Post-Op Practice Questions

The nurse is preparing discharge instructions to a client who has undergone minor same-day surgery. Which client statement indicates that teaching has been effective? a) "I had some type of surgery on my abdomen." b) "There is no need to call my doctor as the surgery was minor." c) "I am not permitted to drive myself home after surgery." d) "I will read up on how to use my walker at home for safety."

"I am not permitted to drive myself home after surgery." Explanation: There are specific educational points that the nurse needs to provide to the client before discharging after a same-day procedure. After teaching, the client should be able to describe activities that can or cannot be performed, such as limited driving for 2 days. Rather than self-teaching at home, the discharge instructions will educate the client how to identify interventions and strategies for adaptive equipment. The client should be instructed to call the health care provider for a follow-up postsurgical appointment. The client should be able to name the procedure that was performed and not just give a vague statement of something being done in the abdomen.

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? "I will have someone stay with me for 24 hours in case I feel dizzy." "I should wait for the pain to be severe before taking the medication." "Because I did not have general anesthesia, I will be able to drive home." "It is expected after this surgery to have a temperature up to 102.4o F."

"I will have someone stay with me for 24 hours in case I feel dizzy." 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 PACU nurse is receiving the client from the OR. Which intervention should the nurse implement first? 1. Assess the client's breath sounds. 2. Apply oxygen via nasal cannula. 3. Take the client's blood pressure. 4. Monitor the pulse oximeter reading.

1. Assess the client's breath sounds. Rationale: The airway should be assessed first. When caring for a client, the nurse should follow the ABC's: airway, breathing, and circulation. Why it's not the rest: After assessing the client's airway and breathing, the nurse can apply oxygen via a nasal cannula if necessary. The blood pressure is taken automatically by the monitor, but this is not a priority over airway. The pulse oximeter is applied to the client's finger to obtain the peripheral oxygenation status, but the nurse should assess the client's breathing first.

Which problem should the nurse identify as priority for client who is one (1) day postoperative? 1. Potential for hemorrhaging. 2. Potential for injury. 3. Potential for fluid volume excess. 4. Potential for infection.

1. Potential for hemorrhaging. Rationale: All clients who undergo surgery are at risk for hemorrhaging , which is the priority problem. Why it's not the rest: The client is at risk for injury but the priority problem the first day postoperative is hemorrhaging. A potential fluid imbalance would be for less fluid as a result of blood loss and decreased oral intake; it would not be for fluid volume excess. Infection would be a potential problem but not priority over hemorrhaging on the first postoperative day.

The nurse and the unlicensed assistive personnel (UAP) are working on a surgical unit. Which task can the nurse delegate to the UAP? 1. Take routine vital signs on clients. 2. Check the Jackson Pratt insertion site. 3. Hang the client's next IV bag. 4. Ensure the client obtains pain relief.

1. Take routine vital signs on clients. Rationale: Taking the vital signs of the stable client may be delegated to the UAP. Why it's not the rest: Assessments cannot be delegated; "check" is a word which means "to assess." IV's cannot be hung by the UAP; this is considered administering a medication. Evaluating the client's pain relief is a responsibility of the RN.

The 26-year-old male client in the PACU has a heart rate of 110 and a rising temperature and complains of muscle stiffness. Which interventions should the nurse implement? Select all that apply. 1. Give a back rub to the client to relieve stiffness. 2. Apply ice packs to the axillary and groin areas. 3. Prepare an ice slush for the client to drink. 4. Prepare to administer dantrolene, a smooth muscle relaxant. 5. Reposition the client on a warming blanket.

2. Apply ice packs to the axillary and groin areas. 4. Prepare to administer dantrolene, a smooth muscle relaxant. Rationale: Ice packs should be applied to the axillary and groin areas for a client experiencing malignant hyperthermia. Dantrolene is the drug of choice for treatment. Why it's not the rest: A back rub is a therapeutic intervention, but it is not appropriate for a life-threatening complication of surgery. The client would be NPO to prepare for intubation, but an ice slush would be used to irrigate the bladder and stomach per nasogastric tube. Cooling blankets, not warming blankets, are used to decrease the fast-rising temperature.

The PACU nurse administers Narcan, an opioid antagonist, to a postoperative client. Which client problem should the nurse include to the plan of care based on this medication? 1. Alteration in comfort. 2. Risk for depressed respiratory pattern. 3. Potential for infection. 4. Fluid and electrolyte imbalance.

2. Risk for depressed respiratory pattern. Rationale: A client with respiratory depression treated with Narcan can have another episode within 15 minutes after receiving the drug as a result of the short half-life of the medication. Why it's not the rest: Narcan does not cause pain for the client. Infection would not be a concern immediately after surgery. Although the client may experience an imbalance in fluid or electrolytes, this problem would not be of concern as a result of the administration of Narcan.

Which statement would be an expected outcome for the postoperative client who had general anesthesia? 1. The client will be able to sit in the chair for 30 minutes. 2. The client will have a pulse oximetry reading of 97% on room air. 3. The client will have a urine output of 30 mL per hour. 4. The client will be able to distinguish sharp from dull sensations.

2. The client will have a pulse oximetry reading of 97% on room air. Rationale: The anesthesia machine takes over the function of the lungs during surgery, so the expected outcome should directly reflect the client's respiratory status; the alveoli can collapse, causing atelectasis. Why it's not the rest: The postoperative client is expected to be out of bed as soon as possible, but this goal is not specific to having general anesthesia. Urine output should be 30mL/hr, but the expected outcome is not specific to general anesthesia. Sensation would be an outcome assessed after the use of a spinal anesthesia or block, but it is not specific to general anesthesia.

The postoperative client is transferred from the PACU to the surgical floor. Which action should the nurse implement first? 1. Apply antiembolism hose to the client. 2. Attach the drain to 20 cm suction. 3. Assess the client's vital signs. 4. Listen to the report from the anesthesiologist.

3. Assess the client's vital signs. Rationale: Assessing the client's status after transfer from the PACU should be the nurse's first intervention. Why it's not the rest: Applying antiembolism hose may be appropriate, but it is not the first intervention. Attaching a drain would be appropriate but not before assessing the client. Receiving reports is not the nurse's first intervention.

The surgical client's vital signs are T 98'F, P 106, R 24, and BP 88/40. The client is awake and oriented times three (3) and the skin is pale and damp. Which intervention should the nurse implement first? 1. Call the surgeon and report the vital signs. 2. Start an IV of D5RL with 20 mEq KCl at 125 ml/hr. 3. Elevate the feet and lower the head. 4. Monitor the vital signs every 15 minutes.

3. Elevate the feet and lower the head. Rationale: By lowering the head of the bed and raising the feet, the blood is shunted to the brain until volume-expanding fluids can be administered, which is the first intervention for a client who is hemorrhaging. Why it's not the rest: The surgeon should be notified, but this is not the first action; the client must be cared for. The postoperative client had lactated Ringer's infused during surgery; the rate should be increased during hemorrhage-which the vital signs indicate is occurring-but potassium should not be added. When signs and symptoms of shock are observed, the nurse will monitor the vital signs more frequently than every 15 minutes.

