Chapter 16: Care of Postoperative Patients
SG#5 The patient is recovering in a postanesthesia care unit (PACU) environment that advances the patient quickly from a Phase 1 care level to a phase III care level, preparing for discharge at 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
1. A postoperative client has the following orders: IV lactated Ringers 125 mL/hr NG tube to low continuous suction Replace NG output every 4 hours with normal saline over 4 hours Morphine sulfate 2 mg IV push every hour as needed for pain NPO Up in chair tonight At 1600 (4:00 PM), the nurse measures the nasogastric (NG) output from noon to be 200 mL. What is the clients total IV rate for the next 4 hours? (Record your answer using a whole number.) _____ mL/hr
175 mL/hr 200 mL of NG output 4 hours = 50 mL/hr. 125 mL/hr + 50 mL/hr = 175 mL/hr.
SG#16 The post anesthesia care unit (PACU) nurse is receiving the "handoff" report for a patient transferred in from the OR. Which statements about this report are accurate? Select all that apply a. A handoff report requires clean, 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 revising nurse continues assessing other patient's while the handoff report is being given.
a. A handoff report requires clean, 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
7. A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a. Airway b. Bleeding c. Breathing d. Cardiac rhythm
a. Airway Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is part of the circulation assessment, as is cardiac rhythm.
SG#23 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 put on a dry, sterile dressing b. Reinforces the dressing by adding dry, sterile dressing material on top of the existing dressing c. Applies dry, sterile dressing material directly to the wound and then retakes 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 the existing dressing
SG#19 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 hand washing 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 hand washing
3. A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the clients plan of care to minimize the potential for this occurring? (Select all that apply.) a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. d. Place the client in a room secluded at the end of the hall. e. Provide the client with uninterrupted periods of sleep.
a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed e. Provide the client with uninterrupted periods of sleep Older clients may have difficulty adjusting to the stress of the hospital environment and illness or surgery. Techniques that are helpful include allowing liberal visitation, assisting the client to use successful coping techniques, and keeping the client bathed and groomed. Sleep deprivation can contribute to confusion, so the nurse ensures the client receives adequate sleep. Secluding the client at the end of the hall may lead to sensory deprivation and loneliness.
SG#10 Which members of the surgical team usually accompany a postoperative patient to the post anesthesia 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
5. A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.) a. Apply stimulation to the contralateral leg. b. Assess the clients willingness to try meditation. c. Elevate the clients operative leg and apply ice. d. Reduce the noise level in the clients environment. e. Turn the TV on loudly to distract the client.
a. Apply stimulation to the contralateral leg. b. Assess the clients willingness to try meditation. c. Elevate the clients operative leg and apply ice. d. Reduce the noise level in the clients environment. There are many nonpharmacologic comfort measures for pain, including applying stimulation to the opposite leg, providing opportunities for meditation, elevation of the leg, applying ice, and reducing noxious stimuli in the environment. Participating in diversional activities is another approach, but simply turning the TV on loudly does not provide a good diversion.
SG#34 The health care 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? Select all that apply a. Ask the patient's family or significant other to observe the dressing change b. Asking 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 (ED) 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. Asking 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.
SG#17 A patient arrives in the post anesthesia 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. Postion 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
SG#31 Which indicator of return to consciousness occurs FIRST as a patient recovers from general anesthesia? a. Muscular irritability b. Restlessness an delirium c. Recognition of pain d. Ability to reason and control behavior
a. Muscular irritability
3. A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate? a. Assess other indicators of oxygenation. b. Call the Rapid Response Team. c. Notify the anesthesia provider. d. Prepare to intubate the client.
a. Assess other indicators of oxygenation. If a postoperative clients oxygen saturation (SaO2) drops below 95% (or the clients baseline), the nurse should notify the anesthesia provider. If the SaO2 drops by 10% or more, the nurse should call the Rapid Response Team. Since this is approximately a 3% drop, the nurse should further assess the client. Intubation (if the client is not intubated already) is not warranted.
