NSG320 Topic 2 Chapter 20 NCLEX
The nurse is caring for a 54-year-old unconscious female patient who has just been admitted to the postanesthesia care unit after abdominal hysterectomy. How should the nurse position the patient? A. Left lateral position with head supported on a pillow B. Prone position with a pillow supporting the abdomen C. Supine position with head of bed elevated 30 degrees D. Semi-Fowler's position with the head turned to the right
A. The unconscious patient should be placed in the lateral "recovery" position to keep the airway open and reduce the risk of aspiration. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated to maximize expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.
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,D,E. Phase II discharge criteria that must be met include the following: all PACU discharge criteria (Phase I) met; no intravenous opioid drugs administered for the past 30 minutes; patient's ability to void (if appropriate with regard to surgical procedure or orders); patient's ability to ambulate if it is not contraindicated; presence of a responsible adult to accompany or drive patient home; and written discharge instructions given and understood.
The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)? A. Vital signs baseline or stable B. Minimal nausea and vomiting C. Wants to go to the bathroom at home D. Responsible adult taking patient home E. Comfortable after IV opioid 15 minutes ago
A,B,D Ambulatory surgery discharge criteria includes meeting Phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria includes a responsible adult driving patient, no IV opioid drugs for last 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.
After admission of the postoperative patient to the clinical unit, which assessment data require 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 90/60 mm Hg
A. During the initial assessment, identify signs of inadequate oxygenation and ventilation. Pulse oximetry monitoring is initiated because it provides a noninvasive means of assessing the adequacy of oxygenation. Pulse oximetry may indicate low oxygen saturation (<90% to 92%) with respiratory compromise. This necessitates prompt intervention.
In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes? A. Administering adequate analgesics to promote relief or control of pain B. Asking the patient to demonstrate the postoperative exercises every 1 hour C. Giving the patient positive feedback when the activities are performed correctly D. Warning the patient about possible complications if the activities are not performed
A. Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.
Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing? A. Atelectasis B. Bronchospasm C. Hypoventilation D. Pulmonary embolism
A. 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.
The nurse is providing discharge teaching to a 51-year-old female patient who has had a laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the patient, indicates an understanding of the discharge instructions? A. "I will have someone stay with me for 24 hours in case I feel dizzy." B. "I should wait for the pain to be severe before taking the medication." C. "Because I did not have general anesthesia, I will be able to drive home." D. "It is expected after this surgery to have a temperature up to 102.4o F."
A. The nurse must assess understanding of discharge instructions and the ability of the patient and caregiver to provide for home care needs. The patient must be accompanied by a responsible adult caregiver. The patient may not drive after receiving anesthetics or sedatives. The patient should understand how to manage pain, and pain medication should be taken before the pain becomes severe. The patient should understand symptoms to be reported, such as a fever.
The nurse is monitoring a patient who is about to be transferred to the clinical unit from the postanesthesia care unit (PACU). Which assessment data require the most immediate attention? A. Pulse rate 128 beats/minute B. Oxygen saturation of 94% C. Respiratory rate of 13/minute D. Temperature of 99.8° F (37.7° C)
A. 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. Text Reference - p. 350
The nurse cares for a 72-year-old Native American male patient 2 days after a thoracotomy for tumor resection. What would be the most appropriate action if the patient does not report any pain? A. Contact the health care provider. B. Identify possible reasons for denial of pain. C. Administer the prescribed pain medication. D. Assess the renal and liver function test results.
B. Encourage the older adult to report pain, especially those who are reluctant to discuss pain or deny pain when it is likely present, such as after surgery. Older patients may be hesitant to request pain medication, believe pain is an inevitable consequence of surgery, and may not understand how to use patient-controlled machines. Some cultures discourage the expression of pain. The nurse should encourage the use of analgesics, explaining to the patient that untreated pain has a negative effect on recovery. Assessment of pain and administration of medications are within the scope of practice of a nurse. An older patient may have decreased renal and liver function that may lead to drug toxicity. However, this would not be a reason for denial of pain. Administration of pain medication must be based on the patient assessment.
The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? A. Assess the patient's pain. B. Assess the patient's vital signs. C. Check the rate of the IV infusion. D. Check the physician's postoperative orders.
B. The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence.
The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient? A. Blood administration B. Restoring circulating volume C. An ECG to check circulatory status D. Return to surgery to check for internal bleeding
B. The nurse should 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. An ECG may be done if there is no response to the fluid administration, or 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 patient's level of consciousness changes or the abdomen becomes firm and distended.
Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately postoperative? A. Supine B. Lateral C. Semi-Fowler's D. High-Fowler's
B. Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated.
What is the priority nursing action when a patient is transferred from the postanesthesia care unit (PACU) to the surgical unit after a lobectomy? A. Assess the patient's pain. B. Take the patient's vital signs. C. Check the rate of the intravenous (IV) infusion. D. Check the health care provider's postoperative prescriptions.
B. The highest 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. Text Reference - p. 350
A patient is transferred to the postanesthesia care unit (PACU) after surgery. Which nursing intervention is the highest priority initially? A. Assess intake, output, and fluid balance. B. Assess airway, breathing, and circulation status. C. Note the presence of all IV lines and drainage catheters. D. Assess the surgical site and condition of the dressing.
B. 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. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action. Text Reference - p. 350
A patient has been admitted to the postanesthesia care unit (PACU). Which of these assessment findings require the nurse's immediate action? A. The patient indicates that he or she is in pain. B. The patient is groggy but arouses to voice. C. The patient is restless, agitated, and hypotensive. D. The Jackson-Pratt is draining serosanguinous fluid
C. 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. Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early. Text Reference - p. 350
When a patient is admitted to the PACU, what are the priority interventions the nurse performs? 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. Assessment in the postanesthesia care unit (PACU) begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Identification of inadequate oxygenation and ventilation or respiratory compromise necessitates prompt intervention.
A patient transferred to the medical-surgical unit from the postanesthesia care unit (PACU) has regained consciousness. In which position should the nurse place the patient in order to prevent respiratory problems? A. Lithotomy position B. Lateral recovery position C. Supine position with head elevated D. Prone position with extra pillows
C. 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. Text Reference - p. 354
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 would be to A. increase the rate of the IV fluids. B. obtain vital signs, including O2 saturation. C. position patient in lateral recovery position. D. administer antiemetic medication as ordered.
C. 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
A patient on the postoperative unit has shallow respirations. On examination, the nurse finds the patient to be hypoxemic. After inquiry, it was discovered that the patient was given a large dose of opioids during the surgery. What would the nurse expect to be prescribed to manage hypoxemia in this patient? A. Opioids B. Benzodiazepines C. Drugs to reverse the effects of opioids D. Withholding mechanical ventilation
C. Shallow respiration associated with hypoxemia and reduced respiratory rate in a patient who received large doses of opioids indicates hypoventilation due to medullary depression. Drugs that reverse the effect of opioids should be administered to stimulate the medullary respiratory center. Opioids and benzodiazepines should be avoided because they further aggravate medullary depression. In severe medullary depression, the patient may need mechanical ventilation. Text Reference - p. 352
In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)? A. Monitor the patient's pain. B. Do the admission vital signs. C. Assist the patient to take deep breaths and cough. D. Change the dressing when there is excess drainage.
C. 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 RN should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The LPN or RN will monitor and treat the patient's pain and change the dressings.
When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first? A. Recheck in 1 hour for increased drainage. B. Notify the surgeon of a potential hemorrhage. C. Assess the patient's blood pressure and heart rate. D. Remove the dressing and assess the surgical incision.
C. The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.
A patient, who is eight hours postappendectomy, has not voided since surgery. What action should the nurse take? A. Encourage oral (PO) fluid intake B. Insert an in and out catheter to assess for retention C. Palpate the suprapubic area for bladder distention D. Check the medical record to determine the type of anesthetic given
C. The nurse needs to know first if there is urine in the bladder. The assessment can be done by palpating or scanning the suprapubic area. Encouraging PO fluid intake is appropriate if the patient can tolerate PO fluids and there is no bladder distention. Because of the risk of infection, an in and out catheter is not used for assessment purposes but to relieve known urine retention. No matter what type of anesthetic was administered, the nurse needs to determine if the patient has not voided because of a lack of urine output or if the issue is an alteration in micturition. Text Reference - p. 360
Which nursing intervention is important to prevent syncope in a postoperative patient? A. Administer oxygen therapy. B. Administer analgesics before ambulation. C. Make changes in the patient's position slowly. D. Encourage deep breathing and coughing exercises
C. 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 1 to 2 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. Text Reference - p. 357
A 67-year-old male patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression? A. Increased respiratory rate B. Decreased oxygen saturation C. Increased carbon dioxide pressure D. Frequent premature ventricular contractions (PVCs)
C. Transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a sensitive indicator of respiratory depression. Increased CO2 pressures would indicate respiratory depression. Clinical manifestations of inadequate oxygenation include increased respiratory rate, dysrhythmias (e.g., premature ventricular contractions), and decreased oxygen saturation.
