SPC Level 2 Exam 1- Postoperative Care Adaptive Quiz

Which finding would the nurse expect to assess in a postoperative patient with acute pulmonary edema? -Bradypnea -Rhonchi -Oxygen saturation 89% -Dry, hacking cough

-Oxygen saturation 89% The patient experiencing acute pulmonary edema would most likely have a decreased oxygen saturation, such as 89%. The patient would have shortness of breath with tachypnea, not bradypnea. Auscultation of lungs would reveal crackles due to fluid overload, not rhonchi. The cough associated with pulmonary edema will be moist and productive; in severe cases, this may present as pink and frothy sputum.

Which priority action would the nurse on the clinical unit take when receiving a patient transferred from the postanesthesia care unit (PACU)? -Assess the patient's pain. -Take the patient's vital signs. -Check the rate of the IV infusion. -Check the health care provider's postoperative prescriptions.

-Take the patient's vital signs. The priority action by the nurse is to assess the physiologic stability of the patient. This is in part accomplished by taking the patient's vital signs. Assessing the patient's pain, checking the prescriptions, and checking the rate of IV infusion can take place in a rapid sequence after taking the vital signs.

Which assessment finding in a patient who has just been admitted to the postanesthesia care unit (PACU) requires the nurse's immediate action? -The patient is groggy but arouses to voice. -The patient indicates that he or she is in pain. -The patient is restless, agitated, and hypotensive. -The Jackson-Pratt is draining serosanguinous fluid.

-The patient is restless, agitated, and hypotensive. Assessment in the PACU begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Restlessness, agitation, and hypotension are clinical manifestations of inadequate oxygenation. Identification of inadequate oxygenation and ventilation or respiratory compromise requires prompt intervention. Pain, sedation, and draining serosanguinous fluid are expected findings.

A postoperative patient who is an alcoholic is restless, irritable, and having auditory hallucinations Which statement is accurate regarding this patient? -These effects are due to alcohol withdrawal. -The situation is normal, due to the anesthetic drugs. -The patient is suffering from a psychotic disorder. -The patient is suffering from pain and needs an analgesic.

-These effects are due to alcohol withdrawal. The patient is irritable and restless due to loss of the inhibitory effects of alcohol; this is also causing the hallucinations. The patient is not stated to have a history of psychotic illness; therefore the symptoms cannot be attributed to a psychotic disorder. Anesthetic drugs may cause delirium, but not hallucinations. Pain may cause restlessness and irritability but not hallucinations.

A nurse is caring for an older adult patient who had a knee replacement the previous day and denies any pain. Which response by the nurse would be most appropriate? -"Excellent. You must be able to handle a lot of pain." -"Great. It is wise to only take the pain medication if you need it." -"It is important that you take pain medication. It will help you recover more quickly." -"Almost everyone has pain after this surgery. Are you certain that you are not experiencing pain?"

-"Almost everyone has pain after this surgery. Are you certain that you are not experiencing pain?" Thoroughly assessing the presence of pain is imperative, especially for those who deny any pain after surgery, especially the elderly. Gerontology patients may hesitate about reporting pain because of the belief that pain should be tolerated and is inevitable postsurgery. It is not appropriate to compliment the patient on being able to handle pain. The patient will not develop an addiction to pain medication, so it is not appropriate to tell the patient he or she should only take it when necessary. The nurse should not tell the patient that pain medication will help him or her recover quicker, because that could give the patient false reassurance.

Which explanation would the nurse give to a postoperative patient who is reluctant to get up and walk? -"Early walking keeps your legs limber and strong." -"Early ambulation will help you be ready to go home." -"Early ambulation will help you get rid of your syncope and pain." -"Early walking is the best way to prevent postoperative complications."

-"Early walking is the best way to prevent postoperative complications." The best rationale is that early ambulation will prevent postoperative complications that then can be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and venous thromboembolism (VTE), speeds wound healing, increases vital capacity, and maintains normal respiratory function. These things help the patient to be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management always should occur before walking.

A patient is admitted to the postanesthesia care unit (PACU) after bowel surgery and tells the nurse that he or she is going to "throw up." Which statement by the nurse reflects a priority nursing intervention? -"I need to check your vital signs." -"Let me help you turn to your side." -"Here is a sip of ginger ale for you." -"I can give you some anti-nausea medicine."

-"Let me help you turn to your side." If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs. Checking vital signs does not address the nausea. It may not be appropriate to give the patient oral fluids immediately following bowel surgery. Administering an antiemetic may be appropriate after turning the patient to the side.

