Postop

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Assessment) 2. The nurse is to administer 1 mg of butorphanol tartrate (Stadol) IV to a postoperative client. Stadol is available as 2 mg/mL. How much Stadol does the nurse administer to the client? ________ mL

0.5 mL 1 mg 1 mL/2 mg = 0.5 mL DIF: Cognitive Level: Application/Applying or higher

85-88 OBJ: 3 (clinical) TOP: Core Measures KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care COMPLETION 26. The nurse in the PACU performs postsurgical assessments on the newly admitted patient every _________ minutes.

15 fifteen The staff in PACU make postoperative assessments every 15 minutes on the newly admitted patient. DIF: Cognitive Level: Knowledge

85-86 OBJ: 3 (clinical) TOP: Prevention of Injury KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 12. To help seal the insertion site from the spinal anesthesia, the nurse will offer: a. tea. b. Jell-O. c. milk. d. iced water.

A Caffeine drinks increase the vascular pressure and help seal the punctured area. DIF: Cognitive Level: Application

267 KEY: Postoperative nursing care| infection control| hand hygiene| Surgical Care Improvement Project (SCIP)| wound infection MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control COMPLETION 1. A postoperative client has the following orders: IV lactated Ringers 125 mL/hr NG tube to low continuous suction Replace NG output every 4 hours with normal saline over 4 hours Morphine sulfate 2 mg IV push every hour as needed for pain NPO Up in chair tonight At 1600 (4:00 PM), the nurse measures the nasogastric (NG) output from noon to be 200 mL. What is the clients total IV rate for the next 4 hours? (Record your answer using a whole number.) _____ mL/hr

175 mL/hr 200 mL of NG output 4 hours = 50 mL/hr. 125 mL/hr + 50 mL/hr = 175 mL/hr. DIF: Applying/Application

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Nursing Process (Implementation) 3. A client is receiving morphine via patient-controlled analgesia (PCA) pump. Morphine is available in a 5-mg/mL solution. The basal rate is 0.8 mg/hr. What is the total volume the client will receive in 24 hours? _________ mL

3.8 mL 0.8 mg/5 mg 1 mL = 0.16 mL/hr 24 = 3.8 mL/24 hr DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation) SHORT ANSWER 1. The nurse is caring for a postoperative client with a nasogastric (NG) tube to suction. The collection container was marked at 125 mL at 7 AM. At 3 PM, 675 mL was in the container. During the shift, the nurse used 45 mL of saline to irrigate the tube three times as prescribed by the physician. What is the total amount of drainage from the NG tube that is entered into the clients record? ___________ mL

415 675 mL 125 mL = 550 mL of drainage 45 mL 3 = 135 mL of irrigant 550 mL 135 mL = 415 mL of actual drainage from the NG tube DIF: Cognitive Level: Application/Applying or higher

90 OBJ: 4 (theory) TOP: Wound Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 28. A postsurgical patient consumed a cup of ice chips filled to the 120-mL mark, 2 oz of broth, and 120 mL of water. In addition, 750 mL of IV fluids were infused. The patient voided 650 mL and vomited 100 mL. What is the total intake for this patient? ________ mL What is the total output for this patient? ________ mL

990; 750 One cup of ice is equal to one-half cup of water. Therefore, 120 mL of ice is 60 mL of intake. One ounce is equal to 30 mL, so 2 ounces equals 60 mL. Therefore, the combined intake is 990 mL and the combined output is 750 mL. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning 33. The nurse is caring for several postoperative clients on the unit. Which client does the nurse assess first? a. Client with 200 mL dark drainage from the nasogastric tube in an hour b. Client who received oral pain medication 20 minutes ago c. Client who has not yet ambulated after surgery 4 hours ago d. Client requiring discharge teaching and whose family is present

A 200 mL of dark drainage from the nasogastric tube in an hour should be assessed and communicated to the physician because it may indicate a bleed. Oral pain medication needs more than 20 minutes to be effective, and the nurse should re-assess the client when the pain medication has had time to take effect. Four hours is probably too soon for a client to ambulate after an operation. The nurse should include the family in discharge teaching, but the client with the nasogastric (NG) drainage needs to be seen first. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Assessment) 18. The nurse is changing the clients dressing on the second postoperative day and notes a small amount of serosanguineous drainage. What is the nurses best action? a. Cleanse the suture line and apply a sterile dressing. b. Culture the drainage and leave the incision open to air. c. Cover the incision with a transparent dressing. d. Notify the surgeon to assess the client.

A A small amount of serosanguineous drainage is a normal assessment finding on the second postoperative day. The incision should be cleaned and dressed. DIF: Cognitive Level: Application/Applying or higher

355 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 16. When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8 F. Which action should the nurse take first? a. Have the patient use the incentive spirometer. b. Assess the surgical incision for redness and swelling. c. Administer the ordered PRN acetaminophen (Tylenol). d. Ask the health care provider to prescribe a different antibiotic.

A A temperature of 100.8 F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because a wound infection does not usually occur before the third postoperative day, a wound infection is not a likely source of the elevated temperature. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareContinuity of Care) MSC: Integrated Process: Communication and Documentation 5. The nurse reviews the initial postanesthesia care unit (PACU) flow record and notes that the client is alert and oriented 3 when stimulated, pulse is 88 per minute and regular, respirations are 12 per minute and unlabored, and oxygen saturation is 95% on 2 LPM of nasal oxygen. What is the nurses priority action at this time? a. Examine the surgical site; obtain blood pressure and temperature. b. Suction the client and assess anterior and posterior lung sounds. c. Assess urinary output, the IV site, and the clients pain. d. Turn the client and perform chest physiotherapy.

A Initial assessment on the client entering the PACU that should be recorded on the flow chart record includes level of consciousness, temperature, pulse, respirations, oxygen saturation, and blood pressure. In addition, the nurse should examine the surgical area for bleeding. These items were missing from the initial assessment. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Implementation) 20. A client reports pain 8 hours after surgery. The client has already received an opioid within the past 2 hours. What is the nurses best action? a. Assess the pain further. b. Administer naloxone (Narcan). c. Call the surgeon. d. Document the finding.

A Opioids are short acting. The client may be undermedicated. The nurse should further assess location, intensity, etc., of the pain. If the client has no respiratory depression, it is possible that the dose can be increased. The nurse would not call the surgeon until the pain is further assessed. Narcan is used to reverse opioid effects but would not be appropriate in this case. Documentation is important, but the higher priority is a more complete assessment of the clients pain. DIF: Cognitive Level: Application/Applying or higher

p. 299 TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortNutrition and Oral Hydration) MSC: Integrated Process: Teaching/Learning 40. A client has received an overdose of a benzodiazepine. What medication does the nurse anticipate an order for? a. Flumazenil (Romazicon) b. Naloxone (Narcan) c. Acetylcysteine (Mucomyst) d. Digoxin immune fab (Digibind)

A Romazicon is the most commonly used antidote for benzodiazepine overdose. Narcan is used to treat overdoses of narcotics, Mucomyst can be used for acetaminophen overdose, and Digibind is used for digoxin overdoses. DIF: Cognitive Level: Knowledge/Remembering TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation) MULTIPLE RESPONSE 1. Which clients are at increased risk for postoperative nausea and vomiting? (Select all that apply.) a. Older adult with a history of hypertension b. Client who was in the lateral position during surgery c. Middle aged client with a body mass index (BMI) of 46 d. Woman who has undergone a cholecystectomy e. Young adult who received 3 L of IV fluid during surgery f. Man who has a history of seasickness g. Man who has a nasogastric tube to suction ANS: C, D, F Obesity, motion sickness, and general anesthesia carry increased risk for postoperative nausea and vomiting. DIF: Cognitive Level: Knowledge/Remembering

351 | 352 | 323 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 18. The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider? a. The right calf is swollen, warm, and painful. b. The patients temperature is 100.3 F (37.9 C). c. The 24-hour oral intake is 600 mL greater than the total output. d. The patient complains of abdominal pain at level 6 (0 to 10 scale) when ambulating.

A The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require the health care provider to order diagnostic tests and/or anticoagulants. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3 F on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Assessment) 6. A client who has just been transferred to the postanesthesia care unit (PACU) from surgery is very restless and confused. What is the nurses first action? a. Orient the client and remain with him or her. b. Call the surgeon for an intraoperative report. c. Notify the physician on call. d. Assess the clients level of pain.