The UAP reports the vital signs for a first-day postoperative client as T 100.8'F, P 80, R 24, and BP 148/80. Which intervention would be most appropriate for the nurse to implement? 1. Administer the antibiotic earlier than scheduled. 2. Change the dressing over the wound. 3. Have the client turn, cough, and deep breathe every two (2) hours. 4. Encourage the client to ambulate in the hall.

3. Have the client turn, cough, and deep breathe every two (2) hours. Rationale: Having the client turn, cough, and deep breath (TCDB) is the best intervention for the nurse to implement because, if a client has a fever within the first day, it is usually caused by a respiratory problem. Why it's not the rest: Antibiotics need to be administered at the scheduled time. The data does not support the need for a dressing change, and surgeons usually want to change the surgical dressing for the first time. The client is first-day postoperative, and ambulating in the hall would not be appropriate.

Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia? 1. Loss of sensation at the lumbar (L5) dermatome. 2. Absence of the client's posterior tibial pulse. 3. The client has a respiratory rate of eight (8). 4. The blood pressure is within 20% of the client's baseline.

3. The client has a respiratory rate of eight (8). Rationale: If the effects of the spinal anesthesia move up rather than down the spinal cord, respirations can be depressed and even blocked. Why it's not the rest: Loss of sensation in the L5 dermatome is expected from spinal anesthesia. Absence of a posterior tibial pulse is indicative of a block in the blood supply, but is not a complication of the spinal anesthesia. The BP is an expected outcome and does not indicate a complication.

Which data indicate to the nurse the client who is one (1) day postoperative right total hip replacement is progressing as expected? 1. Urine output was 160 mL in the past eight (8) hours. 2. Paralysis and paresthesia of the right leg. 3. T 99.0'F, P 98, R 20, and BP 100/60. 4. Lungs are clear bilaterally in all lobes.

4. Lungs are clear bilaterally in all lobes. Rationale: Lung sounds which are clear bilaterally in all lobes indicate the client has adequate gas exchange, which prevents postoperative complications and indicates effective nursing care. Why it's not the rest: Adequate urine output should be 30 mL/hr or at least 240 mL in an eight (8)-hour period. Paralysis (inability to move) and paresthesia (numbness and tingling) indicate neurovascular compromise to the right leg, which indicates a complication and is not an expected outcome. The client's temperature and pulse are slightly elevated, and the BP is low, which does not indicate effective nursing care.

The charge nurse is making shift assignments. Which postoperative client should be assigned to the most experienced nurse? 1. The 4-year-old who had a tonsillectomy and is able to swallow fluids. 2. The 74-year-old client with a repair of the left hip who is unable to ambulate. 3. The 24-year-old client who had an uncomplicated appendectomy the previous day. 4. The 80-year-old client with a small bowel obstruction and congestive heart failure.

4. The 80-year-old client with a small bowel obstruction and congestive heart failure. Rationale: An older client with a chronic disease would be a complicated case, requiring the care of a more experienced nurse. Why it's not the rest: The 4-year-old appears stable; pediatric clients can become unstable quickly, but the most experienced nurse would not need to care for this client. The 74-year-old will be ambulated by the physical therapist and is stable. The 24-year-old would require routine postoperative care.

Which patient would be at highest risk for hypothermia after surgery? A 42-year-old patient who had a laparoscopic appendectomy A 38-year-old patient who had a lumpectomy for breast cancer A 20-year-old patient with an open reduction of a fractured radius A 75-year-old patient with repair of a femoral neck fracture after a fall

A 75-year-old patient with repair of a femoral neck fracture after a fall 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.

A surgical patient has just been admitted to the unit from PACU with patient controlled analgesia (PCA). The nurse should know that the requirements for safe and effective use of PCA include what? A) A clear understanding of the need to self-dose B) An understanding of how to adjust the medication dosage C) A caregiver who can administer the medication as ordered D) An expectation of infrequent need for analgesia

A) A clear understanding of the need to self-dose The two requirements for PCA are an understanding of the need to self-dose and the physical ability to self-dose. The patient does not adjust the dose and only the patient himself or herself should administer a dose. PCAs are normally used for patients who are expected to have moderate to severe pain with a regular need for analgesia.

The nurse is performing the shift assessment of a postsurgical patient. The nurse finds his mental status, level of consciousness, speech, and orientation are intact and at baseline, but the patient tells you he is very anxious. What should the nurse do next? A) Assess the patient oxygen level B) Administer antianxiety medications C) Page the patients physicians D) Initiate a social work referral.

A) Assess the patients oxygen level The nurse assesses the patient's mental status and level of consciousness, speech, and orientation and compares them with the preoperative baseline. Although a change in mental status or postoperative restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit or hemorrhage. Antianxiety medications are not given until the cause of the anxiety is known. The physician is notified only if the reason for the anxiety is serious of if an order for medication is needed. A social work consult is inappropriate at this time.

The perioperative nurse is providing care for a patient who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The patient is reluctant to ambulate, citing the need to recover in bed. For what complication is the patient most at risk? A) Atelectasis B) Anemia C) Dehydration D) Peripheral edema

A) Atelectasis Atelectasis occurs when the postoperative patient fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia occurs rarely and usually in situations where the patient loses a significant amount of blood or continurse bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the patient is most at risk for atelectasis.

An adult patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the patient may be at risk for what? A) Hemorrhage and shock B) Aspiration C) Postoperative infection D) Hypertension and dysrhythmias

A) Hemorrhage and shock The patient with a hemorrhage presents with hypotension; rapid thready pulse; disorientation; restlessness; oliguria; and cold, pale skin. Aspiration would manifest in airway disturbance. Hypertension or dysrhythmias would be less likely to cause pallor and cool skin. An infection would not be present at this early postoperative stage.

The PACU nurse is caring for a 45-year-old make patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply? A) Hypotension B) Hypervolemia C) Heart murmurs D) Dysrhythmias E) Hypertension

A) Hypotension D) Dysrhythmias E) Hypertension The primary cardiovascular complications seen in the PACU include hypotension and shock, hemorrhage, hypertension, and dysrhythmias. Heart murmurs are not adverse reactions to surgery. Hypervolemia is not a common cardiovascular complication seen in the PACU, though fluid balance must be vigilantly monitored.

The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect is the problem with the patient? A) Postoperative delirium B) Postoperative dementia C) Senile dementia D) Senile confusion

A) Postoperative delirium Postoperative delirium, characterized by confusion, perceptual and cognitive deficits, altered attention levels, disturbed sleep patterns, and impaired psychomotor skills, is a significant problem for older adults. Dementia does not have a sudden onset. Senile confusion is not a recognized health problem.

The perioperative nurse is preparing to discharge a female patient home from day surgery performed under general anesthetic. What instruction should the nurse give the patient prior to the patient leaving the hospital? A) The patient should not drive herself home B) The patient should take an OTC sleeping pill for 2 nights C) The patient should attempt to eat a large meal at home to aid wound healing D) The patient should remain in bed for the first 48 hours postoperative.

A) The patient should not drive herself home Although recovery time varies, depending on the type and extent of surgery and the patients overall condition, instructions usually advise limited activity for 24 to 48 hours. Complete bedrest is contraindicated in most cases, however. During this time, the patient should not drive a vehicle and should eat only as tolerated. The nurse does not normally make OTC recommendations for hypnotics.

