7.2 Ch. 19 Postop

6. 65-year-old Dominic is being transferred into the PACU from the OR. Once there, initial assessment will focus on: (a) airway, breathing, circulation, and wound site. (b) intake, output, and intravenous access. (c) abdominal sounds, oxygen setting, and level of consciousness. (d) pulse oximeter, pupil responses, and deep tendon reflexes.

A

17. The nurse received a male client from the post-anesthesia care unit. Which assessment data would warrant immediate intervention? 1. The client's vital signs are T 97˚F, P 108, R 24, and BP 80/40. 2. The client is sleepy but opens the eyes to his name. 3. The client is complaining of pain at a "5" on a 1-to-10 pain scale. 4. The client has 20 mL of urine in the urinary drainage bag.

1. These are symptoms of hypovolemic shock and require immediate intervention.

176. The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. A pulse of 86 beats/minute 3. Blood pressure of 110/70 mm Hg 4. Hypoactive bowel sounds in all 4 quadrants

1 Rationale: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all 4 quadrants are a normal occurrence in the immediate postoperative period.

169. The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? 1. "Use of an incentive spirometer will help prevent pneumonia." 2. "Close monitoring of your oxygen saturation will detect hypoxemia." 3. "Administration of intravenous fluids will prevent or treat fluid imbalance." 4. "Early ambulation and administration of blood thinners will prevent 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. Use of an incentive spirometer helps to prevent pneumonia and atelectasis. Hypoxemia is an inadequate concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help to detect hypoxemia, monitoring is not directly related to coughing and deep breathing techniques. Fluid imbalance can be a deficit or excess related to fluid loss or overload, and surgical clients are often given intravenous fluids to prevent a deficit; however, this is not related to coughing and deep breathing. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to 1 or more lobes of the lung; this is usually due to clot formation. Early ambulation and administration of blood thinners helps to prevent this complication; however, it is not related to coughing and deep-breathing techniques.

179. The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? 1. Assess the patency of the airway. 2. Check tubes or drains for patency. 3. Check the dressing to assess for bleeding. 4. Assess the vital signs to compare with preoperative measurements.

1 Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established.

168. 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 37.6 °C (99.6 °F) 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 30 mL for 2 consecutive hours should be reported to the health care provider. A temperature higher than 37.7 °C (100 °F) or lower than 36.1 °C (97 °F) 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. Moderate or light serous drainage from the surgical site is considered normal.

177. A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply. 1. Contact the surgeon. 2. Instruct the client to remain quiet. 3. Prepare the client for wound closure. 4. Document the findings and actions taken. 5. Place a sterile saline dressing and ice packs over the wound. 6. Place the client in a supine position without a pillow under the head.

1, 2, 3, 4 Rationale: Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low Fowler's position, and the client is kept quiet and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.

35. Which problem should the nurse identify as priority for client who is one (1) day postoperative? 1. Potential for hemorrhaging. 2. Potential for injury. 3. Potential for fluid volume excess. 4. Potential for infection.

1. All clients who undergo surgery are at risk for hemorrhaging, which is the priority problem.

23. The nurse received a report the elderly postoperative client became confused during the previous shift. Which client problem would the nurse include in the plan of care? 1. Risk for injury. 2. Altered comfort level. 3. Impaired circulation. 4. Impaired skin integrity.

1. Anytime the nurse has a client who is disoriented, the nurse must initiate fall fall/safety precautions.

31. The nurse and the unlicensed assistive personnel (UAP) are working on the surgical unit. Which task can the nurse delegate to the UAP? 1. Take routine vital signs on clients. 2. Check the Jackson Pratt insertion site. 3. Hang the client's next IV bag. 4. Ensure the client obtains pain relief.

1. Taking the vital signs of the stable client may be delegated to the UAP.

25. The PACU nurse is receiving the client from the OR. Which intervention should the nurse implement first? 1. Assess the client's breath sounds. 2. Apply oxygen via nasal cannula. 3. Take the client's blood pressure. 4. Monitor the pulse oximeter reading.

