NURS 309 Quiz 3 Postoperative Patients

The nurse is caring for an obese postoperative client who underwent surgery for bowel resection. As the client is moving up in bed, he comments, "Something popped open." Upon examination, the nurse notes wound evisceration. Place the steps in order for handling this complication. 1. Cover the intestine with sterile moistened gauze 2. Stay calm and stay with the client 3. Check the vital signs, especially blood pressure and pulse 4. Have a colleague gather sterile supplies and contact the health care provider 5. Put the client into semi-Fowler position with knees slightly flexed 6. Prepare the client for surgery as ordered

2. Stay calm and stay with the client 5. Put the client into semi-Fowler position with knees slightly flexed 3. Check the vital signs, especially blood pressure and pulse 4. Have a colleague gather sterile supplies and contact the health care provider 1. Cover the intestine with sterile moistened gauze 6. Prepare the client for surgery as ordered

The RN has just received reports about all of these clients on the inpatient surgical unit. Which client does the nurse care for first? A. A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing B. A 46-year-old who had a thoracotomy 5 days ago and needs discharge teaching before going home C. A 48-year-old who had bladder surgery earlier in the day and is reporting pain when coughing D. A 49-year-old who underwent repair of a dislocated shoulder this morning and has a temperature of 100.4°F (38°C)

A. A 43-year-old who had a bowel resection 7 days ago and has new serosanguineous drainage on the dressing

The postanesthesia care unit (PACU) nurse is receiving the "handoff" report for a patient transferred from the OR. Which statements about this report are accurate? SATA A. A handoff report requires clear, concise language B. A handoff report is a two-way verbal interaction between the health care professional giving the report and the nurse receiving it C. A handoff report should be individualized based on the patient and his or her surgery D. The receiving nurse takes the time to restate (report back) the information to verify what was said E. The receiving nurse takes the time to ask questions, and the reporting professional must respond to the questions until a common understanding is established F. The receiving nurse continues assessing other patients while the handoff report is being given

A. A handoff report requires clear, concise language B. A handoff report is a two-way verbal interaction between the health care professional giving the report and the nurse receiving it D. The receiving nurse takes the time to restate (report back) the information to verify what was said E. The receiving nurse takes the time to ask questions, and the reporting professional must respond to the questions until a common understanding is established

Which members of the surgical team usually accompany a postoperative patient to the postanesthesia care unit (PACU)? A. Anesthesia provider and circulating nurse B. Circulating nurse and surgeon C. Surgeon and anesthesia provider D. Surgical assistant and surgeon

A. Anesthesia provider and circulating nurse

The healthcare provider removed a patient's original surgical dressing 2 days after surgery and is discharging the patient home with daily dressing changes. Which actions will the nurse take for this patient's discharge teaching? SATA A. Ask the patient's family or significant other to observe the dressing change B. Ask the UAP to get dressing supplies for the patient C. Instruct that the drainage will appear serosanguineous D. Instruct the patient to go to the emergency department for problems related to dressing changes E. Have the case manager arrange for a home health nurse to ensure that dressing changes are done and there are no complications or infection F. Teach the patient and family the signs and symptoms of infection

A. Ask the patient's family or significant other to observe the dressing change B. Ask the UAP to get dressing supplies for the patient E. Have the case manager arrange for a home health nurse to ensure that dressing changes are done and there are no complications or infection F. Teach the patient and family the signs and symptoms of infection

A patient arrives in the postanesthesia care unit (PACU). Which action does the nurse perform first? A. Assess for a patent airway and adequate gas exchange B. Assess the patient's pain level using the 0-10 pain assessment scale C. Position the patient in a supine position to prevent aspiration D. Calculate the patient-controlled analgesia (PCA) pump maximum dose per hour to avoid an overdose

A. Assess for a patent airway and adequate gas exchange

In conducting a postoperative assessment of a client, what is important for the nurse to examine first? A. Breathing pattern B. Level of consciousness C. Oxygen saturation D. Surgical site

