PACU post op

A client is excavated in the post anesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? 1. Restlessness 2. Bradycardia 3. Constricted pupils 4. Clubbing of the fingers

1

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure? 1. Keeps the area free of microorganisms 2. Confines microorganisms to the surgical site 3. Protects self from microorganisms in the wound 4. Reduces the risk for growing opportunistic microorganisms

1

After undergoing a modified radical mastectomy, a client is transferred to the postanesthesia care unit. Which nursing action is best tossing to an experienced LPN/LVN? 1. Monitoring the client's dressing for any signs of bleeding 2. Documenting the initial assessment ont eh client's chart 3. Communicating the client's status report to the charge nurse on the surgical unit 4. Teaching the client about the importance of using pain medication as needed

1

On which concern should the nurse focus when caring for a client after abdominal surgery? 1. Identifying sign of bleeding 2. Preventing pressure on the suture site 3. Encouraging use of an incentive spirometer 4. Detecting clinical manifestations of inflammation

1

A client experiences abdominal distention following surgery. Which nursing actions are appropriate? SELECT ALL THAT APPLY 1. Encouraging ambulation 2. Giving sips of ginger ale 3. Auscultating bowel sounds 4. Providing a straw for drinking 5. Offering the prescribed opioid analgesic

1, 3

A client reports severe pain 2 days after surgery. Which initial action should the nurse take after assessing the character of the pain? 1. Encourage rest 2. Obtain the vital signs 3. Administer the pen analgesic 4. Document the clients pain response

2

A nurse in the post anesthesia care unit (PACU) observes that after an abdominal cholecystectomy a client has serosanguineous drainage on the abdominal dressing. What is the next nursing action? 1. Change the dressing 2. Reinforce the dressing 3. Replace the tape with Montgomery ties. 4. Support the incision with an abdominal binder

2

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileum is suspected. What does the nurse conclude is the most likely cause of the ileum? 1. Decreased blood supply 2. Impaired neural functioning 3. Perforation of the bowel wall 4. Obstruction of the bowel lumen

2

In what position should the nurse place a client recovering from general anesthesia? 1. Supine 2. Side-lying 3. High-Fowler 4. Trendelenburg

2

Mr. H returns from the OR after a hernia repair. He says that he is :afraid to walk because it will make the pain really bad." What does the nurse explain as being the best option? 1. Pain mediation every 4 hours if he needs or wants it 2. Medication 30 to 40 minutes before ambulations or dressing changes 3. Around the clock pain medication even if he has no report of pain 4. Talking to the HCP for reassurance about the treatment plan

2

The nurse is responsible for the care of postoperative patient with a thoracotomy. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Instructing the patient to alternate rest and activity periods 2. Encouraging, monitoring, and recording nutritional intake 3. Monitoring cardiorespiratory response to activity 4. Planning activities for periods when the patient has the most energy

2

The nurse is caring for an obese postoperative client who underwent surgery for bowel resection. As the client is moving in bed, he comments, "Something popped open." upon examination, the nurse notes would evisceration. Place the steps in order for handling this complication. 1. Cover the intestine with sterile moistened gauze 2. stay calm and stay with the client 3. Check the vital signs, especially blood pressure and pulse 4. Have a colleague gather sterile supplies and contact the health care provider (HCP) 5. Put the client into semi-Fowler position with knees slightly flexed. 6. Prepare the client for surgery as ordered

2, 5, 3, 4, 1, 6

After an abdominal cholecystectomy, a client has a T-tube attached to a collection device. On the day of surgery, at 10:30 PM, 300 mL of bile is emptied from the collection bag. At 6:30 AM the next day, the bag contains 60 mL of bile. What should the nurse consider in response to this information? 1. The T-tube may have to irrigated 2. The bile is now draining into the duodenum 3. Mechanical problems may have developed with the T-tube 4. Suction must be reestablished in the portable drainage system

3

In the immediate postoperative period after a gastrectomy, the client's nasogastric tube is draining a light-red liquid. For how long should the nurse expect this type of drainage? 1. 1 to 2 hours 2. 3 to 4 hours 3. 10 to 12 hours 4. 24 to 48 hours

3

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? 1. Obtaining an oversized blood pressure cuff and a large size bed 2. Setting up a reinforced trapeze bar 3. Assisting in the planning of toiling, turning, and ambulation 4. Assigning tasks to unlicensed assistive personnel (UAP) and other ancillary staff

3

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? 1. Vitamin A (Aquasol A) 2. Cyanocobalamin (Cobex) 3. Phytonadione (Mephyton) 4. Ascorbic Acid (Ascorbicap)

4

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? 1. Dialysis 2. Osmosis 3. Diffusion 4. Capillary

4

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? 1. postural drainage 2. Cupping the chest 3. Nasotracheal suctioning 4. Frequent changes of position

4

A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? 1. Productive cough 2. Clubbing of the fingertips 3. Crackles at the height of inhalation 4. Diminished breath sounds on auscultation

4

After abdominal surgery a client reports pain. What action should ht nurse take first? 1. Reposition the client. 2. Obtain the clients vital signs. 3. Administer the prescribed analgesic 4. Determine the characteristics of the pain

