Med Surg Ch 17 PostOp

Which nursing action is appropriate when providing care to a patient who is exhibiting low oxygen saturation levels in the postanesthesia care unit (PACU). 1) Monitor breath sounds 2) Administer prescribed heparin 3) Hold prescribed opioid analgesics 4) Assess for malignant hyperthermia

ANS: 1 The nurse would monitor breath sounds for a patient experiencing inadequate oxygenation.

Which laboratory test should the postanesthesia care nurse monitor for a patient who is having difficulty regaining consciousness after a surgical procedure? 1) Serum glucose 2) Serum potassium 3) Prothrombin (PT) time 4) Blood urea nitrogen (BUN)

ANS: 1 Serum glucose is monitored for a patient who is having difficult regaining consciousness in the postoperative period.

Which are appropriate nurse-to-patient ratios in the postanesthesia care unit (PACU)? Select all that apply. 1) 1:1 2) 1:2 3) 1:3 4) 1:4 5) 1:5

ANS: 1, 2, 3 1. This is correct. This is an appropriate nurse to patient ratio in the PACU. 2. This is correct. This is an appropriate nurse to patient ratio in the PACU. 3. This is correct. This is an appropriate nurse to patient ratio in the PACU if one patient is awaiting transfer to another unit or awaiting discharge home.

Which information should the postanesthesia care unit (PACU) nurse include in the hand-off that occurs with the medical-surgical nurse who will assume care? Select all that apply. 1) Fluid intake and blood loss 2) Placement of intravenous (IV) lines 3) Patient identification using one identifier 4) Information regarding the surgical procedure 5) Over-the-counter (OTC) medications taken at home

ANS: 1, 2, 4 1. This is correct. Fluid intake and blood loss is included in the hand-off communication process between the PACU and medical-surgical nurses. 2. This is correct. Information regarding the placement of IV lines is included in the hand-off communication process between the PACU and medical-surgical nurses. 4. This is correct. Information regarding the surgical procedure is included in the hand-off communication process between the PACU and medical-surgical nurses.

The postoperative nurse is planning care for a patient recovering from major thoracic surgery. Which nursing diagnoses should the nurse select to plan for this patient's immediate care needs? Select all that apply. 1) Risk for Impaired Gas Exchange 2) Risk for Decreased Cardiac Output 3) Risk for Ineffective Airway Clearance 4) Risk for Imbalanced Nutrition: Less than Body Requirements 5) Risk for Imbalanced Fluid Volume

ANS: 1, 2, 5 1. This is correct. Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. 2. This is correct. Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status. 5. This is correct. Nursing diagnoses appropriate for the immediate postoperative phase include the Risk for Impaired Gas Exchange because of anesthesia medications and hypothermia, the Risk for Decreased Cardiac Output because of anesthesia, and the Risk for Imbalanced Fluid Volume because of blood loss and nothing by mouth status.

The postanesthesia care nurse is providing care to a patient with fluid volume overload who is experiencing cardiac dysrhythmias. Which laboratory test should the nurse monitor for this patient? 1) Serum glucose 2) Serum potassium 3) Prothrombin (PT) time 4) Blood urea nitrogen (BUN)

ANS: 2 Serum potassium is monitored for patients who experienced abnormal fluid or blood losses and for patients who may have been overhydrated. Patients who experience either hyperkalemia, or hypokalemia, may exhibit cardiac dysrhythmias.

The nurse is providing care to a patient in the postanesthesia care unit (PACU) who lost a large amount of blood during a surgical procedure. Which assessment finding should the nurse monitor this patient for based on the current data? 1) Bradypnea 2) Tachycardia 3) Hypothermia 4) Hypertension

ANS: 2 Tachycardia is an anticipated assessment finding for a patient who loses a significant amount of blood during a surgical procedure.

Which nursing action is appropriate when providing care to a patient who is exhibiting symptoms of a venous thromboembolism (VTE)? 1) Monitor breath sounds 2) Administer prescribed heparin 3) Hold prescribed opioid analgesics 4) Assess for malignant hyperthermia

ANS: 2 The nurse would administer a prescribed anticoagulant, such as heparin, for a patient who is experiencing venous thromboembolism (VTE).

The patient arrives at the surgeon's office one week after surgery to have the sutures removed. Which classification would the nurse use when documenting care for this patient? 1) Preoperative 2) Postoperative 3) Perioperative 4) Intraoperative

ANS: 2 The patient is in the postoperative phase. The postoperative phase begins with the admission of the patient to the postanesthesia care unit, and ends when healing is complete.

Which nursing actions are appropriate during Phase I of the postoperative period? Select all that apply. 1) Providing discharge instructions 2) Assessing vital signs per protocol 3) Monitoring electrocardiogram continuously 4) Providing ongoing care until a bed is available 5) Preparing for transfer to the medical-surgical unit

ANS: 2, 3 2. This is correct. Assessing vital signs per protocol is an appropriate nursing action during Phase I of the postoperative period. 3. This is correct. Monitoring the electrocardiogram continuously is an appropriate nursing action during Phase I of the postoperative period.

Which tasks can the nurse assign to the unlicensed assistive personnel (UAP) who is assisting with providing care to postoperative patients on a medical-surgical unit? Select all that apply. 1) Documenting the assessment completed by the nurse 2) Giving the patient pain medication as ordered by the health-care provider 3) Assisting with patient exercises 4) Reporting when a patient cannot complete exercises 5) Conducting discharge teaching

ANS: 2, 3, 4 2. This is incorrect. The UAP cannot pass medications. 3. This is correct. The UAP can assist the patient with exercises and report any problems the patient has when performing exercises. 4. This is correct. The UAP can assist the patient with exercises and report any problems the patient has when performing exercises. 5. This is incorrect. The UAP cannot conduct discharge teaching.

