![]() ![]() The nurse should review the previous vital signs to determine whether this is a change from how the vital signs have been trending since the BP is slightly low and the pulse rate is slightly fast. The nurse needs to consider if this data is an early sign of a complication. 5.Review when the client last received pain medication Postoperative vital signs and urinary output are important parameters to determine how the client is recovering from the surgical procedure. 4.Observe the IV site for patency and correct flow rate. 3.Observe the urinary catheter for patency and flow. Review:Preoperative and postoperative care.Color Key:Cyan = StrategyMagenta = Content ReviewĢ.Review vital signs from previous hour. Options 4, 5, and 6 refer to information that should be taught preoperatively. Options 1, 2, and 3 refer to information that needs to be taught postoperatively. Test-Taking Strategy(ies):Focus on the subject, preoperative instructions. Specific instructions that the client needs to receive before discharge should include wound care, activity restrictions, dietary instructions, postoperative medication instructions, personal hygiene, and follow-up appointments. Addressing that pain will be monitored and controlled with prescribed analgesia should allay client fears regarding pain. Therefore, coughing and deep breathing are important exercises to be taught in the preoperative period. General anesthesia predisposes clients to respiratory problems that can lead to atelectasis and pneumonia in the postoperative period. Postoperatively, the client will be monitored closely with vital signs and the client should understand this is routine. Preoperative education, including rationales related to a client's expected postoperative behavior, has a positive outcome on recovery and prevention of postoperative complications. Noting the words purulent, tender, and hardness will direct you to the correct options.Review:The signs of a wound infection.Color Key:Cyan = StrategyMagenta = Content ReviewĤ.Frequent assessment of vital signs 5.Coughing and deep breathing exercises 6.Pain monitoring and medications to relieve pain Rationale:The type of planning and instruction required varies with each individual and type of surgery. Test-Taking Strategy(ies):Focus on the subject, wound infection. The room temperature may be too cold for client comfort. The fact that a client feels cold is not indicative of an infection, although chills and fever are signs of infection. Itching around a wound may be from irritation or dryness and is not associated with infection. A temperature of 98.8° F (37.1° C) is not an abnormal finding in a postoperative client. Slight redness along an incision is a sign of inflammation and should be monitored to determine whether it progresses. Infection may be caused by poor aseptic technique or a wound that was contaminated before surgical exploration it appears 3 to 6 days after surgery. ![]() Purulent material may exit from drains or from separated wound edges. Signs and symptoms of a wound infection include warmth, redness, swelling, and tenderness of skin around the incision. ![]() 2.The presence of purulent drainage 6.Tender firmness palpable around the incision Rationale:A wound infection occurs when healing is delayed and pathogens such as bacteria grow in the wound. ![]()
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