Which postoperative patient is at the greatest risk for development of atelectasis? -A patient after a hypoxic episode during an acute asthma attack -An older adult patient who has undergone cardiothoracic surgery -A patient not adherent with the pulmonary regimen after surgery -A patient experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD)

-A patient not adherent with the pulmonary regimen after surgery Atelectasis is a common postoperative complication that is prevented by a pulmonary regimen of interventions such as deep breathing, coughing, turning, and using an incentive spirometer. Patients who have received general anesthesia and are noncompliant with a pulmonary regimen are at highest risk for atelectasis. Patients who have experienced a hypoxic episode during an acute asthma attack or with an acute exacerbation of chronic obstructive pulmonary disease are at lower risk for atelectasis than are postoperative patients. Postoperative older adults who have had cardiothoracic surgery are also at risk for atelectasis if they do not adhere to a pulmonary regimen.

The nurse in the postanesthesia care unit (PACU) assesses a patient with a history of asthma and finds the patient tachypneic, wheezing, and with reduced oxygen saturation. Which action will the nurse take to prevent further pulmonary complications? -Administer bronchodilators. -Provide incentive spirometry. -Encourage chest physical therapy. -Provide nebulization of histamine vapors.

-Administer bronchodilators. The presence of wheeze, tachypnea, and reduced oxygen saturation indicates bronchospasm. The use of bronchodilators relieves bronchospasm and promotes a patent airway. Incentive spirometry is useful in managing atelectasis when the airway is patent. Chest physical therapy is helpful to clear secretions from the respiratory tract. Histamine vapors aggravate bronchospasm and therefore should be avoided.

A patient on the postoperative unit reports difficulty breathing. The nurse discovers that the patient received large doses of benzodiazepines during surgery. Which action would the nurse include in the patient's plan of care to promote breathing? -Administer opioids -Loosen the dressings -Reposition the patient -Administer drugs for reversal of benzodiazepines

-Administer drugs for reversal of benzodiazepines The use of benzodiazepines may depress the muscles required for breathing. Administering drugs for reversal of this may make breathing easier. Use of opioids aggravates the condition by causing respiratory depression. Loosening the dressing and repositioning the patient are helpful when the breathing difficulty is caused by mechanical restriction but may not help in this case.

Which actions would the nurse take for a postoperative patient who has an oxygen saturation of 85% and decreased breath sounds? Select all that apply. -Restrict intake of fluid. -Administer humidified oxygen therapy. -Administer diuretics as advised. -Encourage deep-breathing exercises. -Assist the patient to walk around, if tolerated.

-Administer humidified oxygen therapy. -Encourage deep-breathing exercises. -Assist the patient to walk around, if tolerated. Low oxygen saturation and decreased breath sounds may indicate atelectasis. Therefore the nurse should administer humidified oxygen therapy and encourage deep-breathing exercises. Deep breathing and coughing techniques help prevent alveolar collapse and move respiratory secretions to larger airway passages for expectoration. Assisting the patient to walk around will also help, because lying down will only settle secretions into the respiratory system. Fluid restriction and diuretics may not be required; these are therapies best used for pulmonary edema (PE).

A postoperative patient develops laryngeal edema after receiving a penicillin injection. Which treatments would be implemented to prevent further complications in the patient? Select all that apply. -Suctioning the airway -Administration of sedatives -Administration of antihistamines -Administration of corticosteroids -Chest physical therapy

-Administration of sedatives -Administration of antihistamines -Administration of corticosteroids The patient's laryngeal edema is caused by an anaphylactic reaction to the penicillin injection. Sedatives reduce the emotional disturbance and calm down the patient. Antihistamines and corticosteroids help reduce the allergic manifestation and the laryngeal edema. Suctioning helps in cases of increased secretions in the airways, not laryngeal edema. Chest physical therapy is helpful to drain the secretions in the airway, not with laryngeal edema.

Which factors contribute to a patient's risk for constipation postoperatively? Select all that apply. -Anesthesia -Opioid analgesics -IV fluids -Decreased mobility -Diminished peristalsis

-Anesthesia -Opioid analgesics -Decreased mobility -Diminished peristalsis Causes of constipation in a patient who underwent surgery would be the anesthesia, opioid analgesics, decreased mobility, and diminished peristalsis. IV fluids could cause fluid volume excess.

