med surg ch 16 postop
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. Take routine vital signs on clients.
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. Assess the client's vital signs. Assessing the client's status after transfer from the PACU should be the nurse's first intervention.
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 the client's baseline.
3. The client has a respiratory rate of eight (8). If the effects of the spinal anesthesia move up rather than down the spinal cord, respirations can be depressed and even blocked.
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 paresthesia 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. Lungs are clear bilaterally in all lobes. 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.
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. The 80-year-old client with small bowel obstruction and congestive heart failure.
7. In the PACU, the nurse assesses that a patient is bleeding profusely from an abdominal incision. What is the nurses's best first action? a. Notify the surgeon. b. Apply pressure to the wound dressing. c. Instruct the UAP to get additional dressing supplies. d. Request and draw a complete blood count.
b. Apply pressure to the wound dressing.
Which are criteria used by the health care team to determine when a patient is ready to be discharged from the PACU? Select all that apply. a. recovery rating score of 7/10 b. stable vital signs with normal body temperature c. ability to swallow but remains npo for at least 4 hours d. intact cough and swallow reflexes e. adequate urine output f. return of gag reflex
b. stable vital signs with normal body temperature d. intact cough and swallow reflexes e. adequate urine output f. return of gag reflex
In the immediate postoperative period after a gastrectomy, the client's NG tube is draining a light-red liquid. For how long should the nurse expect this type of drainage? a. 1-2 hr b. 3-4 hr c. 10-12 hr d. 24-48 hr
c. 10-12 hr
27. The medical-surgical nurse is caring for a postoperative patient whose lab values reveal an increase in band cells (immature neutrophils). What is the nurse's best interpretation of this value? a. The patient may need a transfusion. b. The patient is using up clotting factors. c. The patient is developing an infection. d. The patient's result is expected postoperatively.
c. The patient is developing an infection.
3. A patient develops respiratory distress after having a left total hip replacement. The patient develops labored breathing and a pulse oximetry reading is 83% on 2 L oxygen via nasal cannula. which intervention is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Assess change in patient's respiratory status. b. Order necessary medications to be administered. c. Intubate the patient for maintenance of airway and assisted breathing. d. Check the patient's vital signs.
d. Check the patient's vital signs.
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. Assess the client's breath sounds. The airway should be assessed first. When caring for a client, the nurse should follow the ABCs: airway, breathing, and circulation.
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 that 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. Apply ice packs to the axillary and groin areas. 4. Prepare to administer dantrolene, a smooth-muscle relaxant.
Test hint: With clients who have undergone surgery, the priority problems are respiration and hemorrhaging. The test taker should select an option which addresses one of these two (2) areas.
Test hint: The test taker cannot delegate assessment, teaching, or evaluating care of the client.
A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure? a. keeps the area free of microorganisms b. confines microorganisms to the surgical site. c. protects self from microorganisms in the wound. d. reduces the risk for growing opportunistic microorganisms
a. keeps the area free of microorganisms
A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. What medication does the nurse anticipate will be prescribed for this client? a. vitamin a (aquasol a) b. cyanocobalamin (cobex) c. phytonadione (mephyton) d. ascorbic acid (ascorbicap)
d. ascorbic acid (ascorbicap)
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. Potential for hemorrhaging. All clients who undergo surgery are at risk for hemorrhaging, which is the priority problem.
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. Risk for depressed respiratory pattern.
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 client will have a pulse oximetry reading of 97% on room air. 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.
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. Elevate the feet and lower the head. 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.
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. Have the client turn, cough, and deep breathe every two (2) hours. 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.
