Deck 18: Care of Postoperative Patients

Question 1

The nurse assesses a client who has just been brought to the postanesthesia care unit (PACU).In the operating room,the client's blood pressure was 136/80 mm Hg; it is now 110/80 mm Hg.Urine output was 40 mL/hr and is now 10 mL/hr.Which action by the nurse is best?

A) Awaken the client and encourage oral fluids.
B) Increase the IV of 0.9 NS as ordered to 100 mL/hr.
C) Put the client in Trendelenburg position.
D) Assess the client's levels of consciousness and pain.

Answer 1

Increase the IV of 0.9 NS as ordered to 100 mL/hr.

Question 2

A client who is being admitted to the postanesthesia care unit (PACU)has weak hand grasps on assessment and is unable to lift his head off the bed.During hand-off report,the nurse notes that the client has received a neuromuscular-blocking agent.What is the nurse's best action?

A) Document the finding.
B) Check the client's pulses.
C) Place the client in Fowler's position.
D) Auscultate the lungs.

Answer 2

Auscultate the lungs.

Question 3

The nurse is assessing a client admitted to the postanesthesia care unit (PACU)after abdominal surgery.The client's respiratory rate is 8 breaths/min and breath sounds are decreased in the bases.What is the nurse's priority action?

A) Prepare to administer naloxone (Narcan).
B) Assess oxygen saturation and level of consciousness.
C) Call a code or the Rapid Response Team.
D) Turn the client and perform chest physiotherapy.

Answer 3

Assess oxygen saturation and level of consciousness.

Question 4

The nurse is caring for a client in the postanesthesia care unit (PACU)2 hours after abdominal surgery.The nurse auscultates the client's abdomen and notes that there are no bowel sounds.What action does the nurse take?

A) Position the client on the left side with the bed flat.
B) Insert a nasogastric tube to low intermittent suction.
C) Palpate the bladder and measure abdominal girth.
D) Document the finding and continue to monitor.

Question 5

A client who has just been transferred to the postanesthesia care unit (PACU)from surgery is very restless and confused.What is the nurse's first action?

A) Orient the client and remain with him or her.
B) Call the surgeon for an intraoperative report.
C) Notify the physician on call.
D) Assess the client's level of pain.

Question 6

The nurse reviews the initial postanesthesia care unit (PACU)flow record and notes that the client is alert and oriented -3 when stimulated,pulse is 88 per minute and regular,respirations are 12 per minute and unlabored,and oxygen saturation is 95% on 2 LPM of nasal oxygen.What is the nurse's priority action at this time?

A)Examine the surgical site; obtain blood pressure and temperature.
B)Suction the client and assess anterior and posterior lung sounds.
C)Assess urinary output,the IV site,and the client's pain.
D)Turn the client and perform chest physiotherapy.

Question 7

The nurse is caring for a client who had surgery 24 hours ago.He is alert and oriented when awakened and reports pain,but goes back to sleep when not being stimulated.He is on patient-controlled analgesia (PCA).What is the nurse's next action?

A) Push the PCA control for the client.
B) Discontinue the PCA immediately.
C) Assess the client's respiratory status.
D) Keep the client awake as much as possible.

Question 8

A client is brought to the postanesthesia care unit (PACU)after surgery that took place with the client in the lithotomy position.Which action does the nurse take after assessing vital signs?

A) Assess for sacral decubiti.
B) Assess dorsalis pedis pulses.
C) Turn the client on the left side.
D) Put the client in the Trendelenburg position.

Question 9

The nurse is caring for several clients on the postoperative unit.Which client does the nurse determine has the highest risk of respiratory complications after general anesthesia?

A) Older woman taking a calcium channel blocker for hypertension
B) Middle-aged man with a deviated nasal septum
C) Middle-aged woman taking St. John's wort daily for depression
D) Young adult with a body mass index of 40

Question 10

The nurse is caring for a client who has just been brought to the postanesthesia care unit (PACU)after surgery.The client's oxygen saturation is 92% and his hemoglobin is 14 g/dL.What is the nurse's first action?