A The client who is not oriented is at risk of falling. The nurse should remain with the client to ensure safety, and should assign another staff member to the client if care has to be given to others. The client should not be left alone. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Implementation) 14. The nurse is caring for clients in the postanesthesia care unit (PACU). Which client does the nurse intervene for first? a. Client with a pulse deficit of 15 b. Client who is reporting leg pain c. Client with dementia who is confused d. Client who is reporting a headache

A The client with an apical radial pulse deficit could be having dysrhythmias, which may be indicative of volume deficit, acidosis, electrolyte imbalances, or hypothermia. All clients must be assessed and cared for according to their needs, but this client would be the nurses highest priority. DIF: Cognitive Level: Application/Applying or higher

363 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 19. A patient who had knee surgery received intramuscular ketorolac (Toradol) 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is best for the nurse to take at this time? a. Administer the prescribed PRN IV morphine sulfate. b. Notify the health care provider about the ongoing knee pain. c. Reassure the patient that postoperative pain is expected after knee surgery. d. Teach the patient that the effects of ketorolac typically last about 6 to 8 hours.

A The priority at this time is pain relief. Concomitant use of opioids and nonsteroidal antiinflammatory drugs (NSAIDs) improves pain control in postoperative patients. Patient teaching and reassurance are appropriate, but should be done after the patients pain is relieved. If the patient continues to have pain after the morphine is administered, the health care provider should be notified. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation) 31. The nurse is assisting a client to ambulate several hours after his surgery. The client coughs and says to the nurse, I feel like something ripped in my incision. A large amount of blood is suddenly apparent on the clients gown near the incision. What action does the nurse take first? a. Ease the client to the floor and call for assistance. b. Put immediate pressure over the incision with the hands. c. Call the Rapid Response Team to assess the client. d. Lift up the gown and take off the dressing.

A The first action of the nurse should be to ease the client to the floor to reduce tension on the incision. This will help keep organs within the abdominal cavity and will help prevent the client from fainting and falling to the floor. The nursing staff should return the client to bed, and the nurse needs to reinforce the dressing while leaving the original one intact. The surgeon or the Rapid Response Team should be notified. DIF: Cognitive Level: Application/Applying or higher

p. 294 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialTherapeutic Procedures) MSC: Integrated Process: Nursing Process (Assessment) 26. The nurse is working in the postanesthesia care unit (PACU) and receives a client from the operating room (OR). What does the nurse assess first? a. Clients endotracheal tube b. Clients nasogastric tube c. Clients Foley catheter d. Hemovac drain at the incision site

A The first priority for this client is to assess airway, breathing, and circulation postoperatively. Therefore, the patency of the clients endotracheal (ET) tube should be determined first. All other drains should be assessed, but they are not the priority. DIF: Cognitive Level: Application/Applying or higher

357 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 14. A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first? a. Perform a bladder scan. b. Encourage increased oral fluid intake. c. Assist the patient to ambulate to the bathroom. d. Insert a straight catheter as indicated on the PRN order.

A The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Because of the risk for urinary tract infection, catheterization should only be done after other measures have been tried without success. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful. DIF: Cognitive Level: Apply (application)

88 OBJ: 4 (clinical) TOP: Promotion of Comfort KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 16. Prior to getting the postsurgical patient up for the first time, the nurse should initially: a. raise the head of the bed. b. dangle the patients legs over side of bed. c. offer patient some fluids. d. apply gait belt to patient.

A The initial intervention prior to the first ambulation is to raise the head of the bed to gradually change the patients posture. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlError Prevention) MSC: Integrated Process: Communication and Documentation 35. The nurse is caring for a client who is reporting severe postoperative pain. The physicians order states that the client is to receive hydromorphone hydrochloride (Dilaudid) 10-15 mg every 1-2 hours PRN pain. What is the nurses priority action? a. Call the physician to clarify the order. b. Give the medication as ordered. c. Refuse to give the medication. d. Call the hospital pharmacist.

A The order must be clarified before the medication is given because the Dilaudid dosage is beyond safe parameters. The nurse can consult the pharmacist, but then would still need to call the physician to determine the specific route of administration and eliminate the ranges in the order. Refusing to give the medication will not help the client obtain pain relief. DIF: Cognitive Level: Application/Applying or higher

358 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 20. The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5 F (35.8 C). Which action should the nurse take? a. Cover the patient with a warm blanket and put on socks. b. Notify the anesthesia care provider about the temperature. c. Avoid the use of opioid analgesics until the patient is warmer. d. Administer acetaminophen (Tylenol) 650 mg suppository rectally.

A The patient assessment indicates the need for active rewarming. There is no indication of a need for acetaminophen. Opioid analgesics may help reduce shivering. Because hypothermia is common in the immediate postoperative period, there is no need to notify the anesthesia care provider, unless the patient continues to be hypothermic after active rewarming. DIF: Cognitive Level: Apply (application)

361 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 23. After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery c. Patient who has bibasilar crackles and a temperature of 100F (37.8C) on the first postoperative day after chest surgery d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) administration

A The patients history and assessment suggests possible wound dehiscence, which should be reported immediately to the surgeon. Although the information about the other patients indicates a need for ongoing assessment and/or possible intervention, the data do not suggest any acute complications. Small amounts of red drainage are common in the first postoperative hours. Bibasilar crackles and a slightly elevated temperature are common after surgery, although the nurse will need to have the patient cough and deep breathe. Oral medications typically take more than 15 minutes for effective pain relief. DIF: Cognitive Level: Analyze (analysis)

262 KEY: Postoperative nursing| nausea and vomiting| respiratory assessment| nursing assessment MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 7. A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a. Airway b. Bleeding c. Breathing d. Cardiac rhythm

A Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of the circulation assessment, as is cardiac rhythm. DIF: Applying/Application

266 KEY: Postoperative nursing| nursing assessment| respiratory assessment| respiratory system| postanesthesia care unit (PACU)| airway MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 8. A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer? a. Flumazenil (Romazicon) 0.2 to 1 mg b. Flumazenil (Romazicon) 2 to 10 mg c. Naloxone (Narcan) 0.4 to 2 mg d. Naloxone (Narcan) 4 to 20 mg

A Flumazenil is a benzodiazepine antagonist and would be the correct drug to use in this situation. The correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist. DIF: Remembering/Knowledge

258 KEY: Postoperative nursing| nursing assessment| sedation| respiratory system MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate? a. Assess other indicators of oxygenation. b. Call the Rapid Response Team. c. Notify the anesthesia provider. d. Prepare to intubate the client.

A If a postoperative clients oxygen saturation (SaO2) drops below 95% (or the clients baseline), the nurse should notify the anesthesia provider. If the SaO2 drops by 10% or more, the nurse should call the Rapid Response Team. Since this is approximately a 3% drop, the nurse should further assess the client. Intubation (if the client is not intubated already) is not warranted. DIF: Applying/Application

p. 290 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) 2. A postoperative client is receiving morphine for pain. For which side effects does the nurse monitor this client? (Select all that apply.) a. Hypotension b. Respiratory depression c. Constipation d. Increased intracranial pressure e. Altered bleeding times

A, B, C Morphine can cause hypotension, respiratory depression, constipation, and urinary retention. Increased intracranial pressure is a side effect of butorphanol tartrate (Stadol), and altered bleeding times can occur owing to combination drugs that contain aspirin or ibuprofen. DIF: Cognitive Level: Knowledge/Remembering

269 KEY: Postoperative nursing| discharge planning/teaching| opioid analgesics| acetaminophen| constipation MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 5. A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.) a. Apply stimulation to the contralateral leg. b. Assess the clients willingness to try meditation. c. Elevate the clients operative leg and apply ice. d. Reduce the noise level in the clients environment. e. Turn the TV on loudly to distract the client.

A, B, C, D There are many nonpharmacologic comfort measures for pain, including applying stimulation to the opposite leg, providing opportunities for meditation, elevation of the leg, applying ice, and reducing noxious stimuli in the environment. Participating in diversional activities is another approach, but simply turning the TV on loudly does not provide a good diversion. DIF: Remembering/Knowledge

262 KEY: Postoperative nursing| nasogastric tube| fluid and electrolyte balance| nursing assessment| laboratory values MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 3. A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the clients plan of care to minimize the potential for this occurring? (Select all that apply.) a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. d. Place the client in a room secluded at the end of the hall. e. Provide the client with uninterrupted periods of sleep.