29. The health care provider removed a patient's original surgical dressing 2 days after surgery and is discharging the patient home on daily dressing changes. Which actions does the nurse take for this patient's discharge teaching? (Select all that apply.) a. Ask the patient's family or significant other to observe the dressing change. b. Ask the UAP to get dressing supplies for the patient. c. Instruct that the drainage will appear serosanguineous. d. Instruct the patient to go to the emergency department (ED) for problems related to dressing changes. e. Have the case manager arrange for a home health nurse to ensure that dressing changes are done and there are no complications of infection. f. Teach the patient and family the signs and symptoms of infection.
a. Ask the patient's family or significant other to observe the dressing change. b. Ask the UAP to get dressing supplies for the patient. e. Have the case manager arrange for a home health nurse to ensure that dressing changes are done and there are no complications of infection. f. Teach the patient and family the signs and symptoms of infection.
13. A patient arrives in the PACU. Which action does the nurse perform first? a. Assess for a patent airway and adequate gas exchange. b. Rate the patient's pain using the 0-10 pain assessment scale. c. Position the patient in a supine position to prevent aspiration. d. Calculate the patient-controlled analgesia (PCA) pump maximum dose per hour to avoid an overdose.
a. Assess for a patent airway and adequate gas exchange.
28. Which are interventions for the medical-surgical nurse to use in preventing hypoxemia for the postoperative patient? (Select all that apply.) a. Monitor the patient's oxygen saturation. b. Position the patient supine. c. Encourage the patient to cough and breathe deeply. d. Get the patient up ambulating as soon as possible. e. Instruct the patient to rest as much as possible. f. Remind the patient to use incentive spirometry every hour while awake.
a. Monitor the patient's oxygen saturation. c. Encourage the patient to cough and breathe deeply. d. Get the patient up ambulating as soon as possible. f. Remind the patient to use incentive spirometry every hour while awake.
10. A patient cared for in the PACU has had a colostomy placed for treatment of Crohns's disease. The nurse assesses that an abdominal dressing is 25% saturated with serosanguineous drainage and notes that the incision is intact. An IV is infusing with D5/lactated Ringer's at 100mL/hr through a 20-g peripheral IV access. Auscultation of abdomen reveals hypoactive bowel sounds in all four quadrants, abdomen soft, and no distention. Foley catheter is in place and draining yellow urine with sediment, 375 mL output in Foley bag. Which body systems have been assessed by the nurse? (Select all that apply.) a. Renal/urinary b. Gastrointestinal c. Respiratory d. Musculoskeletal e. Integumentary f. Cardiovascular
a. Renal/urinary b. Gastrointestinal e. Integumentary
9. A postoperative patient in the PACU has had an open reduction internal fixation of a left fractured femur. Vital signs are blood pressure 87/49 mm Hg, heart rate 100/min sinus rhythm, respirations 22/min, temperature 98.3 F. The Foley catheter has a total amount of 110 mL of clear, yellow urine in the last 4 hours. Which body systems have been assessed by the nurse? (Select all that apply.) a. Respiratory b. Cardiovascular c. Neurovascular d. Intergumentary e. Renal/urinary f. Gastrointestinal
a. Respiratory b. Cardiovascular e. Renal/urinary
26. The PACU nurse is assessing an older adult postoperative patient for pain. Which nonverbal manifestations by the patient suggest pain to the nurse? (Select all that apply.) a. Restlessness b. Profuse sweating c. difficult to arouse d. Confusion e. Increased blood pressure f. Decreased heart rate
a. Restlessness b. Profuse sweating d. Confusion e. Increased blood pressure
17. The nurse is caring for a patient who has had abdominal surgery. After a hard sneeze, the patient reports pain in the surgical area, and the nurse immediately sees that the patient has a wound evisceration. What priority action must the nurse do first? a. The nurse calls for help and stays with the patient. b. The nurse leaves the patient to immediately call the surgeon. c. The nurse covers the wound with a non-adherent dressing moistened with normal saline. d. Th nurse takes the patient's vital signs.
a. The nurse calls for help and stays with the patient.