1. The airway should be assessed first. When caring for a client, the nurse should follow the ABCs: airway, breathing, and circulation.

24. The client one (1) day postoperative develops an elevated temperature. Which intervention would have priority for the client? 1. Encourage the client to deep breathe and cough every hour. 2. Encourage the client to drink 200 mL of water every shift. 3. Monitor the client's wound for drainage every eight (8) hours. 4. Assess the urine output for color and clarity every four (4) hours.

1. When a postoperative client develops a fever within the first 24 hours, the cause is usually in the respiratory system. The client should increase deep breathing and coughing to assist the client to expand the lungs and decrease pulmonary complications.

175. The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin

2 Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk.

29. The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature, and complains of muscle stiffness. Which interventions should the nurse implement? Select all apply. 1. Give a back rub to the client to relieve stiffness. 2. Apply ice packs to the axillary and groin areas. 3. Prepare an ice slush for the client to drink. 4. Prepare to administer dantrolene, a smooth-muscle relaxant. 5. Reposition the client on a warming blanket.

2, 4 1. A back rub is a therapeutic intervention, but it is not appropriate for a life-threatening complication of surgery. 2. Ice packs should be applied to the axillary and groin areas for a client experiencing malignant hyperthermia. 3. The client would be NPO to prepare for intubation, but an ice slush would be used to irrigate the bladder and stomach per nasogastric tube. 4. Dantrolene is the drug of choice for treatment. 5. Cooling blankets, not a warming blanket, are used to decrease the fast-rising temperature.

28. The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication? 1. Alteration in comfort. 2. Risk for depressed respiratory pattern. 3. Potential for infection. 4. Fluid and electrolyte imbalance.

2. A client with respiratory depression treated with Narcan can have another episode within 15 minutes after receiving the drug as a result of the short half-life of the medication.

33. Which statement would be an expected outcome for the postoperative client who had general anesthesia? 1. The client will be able to sit in the chair for 30 minutes. 2. The client will have a pulse oximetry reading of 97% on room air. 3. The client will have a urine output of 30 mL per hour. 4. The client will be able to distinguish sharp from dull sensations.

2. The anesthesia machine takes over the function of the lungs during surgery, so the expected outcome should directly reflect the client's respiratory status; the alveoli can collapse, causing atelectasis.

20. Which client assessment data are priority for the post-anesthesia care nurse? 1. Bowel sounds. 2. Vital signs. 3. IV fluid rate. 4. Surgical site.

2. The post-anesthesia care unit nurse should follow the ABCs format described by the American Heart Association. "A" is for airway, "B" is for breathing, and "C" is for circulation. Vital signs assess for hemodynamic stability; this is priority in the PACU.

34. The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first? 1. Apply antiembolism hose to the client. 2. Attach the drain to 20 cm suction. 3. Assess the client's vital signs. 4. Listen to the report from the anesthesiologist.

3. Assessing the client's status after transfer from the PACU should be the nurse's first intervention.

27. The surgical client's vital signs are T 98˚F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3) and the skin is pale and damp. Which intervention should the nurse implement first? 1. Call the surgeon and report the vital signs. 2. Start an IV of D5RL with 20 mEq KCl at 125 mL/hr. 3. Elevate the feet and lower the head. 4. Monitor the vital signs every 15 minutes.

3. By lowering the head of the bed and raising the feet, the blood is shunted to the brain until volume-expanding fluids can be administered, which is the first intervention for a client who is hemorrhaging.

19. Which nursing task would be most appropriate to delegate to the unlicensed assistive personnel (UAP) on a postoperative unit? 1. Change the dressing over the surgical site. 2. Teach the client how to perform incentive spirometry. 3. Empty and record the amount of drainage in the JP drain. 4. Auscultate the bowel sounds in all four (4) quadrants.

