Chapter 19: Postoperative Care

With what are the postoperative respiratory complications of atelectasis and aspiration of gastric contents associated? a. Hypoxemia b. Hypercapnia c. Hypoventilation d. Airway obstruction

a. Hypoxemia

A patient's blood pressure in the postanesthesia care unit (PACU) has dropped from an admission blood pressure of 140/86 to 102/60 mm Hg with a pulse change of 70 to 96 beats/min. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions? a. Increase the IV infusion rate. b. Assess the patient's dressing. c. Increase the oxygen flowrate. d. Check the patient's temperature.

A, C, B, D

While ambulating in the room, a patient reports feeling dizzy. In what order will the nurse accomplish the following activities? (Put a comma and a space between each answer choice [A, B, C, D].) a. Have the patient sit down in a chair. b. Give the patient something to drink. c. Take the patient's blood pressure (BP). d. Inform the patient's health care provider.

A, C, B, D

A patient who had knee surgery received IV ketorolac 30 minutes ago and continues to report pain at a level of 7 (0 to 10 scale). Which action is most effective for the nurse to take at this time? a. Administer the prescribed PRN IV morphine sulfate. b. Notify the health care provider about the ongoing pain. c. Teach the patient that effects of ketorolac last 6 to 8 hours. d. Reassure the patient that pain is expected after knee surgery.

a. Administer the prescribed PRN IV morphine sulfate.

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help to transport a patient to the clinical unit? a. Help to transfer the patient onto a stretcher. b. Clarify postoperative orders with the surgeon. c. Document the appearance of the patient's incision in the chart. d. Provide hand-off communication to the surgical unit charge nurse.

a. Help to transfer the patient onto a stretcher.

After receiving change-of-shift report about these postoperative patients, which patient should the nurse assess first? a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating. b. Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement surgery. c. Patient who has bibasilar crackles and a temperature of 100° F (37.8 °C) on the first postoperative day after chest surgery. d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) was given.

a. Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating.

A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first? a. Perform a bladder scan. b. Insert a straight catheter. c. Encourage increased oral fluid intake. d. Assist the patient to ambulate to the bathroom.

a. Perform a bladder scan.

Priority Decision: The nurse notes drainage on the surgical dressing when the patient is transferred from the PACU to the clinical unit. In what order of priority should the nurse perform the following actions? Number the options with 1 for the first action and 5 for the last action. a. Reinforce the surgical dressing. b. Change the dressing and assess the wound as ordered. c. Notify the surgeon of excessive drainage type and amount. d. Recall the report from PACU for the number and type of drains in use. e. Note and record the type, amount, and color and odor of the drainage.

a. 2; b. 5; c. 4; d. 1; e. 3

What does progression of patients through various phases of care in a postanesthesia care unit (PACU) primarily depend on? a. Condition of patient b. Type of anesthesia used c. Preference of surgeon d. Type of surgical procedure

a. Condition of patient

Priority Decision: A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess the patient for first? a. Hypoxemia b. Neurologic injury c. Distended bladder d. Cardiac dysrhythmias

a. Hypoxemia

After admitting a postoperative patient to the clinical unit, which assessment data require the most immediate attention? a. O2 saturation of 85% b. Respiratory rate of 13/min c. Temperature of 100.4°F (38°C) d. Blood pressure of 90/60 mm Hg

a. O2 saturation of 85%

The PACU nurse applies warm blankets to a postoperative patient who is shivering and has a body temperature of 96.0° F (35.6° C). What treatment may also be used to treat the patient? a. Oxygen therapy b. Vasodilating drugs c. Antidysrhythmic drugs d. Analgesics or sedatives

a. Oxygen therapy

Which action by the nurse will be most helpful to a patient who is expected to ambulate, deep breathe, and cough on the first postoperative day? a. Schedule the activity to begin after the patient has taken a nap. b. Administer prescribed analgesic medications before the activities. c. Ask the patient to state two possible complications of immobility. d. Encourage the patient to discuss the purpose of splinting the incision.

b. Administer prescribed analgesic medications before the activities.

Which finding would indicate to the nurse that a postoperative patient is at increased risk for poor wound healing? a. Potassium 3.5 mEq/L b. Albumin level 2.2 g/dL c. Hemoglobin 10.2 g/dL d. White blood cells 11,900/µL

b. Albumin level 2.2 g/dL

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%, and recent laboratory results are all normal. Which action by the nurse is most appropriate? a. Increase the IV fluid rate. b. Assess for bladder distention. c. Notify the anesthesia care provider (ACP). d. Demonstrate the use of the nurse call bell button.

b. Assess for bladder distention.

On the second postoperative day, the patient's nasogastric (NG) tube is removed and the patient begins drinking clear liquids. Four hours later, the patient reports frequent, cramping gas pains. What action by the nurse is the most appropriate? a. Reinsert the NG tube. b. Assist the patient to ambulate. c. Place the patient on NPO status. d. Give the prescribed PRN IV opioid.

b. Assist the patient to ambulate.

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? a. Administer the prescribed opioid. b. Check the oxygen (O2) saturation. c. Take the blood pressure and pulse. d. Apply wrist restraints to secure IV lines.

b. Check the oxygen (O2) saturation.