A. Breathing pattern

The nurse is caring for a patient who has had abdominal surgery. After a hard sneeze, the patient reports pain in the surgical area, and the nurse immediately sees that the patient has a wound evisceration. What priority action must the nurse do first? A. Call for help and stay with the patient B. Leave the patient immediately call the surgeon C. Cover the wound with a non adherent dressing moistened with normal saline D. Take the patient's vital signs

A. Call for help and stay with the patient

Which assessment is most important for the nurse to perform for the client admitted to the post anesthesia care unit (PACU) after surgery under general anesthesia? A. Determining the client's level of consciousness B. Checking for pain on dorsi and plantar flexion of the foot C. Assessing the response to pin-prick stimulation from feet to mid-chest level D. Comparing blood pressure taken in the right arm to blood pressure taken in the left arm

A. Determining the client's level of consciousness

A client experiences abdominal distention following surgery. Which nursing actions are appropriate? SATA A. Encouraging ambulation B. Giving sips of ginger ale C. Auscultating bowel sounds D. Providing a straw for drinking E. Offering the prescribed opioid analgesic

A. Encouraging ambulation C. Auscultating bowel sounds

On which concern should the nurse focus when caring for a client after abdominal surgery? A. Identifying signs of bleeding B. Preventing pressure on the suture site C. Encouraging the use of an incentive spirometer D. Detecting clinical manifestations of inflammation

A. Identifying signs of bleeding

Which are interventions for the medical-surgical nurse to use in preventing hypoxemia for the postoperative patient? SATA A. Monitor the patient's oxygen saturation B. Position the patient supine C. Encourage the patient to cough and breath deeply D. Get the patient ambulating as soon as possible E. Instruct the patient to rest as much as possible F. Remind the patient to use incentive spirometry every hour while awake

A. Monitor the patient's oxygen saturation C. Encourage the patient to cough and breath deeply D. Get the patient ambulating as soon as possible F. Remind the patient to use incentive spirometry every hour while awake

After undergoing a modified radical mastectomy, a client is transferred to the postanesthesia care unit. Which nursing action is best to assign to an experienced LPN/LVN? A. Monitoring the client's dressing for any signs of bleeding B. Documenting the initial assessment on the client's chart C. Communicating the client's status report to the charge nurse on the surgical unit D. Teaching the client about the importance of using pain medications as needed

A. Monitoring the client's dressing for any signs of bleeding

Which indicator of return to consciousness occurs first as a patient recovers from general anesthesia? A. Muscular irritability B. Restlessness and delirium C. Recognition of pain D. Ability to reason and control behavior

A. Muscular irritability

Which intervention by the nurse will help a postoperative patient with compliance in getting up to ambulate? A. Offer the patient pain medication 30-45 minutes before ambulation B. Assist the patient to turn from side to side every 2 hours C. Remind the patient to perform extremity exercises every 4 hours D. Teach the patient that activity helps prevent postoperative complications

A. Offer the patient pain mediation 30-45 minutes before ambulation

Which statement best describes phase I care after surgery? A. Phase I care occurs immediately after surgery, most often in a postanesthesia care unit (PACU) B. Phase I care focuses on preparing the patient for care in an extended care environment C. Phase I care discharge occurs when presurgery level of consciousness has returned, oxygen saturation is at baseline, and vital signs are stable D. Phase I care most often occurs on a hospital unit, in an extended care facility, or in the home

A. Phase I care occurs immediately after surgery, most often in a postanesthesia care unit (PACU)

A patient cared for in the postanesthesia care unit (PACU) had a colostomy placed for treatment of Crohn's disease. The nurse assess that an abdominal dressing is 25% saturated with serosanguineous drainage and the incision is intact. An IV is infusing with D5/lactated Ringer's at 100 mL/hr through a 20-g peripheral IV access. Auscultation of abdomen reveals hypoactive bowel sounds in all four quandrants, abdomen soft, and no distension. Foley catheter is in place and draining yellow urine with sediment, 375 mL output in foley bag. Which body systems have been assessed by the nurse? SATA A. Renal/urinary B. Gastrointestinal C. Respiratory D. Musculoskeletal E. Integumentary F. Skeletal

