CH 19 EAQ Postoperative Care

A postoperative patient is transferred from the postanesthesia unit to the medical-surgical nursing floor. The nurse notes that the patient has a prescription for D 5½ normal saline (NS) to infuse at 120 mL/hr. The nurse regulates the intravenous (IV) at what flow rate in drops (gtts)/min, noting that the tubing has a drop factor of 10 drops/mL? Fill in the blank using a whole number.

ANS: 20 gtts/min 120 mL/hr × 10 gtts/mL = 1200 gtts/hr 1200 gtts ÷ 60 min = 20 gtts/min

The nurse is educating a patient that had a coronary bypass graft (CABG) about the risk of venous thromboembolism (VTE). What should the nurse be sure to include in the education to the patient? a. Early ambulation b. Turning every 2 hours c. Splinting chest while coughing d. Importance of taking pain medication

ANS: A Activity has proven vital in helping to prevent postoperative VTEs. Other forms of treatment include anticoagulants and sequential compression devices (SCDs). Splinting the chest while coughing, taking pain medication, and turning every 2 hours are important for the recovery of the coronary bypass patient but have little impact on preventing VTE.

A patient's blood pressure increases from 110/76 mm Hg to 160/90 mm Hg two hours after a cholecystectomy. What action should the nurse take first? a. Assess pain level. b. Reposition the patient. c. Decrease the intravenous (IV) fluid rate. d. Restart the patient's antihypertensive medication.

ANS: A Treatment for hypertension focuses on the source of the problem. Pain often causes a rise in blood pressure. If a patient becomes hypertensive, the nurse should begin with assessing and treating the pain. Repositioning will not lower the blood pressure. Per prescription of the primary health care provider, decreasing the IV fluid and administering an antihypertensive medication may be appropriate but are not the first nursing interventions.

The nurse is monitoring a postoperative patient in the Phase I postanesthesia care unit (PACU). What criteria must the patient meet in order to be discharged from this phase? Select all that apply. a. No nausea or vomiting b. No respiratory depression c. Oxygen saturation above 90% d. Written discharge instructions understood e. Patient reports pain level of 4 on a 1 to 10 scale

ANS: B C E Discharge criteria from Phase I are listed in Table 20-8 and include oxygen saturation above 90%; no respiratory depression; and pain controlled or tolerable. Nausea and vomiting should be minimal. Understanding written discharge instructions are part of Phase II discharge criteria.

A patient who is still drowsy and recovering from anesthesia has been vomiting. How can the nurse prevent aspiration in this patient? a. Avoid using suctioning devices. b. Position the patient in prone position. c. Position the patient in supine position. d. Place the patient in lateral recovery position.

ANS: D Aspiration of the vomitus can be prevented by placing the patient in the lateral recovery position. This position helps the vomitus escape through the mouth. A suctioning device may be used to remove the vomitus to prevent aspiration. Supine and prone positions are less helpful in preventing aspiration than the lateral recovery position.

An older patient is having problems with concentration and memory after extensive surgery to repair an abdominal aortic aneurysm. What determines if this is a factor of delirium or postoperative cognitive dysfunction? a. Preexisting dementia identified before surgery b. Ability of the patient to state name, location, and date c. Ability to ambulate in the halls and follow commands d. An undisturbed sleep-wake cycle in the critical care unit

ANS: A Dementia should be assessed preoperatively so interventions can be established after surgery to help the patient meet outcomes. Orientation of name, location, and date and ability to ambulate in halls and follow commands do not determine differences in concentration and memory. A disturbed sleep-wake cycle may cause postoperative cognitive dysfunction.

An older adult patient has a complication after a cardiac catheterization and has to remain in the intensive care unit (ICU) for an extra three days. For what is the patient most at risk? a. Delirium b. Depression c. Alcohol withdrawal d. Aggressive behaviors

ANS: A Older adult patients who spend prolonged amounts of time in the ICU are at risk for delirium caused by ICU psychosis. Aggressive behaviors and depression can also be parts of ICU psychosis, but this disorder is most often characterized by delirium. There is not enough information in this scenario to determine if the patient is at risk for alcohol withdrawal.

A patient undergoes abdominal surgery. Before asking the patient to perform postoperative breathing exercises, what evaluation or intervention should the nurse perform? a. Gauging the patient's level of pain b. Evaluating the patient's vital signs c. Assisting the patient out of bed and into a chair d. Reviewing the primary health care provider's plan of care

ANS: A Pain management is essential to postoperative care. Assessing the level of pain and offering an analgesic before performing postoperative breathing exercises or any activities will ease pain and facilitate compliance, thus decreasing the risk of complications. Checking vital signs, assisting the patient into a chair, and reviewing the primary health care provider's plan of care are all appropriate after the patient's pain level has been assessed.

A patient with asthma develops wheezing on the postanesthesia care unit. The nurse finds that the patient is tachypneic, has dyspnea, and has reduced oxygen saturation. How will the nurse prevent further pulmonary complications? a. Administer bronchodilators. b. Provide incentive spirometry. c. Encourage chest physical therapy. d. Provide nebulization of histamine vapors.

ANS: A The presence of wheeze, tachypnea, and reduced oxygen saturation indicates bronchospasm. The use of bronchodilators relieves bronchospasm and promotes a patent airway. Incentive spirometry is useful in managing atelectasis when the airway is patent. Chest physical therapy is helpful to clear secretions from the respiratory tract. Histamine vapors aggravate bronchospasm and therefore should be avoided.

The nurse is reinforcing deep breathing and coughing techniques to a postoperative patient with an abdominal incision. Which important instruction should the nurse include in her teaching regarding safe use of this technique? a. Splint the abdominal incision with a pillow. b. Perform the technique two times every waking hour. c. Limit fluid intake to thicken the secretions and membranes. d. Encourage deep breathing and coughing if the patient is in pain or feels the urge to clear secretions.

