Perioperative

Which is the most common dietary order the nurse can anticipate after a patient who had abdominal surgery exhibits a return of intestinal peristalsis? 1. Clear liquids 2. Full liquids 3. Low fiber 4. Regular

1. Clear liquids

A nurse is assessing a patient who had spinal anesthesia. For which common response should the nurse assess the patient? 1. Headache 2. Neuropathy 3. Lower back discomfort 4. Increased blood pressure

1. Headache

Which patient having emergency surgery should the nurse anticipate to be at the greatest risk for postoperative mortality? 1. Individual who has alcoholism 2. Person who has epilepsy 3. Middle-aged adult 4. Infant

1. Individual who has alcoholism

Which factor places a patient at the greatest risk for postoperative nausea and vomiting after receiving general anesthesia? 1. Obesity 2. Inactivity 3. Hypervolemia 4. Unconsciousness

1. Obesity

A postoperative patient experiences tachycardia, sudden chest pain, and low blood pressure. Which complication associated with the postoperative period should the nurse conclude that the patient most likely experienced? 1. Pulmonary embolus 2. Hemorrhage 3. Heart attack 4. Pneumonia

1. Pulmonary embolus

Which patient responses best support the decision to discharge the patient from the postanesthesia care unit? 1. Sa o 2 of 95%, vital signs stable for 30 minutes, active gag reflex 2. Tolerable pain, ability to move extremities, dry intact dressing 3. Urinary output of 30 mL/hr, awake, turning from side to side 4. Afebrile, adventitious breath sounds, ability to cough

1. Sa o 2 of 95%, vital signs stable for 30 minutes, active gag reflex

On the second postoperative day after an above-the-knee amputation, the patient's elastic dressing accidentally comes off. Which should the nurse do fi rst ? 1. Wrap the residual limb with an elastic compression bandage. 2. Apply a saline dressing to the residual limb. 3. Notify the primary health-care provider. 4. Place two pillows under the limb.

1. Wrap the residual limb with an elastic compression bandage.

A nurse is instructing an AP about caring for a patient who has low platelet count. which one of the following is priority for measuring vital signs for the patient? 1. dont take rectal tempurature 2. count the patients radial pulse then multiply by 2 3. do not let the client know your count their respirations 4. let the patient rest for 5 mins before taking their vitals.

1. dont take rectal tempurature

A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3° C (101° F), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply.) 1. obtain culture specimen before initaiting antimicrobials 2. restrict the clients oral fluid intake 3. encourage patient to rest and limit activity 4. allow client to shiver to dispeal excess heat. 5. assist the client with oral hygiene frequently.

1. obtain culture specimen before initaiting antimicrobials 3. encourage patient to rest and limit activity 5. assist the client with oral hygiene frequently.

A nurse compares the advantages and disadvantages of a central venous catheter inserted into a peripheral vein and a central venous catheter inserted into a subclavian vein. Which of the following reasons does the nurse conclude is the reason why a peripheral catheter is more desirable? 1. Because it will not be in the superior vena cava 2. Because it will not cause a tension pneumothorax 3. Because it will not prevent the development of an infection 4. Because it will not allow large volumes of fluid to be administered

2. Because it will not cause a tension pneumothorax

A postoperative patient is transferred back to the surgical unit with an abdominal dressing and a Penrose drain. Which is the most important nursing action associated with caring for a patient with a Penrose drain? 1. Removing the excess external portion until drainage stops 2. Changing the soiled dressing carefully 3. Maintaining the negative pressure 4. Pinning the drain to the dressing

2. Changing the soiled dressing carefully

There are discharge criteria for patients in the postanesthesia care unit (PACU) regardless of the type of anesthesia used and additional criteria for specifi c types of anesthesia. Which is the criterion specific for the patient who has received spinal anesthesia? 1. Oxygen saturation reaches the presurgical baseline. 2. Motor and sensory function returns. 3. Nausea and vomiting are minimal. 4. Headache is reported as tolerable.

2. Motor and sensory function returns.

How many days after surgery should the nurse anticipate that a postoperative patient will begin to exhibit signs and symptoms of a wound infection if it should occur? 1. Fifth day 2. Third day 3. Ninth day 4. Seventh day

2. Third day

A patient arrives in the postanesthesia care unit. Which is the most important information that the nurse needs to know? 1. Anxiety level before surgery 2. Type and extent of the surgery 3. Type of intravenous fluids administered 4. Special requests that were verbalized by the patient

2. Type and extent of the surgery

a nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mm Hg, and the client denies any history of hypertension. Which of the following actions should the nurse take first? 1. request a perscription for antihypersensative medication 2. ask the client if their having pain 3. request a perscription for antianxiety medication 4. come back in 30 mins to take patients vitals

2. ask the client if their having pain

A nurse is caring for a postoperative patient. Which action is effective in preventing postoperative urinary tract infections? 1. Eating foods with roughage 2. Taking sitz baths twice a day 3. Drinking an adequate amount of fluid 4. Increasing the intake of citrus fruit juices

3. Drinking an adequate amount of fluid

A nurse is caring for a patient who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombophlebitis? 1. Utilization of compression stockings at night 2. Deep breathing and coughing exercises daily 3. Leg exercises 10 times per hour when awake 4. Elevation of the legs on 2 pillows

3. Leg exercises 10 times per hour when awake

A patient received conscious sedation during a colonoscopy. Which should the nurse expect regarding the patient's experience with this procedure? 1. Patient will be unresponsive and pain free. 2. Patient will be at risk for malignant hyperthermia. 3. Patient will be sleepy but able to follow verbal commands. 4. Patient will be positioned in the supine position to prevent headache.

3. Patient will be sleepy but able to follow verbal commands.

Four days after abdominal surgery, while being transferred from a bed to a chair, a patient says to a nurse, "My incision feels funny all of a sudden." Which should the nurse do fi rst ? 1. Take the vital signs. 2. Apply an abdominal binder immediately. 3. Place the patient in the low-Fowler position. 4. Encourage slow deep breathing by the patient.

3. Place the patient in the low-Fowler position.

A patient has abdominal surgery for removal of the gallbladder. Which should the nurse be most concerned about if exhibited by the patient? 1. Constipation 2. Urinary retention 3. Shallow breathing 4. Inability to provide self-care

3. Shallow breathing

A patient has abdominal surgery. Which should the nurse do to best assess for a sign of postoperative ileus in this patient after surgery? 1. Identify the time of the fi rst bowel movement. 2. Monitor the tolerance of a clear liquid diet. 3. Palpate for abdominal distention. 4. Auscultate for bowel sounds.

4. Auscultate for bowel sounds.

A hospitalized patient who has been receiving medications via a variety of routes for several days is scheduled for surgery at 10 a.m. Which should the nurse plan to do on the day of surgery? 1. Use an alternative route for the oral medications. 2. Withhold all the previously prescribed medications. 3. Withhold the oral medications and administer the other drugs. 4. Obtain directions from the primary health-care provider regarding the medications.

4. Obtain directions from the primary health-care provider regarding the medications.

A patient is admitted to the postanesthesia care unit. Which nursing action is most important during the patient's stay in this unit? 1. Monitoring urinary output 2. Assessing level of consciousness 3. Ensuring patency of drainage tubes 4. Suctioning mucus from respiratory passages

4. Suctioning mucus from respiratory passages