SG#21 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 to 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
4. A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.) a. Check all over-the-counter medications for acetaminophen. b. Do not take more pills each day than you are prescribed. c. Eat a diet that is high in fiber and drink lots of water. d. If this gives you diarrhea, loperamide (Imodium) can help. e. You shouldnt drive while you are taking this medication.
a. Check all over-the-counter medications for acetaminophen. b. Do not take more pills each day than you are prescribed. c. Eat a diet that is high in fiber and drink lots of water. e. You shouldnt drive while you are taking this medication. Percocet is a common opioid analgesic that contains acetaminophen. The client should be taught to check all over-the-counter medications for acetaminophen and to not take more than the prescribed amount of Percocet, as the maximum daily dose of acetaminophen is 3000 mg. Percocet, like all opioid analgesics, can cause constipation, and the client can minimize this by eating a high-fiber diet and drinking plenty of water. Since Percocet can cause drowsiness, the client taking it should not drive or operate machinery. The medication is more likely to cause constipation than diarrhea.
8. A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer? a. Flumazenil (Romazicon) 0.2 to 1 mg b. Flumazenil (Romazicon) 2 to 10 mg c. Naloxone (Narcan) 0.4 to 2 mg d. Naloxone (Narcan) 4 to 20 mg
a. Flumazenil (Romazicon) 0.2 to 1 mg Flumazenil is a benzodiazepine antagonist and would be the correct drug to use in this situation. The correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist.
SG#33 Which are interventions for the medical-surgical nurse to use in preventing hypoxemia for the postoperative patient? Select all that apply 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.
SG#37 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 medication 30-45 minutes before ambulation
SG#4 Which statement best describes phase I care after surgery? a. Phase 1 care occurs immediately after surgery, most often in a postanesthesia care unit(PACU) b. Phase 1 care focuses on preparing the patient for care in an extended care environment c. Phase 1 care discharge occurs when presurgery level of consciousness has returned, oxygen saturation is at baseline, and vital signs are stable d. Phase 1 care most often occurs on a hospital unit, in an extended care facility, or in the home
a. Phase 1 care occurs immediately after surgery, most often in a postanesthesia care unit(PACU)
SG#13 A patient cared for in the post anesthesia 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 revels hypoactive bowel sounds in all four quadrants, abdomen soft, and no distention. Foley catheter is in place and draining yellow urine with sediment, 375 mL output in Foley bag. Which body system have been assessed by the nurse? Select all that apply. a. Renal/urinary b. Gastrointestinal c. Respiratory d. Musculoskeletal e. Integumentary f. Cardiovascular
a. Renal/urinary b. Gastrointestinal e. Integumentary
SH#12 A postoperative patient in the post anesthesia care unit (PACU) has had an open reduction internal fixation of a left fractured femur. Vital signs are blood pressure 87/49 mm Hg, heart rate 100/min sinus rhythm, respirations 22/min, and temperature 98.3 F (36.8 C). The foley catheter has a total of 110 mL of clear yellow urine in the last 4 hours. Which body systems have been assed by the nurse? Select all that Apply a. Respiratory b. Cardiovascular c. Neurovascular d. Integumentary e. Renal/Urinary f. Gastrointestinal
a. Respiratory b. Cardiovascular e. Renal/Urinary
SG#30 The post anesthesia care unit (PACU) nurse is assessing an older adult patient for postoperative pain. Which nonverbal manifestations by the patient suggest pain to the nurse? Select all that apply 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
SG#28 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
SG#25 What information should be included in the handoff report when a patient is transferred from the OR to the post anesthesia care unit (PACU) staff? Select all that apply 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
SG#15 The post anesthesia care unit (PACU) nurse is assessing a patient transferred in from the OR. Which assessment findings apply to assessment of the cardiovascular system? Select all that apply 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.
