Surgical Site/Pain/Cell Reg

Mr. Jones just underwent abdominal surgery and has a pH 7.29, PaCO2 54, HCO3 23. What could be the cause of this ABG imbalance?

• Too much IV fluid

• Too much sedation

• Breathing too fast

• Patient is vomiting

Answer explanation

This pt is in respiratory acidosis (uncompensated). This causes respiratory depression and retention of CO2 which causes acidosis.

A client requests the nurse to come to the room. When the nurse enters the room, this is what they see: (see picture). What would the nurses IMMEDIATE action be?

• Push it back into place

• Ask the client if they are hurting

• Cover the intestine with sterile gauze covered with saline

• Cover with a dry towel

Answer explanation

When a client has an evisceration of a wound, the most important thing to do is to immediately cover the wound with a sterile wet gauze to prevent the organ from drying out and it has to be sterile to prevent infection. You do need to notify the provider and the client will potentially return to surgery, but first you need to cover it up. If you cover with a dry gauze or towel, it can dry to organ/tissue out.

The nurse is preparing a client for surgery. Which is part of the preop assessment?

• Observing a time out

• Assessing the client for Malignant hyperthermia

• Assessment of the wound

• Manage pain

Answer explanation

The preop checklist includes measures such as allergy/ID bands, client teaching, NPO, gown, voiding, removal of dentures/partials/jewelry, skin prep, reviewing lab-preop information, etc. Pain/wound assessment is more important in post op and time out occurs intraop.

Which assessment is PRIORITY when the client arrives in PACU?

• Pain assessment
• Mobility assessment
• Temperature assessment
• Airway assessment

Answer explanation

Airway assessment is always priority! Remember your ABCs. They have been given medication to sedate/slow their breathing and you need to make sure they have an adequate airway.

The nurse is concerned a client is developing malignant hyperthermia. Which symptom would support the hypothesis?

• Rapid increase in body temperature
• Sudden decrease in heart rate
• Low blood pressure
• Decreased respiratory rate

The nurse is caring for a client who is post-surgery. The client has a temp of 99.2. Which intervention would be best to help with the temperature?

• Encourage the client to use an incentive spirometer

• Administer a cooling blanket
• Apply a heating pad
• Administer acetaminophen

Answer explanation

Many pts who are post surgery can develop atelectasis which can turn into pneumonia. This can present as a beginning temp, but once this is found start using a IS and it can help decrease/prevent further complications.

Match the following complication with the preventative measure

• I & O monitoring

• PE

• docusate

• Urinary retention

• Anticoagulation therapy

• DVT

• Early ambulation

• Constipation

• Regular repositioning

• Pressure ulcer

A client has had a right below the knee amputation. The RN removes the dressing and assesses the wound. (see the picture). What would the nurse note is happening to the wound?

• Cellulitis

• Normal healing

• Dehiscence

• Sepsis

Answer explanation

This wound shows signs of cellulitis. There is no indication of sepsis in this question. the wound is not separated to indicate dehiscense, but this is not normal healing.

What is the Post-operative period?

• This period occurs after the surgery where the provider monitors the patient on a timely basis to make sure that the patient is safe & comfortable

• This period occurs prior to the surgery where the provider gathers all the relevant information to make sure there is no obstacle when performing the surgery

• This is a period where actual surgery is performed

• All of the above

A client is experiencing difficulty breathing post-surgery. What is the nurse's first action?

• Administer oxygen

• Call the physician

• Check the client's airway

• Elevate the head of the bed