EAQ - perioperative

which clinical manifestation of pulmonary edema secondary to heart failure would the nurse assess in a postop patient? a. early-morning cough b. increased urine output d. inspiratory stridor d. crackles heard on auscultation

crackles heard on auscultation

an older adult patient has a complication after a cardiac catheterization and has to remain in the PACU for several days. which complication is the patient most at risk for? a. delirium b. depression c. alcohol withdrawal d. aggressive behaviors

delirium

a patient with a history of DVT is recovering in the PACU after surgery. which symptoms would the nurse assess if this patient develops a pulmonary embolism? select all that apply: a. dyspnea b. tachypnea c. tachycardia d. coarse crackles e. noisy respirations

dyspnea, tachypnea, tachycardia

the nurse is educating a patient who had a coronary bypass graft about the risk of venous thromboembolism. which topic would the nurse include in the education to the patient? a. early ambulation b. turning every two hours c. splinting chest while coughing d. importance of taking pain medication

early ambulation

which explanation would the nurse give to a postoperative patient who is reluctant to get up and walk? a. "early walking keeps your legs limber and strong" b. "early ambulation will help you be ready to go home" c. "early ambulation will help you get rid of your syncope and pain" d. "early walking is the best way to prevent postop complications"

early walking is the best way to prevent postop complications

a postop patient has absence of breath sounds on the left lung and an oxygen saturation of 86%. which interventions would the nurse take to maintain adequate oxygen saturation? select all that apply: a. administer diuretics b. allow delayed ambulation c. instruct shallow breathing d. encourage incentive spirometry e. provide humidified oxygen therapy

encourage incentive spirometry, provide humidified oxygen therapy

which nursing intervention would help prevent postop atelectasis? a. medicating the patient with a narcotic analgesic as prescribed b. providing an abdominal binder to help the patient in ambulation c. encouraging frequent use of an incentive spirometer d. turning the patient from one side to the other at least every 2-4 hours

encouraging frequent use of an incentive spirometer

an older adult wakes up in the PACU and becomes restless and agitated and starts thrashing and shouting. the nurse finds that the patient was administered benzodiazepines during surgery. which interventions would the nurse include on the patient's plan of care? a. ensure patient safety b. administer an antianxiety drug c. administer an antipsychotic drug d. use drugs to reverse the benzodiazepines

ensure patient safety, use drugs to reverse the benzodiazepines

which surgery requires a sensory level L2-L3 anesthesia? a. hip surgery b. foot surgery c. appendectomy d. hemorrhoidectomy

foot surgery

before asking a patient who had abdominal surgery to perform postop breathing exercises, which evaluation or intervention would the nurse perform first? a. gauging the patient's level of pain b. evaluating the patient's vital signs c. assisting the patient out of bed and into a chair d. reviewing the health care provider's plan of care

gauging the patient's level of pain

which factor is associated with the highest risk for respiratory complication following surgery? a. general anesthesia used during surgery b. hydromorphone patient-controlled analgesia (PCA) for pain control c. history of obstructive sleep apnea d. endotracheal intubation for surgery

history of obstructive sleep apnea

postoperative hypotension can be managed with which intervention? a. infusion of IV fluids b. assessment of a basic metabolic panel (BMP) c. administration of oxygen d. performing an ECG

infusion of IV fluids

which benefits of early ambulation would the nurse explain to a postop patient? select all that apply: a. it stimulates circulation b. it improves muscle tone c. it promotes venous stasis d. it decreases vital capacity e. it prevents thrombus embolism

it stimulates circulation, it improves muscle tone, it prevents thrombus embolism

in the PACU, which position would be the safest to place an unconscious postop patient immediately after the operation? a. supine b. lateral c. semi-fowlers d. high-fowlers

lateral

which position would the nurse place a patient who is still drowsy from anesthesia and has been vomiting? a. high fowler's b. prone c. supine d. lateral recovery position

lateral recovery position

the nurse places an abdominal binder on a patient after colon surgery. after approximately an hour, the nurse assesses that the patient has shallow respirations, is hypoxemic, and hypercapnic. how would the nurse promote optimal breathing in this patient? select all that apply: a. loosen the binder b. reposition the patient c. provide music therapy d. elevate the foot of the bed e. raise the head end of the bed

loosen the binder, reposition patient, raise the head end of the bed

which nursing intervention is important to prevent syncope in a postop patient? a. administer oxygen therapy b. administer analgesics before ambulation c. make changes in the patient's position slowly d. encourage deep-breathing and coughign exercises