ANS: A When performing deep breathing and coughing exercises, the patient should splint the abdominal incision site with a pillow or folded blankets to support the incision. The patient may be instructed to perform the technique 10 times every hour if the condition allows. The nurse should assure the patient that the breathing and coughing techniques will not harm the incision site and are essential to mobilizing secretions. The patient should be instructed to drink sufficient water to keep the secretions thin.

The nurse is caring for a patient in the postanesthesia care unit (PACU) when they become agitated. What is the priority action by the nurse? Select all that apply. a. Put the side rails up. b. Evaluate respiratory status. c. Monitor fluid intake and output. d. Use clocks to orient the patient if needed. e. Sedate the patient, if the patient is not hypoxemic.

ANS: A B D E Hypoxemia is the most common cause of postoperative agitation. Therefore the nurse should first evaluate the respiratory status of the patient. If the patient is not hypoxemic, and other causes are ruled out, sedation can be given to calm the patient. It is important to ensure patient safety at this time, so the nurse should put the side rails up, secure all equipment, and monitor the physiologic status. Clocks are used to orient the patient who experiences postoperative cognitive dysfunction or delirium. Monitoring fluid intake and output is a general activity during the postoperative period and not specific to delirium.

A nurse is assisting a postoperative patient with ambulation. What benefits of early ambulation should the nurse explain to the patient? Select all that apply. a. It stimulates circulation. b. It improves muscle tone. c. It promotes venous stasis. d. It decreases vital capacity. e. It prevents thrombus embolism.

ANS: A B E Early ambulation is the most significant general nursing measure to prevent postoperative complications. Early ambulation increases muscle tone and strength and promotes venous return. This is turn improves circulation, which prevents formation of thrombus in the blood vessels. Early ambulation increases vital capacity by promoting lung expansion, and prevents venous stasis.

A nurse cares for a patient with acute pulmonary edema. What findings would the nurse expect to assess? a. Vertigo and headache b. Palpitations and nausea c. Anxiety and distended neck veins d. Dry, hacking cough and chest pain

ANS: C The patient experiencing acute pulmonary edema would most likely experience anxiety related to hypoxia. Distended neck veins would be present because of decreased cardiac output resulting in right-sided heart congestion, causing blood to back up into the neck veins. Vertigo and headaches, and palpitations and nausea, may be present but are not as distinct and common as anxiety, distended neck veins, and shortness of breath. The cough associated with pulmonary edema will be moist and productive. In severe cases, this may present as pink and frothy sputum. Chest pain may also be present.

A patient with a history of venous thrombosis had major abdominal surgery. Which nursing interventions are helpful in preventing the development of venous thrombosis? Select all that apply. a. Corticosteroids b. Use of diuretics c. Use of dalteparin d. Delayed ambulation e. Sequential compression devices

ANS: C E Dalteparin is an anticoagulant that may be used as prophylactic agent to prevent development of venous thrombosis. Sequential compression devices also help prevent development of venous thrombosis by promoting venous return. Diuretics help remove excess fluid from the body; however, they do not help prevent thromboembolism. Corticosteroids suppress the immune response but have no effect on blood clotting. Late ambulation is a risk factor for venous thrombosis.

The nurse is caring for a group of patients. What patient should the nurse be sure to institute interventions for the prevention of thrombophlebitis? a. A patient with a 25-year smoking history b. A female patient in the fifth month of pregnancy c. An older adult patient taking anticoagulant medications d. A hospitalized patient who has been on bed rest for 3 days

ANS: D Patients at highest risk for thrombophlebitis are those who stand, sit, or remain on bed rest for prolonged periods. Hypercoagulable states, such as pregnancy, and vessel wall trauma due to the effects of smoking also may place a person at risk for thrombophlebitis. An older adult patient taking anticoagulant medications would be at less risk for thrombophlebitis.

A postoperative patient develops fever, abdominal pain, and diarrhea despite being on long-term antibiotics. What should the nurse evaluate for? a. Wound infection b. Urinary infection c. Respiratory infection d. Clostridium difficile infection

ANS: D Prolonged use of antibiotics increases the risk of Clostridium difficile infection by damaging the normal flora of the intestine. The infection is manifested as fever, diarrhea, and abdominal pain. Wound infection, urinary infection, and respiratory infection may present with fever, but these infections rarely present with diarrhea and abdominal pain.

A patient is having elective cosmetic surgery performed on the face. The patient will remain at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? a. Manage patient pain b. Control the bleeding c. Maintain fluid balance d. Manage oxygenation status

ANS: D The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise the patient's ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase the risk for upper airway edema, causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.

A patient is being discharged after having a laparoscopic cholecystectomy. The nurse should instruct the patient to notify the surgeon immediately if which condition develops? a. Constipation b. Right shoulder pain c. Decreased appetite d. Temperature of 103° F

ANS: D The primary health care provider should be notified immediately if the patient experiences an increase in temperature higher than 101° F because this may be indicative of an infectious process that will require immediate interventions to resolve. Right shoulder pain is expected after a laparoscopic surgery and is resolved within 48 to 72 hours. Constipation and decreased appetite may occur. If these do not resolve after discharge, the patient should be instructed to contact the primary health care provider.

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure of 100/60 mm Hg. Which action should the nurse take first? a. Rouse the patient. b. Place the patient in the Trendelenburg position. c. Notify the anesthesiologist of the low blood pressure. d. Check the medical record for the patient's baseline blood pressure.

