Week 3: Post OP/PE

Question 1

You find your post op pt lying in bed breathing rapidly and rubbing the right side of his chest. He is complaining of right-sided chest pain and appears to be restless
What do you do?

Answer 1

1. ABCs
2. Place in high fowlers. Apply O2 3-6 L/min
3. Assess VS, cardiorespiratory, neurologic status, pain
4. RACE team
5. Call physician (ECG, blood work, chest x ray)

Question 3

Name the diagnostic test which matches each description
1. Provide baseline for anticoagulation therapy.
2. Determine oxygenation status.
3. The physician will determine whether to increase or decrease the O2.
4. Determines fluid status in lungs. Rule out atelectasis, pneumonia, collapsed lung, and pneumothorax.
5. Determines rate, rhythm, and ST-T wave changes indicating ischemia

Answer 3

1. Blood coagulation studies (aPTT, PTT, INR)
2. ABG on RA
3. continuous pulse oximetry
4. Chest x ray
5. ECG

Question 4

Why would a physician order ABGs on RA instead of with O2 therapy?

Answer 4

The physician wants to evaluate basic pulmonary status.
This will help determine the need for spiral computed tomography (CT) scan of the lungs or other testing for PE.

Question 5

Interpret these ABGs:
pH 7.55
PaC02 24 mm Hg
HCO3 24 mEq/L
Pao2 56 mm Hg
Sao2 86% (room air)

Answer 5

pH 7.55 – high = alkalosis
PaC02 24 mm Hg – low = opposite to PH therefore is a primary respiratory disorder
HCO3 24 mEq/L – normal
Pao2 56 mm Hg – low - ungs unable to oxygenate blood causing low oxygen tension in arterial blood
Sao2 86% (room air) – low – hypoxia

Question 6

What is a therapeutic aPTT for a pt on heparin therapy?
What is a critically high value?

Answer 6

1.5-2.5x normal aPTT or 65-105 seconds
> 140 seconds - hold heparin and notify MD, monitor for signs of bleeding and disseminated intravascular coagulation

Question 7

The physician is considering administering an antidote to the heparin. Which generic drug is 
considered an antidote to heparin therapy?
a. atropine
b. Vitamin K
c. Protamine sulfate
d. potassium chloride

Answer 7

c. Protamine sulfate is the antidote to heparin overdose; (Vit K is the antidote to warfarin overdose).

Question 7

What is a normal aPTT value?

Answer 7

30-40 seconds

Question 7

When switching from heparin to warfarin, why does the pt need to continue heparin fro several days?

Answer 7

It takes at least 3 days for warfarin to reach therapeutic levels. The parental (heparin) and oral (warfarin) anticoagulant therapy should overlap for a minimum of 5 days with aPTT, PT and INR rates to monitor both heparin and warfarin effects until INR is >2

Question 8

1.A 67-year-old male patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression?

1. Increased respiratory rate
2. Decreased oxygen saturation
3. Increased carbon dioxide pressure
4. Frequent premature ventricular contractions (PVCs)

Answer 8

Increased carbon dioxide pressure

Transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a sensitive indicator of respiratory depression. Increased CO2 pressures would indicate respiratory depression. Clinical manifestations of inadequate oxygenation include increased respiratory rate, dysrhythmias (e.g., premature ventricular contractions), and decreased oxygen saturation.

Question 9

The nurse is caring for a 54-year-old unconscious female patient who has just been admitted to the postanesthesia care unit after abdominal hysterectomy. How should the nurse position the patient?

1. Left lateral position with head supported on a pillow
2. Prone position with a pillow supporting the abdomen
3. Supine position with head of bed elevated 30 degrees
4. Semi-Fowler’s position with the head turned to the right

Answer 9

1. Left lateral position with head supported on a pillow

The unconscious patient should be placed in the lateral “recovery” position to keep the airway open and reduce the risk of aspiration. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated to maximize expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.

Question 9

Pt is being discharged on Rivaroxaban (Xalrelto), which of these statements will be included in their teaching? (Select all that apply)
a. “Take the Xarelto at the same time every day.”
b. “There are no dietary restrictions while on this drug.”
c. “Watch for bleeding from your gums, nose, and bowels.”
d. You will need to have blood work done on a regular basis while on this drug.”
e. “It’s a good idea to wear a medical alert bracelet or necklace while on this drug.”

