Lewis Ch20 - postoperative care

B

A 70-kg postoperative patient has an average urine output of 25ml?hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to: A. place in indwelling urinary catheter and assess urine characteristics B. evaluate the patient's fluid volume status and obtain a bladder ultrasound C. notify the physician and anticipate the patient returning to the operating room D. continue to monitor the patient as this is a normal, expected finding after surgery

B

A patient is admitted to the PACU following major abdominal surgery. During the initial assessment, the patient tells the nurse that he thinks he is going to "throw up". A priority nursing intervention would be to: A. obtain vital signs, including O2 saturation B. position the patient in a lateral recovery position C. administer antiemetic medications as ordered D. apply intermittent compression devices (ICDs)

B, C, D

Discharge criteria for the phase II patient includes (select all that apply): A. ability to drive self home B. no respiratory depression C. minimal nausea and vomiting D. written discharge instruction

C

During the patient's admission to the PACU, what are the primary interventions the nurse performs? A. assess the surgical site, noting the presence and character of drainage B. assess the amount of urinary output and the presence of bladder distention C. assess the airway for patency and quality of respirations and obtain vital signs D. review the results of intraoperative laboratory values and medications received

A

Following admission of a postoperative patient to the clinical unit, which of the following assessment data requires the most immediate attention? A. oxygen saturation of 85% B. respiratory rate of 13/min C. temperature of 100.4*F (38*C) D. blood pressure of 90/60mmHg