The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply A) Provide all discharge instructions in writing B) Provide the nurse or surgeons contact information C) Give prescriptions to the patient D) Irrigate the patients incision and perform a sterile dressing change E) Administer a bolus dose of an opioid analgesic

A, B, C A) Provide all discharge instruction in writing B) Provide the nurse or surgeons contact information C) Give prescriptions to the patient. Before discharging the patient, the nurse provides written instructions, prescriptions and the nurses or surgeons telephone number. Administration of an opioid would necessitate further monitoring to ensure safety. A dressing change would not normally be ordered on the day of surgery.

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? Recheck in 1 hour for increased drainage. Notify the surgeon of a potential hemorrhage. Assess the patient's blood pressure and heart rate. Remove the dressing and assess the surgical incision.

Assess the patient's blood pressure and heart rate. 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.

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? Assess the patient's pain. Assess the patient's vital signs. Check the rate of the IV infusion. Check the physician's postoperative orders.

Assess the patient's vital signs. 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.

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? 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.

The nurse is creating the plan of care for a patient who is status postsurgery for reduction of a femur fracture. What is the most important short-term goal for this patient? A) Relief of pain B) Adequate respiratory function C) Resumption of activities of daily living (ADLs) D) Unimpaired wound healing

B) Adequate respiratory function maintenance of the patients airway and breathing are imperative. Respiratory status is important because pulmonary complications are among the most frequent and serious problems encountered by the surgical patient. Wound healing and eventual resumption of ADLs would be later concerns. Pain management is a high priority, but respiratory function is a more acute physiological need.

The nurse is preparing to change a patients abdominal dressing. The nurse recognizes the first step is to provide the patient with information regarding the procedure. Which of the following explanations should the nurse provide to the patient? A) The dressing change is often painful, and we will be giving you pain medication prior to the procedure so you do not have to worry B) During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to. C) The dressing change should not be painful, but you can never be sure, and infection is always a concern D) The best time for doing a dressing change is during lunch so we are not interrupted. I will provide privacy, and it should not be painful.

B) During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to. When having dressing changed, the patient needs to be informed that the dressing change is a simple procedure with little discomfort; privacy will be provided; and the patient is free to look at the incision or even assist in the dressing change itself. If the patient decides to look at the incision, assurance is given that the incision will shrink as it heals and that the redness will likely fade. Dressing changes should not be painful, but giving pain medication prior to the procedure is always a good preventive measure. Telling the patient that the dressing change should not be painful, but you can never be sure, and infection is always a concern does not offer the patient any real information or options and serves only to create fear. The best time for dressing changes is when it is most convenient for the patient; nutrition is important so interrupting lunch is probably a poor choice.

The surgeons preoperative assessment of a patient has identified that the patient is at a high risk for venous thromboembolism. Once the patient is admitted to the post-surgical unit, what intervention should the nurse prioritize to reduce the patients risk of developing this complication? A) Maintain the head of the bed at 45 degrees or higher B) Encourage early ambulation C) Encourage oral fluid intake D) Perform passive range of motion exercises every 8 hours

B) Encourage early ambulation The benefits of early ambulation and leg exercises in preventing DVT cannot be overemphasized, and these activities are recommended for all patients, regardless of their risk. Increasing the head of the bed is not effective. Ambulation is superior to passive range-of-motion exercises. Fluid intake is important, but is less protective than early ambulation.

The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the patient blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the patients skin is cold, moist, and pale. Of what is the patient showing signs? A) Hypothermia B) Hypovolemic shock C) Neurogenic shock D) Malignant hyperthermia

B) Hypovolemic shock The patient is exhibiting symptoms of hypovolemic shock; therefore, the nurse should notify the patients physician and anticipate ordres for fluid and/or blood product replacement. Neurogenic shock does not normally result in tachycardia and malignant hyperthermia would not present at this stage in the operative experience. Hypothermia does not cause hypotension and tachycardia.

The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority? A) Assessing for hemorrhage B) Maintaining a patent airway C) Managing the patients pain D) Assessing vital signs every 30 minutes

B) Maintaining a patent airway The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Assessing for hemorrhage and assessing vital sign are also important, but constitute second and third priorities. Pain management is important but only after the patient has been stabilized.

A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do? A) Irrigate the Foley with 30 mL normal saline B) Notify the physician and continue to monitor the hourly urine output closely C) Decrease the IV fluid rate and massage the patients abdomen D) Have the patient sit in high-Flowlers position.

B) Notify the physician and continue to monitor the hourly urine output closely If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/hr are reported. The urine output should continue to be monitored hourly by the nurse. Irrigation would not be warranted.

The nursing instructor is discussing the difference between ambulatory surgical centers and hospital-based surgical units. A student asks why some patients have surgery in the hospital and others are sent to ambulatory surgery centers. What is the instructors best response? A) Patients who go to ambulatory surgery centers are more independent than patients admitted to the hospital B) Patients admitted to the hospital for surgery usually have multiple health needs C) In most cases, only emergency and trauma patients are admitted to the hospital. D) Patients who have surgery in the hospital are those who need to have anesthesia administered

B) Patients admitted to the hospital for surgery usually have multiple health needs Patients admitted to the clinical unit for postoperative care have multiple needs and stay for a short period of time. Patients who have surgery in ambulatory centers do not necessarily have greater independence. It is not true that only trauma and emergency surgeries are done in the hospital. Ambulatory centers can administer anesthesia.

The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurses first response? A) Return the patient to his previous position and call the physician B) Place saline-soaked sterile dressing on the wound C) Assess the patients blood pressure and pulse D) Pull the dehiscence closed using gloved hands

B) Place saline-soaked sterile dressing on the wound The nurse should first place saline-soaked sterile dressing on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the patients vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.

A postoperative patient rapidly presents with hypotension; rapid, thready pulse, oliguria; and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should the nurses first action? A) Leave and promptly notify the physician B) Quickly attempt to determine the cause of hemorrhage C) Begin resuscitation D) Put the patient in the Trendelenburg position

B) Quickly attempt to determine the cause of hemorrhage Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures. Resuscitation is not necessarily required and the nurse must not leave the patient. The Trendelenburg position would be contraindicated.

A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? Select all that apply A) Absence of pain B)Stable blood pressure C) Ability to tolerate oral fluids D) Sufficient oxygen saturation E) Adequate respiratory function

B) Stable blood pressure D) Sufficient oxygen saturation E) Adequate respiratory function A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. Patients can be released from PACU before resuming oral intake. Pain is often present at discharge from the PACU and can be addressed in other inpatient settings.

The nursing instructor is discussing postoperative care with a group of nursing students. A student nurse asks, Why does the patient go to the PACU instead of just going straight up to the postsurgical unit? What is the nursing instructors best response? B) The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications C) Frequently, patients are placed in the medical surgical unit to recover, but hospitals are usually short of beds, and the PACU is an excellent place to triage patients D) Patients remain in the PACU for a predetermined time because the surgeon will often need to reinforce or alter the patien

B) The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications The PACU provides care for the patient while he or she recovers from the effects of anesthesia. The patient must be oriented, have stable vital signs, and show no evidence of hemorrhage or other complications. Patients will sometimes recover in the ICU, but this is considered an extension of the PACU. The PACU does allow the patient to recover from anesthesia, but the environment is calm and quiet as patients are initially disoriented and confused as they begin to awaken and reorient. Patients are not usually placed in the medical surgical unit for recovery and, although hospitals are occasionally short of beds, the PACU is not used for patient triage. Incisions are very rarely modified in the immediate postoperative period.

A patient underwent an open bowel resection 2 days ago and the nurses most recent assessment of the patients abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have caused the dehiscence? A) The patient surgical dressing was changed yesterday and today B) The patient has vomited three times in the past 12 hours C) The patient has begun voiding on the commode instead of a bedpan D) The patient used PCA until this morning.

B) The patient has vomited three times in the past 12 hours Vomiting can produce tension on wounds, particularly of the torso. Dressing changes and light mobilization are unlikely to cause dehiscence. The use of a PCA is not associated with wound dehiscence.

The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patients is not breathing. What is the priority intervention? A) Check the patients oxygen saturation level, continue to monitor for apnea, and perform a focused assessment B) Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw C) Assess the arterial pulses, and place the patient in the Trendelenburg position D) Reintubate the patient

B) Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw. When a nurse finds a patient who is not breathing, the priority intervention is to open the airway and treat a possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the head back and then pushes forward on the angle of the lower jaw or performs the jaw thrust method to open the airway. This is an emergency and requires the basic life support intervention of airway, breathing, and circulation assessment. Arterial pulses should be checked only after airway and breathing have been established. Reintubation and resuscitation would begin after rapidly ruling out a hypopharyngeal obstruction.

The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patients possible readiness to learn how to change her dressing? Select all that apply. A) The patient wants you to teach a family member to do dressing changes B) The patient expresses interest in the dressing change C) The patient is willing to look at the incision during a dressing change D) The patient expresses dislike of the surgical wound E) The patient assist in opening the packages of dressing material for the nurse.

B, C, E B) The patient expresses interest in the dressing change C) The patient is willing to look at the incision during a dressing change E) The patient assist in opening the packages of dressing material for the nurse While changing the dressing, the nurse has an opportunity to teach the patient how to care for the incision and change the dressings at home. The nurse observes for indicators of the patients readiness to learn, such as looking at the incision, expressing interest, or assisting in the dressing change. Expressing dislike and wanting to delegate to a family member do not suggest readiness to learn.

Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5 g/dL, and a blood pressure lying in bed of 110/70 mm Hg. The nurse suspects abnormal orthostatic changes when the client gets out of bed and reports vertigo. What vital sign value most supports the client's orthostatic changes? a) Blood pressure of 120/90 mm Hg b) Blood pressure of 110/80 mm Hg c) Blood pressure of 90/50 mm Hg d) Blood pressure of 150/100 mm Hg

Blood pressure of 90/50 mm Hg Explanation: The client had blood loss during the splenectomy and developed subsequent anemia. With a subnormal Hb level and vertigo when getting out of bed, the nurse is accurate in suspecting orthostasis. Orthostatic changes develop from hypovolemia and cause a drop in blood pressure (evidenced by a blood pressure of 80/40 mm Hg) when the client rises from a lying position.

A client is transferred from the postanesthesia care unit (PACU) to an inpatient care unit. What will the nurse assess first? a) Breathing b) Pain level c) Surgical site d) Level of consciousness

Breathing Explanation: The nurse will assess the client being transferred from the PACU to an inpatient care unit. The priority is to assess breathing and administer oxygen if prescribed because this provides a baseline and helps identify for the development of respiratory distress. Pain level is assessed after the surgical site and level of consciousness are assessed.

The nurse just received a postoperative patient from the PACU to the medical surgical unit. The patient is an 84-year old woman who had surgery for a left hip replacement. Which of the following concerns should the nurse prioritize for this patient in the first few hours on the unit? A) Beginning early ambulation B) Maintaining clean dressings on the surgical site C) Close monitoring of neurologic status D) Resumption of normal oral intake

C) Close monitoring of neurologic status In the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding are primary concerns. A patient who has had total hip replacement does not ambulate during the first few hours on the unit. Dressings are assessed, but may have some drainage on them. Oral intake will take more time to resume.

The home health nurse is caring for a postoperative patient who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the patients postoperative day 2. During the visit, the nurse will assess for wound infection. For most patients, what is the earliest postoperative day that a wound infection becomes evident? A) Day 9 B) Day 7 C) Day 5 D) Day 3

C) Day 5 Wound infection may not be evident until at least postoperative day 5. This makes the other options incorrect.

The intraoperative nurse is transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year-old woman. The nurse should prioritize which of the following actions? A) Keeping the patient sterile B) Keeping the patient restrained C) Keeping the patient warm D) Keeping the patient hydrated

C) Keeping the patient warm Special attention is given to keeping the patient warm because elderly patients are more susceptible to hypothermia. It is all important for the nurse to pay attention to hydration, but hypovolemia does not occur as quickly as hypothermia. The patient is never sterile and restraints are very rarely necessary.

The nurse is caring for an 82-year-old female patient in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurses subsequent assessment? A) Postoperative confusion in older adults is an indication of impaired oxygenation or possibly a stroke during surgery B) Confusion, restlessness, and agitation are expected postoperative findings in older adults and they will diminish in time. C) Postoperative confusion is common in the older patient, but it could also indicate a significant blood loss. D)Confusion, restlessness, and agitation indicate an underlying cognitive deficit such as dementia

C) Postoperative confusion is common in the older patient, but it could also indicate a significant blood loss Postoperative confusion is common in the older adult patient, but it could also indicate blood loss and the potential for hypovolemic shock; it is a critical symptom for the nurse to identify. Despite being common, it is not considered to be an expected finding. Postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery, but blood loss is more likely. A new onset of confusion, restlessness, and agitation does not necessarily suggest an underlying cognitive disorder.

The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication? A) Sepsis B) Infection C) Pulmonary embolism D) Hematoma

C) Pulmonary embolism Patients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of an external pneumatic compression stocking significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection or sepsis would not be affected by an external pneumatic compression stocking. A hematoma or bruise would not be affected by the external pneumatic compression stocking unless the stockings were placed directly over the hematoma.

The nurse is caring for a patient on the medical surgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection? A) Presence of an indwelling urinary catheter B) Rectal temperature of 99.5 F (37.5C) C) Red, warm, tender incision D) White blood cell (WBC) count of 8,000/mL

C) Red, warm, tender incision Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a patient to infection, but by itself does not indicate infection. An oral temperature of 99.5F may not signal infection in a postoperative patient because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/mL

The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do? A) Sit in a chair for 10 minutes prior to ambulating B) Drink plenty of fluids to increase circulating blood volume C) Stand upright for 2 to 3 minutes prior to ambulating D) Perform range-of-motion exercises for each joint

C) Stand upright for 2 to 3 minutes prior to ambulating Older adults are at an increased risk for orthostatic hypotension secondary to age-related changes in vascular tone. The patient should sit up and then stand for 2 to 3 minutes before ambulating to alleviate orthostatic hypotension. The nurse should assess the patients ability to mobilize safely, but full assessment of range of motion in all joints is not normally necessary. Sitting in a chair and increasing fluid intake are insufficient to prevent orthostatic hypotension and consequent falls.

The nurse is caring for a patient after abdominal surgery in the PACU. The patients blood pressure has increased and the patient is restless. The patients oxygen saturation is 97%. What cause for this change is status should the nurse first suspect? A) The patient is hypothermic B) The patient is in shock C) The patient is in pain D) The patient is hypoxic

C) The patient is in pain An increase in blood pressure and restless are symptoms of pain. The patients oxygen saturation is 97%, so hypothermia, hypoxia, and shock are not likely causes of the patients restlessness.

The nurse is the Ed is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what mean? A) Late intention B) Second intention C) Third intention D) First intention

C) Third intention Third-intention healing or secondary suture is used for deep wounds that either had not been sutured early or that had the suture break down and are resutured later, which is what has happened in this case. Secondary suture brings the two opposing granulation surfaces back together; however, this usually results in a deeper and wider scar. These wounds are also packed postoperatively with moist gauze and covered with a dry, sterile dressing. Late intention is a term that sounds plausible, but is not used in practice. Second intention is when the wound is left open and the wound is filled with granular tissue. First intention wounds are wounds made aseptically with a minimum of tissue destruction.

The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion? A) Describe the appearance of the dressing in the electronic health record B) Photograph the patients abdomen for later comparison using a smartphone C) Trace the outline of the drainage on the dressing for future comparison. D) Remove and weigh the dressing, reapply it, and then repeat it 8 hours

C) Trace the outline of the drainage on the dressing for future comparison Spots of drainage on a dressing are outlined with a pen, and the date and time of the outline are recorded on the dressing so that increased drainage can be easily seen. A dressing is never removed and then reapplied. Photographs normally require informed consent, so they would not be used for this purpose. Documentation is necessary, but does not confirm or rule out an increase in drainage.

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? Check his chart for intraoperative complications. Check which medications were used for anesthesia. Check the effectiveness of the analgesics he has received. Check his preoperative assessment for previous delirium or dementia.

Check his preoperative assessment for previous delirium or dementia. 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.

The recovery room nurse is admitting a patient from the OR following the patients successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted patient? A) Heart rate and rhythm B) Skin integrity C) Core body temperature D) Airway patency

D) Airway patency The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).

The nursing instructor is talking with a group of medical surgical students about deep vein thrombosis (DVT). A student asks what factors contribute to the formation of a DVT. What would be the instructors best response? A) There is a genetic link in the formation of deep vein thrombi B)Hypervolemia is often present in patients who go on to develop deep vein thrombi C) No known factors contribute to the formation of deep vein thrombi; they just occur D) Dehydration is a contributory factor to the formation of deep vein thrombi

D) Dehydration is a contributory factor to the formation of deep vein thrombi The stress response that is initiated by surgery inhibits the fibrinolytic system, resulting in blood hyper coagulability. Dehydration, low cardiac output, blood pooling in the extremities, and bedrest add to the risk of thrombosis formation. Hypervolemia is not a risk factor and there are no known genetic factors.

The nurse is admitting a patient to the medical surgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia? A) Encourage the patient to eat a balanced diet that is high in protein B) Encourage the patient to limit his activity for the first 72 hours C) Encourage the patient to take his medication as ordered D) Encourage the patient to use the incentive spirometer every 2 hours

D) Encourage the patient to use the incentive spirometer every 2 hours To clear secretions and prevent pneumonia, the nurse encourages the patient to turn frequently, take deep breaths, cough, and use the incentive spirometer at lest every 2 hours. These pulmonary exercises should begin as soon as the patient arrives on the clinical unit and continue until the patient is discharged. A balanced, high protein diet; visiting family in the waiting room; or taking medications as ordered would not help to clear secretions or prevent pneumonia.

The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer. Which of the following statements by the patient indicates that teaching has been effective? A) I'll make sure to limit my intake of protein B)I'll make sure that the bandage is wrapped tightly C) My foot should feel cool or cold while my legs healing D) I'll eat plenty of fruits and vegetables.

D) I'll eat plenty of fruits and vegetables Optimal nutritional status is important for wound healing; the patient should eat plenty of fruits and vegetables and not reduce protein intake. To avoid impeding circulation to the area, the bandage should be secure but not tight. If the patients foot feels cold, circulation is impaired, which inhibits wound healing.

The PACU nurse is caring for a male patient who had a hernia repair. The patients blood pressure is now 164/92 mm/Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery? A) Dysrhythmias, blood loss, and hyperthermia B) Electrolyte imbalances and neurologic changes C) A parasympathetic reaction and low blood volumes D) Pain, hypoxia, or bladder distention

D) Pain, hypoxia, or bladder distention Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Dysrhythmias, blood loss, hyperthermia, electrolyte imbalances, and neurologic changes are not common postoperative reasons for hypertension. A parasympathetic reaction and low blood volumes would cause hypotension.

An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patients vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next? A) Administer a dose of IV analgesic B) Apply a cool cloth to the patients forehead C) Offer the patient a small amount of ice chips D) Turn the patient completely to one side

D) Turn the patient completely to one side Turning the patient completely to one side allows collected fluid to escape from the side of the mouth if the patient vomits. After turning the patient to the side, the nurse can offer a cool cloth to the patients forehead. Ice chips can increase feelings of nausea. An analgesic is not administered for nausea and vomiting.

The nurse is changing the dressing of a client who is 4 days postoperative with an abdominal wound. The nurse has changed this dressing daily since surgery. Today, the nurse notes increased serosanguinous drainage, wound edges not approximated, and a ¼-inch (6 mm) gap at the lower end of the incision. The nurse concludes which of the following conditions exists? a) Evisceration b) Normal healing by primary intention. c) Hemorrhage d) Dehiscence

Dehiscence Explanation: Dehiscence is a disruption of the incision.

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? a) Third intention b) Fourth intention c) First intention d) Second intention

First intention Explanation: When wounds heal by first intention, granulation tissue is not visible and scar formation is minimal. Many postoperative wounds are covered with a dry sterile dressing. Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in which the edges have not been well approximated. Third-intention healing (secondary suture) is used for deep wounds that either have not been sutured early or break down and are resutured later, thus bringing together two apposing granulation surfaces. Fourth-intention is not a type of wound healing.

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? Increased respiratory rate Decreased oxygen saturation Increased carbon dioxide pressure Frequent premature ventricular contractions (PVCs)

Increased carbon dioxide pressure 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.

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? Left lateral position with head supported on a pillow Prone position with a pillow supporting the abdomen Supine position with head of bed elevated 30 degrees Semi-Fowler's position with the head turned to the right

Left lateral position with head supported on a pillow 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.

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? 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 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.

Corticosteroids have which effect on wound healing? a) May cause protein-calorie depletion b) Mask the presence of infection c) Cause hemorrhage d) Reduce blood supply

Mask the presence of infection Explanation: Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. Edema may reduce blood supply. Corticosteroids do not cause hemorrhage or protein-calorie depletion.

A client is at postoperative hour 8 after an appendectomy and is anxious, stating "Something is not right. My pain is worse than ever and my stomach is swollen." Blood pressure is 88/50, pulse is 115, and respirations are 24 and labored. The abdomen is soft and distended. No obvious bleeding is noted. What action by the nurse is most appropriate? a) Ambulate the client to reduce abdominal distention. b) Inform the client this is the normal progression after abdominal surgery. c) Notify the physician. d) Administer morphine per orders.

Notify the physician. Explanation: The physician should be notified of the findings. The client may be hemorrhaging internally and may need to return to surgery. The client may be in need of pain medication, but morphine will lower the blood pressure further and may cause further complications. Ambulating the client increases the risk of injury because the client may experience orthostatic hypotension. What the client is experiencing is not the normal progression after abdominal surgery

A postoperative client with an open abdominal wound is currently taking corticosteroids. The physician orders a culture of the abdominal wound even though no signs or symptoms of infection are seen. What action by the nurse is appropriate? a) Hold the order until purulent drainage is noted. b) Request the order be discontinued without obtaining the specimen. c) Obtain the wound culture specimen. d) Use an antibiotic cleaning agent before obtaining the specimen.

Obtain the wound culture specimen. Explanation: Corticosteroids may mask the presence of infection by impairing the normal inflammatory response. The culture should be obtained even though the client is not demonstrating traditional signs and symptoms of infection. The order should not be discontinued or held until purulent drainage is noted because the infection could worsen and the client could develop sepsis. An antibiotic cleaning agent should not be used before obtaining the specimen because it will alter the growth of the organisms.

Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention? a) Respiratory rate of 12 breaths per minute b) Blood pressure of 94/62 mm Hg c) Urine output of 60 ml/hr d) Oxygen saturation of 82%

Oxygen saturation of 82% Explanation: Normal pulse oximetry is 95% to 100%. An oxygen saturation of 82% indicates respiratory compromise and requires immediate attention

Which is a classic sign of hypovolemic shock? a) Bradypnea b) Pallor c) High blood pressure d) Dilute urine

Pallor Explanation: The classic signs of hypovolemic shock are pallor, rapid, weak thready pulse, low blood pressure, and rapid breathing.

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? a) Pale yet able to blanch with digital pressure b) Pink to red and soft, noting that it bleeds easily c) White with long, thin areas of scar tissue d) Necrotic and hard

Pink to red and soft, noting that it bleeds easily Explanation: Second-intention healing (granulation) occurs in infected wounds or in wounds in which the edges have not been approximated. Gradually, the necrotic material disintegrates and escapes, and the abscess cavity fills with a red, soft, sensitive tissue that bleeds easily. This tissue is composed of minute, thin-walled capillaries and buds that later form connective tissue. These buds, called granulations, enlarge until they fill the area left by the destroyed tissue. Healing is complete when skin cells grow over these granulations.

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? a) Pneumonia b) Hypoxemia c) Pleurisy d) Pulmonary edema

Pneumonia Explanation: Older clients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Delirium, pneumonia, decline in functional ability, exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and falls are all threats to recovery in the older adult.

A nurse is caring for a client in the PACU after surgery requiring general anesthesia. The client tells the nurse, "I think I'm going to be sick." What is the primary action taken by the nurse? a) Obtain an emesis basin. b) Position the client in the side-lying position. c) Ask the client for more clarification. d) Administer an anti-emetic.

Position the client in the side-lying position. Explanation: The primary action taken by the nurse should be to position the client in the side-lying position in order to prevent aspiration of stomach contents if the client vomits. The nurse may also obtain an emesis basin and administered an anti-emetic if one is ordered; however, these will be done after the client is repositioned. There is no need for the nurse to ask the client for more clarification.

The nurse is caring for the postoperative client in the postanesthesia care unit. Which of the following is the priority nursing action? a) Assess the incisional dressing to detect hemorrhage. b) Monitor vital signs for early detection of shock. c) Position the client to maintain a patent airway. d) Administer antiemetics to prevent nausea and vomiting.

Position the client to maintain a patent airway. Explanation: Maintaining a patent airway is the immediate priority in the PACU.

What complication is the nurse aware of that is associated with deep venous thrombosis? a) Pulmonary embolism b) Immobility because of calf pain c) Marked tenderness over the anteromedial surface of the thigh d) Swelling of the entire leg owing to edema

Pulmonary embolism Explanation: Serious potential venous thromboembolism complications of surgery include deep vein thrombosis and pulmonary embolism (Rothrock, 2010).

Which action should a nurse perform to prevent deep vein thrombosis when caring for a postsurgical client? a) Reinforce the need to perform leg exercises every hour when awake. b) Instruct the client to prop a pillow under the knees. c) Administer prophylactic high-dose heparin. d) Maintain bed rest.

Reinforce the need to perform leg exercises every hour when awake. Explanation: The nurse should reinforce the need to perform leg exercises every hour when awake. Maintaining bed rest increases the pooling of blood in the lower extremities, increasing the risk for deep vein thrombosis. The client may be given low-dose heparin for prophylactic treatment, but not high-dose heparin. The nurse should instruct the client not to prop a pillow under the knees because it can constrict the blood vessels.

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? a) Elevating the head of the bed b) Reinforcing the dressing or applying pressure if bleeding is frank c) Monitoring vital signs every 15 minutes d) Encouraging the client to breathe deeply

Reinforcing the dressing or applying pressure if bleeding is frank Explanation: The nurse should reinforce the dressing or apply pressure if bleeding is frank. The nurse should keep the head of the bed flat unless it is contraindicated. Encouraging the client to breathe deeply will not help manage and minimize hemorrhage and shock. Monitoring vital signs every 15 minutes is an appropriate nursing intervention but will not minimize hemorrhage and shock; it will just help to determine the extent and progression of the problem.

A nurse is teaching a client about deep venous thrombosis (DVT) prevention. What teaching would the nurse include about DVT prevention? a) Rely on the IV fluids for hydration. b) Report early calf pain. c) Dangle at the bedside. d) Take off the pneumatic compression devices for sleeping.

Report early calf pain. Explanation: The client needs to report calf pain or cramping for the nurse to investigate any swelling or potential DVT. Blanket rolls or prolonged dangling should be avoided to reduce impediment of circulation behind the knee. Prevention of DVT includes early ambulation, use of antiembolism or pneumatic compression devices, and low-molecular-weight or low-dose heparin and low-dose warfarin for clients postoperatively. Adequate fluids need to be offered to avoid dehydration.

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? Blood administration Restoring circulating volume An ECG to check circulatory status Return to surgery to check for internal bleeding

Restoring circulating volume 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.

Which method of wound healing is one in which wound edges are not surgically approximated and integumentary continuity is restored by granulation? a) Third-intention healing b) Second-intention healing c) First-intention healing d) Primary-intention healing

Second-intention healing Explanation: When wounds dehisce, they are allowed to heal by secondary intention. Primary or first-intention healing is the method of healing in which wound edges are surgically approximated and integumentary continuity is restored without granulation. Third-intention healing is a method of healing in which surgical approximation of wound edges is delayed and integumentary continuity is restored by bringing apposing granulations together.

A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition? a) The client is displaying early signs of shock. b) The client is showing signs of an anesthesia reaction. c) The client is showing signs of a medication reaction. d) The client is displaying late signs of shock.

The client is displaying early signs of shock. Explanation: The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated. Medication or anesthesia reactions may cause client symptoms similar to these; however, these causes are not as likely as early shock.

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)? Vital signs baseline or stable Minimal nausea and vomiting Wants to go to the bathroom at home Responsible adult taking patient home Comfortable after IV opioid 15 minutes ago

Vital signs baseline or stable Minimal nausea and vomiting Responsible adult taking patient home 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.

The nurse is caring for a client during the immediate postoperative period and is assessing for signs of shock. What signs and symptoms indicate that the client may be in shock? a) Weak and rapid pulse rate b) Obstructed airway c) Warm, dry skin d) Pooling of secretions in the lungs

Weak and rapid pulse rate Explanation: Signs and symptoms of shock include pallor, fall in blood pressure, weak and rapid pulse rate, restlessness, and cool, moist skin. Pooling of secretions in the lungs and an obstructed airway predispose the client to hypoxia and not to shock.

The nurse's assessment of a postop client reveals a temperature of 103.2°F, tachycardia, and client complaints of increased incisional pain. What does the nurse recognize that this client is experiencing? a) Wound infection b) Uncontrolled pain c) Hyperthermia d) Atelectasis

Wound infection Explanation: Clinical manifestations of a wound infection include fever, tachycardia, an elevated white blood cell count, and increased incisional pain.

What measurement should the nurse report to the physician in the immediate postoperative period? a) A systolic blood pressure lower than 90 mm Hg b) A temperature reading between 97°F and 98°F c) A hemoglobin of 13.6 d) Respirations between 20 and 25 breaths/min

a) A systolic blood pressure lower than 90 mm Hg Pg. 440 A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal.

A client recovering from surgery asks, "When can I go home?" The nurse responds by stating which of the following activities must be completed before discharging home? Select all that apply. a) Be independent with toileting b) Perform instrumental activities of daily living c) Get in and out of bed unassisted d) Ambulate a functional distance e) Complete total self-care

a) Be independent with toileting c) Get in and out of bed unassisted d) Ambulate a functional distance Pg. 449 For a safe discharge to home, clients need to be independent with toileting, able to ambulate a functional distance (e.g., length of the house or apartment), and get in and out of bed unassisted. The client does not need to be able to complete total self-care or perform instrumental activities of daily living before being discharged after surgery.

A patient has a wound that has hemorrhaged. What does the nurse understand is the cause of the patient's increased risk of infection? a) Dead space and dead cells provide a culture medium b) The tissue becomes less resilient c) Reduced amounts of oxygen and nutrients are available d) Retrograde bacterial contamination may occur

a) Dead space and dead cells provide a culture medium Pg. 451 In hemorrhage, accumulation of blood creates dead spaces as well as dead cells that must be removed. The area becomes a growth medium for organisms.

The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply.) a) Encouraging early ambulation b) Assisting the patient with leg exercises c) Applying compression stockings only at night d) Massaging the legs every 4 hours e) Avoiding placement of pillows or blanket rolls under the patient's knees

a) Encouraging early ambulation b) Assisting the patient with leg exercises e) Avoiding placement of pillows or blanket rolls under the patient's knees Pg. 449 The benefits of early ambulation and leg exercises in preventing deep vein thrombosis cannot be overemphasized, and these activities are recommended for all patients, regardless of their risk. It is important to avoid the use of blanket rolls, pillow rolls, or any form of elevation that can constrict vessels under the knees. Compression stockings should be worn all the time, not just at night. Massage would be contraindicated due to the risk of dislodging a clot.

A nurse assesses a postoperative client as having abdominal organs protruding through the surgical incision. Which term best describes this assessment finding? a) Evisceration b) Erythema c) Dehiscence d) Hernia

a) Evisceration Pg. 456 Evisceration is a surgical emergency. A hernia is a weakness in the abdominal wall. Dehiscence refers to the partial or complete separation of wound edges. Erythema refers to the redness of tissue.

A client in the postanesthesia care unit (PACU) develops a blood pressure of 180/90 mm Hg. Which assessment will the nurse complete to determine the cause of the blood pressure findings? Select all that apply. a) Hypoxia b) Pain c) Bladder distention d) Nausea e) Bowel obstruction

a) Hypoxia b) Pain c) Bladder distention Pg. 440 Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation. Reasons for an increase in blood pressure in the PACU include pain, hypoxia, or bladder distention. This assessment finding is managed by treating the underlying cause. Nausea and bowel obstruction are not identified as causing hypertension in clients during the PACU period.

The nurse is attempting to ambulate a client who underwent shoulder surgery earlier in the day, but the client is refusing to do so. What action by the nurse is most appropriate? a) Reinforce the importance of early mobility in preventing complications b) Document the client's refusal c) Delegate the task to the unlicensed assistive personnel d) Use multiple staff members to remove the client from the bed

a) Reinforce the importance of early mobility in preventing complications Pg. 449 The client may be refusing to ambulate because of fear or pain. Educating the client on the importance of mobility in preventing complications may encourage the client to ambulate. The nurse should try all reasonable measures (e.g., pain control, education) before documenting the client's refusal to ambulate. If the client is already refusing to ambulate, delegating the task to the unlicensed assistive personnel is not an appropriate action. The client should not be forcefully removed from the bed.

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what? a) Urine retention b) Urinary infection c) Calculus formation d) Requirement of intermittent catheterization

a) Urinary retention Pg. 455 Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus.

When should the nurse encourage the postoperative patient to get out of bed? a) Within 6 to 8 hours after surgery b) As soon as it is indicated c) Between 10 and 12 hours after surgery d) On the second postoperative day

b) As soon as it is indicated Pg. 449 Postoperative activity orders are checked before the patient is assisted to get out of bed, in many instances, on the evening following surgery. Sitting up at the edge of the bed for a few minutes may be all that the patient who has undergone a major surgical procedure can tolerate at first.

When the nurse observes that a postoperative client demonstrates a constant low level of oxygen saturation via the O2 saturation monitor despite the client's breathing appearing normal, what action should the nurse take first? a) Document the findings b) Assess the client's heart rhythm and nail beds c) Notify the physician d) Apply oxygen

b) Assess the client's heart rhythm and nail beds Pg. 439 A client may demonstrate low oxygenation readings because of certain colors of nail polish or may show an irregular heart rate such as atrial fibrillation. These factors should be assessed to ensure the accuracy of the oxygen reading. Once the reading is confirmed as accurate, then the nurse may need to apply oxygen, notify the physician, and document the findings.

A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention? a) Obtaining dietary consultation for improved wound healing b) Assessing WBC count, temperature, and wound appearance c) Administering pain medications within 1 hour of the client's request d) Educating the client on safe bed-to-chair transfer procedures

b) Assessing WBC count, temperature, and wound appearance Pg. 456 The client has an increased risk for infection related to the surgical wound, which is classified as dirty. Assessing the WBC count, temperature, and wound appearance allows the nurse to intervene at the earliest sign of infection. The client will have special nutritional needs during wound healing and needs education on safe transfer procedures, but the need to monitor for infection is a higher priority. The client should receive pain medication as soon as possible after asking, but the latest literature suggests that pain medication should be given on a schedule versus "as needed."

A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action? a) Prepare to administer a stool softener b) Call the health care provider c) Re-attempt to auscultate bowel sounds d) Prepare to insert a nasogastric tube

b) Call the health care provider The client presents with a possible paralytic ileus, a serious condition where the intestines are paralyzed and peristalsis is absent. This may occur as a result of surgery, especially abdominal surgery. If the nurse is unable to auscultate bowel sounds and the client has pain and a rigid abdomen, the nurse will suspect an ileus and immediately call the health care provider. Re-attempting auscultation may occur, but only after the health care provider has been notified. The health care provider may order the placement of an NG tube, however, the nurse cannot do this without the provider's order. Administering a stool softener will not help the client and may make the condition worse.