A patient in the postanesthesia care unit (PACU) becomes delirious and restless and shouts at the nurse about pain. Which factor would the nurse consider may be a cause of this behavior? -A new diagnosis of psychosis -Decreased ability to tolerate pain -Anesthetic agents used in surgery -Overdose of analgesics

-Anesthetic agents used in surgery Anesthetic agents used in surgery can cause short-term psychotic-type behaviors that are relieved after the anesthetic drugs have cleared the body. A new diagnosis of psychosis is not warranted in the acute phase following surgery. The patient may not be tolerating the pain, but the delirium, yelling, and restlessness denote short-term psychotic-like behavior caused by the anesthetic agents and postoperative pain. An overdose of pain medications would present as increased sedation and decreased respiratory rate.

Which nursing intervention is the highest priority for a patient just transferred to the postanesthesia care unit (PACU) after surgery? -Assess intake, output, and fluid balance. -Assess airway, breathing, and circulation status. -Assess the surgical site and condition of the dressing. -Note the presence of all IV lines and drainage catheters.

-Assess airway, breathing, and circulation status. When the patient is shifted to the PACU after surgery, the nurse should first assess the patient's airway, breathing, and circulation status. Any evidence of respiratory or circulatory compromise needs immediate intervention. Thereafter, the nurse may assess the patient's intake, output, and fluid status and note the presence of IV lines and drainage bags. The nurse should also assess the surgical site and condition of the wound.

In caring for the postoperative patient on the clinical unit after transfer from the postanesthesia care unit (PACU), which care can be delegated to the unlicensed assistive personnel (UAP)? -Monitor the patient's pain. -Increase oxygen if needed. -Assist the patient to take deep breaths and cough. -Reinforce the dressing when there is excess drainage.

-Assist the patient to take deep breaths and cough. The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The registered nurse (RN) would titrate oxygen, not the UAP. The licensed practical nurse (LPN) or RN will monitor and treat the patient's pain and change the dressings.

Which condition is the most likely reason for a patient having a partial pressure of arterial oxygen (PaO2) less than 60 mm Hg after surgery? -Atelectasis -Bronchospasm -Pulmonary edema -Pulmonary embolism

-Atelectasis Atelectasis, partial collapse of the small airways, is the most common cause of hypoxemia after surgery and results from alveolar collapse, bronchial obstruction caused by retained secretions, decreased respiratory excursion, or general anesthesia. Bronchospasm, pulmonary edema, and pulmonary embolism are all causes of hypoxemia, but not as common as atelectasis.

A postoperative patient with bronchial obstruction has a pulse oximetry reading of 87%. Which complication would the nurse suspect is occurring with this patient? -Atelectasis -Bronchospasm -Hypoventilation -Pulmonary embolism

-Atelectasis The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.

Which occurrence might cause secondary heart dysfunction? -Cardiac tamponade -Certain medications -Pulmonary embolism -Myocardial infarction

-Certain medications Certain medications, including β-adrenergic blockers, digoxin, or opioids, can cause secondary heart dysfunction. Cardiac tamponade, pulmonary embolism, and myocardial infarction are causes of primary heart dysfunction.

Which action would the nurse take first for a patient is admitted to the postanesthesia care unit (PACU) with a BP of 100/60 mm Hg? -Rouse the patient. -Assess the patient's pulse and skin color. -Notify the anesthesiologist of the low BP. -Check the medical record for the patient's baseline BP. -Check the medical record for the patient's baseline BP.

-Check the medical record for the patient's baseline BP. The first action of the nurse is to identify what the patient's normal BP is. Interventions are dependent on the baseline variation. Rousing the patient is an intervention that can increase the BP, but would be done after determining the baseline BP. Hypotension accompanied by a normal pulse and warm, dry skin is usually from the residual vasodilating effects of anesthesia and suggests only a need for continued observation, but assessing the pulse and skin would not be done first. Before notifying the anesthesiologist of the BP, the nurse needs to check the baseline BP.

An older adult patient who had surgery is displaying manifestations of delirium. Which action would the nurse take first to provide the best care for this patient? -Check the chart for intraoperative complications. -Check the effectiveness of the analgesics received. -Check which medications were used for anesthesia. -Check the preoperative assessment for previous delirium or dementia.

-Check the preoperative assessment for previous delirium or dementia. If the patient's airway, breathing, and circulation are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed, because these can all contribute to delirium.

For which type of infection would a postoperative patient who developed a fever, abdominal pain, and diarrhea despite being on long-term antibiotics be evaluated? -Wound infection -Urinary infection -Respiratory infection -Clostridium difficile infection

-Clostridium difficile infection Prolonged use of antibiotics increases the risk of Clostridium difficile infection by damaging the normal flora of the intestine. The infection is manifested as fever, diarrhea, and abdominal pain. Wound infection, urinary infection, and respiratory infection may present with fever, but these infections rarely present with diarrhea and abdominal pain.