ANS: D The first action of the nurse is to identify what the patient's normal blood pressure is. Interventions are dependent on the baseline variation. Rousing the patient is an intervention that can increase the blood pressure, but would be done after determining the baseline blood pressure. Placing the patient in Trendelenburg is not an appropriate action in this situation. Before notifying the anesthesiologist of the blood pressure, the nurse needs to check the baseline blood pressure.

A patient with a history of psychosis has newly developed anxiety and is combative with the nurse. What does the nurse know may be causes of this change in behavior? a. Delirium b. Excessive sleep c. Hyperoxygenation d. Electrolyte imbalances

ANS: D The nurse knows electrolyte imbalances can cause an acute change in a patient's behavior. A new onset of anxiety and combativeness may cause delirium rather than the other way around. Sleep deprivation, not excessive sleep, would cause anxiety and aggression. Hyperoxygenation would not cause such behavior changes; hypoxemia does.

The nurse is caring for a patient in the postanesthesia care unit (PACU), when the blood pressure drops from 110/60 mm HG to 92/58 mm Hg. What actions should the nurse take? Select all that apply. a. Assess ECG tracing. b. Inspect the surgical site. c. Administer pain medication. d. Administer prescribed metoprolol. e. Have the patient take deep breaths. f. Administer intravenous (IV) fluid bolus per protocol.

A B E F

The nurse is preparing to administer cefazolin 2 gm in 100 mL of normal saline to a postoperative patient. What infusion rate on the infusion pump will infuse this medication over 20 minutes? Record your answer using a whole number.

ANS: 300 mL/hr Volume ÷ time in hours = rate in mL/hr. Therefore, 100 mL ÷ 0.33 hr (20 min) = 300 mL/hr.

A patient with a history of bipolar disorder underwent an amputation of the left leg. The patient has diabetes and a complicated diabetic foot ulcer. Which factor will best determine the patient's ability to cope? a. Ability to regain independence b. Previous diagnosis of depression c. Anxiety during the discharge process d. Ability to complete the rehabilitation program

ANS: A Ability to regain independence will be the biggest factor in the patient's ability to cope after an amputation. Completing the rehabilitation program will help the patient meet this goal of independence. A previous diagnosis of depression and anxiety during the discharge process may cause problems with coping, but regaining independence is the biggest factor in the patient's coping ability.

While caring for a patient after a colectomy on the first postoperative day, the nurse notes new bright-red drainage about 4 cm in diameter on the surgical dressing. What is the priority nursing action? a. Take the patient's vital signs. b. Mark the area on the dressing and document the finding. c. Recheck the dressing in one hour for increased drainage. d. Notify the health care provider of a potential hemorrhage.

ANS: A The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse then can report the findings to the provider. Marking the area is acceptable, but not the priority nursing action. Rechecking the dressing in an hour increases the risk of adverse outcomes by waiting more time to notify the health care provider about a potential bleeding complication. The health care provider should be notified after the nurse assesses the patient.

A postoperative patient with bronchial obstruction has a pulse oximetry reading of 87%. What does the nurse suspect is occurring with this patient? a. Atelectasis b. Bronchospasm c. Hypoventilation d. Pulmonary embolism

ANS: A The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.

A patient had an estimated blood loss of 400 mL during abdominal surgery. The patient received 300 mL of 0.9% saline during surgery and now is experiencing hypotension postoperatively. What should the nurse anticipate for this patient? a. Restoring circulating volume b. Monitor pulse and blood pressure c. An ECG to check circulatory status d. Return to surgery to check for internal bleeding

ANS: A The nurse should anticipate restoring circulating volume with intravenous (IV) infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. The nurse will need to do more than monitor pulse and blood pressure. An ECG may be done if there is no response to the fluid administration or there is a past history of cardiac disease or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if the patient's level of consciousness changes or the abdomen becomes firm and distended.

A patient that is an alcoholic had a hernia operation and is restless and irritable. On assessment, the nurse finds that the patient has auditory hallucinations. What is the most appropriate nursing action? a. Conclude that these effects are due to alcohol withdrawal. b. Consider the situation normal, due to the anesthetic drugs. c. Conclude that the patient suffers from a psychotic disorder. d. Infer that the patient is suffering from pain and suggest using pain killers.

ANS: A The patient is irritable and restless due to loss of the inhibitory effects of alcohol; this is also causing the hallucinations. The patient does not have a history of psychotic illness; therefore, the symptoms cannot be attributed to a psychotic disorder. Anesthetic drugs may cause delirium, but not hallucinations. Pain may cause restlessness and irritability, but not hallucinations.

A patient reports abdominal distention and gas pains after abdominal surgery. What nursing action(s) will help to treat the problem? Select all that apply. a. Ambulate the patient b. Reposition frequently c. Administer bisacodyl d. Turn patient onto left side e. Administer morphine sulfate f. Discontinue the nasal gastric tube (NGT)

ANS: A B C Ambulating, repositioning the patient, and administering bisacodyl all help to relieve gas after surgery. Morphine sulfate tends to cause constipation and may increase abdominal pain because of distention. Turning the patient onto the right side, not left side, helps the gas to move into the transverse colon and then into the rectum. Discontinuing the NGT too early can increase abdominal distention.

A patient with a history of deep vein thrombosis is recovering in the postanesthesia care unit (PACU) after an abdominal surgery. Considering that the patient is at risk of developing pulmonary embolism (PE), what signs should the nurse watch out for? Select all that apply. a. Dyspnea b. Tachypnea c. Tachycardia d. Coarse crackles e. Noisy respirations

ANS: A B C PE can be recognized by the presence of tachycardia, tachypnea, and dyspnea, especially if the patient is already receiving oxygen therapy. PE may occur in a postoperative patient who already has a history of deep vein thrombosis and is an older adult. Other symptoms of PE may include agitation, chest pain, hypotension, hemoptysis, dysrhythmias, and heart failure. Coarse crackles and noisy respirations may happen if thick secretions are present in the airway.