make changes in the patient's position slowly

a patient is having elective cosmetic surgery performed on the face. which action is the nurse's postop priority for this patient? a. manage pain b. control bleeding c. maintain fluid balance d. manage oxygenation status

manage oxygenation status

which nursing care measures are useful in the prevention of postop respiratory complications? Select all that apply: a. monitor oxygen saturation b. measure intake and output c. assess bilateral lung sounds d. ambulate the halls with patient e. instruct on incentive spirometer use

monitor oxygen saturation, assess bilateral lung sounds, ambulate the halls with patient, instruct on incentive spirometer use

Which criteria must a patient meet in order to be discharged from the PCA (phase 1) to the clinical unit? Select all that apply: a. no nausea or vomiting b. no respiratory depression c. oxygen saturation above 90% d. written discharge instructions understood e. patient reports pain level of 4 on a 1-10 scale

no respiratory depression, oxygen saturation above 90%, patient reports pain level of 4 on a 1-10 scale

a patient underwent a laparoscopic surgical procedure two days ago and is now experiencing chills and a temperature of 102.2*F. which nursing action is priority? a. administer the final dose of antibiotic b. notify the HCP c. have the patient deep breathe and cough d. administer as needed acetaminopehn

notify HCP

a nurse is caring for a patient who had a bowel resection 10 hours before. the patient weighs 200 pounds and has a urine output of 240 cc for the past 8 hours. which action would the nurse take? a. encourage oral (PO) fluids b. continue to monitor the urine output c. notify the health care provider d. administer a 500 cc normal saline IV bolus

notify the health care provider

which finding would the nurse expect to assess in a postop patient with acute pulmonary edema? a. bradypnea b. rhonci c. oxygen saturation 89% d. dry, hacking cough

oxygen saturation 89%

which medication or therapy would the nurse administer to a patient who is having acute tachypnea, dyspnea, tachycardia, and decreased oxygen saturation following a major orthopedic procedure? a. lidocaine b. oxygen therapy c. bronchodilators d. anticoagulant therapy e. skeletal muscle relaxant

oxygen therapy, anticoagulant therapy

which action would the nurse take for a patient who has not voided 8 hours after having surgery? a. encourage oral (PO) fluid intake b. palpate the suprapubic area for bladder distention c. use a straight catheter to assess for retention d. check the medical record to determine the type of anesthetic given

palpate the suprapubic area for bladder distention

alteration in which electrolyte level may be associated with occurrence of postoperative dysrhythmia? a. blood urea nitrogen b. sodium c. chloride d. potassium

potassium

which factor would determine if an older patient who is having problems with concentration and memory after an extensive surgery is experiencing delirium or postop cognitive dysfunction? a. preexisting cognitive impairment identified before surgery b. ability of the patient to state name, location, date c. ability to ambulate in halls and follow commands d. an undisturbed sleep/wake cycle in critical care unit

preexisting cognitive impairment identified before surgery

a postop patient has newly developed anxiety and is combative with the nurse in the postanesthesia care unit. which factor does the nurse know may be the cause of this change in behavior? a. delirium b. excessive sleep c. hyperoxygenation d. presence of endotracheal tube

presence of endotracheal tube

which interventions would the nurse take to prevent pulmonary complications in a patient who has just been admitted to the PACU and develops coarse crackles? select all that apply: a. teach abdominal exercises b. provide IV hydration c. suction airways d. administer sedatives e. administer cough suppressants

provide IV hydration, suction airways

which action would the nurse take to assist an older adult postop patient who has difficulty with memory and the ability to concentrate? select all that apply: a. provide adequate nutrition b. encourage delayed mobility c. provide bowel and bladder care d. sedate the patient for long durations e. monitor fluid and electrolyte disturbance

provide adequate nutrition, provide bowel and bladder care, monitor fluid and electrolyte disturbance

which assessment data require the most immediate attention in a patient who is about to be transferred to the clinical unit from the PACU? a. oxygen saturation of 94% b. pulse rate of 128 bpm c. respiratory rate of 13/min d. temperature of 99.8*F

pulse rate of 128 bpm

the nurse is caring for a patient in the PACU when he becomes agitated. which priority actions would the nurse take? select all that apply: a. put the side rails up b. evaluate respiratory status c. monitor fluid intake and output d. use clocks to orient the patient if needed