4

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 bend and encourages the client to lie still. What is the next nursing action? 1. Obtain the vital signs. 2. Notify the health care provider 3. Reinsert the protruding organs using aseptic technique 4. Cover the wound with a sterile towel moistened with normal saline

4

While caring for a client with portable wound drainage system, a nurse observes that the collection container is half full and empties it. What is the next nursing intervention? 1. Enciricle the drainage on the dressing 2. Irrigate the suction tube with sterile saline 3. Clean the drainage port with an alcohol wipe 4. Compress the container before closing the port

4

A patient arrives int he postanethesia care unit (PACU). Which action does the nurse perform first? a. assess for a patent airway and adequate gas exchange b. assess the patient's pain level 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

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 see the patient has a would evisceration. What priority action must the nurse do first? a. Call for help and stay with the patient b. leave the patient to immediately call the surgeon c. cover the wound with a non adherent dressing moistened with normal saline d. take the patients vital signs

a

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

Which intervention by the nurse will help a postoperative patient with compliance in getting up to ambulate? a offer the patient pain medication 30-45 minutes before ambulation b. assist the patient to turn from side to side every 2 hours c. remind that patient to perform extremity exercises every 4 hours d. teach the patient that activity helps prevent postoperative complications

a

Which members of the surgical team usually accompany a postoperative patient to the post anesthesia care unit (PACU)? a. anesthesia provider and circulating nurse b. circulating nurse and surgeon c. surgeon and anesthesia provider d. surgical assistant and surgeon

a

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 nasogastric tube c. the patient who recently experienced a weight loss of 50 pounds d. the patient who had minimally invasive surgery (MIS)

a

Which statement best describes phase I care after surgery? a. Phase I care occurs immediately after surgery, most often in a post anesthesia care unit (PACU). b. Phase I care focuses on preparing the patient for care in an extended care environment. c. Phase I care discharge occurs when pre surgery level of consciousness has returned, oxygen saturation is at baseline, and vital signs are stable.

a

The post anesthesia care unit (PACU) nurse is assessing an older adult patient for postoperative 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, b, d, e

The postanesthsia care unit (PACU) nurse i receiving the "handoff" report for a patient transferred in from the OR. Which statements about this report are accurate? SELECT ALL THAT APPLY a. a handoff report requires clear, concise language b. a handoff report is a two-way verbal interactions between the health care professional giving the report and the nurse receiving it c. a handoff report should be individualized based on the patient and his or her surgery d. the receiving nurse takes the time to restate (report back) the information to verify what was said e. the receiving nurse takes the time to ask questions, and the reporting professional must respond to the questions until a common understanding is established f. the receiving nurse continues assessing other patients while the handoff report is being given

a, b, d, e

What information should be included in the handoff report when a patient is transferred from the OR to the post anesthesia care unit (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. locations and type of incision, dressing, caterers, tubes, drains, or packing f. name, address, and phone number of next of kin

a, b, d, e

A patient cared for in the post anesthesia care unit (PACU) had a colostomy placed for treatment of Crohn's disease. The nurse assesses that an abdominal dressing is 25% saturated and serosanguineous drainage and the incision is intact. An IV is infusing with D5/lactated Ringer's at 100 mL/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, b, e

A postoperative patient in the poastanesthesia care unit (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, and temperature 98.3 F (36.8 C). The Foley catheter has a total of 100 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. integumentary e. real/urinary f. gastrointestinal

a, b, e

The health care provider removed a patient's original surgical dressing 2 days after surgery and is discharging the patient home with daily dressing changes. Which actions will the nurse take for the patient discharge teaching? SELECT ALL THAT APPLY a. ask for 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 depertment (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 or infection f. teach the patient and family the signs and symptoms of infection

a, b, e, f

What are interventions for the medical surgical nurse to use in preventing hypoxemia for the postoperative patient? SELECT ALL THAT APPLY a. monitor the patient oxygen saturation b. position the patient supine c. encourage the patient to cough and breath deeply d. get the patient ambulating as soon as possible e. instruct the patient to rest as much as possible f. remind that patient to use incentive spirometry every hour while awake

a, c, d, f

In the post anesthesia care unit (PACU), the nurse assesses that a patient is bleeding profusely from an abdominal incision. What is the nurses best first action? a. notify the surgeon b. apply pressure to the wound dressing c. instruct the unlicensed assistive personnel (UAP) to get additional dressing supplies d. request and draw a complete blood count

b

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 and then retypes the original dressing d. does nothing to the dressing but call the surgeon o evaluate the patient immediately

b

The nurse is teaching incisional care to a patient who is being discharged after abdominal surgery. Which priority instruction must the nurse include? a. do not rub or touch the incision site b. practice proper hand washing c. clean the incision site two times a day with soap and water d. splint the incision site as often as needed for comfort

b

The postoperative patient has Penrose drain in place. Which action does the nurse take to prevent skin irritation, wound contamination, and infection? a. keeps a sterile safety pin in place at the end of the drain b. places absorbent pads under and around the exposed drain c. uses minimal tape; when tape is needed, uses hypoallergenic tap d. shortens the drain by pulling it out a short distance and timing off the excess external portion

b

What is the primary purpose of a post anesthesia care unit (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