24. Which patient is most at risk for postoperative nausea and vomiting (PONV)? a. The patient with a history of motion sickness b. The patient with a nasogastric tube c. The patient who recently experienced a weight loss of 50 pounds d. The patient who had minimally invasive surgery (MIS)
a. The patient with a history of motion sickness
Which members of the surgical team usually accompany a postoperative patient to the PACU? a. anesthesia provider and circulating nurse b. circulating nurse and surgeon c. surgeon and anesthesia provider d. surgical assistant and surgeon
a. anesthesia provider and circulating nurse
A client experiences abdominal distention following surgery. Which nursing actions are appropriate? Select all that apply. a. encouraging ambulation b. giving sips of ginger ale. c. auscultating bowel sounds d. providing a straw for drinking e. offering the prescribed opioid analgesic
a. encouraging ambulation c. auscultating bowel sounds
On which concern should the nurse focus when caring for a client after abdominal surgery? a. identifying signs of bleeding b. preventing pressure on the suture site. c. encouraging use of an incentive spirometer d. detecting clinical manifestations of inflammation
a. identifying signs of bleeding
After undergoing a modified radical mastectomy, a client is transferred to the postanesthesia care unit. Which nursing action is best to assign to an experienced LPN/LVN? a. monitoring the client's dressing for any signs of bleeding b. documenting the initial assessment on the client's chart c. communicating the client's status report to the charge nurse on the surgical unit d. teaching the client about the importance of using pain medication as needed.
a. monitoring the client's dressing for any signs of bleeding
Which indicator of return to consciousness occurs first as a patient recovers from general anesthesia? a. muscular irritability b. restlessness and delirium c. recognition of pain d. ability to reason and control behavior
a. muscular irritability
A client is extubated in the PACU after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? a. restlessness b. bradycardia c. constricted pupils d. clubbing of the fingers
a. restlessness
What information should be included in the handoff report when a patient is transferred from the OR to the PACU staff? Select all that apply. a. type and extent of surgical procedure. b. intraoperative complications and how they were handled c. list of usual daily medications d. type and amount of IV fluids and blood products given e. location and type of incisions, dressings, catheters, tubes, drains, or packing. f. name, address, and phone number of next of kin
a. type and extent of surgical procedure. b. intraoperative complications and how they were handled d. type and amount of IV fluids and blood products given e. location and type of incisions, dressings, catheters, tubes, drains, or packing.
12. The PACU nurse is assessing a patient transferred in from the OR. Which assessment findings apply to assessment of the cardiovascular system? (Select all that apply.) a. Opens eyes on command. b. Absent dorsalis pedis pulse left foot. c. Foley catheter in place with clear yellow drainage. d. Monitor shows normal sinus rhythm. e. States name correctly when asked. f. Apical pulse 85 beats/minute.
b. Absent dorsalis pedis pulse left foot. d. Monitor shows normal sinus rhythm. f. Apical pulse 85 beats/minute.
11. A 49-year-old patient is in the PACU following a frontal craniotomy for repair of a ruptured cerebral aneurysm. The nurse assesses that the patient's eyes open on verbal stimulation. Pupils are equal, reactive to light, and diameter is 3 mm. The patient's hand grasps are equal and strong. When the nurse asks the patient to state name, the patient states name correctly. The patient has had one episode of nausea and vomiting. Incision edges are dry and approximated with sutures. Lung sounds are slightly diminished per auscultation and the nurse observes the patient is using abdominal accessory muscles to breathe. Which body systems has the nurse assessed? (Select all that apply.) a. Cardiovascular b. Gastrointestinal c. Neurologic d. Integumentary e. Respiratory f. Renal/urinary
b. Gastrointestinal c. Neurologic d. Integumentary e. Respiratory
23. When assessing the older postoperative patient for hydration status, where must the nurse assess for tenting of the skin? (Select all that apply.) a. On the back of the hand b. On the forehead c. On the forearm d. On the sternum e. On the abdomen
b. On the forehead d. On the sternum
2. what is the primary purpose of a PACU? a. follow-through on the surgeon's postoperative orders b. Ongoing critical evaluation and stabilization of the patient c. Prevention of lengthened hospital stay d. Arousal of patient following the use of conscious sedation
b. Ongoing critical evaluation and stabilization of the patient
15. The nurse is teaching incisional care to a patient who has been discharged after abdominal surgery. Which priority instruction must the nurse include? a. Do not rub or touch the incision site. b. Practice proper handwashing. c. Clean the incision site two times a day with soap and water. d. Splint the incisional site as often as needed for comfort.
b. Practice proper handwashing.