A. Renal/urinary B. Gastrointestinal E. Integumentary

A postoperative patient in the postanesthesia care unit (PACU) has had an open reduction internal fixation of a left fractured femur. Vital signs are BP 87/49 mm Hg, HR 100/min sinus rhythm, respirations 22/min, and temp 98.3F. The Foley catheter has a total of 110 mL of clear yellow urine in the last 4 hours. Which body systems have been assessed by the nurse? SATA A. Respiratory B. Cardiovascular C. Neurovascular D. Integumentary E. Renal/Urinary F. Gastrointestinal

A. Respiratory B. Cardiovascular E. Renal/Urinary

The postanesthesia care unit (PACU) nurse is assessing an older adult patient for postoperative pain. Which nonverbal manifestations by the patient suggest pain to the nurse? SATA A. Restlessness B. Profuse sweating C. Difficult to arouse D. Confusion E. Increased blood pressure F. Decreased heart rate

A. Restlessness B. Profuse sweating D. Confusion E. Increased blood pressure

A client has an acute case of opioid depression and receives a dose of naloxone (Narcan). Which statement is true about this client? A. Supplemental pain reduction is needed. B. One dose is needed. C. This is an acute emergency. D. The client will be hostile.

A. Supplemental pain reduction is needed.

Which patient is most at risk for postoperative nausea and vomiting (PONV)? A. The patient with a history of motion sickness B. The patient with a nasogastric tube C. The patient who recently experienced a weight loss of 50 pounds D. The patient who had minimally invasive surgery (MIS)

A. The patient with a history of motion sickness

What information should be included in the handoff report when a patient is transferred from the OR to the postanesthesia care unit (PACU) staff? SATA A. Type and extent of surgical procedure B. Intraoperative complications and how they were handled C. List of usual daily medications D. Type and amount of IV fluids and blood products given E. Location and type of incisions, dressings, catheters, tubes, drains or packing F. Name, address, and phone number of next of kin

A. Type and extent of surgical procedure B. Intraoperative complications and how they were handled D. Type and amount of IV fluids and blood products given E. Location and type of incisions, dressings, catheters, tubes, drains or packing

The postanesthesia care unit (PACU) nurse is assessing a patient transferred in from the OR. Which assessment findings apply to assessment of the cardiovascular system? SATA A. Opens eyes on command B. Absent dorsalis pedis pulse in left foot C. Foley catheter in place with clear yellow drainage D. Monitor shows normal sinus rhythm E. States name correctly when asked F. Apical pulse 85 beats/minute

B. Absent dorsalis pedis pulse in left foot D. Monitor shows normal sinus rhythm F. Apical pulse 85 beats/minute

Which action does the nurse implement for a client with wound evisceration? A. Apply direct pressure to the wound. B. Cover the wound with a sterile, warm, moist dressing. C. Irrigate the wound with warm, sterile saline. D. Replace tissue protruding into the opening.

B. Cover the wound with a sterile, warm, moist dressing.

An RN and an LPN/LVN are working together in caring for a client who needs all of these interventions after orthopedic surgery. Which action(s) would be best for the RN to accomplish? A. Reinforce the need to cough and deep-breathe every 2 to 4 hours. B. Develop the discharge teaching plan in conjunction with the client. C. Administer narcotic pain medications before assisting the client with ambulation. D. Listen for bowel sounds and monitor the abdomen for distention and pain.

B. Develop the discharge teaching plan in conjunction with the client.

The nurse is responsible for the care of a postoperative patient with a thoracotomy. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? A. Instructing the patient to alternate rest and activity periods B. Encouraging, monitoring, and recording nutritional intake C. Monitoring cardiorespiratory response to activity D. Planning activities for periods when the patient has the most energy

B. Encouraging, monitoring, and recording nutritional intake

A 49-year-old patient is in the postanesthesia care unit (PACU) following a frontal craniotomy for repair of a ruptured cerebral aneurysm. The nurse assesses that the patient's eyes open on verbal stimulation. Pupils are equal and reactive to light, and diameter is 3 mm. The patient's hand grasps are equal and strong. The patient is able to state name correctly. The patient has and one episode of nausea and vomiting. Incision edges are dry and approximated with sutures. Lung sounds are slightly diminished on auscultation, and the nurse observes the patient is using abdominal accessory muscles to breath. Which body systems has the nurse assessed? SATA A. Cardiovascular B. Gastrointestinal C. Neurological D. Integumentary E. Respiratory F. Renal/urinary

