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PrepU Chapter 19: Postop Care - Exam 1
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PrepU Chapter 19: Postop Care - Exam 1 PrepU Chapter 19: Postop Care - Exam 1 PrepU Chapter 19: Postop Care - Exam 1
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PrepU Chapter 19: Postop Care (Exam1)
A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours
ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since
surgery. The nurse reports that according to documentation, no drainage has been recorded. When
the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains
the absence of drainage?
-The client has been lying on his side for 2 hours with the drain positioned upward.
-The client has a nasogastric (NG) tube in place that drained 400 ml.
-The Hemovac drain isn't compressed; instead it's fully expanded.
-There is a moderate amount of dry drainage on the outside of the dressing. - -The Hemovac drain
isn't compressed; instead it's fully expanded.
The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand,
suction is no longer present, causing the drain to malfunction. The client who requires major
abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube
drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is
normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the
dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which
nursing intervention will manage and minimize hemorrhage and shock?
-Elevating the head of the bed
-Reinforcing dressings or applying pressure if bleeding is frank
-Rubbing the back
-Encouraging the client to breathe deeply - -Reinforcing dressings or applying pressure if bleeding is
frank
The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep
the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply and
rubbing the back will not help manage and minimize hemorrhage and shock.
A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8.
Which of the following is the most likely outcome for this client?
,-The client can be discharged from the PACU.
-The client must remain in the PACU.
-The client should be transferred to an intensive care area.
-The client must be put on immediate life support. - -The client can be discharged from the PACU.
The Aldrete score is usually 8 to 10 before discharge from the PACU. Clients with a score of less than
7 must remain in the PACU until their condition improves or they are transferred to an intensive care
area, depending on their preoperative baseline score.
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?
-First intention
-Second intention
-Third intention
-Fourth intention - -First intention
When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal.
Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing
(granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been
well approximated. Third-intention healing (secondary suture) is used for deep wounds that either
have not been sutured early or break down and are resutured later, thus bringing together two
apposing granulation surfaces. Fourth-intention is not a type of wound healing.
A nurse prepares to suction a client's tracheostomy tube. Place the procedure steps in correct order.
-Position the client in Fowlers position.
-Insert suction catheter into the lumen of the tube.
-Apply intermittent suction while withdrawing the catheter.
-Don sterile gloves.
-Lubricate the sterile suction catheter. - -Position the client in Fowlers position.
-Don sterile gloves.
-Lubricate the sterile suction catheter.
-Insert suction catheter into the lumen of the tube.
-Apply intermittent suction while withdrawing the catheter.
Suctioning a tracheostomy is a sterile procedure. The nurse should first position the client in Fowler's
position then don sterile gloves. Next, the nurse will lubricate the sterile suction catheter and insert
,the catheter into the lumen of the tube. Finally, the nurse will apply intermittent suction while
withdrawing the catheter.
Which of the following factors may contribute to rapid and shallow respirations in a postoperative
client? Select all that apply.
-Pain
-Constricting dressings
-Abdominal distention
-Obesity
-Effects of analgesics and anesthesia - -Pain
-Constricting dressings
-Abdominal distention
-Obesity
Often, because of the effects of analgesic and anesthetic medications, respirations are slow. Shallow
and rapid respirations may be caused by pain, constricting dressings, gastric dilation, abdominal
distention, or obesity.
Which type of healing occurs when granulation tissue is not visible and scar formation is minimal?
-First intention
-Second intention
-Third intention
-Fourth intention - -First intention
When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal.
Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing
(granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been
well approximated. Third-intention healing (secondary suture) is used for deep wounds that either
have not been sutured early or break down and are resutured later, thus bringing together two
apposing granulation surfaces. Fourth-intention is not a type of wound healing.
The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which
nursing intervention will manage and minimize hemorrhage and shock?
, -Elevating the head of the bed
-Reinforcing the dressing or applying pressure if bleeding is frank
-Monitoring vital signs every 15 minutes
-Encouraging the client to breathe deeply - -Reinforcing the dressing or applying pressure if bleeding
is frank
The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep
the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply will not
help manage and minimize hemorrhage and shock. Monitoring vital signs every 15 minutes is an
appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to
determine the extent and progression of the problem.
A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic
amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing
intervention?
-Assessing WBC count, temperature, and wound appearance
-Obtaining dietary consultation for improved wound healing
-Educating the client on safe bed-to-chair transfer procedures
-Administering pain medications within 1 hour of the client's request - -Assessing WBC count,
temperature, and wound appearance
The client has an increased risk for infection related to the surgical wound, which is classified as
dirty. Assessing the WBC count, temperature, and wound appearance allows the nurse to intervene
at the earliest sign of infection. The client will have special nutritional needs during wound healing
and needs education on safe transfer procedures, but the need to monitor for infection is a higher
priority. The client should receive pain medication as soon as possible after asking, but the latest
literature suggests that pain medication should be given on a schedule versus "as needed."
A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right
with my wound." The nurse asses the upper half of the wound edges, noticing that they are no
longer approximated and the lower half remains well approximated. The nurse would document
that following a sneeze, the wound
-dehisced.
-eviscerated.
-pustulated.
-hemorrhaged. - -dehisced.
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