19. The morning after a patient's lower leg surgery, the nurse notes that the dressing is wet from drainage. The surgeon has not yet been in to see the patient on rounds. What does the nurse do about the dressing? a. Removes the dressing and puts on a dry, sterile dressing b. Reinforces the dressing by adding dry, sterile dressing material on top of the existing dressing c. Applies dry, sterile dressing material directly to the wound, then retapes the original dressing d. Does nothing to the dressing but calls the surgen to evaluate the patient immediately
b. Reinforces the dressing by adding dry, sterile dressing material on top of the existing dressing
22. The nurse on the medical-surgical unit is caring for a postoperative patient. Which assessment criteria indicate to the nurse that the patient is experiencing respiratory difficulty? (Select all that apply.) a. The patient's oxygen saturation drops from 98% to 94%. b. The patient is using accessory muscles to breathe. c. The patient makes a high-pitched crowing sound when breathing. d. The patient's blood pressure drops from 120/80 to 110/78 mm Hg. e. The patient's respiratory rate is 29/min. f. The patient's urine output drops from 50 mL/hr to 30 mL/hr
b. The patient is using accessory muscles to breathe. c. The patient makes a high-pitched crowing sound when breathing. e. The patient's respiratory rate is 29/min.
6. A patient who is 2 days postoperative for abdominal surgery states, "I coughed and heard something pop." The nurse's immediate assessment reveals an opened incision with a portion of large intestine protruding. Which statements apply to this clinical situation? (Select all that apply.) a. Incision dehiscence has occurred. b. This is an emergency situation. c. The wound must be kept moist with normal saline-soaked sterile dressings. d. This is an urgent situation. e. Incision evisceration has occurred. f. A nasogastric tube may be ordered to decompress the stomach.
b. This is an emergency situation. c. The wound must be kept moist with normal saline-soaked sterile dressings. e. Incision evisceration has occurred. f. A nasogastric tube may be ordered to decompress the stomach.
The nurse is responsible for the care of a postoperative patient with a thoracotomy. Which action should the nurse delegate to the unlicensed assistive personnel? a. instructing the patient to alternate rest and activity b. encouraging, monitoring, and recording nutritional intake c. monitoring cardiorespiratory response to activity d. planning activities for periods when the patient has the most energy.
b. encouraging, monitoring, and recording nutritional intake
Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus? a. decreased blood supply b. impaired neural functioning c. perforation of the bowel wall d. obstruction of the bowel lumen
b. impaired neural functioning
A client reports severe pain 2 days after surgery. Which initial action should the nurse take after assessing the character of the pain? a. encourage rest b. obtain the vital signs c. administer the prn analgesic d. document the client's pain response
b. obtain the vital signs
A nurse in the PACU observes that after an abdominal cholecystectomy a client has serosanguineous drainage on the abdominal dressing. What is the next nursing action? a. change the dressing b. reinforce the dressing. c. replace the tape with montgomery ties. d. support the incision with an abdominal binder
b. reinforce the dressing.
5. If a patient experiences a wound dehiscence, which description illustrates what is happening with the wound? a. Purulent drainage is present at incision site because of infection. b. Extreme pain is present at incision site. c. A partial or complete separation of outer layers is present at incision site. d. The inner and outer layers of the incision are separated.
c. A partial or complete separation of outer layers is present at incision site.
