Deck 19: Postoperative Nursing

Question 1

The nurse has conducted assessment of a patient who had surgery for a ruptured appendix 3 days ago. The patient complains of nausea, the abdomen is firm, and bowel sounds are rare in all quadrants. The nurse discusses these assessment findings with the health care provider due to concern regarding development of which condition?

A) Paralytic ileus
B) Dehydration
C) Intestinal obstruction
D) Hyperkalemia

Answer 1

Paralytic ileus

Question 2

Progression through the various phases in the postanesthesia recovery unit PACU) depends on which factor?

A) The severity of the procedure the patient underwent
B) The attentiveness and caring of the nursing staff
C) The temperature and environment of the unit
D) The patient's progress toward physiological homeostasis

Answer 2

The patient's progress toward physiological homeostasis

Question 3

A patient has just arrived in the recovery room. As part of the evaluation for determining discharge from the postanesthesia recovery unit, what will be the nurse's next action?

A) Assess the patient's respirations, oxygen saturation, consciousness, circulation, and activity.
B) Assess whether the patient wants the family in the recovery room.
C) Assess the patient for pain.
D) Take the patient's temperature.

Answer 3

Assess the patient's respirations, oxygen saturation, consciousness, circulation, and activity.

Question 4

What is the purpose of a call by the ambulatory care unit nurse to the patient on the day after discharge?

A) To minimize patient complications and ensure patient safety
B) To let the patient know the nurse cares about him or her
C) To assist in collecting discharge data for the health care provider
D) To meet federal and regulatory requirements

Question 5

The nurse assesses a patient in the postanesthesia recovery unit and finds a BP of 88/50, pulse 116, and respirations of 20. What assessment data will the nurse collect next?

A) Pain assessment
B) Urine output
C) Pulse oximeter reading
D) Whether the patient is nauseated

Question 6

A patient is just arriving in the postanesthesia care unit following general anesthesia. What is the nurse's priority intervention?

A) Assess the patient's respiratory status.
B) Assess the patient's IV.
C) Ask the patient about pain.
D) Assess the patient's cardiac status.

Question 7

The nurse wonders which nursing interventions increase patients' competence in managing their own recovery after discharge. Which intervention might be appropriate to help determine this?

A) The nurse will discuss the patient's discharge with the health care provider.
B) The nurse will measure the patient's ability to ambulate without dyspnea.
C) The nurse will provide the patient with 4 hours of uninterrupted sleep while in the inpatient facility.
D) The nurse will adjust patient teaching to allow for cultural diversity.

Question 8

A patient is preparing for discharge to home. The nurse has provided discharge instructions regarding activities. Which instruction is most helpful to the patient?

A) "You may complete activities as tolerated."
B) "Be sure to rest throughout the day."
C) "You can start exercising in 7 days if there are no signs of wound infection."
D) "You can bathe normally."

Question 9

A 75-year-old patient is received into the postanesthesia recovery room PACU) following a 6-hour abdominal surgery. The patient's hemodynamic status is stable. Based on knowledge of the patient's surgery and the common postoperative complications the patient might be at risk for, the recovery room nurse would perform which interventions?

A) Keep the room temperature at 70 degrees, consider supplemental oxygen, and provide warm blankets.
B) Consider increasing the IV fluids, assess for urine output, and monitor the oxygen saturation.
C) Assess the patient's blood pressure more frequently than for younger clients and provide oxygen.
D) Provide postoperative instructions to avoid straining and eat a low-fiber diet.

Question 10

An elderly postoperative patient is given metoclopramide Reglan) for nausea. Which assessment finding would indicate this patient is experiencing a possible adverse reaction to this medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Involuntary muscle movements
B) Sedation
C) Dry mouth
D) Breakthrough vomiting
E) Hypotension

Question 11

The recovery room nurse has just received a patient whose abdominal drain has an excessive amount of sanguineous drainage. The nurse contacts the physician without delay, recognizing that the drainage could indicate which critical situation?

A) A major wound infection
B) Need for further assessment
C) A potential respiratory crisis
D) Need to return immediately to surgery

Question 12

A nurse notices that patients who ambulate within the first 12 hours of surgery have fewer postoperative complications. Which approach would provide validation for the nurse's belief that early ambulation reduces postoperative complications?

A) Correlation of postoperative complications with the patients' activity
B) Modification of the patients' activity based on the surgical severity
C) Discussion of postoperative complications with a physical therapist
D) Adjustment of the patients' medications related to their activity levels

Question 13

The nurse is assisting a postoperative patient in using an incentive spirometer. Which postoperative complication is the nurse attempting to avoid?

A) Atelectasis
B) Deep vein thrombosis
C) Hemorrhage
D) Pulmonary embolism

Question 14

A potential research study focuses on identifying topics essential for inclusion in patients' discharge instructions. Such a study might provide insight into which question?

A) How can hospitalizations be reduced?
B) When should the patient be discharged?
C) In what ways can patients better manage their own recovery?
D) How might the nurse improve care provided in the hospital?

Question 15

A patient is being evaluated for discharge from the postanesthesia care unit. The patient had a preoperative baseline blood pressure of 124/80. Currently, the patient is moving all four extremities voluntarily, has a respiratory rate of 11, and rouses when her name is called. Which other assessment would mandate that the patient stay in postanesthesia care until more stable?

