Postoperative Care
When a patient is admitted to the PACU, what are the priority interventions the nurse performs? A) Asses the surgical site, noting presence and character of drainage B) Assess the amount of urine output and the presence of bladder distention C) Assess for airway patency and quality of respirations, and obtain vital signs D) Review results of intraoperative laboratory values and medications received.
Answer: C Assessment in the postanesthesia care unit (PACU) begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Identification of inadequate oxygenation and ventilation or respiratory compromise necessitates prompt intervention.
A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to "throw up." A priority nursing intervention would be to: A) increase the rate of the IV fluids. B) obtain vital signs including O2 saturation. C) position patient in lateral recovery position. D) administer antiemetic medication as ordered.
Answer: C If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs.
In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)? A) Monitor the patient's pain. B) Do the admission vital signs. C) Assist the patient to take deep breaths and cough. D) Change the dressing when there is excess drainage.
Answer: C The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The LPN or RN will monitor and treat the patient's pain and change the dressings.
When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first? A) Recheck in 1 hour for increased drainage. B) Notify the surgeon of a potential hemorrhage. C) Assess the patient's blood pressure and heart rate. D) Remove the dressing and assess the surgical incision.
Answer: C The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.
After admission of the postoperative patient to the clinical unit, which assessment data requires the most immediate attention? A) Oxygen saturation of 85% B) Respiratory rate of 13/minute C) Temperature of 100.4F (38 C) D) Blood pressure of 90/60
Answer: A During the initial assessment, identify signs of inadequate oxygenation and ventilation. Pulse oximetry monitoring is initiated because it provides a noninvasive means of assessing the adequacy of oxygenation. Pulse oximetry may indicate low oxygen saturation (<90% to 92%) with respiratory compromise. This necessitates prompt intervention.
In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes? A) Administering adequate analgesics to promote relief or control of pain. B) Asking the patient to demonstrate the postoperative exercises every 1 hour C) Giving the patient positive feedback when the activities are performed correctly D) Warning the patient about possible complications if the activities are not performed
Answer: A Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.
The nurse is caring for a 54-year-old unconscious female patient who has just been admitted to the postanesthesia care unit after abdominal hysterectomy. How should the nurse position the patient? A) Left lateral position with head supported on a pillow B) Prone position with a pillow supporting the abdomen C) Supine position with head of bed elevated 30 degrees D) Semi-Fowler's position with the head turned to the right
Answer: A The unconscious patient should be placed in the lateral "recovery" position to keep the airway open and reduce the risk of aspiration. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated to maximize expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.
The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? A) Assess the patient's pain. B) Assess the patient's vital signs. C) Check the rate of the IV infusion. D) Check the physician's postoperative orders
Answer: B The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence.
The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient? A) Blood administration B) Restoring circulating volume C) An ECG to check circulatory status D) Return to surgery to check for internal bleeding
Answer: B The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, or there is a past history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient's level of consciousness changes or the abdomen becomes firm and distended.
Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately postoperative? A) Supine B) Lateral C) Semi-Fowler's D) High-Fowler's
Answer: B Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated.
A 67-year-old male patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression? A) Increased respiratory rate B) Decreased oxygen saturation C) Increased carbon dioxide pressure D) Frequent premature ventricular contractions (PVCs)
Answer: C Transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a sensitive indicator of respiratory depression. Increased CO2 pressures would indicate respiratory depression. Clinical manifestations of inadequate oxygenation include increased respiratory rate, dysrhythmias (e.g., premature ventricular contractions), and decreased oxygen saturation.
A 70kg postoperative patient has an average urine output of 25mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to: A) perform a straight catheterization to measure the amount of urine in the bladder. B) notify the physician and anticipate obtaining blood work to evaluate renal function. C) continue to monitor the patient because this is a normal finding during this time period. D) evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound.
Answer: D Because of the possibility of infection associated with catheterization, the nurse should first try to validate that the bladder is full. The nurse should consider fluid intake during and after surgery and should determine bladder fullness by percussion, by palpation, or by a portable bladder ultrasound study to assess the volume of urine in the bladder and avoid unnecessary catheterization.
The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)? A) Vital signs baseline or stable B) Minimal nausea and vomiting C) Wants to go to the bathroom at home D) Responsible adult taking patient home E) Comfortable after IV opioid 15 minutes ago
Answers: A, B, D Ambulatory surgery discharge criteria includes meeting Phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria includes a responsible adult driving patient, no IV opioid drugs for last 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.