Answer 9

A,B,C,E

Question 9

3.Which patient would be at highest risk for hypothermia after surgery?

1. A 42-year-old patient who had a laparoscopic appendectomy
2. A 38-year-old patient who had a lumpectomy for breast cancer
3. A 20-year-old patient with an open reduction of a fractured radius
4. A 75-year-old patient with repair of a femoral neck fracture after a fall

Answer 9

4. A 75-year-old patient with repair of a femoral neck fracture after a fall

Patients at highest risk for hypothermia are those who are older, debilitated, or intoxicated. Also, long surgical procedures and prolonged anesthetic administration place the patient at increased risk for hypothermia.

Question 10

4.The nurse is providing discharge teaching to a 51-year-old female patient who has had a laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the patient, indicates an understanding of the discharge instructions?

1. “I will have someone stay with me for 24 hours in case I feel dizzy.”
2. “I should wait for the pain to be severe before taking the medication.”
3. “Because I did not have general anesthesia, I will be able to drive home.”
4. “It is expected after this surgery to have a temperature up to 102.4o F.”

Answer 10

“I will have someone stay with me for 24 hours in case I feel dizzy.”

The nurse must assess understanding of discharge instructions and the ability of the patient and caregiver to provide for home care needs. The patient must be accompanied by a responsible adult caregiver. The patient may not drive after receiving anesthetics or sedatives. The patient should understand how to manage pain, and pain medication should be taken before the pain becomes severe. The patient should understand symptoms to be reported, such as a fever.

Question 11

Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately postoperative?

1. Supine
2. Lateral
3. Semi-Fowler’s
4. High-Fowler’s

Answer 11

2. Lateral

Question 11

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse’s initial action be upon the patient’s arrival?

1. Assess the patient’s pain.
2. Assess the patient’s vital signs.
3. Check the rate of the IV infusion.
4. Check the physician’s postoperative orders.

Answer 11

2. Assess the patient’s vital signs.

The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient’s vital signs. The other actions can then take place in rapid sequence.

Question 12

When assessing a patient’s surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first?

1. Recheck in 1 hour for increased drainage.
2. Notify the surgeon of a potential hemorrhage.
3. Assess the patient’s blood pressure and heart rate.
4. Remove the dressing and assess the surgical incision.

Answer 12

3. Assess the patient’s blood pressure and heart rate.

The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

Question 13

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes?

1. Administering adequate analgesics to promote relief or control of pain
2. Asking the patient to demonstrate the postoperative exercises every 1 hour
3. Giving the patient positive feedback when the activities are performed correctly
4. Warning the patient about possible complications if the activities are not performed

Answer 13

1.

Question 14

Bronchial obstruction by retained secretions has contributed to a postoperative patient’s recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing?

1. Atelectasis
2. Bronchospasm
3. Hypoventilation
4. Pulmonary embolism

Answer 14

1. Atelectasis

The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.

Question 15

The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient?

1. Blood administration
2. Restoring circulating volume
3. An ECG to check circulatory status
4. Return to surgery to check for internal bleeding

Answer 15

2. Restoring circulating volume

The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, or there is a past history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient’s level of consciousness changes or the abdomen becomes firm and distended.

Question 16

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)?

1. Vital signs baseline or stable
2. Minimal nausea and vomiting
3. Wants to go to the bathroom at home
4. Responsible adult taking patient home
5. Comfortable after IV opioid 15 minutes ago

Answer 16

1. Vital signs baseline or stable
2. Minimal nausea and vomiting
3. Responsible adult taking patient home

Ambulatory surgery discharge criteria includes meeting Phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria includes a responsible adult driving patient, no IV opioid drugs for last 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.

Question 17

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?
a. Assess the clients lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs.

Answer 17

B ~ This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.

Question 18

A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate?
a. Encourage the client to walk 5 minutes each hour.
b. Refer the client to smoking cessation classes.
c. Teach the client about factor V Leiden testing.
d. Tell the client that sometimes no cause for disease is found.

