse closely monitors the client for signs of hyperthermia. The pulse rate, respiratory rate, and blood pressure did not indicate a significant concern.
The nurse is assigned a client scheduled for an outpatient colonoscopy in an ambulatory care setting. During which phase of perioperative care would the nurse document the admission vital signs in the recovery room?
- A. During the preoperative phase
- B. During the intraoperative phase
- C. During the transfer phase
- D. During the postoperative phase
Correct Answer: D
Rationale: The nurse realizes that documentation of vital signs in the recovery room begins the postoperative phase of perioperative care. The preoperative phase occurs until the client reaches the operating area. The intra operative phase includes the entire surgical procedure until the transfer to the recovery area. There is no transfer phase of perioperative care.