B. Gastrointestinal C. Neurological D. Integumentary E. Respiratory

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus? A. Decreased blood supply B. Impaired neural functioning C. Perforation of the bowel wall D. Obstruction of the bowel lumen

B. Impaired neural functioning

Mr. H returns from the OR after a hernia repair. He says that he is "afraid to walk because it will make the pain really bad." What does the nurse explain as being the best option? A. Pain medication every 4 hours if he needs or wants it B. Medication 30 to 40 minutes before ambulation or dressing changes C. Around-the-clock pain medication even if he has no report of pain D. Talking to the HCP for reassurance about the treatment plan

B. Medication 30 to 40 minutes before ambulation or dressing changes

When assessing the hydration status of an older postoperative patient, where must the nurse assess for tenting of the skin? SATA A. On the back of the hand B. On the forehead C. On the forearm D. On the sternum E. On the abdomen F. On the thigh

B. On the forehead D. On the sternum

What is the primary purpose of a postanesthesia care unit (PACU) A. Follow-through on the surgeon's postoperative orders B. Ongoing critical evaluation and stabilization of the patient C. Prevention of lengthened hospital stay D. Arousal of patient following the use of conscious sedation

B. Ongoing critical evaluation and stabilization of the patient

The postoperative patient has a Penrose drain in place. Which action does the nurse take to prevent skin irritation, wound contamination, and infection? A. Keeps a sterile safety pin in place at the end of the drain B. Places absorbent pads under and around the exposed drain C. Uses minimal tape; when tape is needed, use hypoallergenic tape D. Shortens the drain by pulling it out a short distance and trimming off the excess external portion

B. Places absorbent pads under and around the exposed drain

The nurse is teaching incisional care to a patient who is being discharged after abdominal surgery. Which priority instruction must the nurse include? A. Do not rub or touch the incision site B. Practice proper handwashing C. Clean the incision site two times a day with soap and water D. Splint the incision site as often as needed for comfort

B. Practice proper handwashing

The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse the greatest concern and should be reported to the surgeon? A. Crusting along the incision line B. Redness and swelling around the incision C. Sanguineous drainage at the suture site D. Serosanguineous drainage on the dressing

B. Redness and swelling around the incision

A nurse in the postanesthesia care unit (PACU) observes that after an abdominal cholecystectomy a client has serosanguineous drainage on the abdominal dressing. What is the next nursing action? A. Change the dressing B. Reinforce the dressing C. Replace the tape with Montgomery ties D. Support the incision with an abdominal binder

B. Reinforce the dressing

The morning after a patient's lower leg surgery, the nurse notes that the dressing is wet from drainage. The surgeon has not yet been in to see the patient on rounds. What does the nurse do about the dressing? A. Removes the dressing and puts on a dry, sterile dressing B. Reinforces the dressing by adding dry, sterile dressing material on top of existing dressing C. Applies dry, sterile dressing material directly to the wound and then retapes the original dressing D. Does nothing to the dressing but calls the surgeon to evaluate the patient immediately

B. Reinforces the dressing by adding dry, sterile dressing material on top of existing dressing

The nurse on the medical-surgical unit is caring for a postoperative patient. Which assessment criteria indicate to the nurse that the patient is experiencing respiratory difficulty? SATA A. The patient's oxygen saturation drops from 98% to 94% B. The patient is using accessory muscles to breathe C. The patient makes a high-pitched crowing sound when breathing D. The patient's blood pressure drops from 120/80 to 110/78 E. The patient's respiratory rate is 29/min F. The patient's urine output drops from 50 mL/hr to 30 mL/hr

B. The patient is using accessory muscles to breathe C. The patient makes a high-pitched crowing sound when breathing E. The patient's respiratory rate is 29/min

