transition to med surg unit

Question 1

airway

Answer 1

• Monitor oxygen saturation using a pulse oximeter.
• Assist with coughing and deep breathing at least every 1 hr while awake, and provide a pillow or folded blanket so the client can splint as necessary for abdominal incision.
• Contraindications to coughing include cosmetic, eye, or intracranial surgeries.
  (ICP below 20)

Question 2

incentive spirometer use

Answer 2

• Assist with the use of an incentive spirometer at least every 1 to 2 hr while awake to encourage expansion of the lungs and prevent atelectasis.

Question 3

positioning

Answer 3

• Reposition every 2 hr, and ambulate early and regularly
• Do not put pillows under knees or elevate the knee gatch on the bed (decreases venous return).
• Encourage early ambulation with adequate rest periods to prevent cardiovascular disorders:
• Deep-vein thrombosis
• Pulmonary complications

Question 4

A nurse is planning care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse include in the plan of care?
Select all that apply.

1.Encourage use of the incentive spirometer every 2 hr.
2.Instruct the client to splint the incision when coughing and deep breathing.
3.Reposition the client every 2 hr.
4.Administer antibiotic therapy.
5. Assist with early ambulation

Answer 4

1-3, 5

Question 5

pain managment

Answer 5

• If prescribed, provide continuous pain relief through the use of a patient-controlled analgesia pump. (morphine and dilauid)
• Epidural and intrathecal infusions are also used postoperatively.
• A preventative approach using around-the-clock scheduling is more effective than PRN medication delivery during the first 24 to 48 hr postoperatively.
• Assess pain level frequently, using a standardized pain scale.

Question 6

manifestations of pain

Answer 6

• Increased pulse, respirations, or blood pressure
• Restlessness
• Wincing or moaning during movement

Question 7

adverse effects of opioids

Answer 7

Respiratory depression
Nausea
Encourage the patient to change positions slowly
Urinary retention
Constipation.

Question 8

ambulation

Answer 8

• Provide analgesia 30 min before ambulation or painful procedures.
• Assess for effectiveness of pain medication after administration.

Question 9

kidney function

Answer 9

• Output should equal intake.
• Monitor and report urinary output less than 30 mL/hr.
• Palpate bladder following voiding to assess for distention.
• Consider using a bladder scan to assess suspected retention of urine.

Question 10

bowl and gi function

Answer 10

• Maintain NPO status until return of gag reflex (risk of aspiration) and peristalsis (risk of paralytic ileus).
• Irrigate NG suction tubes with saline as needed to maintain patency.
• Do not move NG tubes in clients who are postoperative following gastric surgery as prescribed (risk to incision).
• Monitor bowel sounds in all four quadrants as well as ability to pass flatus.
• Advance diet as prescribed and tolerated (clear liquids to regular).

Question 11

preventing thromboembolism

Answer 11

• Apply pneumatic compression devices and/or antiembolism stockings.
• Reposition every 2 hr, and ambulate early and regularly.
• Administer prescribed anticoagulants or antiplatelet medications.
• Monitor extremities for calf pain, warmth, erythema, and edema.

Question 12

TPA

Answer 12

dissolve clot

Question 13

heparin

Answer 13

prevent clot from getting better

Question 14

s/s of thromboembolism

Answer 14

calf red, warm, swollen

Question 15

late s/s thromboembolism

Answer 15

short breath

Question 16

Monitor the incision site. Expected findings include

Answer 16

Pink wound edges
Slight swelling under sutures/staples
Slight crusting of drainage

Question 17

Report any evidence of infection:

Answer 17

Redness
Excessive tenderness
Purulent drainage

Question 18

drainage lifeline

Answer 18

sanguineous to serosanguineous to serous

Question 19

airway obstruction nuring considerations

Answer 19

• Monitor for choking; noisy, irregular respirations; decreased oxygen saturation values; and cyanosis. Intervene accordingly.
• Implement a head-tilt/chin-lift maneuver to pull the tongue forward and open the airway.
• Keep emergency equipment at the bedside in the PACU (resuscitation bag, suction equipment, airways).
• Notify the anesthesiologist, elevate head of bed if not contraindicated, provide humidified oxygen, and plan for reintubation with endotracheal tube.

Question 20

hypoxia nursing considerations

Answer 20

• Monitor oxygenation status, and administer oxygen as prescribed.
• Encourage coughing and deep breathing to prevent atelectasis.
• Position client with head of bed elevated, and turn every 2 hr to facilitate chest expansion.

Question 21

hypovolemic shock nursing considerations

Answer 21

• Monitor for decreased blood pressure and urinary output, increased heart and respiratory rates, narrowing of pulse pressure, and slow capillary refill.
• Administer oxygen.
• Place the client in a supine position with legs elevated.
• Administer IV fluids and vasopressors as prescribed.

Question 22

paralytic illeus

Answer 22

Can occur due to the absence of GI peristaltic activity caused by abdominal surgery or other physical trauma.

Question 23

paralytic illeus nursing considerations

Answer 23

• Monitor bowel sounds.
• Encourage ambulation.
• Advance the diet as tolerated when bowel sounds or flatus are present.
• The client can have an NG tube inserted to empty stomach contents.
• Administer prokinetic agents, such as metoclopramide, as prescribed.

Question 24

A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following hysterectomy.
Which of the following actions should the nurse perform first?

1. Assess bowel sounds.
2. Administer antiemetic medication.
3. Restart prescribed IV fluids.
4. Insert a prescribed nasogastric tube.

Answer 24

a

Question 25

Wound Dehiscence

Answer 25

• Caused by spontaneous opening of the incisional wound (dehiscence)
• Can progress to the protrusion of the internal organs through the incision (evisceration)

Question 26

risk factors for wound dehiscence

Answer 26

Obesity
Coughing
Moving without splinting
Poor nutritional status
Diabetes mellitus
Infection
Hematoma
Steroid use

Question 27

If wound dehiscence or evisceration occurs:

Answer 27

• Call for help
• Stay with the patient
• Cover the wound with a sterile towel or dressing that is moistened with sterile saline
• Do not attempt to reinsert organs
• Place in a low-Fowler’s position with hips and knees bent
• Monitor for shock
• Notify the provider immediately

Question 28

Deep Vein Thrombosis caused by

Answer 28

• Dehydration
• Stress response that leads to hypercoagulability of the blood
• Immobility
• Obesity
• Trauma
• History of thrombosis
• Hormones
• Use of indwelling venous catheter

Question 29

nursing considerations for deep vein thrombosis

Answer 29

Prophylactic measures include administration of:
- Low-molecular-weight heparin
- Low-dose heparin, or low-dose warfarin
- Antiembolism stockings
- Pneumatic compression devices
- Range-of motion exercises
- Early ambulation.

Question 30

what to advoid for deep vein thrombosis

Answer 30

• Avoid any form of pressure behind the knee with a pillow or blanket, which can cause constriction of blood vessels and decreased venous return.
• Avoid dangling the client’s legs for long periods of time.
• Provide adequate hydration by administering IV fluids or encouraging increased oral fluid intake