Which clinical manifestation of pulmonary edema secondary to heart failure would the nurse assess in a postoperative patient? -Early-morning cough -Increased urine output -Inspiratory stridor -Crackles heard on auscultation

-Crackles heard on auscultation The most common cause of pulmonary edema is left-sided congestive heart failure, which commonly manifests as shortness of breath and crackles in the lungs. An early-morning cough may be seen with respiratory infection or chronic obstructive pulmonary disease but is not usually a symptom of pulmonary edema. In pulmonary edema, urine output is typically decreased due to fluid retention. Inspiratory stridor is typically due to laryngospasm.

An older adult patient has a complication after a cardiac catheterization and has to remain in the postanesthesia care unit (PACU) for several days. Which complication is the patient most at risk for? -Delirium -Depression -Alcohol withdrawal -Aggressive behaviors

-Delirium Older adult patients who spend prolonged amounts of time in the PACU are at risk for delayed emergence, a type of delirium caused by spending a longer amount of time in an ICU-like environment. Aggressive behaviors and depression can also be part of delayed emergence, but this disorder is most often characterized by delirium. There is not enough information in this scenario to determine if the patient is at risk for alcohol withdrawal.

A patient with a history of deep vein thrombosis is recovering in the postanesthesia care unit (PACU) after surgery. Which symptoms would the nurse assess if this patient develops a pulmonary embolism (PE)? Select all that apply. -Dyspnea -Tachypnea -Tachycardia -Coarse crackles -Noisy respirations

-Dyspnea -Tachypnea -Tachycardia PE can be recognized by the presence of tachycardia, tachypnea, and dyspnea, especially if the patient is already receiving oxygen therapy. PE may occur in a postoperative patient who already has a history of deep vein thrombosis and is an older adult. Other symptoms of PE may include agitation, chest pain, hypotension, hemoptysis, dysrhythmias, and heart failure. Coarse crackles and noisy respirations may happen if thick secretions are present in the airway.

The nurse is educating a patient who had a coronary bypass graft (CABG) about the risk of venous thromboembolism (VTE). Which topic would the nurse include in the education to the patient? -Early ambulation -Turning every two hours -Splinting chest while coughing -Importance of taking pain medication

-Early ambulation Activity has proven vital in helping to prevent postoperative VTE. Other forms of treatment include anticoagulants and sequential compression devices (SCDs). Splinting the chest while coughing, taking pain medication, and turning every two hours are important for the recovery of the coronary bypass patient but have little impact on preventing VTE.

A postoperative patient has absence of breath sounds on the left lung and an oxygen saturation of 86%. Which interventions would the nurse take to maintain adequate oxygen saturation? Select all that apply. -Administer diuretics. -Allow delayed ambulation. -Instruct shallow breathing. -Encourage incentive spirometry. -Provide humidified oxygen therapy.

-Encourage incentive spirometry. -Provide humidified oxygen therapy. Decreased breath sounds and a low oxygen saturation level may indicate atelectasis due to retained secretions. Incentive spirometry helps lung expansion and promotes removal of secretions. Humidified oxygen therapy helps maintain the oxygen saturation levels. Diuretics help remove excess fluid in the body, but do not help in atelectasis. Late ambulation and shallow breathing aggravate atelectasis; therefore the patient should be mobilized early, and deep breathing should be encouraged.

Which nursing intervention would help prevent postoperative atelectasis? -Medicating the patient with a narcotic analgesic as prescribed -Providing an abdominal binder to help the patient in ambulation -Encouraging frequent use of an incentive spirometer -Turning the patient from one side to the other at least every two to four hours

-Encouraging frequent use of an incentive spirometer Use of an incentive spirometer after surgery encourages the patient to take deep, slow breaths, which facilitates the opening of terminal airways, mobilizes secretions, and prevents postoperative atelectasis. The patient should be instructed to perform 10 repetitions every hour. Narcotic analgesics, use of an abdominal binder for ambulation, and frequent turning in bed may indirectly support recovery and prevention of complications postoperatively. However, these interventions do not specifically address the prevention of atelectasis and pneumonia in the way that the use of an incentive spirometer does.

An older adult wakes up in the postanesthesia care unit (PACU) and becomes restless and agitated and starts thrashing and shouting. The nurse finds that the patient was administered benzodiazepines during surgery. Which interventions would the nurse include on the patient's plan of care? Select all that apply. -Ensure patient safety. -Administer an antianxiety drug. -Administer a narcotic analgesic. -Administer an antipsychotic drug. -Use drugs to reverse the benzodiazepines.

