ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 19 : Postoperative Nursing Management Questions
Question 1 of 5
A patient underwent an open bowel resection 2 days ago and the nurses most recent assessment of the patients abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have caused the dehiscence?
Correct Answer: B
Rationale: Vomiting can produce tension on wounds, particularly of the torso. Dressing changes and light mobilization are unlikely to cause dehiscence. The use of a PCA is not associated with wound dehiscence.
Question 2 of 5
The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion?
Correct Answer: C
Rationale: Spots of drainage on a dressing are outlined with a pen, and the date and time of the outline are recorded on the dressing so that increased drainage can be easily seen. A dressing is never removed and then reapplied. Photographs normally require informed consent, so they would not be used for this purpose. Documentation is necessary, but does not confirm or rule out an increase in drainage.
Question 3 of 5
The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patients possible readiness to learn how to change her dressing? Select all that apply.
Correct Answer: B,C,E
Rationale: While changing the dressing, the nurse has an opportunity to teach the patient how to care for the incision and change the dressings at home. The nurse observes for indicators of the patients readiness to learn, such as looking at the incision, expressing interest, or assisting in the dressing change. Expressing dislike and wanting to delegate to a family member do not suggest readiness to learn.
Question 4 of 5
The nursing instructor is talking with a group of medicalsurgical students about deep vein thrombosis (DVT). A student asks what factors contribute to the formation of a DVT. What would be the instructors best response?
Correct Answer: D
Rationale: The stress response that is initiated by surgery inhibits the fibrinolytic system, resulting in blood hypercoagulability. Dehydration, low cardiac output, blood pooling in the extremities, and bedrest add to the risk of thrombosis formation. Hypervolemia is not a risk factor and there are no known genetic factors.
Question 5 of 5
The home health nurse is caring for a postoperative patient who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the patients postoperative day 2. During the visit, the nurse will assess for wound infection. For most patients, what is the earliest postoperative day that a wound infection becomes evident?
Correct Answer: C
Rationale: Wound infection may not be evident until at least postoperative day 5. This makes the other options incorrect.