3. Emptying the drainage devices and recording the amounts on the bedside intake and output forms can be delegated.

36. The unlicensed assistive personnel (UAP) reports the vital signs for a first-day postoperative client as T 100.8˚F, P 80, R 24, and BP 148/80. Which intervention would be most appropriate for the nurse to implement? 1. Administer the antibiotic earlier than scheduled. 2. Change the dressing over the wound. 3. Have the client turn, cough, and deep breathe every two (2) hours. 4. Encourage the client to ambulate in the hall.

3. Having the client turn, cough, and deep breathe is the best intervention for the nurse to implement because, if a client has a fever within the first day, it is usually caused by a respiratory problem.

21. The male client in the day surgery unit complains of difficulty urinating postoperatively. Which intervention should the nurse implement? 1. Insert an indwelling catheter. 2. Increase the intravenous fluid rate. 3. Assist the client to stand to void. 4. Encourage the client to increase fluids.

3. Helping the male client to stand can offer the assistance needed to void. The safety of the client should be ensured.

26. Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia? 1. Loss of sensation at the lumbar (L5) dermatome. 2. Absence of the client's posterior tibial pulse. 3. The client has a respiratory rate of eight (8). 4. The blood pressure is within 20% of client's baseline.

3. If the effects of the spinal anesthesia move up rather than down the spinal cord, respirations can be depressed and even blocked.

22. The postoperative client complains of hearing a "popping sound" and feeling "something opening" when ambulating in the room. Which intervention should the nurse implement first? 1. Notify the surgeon the client has had an evisceration. 2. Contact the surgery department to prepare for emergency surgery. 3. Assess the operative site and cover the site with a moistened dressing. 4. Explain this is a common feeling and tell the client to continue with activity.

3. The nurse should assess the surgical site and, if the site has eviscerated, cover the opening with a sterile dressing moistened with sterile 0.9% saline. This will prevent the tissues from becoming dry and infected.

25. Which statement made by the client who is postoperative abdominal surgery indicates the discharge teaching has been effective? 1. "I will take my temperature each week and report any elevation." 2. "I will not need any pain medication when I go home." 3. "I will take all of my antibiotics until they are gone." 4. "I will not take a shower until my three (3)-month checkup."

3. This statement about taking all the antibiotics ordered indicates the teaching is effective.

32. The charge nurse is making shift assignments. Which postoperative client should be assigned to the most experienced nurse? 1. The 4-year-old client who had a tonsillectomy and is able to swallow fluids. 2. The 74-year-old client with a repair of the left hip who is unable to ambulate. 3. The 24-year-old client who had an uncomplicated appendectomy the previous day. 4. The 80-year-old client with small bowel obstruction and congestive heart failure.

4. An older client with a chronic disease would be a complicated case, requiring the care of a more experienced nurse.

30. Which data indicate to the nurse the client who is one (1) day postoperative right total hip replacement is progressing as expected? 1. Urine output was 160 mL in the past eight (8) hours. 2. Paralysis and parasthesia of the right leg. 3. T 99.0˚F, P 98, R 20, and BP 100/60. 4. Lungs are clear bilaterally in all lobes.

4. Lung sounds which are clear bilaterally in all lobes indicate the client has adequate gas exchange, which prevents postoperative complications and indicates effective nursing care.

18. The client received naloxone (Narcan), an opioid antagonist, in the post-anesthesia care unit. Which nursing intervention should the nurse include in the care plan? 1. Measure the client's intake and output hourly. 2. Administer sleep medications at night. 3. Encourage the client to verbalize feelings. 4. Monitor respirations every 15 to 30 minutes.

4. Narcan is given to reverse respiratory depression from opioid analgesic medications and has a short half-life. The client may experience a rebound respiratory depression in 15 to 20 minutes, so this nursing intervention of monitoring respirations every 15 to 30 minutes is appropriate.

6. Discharge planning should begin on: A. the day of admission. B. the day after surgery. C. the day of discharge. D. the day of surgery.

A. Although the day of admission may also be the day of surgery, planning for the patient's discharge should begin on admission and first contact with the patient.