-Ensure patient safety. -Use drugs to reverse the benzodiazepines. The patient's presentation of restlessness, agitation, thrashing, and shouting indicates emergence delirium. It is due to the prolonged action of opioids and benzodiazepines during the surgery. The use of opioid and benzodiazepine antagonists may reverse the effect and alleviate agitation in the patient. Until the patient is fully conscious, the nurse should ensure the patient's safety by raising the side rails of the bed and securing the equipment, such as the IV line. Antianxiety drugs are less helpful in managing emergence delirium. Emergence delirium is not a psychotic condition; therefore antipsychotic drugs are not useful. Narcotic analgesics would further enhance the action of opioids that were used during surgery.

Which surgery requires a sensory level L2-L3 anesthesia? -Hip surgery -Foot surgery -Appendectomy -Hemorrhoidectomy

-Foot surgery Foot surgery would require sensory level L2-L3 anesthesia. Hip surgery would require T10 level, an appendectomy necessitates T6-T7, and a hemorrhoidectomy calls for sensory level S2-S3 anesthesia.

Before asking a patient who had abdominal surgery to perform postoperative breathing exercises, which evaluation or intervention would the nurse perform first? -Gauging the patient's level of pain -Evaluating the patient's vital signs -Assisting the patient out of bed and into a chair -Reviewing the health care provider's plan of care

-Gauging the patient's level of pain Pain management is essential to postoperative care. Assessing the level of pain and offering an analgesic before performing postoperative breathing exercises or any activities will ease pain and facilitate compliance, thus decreasing the risk of complications. Checking vital signs, assisting the patient into a chair, and reviewing the health care provider's plan of care are all appropriate after the patient's pain level has been assessed.

Postoperative hypotension can be managed with which intervention? -Infusion of IV fluids -Assessment of a basic metabolic panel (BMP) -Administration of oxygen -Performing an electrocardiogram (ECG)

-Infusion of IV fluids Hypotension that occurs postoperative is mainly due to fluid and/or blood loss. Administration of IV fluids helps to increase the blood pressure. A BMP monitors electrolytes and renal function, but these imbalances in a postoperative patient are less likely a contributing cause of hypotension. Administration of oxygen will not improve hypotension. An ECG would detect abnormal heart rhythms, but this is unlikely to contribute to hypotension in a postoperative patient.

Which factor is associated with the highest risk for respiratory complication following surgery? -General anesthesia used during surgery -Hydromorphone patient-controlled analgesia (PCA) for pain control -History of obstructive sleep apnea -Endotracheal intubation for surgery

-History of obstructive sleep apnea A history of obstructive sleep apnea would be associated with the highest risk for postoperative respiratory complication. General anesthesia, a PCA with hydromorphone, and endotracheal intubation are also risk factors, but sleep apnea poses the highest risk.

In the postanesthesia care unit (PACU), which position would be the safest to place an unconscious postoperative patient immediately after the operation? -Supine -Lateral -Semi-Fowler's -High Fowler's

-Lateral Unless contraindicated by the surgical procedure, the unconscious patient is positioned in lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient usually is returned to a supine position with the head of the bed elevated. Supine, semi-Fowler's, and high Fowler's positions are all supine; they are not as helpful in keeping the airway open and reducing the risk of aspiration.

Which position would the nurse place a patient who is still drowsy from anesthesia and has been vomiting? -High Fowler's -Prone -Supine -Lateral recovery position

-Lateral recovery position Aspiration of the vomitus is a concern in the drowsy patient and can be prevented by placing the patient in the lateral recovery position. This position helps the vomitus escape through the mouth. Supine and prone positions are less helpful in preventing aspiration than the lateral recovery position. High Fowler's position would not be recommended for a drowsy patient and would not be helpful in preventing aspiration.

The nurse places an abdominal binder on a patient after colon surgery. After approximately an hour, the nurse assesses that the patient has shallow respirations, is hypoxemic, and hypercapnic. How would the nurse promote optimal breathing in this patient? Select all that apply. -Loosen the binder. -Reposition the patient. -Provide music therapy. -Elevate the foot end of bed. -Raise the head end of the bed.

-Loosen the binder. -Reposition the patient. -Raise the head end of the bed. The hypoventilation observed in this patient is due to mechanical restriction caused by the abdominal binder. Therefore the patient should be repositioned to improve comfort and the binder should be loosened to relieve the constriction. Raising the head end of the bed would promote lung expansion and facilitate breathing. Music therapy may relax the patient but would not relieve the mechanical restriction. Elevating the foot end of the bed would further aggravate the patient's condition.