A patient who has just been transported from the operating room to the postanesthesia care unit (PACU) is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take next? a. Notify the anesthesia care provider. b. Cover the patient with a warm blanket. c. Hold opioid analgesics until the patient is warmer. d. Give acetaminophen 650 mg suppository rectally.

b. Cover the patient with a warm blanket.

An older adult patient is being discharged from the ambulatory surgical unit after left eye surgery. The patient tells the nurse, "I don't know if I can take care of myself once I'm home." Which action by the nurse is most appropriate to implement first? a. Assess the patient's home support system. b. Discuss patient concerns regarding self-care. c. Refer the patient for home health care services. d. Provide written instructions for the patient's care.

b. Discuss patient concerns regarding self-care.

In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72 mm Hg, pulse 74 beats/min, respirations 12 breaths/min, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take first? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient to a clinical unit. d. Increase the rate of the postoperative IV fluids.

b. Encourage the patient to take deep breaths.

On the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, a patient has an oral temperature of 100.8° F (38.2° C). Which action should the nurse take next? a. Place ice packs in the patient's axillae. b. Have the patient use the incentive spirometer. c. Request a prescription for acetaminophen suppositories. d. Ask the health care provider to change the antibiotic prescription.

b. Have the patient use the incentive spirometer.

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider? a. The patient's temperature is 100.3° F (37.9° C). b. The patient's calf is swollen and warm to touch. c. The patient reports abdominal pain when ambulating. d. The patient has fluid intake 600 mL greater than the output.

b. The patient's calf is swollen and warm to touch.

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which potential complication should the nurse identify as a priority for this patient? a. Hypovolemic shock b. Venous thromboembolism c. Fluid and electrolyte imbalance d. Impaired surgical wound healing

b. Venous thromboembolism

Which patient is ready for discharge from Phase I PACU care to the clinical unit? a. Arouses easily, pulse is 112 bpm, respiratory rate is 24 breaths/min, dressing is saturated, arterial oxygen saturation by pulse oximetry (SpO2) is 88% b. Awake, vital signs stable, dressing is dry and intact, no respiratory depression, SpO2 is 92% c. Difficult to arouse, pulse is 52 bpm, respiratory rate is 22 breaths/min, dressing is dry and intact, SpO2 is 91% d. Arouses, BP higher than preoperative and respiratory rate is 10 breaths/min, no excess bleeding, SpO2 is 92%

b. Awake, vital signs stable, dressing is dry and intact, no respiratory depression, SpO2 is 92%

What is included in the routine assessment of the patient's cardiovascular function on admission to the PACU? a. Monitoring arterial blood gases b. Electrocardiographic (ECG) monitoring c. Determining fluid and electrolyte status d. Direct arterial blood pressure monitoring

b. Electrocardiographic (ECG) monitoring

To prevent agitation during the patient's recovery from anesthesia, when should the nurse begin orientation explanations? a. When the patient is awake b. When the patient first arrives in the PACU c. When the patient becomes agitated or frightened d. When the patient can be aroused and recognizes where he or she is

b. When the patient first arrives in the PACU

A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate? a. Increase the postoperative IV fluid rate. b. Notify the anesthesia care provider (ACP). c. Continue to take vital signs every 15 minutes. d. Administer oxygen therapy at 100% per mask.

c. Continue to take vital signs every 15 minutes.

A postoperative patient has ineffective airway clearance. Which data would indicate to the nurse that interventions for this patient problem have been successful? a. Patient drinks 2 to 3 L of fluid in 24 hours. b. Patient uses the spirometer 10 times every hour. c. Patient's breath sounds are clear to auscultation. d. Patient's temperature is less than 100.2° F orally.

c. Patient's breath sounds are clear to auscultation.

An unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action should the nurse take first? a. Suction the patient's mouth. b. Increase the oxygen flowrate. c. Perform the jaw-thrust maneuver. d. Elevate the patient's head on two pillows.

c. Perform the jaw-thrust maneuver.

A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first? a. Assess the patient's pain. b. Orient the patient to the unit. c. Take the patient's vital signs. d. Read the postoperative orders.

c. Take the patient's vital signs.

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first? a. Reinforce the dressing. b. Apply an abdominal binder. c. Take the patient's vital signs. d. Plan to recheck the dressing in 1 hour.

c. Take the patient's vital signs.

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful? a. The new nurse assists a nauseated patient to a supine position. b. The new nurse places a sleeping patient supine with the head elevated. c. The new nurse positions an unconscious patient on the side upon arrival in the PACU. d. The new nurse places a patient in the Trendelenburg position for a low blood pressure.

c. The new nurse positions an unconscious patient on the side upon arrival in the PACU.