A postoperative patient had his or her Foley catheter removed at 1200. At 2100, the patient still has not voided. The priority nursing intervention for this assessment would be to A. Perform a straight catheterization. B. Continue to monitor the patient, because this is an expected finding. C. Assess for bladder fullness by percussion, palpation, or portable bladder scanner. D. Notify the health care provider and anticipate obtaining blood work to evaluate renal function
C. Most patients urinate within 6 to 8 hours after surgery. If no voiding occurs, the nurse should consider fluid intake during and after surgery and should determine bladder fullness by percussion, palpation, or by a portable bladder ultrasound to assess the volume of urine in the bladder and avoid unnecessary catheterization. Inability to void is not an expected finding. It is not necessary to assess renal function. Text Reference - p. 360
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. perform a straight catheterization to measure the amount of urine in the bladder. B. notify the physician and anticipate obtaining blood work to evaluate renal function. 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. Because of the possibility of infection associated with catheterization, the nurse should first try to validate that the bladder is full. The nurse should consider fluid intake during and after surgery and should determine bladder fullness by percussion, by palpation, or by a portable bladder ultrasound study to assess the volume of urine in the bladder and avoid unnecessary catheterization.
An older patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this new patient? A. Check his chart for intraoperative complications. B. Check which medications were used for anesthesia. C. Check the effectiveness of the analgesics he has received. D. Check his preoperative assessment for previous delirium or dementia.
D. If the patient's ABCs 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 as these can all contribute to delirium.
Which patient would be at highest risk for hypothermia after surgery? A. A 42-year-old patient who had a laparoscopic appendectomy B. A 38-year-old patient who had a lumpectomy for breast cancer C. A 20-year-old patient with an open reduction of a fractured radius D. A 75-year-old patient with repair of a femoral neck fracture after a fall
D. Patients at highest risk for hypothermia are those who are older, debilitated, or intoxicated. Also, long surgical procedures and prolonged anesthetic administration place the patient at increased risk for hypothermia.
The patient donated a kidney, and early ambulation is included in her plan of care. But the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? A. "Early walking keeps your legs limber and strong." B. "Early ambulation will help you be ready to go home." C. "Early ambulation will help you get rid of your syncope and pain." D. "Early walking is the best way to prevent postoperative complications."
D. The best rationale is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and VTE, speeds wound healing, and increases vital capacity and maintains normal respiratory function. These things help the patient be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management should always occur before walking.
The patient donated a kidney and early ambulation is included in the plan of care; however, the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? A. "Early walking keeps your legs limber and strong." B. "Early ambulation will help you be ready to go home." C. "Early ambulation will help you get rid of your syncope and pain." D. "Early walking is the best way to prevent postoperative complications."
D. 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. Text Reference - p. 356
A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure of 100/60 mm Hg. Which action should the nurse take first? A. Rouse the patient B. Place the patient in the Trendelenburg position C. Notify the anesthesiologist of the low blood pressure D. Check the medical record for the patient's baseline blood pressure
D. The first action of the nurse is to identify what the patient's normal blood pressure is. Interventions are dependent on the baseline variation. Rousing the patient is an intervention that can increase the blood pressure, but would be done after determining the baseline blood pressure. Placing the patient in Trendelenburg is not an appropriate action in this situation. Before notifying the anesthesiologist of the blood pressure, the nurse needs to check the baseline blood pressure. Text Reference - p. 355
A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? A. Manage patient pain. B. Control the bleeding. C. Maintain fluid balance. D. Manage oxygenation status.
D. 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 her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.
An alcoholic patient who has undergone a hernia operation is restless and irritable. On assessment, the nurse finds that the patient has auditory hallucinations. What is the most appropriate nursing action? A. Conclude that the patient suffers from a psychotic disorder. B. Consider the situation normal, due to the anesthetic drugs. C. Infer that the patient is suffering from pain and suggest using pain killers. D. Conclude that these effects are due to alcohol withdrawal
D. The patient is irritable and restless due to loss of the inhibitory effects of alcohol; this is also causing the hallucinations. The patient does not 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. Text Reference - p. 357