7. Denise is recovering from an open cholecystectomy. You know that because of the location of the surgery, she has an increased risk of postoperative: (a) myocardial infarction. (b) respiratory complications. (c) deep vein thrombosis. (d) wound infection.

B

8. Three days after surgery, Mark notices that the wound site is more painful now than it was the day before. When you inspect the surgical site you are looking for redness or inflammation. Other indicators of infection would include: (a) elevated RBC and elevated respiratory rate. (b) elevated WBC and elevated temperature. (c) elevated erythrocyte sedimentation rate and decreased pulse. (d) decreased platelets and decreased blood pressure.

B

4. The reason that patients are sent to a PACU after surgery is: A. to be monitored while recovering from anesthesia. B. to remain near the surgeon immediately after surgery. C. to allow the medical-surgical unit time to prepare for transfer. D. to provide time for the patient to cope with the effects of surgery.

Answer: A. Patients are sent to a PACU to be monitored while they're recovering from anesthesia.

9. Paralytic ileus may occur as a postoperative complication. Which of the following patients would cause you the greatest concern about the development of paralytic ileus? (a) Kim, a 27-year-old postlaparscopic appendectomy. (b) Joyce, a 39-year-old post-open right hemicolectomy. (c) Nancy, a 56-year-old postmediastinoscopy. (d) John, a 47-year-old post-total joint replacement.

B

2. In teaching about postoperative pain management, a nurse-educator should discuss: A. the need to use pain medication only when absolutely necessary. B. that pain medication will be ordered and given according to the patient's needs. C. how the method of pain medication administration can't be altered after surgery. D. the need to limit narcotics to avoid addiction.

B. The patient should be aware that pain medication will be ordered and given according to his needs. Because each patient responds differently to pain and medication, dosage and administration is individualized.

10. Steve has developed pneumonia following intrathoracic surgery performed last week. Treatment for postoperative pneumonia would most likely include: (a) a cephalosporin, such as cefazolin. (b) a penicillin, such as amoxicillin. (c) a fluoroquinolone, such as levofloxacin. (d) a tetracycline, such as doxycycline.

C

5. To help prevent postoperative complications, the nurse should: A. have the patient rest quietly for the first 24 hours with minimal exertion. B. have the patient splint his incision and take deep, rapid breaths before moving. C. encourage the patient to begin exercising as soon as possible after surgery. D. encourage the patient to drink increased fluids beginning immediately after surgery.

C. Early postoperative exercises and ambulation can significantly improve circulation, ventilation, and psychological outlook.

26. The client diagnosed with appendicitis has undergone an appendectomy. At two (2) hours postoperative, the nurse takes the vital signs and notes T 102.6˚F, P 132, R 26, and BP 92/46. Which interventions should the nurse implement? List in order of priority. 1. Increase the IV rate. 2. Notify the health-care provider. 3. Elevate the foot of the bed. 4. Check the abdominal dressing. 5. Determine if the IV antibiotics have been administered.

In order of priority: 1, 3, 4, 5, 2. 1. The nurse should increase the IV rate to maintain the circulatory system function until further orders can be obtained. 3. The foot of the bed should be elevated to help treat shock, the symptoms of which include elevated pulse and decreased blood pressure. Those signs and an elevated temperature indicate an infection may be present and the client could be developing septicemia. 4. The dressing should be assessed to determine if bleeding is occurring. 5. The nurse should administer any IV antibiotics ordered after addressing hypovolemia. The nurse will need this information when reporting to the health-care provider. 2. The health-care provider should be notified when the nurse has the needed information.

10. Priority Decision: A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess for first in the patient? a. Hypoxemia b. Neurologic injury c. Distended bladder d. Cardiac dysrhythmias

a. The most common cause of emergence delirium is hypoxemia and initial assessment should evaluate respiratory function. When hypoxemia is ruled out, other causes, such as a distended bladder, pain, and fluid and electrolyte disturbances, should be considered. Delayed awakening may result from neurologic injury and cardiac dysrhythmias most often result from specific respiratory, electrolyte, or cardiac problems.

