Question 1

After a new nurse has been oriented to the postanesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse

Accepted Answer

The patient should initially be positioned in the lateral "recovery" position to keep the airway open and avoid aspiration. The prone position is not usually used and would make it difficult to assess the patient's respiratory effort and cardiovascular status. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness.

Question 2

When a patient is transferred from the postanesthesia care unit (PACU) to the clinical surgical unit, the first action by the nurse on the surgical unit should be to

Accepted Answer

Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer.

Question 3

During recovery from anesthesia in the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO₂ 91%. The patient is sleepy but awakens easily. Which action should the nurse take at this time?

Accepted Answer

The patient's borderline SpO₂ and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable BP and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO₂, indicating that transfer from the PACU is not appropriate.

Question 4

A patient complains of dizziness when ambulating in the room on the first postoperative day. In what order will the nurse accomplish the following activities? (All the activities are appropriate.) Put a comma and space between each solve choice (a, b, c, d, etc.) ____________________

Accepted Answer

The first priority for the patient with syncope is to prevent a fall, so the patient should be assisted to a chair. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the fluid intake will help prevent orthostatic dizziness. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no urgent need to notify the health care provider.

Question 5

An 83-year-old who had a surgical repair of a hip fracture 2 days previously has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for the patient as

Accepted Answer

The patient is older and relatively immobile, two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient.

Question 6

When caring for a patient during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 100.8° F. Which action should the nurse take first?

Accepted Answer

A temperature of 100.8° F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because evidence of wound infection does not usually occur before the third postoperative day, assessment of the incision is not likely to be useful.

Question 7

Which action should the postanesthesia care unit (PACU) nurse delegate to nursing assistive personnel (NAP) who help with the transfer of a patient to the surgical unit?

Accepted Answer

The scope of practice for nursing assistants includes repositioning and moving patients under the supervision of an RN. Providing report to another RN, assessing and documenting the wound appearance, and clarifying physician orders with another RN require RN level education and scope of practice.

Question 8

A postoperative patient has not voided for 7 hours after return to the postsurgical unit. Which action should the nurse take first?

Accepted Answer

The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Catheterization should only be done after other measures have been tried without success because of the risk for urinary tract infection. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful.

Question 9

After removal of the nasogastric (NG) tube on the second postoperative day, the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. Which action should the nurse take?

Accepted Answer

Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient's discomfort. If distention persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains.

Question 10

A patient's blood pressure in the PACU has dropped from an admission blood pressure of 138/84 to 100/58 with a pulse change of 68 to 94. SpO₂ is 98% on 3L of oxygen. In which order should the nurse take these actions? Put a comma and space between each solve choice (a, b, c, d, etc.) ____________________

Accepted Answer

The first nursing action should be to increase the IV infusion rate. Since the most common cause of hypotension is volume loss, the IV rate should be increased. The next action should be to increase the oxygen flow rate to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient should be assessed for vasodilation caused by rewarming.

Question 11

A 42-year-old patient is recovering from anesthesia in the postanesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure falls to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at this time is to

Accepted Answer

A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration.

Question 12

In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which action by the nurse is most helpful?

Accepted Answer

The most essential nursing action in encouraging these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities.

Question 13

A patient who is just waking up after having a general anesthetic is agitated and confused. Which action should the nurse take first?

Accepted Answer

Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action.

Question 14

Following gallbladder surgery, a patient's T-tube is draining dark green fluid. Which action should the nurse take?

Accepted Answer

A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary.

Question 15

The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when the

Accepted Answer

One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or wheezes, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems.

Question 16

While caring for a patient who had abdominal surgery on the second postoperative day, which information about the patient is most important to communicate to the health care provider?

Accepted Answer

The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require health care provider orders for diagnostic tests and anticoagulants. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 100.3° F on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities.

Question 17

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 99%, and recent lab results are all normal. Which action by the nurse is most appropriate?

Accepted Answer

Because the patient's assessment indicates physiologic stability, the most likely cause of the patient's agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should ensure patient safety through interventions such as raising the bed rails and securing IV lines. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify the ACP. Insertion of an airway is not needed because the oxygen saturation is good. Orientation of the patient is needed but is not likely to be effective until the effects of anesthesia have resolved more completely.

Question 18

A 75-year-old is to be discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I do not know if I can take care of myself with this patch over my eye." The most appropriate nursing action is to

Accepted Answer

The nurse's initial action should be to assess exactly the patient's concerns about self-care. Referral to home health care and assessment of the patient's support system may be appropriate actions but will be based on further assessment of the patient's concerns. Written instructions should be given to the patient, but these are unlikely to address the patient's stated concern about self-care.

