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Questions and Answers
The nurse is assessing a postoperative patient. Which vital sign change is expected within the first 48 hours due to a normal stress response?
The nurse is assessing a postoperative patient. Which vital sign change is expected within the first 48 hours due to a normal stress response?
- Increased temperature (correct)
- Decreased heart rate
- Decreased respiratory rate
- Decreased blood pressure
What is the primary reason for monitoring urine output in a postoperative patient?
What is the primary reason for monitoring urine output in a postoperative patient?
- To assess for electrolyte imbalance
- To ensure the kidneys are perfusing adequately (correct)
- To detect fluid volume overload
- To monitor for surgical site infection
A postoperative patient in the PACU has a respiratory rate of 8 breaths per minute. What is the nurse's first action?
A postoperative patient in the PACU has a respiratory rate of 8 breaths per minute. What is the nurse's first action?
- Administer naloxone
- Increase IV fluids
- Stimulate the patient to wake up (correct)
- Call the provider
The nurse is explaining to a patient why early ambulation is encouraged after surgery. What is the primary reason for this intervention?
The nurse is explaining to a patient why early ambulation is encouraged after surgery. What is the primary reason for this intervention?
A patient in the PACU complains of nausea and vomiting. Which intervention should the nurse implement first?
A patient in the PACU complains of nausea and vomiting. Which intervention should the nurse implement first?
The nurse is caring for a postoperative patient who is confused and trying to remove their IV. What is the priority nursing intervention?
The nurse is caring for a postoperative patient who is confused and trying to remove their IV. What is the priority nursing intervention?
A patient who had abdominal surgery is reporting severe pain at the incision site despite receiving pain medication 30 minutes ago. The nurse notes the dressing is saturated with blood. What should the nurse do first?
A patient who had abdominal surgery is reporting severe pain at the incision site despite receiving pain medication 30 minutes ago. The nurse notes the dressing is saturated with blood. What should the nurse do first?
A nurse is reviewing SBAR communication before calling the provider about a patient's postoperative fever. Which statement represents the "B" (Background) in SBAR?
A nurse is reviewing SBAR communication before calling the provider about a patient's postoperative fever. Which statement represents the "B" (Background) in SBAR?
The nurse is evaluating the effectiveness of an intervention for preventing atelectasis in a postoperative patient. Which finding indicates improvement?
The nurse is evaluating the effectiveness of an intervention for preventing atelectasis in a postoperative patient. Which finding indicates improvement?
A nurse is providing postoperative care for a patient. Which interventions help reduce the risk of pneumonia? (Select all that apply.)
A nurse is providing postoperative care for a patient. Which interventions help reduce the risk of pneumonia? (Select all that apply.)
A nurse is monitoring for signs of infection in a postoperative patient. Which findings indicate a potential infection? (Select all that apply.)
A nurse is monitoring for signs of infection in a postoperative patient. Which findings indicate a potential infection? (Select all that apply.)
A patient who had abdominal surgery 2 days ago complains of sudden, severe pain at the incision site and states, “I felt something pop.” Upon assessment, the nurse sees that the wound edges have separated. What is the priority nursing intervention?
A patient who had abdominal surgery 2 days ago complains of sudden, severe pain at the incision site and states, “I felt something pop.” Upon assessment, the nurse sees that the wound edges have separated. What is the priority nursing intervention?
Which is the primary goal of pain management in the immediate postoperative period?
Which is the primary goal of pain management in the immediate postoperative period?
A nurse is monitoring a postoperative patient's fluid balance. Which laboratory value indicates dehydration?
A nurse is monitoring a postoperative patient's fluid balance. Which laboratory value indicates dehydration?
The nurse is explaining postoperative complications to a nursing student. Which patient is at the highest risk for developing a deep vein thrombosis (DVT)?
The nurse is explaining postoperative complications to a nursing student. Which patient is at the highest risk for developing a deep vein thrombosis (DVT)?
A patient is in the PACU after abdominal surgery. Which finding requires immediate intervention?
A patient is in the PACU after abdominal surgery. Which finding requires immediate intervention?
The nurse is caring for a patient with a PCA (patient-controlled analgesia) pump. What is the priority nursing assessment?
The nurse is caring for a patient with a PCA (patient-controlled analgesia) pump. What is the priority nursing assessment?
The nurse is repositioning a patient after abdominal surgery. Which position is most appropriate?
The nurse is repositioning a patient after abdominal surgery. Which position is most appropriate?
A nurse notes that a postoperative patient's urine output is less than 30 mL/hr. What is the best initial action?
A nurse notes that a postoperative patient's urine output is less than 30 mL/hr. What is the best initial action?
A postoperative patient's wound dressing is saturated with blood. What is the priority action?
A postoperative patient's wound dressing is saturated with blood. What is the priority action?
A nurse is caring for a postoperative patient with a PCA pump. Which instructions should be included in patient teaching? (Select all that apply.)
A nurse is caring for a postoperative patient with a PCA pump. Which instructions should be included in patient teaching? (Select all that apply.)
A patient who had a total knee replacement is refusing to ambulate due to pain. What is the best nursing intervention?
