Deck 20: Nursing Management: Postoperative Care

Question 1

Following gallbladder surgery, a patient has a T-tube with thick, dark green drainage. When the patient asks about the tube and the drainage, the best response by the nurse is

A) "The drainage is from your gallbladder, but it should be bright yellow rather than green."
B) "The drainage is old blood and fluid that accumulates at the surgical site. Its removal will promote healing."
C) "The tube you see has been placed in the bile duct, and the drainage is normal bile."
D) "The tube is draining secretions from the duodenum and small bowel, and this is normal drainage from this area."

Answer 1

"The tube you see has been placed in the bile duct, and the drainage is normal bile."

Question 2

While assessing patients for complications during recovery from anesthesia, the nurse recognizes that the patient who is at the greatest risk for developing postoperative hypothermia is a

A) 34-year-old who is having a repair of a knee cartilage under local anesthesia.
B) 48-year-old trauma victim having repair of multiple injuries under general anesthesia.
C) 62-year-old undergoing a laparoscopic cholecystectomy under general anesthesia.
D) 68-year-old diabetic undergoing a great-toe amputation under local anesthesia.

Answer 2

48-year-old trauma victim having repair of multiple injuries under general anesthesia.

Question 3

Postoperatively a patient is receiving low-molecular-weight heparin (LMWH). When administering this drug, the nurse

A) administers the dose with meals to prevent gastrointestinal irritation and bleeding.
B) explains that the drug will help prevent clot formation in the legs.
C) checks the baseline activated partial thromboplastin time (aPTT).
D) informs the patient that frequent blood testing will be necessary.

Answer 3

explains that the drug will help prevent clot formation in the legs.

Question 4

After a new nurse has been oriented to the PACU, the charge nurse will evaluate that the orientation has been successful when the new nurse

A) assists a patient to the prone position when the patient is nauseated.
B) turns a patient to the side when the patient arrives in the PACU.
C) places a patient in the Trendelenburg position when the BP drops.
D) positions a newly admitted patient supine with the head elevated.

Question 5

A patient becomes restless and agitated while beginning to regain consciousness in the PACU, and the SpO₂ is 88%. The nurse should first

A) suction the patient's mouth and throat to clear the airway.
B) check the nasogastric (NG) tube patency to prevent aspiration of gastric contents.
C) listen to the lung sounds to assess for wheezes or congestion.
D) ask the patient to breathe deeply to open the alveoli.

Question 6

A patient's blood pressure in the PACU has dropped from an admission blood pressure of 138/84 to 110/78 with a pulse change of 68 to 84. The first action indicated by the nurse is to

A) assess the patient's dressing.
B) check the patient's temperature.
C) increase the oxygen flow rate.
D) raise the IV infusion rate.

Question 7

A postoperative patient has not voided for 7 hours after return to the postsurgical unit. Initially the nurse should

A) notify the health care provider.
B) palpate the bladder.
C) assist the patient to ambulate to the bathroom.
D) perform the ordered prn straight catheterization.

Question 8

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) Teach the patient the purpose of respiratory care and ambulation.
B) Give the patient positive reinforcement for accomplishing these activities.
C) Administer ordered analgesic medications before these activities.
D) Discuss the complications of immobility and poor cough effort.

Question 9

On admission of a patient to the postanesthesia care unit (PACU) from surgery, the nurse should first assess the

A) dressing at the surgical site.
B) patient's level of consciousness.
C) patient's oxygen saturation.
D) intravenous (IV) site and fluid rate.

Question 10

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

A) The 24-hour intake is 600 ml greater than the output.
B) The right calf is swollen, warm, and painful.
C) The patient's temperature is 100.3° F.
D) The patient complains of 6 on a 10-point pain scale when walking.

Question 11

An 83-year-old patient had a surgical repair of a hip fracture and has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for the patient as potential complication:

A) fluid and electrolyte imbalance.
B) impaired surgical wound healing.
C) thromboembolism.
D) hypovolemic shock.