A, B, C, E Older clients may have difficulty adjusting to the stress of the hospital environment and illness or surgery. Techniques that are helpful include allowing liberal visitation, assisting the client to use successful coping techniques, and keeping the client bathed and groomed. Sleep deprivation can contribute to confusion, so the nurse ensures the client receives adequate sleep. Secluding the client at the end of the hall may lead to sensory deprivation and loneliness. DIF: Remembering/Knowledge

267 KEY: Postoperative nursing| coping| psychosocial response| older adult MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Health Promotion and Maintenance 4. A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.) a. Check all over-the-counter medications for acetaminophen. b. Do not take more pills each day than you are prescribed. c. Eat a diet that is high in fiber and drink lots of water. d. If this gives you diarrhea, loperamide (Imodium) can help. e. You shouldnt drive while you are taking this medication.

A, B, C, E Percocet is a common opioid analgesic that contains acetaminophen. The client should be taught to check all over-the-counter medications for acetaminophen and to not take more than the prescribed amount of Percocet, as the maximum daily dose of acetaminophen is 3000 mg. Percocet, like all opioid analgesics, can cause constipation, and the client can minimize this by eating a high-fiber diet and drinking plenty of water. Since Percocet can cause drowsiness, the client taking it should not drive or operate machinery. The medication is more likely to cause constipation than diarrhea. DIF: Applying/Application

82-83 OBJ: 2 (clinical) TOP: Neurologic Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 22. The nurse performing the Aldrete scoring system must assess: (Select all that apply.) a. activity. b. circulation. c. presence of wound drainage. d. level of consciousness. e. O2 saturation.

A, B, D, E The Aldrete scoring system requires that the nurse assess activity, circulation, respiration, level of consciousness, and oxygen saturation. DIF: Cognitive Level: Comprehension

82 OBJ: 5 (theory) TOP: Day Surgery KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 24. The day surgery nurse provides written discharge instructions that should include: (Select all that apply.) a. when to resume normal activity. b. signs and symptoms to report. c. a list of probable complications. d. the telephone number of the surgeons office. e. the need to delay driving and decision making.

A, B, D, E The discharge instructions should include information about when to resume activity, signs and symptoms to report, contact information about the surgeon, and the need to delay driving and decision making. DIF: Cognitive Level: Application

357 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. A patients blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Increase the IV infusion rate. b. Assess the patients dressing. c. Increase the oxygen flow rate. d. Check the patients temperature.

A, C, B, D The first nursing action should be to increase the IV infusion rate. Because the most common cause of hypotension is volume loss, the IV rate should be increased. The next action should be to increase the oxygen flow rate to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patients temperature should be assessed to determine the effects of vasodilation caused by rewarming. DIF: Cognitive Level: Analyze (analysis)

361 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment OTHER 1. While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurse accomplish the following activities? (Put a comma and a space between each answer choice [A, B, C, D].) a. Have the patient sit down in a chair. b. Give the patient something to drink. c. Take the patients blood pressure (BP). d. Notify the patients health care provider.

A, C, B, D The first priority for the patient with syncope is to prevent a fall, so the patient should be assisted to a chair. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the fluid intake will help prevent orthostatic dizziness. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no urgent need to notify the health care provider. DIF: Cognitive Level: Apply (application)

82 OBJ: 1 (theory) TOP: Aldrete Scoring System KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 23. Following an outpatient procedure for which the patient received general anesthesia, the day surgery recovery nurse determines that the patient is ready to be discharged based on which of these findings? (Select all that apply.) a. Patient is able to ambulate to the bathroom with minimal assistance. b. Patient is not able to read and voice an understanding of discharge instructions. c. Patient has been awake for 2 hours. d. Patient is able to empty the bladder. e. Patient is going to drive home, which is 2 blocks from the facility.

A, D The criteria for discharge from day surgery are the ability to ambulate unassisted and to empty the bladder. Following general anesthetic, a responsible person may receive the discharge instructions and a written copy should be provided to the patient; being awake for 2 hours is not discharge criteria; and patients cannot drive any distance after general anesthesia. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesMedication Administration) MSC: Integrated Process: Nursing Process (Assessment) 1. On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse ismost appropriate? a. Increase the IV fluid rate. b. Continue to take vital signs every 15 minutes. c. Administer oxygen therapy at 100% per mask. d. Notify the anesthesia care provider (ACP) immediately.

B A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration. DIF: Cognitive Level: Analyze (analysis)

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Implementation) 8. The nurse is assessing a client admitted to the postanesthesia care unit (PACU) after abdominal surgery. The clients respiratory rate is 8 breaths/min and breath sounds are decreased in the bases. What is the nurses priority action? a. Prepare to administer naloxone (Narcan). b. Assess oxygen saturation and level of consciousness. c. Call a code or the Rapid Response Team. d. Turn the client and perform chest physiotherapy.

B Additional data are needed to determine respiratory status, so the nurse must finish the assessment with an oxygen saturation (SaO2) and check the clients level of consciousness. A respiratory rate of less than 10 could indicate an emergency, especially if the SaO2 drops below 95%. A respiratory rate of less than 10 breaths/min may indicate anesthetic-induced depression. Naloxone should not be administered unless there are clear indications for it, and performing chest physiotherapy may not be warranted. Calling a code or the Rapid Response Team may be needed, but only after a complete assessment. DIF: Cognitive Level: Application/Applying or higher

85 OBJ: 4 (theory) TOP: Maintenance of Circulation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. The nurse has been assigned to care for several postoperative patients. The nurse is aware that the patient most likely to develop thrombophlebitis is the patient: a. with a history of blood clots who is being discharged following an outpatient cholecystectomy. b. who is 6 days postoperative for total right hip replacement and has a history of left-sided stroke. c. who has had major abdominal surgery and was dehydrated upon admission. d. who is 2 days postoperative for hernia repair with a history of diabetes.

B Although all of these patients are at varying degrees of risk for thrombophlebitis, the hip replacement surgery places a patient at high risk for thrombophlebitis due to limited mobility, especially after the fifth postoperative day. This patient is at even higher risk of thrombophlebitis because of a history of left-sided stroke. DIF: Cognitive Level: Analysis

361 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 7. A nurse assists a patient on the first postoperative day to ambulate, cough, deep breathe, and turn. Which action by the nurse is most helpful? a. Teach the patient to fully exhale into the incentive spirometer. b. Administer ordered analgesic medications before these activities. c. Ask the patient to state two possible complications of immobility. d. Encourage the patient to state the purpose of splinting the incision.

B An important nursing action to encourage these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities. When using an incentive spirometer, the patient should be taught to inhale deeply, rather than exhale into the spirometer to promote lung expansion and prevent atelectasis. DIF: Cognitive Level: Apply (application)

359 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse reviews the laboratory results for a patient on the first postoperative day after a hiatal hernia repair. Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing? a. Potassium 3.5 mEq/L b. Albumin level 2.2 g/dL c. Hemoglobin 11.2 g/dL d. White blood cells 11,900/L

B Because proteins are needed for an appropriate inflammatory response and wound healing, the low serum albumin level (normal level 3.5 to 5.0 g/dL) indicates a risk for poor wound healing. The potassium level is normal. Because a small amount of blood loss is expected with surgery, the hemoglobin level is not indicative of an increased risk for wound healing. WBC count is expected to increase after surgery as a part of the normal inflammatory response. DIF: Cognitive Level: Apply (application)

353 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 9. A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patients oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Assess for bladder distention. c. Notify the anesthesia care provider (ACP). d. Demonstrate the use of the nurse call bell button.

B Because the patients assessment indicates physiologic stability, the most likely cause of the patients agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should look for a cause such as bladder distention. Although hypoxemia is the most common cause, the patients oxygen saturation is 96%. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify the ACP. Orientation of the patient to bed controls is needed, but is not likely to be effective until the effects of anesthesia have resolved more completely. DIF: Cognitive Level: Analyze (analysis)

84 OBJ: 4 (theory) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse is caring for a patient during the first postoperative day. An appropriate goal to write in the nursing care plan to avoid atelectasis would be: a. patient will turn, cough, and deep-breathe every 4 hours. b. patient will huff cough every 2 hours. c. patient will use the incentive spirometer twice a day. d. nurse will assist the patient to ambulate in the hall three times a day.

