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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.
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The nurse is caring for a postoperative client who reports difficulty urinating. The client does not have a urinary catheter in place. Which nursing action(s) are most appropriate at this time? Select all that apply.
- A. Run water to assist in the let-down reflex.
- B. Assist to the bathroom.
- C. Place a urinary catheter.
- D. Assist the client to stand.
- E. Measure urinary output.
Correct Answer: A,B,D,E
Rationale: The nurse encourages the client to void within 8 hours of surgery to minimize the risk of a urinary tract infection. Ambulating the client to the bathroom promotes normal body positioning for urination. Running water is a common psychological strategy to cause urination. Offering to catheterize is a last option, and a prescription for catheterization must be in place for the nurse to proceed.
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 teaching a postoperative client measures to reduce the risk of postoperative complications. Which teaching point would the nurse reinforce to decrease the risk of thrombophlebitis and phlebothrombosis?
- A. Massage the calves and thigh.
- B. Prop pillows under knees.
- C. Encourage ambulation twice daily.
- D. Avoid crossing the legs.
Correct Answer: D
Rationale: Venous stasis predisposes the client to venous inflammation and clot formation in the veins (thrombophlebitis) or clot formation with minimal or absent inflammation (phlebothrombosis). To decrease the risk of venous stasis, the nurse should teach ways to promote blood circulation and limiting trauma to the site. Avoiding leg crossing promotes circulation. Massaging the calves and thighs may cause further swelling and inflammation of the vein. Propping pillows under the knees decreases circulation. Ambulation is stressed each hour while awake.
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.
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.