NCLEX Questions-Perioperative Nursing Care | Questions and Answers(A+ Solution guide)

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 ml/hour 2. Temperature of 37.6C (99.6F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing - 1. Rationale-Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less than 30mL for each of 2 consecutive hours should be reported to the health care provider. A temperature higher that 37.7C (100F) or lower than 36.1C (97F) and a falling systolic blood pressure lower than 90 mm Hg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderatae or light serous drainage from the surgical site is considered normal. A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition? 1. Pneumonia 2. Hypoxemia 3. Fluid imbalance 4. Pulmonary embolism - 1. Rationale-Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Hypoxemia is an inadequate concentration of oxygen in arterial blood. Fluid imbalance can be a deficit or excess related to fluid loss or overload. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to one or more lobes of the lung; this is usually due to clot formation. The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash 2. Verify that the client has not eaten for the last 24 hours3. Have the client void immediately before going into surgery 4. Report immediately any slight increase in blood pressure or pulse. - 3. Rationale-The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.