8. The nurse transfers a patient to the PACU with an incision and drainage of an abscess in the right groin under general anesthesia. Blood pressure is 80/47 mm Hg, heart rate 117/min in sinus tachycardia, respiratory rate 28/min, pulse oximetry reading 93% on oxygen at 3 L nasal cannula, temp is 38.8 C. The Jackson-Pratt drain has 70 mL of a cream-colored output. Normal saline, two sets of blood cultures, and culture drainage from the Jackson-Pratt drain. The patient's history includes vulvar cancer with a needle biopsy of the right groin, hypertension treated with lisinopril (Zestril) 5 mg PO daily, and no known drug allergies. The patient is a full code. Using the SBAR (situation, background, assessment, recommendation) charting format, which information should be included in assessment? a. Nurse transfers patient to the PACU with an incision and drainage of an abscess in the right groin with general anesthesia. b. Surgeon sending orders to bolus the patient with 500 mL normal saline over an hour, draw two sets of blood cultures and send a culture of drainage from the Jackson-Pratt drain. c. Blood pressure 80/47 mm Hg, heart rate 117/min, sinus tachycardia, respirations 28/min, pulse oximetry 93% on O2 at 3 L nasal cannula, temp 38.5 C, Jackson-Pratt drain with 70 mL cream-colored output. d. Patient had a right groin abscess. History of vulvar cancer. Needle biopsy of right groin completed 1 week ago. History of hypertension treated with lisinopril (Zestril) 5 mg. No know drug allergies. Full code.
c. Blood pressure 80/47 mm Hg, heart rate 117/min, sinus tachycardia, respirations 28/min, pulse oximetry 93% on O2 at 3 L nasal cannula, temp 38.5 C, Jackson-Pratt drain with 70 mL cream-colored output.
20. The PACU nurse is caring for a postoperative patient. The patient's oxygen saturation drops from 98% to 88%. What is the nurse's priority action? a. Call the anesthesia provider. b. Call the surgeon. c. Call the Rapid Response Team. d. Call the respiratory therapist.
c. Call the Rapid Response Team.
25. The nurse is assessing a postoperative patient's gastrointestinal system. What is the best indicator that peristaltic activity has resumed? a. Presence of bowel sounds b. Patient states he is hungry c. Passing of flatus or stool d. Presence of abdominal cramping
c. Passing of flatus or stool
4. Which signs/symptoms are considered postoperative complications? (Select all that apply.) a. Sedation b. Pain at the surgical site c. Pulmonary embolism d. Hypothermia e. Wound evisceration f. Postoperative ileus
c. Pulmonary embolism d. Hypothermia e. Wound evisceration f. Postoperative ileus
The postoperative care of a morbidly obese client is being planned. Which task best uses the expertise of the LPN/LVN, under the supervision of the RN team leader? a. obtaining an oversized blood pressure cuff and a large-sized bed b. setting up a reinforced trapeze bar c. assisting in the planning of toileting, turning, and ambulation. d. assigning tasks to unlicensed assistive personnel and other ancillary staff
c. assisting in the planning of toileting, turning, and ambulation.