Answer 18

C ~ Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder should be referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature.

Question 19

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best?
a. Breathing so rapidly interferes with oxygenation.
b. Maybe the client has respiratory distress syndrome.
c. The blood clot interferes with perfusion in the lungs.
d. The client needs immediate intubation and mechanical ventilation.

Answer 19

C ~ A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

Question 20

A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
a. Decrease the heparin rate.
b. Increase the heparin rate.
c. No change to the heparin rate.
d. Stop heparin; start warfarin (Coumadin).

Answer 20

B ~ For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working. A normal PTT is 25 to 35 seconds, so this clients PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.

Question 21

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?
a. Hemoglobin: 14.2 g/dL
b. Platelet count: 82,000/L
c. Red blood cell count: 4.8/mm3
d. White blood cell count: 8.7/mm3

Answer 21

B ~ This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.
Normal platelets = 150,000-450,000/L

Question 22

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
a. Assess for other manifestations of hypoxia.
b. Change the sensor on the pulse oximeter.
c. Obtain a new oximeter from central supply.
d. Tell the client to take slow, deep breaths.

Answer 22

A ~ Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.

Question 23

A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?
a. Ensure the client has adequate sedation.
b. Find another provider to intubate.
c. Interrupt the procedure to give oxygen.
d. Monitor the clients oxygen saturation.

Answer 23

C ~ Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation during the procedure and monitor the clients oxygen saturation, but these do not take priority. Finding another provider is not appropriate at this time.

Question 24

An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority?
a. Determine if the tube is kinked.
b. Ensure all connections are patent.
c. Listen to the clients lung sounds.
d. Suction the endotracheal tube.

Answer 24

C ~ When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.

Question 25

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?
a. Hamburger and French fries
b. Large chefs salad and muffin
c. No selection; spouse brings pizza
d. Tuna salad sandwich and chips

Answer 25

B ~ Warfarin works by inhibiting the synthesis of vitamin Kdependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. The chefs salad most likely has too many leafy green vegetables, which contain high amounts of vitamin K. The other selections, while not particularly healthy, will not interfere with the medications mechanism of action.

Question 26

A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best?
a. It is chronic hypoxemia that accompanies restrictive airway disease.
b. It is hypoxemia from lung damage due to mechanical ventilation.
c. It is hypoxemia that continues even after the client is weaned from oxygen.
d. It is hypoxemia that persists even with 100% oxygen administration.

Answer 26

D ~ Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.

Question 27

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)
a. Client who had a reaction to contrast dye yesterday
b. Client with a new spinal cord injury on a rotating bed
c. Middle-aged man with an exacerbation of asthma
d. Older client who is 1-day post hip replacement surgery
e. Young obese client with a fractured femur

Answer 27

B, D, E
Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.

Question 28

Which of the following pathophysiological mechanisms that occur in the lung parenchyma allows pneumonia to develop?
1. Atelecstasis
2. Bronchiectasis
3. Effusion
D. Inflammation

Answer 28

Correct Answer: D. Inflammation

The most common feature of all types of pneumonia is an inflammatory pulmonary response to the offending organism or agent. The resident macrophages serve to protect the lung from foreign pathogens. Ironically, the inflammatory reaction triggered by these very macrophages is what is responsible for the histopathological and clinical findings seen in pneumonia.

Question 29

Which of the following respiratory disorders is most common in the first 24 to 48 hours after surgery?

A. Atelectasis
B. Bronchitis
C. Pneumonia
D. Pneumothorax

Answer 29

Correct Answer: A. Atelectasis

Atelectasis develops when there’s interference with the normal negative pressure that promotes lung expansion. Clients in the postoperative phase often splint their breathing because of pain and positioning, which causes hypoxia. Postoperative atelectasis typically occurs within 72 hours of general anesthesia and is a well-known postoperative complication. The decrease in pressure allows for passive movement of air into the lungs. This process is inhibited by general anesthesia due to diaphragm relaxation. Patients lying supine have cephalad displacement of the diaphragm further decreasing the transmural pressure gradient and increasing the likelihood of atelectasis. It’s uncommon for any of the other respiratory disorders to develop.