A) Assess the client's pain response.
B) Determine whether the client is alert and oriented.
C) Increase oxygen and auscultate lung sounds.
D) Assess vital signs and temperature.

Question 11

The nurse is performing a hand-off report in the PACU.What is the best action for the nurse to perform during the hand-off report?

A) Write all information on a chart and hand it to the nurse who will assume care of the client.
B) Follow the nurse assigned to the new client and give a verbal report that does not interrupt care.
C) Focus on the report and sit with the nurse receiving the client to give a detailed report.
D) Finish the report quickly so the nurse can assume care of the client.

Question 12

A client reports pain 8 hours after surgery.The client has already received an opioid within the past 2 hours.What is the nurse's best action?

A) Assess the pain further.
B) Administer naloxone (Narcan).
C) Call the surgeon.
D) Document the finding.

Question 13

The nurse is caring for clients in the postanesthesia care unit (PACU).Which client does the nurse intervene for first?

A) Client with a pulse deficit of 15
B) Client who is reporting leg pain
C) Client with dementia who is confused
D) Client who is reporting a headache

Question 14

The nurse is caring for a client who had abdominal surgery 3 days ago.He tells the nurse,"I felt something 'give way' when I coughed." What is the nurse's best response?

A) "It is good that you are coughing and deep-breathing to prevent pneumonia."
B) "That is a normal feeling in the incision whenever you are moving."
C) "Be sure to splint the incision with a pillow or your hands when you cough."
D) "Lie down flat on the bed with your knees up and let me examine your incision."

Question 15

Postoperatively,a client has a heart rate of 120 beats/min,with dysrhythmias noted on the ECG monitor and a respiratory rate of 34 breaths/min,and is very difficult to arouse.Which action by the nurse is most appropriate?

A) Accompany the client to the postanesthesia care unit (PACU).
B) Keep the client in the surgical suite.
C) Call a code or the Rapid Response Team.
D) Transfer the client to the intensive care unit (ICU).

Question 16

One hour after admission to the postanesthesia care unit (PACU),the postoperative client has become very restless.What is the nurse's first action?

A) Assess for bladder distention.
B) Assess the oxygen saturation level.
C) Call the surgeon to assess the client.
D) Administer pain medication as ordered.

Question 17

The nurse is changing the client's dressing on the second postoperative day and notes a small amount of serosanguineous drainage.What is the nurse's best action?

A) Cleanse the suture line and apply a sterile dressing.
B) Culture the drainage and leave the incision open to air.
C) Cover the incision with a transparent dressing.
D) Notify the surgeon to assess the client.

Question 18

A client is being transferred to the postanesthesia care unit (PACU)after surgery.The client has an endotracheal tube (ET)in place.On assessment,the client has oxygen saturation of 95%,respiratory rate of 14 breaths/min,and asymmetric chest wall expansion.What is the nurse's best action?

A) Attempt to awaken the client.
B) "Bag" the client with a resuscitation bag.
C) Increase the client's fraction of inspired oxygen (FIO₂).
D) Auscultate lung sounds bilaterally.

Question 19

A client had surgical repair of a fractured ankle under local anesthesia and is being transferred from the postanesthesia care unit (PACU)to the surgical floor.Once admitted,what is the nurse's priority action?

A) Assess pressure points for breakdown.
B) Assess the client's pain.
C) Insert an IV for antibiotic therapy.
D) Assess a full set of vital signs.

Question 20

A client has been transferred to the postanesthesia care unit (PACU).Which action does the receiving nurse perform first?

A) Complete a nursing assessment sheet.
B) Change the client's arm band.
C) Enter client data into the computer.
D) Participate in a hand-off report.

Question 21

A client with diabetes mellitus type 1 underwent surgery 24 hours ago.Which precaution does the nurse take to help prevent postoperative complications for this client?

A) Order a high-protein diet.
B) Observe the incision frequently.
C) Have suction available at the bedside.
D) Instruct the client to use an electric razor.