SG#9 In the post anesthesia 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 addition dressing supplies d. Request and draw a complete blood count.
b. Apply pressure to the wound dressing
9. A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort? a. Assess the clients pain on a 0-to-10 scale. b. Assist the client into a position of comfort. c. Have the client sit up in a recliner. d. Tell the client when pain medication is due.
b. Assist the client into a position of comfort. Several nonpharmacologic comfort measures can help postoperative clients with their pain, including distraction, music, massage, guided imagery, and positioning. The nurse should help this client into a position of comfort considering the surgical procedure and position of any tubes or drains. Assessing the clients pain is important but does not improve comfort. The client may be more uncomfortable in a recliner. Letting the client know when pain medication can be given next is important but does not improve comfort.
6. A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? a. Allow the client to rest. b. Auscultate lung sounds. c. Document the episode. d. Encourage the client to eat dry toast.
b. Auscultate lung sounds. Vomiting after surgery has several complications, including aspiration. The nurse should listen to the clients lung sounds. The client should be allowed to rest after an assessment. Documenting is important, but the nurse needs to be able to document fully, including an assessment. The client should not eat until nausea has subsided.
6. A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.) a. Administering antibiotics for 72 hours b. Disposing of dressings properly c. Leaving draining wounds open to air d. Performing proper hand hygiene e. Removing and replacing wet dressings
b. Disposing of dressings properly d. Performing proper hand hygiene e. Removing and replacing wet dressings Interventions necessary to prevent surgical wound infection include proper disposal of soiled dressings, performing proper hand hygiene, and removing wet dressings as they can be a source of infection. Prophylactic antibiotics are given to clients at risk for infection, but are discontinued after 24 hours if no infection is apparent. Draining wounds should always be covered.
SG#14 A 49-year-old patient is in the post anesthesia 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 stay name correctly. The patient has had one episode of nausea and vomiting. Incision edgers 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 breathe. Which body systems has the nurse assessed? Select all that apply. a. Cardiovascular b. Gastrointestinal c. Neurologic d. Integumentary e. Respiratory f. Renal/urinary
b. Gastrointestinal c. Neurologic d. Integumentary e. Respiratory
2. A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.) a. Blood glucose: 120 mg/dL b. Hemoglobin: 7.8 mg/dL c. pH: 7.68 d. Potassium: 2.9 mEq/L e. Sodium: 142 mEq/L
b. Hemoglobin: 7.8 mg/dL c. pH: 7.68 d. Potassium: 2.9 mEq/L Fluid and electrolyte balance are assessed carefully in the postoperative client because many imbalances can occur. The low hemoglobin may be from blood loss in surgery. The higher pH level indicates alkalosis, possibly from losses through the NG tube. The potassium is very low. The blood glucose is within normal limits for a postsurgical client who has been fasting. The sodium level is normal.
SG#27 When assessing the hydration status of an older postoperative patient, where must the nurse assess for tenting of the skin? Select all that apply 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
SG#2 2. what is the primary purpose of a 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
12. A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first? a. Assess the clients blood pressure. b. Perform hand hygiene and apply gloves. c. Reinforce the dressing with a clean one. d. Remove the dressing to assess the wound.
b. Perform hand hygiene and apply gloves. Prior to assessing or treating the drainage from the wound, the nurse performs hand hygiene and dons gloves to protect both the client and nurse from infection.
1. A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.) a. All phases require the client to be in the hospital. b. Phase I care may last for several days in some clients. c. Phase I requires intensive care unit monitoring. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III.
b. Phase I care may last for several days in some clients. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III. There are three phases of postoperative care. Phase I is the most intense, with clients coming right from surgery until they are completely awake and hemodynamically stable. This may take hours or days and can occur in the intensive care unit or the postoperative care unit. Phase II ends when the client is at a presurgical level of consciousness and baseline oxygen saturation, and vital signs are stable. Phase III involves the extended care environment and may continue at home or in an extended care facility if needed.