A patient inadvertently received a large amount of intravenous fluid. The nurse assesses that the patient has reduced oxygen saturation, crackles on auscultation, and infiltrates on chest x-ray. How should the nurse relieve the patient's breathing discomfort and promote oxygen saturation? Select all that apply. a. Restrict fluids. b. Administer diuretics. c. Administer oxygen therapy. d. Administer bronchodilators. e. Implement anticoagulant therapy.

ANS: A B C The breathing difficulty in the patient is due to the development of pulmonary edema caused by the infusion of a large volume of fluids. The patient would be relieved of pulmonary edema by fluid restriction. Use of diuretics would reduce the volume load. Oxygen therapy would help maintain adequate oxygenation saturation levels. Bronchodilators may help patients with constriction of the bronchi, but that is not the case with this patient. Anticoagulant therapy prevents the blood from clotting but may not be helpful in relieving pulmonary edema.

A postoperative patient who has been transferred from surgery to the postanesthesia care unit is cold and shivering. The patient's plan of care includes a prescription for morphine to be administered for pain relief. When managing this patient, which interventions should the nurse perform? Select all that apply. a. Use forced air warmers. b. Administer oxygen therapy. c. Administer warmed IV fluids. d. Use warmed cotton blankets. e. Withhold morphine until shivering stops.

ANS: A B C D Administering warm liquids and using forced air warmers are active warming methods. Using warmed cotton blankets is a passive warming measure. Oxygen therapy is needed to meet the increased oxygen demand during shivering. Opioids are used to treat shivering in the immediate postoperative period, so the nurse should not withhold the morphine dose.

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge? Select all that apply. a. Vital signs baseline or stable b. Minimal nausea and vomiting c. Wants to go to the bathroom at home d. Responsible adult taking patient home e. Comfortable after intravenous (IV) opioid 15 minutes ago

ANS: A B D Ambulatory surgery discharge criteria include meeting Phase I postanesthesia care unit (PACU) discharge criteria, which include vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria include a responsible adult driving patient, no IV opioid drugs for the last 30 minutes, ability to void, ability to ambulate if not contraindicated, and receiving written discharge instruction, with patient understanding confirmed.

The nurse places an abdominal binder on a patient after colon surgery. After approximately an hour, the nurse assesses the patient has shallow respirations, is hypoxemic, and hypercapnic. How should the nurse promote optimal breathing in this patient? Select all that apply. a. Loosen the binder b. Reposition the patient c. Provide music therapy d. Elevate the foot end of bed e. Raise the head end of the bed

ANS: A B E The hypoventilation observed in this patient is due to mechanical restriction caused by the abdominal binder. Therefore the patient should be repositioned to improve comfort and the binder should be loosened to relieve the constriction. Raising the head end of the bed would promote lung expansion and facilitate breathing. Music therapy may relax the patient but would not relieve the mechanical restriction. Elevating the foot end of the bed would further aggravate the patient's condition.

The nurse is preparing to administer an analgesic to a postoperative patient. What actions taken by the nurse would be appropriate? Select all that apply. a. Assess the location, quality, and intensity of pain. b. Monitor the patient for nausea, vomiting, and respiratory depression. c. Assess the patient's sleep/wake cycle and sensory and motor status. d.Assess the patient's level of orientation and ability to follow commands. e. Time the analgesic administration for effectiveness during painful activities.

ANS: A B E When administering analgesics to a postoperative patient, the nurse should assess the location, quality, and intensity of pain. The time of administration of the analgesic should be adjusted so that the patient is free of pain during activities like ambulation. The nurse should monitor the patient for analgesic side effects, including nausea, vomiting, and respiratory depression. Assessing the sleep/wake cycle, sensory and motor status, level of orientation, and ability to follow instructions are part of a neurologic assessment and not a part of administering an analgesic.

An older adult postoperative patient has difficulty with memory and the ability to concentrate. What should the nurse do to help this patient? Select all that apply. a. Provide adequate nutrition. b. Encourage delayed mobility. c. Provide bowel and bladder care. d. Sedate the patient for long durations. e. Monitor fluid and electrolyte disturbance.

ANS: A C E The patient suffers from postoperative cognitive dysfunction, which dissipates over a few weeks. The nurse should provide supportive care during this period, such as bowel and bladder care, adequate nutrition, and fluid and electrolyte monitoring. Early mobilization should be encouraged to prevent pulmonary complications. Sedatives should not be used because they further add to cognitive dysfunction.

An older adult postoperative patient wakes up and becomes restless and agitated and starts thrashing and shouting. The nurse finds that the patient was administered benzodiazepines during surgery. What would be important to have on the patient's plan of care? Select all that apply. a. Ensure patient safety. b. Administer an antianxiety drug. c. Administer a narcotic analgesic. d. Administer an antipsychotic drug. e. Use drugs to reverse the benzodiazepines.

ANS: A E The patient's presentation of restlessness, agitation, thrashing, and shouting indicates emergence delirium. It is due to the prolonged action of opioids and benzodiazepines during the surgery. The use of opioid and benzodiazepine antagonists may reverse the effect and alleviate agitation in the patient. Until the patient is fully conscious, the nurse should ensure the patient's safety by raising the side rails of the bed and securing the equipment, such as the IV line. Antianxiety drugs are less helpful in managing emergence delirium. Emergence delirium is not a psychotic condition; therefore antipsychotic drugs are not useful. Narcotic analgesics would further enhance the action of opioids that were used during surgery.

