Med Surge Chap 5

The nurse in the PACU performs postsurgical assessments on the newly admitted patient every _________ minutes.

ANS: 15 fifteen The staff in PACU make postoperative assessments every 15 minutes on the newly admitted patient.

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

ANS: 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.

To help seal the insertion site from the spinal anesthesia, the nurse will offer: a. tea. b. Jell-O. c. milk. d. iced water.

ANS: A Caffeine drinks increase the vascular pressure and help seal the punctured area.

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 patient's legs over side of bed. c. offer patient some fluids. d. apply gait belt to patient.

ANS: A The initial intervention prior to the first ambulation is to raise the head of the bed to gradually change the patient's posture.

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.

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

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 surgeon's office. e. the need to delay driving and decision making.

ANS: 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.

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.

ANS: 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.

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.

ANS: 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.

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.

ANS: 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.

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

ANS: 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

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.

ANS: 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.

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.

ANS: 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.

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

ANS: 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.

Following abdominal surgery, the PACU nurse demonstrates the best nursing care by placing the semi-conscious patient in _____ position. a. the supine b. semi-Fowler's c. the lateral d. Trendelenburg's

ANS: 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.

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.

ANS: C Age-related changes that interfere with respiration in the older adult are weakened respiratory muscles and calcified costal cartilages

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.

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

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.

ANS: C Stockings should be removed approximately 20 minutes each shift for skin care.

The patient recovering in the PACU awakes confused and disoriented. The nurse's 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."

ANS: C The patient should be reoriented and assured when awaking from anesthesia

The nurse should report to the charge nurse that a 10-hour post-abdominal 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.

ANS: 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.

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."

ANS: C Vitamin C helps with the production of collagen, which restores damaged tissues.

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

ANS: 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.

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 nurse's 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."

ANS: 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.

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.

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

The patient's 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.

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

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."

ANS: 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

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.

ANS: D Repositioning the patient is the best initial remedy.

The postanesthesia care unit (PACU) nurse determines that the patient's 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. patient's condition warrants close monitoring. c. patient is experiencing severe pain. d. patient will soon be transferred to the postoperative unit.

ANS: 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.

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.

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