Podcast
Questions and Answers
A nurse is receiving a post-op patient from the PACU. What is the priority assessment?
A nurse is receiving a post-op patient from the PACU. What is the priority assessment?
- Reviewing the discharge orders
- Administering prescribed pain medications
- Assessing the surgical site
- Checking the patient's vital signs (correct)
A patient in the post-op unit has a temperature of 38.1°C (100.6°F) two hours after surgery. What is the best nursing action?
A patient in the post-op unit has a temperature of 38.1°C (100.6°F) two hours after surgery. What is the best nursing action?
- Administer acetaminophen as prescribed
- Apply cooling blankets
- Notify the physician immediately
- Encourage deep breathing and incentive spirometry (correct)
The nurse is about to call the physician regarding a post-op patient's deteriorating status. What key information should be included first?
The nurse is about to call the physician regarding a post-op patient's deteriorating status. What key information should be included first?
- A structured SBAR report (correct)
- The patient's insurance information
- The last meal the patient ate
- The patient's full medical history
A post-op patient develops a urinary tract infection (UTI). Which factor most likely contributed?
A post-op patient develops a urinary tract infection (UTI). Which factor most likely contributed?
A nurse is assessing a patient's surgical incision and notices redness and warmth around the site. What should be the first action?
A nurse is assessing a patient's surgical incision and notices redness and warmth around the site. What should be the first action?
The nurse is preparing to discharge a post-op patient. Which criteria must be met before discharge? (Select all that apply)
The nurse is preparing to discharge a post-op patient. Which criteria must be met before discharge? (Select all that apply)
A nurse is monitoring a post-op patient for potential complications. Which findings would require immediate intervention? (Select all that apply)
A nurse is monitoring a post-op patient for potential complications. Which findings would require immediate intervention? (Select all that apply)
Which interventions help reduce the risk of post-op lung complications? (Select all that apply)
Which interventions help reduce the risk of post-op lung complications? (Select all that apply)
The nurse receives a patient from the PACU. Which findings indicate a need for immediate action? (Select all that apply)
The nurse receives a patient from the PACU. Which findings indicate a need for immediate action? (Select all that apply)
The nurse is educating a post-op patient about wound care. Which statements indicate understanding? (Select all that apply)
The nurse is educating a post-op patient about wound care. Which statements indicate understanding? (Select all that apply)
The nurse is caring for a post-op patient who reports severe pain despite receiving prescribed pain medications. What should the nurse do first?
The nurse is caring for a post-op patient who reports severe pain despite receiving prescribed pain medications. What should the nurse do first?
A nurse is monitoring a post-op patient with a PCA pump. Which assessment finding requires immediate intervention?
A nurse is monitoring a post-op patient with a PCA pump. Which assessment finding requires immediate intervention?
A post-op patient is at risk for deep vein thrombosis (DVT). Which intervention is most effective for prevention?
A post-op patient is at risk for deep vein thrombosis (DVT). Which intervention is most effective for prevention?
A nurse is caring for a patient experiencing post-op nausea and vomiting (PONV). What is the priority nursing intervention?
A nurse is caring for a patient experiencing post-op nausea and vomiting (PONV). What is the priority nursing intervention?
A post-op patient reports feeling lightheaded when moving from lying to standing. The nurse suspects orthostatic hypotension. What is the best action?
A post-op patient reports feeling lightheaded when moving from lying to standing. The nurse suspects orthostatic hypotension. What is the best action?
The nurse is teaching a post-op patient about proper deep breathing and coughing techniques. Which instruction is most appropriate?
The nurse is teaching a post-op patient about proper deep breathing and coughing techniques. Which instruction is most appropriate?
A nurse assesses a patient with a post-op ileus. Which finding is expected?
A nurse assesses a patient with a post-op ileus. Which finding is expected?
A post-op patient is prescribed an opioid for pain management. Which additional order should the nurse anticipate?
A post-op patient is prescribed an opioid for pain management. Which additional order should the nurse anticipate?
A nurse notices a patient's wound dressing is saturated with bright red blood 2 hours after surgery. What is the priority action?
A nurse notices a patient's wound dressing is saturated with bright red blood 2 hours after surgery. What is the priority action?
A nurse is teaching a post-op patient about preventing atelectasis. Which statement by the patient indicates correct understanding?
A nurse is teaching a post-op patient about preventing atelectasis. Which statement by the patient indicates correct understanding?
Which interventions help prevent post-op infection? (Select all that apply)
Which interventions help prevent post-op infection? (Select all that apply)
The nurse is assessing a patient's readiness for discharge. Which findings indicate readiness? (Select all that apply)
The nurse is assessing a patient's readiness for discharge. Which findings indicate readiness? (Select all that apply)
Which signs suggest post-op hemorrhage? (Select all that apply)
Which signs suggest post-op hemorrhage? (Select all that apply)
A patient is post-op day 2 and at risk for pneumonia. What interventions should the nurse implement? (Select all that apply)
A patient is post-op day 2 and at risk for pneumonia. What interventions should the nurse implement? (Select all that apply)
A nurse is educating a patient about preventing venous thromboembolism (VTE). Which actions should the patient take? (Select all that apply)
A nurse is educating a patient about preventing venous thromboembolism (VTE). Which actions should the patient take? (Select all that apply)
Flashcards
Post-Op Priority Assessment?
Post-Op Priority Assessment?