A patient is admitted to the postanesthesia care unit (PACU) after colon surgery. During the initial assessment, the patient tells the nurse they are going to "throw up." Which statement by the nurse reflects a priority nursing intervention? a. "I need to check your vital signs." b. "Let me help you turn to your side." c. "Here is a sip of ginger-ale for you." d. "I can give you some antinausea medicine."

ANS: B If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs. Checking vital signs does not address the nausea. It may not be appropriate to give the patient oral fluids immediately following bowel surgery. Administering an antiemetic may be appropriate after turning the patient to the side.

The nurse finds that a postoperative patient has low oxygen saturation and crackles on auscultation. Which is an appropriate nursing action? a. Suction the airway. b. Restrict fluid intake. c. Monitor mental status. d. Place the patient in lateral recovery position.

ANS: B Pulmonary edema in a postoperative patient is due to fluid overload. Therefore fluid restriction is the most appropriate intervention. In addition, oxygen therapy and diuretics can be administered. The airway is suctioned if there is any secretion retained in the system. Monitoring of mental status is done in the early postoperative period to determine emergence from anesthesia. Lateral recovery position is used in the early postoperative period to keep the airway patent and prevent aspiration in case the patient vomits.

A patient on the postoperative unit was given a large dose of opioids during a surgical procedure and is now hypoxemic. What would the nurse expect to be prescribed to manage hypoxemia in this patient? a. Opioids b. Naloxone c. Benzodiazepines d. Withholding mechanical ventilation

ANS: B Shallow respiration associated with hypoxemia and reduced respiratory rate in a patient who received large doses of opioids indicates hypoventilation due to medullary depression. Drugs that reverse the effect of opioids should be administered to stimulate the medullary respiratory center such as naloxone. Opioids and benzodiazepines should be avoided because they further aggravate medullary depression. In severe medullary depression, the patient may need mechanical ventilation.

The nurse is assessing a patient's surgical dressing on the first postoperative day and notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first? a. Recheck in one hour for increased drainage b. Assess the patient's blood pressure and heart rate c. Remove the dressing and assess the surgical incision d. Notify the health care provider of a potential hemorrhage

ANS: B The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse then can report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

What is the priority nursing action when a patient is transferred from the postanesthesia care unit (PACU) to the surgical unit after a lobectomy? a. Assess the patient's pain. b. Take the patient's vital signs. c. Check the rate of the intravenous (IV) infusion. d. Check the health care provider's postoperative prescriptions.

ANS: B The highest priority action by the nurse is to assess the physiologic stability of the patient. This is in part accomplished by taking the patient's vital signs. Assessing the patient's pain, checking the prescriptions, and checking the rate of IV infusion can take place in a rapid sequence after taking the vital signs.

The nurse is monitoring a patient who is about to be transferred to the clinical unit from the postanesthesia care unit (PACU). Which assessment data require the most immediate attention? a. Oxygen saturation of 94% b. Pulse rate 128 beats/minute c. Respiratory rate of 13/minute d. Temperature of 99.8° F (37.7° C)

ANS: B The most important aspect of the cardiovascular assessment is frequent monitoring of vital signs. They usually are monitored every 15 minutes in Phase I, or more often until stabilized, and then at less frequent intervals in Phase II. Notify the anesthesia care provider (ACP) or the health care provider if the pulse rate is less than 60 beats/minute or greater than 120 beats/minute. The oxygen saturation should be above 90%, so 94% is good. A respiratory rate of 13 is normal. A temperature of 99.8 is expected.

A patient, who is eight hours postappendectomy, has not voided since surgery. What action should the nurse take? a. Encourage oral (PO) fluid intake. b. Palpate the suprapubic area for bladder distention. c. Insert an in and out catheter to assess for retention. d. Check the medical record to determine the type of anesthetic given.

ANS: B The nurse needs to know first if there is urine in the bladder. The assessment can be done by palpating or scanning the suprapubic area. Encouraging PO fluid intake is appropriate if the patient can tolerate PO fluids and there is no bladder distention. Because of the risk of infection, an in and out catheter is not used for assessment purposes but to relieve known urine retention. No matter what type of anesthetic was administered, the nurse needs to determine if the patient has not voided because of a lack of urine output or if the issue is an alteration in micturition.

A patient underwent a laparoscopic assisted hysterectomy the day before and is now experiencing chills and a temperature of 102.2 °F (39 °C). Which nursing action is priority? a. Administer the final dose of antibiotic. b. Notify the primary health care provider. c. Have the patient deep breath and cough. d. Administer as needed acetaminophen (Tylenol).

ANS: B The patient is demonstrating signs of septicemia. Therefore the priority nursing action is to notify the primary health care provider so tests and treatments can be prescribed. Administering the antibiotic and having the patient deep breath and cough help prevent infections, but the patient is exhibiting signs and symptoms of infection in spite of these interventions. Acetaminophen treats the fever but not the source of the problem.

The nurse receives an unconscious postoperative patient in the post anesthesia care unit (PACU). What position would be the safest to place this patient immediately after the operation? a. Supine b. Lateral c. Semi-Fowler's d. High Fowler's

ANS: B Unless contraindicated by the surgical procedure, the unconscious patient is positioned in lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient usually is returned to a supine position with the head of the bed elevated. Supine, semi-Fowler's, and high Fowler's positions are all supine; they are not as helpful in keeping the airway open and reducing the risk of aspiration.

A patient is transferred to the postanesthesia care unit (PACU) after surgery. Which nursing intervention is the highest priority initially? a. Assess intake, output, and fluid balance. b. Assess airway, breathing, and circulation status. c. Assess the surgical site and condition of the dressing. d. Note the presence of all IV lines and drainage catheters.