A) The patient has vomited once since admission.
B) The patient's blood pressure is 120/76.
C) The patient has had no pain since admission to the unit.
D) The patient's pulse oximeter measures 92% on oxygen.

Question 16

The nurse has just received a patient from the surgical area. After 30 minutes in the recovery area, the patient's vital signs are: pulse 92; blood pressure 110/50; respirations 12; and pulse oximeter 86%. What should be the initial nursing response?

A) Call the physician.
B) Ask another nurse for his or her opinion.
C) Stimulate the patient.
D) Place an oral airway in the patient.

Question 17

An elderly surgical patient is having an epidural catheter inserted for pain control. The nurse tells the patient that this method of pain medication has which benefit?

A) Earlier return of bowel function
B) Faster wound healing
C) Earlier ambulation
D) Improved appetite

Question 18

The recovery room nurse is preparing to discharge a 24-year-old patient to home following ambulatory surgery. Which discharge instructions provided by the nurse would be the most comprehensive?

A) Verbal and written instructions to the patient and family regarding the wound, activity and diet restrictions, new medications, pain management, potential complications, and process for reaching the health care provider if needed
B) Written instructions to manage the wound, instructions to resume activities slowly, methods for pain control, and information on whom to contact in 2 days
C) Verbal and written instructions to the family regarding the patient's activity levels, diet, potential problems, and medications
D) Verbal instructions to restrict all activities, diet restrictions, pain management, and circumstances that require contacting the health care provider

Question 19

The nurse is caring for a patient recovering from surgery conducted in the previous 24 hours. What should the nurse do to assist this patient with pain control?

A) Administer prescribed analgesics around the clock.
B) Administer prescribed analgesics when the patient requests something for pain.
C) Assist the patient to a more comfortable position to reduce the amount of pain.
D) Offer the patient a back rub to reduce the amount of pain.

Question 20

The nurse is preparing to discharge a patient who has had outpatient surgery. Which criteria would make the patient eligible for discharge? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Stable vital signs for 1 hour
B) No nausea or dizziness
C) Acceptable level of pain
D) Ability to void
E) Stated readiness to go home

Question 21

The PACU nurse is using the postanesthetic scoring system to determine if a patient is ready to be discharged home after a same-day surgery. The nurse would determine the patient to be ready when the score reaches _______.

Question 22

A patient who is being prepared for discharge after surgery becomes dizzy and weak when getting up to go the bathroom. The nurse would document that this patient has orthostatic hypotension if the patient's heart rate increases by _______beats per minute when moving from the lying to standing position.

Question 23

A patient in the PACU is nauseated and has vomited. Which nursing actions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Administer an antiemetic per protocol or order.
B) Raise the head of the patient's bed.
C) Place a cool washcloth on the patient's forehead or neck.
D) Offer the patient a small amount of ice chips.
E) Offer the patient sips of tea or coffee.

Question 24

A nurse in the PACU is administering an IV fluid bolus to an unconscious patient whose urine output has been less than 10 mL per hour for the last 2 hours. Which findings would indicate that this patient is having an adverse reaction to this treatment? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) The patient develops crackles in the bilateral lung bases.
B) The patient's respiratory rate and depth increases.
C) The patient's oxygen concentration rises.
D) The patient's urine output increases.
E) The patient's incisional pain increases.

Question 25

The surgical unit has developed a new fast-track system whereby patients are transferred from the operating room to PACU phase II. The nurse anticipates that which patients would benefit from this change? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) A healthy 50-year-old patient with an uncomplicated cataract surgery
B) A 20-year-old basketball player who had arthroscopic repair of the knee
C) A 65-year-old woman who had a hysterectomy for uterine cancer
D) A 40-year-old man who had coronary bypass surgery
E) A 5-year-old whose tonsils and adenoids were removed

Question 26

The PACU nurse is assessing a postoperative patient's intravenous fluids. Which assessments should be documented? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Location of the intravenous catheter
B) The length of time the catheter has been in place
C) The type of IV fluid infusing
D) The rate fluid is infusing
E) The type of IV catheter present

Question 27

A nurse is providing care to a patient who had surgery 5 days ago. Today the patient's right calf is red, warm, swollen, and painful. Which interventions should the nurse implement? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

A) Measure the circumference of both calves and compare the readings.
B) Place the patient on bed rest.
C) Collaborate with the patient's primary health care provider.
D) Place a pillow under the patient's knee on the affected side.
E) Palpate for pedal pulses bilaterally.

Question 28

A child who weighs 30 kg is in the PACU. The nurse would collaborate with the child's health care provider if the child's urine output was less than ______ mL per hour.

Question 29

Which finding would the PACU nurse evaluate as indicating the patient is progressing toward maintaining his own airway?

A) The patient snores while breathing.
B) The patient is "fighting" the oral airway.
C) The patient requires suctioning every 15 minutes.
D) The patient's oxygen saturation is below 90% on room air.

Question 30

A patient recovering from surgery reports a pain level of 6 on a 0 to10 pain scale but refuses additional pain medication to avoid becoming addicted. The nurse's response should focus on which concept?

A) The patient may not understand the importance of treating pain.
B) The patient may already have an addiction problem.
C) The patient might benefit from a placebo dose.
D) The physician should be notified to discuss pain management.