While assessing a patient in the PACU, the nurse finds that the patient's blood pressure (BP) is below the preoperative baseline. The nurse determines that the patient has residual vasodilating effects of anesthesia when what is assessed? a. A urinary output > 30 mL/hr b. An oxygen saturation of 88% c. A normal pulse with warm, dry, pink skin d. A narrowing pulse pressure with normal pulse

c. A normal pulse with warm, dry, pink skin

How is the initial information given to the PACU nurses about the surgical patient? a. A copy of the written operative report b. A verbal report from the circulating nurse c. A verbal report from the anesthesia care provider (ACP) d. An explanation of the surgical procedure from the surgeon

c. A verbal report from the anesthesia care provider (ACP)

What are the priority interventions the nurse performs when admitting a patient to the PACU? a. Assess 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.

c. Assess for airway patency and quality of respirations and obtain vital signs.

A patient who had major surgery is experiencing emotional stress as well as physiologic stress from the effects of surgery. What can this stress cause? a. Diuresis b. Hyperkalemia c. Fluid retention d. Impaired blood coagulation

c. Fluid retention

For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation been found to be an appropriate intervention (select all that apply)? a. Surgical wound; Etiology: incision b. Risk for aspiration; Etiology: decreased level of consciousness c. Impaired physical mobility; Etiology: decreased muscle strength d. Impaired airway clearance; Etiology: decreased respiratory excursion e. Constipation; Etiology: decreased physical activity and impaired gastrointestinal (GI) motility f. Risk for ineffective tissue perfusion; Etiology: venous thromboembolism; Supporting data: dehydration, immobility, vascular manipulation, or injury

c. Impaired physical mobility; Etiology: decreased muscle strength d. Impaired airway clearance; Etiology: decreased respiratory excursion e. Constipation; Etiology: decreased physical activity and impaired gastrointestinal (GI) motility f. Risk for ineffective tissue perfusion; Etiology: venous thromboembolism; Supporting data: dehydration, immobility, vascular manipulation, or injury

Which tubes drain gastric contents (select all that apply)? a. T-tube b. Penrose c. Nasogastric tube d. Indwelling catheter e. GI tube

c. Nasogastric tube e. GI tube

Priority Decision: To promote effective coughing, deep breathing, and ambulation in the postoperative patient, what is most important for the nurse to do? a. Teach the patient controlled breathing. b. Explain the rationale for these activities. c. Provide adequate and regular pain medication. d. Use an incentive spirometer to motivate the patient.

c. Provide adequate and regular pain medication.

In addition to ambulation, which nursing intervention could be implemented to prevent or treat the postoperative complication of syncope? a. Monitor vital signs after ambulation. b. Do not allow the patient to eat before ambulation. c. Slowly progress to ambulation with slow changes in position. d. Have the patient deep breathe and cough before getting out of bed.

c. Slowly progress to ambulation with slow changes in position.

What should be included in the instructions given to the postoperative patient before discharge? a. Need for follow-up care with home care nurses b. Directions for maintaining routine postoperative diet c. Written information about self-care during recuperation d. Need to restrict all activity until surgical healing is complete

c. Written information about self-care during recuperation

Discharge criteria for the Phase II patient include (select all that apply) a. no nausea or vomiting. b. ability to drive self home. c. no respiratory depression. d. written discharge instructions understood. e. opioid pain medication given 45 minutes ago.

c. no respiratory depression. d. written discharge instructions understood. e. opioid pain medication given 45 minutes ago.

Priority Decision: Upon admission of a patient to the PACU, the nurse's priority assessment is a. vital signs. b. surgical site. c. respiratory adequacy. d. level of consciousness.

c. respiratory adequacy.

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for the nurse to report to the surgeon? a. Tympanic temperature 99.2° F (37.3° C) b. Fine crackles audible at both lung bases c. Redness and swelling along the suture line d. 200 mL sanguineous fluid in the wound drain

d. 200 mL sanguineous fluid in the wound drain

A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate? a. Notify the patient's surgeon. b. Place the patient on bed rest. c. Irrigate the T-tube with sterile saline. d. Document the drainage characteristics.

d. Document the drainage characteristics.

The health care provider has ordered IV morphine q2-4hr as needed for a patient following major abdominal surgery. When should the nurse plan to administer the morphine? a. Before all planned painful activities b. Every 2 to 4 hours during the first 48 hours c. Every 4 hours as the patient requests the medication d. After assessing the nature and intensity of the patient's pain

d. After assessing the nature and intensity of the patient's pain

Thirty-six hours postoperatively, a patient has a temperature of 100° F (37.8° C). What is the most likely cause of this temperature elevation? a. Dehydration b. Wound infection c. Lung congestion and atelectasis d. Normal surgical stress response

d. Normal surgical stress response

To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, what will the nurse do? a. Encourage deep breathing. b. Elevate the head of the bed. c. Administer oxygen per mask. d. Position the patient in a side-lying position.

d. Position the patient in a side-lying position.

Which drainage is drained with a Hemovac? a. Bile b. Urine c. Gastric contents d. Wound drainage

d. Wound drainage

A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to a. notify the surgeon and expect obtaining blood work to evaluate renal function. b. perform a straight catheterization to measure the amount of urine in the bladder. 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.

d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound.

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 is to a. increase the rate of the IV fluids. b. give antiemetic medication as ordered. c. obtain vital signs, including O2 saturation. d. position patient in lateral recovery position.

d. position patient in lateral recovery position.