put the side rails up, evaluate respiratory status, use clocks to orient the patient if needed, sedate the patient, if the patient is not hypoxemic

which actions would the nurse take for a patient in the PACU to ensure that this patient has a patent airway? select all that apply: a. suctioning the airway b. administering sedatives c. putting in an artificial airway d. administering oxygen therapy e. tilting the head and thrusting the jaw

putting in an artificial airway, tilting the head and thrusting the jaw

a patient had an estimated blood loss of 400mL during abdominal surgery. the patient received 300 mL of 0.9% saline during surgery. the patient is alert but is now experiencing hypotension postop. which intervention would the nurse take for this patent? a. restore circulating volume with administration of IV fluids b. monitor pulse and BP c. get an ECG to check circulatory status d. return to surgery to check for internal bleeding

restore circulating volume with administration of IV fluids

which action will the nurse take for a postoperative patient who has low oxygen saturation and has crackles on auscultation? a. suction the airway b. restrict fluid intake c. monitor mental status d. place the patient In lateral recovery position

restrict fluid intake

a patient received a large amount of IV fluid during surgery. in the PACU, the nurse assesses that the patient has reduced oxygen saturation, crackles on auscultation, and infiltrates on chest x-ray. which actions would the nurse take to relieve the patient's breathing discomfort and promote oxygen saturation? select all that apply: a. restrict fluids b. administer prescribed diuretics c. administer oxygen therapy d. administer prescribed bronchodilators e. implement anticoagulant therapy

restrict fluids, administer prescribed diuretics, administer oxygen therapy

which action would the nurse take for a postop patient who has not voided for 8 hours? select all that apply: a. scan bladder with a portable ultrasound b. help the patient use a bedside commode c. reassure the patient regarding the ability to void d. obtain a prescription and insert an indwelling catheter e. use techniques like pouring warm water over the perineum

scan bladder with a portable ultrasound, help the patient use a bedside commode, reassure the patient regarding the ability to void, use techniques like pouring warm water over the perineum

two days after abdominal surgery, the patient reports gas pains and abdominal distention. The nurse plans care for the patient on the basis of the knowledge that these symptoms occur as a result of which condition? a. constipation b. hiccups c. slowed gastric emptying d. inflammation of the bowel at the anastomosis site

slowed gastric emptying

which instruction regarding deep-breathing and coughing techniques would the nurse include in a teaching plan for a patient who has an abdominal incision? a. splint the abdominal incision with a pillow b. perform the technique two times every waking hour c. limit fluid intake to thicken the secretions and membranes d. encourage deep breathing and coughing if the patient is in pain or feels the urge to clear secretions

splint the abdominal incision with a pillow

which intervention is effective in managing abdominal pain in a post op patient during ambulation? a. aromatherapy b. use of a gait belt c. splinting the incision d. use of a walker

splinting the incision

which intervention would the nurse take for a postop patient who was given a large dose of an opioid for pain and now has a decreased oxygenation saturation? a. administer a benzo b. stimulate patient to take deep breaths c. place patient in supine position d. suction the patient to clear the airway

stimulate patient to take deep breaths

in which position would the nurse place a postop, conscious patient in order to prevent respiratory problems? a. lithotomy position b. lateral recovery position c. prone position with extra pillows d. supine position with head elevated

supine position with head elevated

which assessment data requires the notification of the health care provider? a. a widened pulse pressure b. systolic BP of 95 mm Hg c. systolic BP of 170 mm Hg d. a pulse of 80 bpm

systolic BP of 170 mm Hg

which symptom indicates that a patient may have a pulmonary embolism? a. lethargy b. tachypnea c. bradycardia d. hypertension

tachypnea

while caring for a patient after surgery on the first postop day, the nurse notes new, bright red drainage about 4 cm in diameter on the surgical dressing. which action would the nurse take first? a. vital signs b. mark area on dressing and document the finding. c. recheck the dressing in one hour for increased drainage d. notify the HCP of potential hemorrhage

take patient's vital signs

which priority action would the nurse on the clinical unit take when receiving a patient transferred from the PACU? a. assess the patient's pain b. take the patient's vitals c. check the rate of the IV infusion d. check the health care provider's postop prescriptions

take the patient's vitals

a patient is being discharged after having laparoscopic surgery. the nurse would instruct the patient to notify the surgeon immediately if which condition develops? a. constipation b. right shoulder pain c. decreased appetite d. temperature of 103*F