B Bi-hourly coughing will help prevent atelectasis. The patient should turn, cough, and deep-breathe every 2 hours; and the incentive spirometer should ideally be used every hour. The nurse assisting the patient to ambulate is an intervention, not a goal. DIF: Cognitive Level: Analysis

84 | Elder Care Points OBJ: 4 (theory) TOP: Maintenance of Ventilation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. Which assessment finding on a patient who had a right total knee replacement this morning should be reported to the charge nurse immediately? a. Pain at level of 8 at operative site b. Capillary refill of right toe of 7 seconds c. Right foot warm to touch d. Swelling of right knee

B Capillary refills should be brisk, less than 3 seconds. Pain and swelling are expected at this early postoperative time. A warm foot is a normal finding. DIF: Cognitive Level: Application

356 OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 13. A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? a. Administer the ordered opioid. b. Check the oxygen (O2) saturation. c. Take the blood pressure and pulse. d. Apply wrist restraints to secure IV lines.

B Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action. DIF: Cognitive Level: Apply (application)

89 OBJ: 4 (theory) TOP: Factors Interfering with Wound Healing KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 18. When the postoperative patient refuses to cough due to incisional pain, the initial nursing action should be: a. encouraging deep breathing instead of coughing. b. splinting the abdomen with a pillow. c. explaining the importance of controlled coughing. d. giving pain medication.

B Giving pain medication and explaining the importance of coughing may be effective, but the best initial action would be splinting the incision with a pillow. Deep breathing should be done in addition to, not in place of, coughing. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Physiologic Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) 9. The nurse assesses a client who has just been brought to the postanesthesia care unit (PACU). In the operating room, the clients blood pressure was 136/80 mm Hg; it is now 110/80 mm Hg. Urine output was 40 mL/hr and is now 10 mL/hr. Which action by the nurse is best? a. Awaken the client and encourage oral fluids. b. Increase the IV of 0.9 NS as ordered to 100 mL/hr. c. Put the client in Trendelenburg position. d. Assess the clients levels of consciousness and pain.

B One of the most sensitive and earliest indicators of vascular volume loss is decreased urine output. The nurse is concerned about urinary output less than 30 mL/hr because this may indicate that the kidneys are not being perfused. The nurse should increase the IV rate. Oral fluids are not an option at this point because the client has not recovered from the anesthesia. Placing the client in Trendelenburg position is not warranted because this puts pressure on the heart and lungs, limiting their effectiveness. Assessing consciousness and pain can wait until later. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Implementation) 39. A client is being discharged after abdominal surgery. What information about the diet does the nurse teach the client? a. Be sure to monitor your fluid intake. b. Eat foods high in protein and vitamin C. c. Call the physician if you develop gas. d. You will need to limit your carbohydrates.

B Postoperatively, a diet high in calories, protein, and vitamin C promotes healing. There is no need to monitor fluid intake, to call the physician for gas, or to limit carbohydrates. DIF: Cognitive Level: Knowledge/Remembering

N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Assessment) 21. A client with diabetes mellitus type 1 underwent surgery 24 hours ago. Which precaution does the nurse take to help prevent postoperative complications for this client? a. Order a high-protein diet. b. Observe the incision frequently. c. Have suction available at the bedside. d. Instruct the client to use an electric razor.

B The client with diabetes is at higher risk for impaired wound healing and the development of wound infection. The nurse should observe the incision for drainage and changes in appearance. The client does not need a high-protein diet, suction, nor an electric razor owing to diabetes. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) 27. The nurse is caring for a client whose wound dehisces after vomiting. What is the nurses first action? a. Prepare the client for emergency surgery. b. Cover the wound with sterile moist dressings. c. Give the client medication for nausea. d. Call the surgeon and the operating room.

B The dehisced wound should be covered immediately with sterile moist dressings. Then the nurse should call the surgeon. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation) 22. The nurse is providing discharge teaching for a client who will be going home with a Jackson-Pratt (JP) drain. Which statement indicates that the client understands how to care for the drain correctly? a. I will flush the tubing to make sure that it stays open. b. I will measure the drainage before I discard it. c. I will close the drain valve and then compress the bulb to create suction. d. I will pull it out once the surgeon says I dont need it anymore.

B The drainage from the JP should be measured before it is discarded. The client does not have to flush the tubing. The tubing is sutured in place, and the client should not pull on it. The bulb should be compressed, then the drain valve closed. DIF: Cognitive Level: Application/Applying or higher

92 | Table 5-2 OBJ: 3 (theory) TOP: Maintenance of Ventilation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. The nurse is caring for a 90-year-old postoperative patient. The nurse notes that the oxygen saturation is frequently dropping below 90%. This is most likely related to: a. prolonged use of a walker. b. poor fluid intake. c. weakened respiratory muscles. d. increased elasticity of costal cartilages.

C Age-related changes that interfere with respiration in the older adult are weakened respiratory muscles and calcified costal cartilages. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Assessment) 11. A client is brought to the postanesthesia care unit (PACU) after surgery that took place with the client in the lithotomy position. Which action does the nurse take after assessing vital signs? a. Assess for sacral decubiti. b. Assess dorsalis pedis pulses. c. Turn the client on the left side. d. Put the client in the Trendelenburg position.

B The lithotomy position can compromise the clients peripheral circulation in the lower extremities, leading to weak pedal pulses. The nurse should check dorsalis pedis pulses. The client would not need to be assessed for decubiti, turned on the side, nor placed in the Trendelenburg position. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) 16. One hour after admission to the postanesthesia care unit (PACU), the postoperative client has become very restless. What is the nurses first action? a. Assess for bladder distention. b. Assess the oxygen saturation level. c. Call the surgeon to assess the client. d. Administer pain medication as ordered.

B The most common causes of restlessness in the immediate postoperative period are hypoxemia and pain. Although pain control is very important, determining the adequacy of ventilation in this case has higher priority. DIF: Cognitive Level: Application/Applying or higher

354 TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 4. An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, I do not know if I can take care of myself with this patch over my eye. Which action by the nurse ismost appropriate? a. Refer the patient for home health care services. b. Discuss the specific concerns regarding self-care. c. Give the patient written instructions regarding care. d. Assess the patients support system for care at home.

B The nurses initial action should be to assess exactly the patients concerns about self-care. Referral to home health care and assessment of the patients support system may be appropriate actions but will be based on further assessment of the patients concerns. Written instructions should be given to the patient, but these are unlikely to address the patients stated concern about self-care. DIF: Cognitive Level: Apply (application)

350 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient? a. Potential complication: hypovolemic shock b. Potential complication: venous thromboembolism c. Potential complication: fluid and electrolyte imbalance d. Potential complication: impaired surgical wound healing

B The patient is older and relatively immobile, which are two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient. DIF: Cognitive Level: Apply (application)

356 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. In the postanesthesia care unit (PACU), a patients vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient to a clinical unit. d. Increase the rate of the postoperative IV fluids.

B The patients borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable blood pressure and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU to a clinical unit is not appropriate. DIF: Cognitive Level: Analyze (analysis)

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Prevention and/or Early Detection of Health ProblemsSelf-Care) MSC: Integrated Process: Teaching/Learning 23. The nurse is caring for a client who has had surgery the previous day. The client tells the nurse, Breathing in using this thing (incentive spirometer) is a ridiculous waste of time. What is the nurses best response? a. The spirometer will help you cough effectively. b. The spirometer will help your lungs expand. c. The spirometer will help prevent blood clots. d. The spirometer will improve blood flow in your lungs.

B The primary purpose of using an incentive spirometer is to promote lung expansion. The incentive spirometer assists the client in seeing how much air he or she can inhale. The nurse can encourage the client by setting a volume and encouraging the client to reach it. Although many clients may cough while using this, it does not help them cough. Clients begin to cough after taking deep breaths. The spirometer will help with airflow into the lungs, not with blood flow. DIF: Cognitive Level: Comprehension/Understanding

357 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 10. Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit? a. Clarify the postoperative orders with the surgeon. b. Help with the transfer of the patient onto a stretcher. c. Document the appearance of the patients incision in the chart. d. Provide hand off communication to the surgical unit charge nurse.

B The scope of practice of UAP includes repositioning and moving patients under the supervision of a nurse. Providing report to another nurse, assessing and documenting the wound appearance, and clarifying physician orders with another nurse require registered-nurse (RN) level education and scope of practice. DIF: Cognitive Level: Apply (application)

261 KEY: Postoperative nursing| older adult| sedation| neurologic system MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Health Promotion and Maintenance 12. A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first? a. Assess the clients blood pressure. b. Perform hand hygiene and apply gloves. c. Reinforce the dressing with a clean one. d. Remove the dressing to assess the wound.