A patient who is 2 day postoperative for abdominal surgery states, "I coughed and head something pop." The nurse's immediate assessment reveals an opened incision with a portion of large intestines protruding. Which statements apply to this clinical situation? SATA A. Incision dehiscence has occurred B. This is an emergency C. The wound must be kept moist with normal saline-soaked sterile dressing D. This is an urgent situation E. Incision evisceration has occurred F. A nasogastric (NG) tube may be ordered to decompress the stomach

B. This is an emergency C. The wound must be kept moist with normal saline-soaked sterile dressing E. Incision evisceration has occurred F. A nasogastric (NG) tube may be ordered to decompress the stomach

The postoperative care of a morbidly obese client is being planned. Which task best uses the expertise of the LPN/LVN, under the supervision of the RN team leader? A. Obtaining an oversized blood pressure cuff and a large-size bed B. Setting up a reinforced trapeze bar C. Assisting in the planning of toileting, turning, and ambulations D. Assigning tasks to unlicensed assistive personnel (UAP) and other ancillary staff

C. Assisting in the planning of toileting, turning, and ambulations

The nurse transfers a patient to the postanesthesia care unit (PACU) with an incision and drainage of an abscess in the right groin under general anesthesia. Blood pressure is 80/47 mm Hg, heart rate 117/min in sinus tachycardia, respiratory rate 28/min, pulse oximetry reading 93% on oxygen at 3 L per nasal cannula, and temp 101.3F. The Jackson-Pratt drain has 70 mL of a cream-colored output. Normal saline is infusing 150 mL/hr. The surgeon orders a bolus of 500 mL IV normal saline over 1 hour, two sets of blood cultures, and culture drainage from the Jackson-Pratt drain. The patient's history includes vulvar cancer with a needle biopsy of the right groin, hypertension treated with lisinopril 5 mg PO daily, and no known drug allergies. The patient is designated as a full code. using the Situation, Background, Assessment, Recommendation (SBAR) charting format, which information should be included in assessment? A. Nurse transfers patient to PACU with an incision and drainage of an abscess in the right groin with general anesthesia B. Surgeon sends orders to bolus the patient with 500 mL normal saline over an hour, draw two sets of blood cultures, and send a culture of drainage from the JP drain C. BP is 80/47, HR 117/min in sinus tachycardia, respirations 28/min, pulse oximetry 93% on O2 at 3 L NC, and temp 101.3F; JP drain with 70 mL cream-colored output D. Patient had a right groin abscess. History of vulvar cancer. Needle biopsy of right groin completed 1 week ago. History of hypertension treated with lisinopril 5 mg. No known allergies. Full code.

C. BP is 80/47, HR 117/min in sinus tachycardia, respirations 28/min, pulse oximetry 93% on O2 at 3 L NC, and temp 101.3F; JP drain with 70 mL cream-colored output

The postanesthesia care unit (PACU) nurse is caring for a postoperative patient. The patient's oxygen saturation drops from 98% to 88%. What is the nurse's priority action? A. Call the anesthesia provider B. Call the surgeon C. Call the Rapid Response Team D. Call the respiratory therapist

C. Call the Rapid Response Team

The patient who received moderate sedation with midazolam appears to be overly sedated and has respiratory depression. Which drug does the nurse prepare to administer to the patient? A. Lorazepam B. Naloxone C. Flumazenil D. Butorphanol tartate

C. Flumazenil

What is the priority nursing intervention for a client during the immediate postoperative period? A. Monitoring vital signs B. Observing for hemorrhage C. Maintaining a patent airway D. Recording the intake and output

C. Maintaining a patent airway

After an abdominal cholecystectomy, a client has a T-tube attached to a collection device. On the day of surgery, at 10:30 p.m., 300 mL of bile is emptied from the collection bag. At 6:30 a.m. the next day, the bag contains 60 mL of bile. What should the nurse consider in response to this information? A. The T-tube may have to be irrigated B. The bile is now draining into the duodenum C. Mechanical problems may have developed with the T-tube (tube compression or kinking) D. Suction must be reestablished in the portable drainage system

C. Mechanical problems may have developed with the T-tube

The nurse is performing a dressing change on a client who underwent abdominal surgery 6 days prior. The nurse notes a moderate amount of serosanguineous drainage on the old dressing. What will the nurse do? A. Apply extra gauze to the new dressing. B. Contact the surgeon to discuss the need for antibiotics. C. Notify the surgeon about possible wound dehiscence. D. Perform the dressing change according to unit protocol.

