09/24/24. MEDSURG. QUIZ 2: Chapter 14, 15,
16, 8 exam with question and 100%correct
A client is at postoperative hour 8 after an appendectomy and is anxious, stating "Something is
not right. My pain is worse than ever and my stomach is swollen." Blood pressure is 88/50,
pulse is 115, and respirations are 24 and labored. The abdomen is soft and distended. No
obvious bleeding is noted. What action by the nurse is most appropriate?
a) Ambulate the client to reduce abdominal distention.
b) Inform the client this is the normal progression after abdominal surgery.
c) Notify the physician.
d) Administer morphine per orders. - Notify the physician.
Explanation:
The physician should be notified of the findings. The client may be hemorrhaging internally and
may need to return to surgery. The client may be in need of pain medication, but morphine will
lower the blood pressure further and may cause further complications. Ambulating the client
increases the risk of injury because the client may experience orthostatic hypotension. What
the client is experiencing is not the normal progression after abdominal surgery.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th
ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management,
Nursing Management After Surgery > Chart 16-6 PATIENT EDUCATION, p. 453.
A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching
would the nurse include about DVT prevention?
,a) Rely on the IV fluids for hydration.
b) Report early calf pain.
c) Dangle at the bedside.
d) Take off the pneumatic compression devices for sleeping. - Report early calf pain.
Explanation:
The client needs to report calf pain or cramping for the nurse to investigate any swelling or
potential DVT. Blanket rolls or prolonged dangling should be avoided to reduce impediment of
circulation behind the knee. Prevention of DVT includes early ambulation, use of antiembolism
or pneumatic compression devices, and low-molecular-weight or low-dose heparin and low-
dose warfarin for clients postoperatively. Adequate fluids need to be offered to avoid
dehydration.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th
ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care
of the Hospitalized Postoperative Patient, p. 455.
What does the nurse recognize as one of the most common postoperative respiratory
complications in elderly clients?
a) Pneumonia
b) Hypoxemia
c) Pleurisy
d) Pulmonary edema - Pneumonia
Explanation:
Older clients recover more slowly, have longer hospital stays, and are at greater risk for
development of postoperative complications. Delirium, pneumonia, decline in functional ability,
,exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and
falls are all threats to recovery in the older adult.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th
ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care
of the Hospitalized Postoperative Patient, p. 447.
The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal
wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes
increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap
at the lower end of the incision. The nurse concludes which of the following conditions exists?
a) Evisceration
b) Normal healing by primary intention.
c) Hemorrhage
d) Dehiscence - Dehiscence
Explanation:
Dehiscence is a disruption of the incision.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th
ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care
of the Hospitalized Postoperative Patient, pp. 456-457.
The primary objective in the immediate postoperative period is
, a) monitoring for hypotension.
b) relieving pain.
c) maintaining pulmonary ventilation.
d) controlling nausea and vomiting. - maintaining pulmonary ventilation.
Explanation:
The primary objective in the immediate postoperative period is to maintain pulmonary
ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and
monitoring for hypotension are important, but they are not primary objectives in the immediate
postoperative period.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th
ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management,
Nursing Management in the Postanesthesia Care Unit > Maintaining a Patent Airway, p. 438.
What complication is the nurse aware of that is associated with deep venous thrombosis?
a) Pulmonary embolism
b) Immobility because of calf pain
c) Marked tenderness over the anteromedial surface of the thigh
d) Swelling of the entire leg owing to edema - Pulmonary embolism
Explanation:
Serious potential venous thromboembolism complications of surgery include deep vein
thrombosis and pulmonary embolism (Rothrock, 2010).
Reference:
16, 8 exam with question and 100%correct
A client is at postoperative hour 8 after an appendectomy and is anxious, stating "Something is
not right. My pain is worse than ever and my stomach is swollen." Blood pressure is 88/50,
pulse is 115, and respirations are 24 and labored. The abdomen is soft and distended. No
obvious bleeding is noted. What action by the nurse is most appropriate?
a) Ambulate the client to reduce abdominal distention.
b) Inform the client this is the normal progression after abdominal surgery.
c) Notify the physician.
d) Administer morphine per orders. - Notify the physician.
Explanation:
The physician should be notified of the findings. The client may be hemorrhaging internally and
may need to return to surgery. The client may be in need of pain medication, but morphine will
lower the blood pressure further and may cause further complications. Ambulating the client
increases the risk of injury because the client may experience orthostatic hypotension. What
the client is experiencing is not the normal progression after abdominal surgery.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th
ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management,
Nursing Management After Surgery > Chart 16-6 PATIENT EDUCATION, p. 453.
A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching
would the nurse include about DVT prevention?
,a) Rely on the IV fluids for hydration.
b) Report early calf pain.
c) Dangle at the bedside.
d) Take off the pneumatic compression devices for sleeping. - Report early calf pain.
Explanation:
The client needs to report calf pain or cramping for the nurse to investigate any swelling or
potential DVT. Blanket rolls or prolonged dangling should be avoided to reduce impediment of
circulation behind the knee. Prevention of DVT includes early ambulation, use of antiembolism
or pneumatic compression devices, and low-molecular-weight or low-dose heparin and low-
dose warfarin for clients postoperatively. Adequate fluids need to be offered to avoid
dehydration.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th
ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care
of the Hospitalized Postoperative Patient, p. 455.
What does the nurse recognize as one of the most common postoperative respiratory
complications in elderly clients?
a) Pneumonia
b) Hypoxemia
c) Pleurisy
d) Pulmonary edema - Pneumonia
Explanation:
Older clients recover more slowly, have longer hospital stays, and are at greater risk for
development of postoperative complications. Delirium, pneumonia, decline in functional ability,
,exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and
falls are all threats to recovery in the older adult.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th
ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care
of the Hospitalized Postoperative Patient, p. 447.
The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal
wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes
increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap
at the lower end of the incision. The nurse concludes which of the following conditions exists?
a) Evisceration
b) Normal healing by primary intention.
c) Hemorrhage
d) Dehiscence - Dehiscence
Explanation:
Dehiscence is a disruption of the incision.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th
ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management, Care
of the Hospitalized Postoperative Patient, pp. 456-457.
The primary objective in the immediate postoperative period is
, a) monitoring for hypotension.
b) relieving pain.
c) maintaining pulmonary ventilation.
d) controlling nausea and vomiting. - maintaining pulmonary ventilation.
Explanation:
The primary objective in the immediate postoperative period is to maintain pulmonary
ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and
monitoring for hypotension are important, but they are not primary objectives in the immediate
postoperative period.
Reference:
Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th
ed., Philadelphia, Wolters Kluwer, 2022, Chapter 16: Postoperative Nursing Management,
Nursing Management in the Postanesthesia Care Unit > Maintaining a Patent Airway, p. 438.
What complication is the nurse aware of that is associated with deep venous thrombosis?
a) Pulmonary embolism
b) Immobility because of calf pain
c) Marked tenderness over the anteromedial surface of the thigh
d) Swelling of the entire leg owing to edema - Pulmonary embolism
Explanation:
Serious potential venous thromboembolism complications of surgery include deep vein
thrombosis and pulmonary embolism (Rothrock, 2010).
Reference:
