Deck 5: Care of Postoperative Surgical Patients

Question 1

When the PACU nurse assesses diminished breath sounds in the unconscious recovering patient,the nurse should:

A)hyperventilate the patient with an Ambu bag.
B)turn the oxygen up to 3 L/min.
C)elevate the head of bed 45 degrees.
D)chart, "Diminished breath sounds in both lower lobes."

Answer 1

chart, "Diminished breath sounds in both lower lobes."

Question 2

The patient's initial vital signs immediately on return from surgery are BP,140/90;P,80;R,14;T,98° F.One hour later the vital signs are BP,130/84;P,72;R,16;T,96.8° F.Based on these assessments,the nurse should:

A)add a blanket for warmth to the patient.
B)notify the charge nurse of probable hemorrhage.
C)raise the head of the bed 45 degrees.
D)note the assessment as normal postoperative recovery.

Answer 2

note the assessment as normal postoperative recovery.

Question 3

Which assessment finding on a patient who had a right total knee replacement this morning should be reported to the charge nurse immediately?

A)Pain at level of 8 at operative site
B)Capillary refill of right toe of 7 seconds
C)Right foot warm to touch
D)Swelling of right knee

Answer 3

Capillary refill of right toe of 7 seconds

Question 4

The nurse is caring for a patient following abdominal surgery.The patient asks the nurse when he will be able to eat a normal diet.The nurse's best response is:

A)"It will depend on how well you tolerate advancing from a clear liquid diet."
B)"We will have to wait until your surgeon orders a regular diet for you."
C)"Most patients are able to eat regular foods within 2 to 3 days following abdominal surgery."
D)"Once you have bowel sounds and are passing gas, you may have clear liquids, and your diet will be advanced based upon your tolerance."

Question 5

The patient asks the nurse which vitamin to take that will enhance wound healing the most.The nurse correctly responds,"Vitamin:

A)A."
B)B."
C)C."
D)E."

Question 6

Prior to getting the postsurgical patient up for the first time,the nurse should initially:

A)raise the head of the bed.
B)dangle the patient's legs over side of bed.
C)offer patient some fluids.
D)apply gait belt to patient.

Question 7

The postanesthesia care unit (PACU)nurse determines that the patient's Aldrete score is 9.The nurse on the postoperative unit knows that this means the:

A)patient is at an increased risk for postoperative respiratory complications.
B)patient's condition warrants close monitoring.
C)patient is experiencing severe pain.
D)patient will soon be transferred to the postoperative unit.

Question 8

The nurse has been assigned to care for several postoperative patients.The nurse is aware that the patient most likely to develop thrombophlebitis is the patient:

A)with a history of blood clots who is being discharged following an outpatient cholecystectomy.
B)who is 6 days postoperative for total right hip replacement and has a history of left-sided stroke.
C)who has had major abdominal surgery and was dehydrated upon admission.
D)who is 2 days postoperative for hernia repair with a history of diabetes.

Question 9

The nurse should report to the charge nurse that a 10-hour post-abdominal surgery patient has:

A)vomited 20 mL of clear green fluid.
B)asked for pain medication twice.
C)not voided since surgery.
D)a weak cough ability.

Question 10

The nurse is caring for a patient who has had spinal anesthesia.The nurse correctly questions which of the following orders?

A)Patient to lie flat for 6 to 8 hours.
B)Resume diet as tolerated.
C)Use incentive spirometer every hour while awake.
D)Notify physician immediately if headache occurs.

Question 11

When the postoperative patient refuses to cough due to incisional pain,the initial nursing action should be:

A)encouraging deep breathing instead of coughing.
B)splinting the abdomen with a pillow.
C)explaining the importance of controlled coughing.
D)giving pain medication.

Question 12

Antiembolic stockings are in place on the obese postsurgical patient.The nurse is aware that the standard of care in regard to antiembolic stockings is that the stockings should be:

A)left in place continually for the first 24 hours.
B)fitted tightly at the knee and ankle.
C)removed approximately 20 minutes every shift.
D)removed when ambulating.

Question 13

For the surgical patient who complains of excessive gas,the nurse will:

A)offer iced fluids.
B)arrange for large meal servings.
C)provide a straw for drinking fluids.
D)ambulate the patient in the hall.

