Chapt. 19: Post-Operative Care

The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention? A) Check the patients oxygen saturation level, continue to monitor for apnea, and perform a focused assessment. B) Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw. C) Assess the arterial pulses, and place the patient in the Trendelenburg position. D) Reintubate the patient.

B) Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw

The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patients possible readiness to learn how to change her dressing? Select all that apply. A) The patient wants you to teach a family member to do dressing changes. B) The patient expresses interest in the dressing change. C) The patient is willing to look at the incision during a dressing change. D) The patient expresses dislike of the surgical wound. E) The patient assists in opening the packages of dressing material for the nurse.

B, C, E

You are caring for a 71-year-old patient who is 4 days postoperative for bilateral inguinal hernias. The patient has a history of congestive heart failure and peptic ulcer disease. The patient is highly reluctant to ambulate and will not drink fluids except for hot tea with her meals. The nurses aide reports to you that this patients vital signs are slightly elevated and that she has a nonproductive cough. When you assess the patient, you auscultate crackles at the base of the lungs. What would you suspect is wrong with your patient? A) Pulmonary embolism B) Hypervolemia C) Hypostatic pulmonary congestion D) Malignant hyperthermia

C) Hypostatic pulmonary congestion

The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication? A) Sepsis B) Infection C) Pulmonary embolism D) Hematoma

C) Pulmonary embolism

A patient underwent an open bowel resection 2 days ago and the nurses most recent assessment of the patients abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have caused the dehiscence? A) The patients surgical dressing was changed yesterday and today. B) The patient has vomited three times in the past 12 hours. C) The patient has begun voiding on the commode instead of a bedpan. D) The patient used PCA until this morning.

B) The patient has vomited three times in the past 12 hours.

The PACU nurse is caring for a male patient who had a hernia repair. The patients blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery? A) Dysrhythmias, blood loss, and hyperthermia B) Electrolyte imbalances and neurologic changes C) A parasympathetic reaction and low blood volumes D) Pain, hypoxia, or bladder distention

D) Pain, hypoxia, or bladder distention

The nursing instructor is discussing postoperative care with a group of nursing students. A student nurse asks, Why does the patient go to the PACU instead of just going straight up to the postsurgical unit? What is the nursing instructors best response? A) The PACU allows the patient to recover from anesthesia in a stimulating environment to facilitate awakening and reorientation. B) The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications. C) Frequently, patients are placed in the medicalsurgical unit to recover, but hospitals are usually short of beds, and the PACU is an excellent place to triage patients. D) Patients remain in the PACU for a predetermined time because the surgeon will often need to reinforce or alter the patients incision in the hours following surgery.

B) The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications.

A surgical patient has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). The nurse should know that the requirements for safe and effective use of PCA include what? A) A clear understanding of the need to self-dose B) An understanding of how to adjust the medication dosage C) A caregiver who can administer the medication as ordered D) An expectation of infrequent need for analgesia

A) A clear understanding of the need to self-dose

The perioperative nurse is providing care for a patient who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The patient is reluctant to ambulate, citing the need to recover in bed. For what complication is the patient most at risk? A) Atelectasis B) Anemia C) Dehydration D) Peripheral edema

A) Atelectasis

The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurses first response? A) Return the patient to his previous position and call the physician. B) Place saline-soaked sterile dressings on the wound. C) Assess the patients blood pressure and pulse. D) Pull the dehiscence closed using gloved hands.

B) Place saline-soaked sterile dressings on the wound.

The nurse is caring for an 82-year-old female patient in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurses subsequent assessment? A) Postoperative confusion in older adults is an indication of impaired oxygenation or possibly a stroke during surgery. B) Confusion, restlessness, and agitation are expected postoperative findings in older adults and they will diminish in time. C) Postoperative confusion is common in the older adult patent, but it could also indicate a significant blood loss. D) Confusion, restlessness, and agitation indicate an underlying cognitive deficit such as dementia.

C) Postoperative confusion is common in the older adult patent, but it could also indicate a significant blood loss.

The recovery room nurse is admitting a patient from the OR following the patients successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted patient? A) Heart rate and rhythm B) Skin integrity C) Core body temperature D) Airway patency

D) Airway patency

An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patients vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next? A) Administer a dose of IV analgesic. B) Apply a cool cloth to the patients forehead. C) Offer the patient a small amount of ice chips. D) Turn the patient completely to one side.

