# Chapter 16 Postoperative Nursing Management

The recovery room nurse is admitting a patient from the OR following the patient's successful
splenectomy. What is the first assessment that the nurse should perform on this newly
A) Heart rate and rhythm
B) Skin integrity
C) Core body temperature
D) Airway patency
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Ans: D
Feedback:
The primary objective in the immediate postoperative period is to maintain ventilation
and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and
ventilation is reduced. This assessment is followed by cardiovascular status and the condition
of the surgical site. The core temperature would be assessed after the airway, cardiovascular
status, and wound (skin integrity).
An adult patient is in the recovery room following a nephrectomy performed for the treatment
of renal cell carcinoma. The patient's vital signs and level of consciousness stabilized, but the
patient then complains of severe nausea and begins to retch. What should the nurse do next?
A) Administer a dose of IV analgesic.
B) Apply a cool cloth to the patient's forehead.
C) Offer the patient a small amount of ice chips.
D) Turn the patient completely to one
side
Ans: D
Feedback:
Turning the patient completely to one side allows collected fluid to escape from the side of the
mouth if the patient vomits. After turning the patient to the side, the nurse can offer a cool cloth to the patient's forehead. Ice chips can increase feelings of nausea. An
analgesic is not administered for nausea and vomiting
The perioperative nurse is preparing to discharge a female patient home from day
surgery performed under general anesthetic. What instruction should the nurse give the
patient prior to the patient leaving the hospital?
A) The patient should not drive herself home.
B) The patient should take an OTC sleeping pill for 2 nights.
C) The patient should attempt to eat a large meal at home to aid wound healing.
D) The patient should remain in bed for the first 48 hours postoperative.
Ans: A
Feedback:
Although recovery time varies, depending on the type and extent of surgery and the
patient's overall condition, instructions usually advise limited activity for 24 to 48 hours.
Complete bedrest is contraindicated in most cases, however. During this time, the patient
should not drive a vehicle and should eat only as tolerated. The nurse does not normally make
OTC recommendations for hypnotics
The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy.
The nurse is getting him up for his first walk postoperatively. To decrease the potential
for orthostatic hypotension and consequent falls, what should the nurse have the patient do?
A)Sit in a chair for 10 minutes prior to ambulating.
B) Drink plenty of fluids to increase circulating blood volume.
C) Stand upright for 2 to 3 minutes prior to ambulating.
D) Perform range-of-motion
exercises for each joint
Ans: C
Feedback:
Older adults are at an increased risk for orthostatic hypotension secondary to age- related
changes in vascular tone. The patient should sit up and then stand for 2 to 3 minutes before
ambulating to alleviate orthostatic hypotension. The nurse should assess the patient's ability to mobilize safely, but full assessment of range of motion in all joints is not normally
necessary. Sitting in a chair and increasing fluid intake are insufficient to prevent orthostatic
hypotension and consequent falls.
The perioperative nurse is providing care for a patient who is recovering on the
postsurgical unit following a transurethral prostate resection (TUPR). The patient is reluctant
to ambulate, citing the need to recover in bed. For what complication is the patient most at
risk?
A) Atelectasis
B) Anemia
C) Dehydration
D) Peripheral edema
Ans: A
Feedback:
Atelectasis occurs when the postoperative patient fails to move, cough, and breathe deeply.
With good nursing care, this is an avoidable complication, but reduced mobility greatly
increases the risk. Anemia occurs rarely and usually in situations where the patient loses a
significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively
may result in dehydration and peripheral edema, but the patient is most at risk for atelectasis
The nurse is caring for a patient on the medicalñsurgical 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
Ans: C
Feedback:
Redness, warmth, and tenderness in the incision area should lead the nurse to suspect 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 preparing to change a patient's abdominal dressing. The nurse recognizes the first
step is to provide the patient with information regarding the procedure. Which of the following
explanations should the nurse provide to the patient?
A) ìThe dressing change is often painful, and we will be giving you pain medication
prior to the procedure so you do not have to worry.î
B) ìDuring the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want
to.î
C) ìThe dressing change should not be painful, but you can never be sure, and infection is always a concern.î
D) ìThe best time for doing a dressing change is during lunch so we are not interrupted. I will provide privacy, and it should not be painful.î
Ans: B
Feedback:
When having dressings changed, the patient needs to be informed that the dressing change is a simple procedure with little discomfort; privacy will be provided; and the patient is free to look at the incision or even assist in the dressing change itself. If the patient decides to look at
the incision, assurance is given that the incision will shrink as it heals and that the redness will
likely fade. Dressing changes should not be painful,
but giving pain medication prior to the procedure is always a good preventive measure.
Telling the patient that the dressing change ìshould not be painful, but you can never be sure, and infection is always a concernî does not offer the patient any real information or options
and serves only to create fear. The best time for dressing changes is when it
is most convenient for the patient; nutrition is important so interrupting lunch is
probably a poor choice.
A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output
recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse
do?
A) Irrigate the Foley with 30 mL normal saline.
B) Notify the physician and continue to monitor the hourly urine output closely.
C) Decrease the IV fluid rate and massage the patient's abdomen.
D) Have the patient sit
in high-Fowler's position.
The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following
abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external
pneumatic compression stocking. The nurse should explain that refusing to wear external
pneumatic compression stockings increases his risk of what postsurgical complication?
A) Sepsis
B) Infection
C) Pulmonary embolism
D) Hematoma
Ans: C
Feedback:
Patients who have surgery that limits mobility are at an increased risk for pulmonary
embolism secondary to deep vein thrombosis. The use of an external pneumatic compression
stocking significantly reduces the risk by increasing venous return to the heart and limiting
blood stasis. The risk of infection or sepsis would not be affected by an external pneumatic
compression stocking. A hematoma or bruise would not be affected by the external pneumatic
compression stocking unless the stockings were placed directly over the hematoma
The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of
68 beats per minute. After 30 minutes, the patient's blood pressure is 94/47 mm Hg, and the
pulse is 110. The nurse documents that the patient's skin is cold, moist, and pale. Of what is
the patient showing signs?
A) Hypothermia
B) Hypovolemic shock
C) Neurogenic shock
D) Malignant hyperthermia
Ans: B
Feedback:
The patient is exhibiting symptoms of hypovolemic shock; therefore, the nurse should notify
the patient's physician and anticipate orders for fluid and/or blood product replacement.
Neurogenic shock does not normally result in tachycardia and malignant hyperthermia would
not present at this stage in the operative experience. Hypothermia does not cause
hypotension and tachycardia