SG#38 The postoperative patient has a Penrose drain in place. Which action does the nurse take to prevent skin irritation, would contamination, and infection? a. Keeps a sterile safety pin in place at the end of the drain b. Places absorbent pads and around the exposed drain c. Uses minimal tape; when tape is needed, uses hypoallergenic tape d.shortens the drain by pulling it out a short distance and trimming off the excess external portion
b. Places absorbent pads and around the exposed drain
Which signs/ symptoms are considered postoperative complications? Select all that apply a. Sedation b. Pain at the surgical site c. Pulmonary embolism d. Hypothermia e. Wound evisceration f. Postoperative ilius
c. Pulmonary embolism d. Hypothermia e. Wound evisceration f. Postoperative ilius
SG#36 Which are criteria used by the health care team to determine when a patient is ready to be discharged from the PACU? Select all that apply a. Recovery rating score of 7 to 10 on rating scale b. Stable vitals 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 vitals signs with normal body temperature d. Intact cough and swallow reflexes e. Adequate urine output f. Return of gag reflex
SG#26 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? Select all that apply 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 sounds when breathing d. The patient's blood pressure drops from 120/80 to 110/78 mm Hg e. The patient's respiratory rate is 29/min f. The patient's ruins 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 sounds when breathing e. The patient's respiratory rate is 29/min
SG#8 A patient who is 2 days postoperative for abdominal surgery states, "I coughed and heard something pop." The nurse's immediate assessment reveals an opened incision with a portion of large intestine protruding. Which statements apply to this clinical situation? Select all that Apply a. Incision dehiscence has occurred b. This is an emergency c. The wound must be kept moist with normal saline-soaked sterile dressings 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 dressings e. Incision evisceration has occurred f. A nasogastric (NG) tube may be ordered to decompress the stomach.
SG# 7 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 layers is present at incision site d. The inner and outer layers of the incision are separated.
c. A partial or complete separation of outer layers is present at incision site
5. A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the clients bed. The clients blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Lower the head of the bed. d. Nothing; this is expected.
c. Lower the head of the bed. A client who had epidural or spinal anesthesia may become hypotensive when the head of the bed is raised. If this occurs, the nurse should lower the head of the bed to its original position. The Rapid Response Team is not needed, nor is an increase in IV rate.
SG#11 The nurse transfers a patient to the post anesthesia care unit (PACU) with an incision and drainage of an access in the right groin under general anesthesia. Blood pressure is 80/47 mm Hg, heart rate 117/in in sinus tachycardia, respiratory rate 28/min, pulse oximetry reading 93% on oxygen at 3 L per nasal cannula, and temp 101.3 F (38.5 C). The Jackson-Pratt drawing has 70 mL of a cream-colored output. Normal saline is infusing at 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 included 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 transfere patient to the PACU with an incision and drainage of an access 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 Jackson-Pratt drain c. Blood pressure is 80/47 mm Hg, heart rate 117/min in sinus tachycardia, respirations 28/min, pulse oximetry 93% on O2 at 3 L nasal cannula, and temp 101.3 F (38.5 C); Jackson-Pratt 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 (Zestril) 5 mg. No known drug allergies. Full code.
c. Blood pressure is 80/47 mm Hg, heart rate 117/min in sinus tachycardia, respirations 28/min, pulse oximetry 93% on O2 at 3 L nasal cannula, and temp 101.3 F (38.5 C); Jackson-Pratt drain with 70 mL cream-colored output
SG#24 The post anesthesia 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
2. The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96 F (35.6 C)
c. Client with a respiratory rate of 6 breaths/min The respiratory rate is the most critical vital sign for any client who has undergone general anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low and indicates respiratory depression. The nurse should assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may be within that clients baseline. A pulse of 118 beats/min is slightly fast, which could be due to several causes, including pain and anxiety. A temperature of 96 F is slightly low and the client needs to be warmed. But none of these other vital signs take priority over the respiratory rate.
SG#35 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 this patient? a. Lorazepam b. Naloxone c. Flumazenil d. Butorphanol tartrate
c. Flumazenil
SG#29 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 of flatus or stool d. Presence of abdominal cramping
c. Passing of flatus or stool
14. A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN? a. Cleaning around the drain per agency protocol b. Placing a new sterile gauze under the drain c. Securing the drains safety pin to the sheets d. Using sterile technique to empty the drain
c. Securing the drains safety pin to the sheets The safety pin that prevents the drain from slipping back into the clients body should be pinned to the clients gown, not the bedding. Pinning it to the sheets will cause it to pull out when the client turns. The other actions are appropriate.