D) Turn the patient completely to one side.

The perioperative nurse is preparing to discharge a female patient home from day surgery performed under general anesthetic. What instruction should the nurse give the patient prior to the patient leaving the hospital? A) The patient should not drive herself home. B) The patient should take an OTC sleeping pill for 2 nights. C) The patient should attempt to eat a large meal at home to aid wound healing. D) The patient should remain in bed for the first 48 hours postoperative.

A) The patient should not drive herself home.

The nurse is performing the shift assessment of a postsurgical patient. The nurse finds his mental status, level of consciousness, speech, and orientation are intact and at baseline, but the patient tells you he is very anxious. What should the nurse do next? A) Assess the patients oxygen levels. B) Administer antianxiety medications. C) Page the patients the physician. D) Initiate a social work referral.

A) Assess the patients oxygen levels.

An adult patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the patient may be at risk for what? A) Hemorrhage and shock B) Aspiration C) Postoperative infection D) Hypertension and dysrhythmias

A) Hemorrhage and shock

The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect is the problem with the patient? A) Postoperative delirium B) Postoperative dementia C) Senile dementia D) Senile confusion

A) Postoperative delirium

The nurse is creating the plan of care for a patient who is status postsurgery for reduction of a femur fracture. What is the most important short-term goal for this patient? A) Relief of pain B) Adequate respiratory function C) Resumption of activities of daily living (ADLs) D) Unimpaired wound healing

B) Adequate respiratory function

The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what means? A) Late intention B) Second intention C) Third intention D) First intention

C) Third intention

The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion? A) Describe the appearance of the dressing in the electronic health record. B) Photograph the patients abdomen for later comparison using a smartphone. C) Trace the outline of the drainage on the dressing for future comparison. D) Remove and weigh the dressing, reapply it, and then repeat in 8 hours.

C) Trace the outline of the drainage on the dressing for future comparison.

The PACU nurse is caring for a 45-year-old male patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply. A) Hypotension B) Hypervolemia C) Heart murmurs D) Dysrhythmias E) Hypertension

A, D, E

The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply. A) Provide all discharge instructions in writing. B) Provide the nurses or surgeons contact information. C) Give prescriptions to the patient. D) Irrigate the patients incision and perform a sterile dressing change. E) Administer a bolus dose of an opioid analgesic.

A, B, C

The nurse is admitting a patient to the medicalsurgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia? A) Encourage the patient to eat a balanced diet that is high in protein. B) Encourage the patient to limit his activity for the first 72 hours. C) Encourage the patient to take his medications as ordered. D) Encourage the patient to use the incentive spirometer every 2 hours.

D) Encourage the patient to use the incentive spirometer every 2 hours.

The nurses aide notifies the nurse that a patient has decreased oxygen saturation levels. The nurse assesses the patient and finds that he is tachypnic, has crackles on auscultation, and his sputum is frothy and pink. The nurse should suspect what complication? A) Pulmonary embolism B) Atelectasis C) Laryngospasm D) Flash pulmonary edema

D) Flash pulmonary edema

The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer. Which of the following statements by the patient indicates that teaching has been effective? A) Ill make sure to limit my intake of protein. B) Ill make sure that the bandage is wrapped tightly. C) My foot should feel cool or cold while my legs healing. D) Ill eat plenty of fruits and vegetables.

D) Ill eat plenty of fruits and vegetables.

A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? Select all that apply. A) Absence of pain B) Stable blood pressure C) Ability to tolerate oral fluids D) Sufficient oxygen saturation E) Adequate respiratory function

B, D, E

The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the patients blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the patients skin is cold, moist, and pale. Of what is the patient showing signs? A) Hypothermia B) Hypovolemic shock C) Neurogenic shock D) Malignant hyperthermia

B) Hypovolemic shock

The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority? A) Assessing for hemorrhage B) Maintaining a patent airway C) Managing the patients pain D) Assessing vital signs every 30 minutes

B) Maintaining a patent airway

The nurse is preparing to change a patients abdominal dressing. The nurse recognizes the first step is to provide the patient with information regarding the procedure. Which of the following explanations should the nurse provide to the patient? A) The dressing change is often painful, and we will be giving you pain medication prior to the procedure so you do not have to worry. B) During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to. C) The dressing change should not be painful, but you can never be sure, and infection is always a concern. D) The best time for doing a dressing change is during lunch so we are not interrupted. I will provide privacy, and it should not be painful.