B Prior to assessing or treating the drainage from the wound, the nurse performs hand hygiene and dons gloves to protect both the client and nurse from infection. DIF: Applying/Application

266 KEY: Postoperative nursing| nursing intervention| benzodiazepine antagonist| critical rescue MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 9. A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort? a. Assess the clients pain on a 0-to-10 scale. b. Assist the client into a position of comfort. c. Have the client sit up in a recliner. d. Tell the client when pain medication is due.

B Several nonpharmacologic comfort measures can help postoperative clients with their pain, including distraction, music, massage, guided imagery, and positioning. The nurse should help this client into a position of comfort considering the surgical procedure and position of any tubes or drains. Assessing the clients pain is important but does not improve comfort. The client may be more uncomfortable in a recliner. Letting the client know when pain medication can be given next is important but does not improve comfort. DIF: Applying/Application

261 KEY: Postoperative nursing| neurologic system MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? a. Allow the client to rest. b. Auscultate lung sounds. c. Document the episode. d. Encourage the client to eat dry toast.

B Vomiting after surgery has several complications, including aspiration. The nurse should listen to the clients lung sounds. The client should be allowed to rest after an assessment. Documenting is important, but the nurse needs to be able to document fully, including an assessment. The client should not eat until nausea has subsided. DIF: Applying/Application

256 KEY: Postoperative nursing| nursing assessment| surgical procedures MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 2. A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.) a. Blood glucose: 120 mg/dL b. Hemoglobin: 7.8 mg/dL c. pH: 7.68 d. Potassium: 2.9 mEq/L e. Sodium: 142 mEq/L

B, C, D Fluid and electrolyte balance are assessed carefully in the postoperative client because many imbalances can occur. The low hemoglobin may be from blood loss in surgery. The higher pH level indicates alkalosis, possibly from losses through the NG tube. The potassium is very low. The blood glucose is within normal limits for a postsurgical client who has been fasting. The sodium level is normal. DIF: Applying/Application

87 OBJ: 4 (theory) TOP: Postoperative Diet KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 21. The nurse is performing a neurological assessment on a male patient who has just been transferred from the PACU following abdominal surgery. The nurse demonstrates knowledge of a neurological assessment by: (Select all that apply.) a. asking the patient to spell his name. b. asking the patient to tell you where he is. c. noting if the patient can identify the sensation of touch. d. asking the patient to move his arms and legs. e. assessing the pupils for response to light.

B, C, D, E The level of consciousness, orientation, sensory status, motor skills, and pupillary responses are all integral components of the neurological assessment. Asking the patient to spell his name is not an assessment of neurological status, particularly immediately following surgery. DIF: Cognitive Level: Application

362-363 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 5. The nasogastric (NG) tube is removed on the second postoperative day, and the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. What action by the nurse is the mostappropriate? a. Reinsert the NG tube. b. Give the PRN IV opioid. c. Assist the patient to ambulate. d. Place the patient on NPO status.

C Ambulation encourages peristalsis and the passing of flatus, which will relieve the patients discomfort. If distention persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains. DIF: Cognitive Level: Analyze (analysis)

97 | Patient Teaching OBJ: 5 (theory) TOP: Discharge Instructions KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 25. The nurse is caring for a patient 48 hours after mastectomy surgery. The nurse is teaching the nursing student about Core Measures. The nursing student correctly implements which Core Measure interventions? (Select all that apply.) a. Administering prophylactic antibiotic therapy 48 hours following surgery b. Encouraging the elderly patient to use the call light attached to her when ambulating to the bathroom c. Asking the patient to rate her pain on a pain scale d. Ensuring that antiembolic stockings are removed during bathing e. Assisting the patient with incentive spirometer every 4 hours

B, D Core Measures for postsurgical patients, issued by The Joint Commission, address prevention of falls and antithrombosis therapy, which are demonstrated by encouraging use of the call light and antiembolic stockings that may be removed during skin care. Core Measures state that prophylactic antibiotics should be discontinued within 24 hours after surgery. The pain scale and incentive spirometer are not Core Measure guidelines. In addition, use of the incentive spirometry should occur more often than every 4 hours. DIF: Cognitive Level: Application

271 KEY: Postoperative nursing| pain| nonpharmacologic pain management| nursing intervention| physical modalities| ice MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 6. A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.) a. Administering antibiotics for 72 hours b. Disposing of dressings properly c. Leaving draining wounds open to air d. Performing proper hand hygiene e. Removing and replacing wet dressings

B, D, E Interventions necessary to prevent surgical wound infection include proper disposal of soiled dressings, performing proper hand hygiene, and removing wet dressings as they can be a source of infection. Prophylactic antibiotics are given to clients at risk for infection, but are discontinued after 24 hours if no infection is apparent. Draining wounds should always be covered. DIF: Applying/Application

268 KEY: Postoperative nursing| drains| infection control MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE 1. A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.) a. All phases require the client to be in the hospital. b. Phase I care may last for several days in some clients. c. Phase I requires intensive care unit monitoring. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III.

B, D, E There are three phases of postoperative care. Phase I is the most intense, with clients coming right from surgery until they are completely awake and hemodynamically stable. This may take hours or days and can occur in the intensive care unit or the postoperative care unit. Phase II ends when the client is at a presurgical level of consciousness and baseline oxygen saturation, and vital signs are stable. Phase III involves the extended care environment and may continue at home or in an extended care facility if needed. DIF: Remembering/Knowledge

360 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 6. A patients T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate? a. Notify the patients surgeon. b. Place the patient on bed rest. c. Document the color and amount of drainage. d. Irrigate the T-tube with sterile normal saline.

C A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlError Prevention) MSC: Integrated Process: Nursing Process (Implementation) 36. Which instruction does the nurse provide to a client to prevent postoperative venous thromboembolism? a. Cough and deep-breathe six times every hour after surgery. b. Use your incentive spirometer hourly. c. Get up and walk as much as possible. d. Keep the sterile dressing on your incision.

C Ambulation will help prevent formation of blood clots in the legs, the most common site for postoperative venous thromboembolism. Coughing and deep breathing will help prevent atelectasis, and sterile dressings will help prevent wound infection. DIF: Cognitive Level: Application/Applying or higher

82 OBJ: 1 (theory) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. Following abdominal surgery, the PACU nurse demonstrates the best nursing care by placing the semi-conscious patient in _____ position. a. the supine b. semi-Fowlers c. the lateral d. Trendelenburgs

C Aspiration is a high-risk complication during this phase of recovery and can best be prevented by placing the unconscious patient on the side with head turned to the side. DIF: Cognitive Level: Application

354 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 11. A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first? a. Assess the patients pain. b. Orient the patient to the unit. c. Take the patients vital signs. d. Read the postoperative orders.

C Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer. DIF: Cognitive Level: Apply (application)

360-361 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 15. The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first? a. Reinforce the dressing. b. Apply an abdominal binder. c. Take the patients vital signs. d. Recheck the dressing in 1 hour for increased drainage.

C New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patients vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeons orders or institutional policy. The nurse should not wait an hour to recheck the dressing. DIF: Cognitive Level: Apply (application)

358 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed? a. Patient drinks 2 to 3 L of fluid in 24 hours. b. Patient uses the spirometer 10 times every hour. c. Patients breath sounds are clear to auscultation. d. Patients temperature is less than 100.4 F orally.

C One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or crackles, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems. DIF: Cognitive Level: Apply (application)

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Intervention) 10. The nurse is caring for a client who has just been brought to the postanesthesia care unit (PACU) after surgery. The clients oxygen saturation is 92% and his hemoglobin is 14 g/dL. What is the nurses first action? a. Assess the clients pain response. b. Determine whether the client is alert and oriented. c. Increase oxygen and auscultate lung sounds. d. Assess vital signs and temperature.

C Oxygen saturation is the most definitive assessment finding for whether or not the client is adequately oxygenated. However, because oxygen saturation is based on the amount of hemoglobin in the blood, this indicator needs to be evaluated, in addition to the saturation. If a client has low hemoglobin, even if the percentage of saturation is high, the client is still underoxygenated. Oxygen should be increased and further respiratory assessment performed. DIF: Cognitive Level: Application/Applying or higher

88 OBJ: 5 (theory) TOP: Promotion of Rest and Activity KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 17. The nurse reminds the postsurgical patient that smoking will complicate postsurgical recovery by: a. increasing probability of hemorrhage. b. increasing blood pressure. c. delaying healing. d. increasing the need for pain medication.