Which laboratory test should the postanesthesia care nurse monitor closely for a patient who is prescribed warfarin in the treatment of atrial fibrillation? 1) Serum glucose 2) Serum potassium 3) Prothrombin (PT) time 4) Blood urea nitrogen (BUN)

ANS: 3 3 A PT time is monitored closely for any patient who is prescribed warfarin. Warfarin is often stopped for several days prior to a surgical procedure. However, this patient will continue to be at an increased risk for bleeding.

Which nursing action is appropriate when providing care to a patient who is difficult to arouse in the postanesthesia care unit (PACU)? 1) Monitor breath sounds 2) Administer prescribed heparin 3) Hold prescribed opioid analgesics 4) Assess for malignant hyperthermia

ANS: 3 A patient who is difficult to arouse should have prescribed analgesics held until the patient stabilizes.

The nurse is providing care to a postoperative patient who is experiencing pain. The patient rates the pain at a 4 on a 1 to 10 numeric pain assessment scale. Which prescribed medication should the nurse administer to this patient? 1) Fentanyl 2) Morphine 3) Ibuprofen 4) Hydromorphone

ANS: 3 Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is appropriate for mild pain in the postoperative period.

Which is the priority initial assessment for a patient who is admitted to the postanesthesia care unit (PACU)? 1) Heart rate 2) Temperature 3) Respirations 4) Blood pressure

ANS: 3 Respirations is the priority initial assessment for a patient who is admitted to the PACU. The ABCs should guide priority during the initial nursing assessment for the patient admitted to the PACU.

The nurse is caring for a patient with a drain connected to a portable drainage suction device shaped like a grenade made of plastic. Which term will the nurse use when describing this system during end-of-shift report? 1) Closed wound drainage system 2) Hemovac 3) Jackson-Pratt 4) Reinfusion drain

ANS: 3 The drain described, shaped like a grenade, is a Jackson-Pratt.

In the ongoing postoperative period, the nurse independently determines, within the protocols of the hospital, the need for which provision of care? 1) Type of diet 2) Activity level 3) Assessment intervals 4) Intravenous solutions

ANS: 3 The nurse will determine the frequency of patient assessments required, within the protocols established by the facility. The minimum frequency is determined by the facility, but more frequent assessment may be determined by the patient's condition, and is the decision of the nurse.

Upon receiving the patient from the postanesthesia care unit, which nursing action is the priority? 1) Apply clean linens to the bed 2) Assemble required equipment, such as suction, IV pole, or oxygen equipment 3) Assess the patient 4) Notify the family of the patient's return to the room

ANS: 3 The priority action for the nurse is to perform a thorough assessment of the patient's condition.

How many providers from the operating room (OR) should participate in the hand-off communication that occurs with the postanesthesia care (PACU) nurse prior to patient transfer? 1) One 2) Two 3) Three 4) Four

ANS: 3 Three members of the OR team (anesthesia, surgical provider, and OR nurse) should participate in the hand-off communication with the PACU nurse.

The nurse is assessing a patient's postoperative wound and finds it has separated from the suture line with extrusion of the bowel through the opening. When documenting this finding, which term will the nurse use? 1) Wound infection 2) Wound dehiscence 3) Wound evisceration 4) Wound tunneling

ANS: 3 Wound evisceration is separation of the wound with internal organs and tissues visible through the opening.

Which is the priority laboratory test that the postanesthesia care nurse should monitor closely for an older adult patient with renal disease who retained fluid during a surgical procedure? 1) Serum glucose 2) Serum potassium 3) Prothrombin (PT) time 4) Blood urea nitrogen (BUN)

ANS: 4 A BUN is monitored for any patient who may have experienced abnormal fluid or blood losses during surgery. A BUN should also be monitored for older adult patients and for those with renal disease.

The medical-surgical nurse is providing care to a postoperative patient who is experiencing an elevated temperature. Which laboratory value should the nurse monitor to gather more information? 1) Platelet count 2) Serum glucose 3) Red blood cell (RBC) count 4) White blood cell (WBC) count

ANS: 4 An elevated temperature often indicates the patient is experiencing an infection. An increased WBC count would support this diagnosis.

Which patient finding would indicate the need for further monitoring rather than discharge home after an outpatient surgical procedure? 1) Pain management with opioid analgesics 2) Lethargy that resolves after several hours 3) Inability to void without fluid retention 4) Persistent nausea without vomiting

ANS: 4 Persistent nausea, without vomiting, would indicate the need for further monitoring. This patient is not stable enough for discharge home.

The postanesthesia care unit (PACU) nurse is providing care for a patient who is exhibiting hypothermia. Which nursing action is appropriate? 1) Monitor breath sounds 2) Check serum glucose level 3) Hold prescribed opioid analgesics 4) Provide warm blankets or warming devices

ANS: 4 The nurse would provide warm blankets or warming devices for a patient with hypothermia.

The postoperative patient displays sudden chest pain, shortness of breath, cyanosis, tachycardia, and low blood pressure. The nurse suspects which postoperative complication? 1) Pneumonia 2) Atelectasis 3) Hypovolemia 4) Pulmonary embolism

ANS: 4 The patient is displaying signs of pulmonary emboli, which will cause sudden chest pain and difficulty breathing.