Lewis Chapter 20: Postoperative Care

A patient is admitted to the post-anesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action would the nurse take?

a. Increase the postoperative IV fluid rate.

b. Notify the anesthesia care provider (ACP).

c. Continue to take vital signs every 15 minutes.

d. Administer oxygen therapy at 100% per mask.

ANS: C

A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration.

In the post-anesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72 mm Hg, pulse 74 beats/min, respirations 12 breaths/min, and SpO2 91%. the patient is sleepy but awakens easily. Which action would the nurse take?

a. Place the patient in a side-lying position.

b. Encourage the patient to take deep breaths.

c. Prepare to transfer the patient to a clinical unit.

d. Increase the rate of the postoperative IV fluids.

ANS: B

The patient‘s borderline SpO2 and sleepiness indicate hypoventilation. the nurse would stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. the stable blood pressure and pulse indicate that no changes in fluid intake are required. the patient is not fully awake and has a low SpO2, indicating that transfer from the PACU to a clinical unit is not appropriate.

An experienced nurse orients a new nurse to the post-anesthesia care unit (PACU). Which action by the new nurse would indicate that the orientation was successful?

a. The new nurse assists a nauseated patient to a supine position.

b. The new nurse places a sleeping patient supine with the head elevated.

c. The new nurse positions an unconscious patient on the side upon arrival from surgery.

d. The new nurse places a patient in the Trendelenburg position for a low blood pressure.

ANS: C

The patient would initially be placed in the lateral “recovery” position to keep the airway open and avoid aspiration. Avoid the Trendelenburg position because it increases the work of breathing. the patient is placed supine with the head elevated after regaining consciousness.

An older adult patient is being discharged from the ambulatory surgical unit after left eye surgery. the patient tells the nurse, ―I don't know if I can take care of myself once I'm home.‖ Which action would the nurse implement first?

a. Assess the patient's home support system.

b. Discuss patient concerns regarding self-care.

c. Refer the patient for home health care services.

d. Provide written instructions for the patient's care.

ANS: B

The nurse‘s initial action would be to assess exactly the patient‘s concerns about self-care. Referral to home health care and assessment of the patient‘s support system may be appropriate actions but will be based on further assessment of the patient‘s concerns. Written instructions for care would be given to the patient, but these may not address the patient‘s stated concern about self-care.

On the second postoperative day, the patient's nasogastric (NG) tube is removed and the patient begins drinking clear liquids. Four hours later, the patient reports frequent, cramping gas pains. Which action would the nurse take?

a. Reinsert the NG tube.

b. Assist the patient to ambulate.

c. Place the patient on NPO status.

d. Give the prescribed PRN IV opioid.

ANS: B

Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient‘s discomfort. If distention persists, the patient may need to be placed on NPO status, but usually this is not necessary. Opioid administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains

A patient's T-tube is draining dark green fluid after gallbladder surgery. Which action would the nurse take?

a. Notify the patient's surgeon.

b. Place the patient on bed rest.

c. Irrigate the T-tube with sterile saline.

d. Document the drainage characteristics.

ANS: D

A T-tube normally drains dark green to bright yellow drainage so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary.

Which action by the nurse will be most helpful to a patient who is expected to ambulate, deep breathe, and cough on the first postoperative day?

a. Schedule the activity to begin after the patient has taken a nap.

b. Administer prescribed analgesic medications before the activities.

c. Ask the patient to state two possible complications of immobility.

d. Encourage the patient to repeat back the purpose of splinting the incision.

ANS: B

An important nursing action to encourage these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, concern about complications, and with rest and sleep, patients will have difficulty if there is a great deal of pain involved with these activities

Which data on the patient's second postoperative day would indicate that interventions to remove secretions from the patient's airway have been successful?

a. Patient drinks 2 to 3 L of fluid in 24 hours.

b. Patient uses the spirometer 10 times every hour.

c. Patient's breath sounds are clear to auscultation.

d. Patient's temperature is less than 100.2ºF orally.

ANS: C

One characteristic of airway secretions is the presence of adventitious breath sounds such as crackles, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions to improve airway clearance but they are not evidence of improvement. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems.

A patient who has begun to awaken after 30 minutes in the post-anesthesia care unit (PACU) is restless and shouting at the nurse. the patient's oxygen saturation is 96%, and recent laboratory results are normal. Which action would the nurse take?

a. Increase the IV fluid rate.

b. Assess for bladder distention.

c. Notify the anesthesia care provider (ACP).

d. Demonstrate how to use the call bell button. Assess for bladder distention.

