Med-Surg Chapter 19: Postoperative Nursing Management

Med-Surg Chapter 19: Postoperative Nursing Management


Question
A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the
nurse?

• “It assists in preventing infection.”

Question
A client develops a hemorrhage one-hour post-surgery. The nurse knows this is most likely an intermediary
hemorrhage from a vein because it occurred:

• within the first few hours and has darkly colored blood that bubbles out slowly.

Question
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first
nursing action should be to:

• auscultate bowel sounds.

Question
A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h,
has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain
with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the
nurse is most appropriate?

• Assess for signs and symptoms of fluid volume deficit.

Question
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?

• Notify the physician.

Question
A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of
the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?

• Assessing WBC count, temperature, and wound appearance



Question

, A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The
nurse observes a wound evisceration. Which nursing action is the first priority?

• Applying a sterile, moist dressing

Question
A client who is receiving the maximum levels of medication for postoperative recovery asks the nurse if ther
are other measures that the nurse can employ to ease pain. Which of the following strategies might the nurs
employ? Select all that apply.

• Performing guided imagery

• Putting on soothing music

• Changing the client’s position

Question
A nurse asks a client who had abdominal surgery 3 days ago if he has moved his bowels since surgery. The
client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?

• Encourage the client to ambulate at least three times per day.

Question
A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse,
think I’m going to be sick.” What is the primary action taken by the nurse?

• Position the client in the side-lying position.

Question
A nurse is caring for a client with a chest tube connected to a dry suction water seal drainage system. The
nurse notes 2cm of water and intermittent bubbling in the water seal chamber. Which action will the nurse
take?

• Document the findings.

Question
A nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform
first?

• Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.

Question
A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine
assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood
pressure of 90/56. What does the nurse consider is the most likely cause of the client’s change in condition?