C Smoking delays healing because it causes a decrease in hemoglobin; hemoglobin carries oxygen to cells and tissues, which is necessary for wound healing. DIF: Cognitive Level: Application

85 OBJ: 4 (theory) TOP: Maintenance of Circulation KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. Antiembolic stockings are in place on the obese postsurgical patient. The nurse is aware that the standard of care in regard to antiembolic stockings is that the stockings should be: a. left in place continually for the first 24 hours. b. fitted tightly at the knee and ankle. c. removed approximately 20 minutes every shift. d. removed when ambulating.

C Stockings should be removed approximately 20 minutes each shift for skin care. DIF: Cognitive Level: Application

263 KEY: Postoperative nursing| nasogastric tube| IV fluids MSC: Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 1. The nurse is caring for a client who had surgery 24 hours ago. He is alert and oriented when awakened and reports pain, but goes back to sleep when not being stimulated. He is on patient-controlled analgesia (PCA). What is the nurses next action? a. Push the PCA control for the client. b. Discontinue the PCA immediately. c. Assess the clients respiratory status. d. Keep the client awake as much as possible.

C The client should be assessed further before action is taken. If the client cannot stay awake 24 hours after surgery, there may be other problems. The nurse should assess respiratory rate and depth and lung sounds, as well as oxygen status. The nurse should never push the PCA for the client, and pain should be assessed before decisions are made and interventions taken. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareContinuity of Care) MSC: Integrated Process: Communication and Documentation 4. The nurse is performing a hand-off report in the PACU. What is the best action for the nurse to perform during the hand-off report? a. Write all information on a chart and hand it to the nurse who will assume care of the client. b. Follow the nurse assigned to the new client and give a verbal report that does not interrupt care. c. Focus on the report and sit with the nurse receiving the client to give a detailed report. d. Finish the report quickly so the nurse can assume care of the client.

C The hand-off report is a time when errors can potentially occur. The nurse should sit with the receiving nurse to give report. That way, both nurses will be focused on the report. Simply handing the information to the new nurse does not ensure that he or she will read or understand it. Following the accepting nurse around and giving report while he or she provides care for other clients would be distracting. The hand-off nurse should not hurry through this report and should provide a report that allows for two-way communication between nurses. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialTherapeutic Procedures) MSC: Integrated Process: Nursing Process (Implementation) 29. The nurse is preparing a client for discharge. The client has a large draining wound. What is the nurses best action? a. Arrange a nurse to come to the house to change the dressing after discharge. b. Have the client come back to the clinic daily to have the dressing changed. c. Teach the client and family how to change the dressing. d. Apply a hydrocolloid dressing and change once a week.

C The nurse should teach the client and family members to change the dressing as necessary. If they are not able to perform this task, a referral can be made for home health nursing. A daily trip to the clinic would be inconvenient; this would increase the chance of noncompliance. A hydrocolloid dressing is not indicated for this wound. DIF: Cognitive Level: Application/Applying or higher

82 OBJ: 2 (theory) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 2. The patient recovering in the PACU awakes confused and disoriented. The nurses most appropriate intervention is to: a. take vital signs. b. encourage the patient to return to sleep. c. say, Your surgery is over. You are in the recovery area. d. chart, Patient awake and disoriented.

C The patient should be reoriented and assured when awaking from anesthesia. DIF: Cognitive Level: Comprehension

353-354 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3. An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful? a. The new nurse assists a nauseated patient to a supine position. b. The new nurse positions an unconscious patient supine with the head elevated. c. The new nurse turns an unconscious patient to the side upon arrival in the PACU. d. The new nurse places a patient in the Trendelenburg position when the blood pressure drops.

C The patient should initially be positioned in the lateral recovery position to keep the airway open and avoid aspiration. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness. DIF: Cognitive Level: Apply (application)

86 OBJ: 4 (theory) TOP: Prevention of Injury KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 13. The nurse should report to the charge nurse that a 10-hour postabdominal surgery patient has: a. vomited 20 mL of clear green fluid. b. asked for pain medication twice. c. not voided since surgery. d. a weak cough ability.

C The postsurgical patient should void in 4 to 8 hours after surgery. Vomiting, pain, and a weak cough are to be expected after abdominal surgery. DIF: Cognitive Level: Application

87-88 | 92 | Table 5-2 OBJ: 3 (clinical) TOP: Maintenance of Ventilation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 19. The patient asks the nurse which vitamin to take that will enhance wound healing the most. The nurse correctly responds, Vitamin: a. A. b. B. c. C. d. E.

C Vitamin C helps with the production of collagen, which restores damaged tissues. DIF: Cognitive Level: Application

260 KEY: Postoperative nursing| Surgical Care Improvement Project (SCIP)| venous thromboembolism prevention| thromboembolic events| core measures| quality improvement MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 5. A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the clients bed. The clients blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Lower the head of the bed. d. Nothing; this is expected.

C A client who had epidural or spinal anesthesia may become hypotensive when the head of the bed is raised. If this occurs, the nurse should lower the head of the bed to its original position. The Rapid Response Team is not needed, nor is an increase in IV rate. DIF: Applying/Application

257 KEY: Postoperative nursing| communication| hand-off communication| SBAR MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96 F (35.6 C)

C The respiratory rate is the most critical vital sign for any client who has undergone general anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low and indicates respiratory depression. The nurse should assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may be within that clients baseline. A pulse of 118 beats/min is slightly fast, which could be due to several causes, including pain and anxiety. A temperature of 96 F is slightly low and the client needs to be warmed. But none of these other vital signs take priority over the respiratory rate. DIF: Applying/Application

265 KEY: Postoperative nursing| support| psychosocial response| anxiety MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Psychosocial Integrity 14. A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN? a. Cleaning around the drain per agency protocol b. Placing a new sterile gauze under the drain c. Securing the drains safety pin to the sheets d. Using sterile technique to empty the drain

C The safety pin that prevents the drain from slipping back into the clients body should be pinned to the clients gown, not the bedding. Pinning it to the sheets will cause it to pull out when the client turns. The other actions are appropriate. DIF: Applying/Application

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Assessment) 17. The nurse is caring for a client in the postanesthesia care unit (PACU) 2 hours after abdominal surgery. The nurse auscultates the clients abdomen and notes that there are no bowel sounds. What action does the nurse take? a. Position the client on the left side with the bed flat. b. Insert a nasogastric tube to low intermittent suction. c. Palpate the bladder and measure abdominal girth. d. Document the finding and continue to monitor.

D Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that should be documented. No intervention specific to this finding is needed at this time. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation) 3. A client has been transferred to the postanesthesia care unit (PACU). Which action does the receiving nurse perform first? a. Complete a nursing assessment sheet. b. Change the clients arm band. c. Enter client data into the computer. d. Participate in a hand-off report.

D After the surgery is completed, the circulating nurse and the anesthesia provider accompany the client to the PACU. A hand-off report that meets National Patient Safety Goal 2 requires effective communication between health care professionals. DIF: Cognitive Level: Application/Applying or higher

89 OBJ: 3 (clinical) TOP: Promotion of Wound Healing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 20. The nurse is caring for a patient following abdominal surgery. The patient asks the nurse when he will be able to eat a normal diet. The nurses best response is: a. It will depend on how well you tolerate advancing from a clear liquid diet. b. We will have to wait until your surgeon orders a regular diet for you. c. Most patients are able to eat regular foods within 2 to 3 days following abdominal surgery. d. Once you have bowel sounds and are passing gas, you may have clear liquids, and your diet will be advanced based upon your tolerance.

D Although the diet order originates with the physician, the nurse must ensure that bowel sounds are present and the patient is able to pass flatus before any type of diet can be given to the patient. Most surgeons will write an order to advance the diet as tolerated once these findings occur. Every patient responds differently based upon their body and the type of surgery, so stating that most patients eat regular foods within 2 to 3 days is inaccurate. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation) 19. The nurse is caring for a client who had abdominal surgery 3 days ago. He tells the nurse, I felt something give way when I coughed. What is the nurses best response? a. It is good that you are coughing and deep-breathing to prevent pneumonia. b. That is a normal feeling in the incision whenever you are moving. c. Be sure to splint the incision with a pillow or your hands when you cough. d. Lie down flat on the bed with your knees up and let me examine your incision.