1. What does progression of patients through various phases of care in a postanesthesia care unit (PACU) primarily depend on? a. Condition of patient b. Type of anesthesia used c. Preference of surgeon d. Type of surgical procedure

a. Although some surgical procedures and drug administration require more intensive postanesthesia care, how fast and through which levels of care patients are moved depend on the condition of the patient. A physiologically unstable outpatient may stay an extended time in Phase I, whereas a patient requiring hospitalization but who is stable and recovering may well be transferred quickly to an inpatient unit.

11. The PACU nurse applies warm blankets to a postoperative patient who is shivering and has a body temperature of 96.0°F (35.6°C). What treatment also may be used to treat the patient? a. Oxygen b. Vasodilating drugs c. Antidysrhythmic drugs d. Analgesics or sedatives

a. During hypothermia, oxygen demand is increased and metabolic processes slow down. Oxygen therapy is used to treat the increased demand for oxygen. Antidysrhythmics and vasodilating drugs would be used only if the hypothermia caused symptomatic cardiac dysrhythmias and vasoconstriction. Sedatives and analgesics are not indicated for hypothermia.

6. With what are the postoperative respiratory complications of atelectasis and aspiration of gastric contents associated? a. Hypoxemia b. Hypercapnia c. Hypoventilation d. Airway obstruction

a. Hypoxemia occurs with atelectasis and aspiration as well as pulmonary edema, pulmonary embolism, and bronchospasm. Hypercapnia is caused by decreased removal of CO2 from the respiratory system that could occur with airway obstruction or hypoventilation. Hypoventilation may occur with depression of central respiratory drive, poor respiratory muscle tone due to disease or anesthesia, mechanical restriction, or pain. Airway obstruction could occur with the tongue blocking the airway, restrained thick secretions, laryngospasm, or laryngeal edema.

18. Priority Decision: The nurse notes drainage on the surgical dressing when the patient is transferred from the PACU to the clinical unit. In what order of priority should the nurse do the following actions? Number the options with 1 for the first action and 5 for the last action. _______ a. Reinforce the surgical dressing. _______ b. Change the dressing and assess the wound as ordered. _______ c. Notify the surgeon of excessive drainage type and amount. _______ d. Recall the report from PACU for the number and type of drains in use. _______ e. Note and record the type, amount, and color and odor of the drainage.

a. 2; b. 5; c. 4; d. 1; e. 3. The nurse must be aware of drains, if used, and the type of surgery to help predict the expected drainage. Dressings over surgical sites are initially removed by the surgeon unless otherwise specified and should not be changed, although reinforcing the dressing is appropriate. Some drainage is expected for most surgical wounds and the drainage should be evaluated and recorded to establish a baseline for continuing assessment. The surgeon should be notified of excessive drainage. Dressings will then be changed as ordered with assessment for infection being done as well.

13. For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation been found to be an appropriate intervention (select all that apply)? a. Impaired skin integrity related to incision b. Impaired mobility related to decreased muscle strength c. Risk for aspiration related to decreased muscle strength d. Ineffective airway clearance related to decreased respiratory excursion e. Constipation related to decreased physical activity and impaired gastrointenstinal (GI) motility f. Venous thromboembolism related to dehydration, immobility, vascular manipulation, or injury

b, d, e, f. These problems are improved with ambulation. Other collaborative problems could be potential complications: urinary retention, atelectasis, and pneumonia.

5. What is included in the routine assessment of the patient's cardiovascular function on admission to the PACU? a. Monitoring arterial blood gases b. Electrocardiographic (ECG) monitoring c. Determining fluid and electrolyte status d. Direct arterial blood pressure monitoring

b. ECG monitoring is performed on patients to assess initial cardiovascular problems during anesthesia recovery. Fluid and electrolyte status is an indication of renal function and determinations of arterial blood gases and direct arterial blood pressure monitoring are used only in special cardiovascular or respiratory problems.