Question 19

The nurse notes that the oxygen saturation is 88% in an unconscious patient who was transferred to the postanesthesia care unit (PACU) 10 minutes previously. Which action should the nurse take first?

Accepted Answer

In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient's head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake.

Question 20

While caring for a patient with abdominal surgery the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this finding, the nurse should first

Accepted Answer

New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing.

Quiz 20: Nursing Management: Postoperative Care

After a new nurse has been oriented to the postanesthesia care unit (PACU) , the charge nurse will evaluate that the orientation has been successful when the new nurse

When a patient is transferred from the postanesthesia care unit (PACU) to the clinical surgical unit, the first action by the nurse on the surgical unit should be to

During recovery from anesthesia in the postanesthesia care unit (PACU) , a patient's vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO₂ 91%. The patient is sleepy but awakens easily. Which action should the nurse take at this time?

A patient complains of dizziness when ambulating in the room on the first postoperative day. In what order will the nurse accomplish the following activities? (All the activities are appropriate.) Put a comma and space between each solve choice (a, b, c, d, etc.) ____________________

An 83-year-old who had a surgical repair of a hip fracture 2 days previously has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for the patient as

When caring for a patient during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 100.8° F. Which action should the nurse take first?

Which action should the postanesthesia care unit (PACU) nurse delegate to nursing assistive personnel (NAP) who help with the transfer of a patient to the surgical unit?

A postoperative patient has not voided for 7 hours after return to the postsurgical unit. Which action should the nurse take first?

After removal of the nasogastric (NG) tube on the second postoperative day, the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. Which action should the nurse take?

In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which action by the nurse is most helpful?

A patient who is just waking up after having a general anesthetic is agitated and confused. Which action should the nurse take first?

Following gallbladder surgery, a patient's T-tube is draining dark green fluid. Which action should the nurse take?

The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when the

While caring for a patient who had abdominal surgery on the second postoperative day, which information about the patient is most important to communicate to the health care provider?

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 99%, and recent lab results are all normal. Which action by the nurse is most appropriate?

A 75-year-old is to be discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I do not know if I can take care of myself with this patch over my eye." The most appropriate nursing action is to

The nurse notes that the oxygen saturation is 88% in an unconscious patient who was transferred to the postanesthesia care unit (PACU) 10 minutes previously. Which action should the nurse take first?

While caring for a patient with abdominal surgery the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this finding, the nurse should first

Quiz 20: Nursing Management: Postoperative Care

After a new nurse has been oriented to the postanesthesia care unit (PACU) , the charge nurse will evaluate that the orientation has been successful when the new nurse

When a patient is transferred from the postanesthesia care unit (PACU) to the clinical surgical unit, the first action by the nurse on the surgical unit should be to

During recovery from anesthesia in the postanesthesia care unit (PACU) , a patient's vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take at this time?

A patient complains of dizziness when ambulating in the room on the first postoperative day. In what order will the nurse accomplish the following activities? (All the activities are appropriate.) Put a comma and space between each solve choice (a, b, c, d, etc.) ____________________

An 83-year-old who had a surgical repair of a hip fracture 2 days previously has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for the patient as

When caring for a patient during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 100.8° F. Which action should the nurse take first?

Which action should the postanesthesia care unit (PACU) nurse delegate to nursing assistive personnel (NAP) who help with the transfer of a patient to the surgical unit?

A postoperative patient has not voided for 7 hours after return to the postsurgical unit. Which action should the nurse take first?

After removal of the nasogastric (NG) tube on the second postoperative day, the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. Which action should the nurse take?

In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which action by the nurse is most helpful?

A patient who is just waking up after having a general anesthetic is agitated and confused. Which action should the nurse take first?

Following gallbladder surgery, a patient's T-tube is draining dark green fluid. Which action should the nurse take?

The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when the

While caring for a patient who had abdominal surgery on the second postoperative day, which information about the patient is most important to communicate to the health care provider?

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 99%, and recent lab results are all normal. Which action by the nurse is most appropriate?

A 75-year-old is to be discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I do not know if I can take care of myself with this patch over my eye." The most appropriate nursing action is to

The nurse notes that the oxygen saturation is 88% in an unconscious patient who was transferred to the postanesthesia care unit (PACU) 10 minutes previously. Which action should the nurse take first?

While caring for a patient with abdominal surgery the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this finding, the nurse should first

During recovery from anesthesia in the postanesthesia care unit (PACU) , a patient's vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO₂ 91%. The patient is sleepy but awakens easily. Which action should the nurse take at this time?