D Although wound dehiscence is not a common complication after surgery, it is usually painless and the client feels as if something has split or given way. This frequently occurs after coughing. Any client report of such a sensation should be assessed immediately. DIF: Cognitive Level: Application/Applying or higher

86 OBJ: 2 (clinical) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 14. For the surgical patient who complains of excessive gas, the nurse will: a. offer iced fluids. b. arrange for large meal servings. c. provide a straw for drinking fluids. d. ambulate the patient in the hall.

D Ambulation, eating small meals, drinking tepid drinks, and avoiding the use of straws help eliminate gas. DIF: Cognitive Level: Application

85 OBJ: 4 (theory) TOP: Maintenance of Circulation KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. The patients initial vital signs immediately on return from surgery are BP, 140/90; P, 80; R, 14; T, 98 F. One hour later the vital signs are BP, 130/84; P, 72; R, 16; T, 96.8 F. Based on these assessments, the nurse should: a. add a blanket for warmth to the patient. b. notify the charge nurse of probable hemorrhage. c. raise the head of the bed 45 degrees. d. note the assessment as normal postoperative recovery.

D Chart the normal recovery assessment and continue to monitor. There is no indication of chilling, hemorrhage, or respiratory distress. DIF: Cognitive Level: Analysis

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) 2. Postoperatively, a client has a heart rate of 120 beats/min, with dysrhythmias noted on the ECG monitor and a respiratory rate of 34 breaths/min, and is very difficult to arouse. Which action by the nurse is most appropriate? a. Accompany the client to the postanesthesia care unit (PACU). b. Keep the client in the surgical suite. c. Call a code or the Rapid Response Team. d. Transfer the client to the intensive care unit (ICU).

D Clients in critical condition are transferred from the operating room directly to the ICU. This client is not stable with elevated heart and respiratory rates, dysrhythmias, and difficulty in arousal. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Implementation) 15. The nurse is caring for several clients on the postoperative unit. Which client does the nurse determine has the highest risk of respiratory complications after general anesthesia? a. Older woman taking a calcium channel blocker for hypertension b. Middle-aged man with a deviated nasal septum c. Middle-aged woman taking St. Johns wort daily for depression d. Young adult with a body mass index of 40

D Clients who are extremely obese have heavy chest walls that make it difficult to expand the lungs fully. The other clients would not have an elevated risk of respiratory complications. DIF: Cognitive Level: Application/Applying or higher

p. 286 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Planning) 25. The nurse is caring for clients in the postanesthesia care unit (PACU). Which client is ready to be extubated? a. Client with an oxygen saturation of 90% b. Client with a respiratory rate of 14 breaths/min c. Client who is alert and oriented d. Client who is coughing and gagging

D Coughing and gagging on the endotracheal (ET) tube indicates readiness for extubation; the client should be further assessed to see whether he or she meets other extubation criteria. Often these criteria include ability to raise and hold the head up and evidence of thoracic breathing. An oxygen saturation of 90% is abnormal. Respiratory rate and orientation status are not sufficient criteria for extubation. DIF: Cognitive Level: Comprehension/Understanding

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Teaching/Learning 37. The nurse is assessing clients in the postanesthesia care unit (PACU). A client is shivering and has a temperature of 95.4 F (35.2 C). What is the nurses best action? a. Get the client warm blankets. b. Elevate the head of the bed. c. Auscultate the clients lungs. d. Assess the clients oxygen saturation.

D Hypothermia can cause shivering and hypoxemia. The nurse first should assess the clients oxygen saturation, then should apply warm blankets to bring the clients temperature up to a normal level. The other two actions may be needed but not as a priority. DIF: Cognitive Level: Application/Applying or higher

359 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 17. The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first? a. Elevate the patients head. b. Suction the patients mouth. c. Increase the oxygen flow rate. d. Perform the jaw-thrust maneuver.

D In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patients head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake. DIF: Cognitive Level: Apply (application)

83 | Assignment Considerations OBJ: 4 (theory) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. The nurse is caring for a patient who has had spinal anesthesia. The nurse correctly questions which of the following orders? a. Patient to lie flat for 6 to 8 hours. b. Resume diet as tolerated. c. Use incentive spirometer every hour while awake. d. Notify physician immediately if headache occurs.

D Lying flat for 6 to 8 hours reduces the risk of spinal headache and allows time for feeling to return to the legs; full diets can usually be resumed; and an incentive spirometer will reduce the chance of respiratory complications resulting from spinal anesthetic effects. The headache can be treated with nursing interventions such as keeping the patient flat if a headache is reported and increasing fluid intake. If the headache becomes severe or does not improve, the physician could be notified. DIF: Cognitive Level: Analysis

84 OBJ: 1 (theory) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 4. When the PACU nurse assesses diminished breath sounds in the unconscious recovering patient, the nurse should: a. hyperventilate the patient with an Ambu bag. b. turn the oxygen up to 3 L/min. c. elevate the head of bed 45 degrees. d. chart, Diminished breath sounds in both lower lobes.

D Mild atelectasis is an expected sign after anesthesia for the first 48 hours after surgery. This would be considered a normal finding while the patient is in the PACU and would require no further intervention unless other signs and symptoms, such as decreased oxygen saturation, were present. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlAccident/Injury Prevention) MSC: Integrated Process: Nursing Process (Implementation) 7. A client had surgical repair of a fractured ankle under local anesthesia and is being transferred from the postanesthesia care unit (PACU) to the surgical floor. Once admitted, what is the nurses priority action? a. Assess pressure points for breakdown. b. Assess the clients pain. c. Insert an IV for antibiotic therapy. d. Assess a full set of vital signs.

D On admission to the surgical floor from the PACU, the nurse should assess vital signs every 15 minutes 4, then every 30 minutes 4 and every 2 hours 4. After vital signs, the nurse would continue with assessments, including the surgical site and pain. An IV should already be inserted before arrival to the surgical unit. DIF: Cognitive Level: Application/Applying or higher

p. 294 TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning) MSC: Integrated Process: Teaching/Learning 24. After discharge from the postanesthesia care unit (PACU), the client returned to the surgical nursing unit at 10 AM. It is now 6 PM, and the client is not experiencing any complications. How often does the nurse assess the clients vital signs? a. Every 15 minutes b. Every 30 minutes c. Every hour d. Every 4 hours

D Once the client leaves the PACU, the nurse should monitor vital signs every 15 minutes 4, every 30 minutes 4, every hour 4, then every 4 to 8 hours for the next 24 to 48 hours. It has been 8 hours since the client returned to the surgical nursing unit, so vital signs should be monitored every 4 hours at this point. DIF: Cognitive Level: Comprehension/Understanding

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Implementation) 32. A client is scheduled for an operation. What does the nurse teach the client about postoperative pain control? a. You should not ask for IV pain medication more than once every 4 or 5 hours. b. You should not take the pain medication if you are nauseated. c. You will not get pain medication until you are transferred to the floor. d. You should ask for pain medication before the pain becomes severe.

D Pain medications are most effective when they are administered before the pain becomes severe. IV pain medications often are given every 1 to 2 hours. If the client is nauseated, the IV route can be used. The client will receive pain medication as needed in the postanesthesia care unit (PACU). DIF: Cognitive Level: Application/Applying or higher

87 OBJ: 3 (clinical) TOP: Promotion of GI Function KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 15. The postoperative patient complains of pain only 1 hour after having been medicated with an opioid, which cannot be repeated for 3 more hours. The nurse should initially: a. give one half of the prescribed dose now. b. contact the prescriber. c. ambulate the patient in the hall. d. reposition the patient.