Question 14

The nurse is caring for a 90-year-old postoperative patient.The nurse notes that the oxygen saturation is frequently dropping below 90%.This is most likely related to:

A)prolonged use of a walker.
B)poor fluid intake.
C)weakened respiratory muscles.
D)increased elasticity of costal cartilages.

Question 15

The postoperative patient complains of pain only 1 hour after having been medicated with an opioid,which cannot be repeated for 3 more hours.The nurse should initially:

A)give one half of the prescribed dose now.
B)contact the prescriber.
C)ambulate the patient in the hall.
D)reposition the patient.

Question 16

To help seal the insertion site from the spinal anesthesia,the nurse will offer:

A)tea.
B)Jell-O.
C)milk.
D)iced water.

Question 17

The nurse is caring for a patient during the first postoperative day.An appropriate goal to write in the nursing care plan to avoid atelectasis would be:

A)patient will turn, cough, and deep-breathe every 4 hours.
B)patient will "huff cough" every 2 hours.
C)patient will use the incentive spirometer twice a day.
D)nurse will assist the patient to ambulate in the hall three times a day.

Question 18

The nurse reminds the postsurgical patient that smoking will complicate postsurgical recovery by:

A)increasing probability of hemorrhage.
B)increasing blood pressure.
C)delaying healing.
D)increasing the need for pain medication.

Question 19

The patient recovering in the PACU awakes confused and disoriented.The nurse's most appropriate intervention is to:

A)take vital signs.
B)encourage the patient to return to sleep.
C)say, "Your surgery is over. You are in the recovery area."
D)chart, "Patient awake and disoriented."

Question 20

Following abdominal surgery,the PACU nurse demonstrates the best nursing care by placing the semi-conscious patient in _____ position.

A)the supine
B)semi-Fowler's
C)the lateral
D)Trendelenburg's

Question 21

The nurse assesses the musty odor coming from the wound drainage as being indicative of an infection by a(n)____________ organism,such as Pseudomonas or Staphylococcus.

Question 22

Following an outpatient procedure for which the patient received general anesthesia,the day surgery recovery nurse determines that the patient is ready to be discharged based on which of these findings? (Select all that apply.)

A)Patient is able to ambulate to the bathroom with minimal assistance.
B)Patient is not able to read and voice an understanding of discharge instructions.
C)Patient has been awake for 2 hours.
D)Patient is able to empty the bladder.
E)Patient is going to drive home, which is 2 blocks from the facility.

Question 23

The nurse is caring for a patient 48 hours after mastectomy surgery.The nurse is teaching the nursing student about Core Measures.The nursing student correctly implements which Core Measure interventions? (Select all that apply.)

A)Administering prophylactic antibiotic therapy 48 hours following surgery
B)Encouraging the elderly patient to use the call light attached to her when ambulating to the bathroom
C)Asking the patient to rate her pain on a pain scale
D)Ensuring that antiembolic stockings are removed during bathing
E)Assisting the patient with incentive spirometer every 4 hours

Question 24

The nurse is performing a neurological assessment on a male patient who has just been transferred from the PACU following abdominal surgery.The nurse demonstrates knowledge of a neurological assessment by: (Select all that apply.)

A)asking the patient to spell his name.
B)asking the patient to tell you where he is.
C)noting if the patient can identify the sensation of touch.
D)asking the patient to move his arms and legs.
E)assessing the pupils for response to light.

Question 25

The day surgery nurse provides written discharge instructions that should include: (Select all that apply.)

A)when to resume normal activity.
B)signs and symptoms to report.
C)a list of probable complications.
D)the telephone number of the surgeon's office.
E)the need to delay driving and decision making.

Question 26

The nurse in the PACU performs postsurgical assessments on the newly admitted patient every _________ minutes.

Question 27

The nurse performing the Aldrete scoring system must assess: (Select all that apply.)

A)activity.
B)circulation.
C)presence of wound drainage.
D)level of consciousness.
E)O2 saturation.

Question 28

A postsurgical patient consumed a cup of ice chips filled to the 120-mL mark,2 oz of broth,and 120 mL of water.In addition,750 mL of IV fluids were infused.The patient voided 650 mL and vomited 100 mL.
What is the total intake for this patient? ________ mL
What is the total output for this patient? ________ mL