ANS: B When the patient is shifted to the PACU after surgery, the nurse should first assess the patient's airway, breathing, and circulation status. Any evidence of respiratory or circulatory compromise needs immediate intervention. Thereafter, the nurse may assess the patient's intake, output, and fluid status and note the presence of IV lines and drainage bags. The nurse should also assess the surgical site and condition of the wound.

A patient who has been admitted to the postanesthesia care unit following major abdominal surgery develops coarse crackles. How should the nurse prevent pulmonary complications in this patient? Select all that apply. a. By abdominal exercises b. By providing IV hydration c. By suctioning the airways d. By administering sedatives e. By administering cough suppressants

ANS: B C Coarse crackles and noisy respiration are caused by increased respiratory secretions due to use of irritant anesthetic drugs. Suctioning helps clear the airway of secretions. IV hydration helps keep the secretions in liquid form, allowing them to be easily suctioned. Sedatives and cough suppressants would hinder clearing the secretions in the airways; therefore, they should not be used. Chest physical therapy, rather than abdominal exercises, would be helpful to clear secretions.

A postoperative patient develops laryngeal edema after receiving a penicillin injection. How can the nurse prevent further complications in the patient? Select all that apply. a. By suctioning the airway b. By administering sedatives c. By administering antihistamines d. By administering corticosteroids e. By providing chest physical therapy

ANS: B C D The patient's laryngeal edema is caused by an anaphylactic reaction to the penicillin injection. Sedatives reduce the emotional disturbance and calm down the patient. Antihistamines and corticosteroids help reduce the allergic manifestation and the laryngeal edema. Suctioning helps in cases of increased secretions in the airways. Chest physical therapy is helpful to drain the secretions in the airway.

A patient who was on mechanical ventilation through an endotracheal tube develops inspiratory stridor and sternal retraction upon removal of the endotracheal tube. How should the nurse manage this patient and ensure oxygenation? Select all that apply. a. Suction the airway. b. Administer oxygen therapy. c. Administer muscle relaxants. d. Tilt the head and thrust the jaw. e. Provide positive pressure ventilation.

ANS: B C E Inspiratory stridor and sternal retraction are due to laryngospasm associated with removal of the endotracheal tube. Oxygen therapy helps maintain the perfusion levels in the patient. Skeletal muscle relaxants help relax the muscles and relieve laryngospasm. Positive pressure ventilation helps keep the patient oxygenated. Suctioning may increase laryngospasm. Tilting the head and thrusting the jaw does not help relieve laryngospasm.

The nurse determines that a postoperative patient has not voided for 8 hours. What appropriate action should the nurse take? Select all that apply. a. Scan the bladder with a portable ultrasound. b. Help the patient to use a bedside commode. c. Reassure the patient regarding the ability to void. d. Obtain a prescription and catheterize the patient. e. Use techniques like pouring warm water over the perineum.

ANS: B C E It is very important that the patient voids within 6 to 8 hours postoperatively. The nurse should reassure the patient regarding the ability to void and help the patient using techniques like providing privacy and pouring warm water over the perineum. The patient should be helped to use a bedside commode if comfortable. If these early measures fail, then the nurse should scan the bladder to assess bladder fullness and catheterize the patient as per the prescription.

A patient is suspected of having a pulmonary embolism following a major orthopaedic procedure. How would the nurse relieve the patient of dyspnea? Select all that apply. a. Administer lidocaine. b. Administer oxygen therapy. c. Administer bronchodilators. d. Administer anticoagulant therapy. e. Administer skeletal muscle relaxant.

ANS: B D Dyspnea associated with tachypnea, tachycardia, hypotension, and reduced oxygen saturation following a major orthopedic surgery indicates a pulmonary embolism. A pulmonary embolism could be a result of dislodgement of thrombus from the peripheral veins. Oxygen therapy helps improve oxygen saturation. Anticoagulant therapy prevents the blood from clotting further. Lidocaine, a local anesthetic, helps relieve laryngospasm but may not relieve pulmonary embolism. Bronchodilators help to dilate the airways but have no effect on embolism because it is associated with the compromised pulmonary circulation. IV skeletal muscle relaxants help relax the muscles to relieve laryngeal spasm but do not help relieve pulmonary embolism.

A patient has difficulty passing urine after surgery for the correction of rectal prolapse. How should the nurse help this patient void? Select all that apply. a. Perform early catheterization. b. Pour warm water over perineum. c. Encourage immobility and bed rest. d. Reassure the patient of the ability to void. e. Help the patient to attain a normal voiding position.

ANS: B D E Following pelvic surgeries, the patient may experience difficulty voiding. Pouring warm water over the perineum stimulates micturition. Reassuring the patient of his ability to void helps him relax and promotes voiding. Patients feel comfortable voiding in a natural voiding position, so the nurse should help the patient attain that position. Early catheterization should be avoided because of the risk of urinary infection. Immobility and rest impair the voiding ability.

The nurse finds that a postoperative patient has an oxygen saturation of 85%. On auscultation the patient has decreased breath sounds. Which nursing interventions are appropriate? Select all that apply. a. Restrict intake of fluid. b. Administer oxygen therapy. c. Administer diuretics as advised. d. Encourage deep breathing exercises. e. Help the patient to walk around, if tolerated.

ANS: B D E Low oxygen saturation and decreased breath sounds may indicate atelectasis. Therefore the nurse should administer humidified oxygen therapy and encourage deep breathing exercises. Deep breathing and coughing techniques help prevent alveolar collapse and move respiratory secretions to larger airway passages for expectoration. Helping the patient walk around will also help because lying down will only settle secretions into the respiratory system. Fluid restriction and diuretics may not be required; these are therapies best used for pulmonary edema (PE).

