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The nurse just received a postoperative patient from the PACU to the medicalsurgical unit. The patient is an 84-year-old woman who had surgery for a left hip replacement. Which of the following concerns should the nurse prioritize for this patient in the first few hours on the unit?
- A. Beginning early ambulation
- B. Maintaining clean dressings on the surgical site
- C. Close monitoring of neurologic status
- D. Resumption of normal oral intake
Correct Answer: C
Rationale: In the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding are primary concerns. A patient who has had total hip replacement does not ambulate during the first few hours on the unit. Dressings are assessed, but may have some drainage on them. Oral intake will take more time to resume.
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The nurse is caring for a patient after abdominal surgery in the PACU. The patients blood pressure has increased and the patient is restless. The patients oxygen saturation is 97%. What cause for this change in status should the nurse first suspect?
- A. The patient is hypothermic
- B. The patient is in shock
- C. The patient is in pain
- D. The patient is hypoxic
Correct Answer: C
Rationale: An increase in blood pressure and restlessness are symptoms of pain. The patients oxygen saturation is 97%, so hypothermia, hypoxia, and shock are not likely causes of the patients restlessness.
A postoperative patient rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be the nurses first action?
- A. Leave and promptly notify the physician
- B. Quickly attempt to determine the cause of hemorrhage
- C. Begin resuscitation
- D. Put the patient in the Trendelenberg position
Correct Answer: B
Rationale: Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures. Resuscitation is not necessarily required and the nurse must not leave the patient. The Trendelenberg position would be contraindicated.
The nurse is caring for a patient on the medicalsurgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?
- A. Presence of an indwelling urinary catheter
- B. Rectal temperature of 99.5 F (37.5 C)
- C. Red, warm, tender incision
- D. White blood cell (WBC) count of 8,000 /mL
Correct Answer: C
Rationale: Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a patient to infection, but by itself does not indicate infection. An oral temperature of 99.5 F may not signal infection in a postoperative patient because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000 /mL.
The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurses first response?
- A. Return the patient to his previous position and call the physician
- B. Place saline-soaked sterile dressings on the wound
- C. Assess the patients blood pressure and pulse
- D. Pull the dehiscence closed using gloved hands
Correct Answer: B
Rationale: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the patients vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.
The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what means?
- A. Late intention
- B. Second intention
- C. Third intention
- D. First intention
Correct Answer: C
Rationale: Third-intention healing or secondary suture is used for deep wounds that either had not been sutured early or that had the suture break down and are resutured later, which is what has happened in this case. Secondary suture brings the two opposing granulation surfaces back together; however, this usually results in a deeper and wider scar. These wounds are also packed postoperatively with moist gauze and covered with a dry, sterile dressing. Late intention is a term that sounds plausible, but is not used in practice. Second intention is when the wound is left open and the wound is filled with granular tissue. First intention wounds are wounds made aseptically with a minimum of tissue destruction.