Question 1

Which of the following adverse outcomes may occur as a complication of changing a patient's position after surgery?&#10;A)Hypotension&#10;B)Diarrhea&#10;C)Somnolence&#10;D)Apnea

Accepted Answer

Hypotension is a potential complication of changing the patient's position after surgery. If the patient has been in the same position during surgery for a significant period of time, vascular changes can occur when moving to a different position, such as from prone to a supine position. The patient should be turned or moved very slowly and monitored for blood pressure changes during repositioning.

Question 2

To prepare the patient for transfer to the post-anesthesia care unit (PACU), the nurse must move the patient to a stretcher and secure their body. What other interventions should the perioperative nurse do to prepare the patient for transfer?

A)Elevate the head of the bed 90 degrees.
B)Gather the patient's belongings and place them at the foot of the bed.
C)Raise the side rails on the stretcher.
D)Swaddle the patient's body with a dry, heavy blanket.

Raise the side rails on the stretcher.

Accepted Answer

The nurse should raise the side rails on the stretcher before transferring a patient to the PACU. This promotes patient safety and prevents injury if the patient were to roll over or fall from the bed. Side rails should be up any time a patient is in bed, even if they are alert and oriented. Lower the side rails when the patient is ready to be transferred to the next bed.

Question 3

Which of the following means that the patient may not leave the post-anesthesia care unit to be transferred to a general care medical-surgical unit?&#10;A)Oxygen saturation of 95%&#10;B)Unconsciousness&#10;C)Adequate respiratory effort&#10;D)Stable blood pressure

Accepted Answer

A patient who is unconscious has not met the criteria to leave the post-anesthesia care unit to be transferred to a general care unit. During the recovery period, the nurse evaluates several aspects of the patient's status, including blood pressure, skin color, respiratory rate and level of consciousness. Part of the assessment involves the patient's response when called by name. A patient who remains unconscious and never responds needs to spend more time in recovery to establish some degree of consciousness.

Question 4

Which of the following outcomes may be most appropriate for a patient to achieve before leaving the post-anesthesia care unit?&#10;A)The patient will achieve and maintain normal heart rate, blood pressure, and oxygen saturation level.&#10;B)The patient will rate their pain at an '8' or less on a 0-10 pain scale.&#10;C)The patient will ambulate at least one time around the PACU.&#10;D)The patient will void at least 100 cc when using the bathroom.

Accepted Answer

The patient will achieve and maintain normal heart rate, blood pressure, and oxygen saturation level. These items indicate the patient's cardiac status is within normal limits and they are recovering from the effects of surgery and anesthesia. A patient's pain should be well controlled before transferring to a general care unit or going home.

Question 5

When preparing a patient for transfer from the operating suite, the nurse notices that their temperature is 96.1 degrees and they are starting to shiver. Which of the following are potential adverse outcomes if the nurse does not correct this situation?

A)The patient may develop increased bleeding.
B)The patient may become combative and violent.
C)The patient may develop peripheral edema.
D)Both A and B

Accepted Answer

The patient with hypothermia may develop increased bleeding. Hypothermia causes metabolic changes that affect how the body processes anesthesia and muscle relaxants. The patient may have an increase in blood clotting of the small vessels, diminishing the number of platelets and clotting factors in the body. This then produces the opposite effect of increased bleeding from the surgical site or other orifices.

Question 6

Which of the following is the most common reason for agitation and confusion during the time period when the patient is transferred from the operating room?&#10;A)Pain&#10;B)Hypothermia&#10;C)Hypoxemia&#10;D)A history of depression

Accepted Answer

Hypoxemia is the most common reason for agitation and confusion during the time period when the patient is transferred from the operating room. Hypoxemia results in decreased blood flow throughout the body, including to the brain, which may cause the confusion. The nurse should assess the patient's levels of oxygenation and provide supplemental oxygen if necessary.

Question 7

Which of the following statements regarding pain control in the patient following the surgical procedure is true?&#10;A)The nurse should determine the cause of the pain before administering analgesics.&#10;B)The goal of pain treatment should be '0' on a 0-10 pain scale.&#10;C)The nurse should use the outward signs of pain in the patient to guide administration of analgesics.&#10;D)The amount of pain is determined by the patient and is the best indicator of its existence.

Accepted Answer

The amount of pain is determined by the patient and is the best indicator of its existence. Pain is whatever the patient says it is, at the intensity that they describe. Because the nurse is not experiencing the pain, they cannot know the intensity, even after administering analgesics. The nurse should try to identify what is causing the pain, but should not withhold treatment until the cause is determined.

Question 8

Which of the following is an essential element of planning for the patient's postoperative care?&#10;A)Involving family members in the patient's care&#10;B)Eliminating the causes of pain before discharge&#10;C)Progressing the diet to return to normal&#10;D)Both A and C

Accepted Answer

An essential element of planning for the patient's postoperative care is involving family members in the patient's care. Family members or significant others are extremely important for providing support and help with a patient after surgery and should be taught the best methods of care alongside the patient. The patient may be free from pain before discharge, but pain may not be eliminated entirely; it should, however, be under control. The patient may or may not return to a normal diet right away, depending on the surgical procedure.

Question 9

Which of the following measures is appropriate for promoting adequate respiratory function after the patient has been transferred to the postoperative surgical unit?&#10;A)Keeping the patient in the Trendelenburg position.&#10;B)Turning, coughing and deep breathing each day.&#10;C)Getting the patient up to walk as soon as possible.&#10;D)Restricting fluids until day two after surgery.

Accepted Answer

The most appropriate measure for promoting adequate respiratory function is getting the patient up to walk as soon as possible. Helping the patient to ambulate will promote circulation and allow for greater lung expansion for breathing. The head of the patient's bed should be elevated if possible, they should practice deep breathing exercises approximately every two hours, and fluids should be encouraged.

Question 10

Which of the following subjects are appropriate teaching topics for the patient's family?&#10;A)The physician's cell number in case of emergency&#10;B)The reasons, side effects, dosage, and timing for every medication the patient will be taking&#10;C)Instructions about what to do if the patient decides to ambulate to use the bathroom&#10;D)Both B and C

Accepted Answer

The family should be taught the reasons, side effects, dosage and timing for every medication the patient will be taking. Medications have a large impact on the patient's ability to heal as well as providing pain control. The family should have knowledge of medications, as well as why they are used and where to obtain them, in order to support the patient's healing process.

Question 11

A nurse in the post-surgical unit assumes care of a patient with a surgical wound that appears clean and dry, with intact sutures and approximated wound edges. Which type of healing process would the state of this wound be described as?

A)Primary intention
B)Secondary intention
C)Closure intention
D)Tertiary intention

Accepted Answer

The answer of A nurse in the post-surgical unit assumes...

Question 12

The first day following surgery, the nurse checks the patient's surgical incision and notes a small amount of inflammation, serosanguineous drainage from the site, and skin that is warm to the touch. What should the nurse do in this situation?

A)Cleanse the area with chlorhexidine soap.
B)Administer antibiotics to treat the developing infection.
C)Notify the physician for further orders.
D)Keep the area clean and continue to monitor the site.

Accepted Answer

The answer of The first day following surgery, the nurse...

Question 13

A nurse is transferring a patient to the post-surgical unit after surgery and recovery from a gastrointestinal procedure. During report, the nurse states that the patient had a large amount of thick, fibrous bands of tissue that were removed because they were obstructing part of the intestine. What is the clinical name for this type of tissue?

A)Proud flesh
B)Keloid tissue
C)Adhesion
D)Connective fascia

Accepted Answer

The answer of A nurse is transferring a patient to...

Deck 9: Transfer