Vital signs indicate stability. Ensure the patient is stable before other assessments.
Post-Op Fever Nursing Action?
Post-Op Fever Nursing Action?
Encourage deep breathing and incentive spirometry to prevent atelectasis.
Calling Physician: What Information First?
Calling Physician: What Information First?
SBAR (Situation, Background, Assessment, Recommendation) ensures effective communication.
Post-Op UTI Risk Factor?
Post-Op UTI Risk Factor?
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Redness/Warmth at Incision: First Action?
Redness/Warmth at Incision: First Action?
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Preventing Post-Op Infection?
Preventing Post-Op Infection?
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DVT Prevention- Effective Intervention?
DVT Prevention- Effective Intervention?
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Saturated Dressing With Blood, Priority?
Saturated Dressing With Blood, Priority?
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Preventing Atelectasis Post-Op?
Preventing Atelectasis Post-Op?
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Post-op Nausea Priority Intervention?
Post-op Nausea Priority Intervention?
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Study Notes
- Post-operative care focuses on assessments, preventing complications, and ensuring patient readiness for discharge
Initial Post-Op Assessment
- Priority is checking the patient's vital signs to ensure hemodynamic stability after receiving a post-op patient from PACU
Managing Post-Op Fever
- Encourage deep breathing and incentive spirometry for a post-op patient with a temperature of 38.1°C (100.6°F) two hours after surgery
- Pulmonary exercises prevent atelectasis, a common cause of post-op fever
- Slightly elevated temperatures are expected post-op due to stress
SBAR Communication
- When calling a physician about a deteriorating post-op patient, use a structured SBAR (Situation, Background, Assessment, Recommendation) report to ensure effective communication
Preventing UTIs
- Prolonged use of an indwelling catheter is a significant risk factor for UTIs due to bacterial colonization
Assessing Surgical Incisions
- If redness and warmth are noted around a surgical incision, assess the patient for systemic infection (fever, increased WBC count)
Discharge Criteria
- A patient must have stable vital signs, tolerance of oral fluids, and ability to void independently before post-op discharge
Identifying Post-Op Complications
- Key findings that require immediate intervention include blood pressure of 88/52 mmHg, sudden shortness of breath and surgical wound evisceration
- A urine output of 35 mL/hr is within normal limits
Preventing Lung Complications
- Interventions to reduce the risk of post-op lung complications include encouraging early ambulation, using an incentive spirometer, and providing adequate pain control
Immediate Action Needed
- Findings that indicate a need for immediate action when receiving a patient from PACU include an oxygen saturation of 88%, no urine output for 3 hours, and restlessness/confusion
Wound Care Education
- Patient understanding of post-op wound care is indicated by stating to wash hands before touching incision, notify the doctor if they see pus or have a fever, and understanding that they should take antibiotics even if they feel fine
- Stitches should only be removed by a provider
Addressing Post-Op Pain
- If a post-op patient reports severe pain despite receiving prescribed pain medications, first assess the location, quality, and intensity of the pain
PCA Pump Monitoring
- A respiratory rate of 8 breaths per minute in a post-op patient using a PCA pump requires immediate intervention due to the risk of opioid-induced respiratory depression
DVT Prevention
- Administering subcutaneous heparin as prescribed is most effective for preventing deep vein thrombosis (DVT) in post-op patients, as heparin prevents clot formation
Managing Post-Op Nausea and Vomiting (PONV)
- Positioning the patient in a side-lying position is the priority nursing intervention for a patient experiencing post-op nausea and vomiting (PONV) in order to prevent aspiration
Orthostatic Hypotension
- Lightheadedness reported by a post-op patient when moving from lying to standing indicates suspected orthostatic hypotension
- The best action is to have the patient sit on the edge of the bed before standing
Deep Breathing and Coughing Techniques
- Proper instruction for deep breathing and coughing includes holding a pillow against the incision while coughing to provide support, reduce pain, and encourage effective lung expansion
Post-Op Ileus Assessment
- Absent bowel sounds are an expected finding in a patient with a post-op ileus, which occurs when bowel motility is temporarily impaired
Opioid Prescription Considerations
- A stool softener or laxative should be anticipated for a post-op patient prescribed an opioid for pain management due to the common side effect of constipation
Wound Dressing Assessment
- Apply direct pressure and notify the provider if a nurse notices a patient's wound dressing is saturated with bright red blood 2 hours after surgery, which may indicate hemorrhage
Preventing Atelectasis
- Patient understanding is indicated by agreement to use the incentive spirometer every hour while awake, as it promotes lung expansion
Preventing Post-Op Infection
- Interventions that help prevent post-op infection include hand hygiene, using sterile technique for dressing changes, and administering prophylactic antibiotics
Assessing Readiness for Discharge
- Readiness for discharge is determined by confirming that pain is well-controlled, oral intake is tolerated, and vital signs are stable
Recognizing Post-Op Hemorrhage
- Signs suggesting post-op hemorrhage include a rapid heart rate, hypotension, and pale, cool skin
Pneumonia Prevention
- Deep breathing exercises, encouraging fluid intake, and assisting with ambulation should be implemented for a patient who is post-op day 2 and at risk for pneumonia
Preventing Venous Thromboembolism (VTE)
- Actions a patient should take to prevent venous thromboembolism (VTE) include leg exercises, using compression stockings if prescribed, and early ambulation
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