The nurse is caring for a postoperative patient. What patient does the nurse determine is at the greatest risk for development of atelectasis? a. A patient after a hypoxic episode during an acute asthma attack b. An older adult patient who has undergone cardiothoracic surgery c. A patient not adherent with the pulmonary regimen after surgery d. A patient experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD)

ANS: C A patient after a hypoxic episode during an acute asthma attack An older adult patient who has undergone cardiothoracic surgery A patient not adherent with the pulmonary regimen after surgery A patient experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD)

A postoperative patient is delirious, restless, and shouting at the nurse about pain. What does the nurse consider may be a cause of this behavior? a. A new diagnosis of psychosis b. Increased ability to tolerate pain c. Anesthetic agents used in surgery d. Inadequately timed administration of pain medication

ANS: C Anesthetic agents used in surgery can cause short-term psychotic type behaviors that are relieved after the anesthetic drugs have cleared the body. A new diagnosis of psychosis is not warranted in the acute phase following surgery. The patient may not be tolerating the pain, but the delirium, yelling, and restlessness denote short-term psychotic-like behavior caused by the anesthetic agents and postoperative pain medications. The nurse should administer pain medications as soon as safely possible.

A patient has been admitted to the postanesthesia care unit (PACU). Which of these assessment findings require the nurse's immediate action? a. The patient is groggy but arouses to voice. b. The patient indicates that he or she is in pain. c. The patient is restless, agitated, and hypotensive. d. The Jackson-Pratt is draining serosanguinous fluid.

ANS: C Assessment in the PACU begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Restlessness, agitation, and hypotension are clinical manifestations of inadequate oxygenation. Identification of inadequate oxygenation and ventilation or respiratory compromise requires prompt intervention. Pain, sedation, and draining serosanguinous fluid are expected findings.

In caring for the postoperative patient on the clinical unit after transfer from the postanesthesia care unit (PACU), which care can be delegated to the unlicensed assistive personnel (UAP)? a. Monitor the patient's pain b. Do the admission vital signs c. Assist the patient to take deep breaths and cough d. Change the dressing when there is excess drainage

ANS: C The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The registered nurse (RN) should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The licensed practical nurse (LPN) or RN will monitor and treat the patient's pain and change the dressings.

A nurse is caring for a patient who had a bowel resection 10 hours before. The patient weighs 200 pounds (91 kg) and has a urine output of 240 cc for the past eight hours. What action should the nurse take? a. Encourage oral (PO) fluids b. Continue to monitor the urine output c. Notify the primary health care provider d. Administer a 500 cc normal saline intravenous (IV) bolus

ANS: C The formula for determining adequate urine output is 0.5 mL/kg/hr. This patient, weighing 91 kg, needs to have 45 cc per hour or about 365 cc of urine in eight hours. It often takes three to five days for the bowel to begin working postabdominal surgery; therefore, it would be inappropriate at this time to encourage PO fluids. Continuing to monitor the urine output, instead of calling the primary health care provider, would delay identifying and treating the cause for the low urine output. The nurse must obtain a prescription for the normal saline bolus before administration.

The nurse caring for a postoperative patient assesses clinical manifestations of early pulmonary edema secondary to heart failure. What manifestations does the nurse determine correlates with this disorder? a. Early-morning cough b. Increased urine output c. Paroxysmal nocturnal dyspnea d. Crackles heard on auscultation

ANS: C The most common cause of pulmonary edema is left-sided congestive heart failure, which commonly manifests as shortness of breath and crackles in the lungs. Between the two, shortness of breath in the form of paroxysmal nocturnal dyspnea is the earlier symptom, although crackles are more common. An early-morning cough may be seen with respiratory infection or chronic obstructive pulmonary disease but is not usually a symptom of pulmonary edema. In pulmonary edema, urine output is typically decreased due to fluid retention. Crackles heard on auscultation of the lungs are one of the more common symptoms of pulmonary edema, along with coughing of frothy pink-tinged sputum.

The nurse is caring for a patient at risk for developing syncope. Which nursing intervention is important to prevent this occurrence in this postoperative patient? a. Administer oxygen therapy. b. Administer analgesics before ambulation. c. Make changes in the patient's position slowly. d. Encourage deep breathing and coughing exercises.

ANS: C To prevent syncope in a postoperative patient, the nurse should slowly change the patient's position. Progression to ambulation can be achieved by first raising the head of the patient's bed for 1 to 2 minutes and then assisting the patient to sit, with legs dangling, while monitoring the pulse rate. If no changes or complaints are noted, start ambulation with ongoing monitoring of the pulse. Oxygen therapy and deep breathing and coughing exercises are interventions to improve pulmonary function, not to prevent syncope. Administering analgesics before ambulation makes the activity painless and encourages the patient to become more active.

Two days after colectomy for an abdominal mass, the patient reports gas pains and abdominal distension. The nurse plans care for the patient on the basis of the knowledge that these symptoms occur as a result of which condition? a. Constipation b. Nasogastric suctioning c. Slowed gastric emptying d. Inflammation of the bowel at the anastomosis site

ANS: C Until peristalsis returns to normal after anesthesia, the patient may experience slowed gastric motility, leading to gas pains and abdominal distension. Colectomy does not require a nasogastric tube; the bowel should not be inflamed following surgery unless infection is present. Constipation may occur following surgery; however, with bowel manipulation, slowed gastric emptying is the most common reason for gas pains and abdominal distention because of gas.