Which nursing intervention is important to prevent syncope in a postoperative patient? -Administer oxygen therapy. -Administer analgesics before ambulation. -Make changes in the patient's position slowly. -Encourage deep-breathing and coughing exercises.

-Make changes in the patient's position slowly. To prevent syncope in a postoperative patient, the nurse should slowly change the patient's position. Progression to ambulation can be achieved by first raising the head of the patient's bed for one to two minutes and then assisting the patient to sit, with legs dangling, while monitoring the pulse rate. If no changes or complaints are noted, start ambulation with ongoing monitoring of the pulse. Oxygen therapy and deep-breathing and coughing exercises are interventions to improve pulmonary function, not to prevent syncope. Administering analgesics before ambulation makes the activity painless and encourages the patient to become more active.

A patient is having elective cosmetic surgery performed on the face. Which action is the nurse's postoperative priority for this patient? -Manage patient pain. -Control the bleeding. -Maintain fluid balance. -Manage oxygenation status.

-Manage oxygenation status. The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise the patient's ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase the risk for upper airway edema, causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.

Which criteria must a patient meet in order to be discharged from the postanesthesia care unit (PACU) (Phase I) to the clinical unit? Select all that apply. -No nausea or vomiting -No respiratory depression -Oxygen saturation above 90% -Written discharge instructions understood -Patient reports pain level of 4 on a 1 to 10 scale

-No respiratory depression -Oxygen saturation above 90% -Patient reports pain level of 4 on a 1 to 10 scale Discharge criteria from Phase I are listed in Table 19.8 and include no respiratory depression, oxygen saturation above 90%, and pain that is controlled or acceptable. Nausea and vomiting should be controlled. Understanding written discharge instructions are part of Phase II discharge criteria.

A nurse is caring for a patient who had a bowel resection 10 hours before. The patient weighs 200 pounds (91 kg) and has a urine output of 240 cc for the past eight hours. Which action would the nurse take? -Encourage oral (PO) fluids. -Continue to monitor the urine output. -Notify the health care provider. -Administer a 500 cc normal saline IV bolus.

-Notify the health care provider. The formula for determining adequate urine output is 0.5 mL/kg/hr. This patient, weighing 91 kg, needs to have 45 cc per hour or about 365 cc of urine in eight hours. It often takes three to five days for the bowel to begin working post-abdominal surgery; therefore it would be inappropriate at this time to encourage PO fluids. Continuing to monitor the urine output, instead of calling the health care provider, would delay identifying and treating the cause for the low urine output. The nurse must obtain a prescription for the normal saline bolus before administration.

A patient underwent a laparoscopic surgical procedure two days ago and is now experiencing chills and a temperature of 102.2 °F (39 °C). Which nursing action is priority? -Administer the final dose of antibiotic. -Notify the health care provider. -Have the patient deep breathe and cough. -Administer as needed acetaminophen (Tylenol).

-Notify the health care provider. The patient is demonstrating signs of septicemia. Therefore the priority nursing action is to notify the health care provider so tests and treatments can be prescribed. Administering the antibiotic and having the patient deep breathe and cough help prevent infections, but the patient is exhibiting signs and symptoms of infection in spite of these interventions. Acetaminophen treats the fever but not the source of the problem.

Alteration in which electrolyte level may be associated with occurrence of postoperative dysrhythmia? -Blood urea nitrogen -Sodium -Chloride -Potassium

-Potassium Potassium is an electrolyte that maintains electrical conductivity of the heart. Hypokalemia (low serum potassium) from urinary and gastrointestinal fluid losses during and after surgery may result in cardiac dysrhythmia. Alterations in blood urea nitrogen, sodium, and chloride will be assessed for, but are not linked to cardiac dysrhythmias.

A postoperative patient has newly developed anxiety and is combative with the nurse in the postanesthesia care unit. Which factor does the nurse know may be the cause of this change in behavior? -Delirium -Excessive sleep -Hyperoxygenation -Presence of endotracheal tube

-Presence of endotracheal tube The nurse knows that the patient may be experiencing emergence delirium, which is a short-term neurologic change manifested by behaviors such as restlessness, agitation, disorientation, thrashing, and shouting; the presence of an endotracheal tube may cause this. A new onset of anxiety and combativeness may cause emergence delirium rather than the other way around. Sleep deprivation, not excessive sleep, would cause anxiety and aggression. Hyperoxygenation would not cause such behavior changes; hypoxemia does.