A patient who had a total knee replacement is refusing to ambulate due to pain. What is the best nursing intervention?
A nurse is reviewing a postoperative patient's discharge instructions. Which statement indicates a need for further teaching?
A nurse is reviewing a postoperative patient's discharge instructions. Which statement indicates a need for further teaching?
Which interventions help prevent paralytic ileus in postoperative patients? (Select all that apply.)
Which interventions help prevent paralytic ileus in postoperative patients? (Select all that apply.)
A nurse is assessing for signs of postoperative wound infection. Which findings are concerning? (Select all that apply.)
A nurse is assessing for signs of postoperative wound infection. Which findings are concerning? (Select all that apply.)
A patient two days post-op reports severe abdominal pain and a rigid abdomen. What is the nurse's priority action?
A patient two days post-op reports severe abdominal pain and a rigid abdomen. What is the nurse's priority action?
The nurse is reviewing standard postoperative discharge criteria. Which finding must be met before a patient is discharged from the Post-Anesthesia Care Unit (PACU)?
The nurse is reviewing standard postoperative discharge criteria. Which finding must be met before a patient is discharged from the Post-Anesthesia Care Unit (PACU)?
Which assessment finding requires the most immediate intervention in a postoperative patient?
Which assessment finding requires the most immediate intervention in a postoperative patient?
The nurse is caring for a patient post-surgery with a Jackson-Pratt drain. What is the purpose of this drain?
The nurse is caring for a patient post-surgery with a Jackson-Pratt drain. What is the purpose of this drain?
A nurse is caring for a patient who had spinal anesthesia for a knee replacement. What position should the nurse encourage to prevent a spinal headache?
A nurse is caring for a patient who had spinal anesthesia for a knee replacement. What position should the nurse encourage to prevent a spinal headache?
A patient who had general anesthesia is experiencing nausea and vomiting. What is the nurse's first action?
A patient who had general anesthesia is experiencing nausea and vomiting. What is the nurse's first action?
The nurse is caring for a patient 6 hours post-op after an abdominal surgery. Which intervention helps prevent paralytic ileus?
The nurse is caring for a patient 6 hours post-op after an abdominal surgery. Which intervention helps prevent paralytic ileus?
A patient reports severe pain, swelling, and redness in the calf after knee surgery. What is the priority nursing action?
A patient reports severe pain, swelling, and redness in the calf after knee surgery. What is the priority nursing action?
A nurse is assessing a postoperative patient's incision site and observes separation of wound edges with protruding bowel loops. What is the priority action?
A nurse is assessing a postoperative patient's incision site and observes separation of wound edges with protruding bowel loops. What is the priority action?
A postoperative patient is reluctant to use an incentive spirometer. What is the best way to increase adherence?
A postoperative patient is reluctant to use an incentive spirometer. What is the best way to increase adherence?
The nurse is preparing to ambulate a postoperative patient with orthostatic hypotension. Which intervention is most important?
The nurse is preparing to ambulate a postoperative patient with orthostatic hypotension. Which intervention is most important?
The nurse is evaluating a patient's pain management after surgery. Which statement indicates the need for further intervention?
The nurse is evaluating a patient's pain management after surgery. Which statement indicates the need for further intervention?
The nurse is assessing for postoperative complications. Which findings indicate a possible pulmonary embolism (PE)? (Select all that apply.)
The nurse is assessing for postoperative complications. Which findings indicate a possible pulmonary embolism (PE)? (Select all that apply.)
The nurse is reinforcing postoperative discharge education. What should be included? (Select all that apply.)
The nurse is reinforcing postoperative discharge education. What should be included? (Select all that apply.)
The nurse is evaluating a patient's incision site. Which findings suggest normal healing? (Select all that apply.)
The nurse is evaluating a patient's incision site. Which findings suggest normal healing? (Select all that apply.)
A nurse is preparing to administer morphine to a postoperative patient. What is the priority assessment before administration?
A nurse is preparing to administer morphine to a postoperative patient. What is the priority assessment before administration?
Flashcards
Postoperative Temperature Change
Postoperative Temperature Change
Slight increase in temperature within the first 48 hours postoperatively.
Monitor Urine Output
Monitor Urine Output
Ensures adequate renal perfusion and function. Decreased urine output indicates hypovolemia.
Initial Response to Respiratory Depression
Initial Response to Respiratory Depression
Stimulating the patient is the priority. May indicate the need for naloxone administration.
Early Ambulation Benefits
Early Ambulation Benefits
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Nausea Nursing Intervention
Nausea Nursing Intervention
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Confusion Priority Assessment
Confusion Priority Assessment
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Saturated Dressing Initial Response
Saturated Dressing Initial Response
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SBAR Background
SBAR Background
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Atelectasis Improvement Indicator
Atelectasis Improvement Indicator
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Pneumonia Prevention
Pneumonia Prevention
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Dehiscence Action
Dehiscence Action
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Pain Management Goal
Pain Management Goal
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Prevent paralytic ileus
Prevent paralytic ileus
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Orthostatic Hypotension Intervention
Orthostatic Hypotension Intervention
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Spinal headache prevention
Spinal headache prevention
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Study Notes
- Slight temperature increases within the first 48 hours postoperatively are expected due to inflammation, but a significant rise indicates possible infection.