Question 22

The nurse is preparing a client for discharge.The client has a large draining wound.What is the nurse's best action?

A) Arrange a nurse to come to the house to change the dressing after discharge.
B) Have the client come back to the clinic daily to have the dressing changed.
C) Teach the client and family how to change the dressing.
D) Apply a hydrocolloid dressing and change once a week.

Question 23

The nurse is working in the postanesthesia care unit (PACU)and receives a client from the operating room (OR).What does the nurse assess first?

A) Client's endotracheal tube
B) Client's nasogastric tube
C) Client's Foley catheter
D) Hemovac drain at the incision site

Question 24

The nurse is caring for a client whose wound dehisces after vomiting.What is the nurse's first action?

A) Prepare the client for emergency surgery.
B) Cover the wound with sterile moist dressings.
C) Give the client medication for nausea.
D) Call the surgeon and the operating room.

Question 25

A postsurgical client's urinary output via the Foley catheter is 30 mL in 3 hours.What is the nurse's first action?

A) Increase the IV infusion rate.
B) Assess the client's skin turgor.
C) Weigh the client.
D) Check the patency of the catheter.

Question 26

A client is being discharged after abdominal surgery.What information about the diet does the nurse teach the client?

A) "Be sure to monitor your fluid intake."
B) "Eat foods high in protein and vitamin C."
C) "Call the physician if you develop gas."
D) "You will need to limit your carbohydrates."

Question 27

The nurse is caring for a client who is reporting severe postoperative pain.The physician's order states that the client is to receive "hydromorphone hydrochloride (Dilaudid)10-15 mg every 1-2 hours PRN pain." What is the nurse's priority action?

A) Call the physician to clarify the order.
B) Give the medication as ordered.
C) Refuse to give the medication.
D) Call the hospital pharmacist.

Question 28

The nurse is caring for clients in the postanesthesia care unit (PACU).Which client is ready to be extubated?

A) Client with an oxygen saturation of 90%
B) Client with a respiratory rate of 14 breaths/min
C) Client who is alert and oriented
D) Client who is coughing and gagging

Question 29

The nurse is reviewing postoperative medication orders.Which order can the nurse implement?

A) Acetaminophen orally PRN pain
B) Meperidine (Demerol) 75-100 mg every 3-4 hours PRN pain
C) MS .5 mg subcutaneously every 1-3 hours PRN pain
D) Hydromorphone hydrochloride (Dilaudid) 1 mg orally every 4 hours PRN pain

Question 30

The nurse is caring for a client who has had surgery the previous day.The client tells the nurse,"Breathing in using this thing (incentive spirometer)is a ridiculous waste of time." What is the nurse's best response?

A) "The spirometer will help you cough effectively."
B) "The spirometer will help your lungs expand."
C) "The spirometer will help prevent blood clots."
D) "The spirometer will improve blood flow in your lungs."

Question 31

The nurse is caring for several postoperative clients on the unit.Which client does the nurse assess first?

A) Client with 200 mL dark drainage from the nasogastric tube in an hour
B) Client who received oral pain medication 20 minutes ago
C) Client who has not yet ambulated after surgery 4 hours ago
D) Client requiring discharge teaching and whose family is present

Question 32

The nurse is assisting a client to ambulate several hours after his surgery.The client coughs and says to the nurse,"I feel like something ripped in my incision." A large amount of blood is suddenly apparent on the client's gown near the incision.What action does the nurse take first?

A) Ease the client to the floor and call for assistance.
B) Put immediate pressure over the incision with the hands.
C) Call the Rapid Response Team to assess the client.
D) Lift up the gown and take off the dressing.

Question 33

The nurse is changing the dressing on a postoperative client's abdominal incision.A Jackson-Pratt (JP)drain is present,along with a moderate amount of serosanguineous drainage.What is the best product for the nurse to use in performing wound care?