The patient who received moderate sedation with midazolam appears to be overly sedated and has respiratory depression. Which drug does the nurse prepare to administer to this patient? a. lorazepam b. naloxone c. flumazenil d. butorphanol tartrate
c. flumazenil
What is the priority nursing intervention for a client during the immediate postoperative period? a. monitoring vital signs b. observing for hemorrhage c. maintaining a patent airway d. recording the intake and output
c. maintaining a patent airway
16. The health care team determines a patient's readiness for discharge from the PACU by noting a postanesthesia recovery score of at least 10. After determining that all criteria have been met, the patient is discharged to the hospital unit or home. Review the patient profiles after 1 hour in the PACU listed below. Which patient should the nurse expect to be discharged from the PACU first? a. 10-year-old girl, tonsillectomy, general anesthesia. Duration of surgery 30 minutes. Immediate response to voice. Alert to place and person. Able to move all extremities. Respirations even, deep, rate of 20. Vital signs are within normal limits. IV solution is D5RL. has voided on bedpan. eating ice chips. complaining of sore throat. b. 55-year-old man, repair of fractured lower left leg. General anesthesia. Duration of surgery 1 hour, 30 minutes. Drowsy, but responds to voice. Nausea and vomiting twice in PACU. No urge to void at this time. IV infusing D5NS. Pedal pulses noted in both lower extremities. VS: temperature 98.6 F; pulse 130 beats/min; respiratory rate 24/min; blood pressure 124/76 mm Hg. c. 24-year-old man, reconstruction of facial scar. General anesthesia. Duration of surgery 2 hours. Sleeping, groans to voice command. VS are within normal limits. Respirations 10 breaths/min. No urge to void. IV of D5RL infusing. Complains of pain in surgical area. d. 42-year-old woman, colonoscopy. IV conscious sedation. Awake and alert. Up to bathroom to void. IV discontinued. Resting quietly in chair. VS ar within normal limits.
d. 42-year-old woman, colonoscopy. IV conscious sedation. Awake and alert. Up to bathroom to void. IV discontinued. Resting quietly in chair. VS ar within normal limits.
1. Which description illustrates the beginning of the postoperative period? a. completion of the surgical procedure and arousal of the patient from anesthesia in the operating room (OR) b. Discharge planning initiated in the preoperative setting c. Closure of the patient's surgical incision with sutures d. Completion of the surgical procedure and transfer of the patient to the postnesthesia care unit (PACU)
d. Completion of the surgical procedure and transfer of the patient to the postnesthesia care unit (PACU)
14. A patient arrives at the PACU and the nurse notes a respiratory rate of 10 with sternal retractions. The report from anesthesia personnel indicates that the patient had received fentanyl during surgery. What is the nurse's best priority first action? a. Monitor the patient for effects of anesthetic for at least 1 hour. b. Closely monitor vital signs and pulse oximetry readings until the patient is responsive. c. Administer oxygen as ordered, monitoring pulse oximetry. d. Maintain an open airway through positioning and suction if needed.
d. Maintain an open airway through positioning and suction if needed.
18. Which intervention for postsurgical care of a patient is correct? a. When positioning the patient, use the knee gatch of the bed to bend the knees and relieve pressure. b. Gentle massage on the lower legs and claves helps promote venous blood return to the heart. c. Encourage bedrest for 3 days after surgery to prevent complications. d. The patient should splint the surgical wound for support and comfort when geting out of bed.
d. The patient should splint the surgical wound for support and comfort when geting out of bed.
A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated? a. dialysis b. osmosis c. diffusion d. capillarity
d. capillarity
While caring for a client with a portable wound drainage system, a nurse observes that the collection container is half full and empties it. What is the next nursing intervention? a. encircle the drainage on the dressing b. irrigate the suction tube with sterile saline. c. clean the drainage port with an alcohol wipe. d. compress the container before closing the port
d. compress the container before closing the port
When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action? a. obtain the vital signs b. notify the health care provider c. reinsert the protruding organs using aseptic technique d. cover the wound with a sterile towel moistened with normal saline.
d. cover the wound with a sterile towel moistened with normal saline.
After abdominal surgery a client reports pain. What action should the nurse take first? a. reposition the client. b. obtain the client's vital signs c. administer the prescribed analgesic d. determine the characteristics of the pain.
d. determine the characteristics of the pain.
A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? a. productive cough b. clubbing of the fingertips. c. crackles at the height of inhalation d. diminished breath sounds on auscultation
d. diminished breath sounds on auscultation
a nurse is caring for a postop client who had general anesthesia during surgery. what independent nursing intervention may prevent an accumulation of secretions? a. postural drainage b. cupping the chest c. nasotracheal suctioning d. frequent changes of position
d. frequent changes of position