- Monitoring urine output is key to assessing renal perfusion and function; decreased output can indicate hypovolemia or renal impairment.
- Postoperative respiratory depression due to anesthesia or opioids requires stimulating the patient as a first action; naloxone may be needed if unresponsive.
- Early ambulation prevents venous stasis and reduces the risk of deep vein thrombosis (DVT).
- In a PACU setting, a patient with nausea and vomiting should be positioned on their side first to prevent aspiration.
- Postoperative confusion can signal hypoxia; assessing oxygen saturation and respiratory function is the priority.
- For a patient reporting severe pain post abdominal surgery with a blood-saturated dressing, apply additional gauze and reinforce the dressing due to the risk of hemorrhage.
- In SBAR communication, the "Background" component includes relevant patient history to provide context, such as "The patient had an appendectomy 24 hours ago."
- Clear lung sounds indicate improvement in a postoperative patient, showing that interventions for preventing atelectasis, such as incentive spirometry and early ambulation, are effective.
- Interventions helping reduce the risk of pneumonia include incentive spirometry, early ambulation, and deep breathing/coughing exercises.
- Purulent drainage, localized redness, and elevated WBC count indicate potential infection in a postoperative patient.
- In wound dehiscence, covering the wound with a sterile saline-moistened dressing is the priority to prevent tissue drying while awaiting further intervention.
- The primary goal of pain management in the immediate postoperative period focuses on pain management to allow early ambulation and recovery.
- An elevated hematocrit suggests hemoconcentration due to dehydration and indicates dehydration.
- A 60-year-old man with hip replacement surgery is at highest risk for deep vein thrombosis (DVT) due to immobility and venous stasis.
- Oxygen saturation of 88% indicates potential respiratory compromise and necessitates immediate intervention.
- When caring for a patient with a PCA pump, the priority is assessing the sedation level and respiratory rate since opioid administration increases the risk of respiratory depression.
- Semi-Fowler's position promotes lung expansion and prevents aspiration post abdominal surgery.
- The best initial action for a postoperative patient with urine output less than 30 mL/hr is assessing for bladder distention, as it may indicate urinary retention or hypovolemia.
- For a postoperative patient's wound dressing saturated with blood, apply direct pressure and reinforce the dressing to prevent further blood loss while preparing to notify the provider.
- Instructions for a patient teaching with a PCA pump: only the patient should control the PCA, and the system is programmed to prevent overdose.
- Offer pain medication before ambulation because it enhances mobility, which is essential for recovery in a patient who had a total knee replacement and refusing to ambulate due to pain.
- "I don't need to take my pain medications if I feel okay" indicates a need for further teaching because it is important to educate patients on managing pain proactively for movement and healing.
- Interventions to prevent paralytic ileus in postoperative patients: early ambulation and stool softeners promote bowel motility; maintaining NPO status prevents complications.
- Redness, warmth, increased WBC count, and purulent drainage are concerning signs of postoperative wound infection.
- Severe acute pain and a rigid abdomen two days post-op can indicate peritonitis, notify the surgeon immediately.
- To be discharged from the PACU, the patient must be alert and oriented to time and place, stable, and free of complications.
- A respiratory rate of 8 breaths per minute requires the most immediate intervention, because a significantly decreased respiratory rate indicates opioid-induced respiratory depression.
- Jackson-Pratt (JP) drains are used to prevent fluid accumulation in surgical sites.
- Ensure that the patient is lying flat to prevent cerebrospinal fluid (CSF) leakage, which causes spinal headaches after spinal anesthesia.
- Place the patient in a side-lying position to prevent aspiration, while preparing to administer antiemetics.
- Early ambulation stimulates bowel motility and prevents ileus in a patient 6 hours post-op after an abdominal surgery.
- Elevate the extremity and notify the provider indicating a deep vein thrombosis (DVT) for a patient reporting severe pain, swelling, and redness in the calf after knee surgery.
- Cover the wound with a sterile saline-moistened dressing, which is a medical emergency requiring immediate protection of the organs for a postoperative patient's incision site and observes separation of wound edges with protruding bowel loops.
- Teaching and demonstration improve patient participation using the incentive spirometer.
- Instruct the patient to dangle their legs before standing to patient to ambulate with orthostatic hypotension, because dangling prevents sudden drops in blood pressure, reducing fall risk.
- Teach the patient that pain is best managed proactively, not just when it becomes severe if someone states, "I will take my pain medications only when the pain is severe.”
- Sudden shortness of breath, chest pain, and hemoptysis (coughing blood) indicate a pulmonary embolism (PE)
- Post-operative discharge education includes: avoiding driving while on opioids, monitoring for infection, and increasing fluid and fiber intake to prevent constipation.
- Normal healing includes mild swelling, pain relief with medication, and well-approximated edges.
- Assessing respiratory rate is crucial because opioids depress respiration.
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