C. Notify the surgeon about possible wound dehiscence.

After gastric surgery, a client arrives in the post-anesthesia care unit. Which nursing action is most appropriate for the RN to delegate to an experienced nursing assistant? A. Monitor respiratory rate and airway patency. B. Irrigate the nasogastric tube with saline. C. Position the client on the left side. D. Assess the client's pain level.

C. Position the client on the left side.

Which signs/symptoms are considered post-operative complications? SATA A. Sedation B. Pain at the surgical site C. Pulmonary embolism D. Hypothermia E. Wound evisceration F. Postoperative ileus

C. Pulmonary embolism D. Hypothermia E. Wound evisceration F. Postoperative ileus

Five RNs from other units have been assigned to the post-anesthesia care unit for the day. A 16-year-old client with diabetes has also just arrived from the operating room (OR) after having laparoscopic abdominal surgery. The charge nurse assigns the RN with which kind of experience to care for this new client? A. RN who usually works on the inpatient pediatric unit B. RN who provides education to diabetic clients in a clinic C. RN who has 5 years of experience in the delivery room D. RN who ordinarily works as a scrub nurse in the OR

C. RN who has 5 years of experience in the delivery room

Which assessment finding in a postoperative client after general anesthesia requires immediate intervention? A. Heart rate of 58 beats/min B. Pale, cool extremities C. Respiratory rate of 6 breaths/min D. Suppressed gag reflex

C. Respiratory rate of 6 breaths/min

The patient is recovering in a postanesthesia care unit (PACU) environment that advances the patient quickly from phase I care level to phase III care level, preparing for discharge to home. What type of surgery is this patient most likely having? A. Elective surgery B. Emergency surgery C. Same-day surgery D. Urgent surgery

C. Same-day surgery

How does the nurse position a client with postoperative nausea and vomiting? A. Flat in bed, with the head in alignment with the body B. Prone, with the head of the bed flat C. Side-lying, with the head in a neutral position D. Supine in bed, with the neck flexed

C. Side-lying, with the head in a neutral position

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further assessment in the post-anesthesia care unit? A. Pain at the surgical site B. Requirement for verbal stimuli to awaken C. Snoring sounds when inhaling D. Sore throat on swallowing

C. Snoring sounds when inhaling

The healthcare team determines a patient's readiness for discharge from the postanesthesia care unit (PACU) by noting a postanesthesia recovery score of at least 10. After determining that ll criteria have been met, the patient is discharged to the hospital unit or home. Review the patient profiles after 1 hour in the PACU listed below. Which patient should the nurse expected to discharged from the PACU first? A. 10-year-old female, tonsillectomy, general anesthesia. Duration of surgery 30 minutes. Immediate response to voice. Alert to place and person. Able to move all extremities. Respirations even, deep, rate of 20. Vital signs are within normal limits. IV solution is D5RL. Has voided on bedpan. Eating ice chips. Complaining of sore throat. B. 55-year-old male, repair of fractured lower left leg. General anesthesia. Duration of surgery 1 hour, 30 minutes. Drowsy, but responds to voice. Nausea and vomiting twice in PACU. No urge to void at this time. IV infusing D5NS. Pedal pulses noted in both lower extremities. VS: T: 98.6F, Pulse 130 beats/min, RR: 24/min, BP: 124/76 C. 24-year-old male, reconstruction of facial scar. General anesthesia. Duration of surgery 2 hours. Sleeping, groans to voice command. VS are within normal limits. RR: 10 breaths/min. No urge to void. IV of D5RL infusing. Complains of pain at surgical site D. 42-year-old female, colonoscopy. IV conscious sedation. Awake and alert. Up to bathroom to void. IV discontinued. Resting quietly in chair. VS are within normal limits.