D Repositioning the patient is the best initial remedy. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) 28. The nurse is changing the dressing on a postoperative clients abdominal incision. A Jackson-Pratt (JP) drain is present, along with a moderate amount of serosanguineous drainage. What is the best product for the nurse to use in performing wound care? a. Half hydrogen peroxide and half sterile saline b. Sterile water and antibacterial ointment c. Betadine swabs or alcohol wipes d. Sterile normal saline

D Sterile saline should be used to clean wounds because it is not harmful to granulating tissues. Hydrogen peroxide, Betadine, and alcohol are all harmful to new tissue. Sterile water is not isotonic so is not recommended. The incision should be cleaned from the least contaminated area to the most contaminated area, from inside the incision toward the surrounding skin. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation) 38. The nurse assesses clients in the postanesthesia care unit (PACU). Which client does the nurse intervene for first? a. Client with a respiratory rate of 12 breaths/min b. Client with an oxygen saturation of 92% c. Client who is reporting pain (5 out of 10) d. Client with audible stridor

D Stridor, a high-pitched crowing sound, indicates airway obstruction resulting from tracheal or laryngeal spasms or edema or other airway blockage. Opening the airway is the highest priority. The other clients are stable, although the client with pain may need pain medication. However, this does not take priority over caring for the client with stridor. DIF: Cognitive Level: Application/Applying or higher

355-356 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 1. The postanesthesia care unit (PACU) nurse determines that the patients Aldrete score is 9. The nurse on the postoperative unit knows that this means the: a. patient is at an increased risk for postoperative respiratory complications. b. patients condition warrants close monitoring. c. patient is experiencing severe pain. d. patient will soon be transferred to the postoperative unit.

D The Aldrete scoring system is a method of determining readiness for a surgery patient to be transferred from PACU to the postoperative unit. Scores are given for activity, respiration, circulation, consciousness, skin color, and oxygen saturation. A score of 9 or 10 indicates readiness for transfer. DIF: Cognitive Level: Application

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Diagnostic Tests, Procedures, and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment) 12. A client is being transferred to the postanesthesia care unit (PACU) after surgery. The client has an endotracheal tube (ET) in place. On assessment, the client has oxygen saturation of 95%, respiratory rate of 14 breaths/min, and asymmetric chest wall expansion. What is the nurses best action? a. Attempt to awaken the client. b. Bag the client with a resuscitation bag. c. Increase the clients fraction of inspired oxygen (FIO2). d. Auscultate lung sounds bilaterally.

D The ET tube could have slipped into the right mainstem bronchus. Auscultating the lungs will help to confirm this; then the nurse should call the health care provider because the tube will need to be pulled back. Attempting to awaken the client will not change the asymmetric chest wall expansion, neither will bagging the client or increasing the fraction of inspired oxygen (FIO2). Because the clients oxygen saturation is still within an acceptable range, this is not warranted. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Analysis) 34. The nurse is reviewing postoperative medication orders. Which order can the nurse implement? a. Acetaminophen orally PRN pain b. Meperidine (Demerol) 75-100 mg every 3-4 hours PRN pain c. MS .5 mg subcutaneously every 1-3 hours PRN pain d. Hydromorphone hydrochloride (Dilaudid) 1 mg orally every 4 hours PRN pain

D The acetaminophen order does not have a frequency (PRN is not sufficient). The Demerol order does not have a route. MS must be spelled out (morphine sulfate), and the dosage must be written as 0.5 mg. The Dilaudid order includes the drug name, dosage, route, and frequencyall correctly written out. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning 30. A postsurgical clients urinary output via the Foley catheter is 30 mL in 3 hours. What is the nurses first action? a. Increase the IV infusion rate. b. Assess the clients skin turgor. c. Weigh the client. d. Check the patency of the catheter.

D The nurse should check to ensure that the clients catheter tubing is patent. If the catheter is patent, the nurse should increase the IV flow rate if there are orders to do so, or should call the surgeon to report the information and request more fluids. Assessing the skin turgor would give information on hydration status, but this would not be the first intervention. Weighing the client probably would not give relevant information related to this client because the concern has arisen in the last 3 hours. DIF: Cognitive Level: Application/Applying or higher

N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Implementation) 13. A client who is being admitted to the postanesthesia care unit (PACU) has weak hand grasps on assessment and is unable to lift his head off the bed. During hand-off report, the nurse notes that the client has received a neuromuscular-blocking agent. What is the nurses best action? a. Document the finding. b. Check the clients pulses. c. Place the client in Fowlers position. d. Auscultate the lungs.

D When neuromuscular blocking agents are used, the client is at risk that these agents could be retained. The primary concern is the clients airway owing to muscular weakness. Because the client cannot raise the head and has a weak hand grasp, this may be a potential problem. The nurse should document all assessment findings. Placing the client in Fowlers position and checking the pulses is not warranted. DIF: Cognitive Level: Application/Applying or higher

173 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 22. The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon? a. Tympanic temperature 99.2 F (37.3 C) b. Fine crackles audible at both lung bases c. Redness and swelling along the suture line d. 200 mL sanguineous fluid in the wound drain

D Wound drainage should decrease and change in color from sanguineous to serosanguineous by the second postoperative day. The color and amount of drainage for this patient are abnormal and should be reported. Redness and swelling along the suture line and a slightly elevated temperature are normal signs of postoperative inflammation. Atelectasis is common after surgery. The nurse should have the patient cough and deep breathe, but there is no urgent need to notify the surgeon. DIF: Cognitive Level: Apply (application)

259 KEY: Postoperative nursing| nursing assessment| respiratory assessment| oxygen saturation MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 4. Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best? a. Let me call the surgeon to see if you really need them. b. No, you have to use those for 24 hours after surgery. c. OK, we can remove them since you are stable now. d. To prevent blood clots you need them a few more hours.

D According to the Surgical Care Improvement Project (SCIP), any prophylactic measures to prevent thromboembolic events during surgery are continued for 24 hours afterward. The nurse should explain this to the client. Calling the surgeon is not warranted. Simply telling the client he or she has to wear the hose and compression devices does not educate the client. The nurse should not remove the devices. DIF: Understanding/Comprehension

268 KEY: Postoperative nursing| Standard Precautions| infection control MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 13. A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What should the nurse assess next? a. Cognitive status b. Family stress c. Nutrition status d. Psychosocial status

D After ensuring the clients physiologic status is stable, these manifestations should lead the nurse to assess the clients psychosocial status. Anxiety especially can be demonstrated with elevations in vital signs. Cognitive and nutrition status are not related. Family stress is a component of psychosocial status. DIF: Remembering/Knowledge

269 KEY: Postoperative nursing| pain| nonpharmacologic pain management MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 10. A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? a. Be sure you keep all your postoperative appointments. b. Call your surgeon if you have any questions at home. c. Eat a diet high in protein, iron, zinc, and vitamin C. d. Wash your hands before touching the drain or dressing.

D All options are appropriate for the client being discharged after surgery. However, for this client who is changing a dressing and managing a drain, infection control is the priority. The nurse should instruct the client to wash hands often, including before and after touching the dressing or drain. DIF: Applying/Application

272 KEY: Postoperative nursing| discharge planning/teaching| client education| infection control| hand hygiene MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 11. An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states She needs to get back to her old self! What response by the nurse is best? a. Everyone comes out of surgery differently. b. Lets just give her some more time, okay? c. She may have had a stroke during surgery. d. Sometimes older people take longer to wake up.

D Due to age-related changes, it may take longer for an older adult to metabolize anesthetic agents and pain medications, making it appear that they are taking too long to wake up and return to their normal baseline cognitive status. The nurse should educate the family on this possibility. While everyone does react differently, this does not give the family any objective information. Saying Lets just give her more time, okay? sounds patronizing and again does not provide information. While an intraoperative stroke is a possibility, the nurse should concentrate on the more common occurrence of older clients taking longer to fully arouse and awake. DIF: Understanding/Comprehension

MULTIPLE CHOICE 1. A client has arrived in the postoperative unit. What action by the circulating nurse takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report

D Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The postoperative nurse and circulating nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the client is warm is a lower priority. DIF: Applying/Application

83 | Focused Assessment OBJ: 4 (theory) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 27. The nurse assesses the musty odor coming from the wound drainage as being indicative of an infection by a(n) ____________ organism, such as Pseudomonas or Staphylococcus.

aerobic A musty odor from the wound drainage is indicative of an infection by an aerobic microorganism such as Pseudomonas or Staphylococcus. DIF: Cognitive Level: Application

Chart 18-6, p. 298 TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Assessment) OTHER 1. A surgical procedure has just been concluded for a client who received a general anesthetic. Place the interventions in order of implementation. (Select in order of priority.) a. Determining pain response b. Assessing the IV c. Taking the clients vital signs d. Applying warmed blankets

d, c, a, b First, warm blankets are applied for client comfort, because the client will start shivering as an effect of the general anesthesia. Next, vital signs should be taken, then pain assessed. Finally, the nurse can assess the IV. DIF: Cognitive Level: Application/Applying or higher