A client arrives to the surgical nursing unit after surgery. The initial nursing action is to check the:
1. Patency of the airway.
If the airway is not patent, immediate measures must be taken for the survival of the client. After checking the client's airway, the nurse would then check the client's vital signs, and this w/be followed by checking the dressings, tubes and drains.
A client who had abdominal surgery complains of feeling as though something gave way in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Select all nursing interventions that nurse w/take.:
1. Notify RN
2. Document the client's complaint.
3. Instruct the client to remain quiet.
4. Prepare the client for wound closure.
A nurse checks the client's surgical incision for signs of infection. Which of the following w/be indicative of a potential infection?
2. The presence of purulent drainage.
S/Sx of a wound infection include warm, red, and tender skin around the incision. The client may have fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a wound that was contaminated before surgical exploration; it appears 3-6 days after surgery. Serous drainage is not indicative of a wound infection. A temp. of 98.8 F is not an abnormal finding in a postoperative client. The fact that a client feels cold is not indicative of an infection, although chills and fever are signs of infection.
A nurse is caring for a client who is scheduled for surgery. The client is concerned about the surgical procedure. To alleviate the client's fears and misconceptions about surgery, the nurse should:
3. Ask the cliet to discuss information known about the planned surgery.
A nurse is caring for a postoperative client who has a drain inserted into the surgical wound. Which of the following nursing actions w/be inappropriate for the care of the drain?
4. Secure the drain by curling or folding it and taping it firmly to the body.
Aseptic technique must be used when emptying the drainage container or changing the dressing to avoid contamination of the wound. Usualy drainage from the wound is pale, red, and watery, whereas active bleeding will be bright red in color. The drain s/be checked for patency to provide an exit for the fluid or blood to promote healing. The nurse needs to ensure that drainage flows freely and that there are no kinks in the drains. Curling or folding the drain prevents the flow of the drainage.
A nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which of the following is the intial action?
2. Apply sterile dressing soaked w/normal saline to the wound.
Wound dehiscence is the separation of the wound edges at the suture line. S/sx include increased drainage and appearance of underlying tissues. It usually occurs as a complication 6-8 days. The client s/be instructed to remain quiet and to avoid coughing or straining, and he or she s/be positioned to prevent further stress on the wound. Sterile dressings soaked w/sterile normal saline s/be used to cover the wound. The physician needs to be notified.
A nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the physician and anticipates that the physician will prescribe which of the following?
3. Discontinue the aspirin 48 hrs. before the scheduled surgery.
Anticoagulants alter normal clotting factors and increase the risk of hemorrhage. Aspirin has properties that can alter the clotting mechanism and s/thus be discontinued at least 48 hrs. before surgery.
A nurse is developing a plan of care for a client who is scheduled for surgery. The nurse w/include which of the following activites in the nuring care plan for the client on the day of surgery?
1. Have the client void immediately before surgery.
(The nurse w/assist client w/voiding immediately before surgery so that bladder will be empty. Oral hygiene is allowed, but client s/not swallow any water. Client usually has restriction of food and fluids for 8 hrs. before surgery rather than 24 hrs. A slight increase in blood pressure and pulse is common during preoperative period; this is generally result of anxiety.
A nurse is explaining the concept of time-out in the perioperative area. The purpose of time out is:
4. To allow the surgical team a chance to verbally verify their agreement about the client's name, surgical procedure, and the site.
The time-out occurs in the perioperative area after the client has been prepped and draped. The entire team must verbally verify their agreement regarding the client's name, the procedure to be performed, and the surgical site.
A nurse is explaining the Joint Commission's universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves:
1. The surgeon marking the area of the operative procedure.
The surgeon is responsible for verifying the operative site, and he or she must mark the operative site before the client is brought into the operating suite. The client will be asked to verify the site that requires surgery. The client may refuse to have the site marked and is asked about marking the site.
A nurse is monitoring an adult client for postoperative complications. Which of the following w/be the most indicative of a potential postoperative complication that requires further observation?
1. A uninary output of 20mL/Hour.
Urine output is maintained at a minimum of at least 30 mL/hr. for an adult. An ouptut of less than 30mL/hr. for each ot 2 consecutive hrs. s/be reported to the physician. A temp. more than 100F or less than 97F and a falling systolic blood pressure <90mm Hg are to be reported. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.
A nurse monitors a postoperatve client for signs of complications. Which of the following signs w/the nurse determine to be indicative of a potential complication?
1. Increasing restlessness noted in a client is a sign that requires continuous and lose monitoring, because it could be a potential indication of a complication such as hemorhage or shock. Neg Homan's sign is normal. + sign indicative of thrombophlebitis. Faint bowel sounds in all 4 quadrants is normal. BP 120/70, pulse of 90 relativel normal.
A nurse monitors the postoperative client frequently for the presence of secretion in the lungs, knowing that accumulated secretions can lead to:
The most common postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes a productive cough, dyspnea, and crackles. Pulmonary edema usually results from L-sided heart failure, and it can be caused by medications, fluid overload, and smoke inhalation. CO2 retention results from the inability to exhale CO2 in clients w/conditions such as COPD. Fluid imbalance can be a deficit or excess related to fluid loss or overload.
A nurse obtains vital signs on a postoperative client who just returned to nursing unit. The client's BP is 100/60 mm Hg, the pulse 90 beats/min., and respiration rate is 20 breaths/min.. On basis of these findings,which of the following nursing actions s/be performed?
2. Continue to monitor vital signs.
A slightly lower-than-normal BP and increased pulse rate are common after surgery. Warm blankets are applied to maintain the client's body temp. The level of consciousness can be determined by checking the client's response to light touch and verbal stimuli rather than by shaking the client. There is no reason to contact the RN immediately.