D. 42-year-old female, colonoscopy. IV conscious sedation. Awake and alert. Up to bathroom to void. IV discontinued. Resting quietly in chair. VS are within normal limits.

A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. What medication does the nurse anticipate will be prescribed for this client? A. Vitamin A (Aquasol A) B. Cyanocobalamin (Cobex) C. Phytonadione (Mephyton) D. Ascorbic acid (Ascorbicap)

D. Ascorbic acid (Ascorbicap)

A patient develops respiratory distress after having a left total hip replacement. The patient develops labored breathing, and a pulse oximetry reading is 83% on 2 L oxygen via nasal cannula. Which intervention is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? A. Assess change in patient's respiratory status B. Order necessary medications to be administered C. Insert oral airway to maintain open airway D. Check the patient's vital signs

D. Check the patient's vital signs

Which description illustrates the beginning of the postoperative period? A. Completion of the surgical procedure and arousal of the patient from anesthesia in the operating room (OR) B. Providing care before, during, and after surgery C. Closure of the patient's surgical incision with sutures D. Completion of the surgical procedure and transfer of the patient to the postanesthesia care unit (PACU)

D. Completion of the surgical procedure and transfer of the patient to the postanesthesia care unit (PACU)

While caring for a client with a portable wound drainage system, a nurse observes that the collection container is half full and empties it. What is the next nursing intervention? A. Encircle the drainage on the dressing B. Irrigate the suction tube with sterile saline C. Clean the drainage port with an alcohol wipe D. Compress the container before closing the port

D. Compress the container before closing the port

When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low-Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action? A. Obtain the vital signs B. Notify the health care provider C. Reinsert the protruding organs using aseptic technique D. Cover the wound with a sterile towel moistened with normal saline

D. Cover the wound with a sterile towel moistened with normal saline

A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? A. Productive cough B. Clubbing of the fingertips C. Crackles at the height of inhalation D. Diminished breath sounds on auscultation

D. Diminished breath sounds on auscultation

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? A. Postural drainage B. Cupping the chest C. Nasotracheal suctioning D. Frequent changes of position

D. Frequent changes of position

The PACU nurse caring for a client with a nasogastric (NG) tube notes that 300 mL of bright red blood has collected. What is the appropriate nursing action? A. Document as a normal finding B. Immediately remove the NG tube C. Place the client in Trendelenburg position D. Call the client's surgeon to report the drainage

D. Call the client's surgeon to report the drainage

The nurse reviews a routine discharge teaching plan concerning postoperative care with a client. Which statement by the client indicates that teaching about wound care was effective? A. "I may need to restrict my activities for several months." B. "I should remove the dressing if the wound is draining." C. "Some bleeding from the incision is normal for several weeks." D. "The wound will completely heal in about 2 months."

A. "I may need to restrict my activities for several months."

A nurse is preparing to change a client's dressing What is the reason for using surgical asepsis during this procedure? A. Keeps the area free of microorganisms B. Confines microorganisms to the surgical site C. Protects self from microorganisms in the wound D. Reduces the risk for growing opportunistic microorganisms

A. Keeps the area free of microorganisms

A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated? A. Dialysis B. Osmosis C. DIffusion D. Capillary

D. Capillary

A client is extubated in the postanesthesia care unit (PACU) after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? A. Restlessness B. Bradycardia C. Constricted pupils D. Clubbing of the fingers

A. Restlessness

Which client is at greatest risk for slow wound healing? A. A 12-year-old healthy girl B. A 47-year-old obese man with diabetes C. A 48-year-old woman who smokes D. A 98-year-old healthy man

B. A 47-year-old obese man with diabetes

After abdominal surgery a client reports pain. What action should the nurse take first? A. Reposition the client B. Obtain the client's vital signs C. Administer the prescribed analegeics D. Determine the characteristics of the pain

D. Determine the characteristics of the pain

In the postanesthesia care unit (PACU), the nurse assesses that a patient is bleeding profusely from an abdominal incision. What is the nurse's best first action? A. Notify the surgeon B. Apply pressure to the wound dressing C. Instruct the unlicensed assistive personnel (UAP) to get additional dressing supplies D. Request and draw a complete blood count