A 49 year old patient is in the post anesthesia care unit (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 and reactive to light, and diameter is 3 mm. The patient's hand grasps are equal and strong. The patient is able to state 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 on auscultation, and the nurse observes the patient is using abdominal accessory muscles to breath. 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, c, d, e

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 patients respiratory rate is 29/min f. the patient's urine output drops from 50 mL/hr to 30 mL/hr

b, c, e

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. 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 (NG) tube may be ordered to decompress the stomach

b, c, e, f

When assessing the hydration status of an older postoperative patient, 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 f. on the thigh

b, d

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 to 10 on rating scale 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, d, e ,f

The post anesthesia care unit (PACU) nurse is assessing a patient transferred in from the OR. Which assessment finding apply to assessment of the cardiovascular system? SELECT ALL THAT APPLY a. opens eyes on command b. absent dorsalis pedis pulse in left foot. c. foley catheter in place with clear yellow drainage d. monitor shows normal sinus rhythm. e. state name correctly when asked f. apical pulse 85 beats/minute

b, d, f

If a patient experiences a wound dehiscence, which description best characterizes 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 out layers of the incision are separated

c

The medical surgical nurse is caring for a postoperative patient who lab values reveal an increase in band cells (immature neutrophils). What is the nurses 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 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

The nurse transfers a patient tot eh postanesthesia care unit (PACU) with an incision and drainage of abscess in the right groin under general anesthesia. Blood pressure is 80/47 mmHg, heart rate 28/min, pulse oximetry reading 93% on oxygen at 3 L per nasal cannula, and temp 101.3 F (38.5 C) The Jackson-Pratt drain has 70 mL of a cream-colored output. Normal saline is infusing at 150 mL/hr. The surgeon orders a bolus of 500 mL IV normal saline over 1 hour, two sets of blood cultures, and culture draining from he Jackson-Pratt drain. The patient's history includes vulvar cancer with a needle biopsy of the right groin, hypertension treated with lisinopril 5 mg PO daily, and no known drug allergies. The patient is designated as a full code. Using the Situation, Background, Assessment, Recommendation (SBAR) charting format, which information should be included in assessment? a. nurse transfers patient to the PACU with an incision and drainage of abscess in the right groin with general anesthesia. b. surgeon sends order 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 is 80/47 mm Hg, heart rate 117/min in sinus tachycardia, respirations 28/min, pulse oximetry 93% on O2 at 3 L nasal cannula, and temp 101.3 F (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 known drug allergies. Full code

c

The patient is recovering in a post anesthesia care unit (PACU) environment that advances the patient quickly from a Phase I care level to a Phase III care level, preparing for discharge to home. What type of surgery is this patient MOST likely having? a. elective surgery b. emergency surgery c. same day surgery d. urgent surgery

c

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

The postanesthesia care unit (PACU) nurse is caring for post operative 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

Which signs/symptoms are considered post operative complications? SELECT ALL THAT APPLY a. sedation b. pain at the surgical site c. pulmonary embolism d. hypothermia e. wound evisceration f. ostoperative ileus

c, d, e, f

A patient arrives at the post anesthesia care nit (PACU), and the nurse notes a respiratory rate of 10 with sternal retractions. The report from the anesthesia provider indicates that the patient received fentanyl during surgery. What is the nurses best first action? a. monster the patient for effects of anesthetic for a 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 positions and suction if needed.

d

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. Insert ora airway to maintain open airway d. Check the patient's vital signs

d

The health care team determines a patient's readiness for discharge from the poastanesthesia care unit (PACU) by noting a post anesthesia 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 hours in the PACU listed below. Which patient should the nurse expect to be discharged from eh PACU first? a. 10 year old female, tonsillectomy, general anesthesia. Duration of surgery 30 minutes. Immediate response to voice. Alert to place and person. Able to move all extremities. Respirtations even, deep, rate of 20. Vital signs (VS) are within normal limits. IV solution is D5RL. Has voided on bedpan. Eating ice chips. Complaining of sore throat. b. 55 year old male, repair of fractures 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: temp 98.6 F; pulse130 beats/min; respiratory rate 24/min; blood pressure 124/76 mm Hg c. 24 year old male, 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 female, colonoscopy. IV conscious sedation. Awake and alert. Up to bathroom to voice. IV discontinued. Resting quietly in chair. VS are within normal limits

d

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 b. Providing care before, during and after surgery c. closure of the patients surgical incision with sutures d. Completion of the surgical procedure and transfer of the patient to the post anesthesia care unit (PACU

d

Which intervention for postsurgical care of a patient is correct? a. when positions the patient, use the knee patch of the bed to bend the knees and relive pressure. b. gently massage the lower legs and calves to promote venous blood return to the heart c. encourage bedrest for 3 days after surgery to prevent complications d. teach the patient to splint the surgical wound for support and comfort when getting out of bed

d