ANS: B

Because the patient‘s assessment indicates physiologic stability, the most likely cause of the patient‘s agitation is emergence delirium, which will resolve as the patient wakes up more fully. the nurse would look for a cause such as bladder distention. Although hypoxemia is the most common cause, the patient‘s oxygen saturation is 96%. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify the ACP. Orientation of the patient to bed controls is needed but is not likely to be effective until the effects of anesthesia have resolved more completely.

Which action could the post-anesthesia care unit (PACU) nurse delegate to assistive personnel (AP) during transfer of a patient to the clinical unit?

a. Help to slide the patient onto a stretcher.

b. Clarify postoperative orders with the surgeon.

c. Document the appearance of the patient's incision.

d. Provide hand-off communication to the surgical unit nurse.

ANS: A

The scope of practice of AP includes repositioning and moving patients under the supervision of a nurse. Providing report to another nurse, assessing and documenting the wound appearance, and clarifying physician orders with another nurse require registered nurse (RN) level education and scope of practice.

A patient is transferred from the post-anesthesia care unit (PACU) to the clinical unit. Which action would the nurse on the clinical unit perform first?

a. Ask the patient about pain.

b. Orient the patient to the unit.

c. Assess the patient's vital signs.

d. Read the postoperative orders.

ANS: C

Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. the other actions would take place after the vital signs are obtained and compared with the vital signs before transfer

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which potential complication would the nurse identify as a priority for this patient?

a. Hypovolemic shock

b. Venous thromboembolism

c. Fluid and electrolyte imbalance

d. Impaired surgical wound healing

ANS: B

The patient is older and relatively immobile, which are two risk factors for development of deep vein thrombosis. the other potential complications are possible postoperative problems, but they are not at a high risk based on the data about this patient.

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action would the nurse take first?

a. Administer the prescribed opioid.

b. Check the oxygen (O2) saturation.

c. Take the blood pressure and pulse.

d. Apply wrist restraints to secure IV lines.

ANS: B

Emergence delirium may be caused by a variety of factors. the nurse would first assess for hypoxemia. the other actions also may be appropriate, but are not the best initial action.

A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action would the nurse take first?

a. Perform a bladder scan.

b. Insert a straight catheter.

c. Encourage increased oral fluid intake.

d. Assist the patient to ambulate to the bathroom.

ANS: A

The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with the patient to the bathroom) will be helpful. Because of the risk for urinary tract infection, catheterization should only be done after other measures have been tried without success. There is no indication of a fluid volume deficit.

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. the nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action would the nurse take first?

a. Reinforce the dressing.

b. Apply an abdominal binder.

c. Take the patient's vital signs.

d. Plan to recheck the dressing in 1 hour.

ANS: C

New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient‘s vital signs for tachycardia and hypotension. the surgeon should then be notified of the drainage and the vital signs. the dressing may be changed or reinforced, based on the surgeon‘s instructions or agency policy. the nurse should not wait an hour to recheck the dressing.

On the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, a patient has an oral temperature of 100.8ºF (38.2ºC). Which action would the nurse take?

a. Place ice packs in the patient's axillae.

b. Have the patient use the incentive spirometer.

c. Request a prescription for acetaminophen suppositories.

d. Ask the health care provider to change the antibiotic prescription.

ANS: B

A temperature of 100.8F (38.2C) in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient deep breathe, cough, and use the incentive spirometer. Nursing intervention may resolve this problem, and therefore notifying the health care provider is not necessary. Acetaminophen or ice packs will reduce the temperature, but it will not resolve the underlying respiratory congestion

An unconscious patient who was transferred from surgery to the post-anesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action would the nurse take first?

a. Suction the patient's mouth.

b. Increase the oxygen flowrate.

c. Perform the jaw-thrust maneuver.

d. Elevate the patient's head on two pillows.

ANS: C

In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flowrate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient‘s head will not be effective in correcting an obstruction but may help with oxygenation after the patient is awake.