A nurse is providing postoperative care for a patient who has undergone exploratory abdominal surgery. Which nursing interventions would help prevent post-operative atelectasis? a. Medicating the patient with a narcotic analgesic as prescribed b. Providing an abdominal binder to help the patient in ambulation c. Encouraging use of an incentive spirometer at least every hour d. Turning the patient from one side to the other at least every 2 to 4 hours

ANS: C Use of an incentive spirometer after surgery encourages the patient to take deep, slow breaths, which facilitates the opening of terminal airways, mobilizes secretions, and prevents postoperative atelectasis. The patient should be instructed to perform 10 repetitions every hour. Narcotic analgesics, use of an abdominal binder for ambulation, and frequent turning in bed may indirectly support recovery and prevention of complications postoperatively. However, these interventions do not specifically address prevention of atelectasis and pneumonia in the way that the use of an incentive spirometer does.

The nurse has received a patient from surgery in the postanesthesia care unit (PACU). What is the best way for the nurse to ensure that this patient has a patent airway? Select all that apply. a. By suctioning the airway b. By administering sedatives c. By putting in an artificial airway d. By administering oxygen therapy e. By tilting the head and thrusting the jaw

ANS: C E The physical repositioning of a patient to reestablish the patency of the airway involves tilting the head and thrusting the jaw. If the physical repositioning does not help, the patient may need an artificial airway to assist in breathing. Suctioning is helpful for patients with increased secretions; it may not help a patient with an airway obstruction. Oxygen therapy does not help unless the airway is patent. Sedatives would worsen the airway prolapse.

The nurse is developing a care plan for the postoperative patient in order to prevent complications and promote ambulation, coughing, deep breathing, and turning. What actions can the nurse provide to achieve desired outcomes? a. Explain easily the rationale for these activities. b. Have family in the room for support and encouragement. c. Warn about pneumonia and clotting if the actions are not completed. d. Administer enough analgesics to promote relative freedom from pain.

ANS: D Even when a patient understands the importance of postoperative activities, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate. Warning the patient about pneumonia and clotting will not enhance proper activities if pain is not managed. Family encouragement and understanding of the rationale for completing these actions are important; however, pain control is the most helpful way to ensure ambulation, coughing, deep breathing, and turning can be performed.

A patient transferred to the medical-surgical unit from the postanesthesia care unit (PACU) has regained consciousness. In which position should the nurse place the patient in order to prevent respiratory problems? a. Lithotomy position b. Lateral recovery position c. Prone position with extra pillows d. Supine position with head elevated

ANS: D If the patient is conscious, the patient should be positioned in supine position with the head elevated. This position helps to maximize the expansion of the thorax by decreasing the pressure of abdominal contents on the diaphragm. Lateral recovery position is usually used in unconscious patients to keep the airway open and reduce the risk of aspiration if vomiting occurs. Prone and lithotomy positions are not used in postsurgery patients.

An older adult patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this patient? a. Check the chart for intraoperative complications. b. Check the effectiveness of the analgesics received. c. Check which medications were used for anesthesia. d. Check the preoperative assessment for previous delirium or dementia.

ANS: D If the patient's airway, breathing, and circulation are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed, because these can all contribute to delirium.

The patient donated a kidney and early ambulation is included in the plan of care; however, the patient refuses to get up and walk. What explanation should the nurse give to the patient for early ambulation? a. "Early walking keeps your legs limber and strong." b. "Early ambulation will help you be ready to go home." c. "Early ambulation will help you get rid of your syncope and pain." d. "Early walking is the best way to prevent postoperative complications."

ANS: D The best rationale is that early ambulation will prevent postoperative complications that then can be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and venous thromboembolism (VTE), speeds wound healing, increases vital capacity, and maintains normal respiratory function. These things help the patient to be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management always should occur before walking.

A patient on the postoperative unit reports difficulty breathing. The nurse discovers that the patient received large doses of skeletal muscle relaxants during surgery. What should the nurse include in the patient's plan of care to promote breathing? a. Administering opioids b. Loosening the dressings c. Repositioning the patient d. Administering drugs for reversal of paralysis

ANS: D The use of skeletal muscle relaxants may paralyze the muscles required for breathing. Administering drugs for reversal of paralysis may make breathing easier. Use of opioids aggravates the condition by causing respiratory depression. Loosening the dressing and repositioning the patient are helpful when the breathing difficulty is caused by mechanical restriction but may not help in this case.

A nurse is caring for an older adult patient, who had a knee replacement the previous day. The patient denies any pain. Which response by the nurse would be most appropriate? a. "Excellent. You must be able to handle a lot of pain." b. "Great. It is wise to only take the pain medication if you need it." c. "It is important that you take pain medication. It will help you recover quicker." d. "Almost everyone has pain after this surgery. Are you certain that you are not experiencing pain?"

ANS: D Thoroughly assessing the presence of pain is imperative, especially for those who deny any pain after surgery, especially the elderly. Gerontology patients may hesitate about reporting pain because of the belief that pain should be tolerated and is inevitable postsurgery. It is not appropriate to compliment the patient on being able to handle pain. The patient will not develop an addiction to pain medication, so it is not appropriate to tell the patient he or she should only take it when necessary. The nurse should not tell the patient that pain medication will help him or her recover quicker, because that could give the patient false reassurance.

A postoperative patient has absence of breath sounds on the left lung and an oxygen saturation of 86%. What interventions should be included to maintain adequate oxygen saturation? Select all that apply. a. Administer diuretics. b. Allow delayed ambulation. c. Instruct shallow breathing. d. Encourage incentive spirometry. e. Provide humidified oxygen therapy.

ANS: D E Decreased breath sounds and a low oxygen saturation level may indicate atelectasis due to retained secretions. Incentive spirometry helps lung expansion and promotes removal of secretions. Humidified oxygen therapy helps maintain the oxygen saturation levels. Diuretics help remove excess fluid in the body, but do not help in atelectasis. Late ambulation and shallow breathing aggravate atelectasis; therefore, the patient should be mobilized early and deep breathing should be encouraged.