SG#32 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 result is expected postoperatively.
c. The patient is developing an infection
SG#20 The health care team determine a patient's readiness for discharge from the post anesthesia care unit (PACU) by noting a post anesthesia recovery score of at least 10. After determining that all 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 expect to be 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. Respiration even, deep, rate of 20. Vital signs (VS) are within normal limits. IV solution is D5RL. Has voided on bedpan. Eating ice chips. Complain 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: temperature 98.6 F (37 C); pulse 130 beats/min; respiratory rate 24/min; blood pressure 124/76 mm Hg 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. Respiration 10 breaths/min. No urge to void. IV of D5RL infusing. Complains of pain in surgical area. 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
SG#3 3. 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 unlicensed assistive personnel (UAP)? a. Assess change in patient's respiratory status. b. Order necessary medications to be administered. c. Intubate the patient for maintenance of airway and assisted breathing. d. Check the patient's vital signs.
d. Check the patient's vital signs.
SG#1 1. 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. Discharge planning initiated in the preoperative setting c. Closure of the patient's surgical incision with sutures d. Completion of the surgical procedure and transfer of the patient to the postnesthesia care unit (PACU)
d. Completion of the surgical procedure and transfer of the patient to the postnesthesia care unit (PACU)
SG#18 A patient arrives at the post anesthesia 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. Monitor the patient for effects of anesthetic for at least 1 hour b. Closely monitor 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.
1. A client has arrived in the postoperative unit. What action by the circulating nurse takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report
d. Participating in hand-off report Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The postoperative nurse and circulating nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the client is warm is a lower priority.
13. A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What should the nurse assess next? a. Cognitive status b. Family stress c. Nutrition status d. Psychosocial status
d. Psychosocial status After ensuring the clients physiologic status is stable, these manifestations should lead the nurse to assess the clients psychosocial status. Anxiety especially can be demonstrated with elevations in vital signs. Cognitive and nutrition status are not related. Family stress is a component of psychosocial status.
11. An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states She needs to get back to her old self! What response by the nurse is best? a. Everyone comes out of surgery differently. b. Lets just give her some more time, okay? c. She may have had a stroke during surgery. d. Sometimes older people take longer to wake up.
d. Sometimes older people take longer to wake up. Due to age-related changes, it may take longer for an older adult to metabolize anesthetic agents and pain medications, making it appear that they are taking too long to wake up and return to their normal baseline cognitive status. The nurse should educate the family on this possibility. While everyone does react differently, this does not give the family any objective information. Saying Lets just give her more time, okay? sounds patronizing and again does not provide information. While an intraoperative stroke is a possibility, the nurse should concentrate on the more common occurrence of older clients taking longer to fully arouse and awake.
SG#22 Which intervention for post surgical care of a patient is correct? a. When position the patient, use the knee catch 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 would for support and comfort when getting out of bed.
d. Teach the patient to splint the surgical would for support and comfort when getting out of bed.
4. Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best? a. Let me call the surgeon to see if you really need them. b. No, you have to use those for 24 hours after surgery. c. OK, we can remove them since you are stable now. d. To prevent blood clots you need them a few more hours.
d. To prevent blood clots you need them a few more hours. According to the Surgical Care Improvement Project (SCIP), any prophylactic measures to prevent thromboembolic events during surgery are continued for 24 hours afterward. The nurse should explain this to the client. Calling the surgeon is not warranted. Simply telling the client he or she has to wear the hose and compression devices does not educate the client. The nurse should not remove the devices.
10. A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important? a. Be sure you keep all your postoperative appointments. b. Call your surgeon if you have any questions at home. c. Eat a diet high in protein, iron, zinc, and vitamin C. d. Wash your hands before touching the drain or dressing.
d. Wash your hands before touching the drain or dressing. All options are appropriate for the client being discharged after surgery. However, for this client who is changing a dressing and managing a drain, infection control is the priority. The nurse should instruct the client to wash hands often, including before and after touching the dressing or drain.