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

A. The patient's temperature is 100.3ºF (37.9ºC).

B. The patient reports abdominal pain when ambulating.

C. The patient's calf is swollen and warm to touch.

D. The patient has fluid intake 600 mL greater than the output.

ANS: B

The calf pain, swelling, and warmth suggest that the patient has a venous thromboembolism (VTE). This will require the health care provider to prescribe diagnostic tests, anticoagulants, or both and is most critical because a VTE could result in a pulmonary embolism. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3F on the second postoperative day is suggestive of atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the prescribed analgesic before patient activities.

A patient who had knee surgery received IV ketorolac 30 minutes ago and continues to report pain at a level of 7 (0 to 10 scale). Which action would the nurse take?

a. Administer the prescribed PRN IV morphine sulfate.

b. Notify the health care provider about the-ongoing pain.

c. Teach the patient that effects of ketorolac last 6 to 8 hours.

d. Reassure the patient that pain is expected after knee surgery.

ANS: A

The priority at this time is pain relief. Concomitant use of opioids and nonsteroidal anti-inflammatory drugs improves pain control in postoperative patients. Patient teaching and reassurance are appropriate but should be done after the patient‘s pain is relieved. If the patient continues to have pain after the morphine is administered, notify the health care provider.

A patient who has just been transported from the operating room to the post-anesthesia care unit (PACU) is shivering and has a temperature of 96.8ºF (36ºC). Which action would the nurse take?

a. Notify the anesthesia care provider.

b. Cover the patient with warm blankets.

c. Hold opioid analgesics until the patient is warmer.

d. Give acetaminophen 650 mg suppository rectally.

ANS: B

The patient assessment indicates the need for rewarming. There is no indication of a need for acetaminophen. Opioid analgesics may help reduce shivering. Because hypothermia is common and expected in the immediate postoperative period, there is no need to notify the anesthesia care provider unless the patient continues to be hypothermic after rewarming measures.

Which finding would indicate to the nurse that a postoperative patient is at increased risk for poor wound healing?

a. Potassium 3.5 mEq/L

b. Albumin level 2.2 g/dL

c. Hemoglobin 10.2 g/dL

d. White blood cells 11,900/uL

ANS: B

Because adequate nutrition including proteins are needed for an appropriate inflammatory response and wound healing, the low serum albumin level (normal level, 3.5 to 5.0 g/dL) indicates a risk for poor wound healing. the potassium level is normal. Because a small amount of blood loss is expected with surgery, the hemoglobin level is not indicative of an increased risk for wound healing. WBC count is expected to increase after surgery as a part of the normal inflammatory response

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon?

a. Tympanic temperature 99.2ºF (37.3ºC)

b. Fine crackles audible at both lung bases

c. Redness and swelling along the suture line

d. 200 mL sanguineous fluid in the wound drain

ANS: D

Wound drainage should decrease and change in color from sanguineous to serosanguineous by the second postoperative day. the color and amount of drainage for this patient are abnormal and should be reported. Redness and swelling along the suture line and a slightly elevated temperature are normal signs of postoperative inflammation. Atelectasis is common after surgery. the nurse should have the patient cough and deep breathe, but there is no urgent need to notify the surgeon.

After receiving change-of-shift report about these postoperative patients, which patient would the nurse assess first?

a. Patient who had abdominal surgery 3 days ago and whose wound edges may be separating

b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery

Patient who has bibasilar crackles and a temperature of 100ºF (37.8ºC) on the first day after chest surgery

d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) was given

ANS: A

The patient‘s history and assessment suggests possible wound dehiscence, which would be reported immediately to the surgeon. Although the information about the other patients indicates a need for ongoing assessment and possible intervention, the data do not suggest any acute complications. Small amounts of red drainage are common in the first postoperative hours. Bibasilar crackles and a slightly elevated temperature are common after surgery, although the nurse will need to have the patient deep breathe and cough. Oral medications typically take more than 15 minutes for effective pain relief.

An awake patient who has a history of smoking has just arrived on the surgical unit from the post-anesthesia care unit. Which action would the nurse take first?

a. Auscultate for adventitious breath sounds.

b. Obtain the temperature and apply warm blankets.

c. Teach the patient about harmful effects of smoking.

d. Ask the health care provider to prescribe a nicotine patch.

ANS: A

The nurse would first ensure a patent airway and check for breathing quality in a responsive patient. Temperature can be assessed and hypothermia addressed after a patent airway and breathing have been established. the immediate postoperative period is not the optimal time for patient teaching about the harmful effects of smoking. Requesting a nicotine patch may be appropriate but is not a priority at this time.