Which action would the nurse take to assist an older adult postoperative patient who has difficulty with memory and the ability to concentrate? Select all that apply. -Provide adequate nutrition. -Encourage delayed mobility. -Provide bowel and bladder care. -Sedate the patient for long durations. -Monitor fluid and electrolyte disturbance.

-Provide adequate nutrition. -Provide bowel and bladder care. -Monitor fluid and electrolyte disturbance. The patient suffers from postoperative cognitive dysfunction, which dissipates over a few weeks. The nurse should provide supportive care during this period, such as bowel and bladder care, adequate nutrition, and fluid and electrolyte monitoring. Early mobilization should be encouraged to prevent pulmonary complications. Sedatives should not be used because they further add to cognitive dysfunction.

Which assessment data require the most immediate attention in a patient who is about to be transferred to the clinical unit from the postanesthesia care unit (PACU). -Oxygen saturation of 94% -Pulse rate of 128 beats/minute -Respiratory rate of 13/minute -Temperature of 99.8° F (37.7° C)

-Pulse rate of 128 beats/minute The most important aspect of the cardiovascular assessment is frequent monitoring of vital signs. They usually are monitored every 15 minutes in Phase I, or more often until stabilized, and then at less frequent intervals in Phase II. Notify the anesthesia care provider (ACP) or the health care provider if the pulse rate is less than 60 beats/minute or greater than 120 beats/minute. The oxygen saturation should be above 90%, so 94% is good. A respiratory rate of 13 is normal. A temperature of 99.8 is expected.

The nurse is caring for a patient in the postanesthesia care unit (PACU) when he becomes agitated. Which priority actions would the nurse take? Select all that apply. -Put the side rails up. -Evaluate respiratory status. -Monitor fluid intake and output. -Use clocks to orient the patient if needed. -Sedate the patient, if the patient is not hypoxemic.

-Put the side rails up. -Evaluate respiratory status. -Use clocks to orient the patient if needed. -Sedate the patient, if the patient is not hypoxemic. Hypoxemia is the most common cause of postoperative agitation. Therefore the nurse should first evaluate the respiratory status of the patient. If the patient is not hypoxemic, and other causes are ruled out, sedation can be given to calm the patient. It is important to ensure patient safety at this time, so the nurse should put the side rails up, secure all equipment, and monitor the physiologic status. Clocks are used to orient the patient who experiences postoperative cognitive dysfunction or delirium. Monitoring fluid intake and output is a general activity during the postoperative period but is not specific to delirium.

Which actions would the nurse take for a patient in the postanesthesia care unit (PACU) to ensure that this patient has a patent airway? Select all that apply. -Suctioning the airway -Administering sedatives -Putting in an artificial airway -Administering oxygen therapy -Tilting the head and thrusting the jaw

-Putting in an artificial airway -Tilting the head and thrusting the jaw The physical repositioning of a patient to reestablish the patency of the airway involves tilting the head and thrusting the jaw. If the physical repositioning does not help, the patient may need an artificial airway to assist in breathing. Suctioning is helpful for patients with increased secretions; it may not help a patient with an airway obstruction. Oxygen therapy does not help unless the airway is patent. Sedatives would worsen the airway prolapse.

A patient had an estimated blood loss of 400 mL during abdominal surgery. The patient received 300 mL of 0.9% saline during surgery. The patient is alert but is now experiencing hypotension postoperatively. Which intervention would the nurse take for this patient? -Restore circulating volume with administration of IV fluids. -Monitor pulse and BP. -Get an electrocardiogram (ECG) to check circulatory status. -Return to surgery to check for internal bleeding.

-Restore circulating volume with administration of IV fluids. The nurse would anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. The nurse will need to do more than monitor pulse and BP. An ECG may be done if there is no response to the fluid administration or if there is a past history of cardiac disease or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if the patient's level of consciousness changes or the abdomen becomes firm and distended.

Which action will the nurse take for a postoperative patient who has low oxygen saturation and has crackles on auscultation? -Suction the airway. -Restrict fluid intake. -Monitor mental status. -Place the patient in lateral recovery position.

-Restrict fluid intake. Pulmonary edema in a postoperative patient is due to fluid overload. Therefore fluid restriction is the appropriate intervention. In addition, oxygen therapy and diuretics can be administered. The airway is suctioned if there is any secretion retained in the system. Monitoring of mental status is done in the early postoperative period to determine emergence from anesthesia. Lateral recovery position is used in the early postoperative period to keep the airway patent and prevent aspiration in case the patient vomits.

