Postoperative Management Exam (PREP U)
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.
-If abdominal distention is accompanied by nausea, the nurse must first auscultate
bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small
intestine dilation and these findings must be reported to the physician. Palpation should
be avoided postoperatively with abdominal distention. If peristalsis is absent, changing
positions and inserting a rectal tube won't relieve the client's discomfort.
When the surgeon performs an appendectomy, the nurse recognizes that the surgical
category will be identified as
Clean-contaminated.
-Clean-contaminated cases are those with a potential, limited source for infection, the
exposure to which, to a large extent, can be controlled. Clean cases are those with no
apparent source of potential infection. Contaminated cases are those that contain an
open and obvious source of potential infection. A traumatic wound with foreign bodies,
fecal contamination, or purulent drainage would be considered a dirty case.
The nursing assessment of the postoperative client reveals an incision that is wellapproximated with sutures intact, minimal redness and edema, and absence of
drainage. The nurse recognizes the wound is healing by:
First intention
-First-intention healing is characterized by a closed incision with little tissue reaction and
the absence of signs and symptoms of infection.
When should the nurse encourage the postoperative patient to get out of bed?
As soon as it's indicated.
-Postoperative activity orders are checked before the patient is assisted to get out of
bed, in many instances, on the evening following surgery. Sitting up at the edge of the
bed for a few minutes may be all that the patient who has undergone a major surgical
procedure can tolerate at first.
The nurse determines that a patient has postoperative abdominal distention. What does
the nurse determine that the distention may be directly related to?
A temporary loss of peristalsis and gas accumulation in the intestines.
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