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound a) Hemorrhaged b) Dehisced c) Pustulated d) Eviscerated

b) Dehisced Pg. 456 Dehiscence is the partial or complete separation of wound edges. Evisceration is the protrusion of organs through the surgical incision. Pustulated refers to the formation of pustules. Hemorrhage is excessive bleeding.

When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority. a) Fluid volume deficit b) Impaired gas exchange c) Altered comfort d) Anxiety e) Risk for infection

b) Impaired gas exchange a) Fluid volume deficit c) Altered comfort d) Anxiety e) Risk for infection Pg. 448-452 According to the Maslow's hierarchy of deeds, airway and gas exchange is of the highest priority. Next would be the deficiency in fluid volume. Altered comfort would be higher than anxiety because decreasing pain may alleviate/reduce anxiety. Lastly, a risk for infection is not a current problem but it is still important to reduce the risk.

Nursing assessment findings reveal a temperature of 96.2°F, pulse oximetry 90%, shivering, and client complains of chilling. The findings are indicative of which nursing diagnosis? a) Ineffective airway clearance b) Ineffective thermoregulation c) Decreased cardiac output d) Acute incisional pain

b) Ineffective thermoregulation Pg. 441-442 Clinical manifestations of hypothermia include a low body temperature, shivering, chilling, and hypoxia.

The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order? a) Omeprazole b) Ondansetron c) Nizatidine d) Chlorpromazine

b) Ondansetron Pg. 441 Ondansetron (Zofran) is used to treat nausea and vomiting.

A postanesthesia care unit (PACU) nurse is preparing to discharge a client home following ankle surgery. The client keeps staring at the ceiling while being given discharge instructions. What action by the nurse is appropriate? a) Ask the client, "Do you understand?" b) Review the instructions with the client and an accompanying adult c) Continuously repeat the instructions until the client restates them d) Give the written instructions to the client's 16-year-old child

b) Review the instructions with the client and an accompanying adult Pg. 438 The effects of anesthesia may impair a client's memory or concentration. It is important that the discharge instructions are covered with the client and an accompanying adult. Giving the instructions to a 16-year-old is not appropriate. Repeating the instructions until the client restates them does not ensure that the client will remember them, because anesthesia can impair memory. Asking whether the client understands the instructions only elicits an yes or no answer; it does not give insight into whether the client comprehends the instructions.

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage? a) The client has been lying on his side for 2 hours with the drain positioned upward b) The Hemovac drain isn't compressed; instead it's fully expanded c) The client has a nasogastric (NG) tube in place that drained 400 ml d) There is a moderate amount of dry drainage on the outside of the dressing

b) The Hemovac drain isn't compressed; instead it's fully expanded Pg. 452 The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.

The nurse is planning care for a client following abdominal surgery. Which outcome demonstrates a return of functioning to the gastrointestinal tract? a) The client states being hungry b) The client reports a small bowel movement and flatus c) The client is breathing calmly d) The client is tolerating sips of water

b) The client reports a small bowel movement and flatus Pg. 454 A bowel movement demonstrates that the nursing outcome of the return to function of the gastrointestinal track has been met. All of the other options are components of meeting the outcome of functioning.

What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? a) Between 75 and 100 mL b) >200 mL c) <30 mL d) Between 100 and 200 mL

c) <30 mL Pg. 448 If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL per hour are reported; if the patient is voiding, an output of less than 240 mL per 8-hour shift is reported.

The nurse is caring for a postoperative client with a Hemovac. The Hemovac is expanded and contains approximately 25 cc of serosanguineous drainage. The best nursing action would be to: a) Notify the surgeon that the Hemovac is not functioning b) Remove the Hemovac because it is expanded c) Empty and measure the drainage and compress the Hemovac d) Assess the client's wound and apply a pressure dressing

c) Empty and measure the drainage and compress the Hemovac Pg. 452 A Hemovac needs to be recompressed periodically, because it operates with the use of gentle, constant suction. The amount of drainage is not excessive.

A postoperative client begins coughing forcefully while eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first? a) Cover the intestines with sterile, moist dressings b) Document the event c) Place the client in the low Fowler's position d) Notify the surgeon

c) Place the client in the low Fowler's position Pg. 457 Placing the client in the low Fowler's position decreases further protrusion of the intestines. The nurse should cover the intestines with a sterile, moist dressing; notify the surgeon and document the event; but first the nurse should minimize further protrusion of the intestines.

The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan? a) There are no advantages of patient-controlled analgesia over a PRN dosing schedule b) The client can self-administer oral pain medication as needed with patient-controlled analgesia c) Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia d) Family members can be involved in the administration of pain medications with patient-controlled analgesia

c) Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia Pg. 447-448 Advantages of patient-controlled analgesia include participation of the client in care, elimination of delayed administration of analgesics, and maintenance of therapeutic drug levels. The client must have the cognitive and physical abilities to self-dose.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: a) Change the client's position b) Insert a rectal tube c) Palpate the abdomen d) Auscultate bowel sounds

d) Auscultate bowel sounds Pg. 454 If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.

The nurse is responsible for monitoring cardiovascular function in a postoperative patient. What method can the nurse use to measure cardiovascular function? a) Complete blood count b) Chest x-ray c) Upper endoscopy d) Central venous pressure

d) Central venous pressure Respiratory rate, pulse rate, blood pressure, blood oxygen concentration, urinary output, level of consciousness, central venous pressure, pulmonary artery pressure, pulmonary artery wedge pressure, and cardiac output are monitored to provide information on the patient's respiratory and cardiovascular status.

You are caring for a client who needs to ambulate. What considerations should be included when planning the postoperative ambulatory activities for the older adult? a) Convalescent period b) Detailed medication history c) Respiratory depressive effects d) Tolerance

d) Tolerance Pg. 446-447 Postoperative ambulatory activities are essential but planned according to the older adult's tolerance, which usually is less than that of a younger person. The respiratory depressive effects should be considered when administering certain drugs for the older adults. The convalescent period usually is longer for older adults. Therefore, they may require positive reinforcement throughout the postoperative period as well as extensive discharge planning. The convalescent period of older adults and detailed medication history may not be necessary to consider when planning the postoperative ambulatory activities.

A PACU nurse is caring for an older adult who presents with clinical manifestations of delirium. What short-term outcome would be most important for this client? a) resumes usual urinary elimination pattern. b) exhibits wound healing without complications. c) experiences pain within tolerable limits. d) maintains adequate fluid status.

experiences pain within tolerable limits. Explanation: Because pain can contribute to postoperative delirium, adequate pain control without oversedation is essential. Nursing assessment of mental status and of all physiologic factors influencing mental status helps the nurse plan for care because delirium may be the initial or only indicator of infection, fluid and electrolyte imbalance, or deterioration of respiratory or hemodynamic status in the older adult client.

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: a) fourth intention. b) first intention. c) second intention. d) third intention.

first intention. Explanation: Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.

The primary objective in the immediate postoperative period is a) monitoring for hypotension. b) relieving pain. c) maintaining pulmonary ventilation. d) controlling nausea and vomiting.

maintaining pulmonary ventilation. Explanation: The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and monitoring for hypotension are important, but they are not primary objectives in the immediate postoperative period.