temperature of 103*F

which assessment finding in a patient who has just been admitted to the PACU requires the nurse's immediate action? a. patient is groggy but arouses to voice b. patient indicates that he or she is in pain c. the patient is restless, agitated, and hypotensive d. the jackson-pratt is draining serosanguinous fluid

the patient is restless, agitated and hypotensive

a postop patient who is an alcoholic is restless, irritable, and having auditory hallucinations. which statement is accurate regarding this patient? a. these effects are d/t alcohol withdrawal b. the situation is normal, d/t anesthetic drugs c. the patient is suffering from a psychotic disorder d. the patient is suffering from pain and needs an analgesic

these effects are d/t alcohol withdrawal

a postop patient who has been transferred from surgery to the PACU unit is cold and shivering. the patient's plan of care includes a prescription for morphine to be administered for pain relief. when managing this patient, which interventions would the nurse perform? select all that apply: a. use forced air warmers b. administer oxygen therapy c. administer warmed IV fluids d. use warmed cotton blankets e. withhold morphine until shivering stops

use forced air warmers, administer oxygen therapy, administer warmed IV fluids, use warmed cotton blankets

which criteria support that a patient is ready for discharge from an ambulatory surgery center? select all that apply: a. vital signs baseline or stable b. minimal nausea or vomiting c. wants to go to the bathroom at home d. responsible adult taking patient home e. comfortable after IV opioid 15 min ago

vital signs baseline or stable, minimal nausea or vomiting, responsible adult taking patient home

a patient is admitted to the postanesthesia care unit (PACU) after bowel surgery and tells the nurse that he/she is going to "throw up." which statement by the nurse reflects a priority nursing intervention? a. "I need to check your vital signs." b. "Let me help you turn to your side." c. "Here is a sip of ginger ale for you." d. "I can give you some anti-nausea medication."

"Let me help you turn to your side."

a nurse is caring for an older patient who had a knee replacement the previous day and denies any pain. which response by the nurse would be most appropriate? a. "excellent. you must be able to handle a lot of pain." b. "great. it is wise to only take the pain medication if you need it." c. "it is important that you take pain medication. it will help you recover more quickly." d. "almost everyone has pain after this surgery. are you certain that you are not experiencing pain?"

"almost everyone has pain after this surgery. are you certain that you are not experiencing pain?"

What factors contribute to a patient's risk for constipation postoperatively? Select all that apply: a. Anesthesia b. Opioid analgesics c. IV fluids d. Decreased mobility e. Diminished peristalsis

Anesthesia, opioid analgesics, decreased mobility, diminished peristalsis

for which type of infection would a postop patient who developed a fever, abdominal pain, and diarrhea despite being on long-term antibiotics be evaluated? a. wound infection b. urinary infection c. respiratory infection d. Clostridium difficile infection

C Diff

which postop patient is at the greatest risk for development of atelectasis? a. patient after hypoxic episode during an acute asthma attack b. an older adult patient who has undergone cardiothoracic surgery c. a patient not adherent with the pulmonary regimen after surgery d. a patient experiencing an acute exacerbation of COPD

a patient not adherent with the pulmonary regimen after surgery

the nurse in the PACU assesses a patient with a history of asthma and finds the patient tachypneic, wheezing, and with reduced oxygen saturation. which action will the nurse take to prevent further pulmonary complications? a. administer bronchodilators b. provide incentive spirometry c. encourage chest physical therapy d. provide nebulization of histamine vapors

administer bronchodilators

a patient on the postop unit reports difficulty breathing. the nurse discovers that the patient received large doses of benzodiazepines during surgery. which action would the nurse include in the patient's plan of care to promote breathing? a. administer opioids b. loosen the dressings c. reposition the patient d. administer drugs for reversal of benzodiazepines

administer drugs for reversal of benzodiazepines

the nurse is developing a care plan for the postop patient in order to prevent complications and promote ambulation, coughing, deep breathing, and turning. which action is the most important for the nurse to provide to achieve these desired outcomes? a. explain easily the rationale for these activities b. have family in the room for support and encouragement c. warn about pneumonia and clotting if the actions are not completed d. administer enough analgesics to promote relative freedom from pain

administer enough analgesics to promote relative freedom from pain

which actions would the nurse take for a postop patient who has an oxygen saturation of 85% and decreased breath sounds? a. restrict intake of fluid b. administer oxygen therapy c. administer diuretics as advised d. encourage deep-breathing exercises e. assist the patient to walk around, if tolerated