A patient received a large amount of IV fluid during surgery. In the postanesthesia care unit (PACU), the nurse assesses that the patient has reduced oxygen saturation, crackles on auscultation, and infiltrates on chest x-ray. Which actions would the nurse take to relieve the patient's breathing discomfort and promote oxygen saturation? Select all that apply. -Restrict fluids. -Administer prescribed diuretics. -Administer oxygen therapy. -Administer prescribed bronchodilators. -Implement anticoagulant therapy.

-Restrict fluids. -Administer prescribed diuretics. -Administer oxygen therapy. The breathing difficulty in the patient is due to the development of pulmonary edema caused by the infusion of a large volume of fluids. The patient would be relieved of pulmonary edema by fluid restriction. Use of diuretics would reduce the volume load. Oxygen therapy would help maintain adequate oxygenation saturation levels. Bronchodilators may help patients with constriction of the bronchi, but that is not the case with this patient. Anticoagulant therapy prevents the blood from clotting but may not be helpful in relieving pulmonary edema.

Two days after abdominal surgery, the patient reports gas pains and abdominal distention. The nurse plans care for the patient on the basis of the knowledge that these symptoms occur as a result of which condition? -Constipation -Hiccups -Slowed gastric emptying -Inflammation of the bowel at the anastomosis site

-Slowed gastric emptying Until peristalsis returns to normal after anesthesia, the patient may experience slowed gastric motility, leading to gas pains and abdominal distention. Hiccups are intermittent spasms of the diaphragm caused by irritation of the phrenic nerve, which may be irritated after surgery by gastric distention but does not cause gas pains. The bowel should not be inflamed following surgery unless infection is present. Constipation may occur following surgery; however, with bowel manipulation, slowed gastric emptying is the most common reason for gas pains and abdominal distention because of gas.

Which instruction regarding deep-breathing and coughing techniques would the nurse include in a teaching plan for a patient who has an abdominal incision? -Splint the abdominal incision with a pillow. -Perform the technique two times every waking hour. -Limit fluid intake to thicken the secretions and membranes. -Encourage deep breathing and coughing if the patient is in pain or feels the urge to clear secretions.

-Splint the abdominal incision with a pillow. When performing deep-breathing and coughing exercises, the patient should splint the abdominal incision site with a pillow or folded blankets to support the incision. The patient may be instructed to perform the technique 10 times every hour if the condition allows. The patient should be instructed to drink sufficient water to keep the secretions thin. Patients should not do deep breathing and coughing only when they feel the urge to clear secretions or when they feel pain.

Which intervention is effective in managing abdominal pain in a postoperative patient during ambulation? -Aromatherapy -Use of a gait belt -Splinting the incision -Use of a walker

-Splinting the incision Managing abdominal pain during ambulation can be accomplished by holding a pillow over the incision (splinting) to provide support. Aromatherapy can be used in the room, but not with ambulation. A gait belt and an assistive device prevent the patient from falling.

In which position would the nurse place a postoperative, conscious patient in order to prevent respiratory problems? -Lithotomy position -Lateral recovery position -Prone position with extra pillows -Supine position with head elevated

-Supine position with head elevated If the patient is conscious, the patient should be positioned in supine position with the head elevated. This position helps to maximize the expansion of the thorax by decreasing the pressure of abdominal contents on the diaphragm. Lateral recovery position is usually used in unconscious patients to keep the airway open and reduce the risk of aspiration if vomiting occurs. Prone and lithotomy positions are not used in postsurgery patients.

Which assessment data requires the notification of the health care provider? -A widened pulse pressure -Systolic BP of 95 mm Hg -Systolic BP of 170 mm Hg -A pulse of 80 beats/minute

-Systolic BP of 170 mm Hg The nurse would notify the health care provider if the patient's systolic BP is higher than 170 mm Hg. It is a narrowed pulse pressure, rather than a widened one, that might necessitate a call to the health care provider. A systolic BP of 95 mm Hg is perfectly acceptable; one that is less than 90 or greater than 160 indicates a problem. A pulse of 80 beats/minute is also acceptable; a pulse that is less than 60 or over 120 can be problematic.

Which symptom indicates that a patient may have a pulmonary embolism? -Lethargy -Tachypnea -Bradycardia -Hypertension

-Tachypnea Tachypnea indicates a potential pulmonary embolism. Agitation, rather than lethargy, is a symptom of pulmonary embolism. A patient with a pulmonary embolism would be more likely to present with tachycardia and hypotension rather than bradycardia and hypertension.