B. Apply pressure to the wound dressing

A client reports severe pain 2 days after surgery. Which initial action should the nurse take after assessing the character of the pain? A. Encourage rest B. Obtain the vital signs C. Administer the PRN analgesic D. Document the client's pain response

B. Obtain the vital signs

Which are criteria used by the health care team to determine when a patient is ready to be discharged from the PACU? SATA A. Recovery rating score of 7 to 10 on rating scale B. Stable vital signs with normal body temperature C. Ability to swallow but remains NPO for at least 4 hours D. Intact cough and swallow reflexes E. Adequate urine output F. Return of gag reflex

B. Stable vital signs with normal body temperature D. Intact cough and swallow reflexes E. Adequate urine output F. Return of gag reflex

The nurse is caring for an older-adult client who reports being "afraid to get hooked" on opioid pain medication after surgery. What is the appropriate nursing response? SATA A. "Why do you think you're going to get hooked?" B. "Don't worry, I won't give you any opioid medications." C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication." E. "There are ways we can keep you from becoming dependent on these drugs." F. "Older adults are much less likely to rely on pain medications than younger people."

C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication."

Which client statement regarding appropriate pain control requires nursing intervention? A. "I'll listen to music when I feel pain." B. "Before exercise or physical therapy, I'll be sure I've taken my medication." C. "If the prescribed dose of medication doesn't help my pain, I'll take an extra dose." D. "I plan to keep a pain diary so I can see trends about when my pain worsens."

C. "If the prescribed dose of medication doesn't help my pain, I'll take an extra dose."

In the immediate postoperative period after a gastrectomy, the client's nasogastric tube is draining a light-red liquid. For how long should the nurse expect this type of drainage? A. 1 to 2 hours B. 3 to 4 hours C. 10 to 12 hours D. 24 to 48 hours

C. 10 to 12 hours

If a patient experiences a wound dehiscence, which description best characterizes what is happening with the wound? A. Purulent drainage is present at incision site because of infection B. Extreme pain is present at incision site C. A partial or complete separation of outer layer is present at incision site D. The inner and outer layers of the incision are separated

C. A partial or complete separation of outer layer is present at incision site

The nurse is assessing a postoperative patient's gastrointestinal system. What is the best indicator that peristaltic activity has resumed? A. Presence of bowel sounds B. Patient states he is hungry C. Passing flatus or stool D. Presence of abdominal cramping

C. Passing flatus or stool

The medical-surgical nurse is caring for a postoperative patient whose lab values reveal an increase in band cells (immature neutrophils). What is the nurse's best interpretation of this value? A. The patient may need a transfusion B. The patient is using up clotting factors C. The patient is developing an infection D. The patient's results is expected postoperatively

C. The patient is developing an infection

What pain management does a client who has been admitted to the post-anesthesia care unit typically receive? A. Intramuscular nonopioid analgesics B. Intramuscular opioid analgesics C. Intravenous nonopioid analgesics D. Intravenous opioid analgesics

D. Intravenous opioid analgesics

A patient arrives at the postanesthesia care unit (PACU), and the nurse notes a respiratory rate of 10 with sternal retractions. The report from the anesthesia provider indicates that the patient received fentanyl during surgery. What is the nurse's best first action? A. Monitory the patient for effects of anesthetic for at least 1 hour B. Closely monitory vital signs and pulse oximetry readings until the patient is responsive C. Administer oxygen as ordered, monitoring pulse oximetry D. Maintain an open airway through positioning and suction if needed

D. Maintain an open airway through positioning and suction if needed

Which intervention for post-surgical care of a patient is correct? A. When positioning the patient, use the knee gatch of the bed to bend the knees and relieve pressure B. Gently massage the lower legs and calves to promote venous blood return to the heart C. Encourage bedrest for 3 days after surgery to prevent complications D. Teach the patient to splint the surgical wound for support and comfort when getting out of bed

D. Teach the patient to splint the surgical wound for support and comfort when getting out of bed