A) Half hydrogen peroxide and half sterile saline
B) Sterile water and antibacterial ointment
C) Betadine swabs or alcohol wipes
D) Sterile normal saline

Question 34

The nurse is providing discharge teaching for a client who will be going home with a Jackson-Pratt (JP)drain.Which statement indicates that the client understands how to care for the drain correctly?

A) "I will flush the tubing to make sure that it stays open."
B) "I will measure the drainage before I discard it."
C) "I will close the drain valve and then compress the bulb to create suction."
D) "I will pull it out once the surgeon says I don't need it anymore."

Question 35

The nurse assesses clients in the postanesthesia care unit (PACU).Which client does the nurse intervene for first?

A) Client with a respiratory rate of 12 breaths/min
B) Client with an oxygen saturation of 92%
C) Client who is reporting pain (5 out of 10)
D) Client with audible stridor

Question 36

A client has received an overdose of a benzodiazepine.What medication does the nurse anticipate an order for?

A) Flumazenil (Romazicon)
B) Naloxone (Narcan)
C) Acetylcysteine (Mucomyst)
D) Digoxin immune fab (Digibind)

Question 37

After discharge from the postanesthesia care unit (PACU),the client returned to the surgical nursing unit at 10 AM.It is now 6 PM,and the client is not experiencing any complications.How often does the nurse assess the client's vital signs?

A) Every 15 minutes
B) Every 30 minutes
C) Every hour
D) Every 4 hours

Question 38

A client is scheduled for an operation.What does the nurse teach the client about postoperative pain control?

A) "You should not ask for IV pain medication more than once every 4 or 5 hours."
B) "You should not take the pain medication if you are nauseated."
C) "You will not get pain medication until you are transferred to the floor."
D) "You should ask for pain medication before the pain becomes severe."

Question 39

The nurse is assessing clients in the postanesthesia care unit (PACU).A client is shivering and has a temperature of 95.4° F (35.2° C).What is the nurse's best action?

A) Get the client warm blankets.
B) Elevate the head of the bed.
C) Auscultate the client's lungs.
D) Assess the client's oxygen saturation.

Question 40

Which instruction does the nurse provide to a client to prevent postoperative venous thromboembolism?

A) "Cough and deep-breathe six times every hour after surgery."
B) "Use your incentive spirometer hourly."
C) "Get up and walk as much as possible."
D) "Keep the sterile dressing on your incision."

Question 41

The nurse is to administer 1 mg of butorphanol tartrate (Stadol)IV to a postoperative client.Stadol is available as 2 mg/mL.How much Stadol does the nurse administer to the client? ________ mL

Question 42

A postoperative client is receiving morphine for pain.For which side effects does the nurse monitor this client?

A) Hypotension
B) Respiratory depression
C) Constipation
D) Increased intracranial pressure
E) Altered bleeding times

Question 43

A client is receiving morphine via patient-controlled analgesia (PCA)pump.Morphine is available in a 5-mg/mL solution.The basal rate is 0.8 mg/hr.What is the total volume the client will receive in 24 hours? _________ mL

Question 44

Which clients are at increased risk for postoperative nausea and vomiting?

A) Older adult with a history of hypertension
B) Client who was in the lateral position during surgery
C) Middle aged client with a body mass index (BMI) of 46
D) Woman who has undergone a cholecystectomy
E) Young adult who received 3 L of IV fluid during surgery
F) Man who has a history of seasickness
G) Man who has a nasogastric tube to suction

Question 45

A surgical procedure has just been concluded for a client who received a general anesthetic.Place the interventions in order of implementation.(Select in order of priority.)

A) Determining pain response
B) Assessing the IV
C) Taking the client's vital signs
D) Applying warmed blankets

Question 46

The nurse is caring for a postoperative client with a nasogastric (NG)tube to suction.The collection container was marked at 125 mL at 7 AM.At 3 PM,675 mL was in the container.During the shift,the nurse used 45 mL of saline to irrigate the tube three times as prescribed by the physician.What is the total amount of drainage from the NG tube that is entered into the client's record? ___________ mL