4. To prevent agitation during the patient's recovery from anesthesia, when should the nurse begin orientation explanations? a. When the patient is awake b. When the patient first arrives in the PACU c. When the patient becomes agitated or frightened d. When the patient can be aroused and recognizes where he or she is

b. Even before patients awaken from anesthesia, their sense of hearing returns and all activities should be explained by the nurse from the time of admission to the PACU to assist in orientation and decrease confusion.

16. Which tubes drain gastric contents (select all that apply)? a. T-tube b. Hemovac c. Nasogastric tube d. Indwelling catheter e. Gastrointestinal tube

c, e. The nasogastric tube and gastrointestinal tube drain gastric contents. The T-tube drains bile, the Hemovac drains blood from a surgical site, and the indwelling catheter drains urine from the bladder.

21. What should be included in the instructions given to the postoperative patient before discharge? a. Need for follow-up care with home care nurses b. Directions for maintaining routine postoperative diet c. Written information about self-care during recuperation d. Need to restrict all activity until surgical healing is complete

c. All postoperative patients need discharge instructions regarding what to expect and what self-care can be assumed during recovery. Diet, activities, follow-up care, symptoms to report, and instructions about medications are individualized to the patient.

9. While assessing a patient in the PACU, the nurse finds that the patient's blood pressure is below the preoperative baseline. The nurse determines that the patient has residual vasodilating effects of anesthesia when what is assessed? a. A urinary output >30 mL/hr b. An oxygen saturation of 88% c. A normal pulse with warm, dry, pink skin d. A narrowing pulse pressure with normal pulse

c. Hypotension with normal pulse and skin assessment is typical of residual vasodilating effects of anesthesia and requires continued observation. An oxygen saturation of 88% indicates hypoxemia, whereas a narrowing pulse pressure accompanies hypoperfusion. A urinary output >30 mL/hr is desirable and indicates normal renal function.

8. Priority Decision: To promote effective coughing, deep breathing, and ambulation in the postoperative patient, what is most important for the nurse to do? a. Teach the patient controlled breathing b. Explain the rationale for these activities c. Provide adequate and regular pain medication d. Use an incentive spirometer to motivate the patient

c. Incisional pain is often the greatest deterrent to patient participation in effective ventilation and ambulation and adequate and regular analgesic medications should be provided to encourage these activities. Controlled breathing may help the patient to manage pain but does not promote coughing and deep breathing. Explanations and use of an incentive spirometer help to gain patient participation but are more effective if pain is controlled.

12. Which patient is ready for discharge from Phase I PACU care to the clinical unit? a. Arouses easily, pulse is 112 bpm, respiratory rate is 24, dressing is saturated, SaO2 is 88% b. Difficult to arouse, pulse is 52, respiratory rate is 22, dressing is dry and intact, SaO2 is 91% c. Awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92% d. Arouses, blood pressure (BP) higher than preoperative and respiratory rate is 10, no excess bleeding, SaO2 is 90%

c. On initial assessment in PACU the airway, breathing, and circulation (ABC) status is assessed using a standardized tool that usually includes consciousness, respiration, oxygen saturation, circulation, and activity. Increased or decreased respiratory rate, hypertension, and a SaO2 below 90% indicate inadequate oxygenation that will be treated or managed in the PACU before discharging the patient to the next phase.

2. Priority Decision: Upon admission of a patient to the PACU, the nurse's priority assessment is a. vital signs. b. surgical site. c. respiratory adequacy. d. level of consciousness.

c. Physiologic status of the patient is always prioritized with regard to airway, breathing, and circulation, and respiratory adequacy is the first assessment priority of the patient on admission to the PACU from the operating room. Following assessment of respiratory function, cardiovascular, neurologic, and renal function should be assessed as well as the surgical site.