administer humidified oxygen therapy, encourage deep-breathing exercises, assist the patient to walk around if tolerated

which action would the nurse take to ensure oxygenation in a patient who develops inspiratory stridor and sternal retraction upon removal of the endotracheal tube? select all that apply: a. suction airway b. administer oxygen therapy c. administer muscle relaxants d. tilt the head and thrust the jaw e. provide positive-pressure ventilation

administer oxygen therapy, administer muscle relaxants, provide positive-pressure ventilation

a postop patient develops laryngeal edema after receiving a penicillin injection. which tx would be implemented to prevent further complications in the patient? select all that apply: a. suctioning the airway b. administration of sedatives c. administration of antihistamines d. administration of corticosteroids e. chest physical therapy

administration of sedatives, administration of antihistamines, administration of corticosteroids

which nursing actions will help to treat the problem of abdominal distention and gas pains after abdominal surgery? select all that apply: a. ambulate patient b. reposition frequently c. administer bisacodyl d. turn patient onto left side e. administer morphine sulfate f. discontinue the nasal gastric tube (NGT)

ambulate patient, reposition frequently, administer bisacodyl

a patient in the PACU becomes delirious and restless and shouts at the nurse about pain. which factor would the nurse consider may be the cause of this behavior? a. new diagnosis of psychosis b. decreased ability to tolerate pain c. anesthetic agents used In surgery d. overdose of analgesics

anesthetic agents used in surgery

which nursing intervention is the highest priority for a patient transferred to the PACU after surgery? a. assess intake, output and fluid balance c. assess airway, breathing, and circulatory status d. assess surgical site and condition of dressing e. note the presence of all IV lines and drainage catheters

assess airway, breathing, and circulation status

the nurse is caring for a patient in the PACU, when the BP drops from 110/60 mm Hg to 92/58 mm Hg. which actions would the nurse take? select all that apply: a. assess electrocardiogram (ECG) tracing b. inspect surgical site c. administer pain medication d. elevate head of bed e. have the patient take deep breaths f. administer IV fluid bolus per protocol

assess electrocardiogram (ECG) tracing, inspect surgical site, have the patient take deep breaths, administer IV fluid bolus per protocol

which actions would the nurse take when administering an analgesic to a postop patient? select all that apply: a. assess location, quality, intensity of pain b. monitor the patient for N/V, resp. depression c. assess patient's sleep/wake cycle and sensory and motor status d. assess patient's level of orientation and ability to follow commands e. time the analgesic administration for effectiveness during painful activities

assess location, quality, intensity of pain. monitor patient for nausea, vomiting and respiratory depression. time the analgesic admin for effectiveness during painful activities

a patient's BP increases from 110/76 mm Hg to 160/90 mm Hg two hours after a surgical procedure. which action would the nurse take first? a. assess pain level b. reassess the BP in 15 minutes c. decrease the IV fluid rate d. restart the patient's antihypertensive medications

assess pain level

the nurse is assessing a patient's surgical dressing on the first postop day and notes new, bright red drainage about 5cm in diameter. which action would the nurse implement first? a. recheck in one hour for increased drainage b. assess the patient's BP and HR c. check agency policy to determine if the nurse can change the first dressing d. notify the HCP of a potential hemorrhage

assess the patient's BP and HR

in caring for the postop patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel? a. monitor the patient's pain b. increase oxygen if needed c. assist the patient to take deep breaths and cough d. reinforce the dressing when there is excess drainage

assist the patient to take deep breaths and cough

a postop patient with bronchial obstruction has a pulse ox of 87%. which complication would the nurse suspect is occurring with this patient? a. atelectasis b. bronchospasm c. hypoventilation d. pulmonary embolism

atelectasis

which condition is most likely the reason for a patient having partial pressure of arterial oxygen (PaO2) less than 60 mm Hg after surgery? a. atelectasis b. bronchospasm c. pulmonary edema d. pulmonary embolism

atelectasis

which occurrence might cause secondary heart dysfunction? a. cardiac tamponade b. certain medications c. pulmonary embolism d. myocardial infarction

certain medications

which action would the nurse first take for a patient who is admitted to PACU with a BP of 100/60 mm Hg? a. rouse the patient b. assess the patient's pulse and skin color c. notify the anesthesiologist of the low BP d. check the medical record for the patient's baseline BPc

check the medical record for the patient's baseline BP

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

check the preoperative assessment for previous delirium or dementia