Perioperative Care Flashcards
(67 cards)
The primary cardiovascular complications seen in the PACU include hypotension and shock, ________________________, hypertension, and arrhythmias.
hemorrhage
________________________ can result from blood loss, hypoventilation, position changes, pooling of blood in the extremities, or side effects of medications and anesthetics.
Hypotension
TRUE or FALSE
The nurse should not intervene at the patient’s first report of nausea postoperatively, but should wait for it to progress to vomiting.
False
In phase II of postanesthesia care, the patient would be prepared for transfer to an inpatient nursing unit, extended care setting, or _______________________.
discharge
TRUE or FALSE
Assessment of respiratory status in the hospitalized postoperative patient is imperative because pulmonary complications are the most frequent problem encountered by the surgical patient.
True
TRUE or FALSE
The first symptom of deep vein thrombosis may be a pain or a cramp in the calf.
True
Many hospitals use a scoring system, called the _________ score, which is used to determine the patient’s general condition and readiness for transfer from the PACU.
aldrete
TRUE or FALSE
The primary objective in the immediate postoperative period is to maintain ventilation and prevent hypoxemia and hypercapnia.
True
TRUE or FALSE
The nurse who admits the patient to the PACU reviews essential information with the anesthesiologist or CRNA and the circulating nurse.
True
A major nursing diagnosis in the postoperative period may include decreased _____________________ output related to shock or hemorrhage.
cardiac
A client who is receiving the maximum levels of pain medication for postoperative recovery asks the nurse if there are other measures that the nurse can employ to ease pain. Which of the following strategies might the nurse employ?
Select all that apply.
a. Performing guided imagery
b. Putting on soothing music
c. Changing the client’s position
d. Applying hot cloths to the client’s face
e. Massaging the client’s legs
a, b, c
Guided imagery, music, and application of heat or cold (if prescribed) have been successful in decreasing pain. Changing the client’s position, using distraction, applying cool washcloths to the face, and providing back massage may be useful in relieving general discomfort temporarily.
A nurse asks a client who had abdominal surgery 1 day ago if they have moved their bowels since surgery. The client states, “I haven’t moved my bowels, but I am passing gas.” How should the nurse intervene?
a. Apply moist heat to the client’s abdomen.
b. Encourage the client to ambulate as soon as possible after surgery.
c. Administer a tap water enema.
d. Notify the health care provider.
b. Encourage the client to ambulate as soon as possible after surgery.
Explanation:
The nurse should encourage the client to ambulate as soon as possible after surgery. Ambulating stimulates peristalsis, which helps the bowels to move. It isn’t appropriate to apply heat to a surgical wound. Moreover, heat application can’t be initiated without a health care provider’s order. A tap water enema is typically administered as a last resort after other methods fail. A health care provider’s order is needed with a tap water enema as well. Notifying the health care provider isn’t necessary at this point because the client is exhibiting bowel function by passing flatus.
A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding?
a. Hernia
b. Dehiscence
c. Erythema
d. Evisceration
d. Evisceration
Explanation:
Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.
The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action?
a. Monitor vital signs for early detection of shock.
b. Assess the incisional dressing to detect hemorrhage.
c. Position the client to maintain a patent airway.
d. Administer antiemetics to prevent nausea and vomiting.
c. Position the client to maintain a patent airway.
Explanation:
Maintaining a patent airway is the immediate priority in the PACU.
The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order?
a. chlorpromazine
b. omeprazole
c. ondansetron
d. nizatidine
c. ondansetron
Explanation:
Ondansetron (Zofran) is used to treat nausea and vomiting.
A postoperative client is being discharged home after minor surgery. The PACU nurse is reviewing discharge instructions with the client and the client’s spouse. What actions by the nurse are appropriate? Select all that apply.
a. Educate on activity limitations.
b. Discuss wound care.
c. Have the spouse review when to notify the health care provider.
d. Have the client sign the advance directive form.
e. Provide information on health promotion topics.
a, b, c, e
Explanation:
The nurse should provide education on activity limitations and wound care, and should review complications that require notification to the health care provider. The nurse should also provide information regarding health promotion topics, such as weight management and smoking cessation. The client should not make any major decisions or sign any legal forms because of the effects of anesthesia.
The nurse is caring for a postoperative client with a Hemovac. The Hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to:
a. Assess the client’s wound and apply a pressure dressing.
b. Notify the surgeon that the Hemovac is not functioning.
c. Remove the Hemovac because it is expanded.
d. Empty and measure the drainage and compress the Hemovac.
d. Empty and measure the drainage and compress the Hemovac.
Explanation:
A Hemovac needs to be recompressed periodically, because it operates with the use of gentle, constant suction. The amount of drainage is not excessive
What abnormal postoperative urinary output should the nurse report to the health care provider for a 2-hour period?
a. < 30 mL
b. Between 75 and 100 mL
c. Between 100 and 200 mL
d. >200 mL
a. < 30mL
If the client has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL per hour are reported; if the client is voiding, an output of less than 240 mL per 8-hour shift is reported.
A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention?
a. Dangle at the bedside.
b. Report early calf pain.
c. Take off the pneumatic compression devices for sleeping.
d. Rely on the IV fluids for hydration.
b. Report early calf pain
Explanation:
The client needs to report calf pain or cramping for the nurse to investigate any swelling or potential DVT. Blanket rolls or prolonged dangling should be avoided to reduce impediment of circulation behind the knee. Prevention of DVT includes early ambulation, use of antiembolism or pneumatic compression devices, and low-molecular-weight or low-dose heparin and low-dose warfarin for clients postoperatively. Adequate fluids need to be offered to avoid dehydration.
The nurse is preparing to discharge a client from the PACU using a PACU room scoring guide. With what score can the client be transferred out of the recovery room?
a. 4
b. 5
c. 6
d. 7
d. 7
Explanation:
Many hospitals use a scoring system (e.g., Aldrete score) to determine the client’s general condition and readiness for transfer from the PACU (Aldrete & Wright, 1992). Throughout the recovery period, the client’s physical signs are observed and evaluated by means of a scoring system based on a set of objective criteria. This evaluation guide allows an objective assessment of the client’s condition in the PACU. The client is assessed at regular intervals, and a total score is calculated and recorded on the assessment record. The Aldrete score is usually between 7 and 10 before discharge from the PACU.
Returning to the unit, what is priority to assess on your fresh, post-op patient? Select all that apply.
a. Position in the bed
b. Level of consciousness
c. Surgical incision and dressing
d. Airway, breathing, and oxygenation
e. Ability to ambulate down the hall
f. IV Site and patency
b, c, d
Level of consciousness
Surgical incision and dressing
Airway, breathing, and oxygenation
On the nursing unit, which patient would be priority to see first after report?
a. A patient on telemetry for atrial fibrillation
b. A chronic pain patient with 8/10 back pain
c. A patient returning from the PACU after surgery
d. A patient being discharged to home to make room for a new patient
c. A patient returning from the PACU after surgery
When should the nurse intervene when the patient shows signs and symptoms of post-op nausea?
a. Wait until the patient actually vomits
b. After giving the next dose of pain medication
c. At the patient’s first report of nausea
d. After calling to verify with anesthesia when the patient’s last antiemetic was given.
c. At the patient’s first report of nausea
True or False
Immediately post operatively, maintenance of pulmonary function and prevention of laryngospasm is the goal.
False