B) During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to.

A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do? A) Irrigate the Foley with 30 mL normal saline. B) Notify the physician and continue to monitor the hourly urine output closely. C) Decrease the IV fluid rate and massage the patients abdomen. D) Have the patient sit in high-Fowlers position.

B) Notify the physician and continue to monitor the hourly urine output closely.

The nursing instructor is discussing the difference between ambulatory surgical centers and hospital- based surgical units. A student asks why some patients have surgery in the hospital and others are sent to ambulatory surgery centers. What is the instructors best response? A) Patients who go to ambulatory surgery centers are more independent than patients admitted to the hospital. B) Patients admitted to the hospital for surgery usually have multiple health needs. C) In most cases, only emergency and trauma patients are admitted to the hospital. D) Patients who have surgery in the hospital are those who need to have anesthesia administered.

B) Patients admitted to the hospital for surgery usually have multiple health needs.

A postoperative patient rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be the nurses first action? A) Leave and promptly notify the physician. B) Quickly attempt to determine the cause of hemorrhage. C) Begin resuscitation. D) Put the patient in the Trendelenberg position.

B) Quickly attempt to determine the cause of hemorrhage.

The nurse just received a postoperative patient from the PACU to the medicalsurgical unit. The patient is an 84-year-old woman who had surgery for a left hip replacement. Which of the following concerns should the nurse prioritize for this patient in the first few hours on the unit? A) Beginning early ambulation B) Maintaining clean dressings on the surgical site C) Close monitoring of neurologic status D) Resumption of normal oral intake

C) Close monitoring of neurologic status

The home health nurse is caring for a postoperative patient who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the patients postoperatative day 2. During the visit, the nurse will assess for wound infection. For most patients, what is the earliest postoperative day that a wound infection becomes evident? A) Day 9 B) Day 7 C) Day 5 D) Day 3

C) Day 5

The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do? A) Sit in a chair for 10 minutes prior to ambulating. B) Drink plenty of fluids to increase circulating blood volume. C) Stand upright for 2 to 3 minutes prior to ambulating. D) Perform range-of-motion exercises for each joint.

C) Stand upright for 2 to 3 minutes prior to ambulating.

The nurse is caring for a patient after abdominal surgery in the PACU. The patients blood pressure has increased and the patient is restless. The patients oxygen saturation is 97%. What cause for this change in status should the nurse first suspect? A) The patient is hypothermic. B) The patient is in shock. C) The patient is in pain. D) The patient is hypoxic.

C) The patient is in pain.

The intraoperative nurse is transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year-old woman. The nurse should prioritize which of the following actions? A) Keeping the patient sterile B) Keeping the patient restrained C) Keeping the patient warm D) Keeping the patient hydrated

C) Keeping the patient warm

The nursing instructor is talking with a group of medicalsurgical students about deep vein thrombosis (DVT). A student asks what factors contribute to the formation of a DVT. What would be the instructors best response? A) There is a genetic link in the formation of deep vein thrombi. B) Hypervolemia is often present in patients who go on to develop deep vein thrombi. C) No known factors contribute to the formation of deep vein thrombi; they just occur. D) Dehydration is a contributory factor to the formation of deep vein thrombi.

D) Dehydration is a contributory factor to the formation of deep vein thrombi.

The surgeons preoperative assessment of a patient has identified that the patient is at a high risk for venous thromboembolism. Once the patient is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the patients risk of developing this complication? A) Maintain the head of the bed at 45 degrees or higher. B) Encourage early ambulation. C) Encourage oral fluid intake. D) Perform passive range-of-motion exercises every 8 hours.

B) Encourage early ambulation.

The nurse is caring for a patient on the medicalsurgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection? A) Presence of an indwelling urinary catheter B) Rectal temperature of 99.5F (37.5C) C) Red, warm, tender incision D) White blood cell (WBC) count of 8,000/mL

C) Red, warm, tender incision