15. In addition to ambulation, which nursing intervention could be implemented to prevent or treat the postoperative complication of syncope? a. Monitor vital signs after ambulation b. Do not allow the patient to eat before ambulation c. Slowly progress to ambulation with slow changes in position d. Have the patient deep breathe and cough before getting out of bed

c. Slow progression to ambulation by slowly changing the patient's position will help to prevent syncope. Monitoring vital signs after walking will not prevent or treat syncope. Monitor the patient's pulse and blood pressure (BP) before, during, and after position changes. Elevate the patient's head, then slowly have the patient dangle, then stand by the bed to help determine if the patient is safe for walking. Eating will not have an effect on syncope. Deep breathing and coughing will not decrease syncope, although it will prevent respiratory complications.

3. How is the initial information given to the PACU nurses about the surgical patient? a. A copy of the written operative report b. A verbal report from the circulating nurse c. A verbal report from the anesthesia care provider (ACP) d. An explanation of the surgical procedure from the surgeon

c. The admission of the patient to the PACU is a joint effort between the ACP, who is responsible for supervising the postanesthesia recovery of the patient, and the PACU nurse, who provides care during anesthesia recovery. The ACP gives a verbal report that presents the details of the surgical and anesthetic course, preoperative conditions influencing the surgical and anesthetic outcome, and PACU treatment plans to ensure patient safety and continuity of care.

14. A patient who had major surgery is experiencing emotional stress as well as physiologic stress from the effects of surgery. What can this stress cause? a. Diuresis b. Hyperkalemia c. Fluid retention d. Impaired blood coagulation

c. The stress response causes fluid retention during the first 1 to 3 days postoperatively and fluid overload is possible during this time. Fluid retention results from secretion and release of antidiuretic hormone (ADH) and adrenocorticotropic hormone (ACTH) by the pituitary and activation of the renin-angiotensin-aldosterone system (RAAS). ACTH stimulates the adrenal cortex to secrete cortisol and aldosterone. The RAAS increases aldosterone release, which also increases fluid retention. Aldosterone causes renal potassium loss with possible hypokalemia and blood coagulation is enhanced by cortisol.

7. To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, what will the nurse do? a. Encourage deep breathing b. Elevate the head of the bed c. Administer oxygen per mask d. Position the patient in a side-lying position

d. An unconscious or semiconscious patient should be placed in a lateral position to protect the airway from obstruction by the tongue. Deep breathing and elevation of the head of the bed are implemented to facilitate gas exchange when the patient is responsive. Oxygen administration is often used but the patient must first have a patent airway.

20. The health care provider has ordered IV morphine q2-4hr PRN for a patient following major abdominal surgery. When should the nurse plan to administer the morphine? a. Before all planned painful activities b. Every 2 to 4 hours during the first 48 hours c. Every 4 hours as the patient requests the medication d. After assessing the nature and intensity of the patient's pain

d. Before administering all analgesic medications, the nurse should first assess the nature and intensity of the patient's pain to determine if the pain is expected, prior doses of the medication have been effective, and any undesirable side effects are occurring. The administration of PRN analgesic medication is based on the nursing assessment. If possible, pain medication should be in effect during painful activities but activities may be scheduled around medication administration.

17. Which drainage is drained with a Hemovac? a. Bile b. Urine c. Gastric contents d. Wound drainage

d. Bile is drained by a T-tube, urine is drained by an indwelling urinary catheter, and gastric contents are drained by a nasogastric tube or a gastrointestinal tube.

19. Thirty-six hours postoperatively a patient has a temperature of 100°F (37.8°C).What is the most likely cause of this temperature elevation? a. Dehydration b. Wound infection c. Lung congestion and atelectasis d. Normal surgical stress response

d. During the first 24 to 48 postoperative hours, temperature elevations to 100.4°F (38°C) are a result of the inflammatory response to surgical stress. Dehydration and lung congestion or atelectasis in the first 2 days will cause a temperature elevation above 100.4°F (38°C). Wound infections usually do not become evident until 3 to 5 days postoperatively and manifest with temperatures above 100°F (37.8°C).