Question 12

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

A) patient uses the spirometer 10 times every hour.
B) patient's temperature is less than 100.4° F orally.
C) patient drinks 2 to 3 L of fluid in 24 hours.
D) patient's breath sounds are clear to auscultation.

Question 13

The nasogastric (NG) tube is removed on the second postoperative day for a patient who had abdominal surgery. A clear liquid diet is ordered. Four hours later, the patient complains of abdominal distention and sharp, cramping gas pains. The most appropriate nursing action is to

A) place the patient on NPO status.
B) assist the patient to ambulate in the hall.
C) administer the ordered as-needed morphine sulfate.
D) reinsert the NG tube.

Question 14

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

A) assess the patient's pain.
B) take the patient's vital signs.
C) check the rate of the IV infusion.
D) read the postoperative orders.

Question 15

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 initially

A) take the patient's vital signs.
B) notify the patient's surgeon of a potential hemorrhage.
C) reinforce the dressing.
D) recheck the dressing in 1 hour for increased drainage.

Question 16

A 42-year-old patient is recovering from anesthesia in the PACU. On admission to the PACU the blood pressure (BP) was 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

A) administer oxygen therapy at 100% per mask.
B) notify the anesthesia care provider (ACP) immediately.
C) increase the rate of the IV fluid replacement.
D) continue to take vital signs every 15 minutes.

Question 17

When a postoperative patient in the PACU complains of pain at the abdominal incision site, the nurse should

A) administer analgesics as written in the patient's postoperative orders.
B) give half of the postoperative dose of analgesic ordered for the patient.
C) tell the patient that the respiratory rate and effort must be adequate before pain medication can be administered.
D) consult with the ACP to determine an effective dose of an analgesic for the patient.

Question 18

A 75-year-old patient 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

A) refer the patient for home health care services.
B) discuss the specific concerns regarding self-care.
C) assess the patient's support system for care at home.
D) give the patient written instructions regarding care.

Question 19

During recovery from anesthesia in the PACU, a patient's vital signs for the past hour have been blood pressure 112/82, 110/82, 112/80, 114/82; pulse 76, 78, 78, 80; and respirations 22, 24, 24, 26; her SpO₂ is 90%. The patient is sleepy but awakens easily and is oriented when spoken to. Her surgical dressing is dry and intact. The most appropriate action by the nurse is to

A) place the patient in a side-lying position.
B) encourage the patient to take deep breaths.
C) decrease the rate of the postoperative IV fluids.
D) prepare to transfer the patient from the PACU.

Question 20

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 is appropriate for the nurse to take first?

A) Notify the patient's health care provider about the fever.
B) Administer the ordered prn acetaminophen (Tylenol).
C) Have the patient use the incentive spirometer.
D) Assess the surgical incision for redness and swelling.

Question 21

A patient who has begun to awaken after 30 minutes in the 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) Be sure that the patient's IV lines are secure.
B) Notify the anesthesia care provider.
C) Insert an oral or nasal airway.
D) Orient the patient to time, place, and person.

Question 22

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

A) Perform the jaw-thrust maneuver.
B) Increase the oxygen flow rate.
C) Suction the patient's mouth.
D) Elevate the patient's head.

Question 23

To promote venous return from the lower extremities for a patient who has had an open cholecystectomy, the nurse will encourage the patient to do which exercises? (Select all that apply.)

A) Dorsiflex and plantar flex the feet
B) Curl the toes with flexion and extension
C) Tighten and relax the abdominal muscles
D) Rotate the ankles, making circles with the feet
E) Flex the hip and knee and rotate the lower leg laterally
F) Press the back of the knee into the bed while lying supine

Question 24

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.)

A) Take the patient's blood pressure.
B) Have the patient sit down in a chair.
C) Notify the patient's health care provider.
D) Give the patient something to drink.