Deck 5: Care of Postoperative Patients

Question 1

The nurse is caring for a surgical patient who complains of excessive gas.Which action should the nurse take?

A) Offer iced fluids.
B) Arrange for large meal servings.
C) Provide a straw for drinking fluids.
D) Ambulate the patient in the hall.

Answer 1

Ambulate the patient in the hall.

Question 2

The nurse is caring for a patient during the first postoperative day.Which goal works to prevent atelectasis and is most appropriate for the nursing care plan?

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) Patient will resume diet as soon as possible.

Answer 2

Patient will "huff-cough" every 2 hours.

Question 3

Anti-embolic stockings are in place on the obese postsurgical patient.Which statement accurately describes the standard of care in regard to anti-embolic stockings?

A) The stockings should remain in place continually for the first 24 hours.
B) The stockings should fit tightly at the knee and ankle.
C) The stockings should be removed approximately 20 minutes every shift.
D) The stockings should be removed when ambulating.

Answer 3

The stockings should be removed approximately 20 minutes every shift.

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.Which response is best?

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

When the postoperative patient refuses to cough due to incisional pain,which action should the nurse take first?

A) Encourage deep breathing instead of coughing.
B) Splint the abdomen with a pillow.
C) Explain the importance of controlled coughing.
D) Administer pain medication.

Question 6

The nurse has been assigned to care for several postoperative patients.Which patient is most likely to develop thrombophlebitis?

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

Question 7

The nurse is caring for a patient recovering in the PACU.The patient awakens confused and disoriented.What action should the nurse take first?

A) Take the patient's vital signs.
B) Encourage the patient to return to sleep.
C) Reorient and reassure the patient.
D) Document that the patient is awake and disoriented.

Question 8

The nurse is caring for a 90-year-old postoperative patient whose oxygen saturation is frequently dropping below 90%.Which age-related change is most likely related to this finding?

A) Prolonged use of a walker
B) Poor fluid intake
C) Weakened respiratory muscles
D) Increased elasticity of costal cartilages

Question 9

When caring for a 10-hour postabdominal surgery patient,which finding the nurse should report to the charge nurse?

A) 20 mL of clear green emesis
B) Pain level of 5/10
C) No urine output since surgery
D) A weak cough ability

Question 10

The nurse is caring for a patient who had spinal anesthesia.Which drink is the best choice for the nurse to offer the patient?

A) Tea
B) Orange juice
C) Milk
D) Water

Question 11

The postoperative patient complains of pain only 1 hour after having been medicated with an opioid,which cannot be repeated for three more hours.What action should the nurse take?

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 12

The patient's initial vital signs immediately on return from surgery include: blood pressure (BP)of 140/90; pulse (P)of 80; respirations (R)of 14; and temperature (T)of 98° F.One hour later the vital signs are: BP of 130/84; P of 72; R of 16; and T of 96.8° F.What action should the nurse take next?

A) Add a blanket for warmth to the patient.
B) Notify the charge nurse of a probable hemorrhage.
C) Raise the head of the bed 45 degrees.
D) Document the assessment findings.

Question 13

The PACU nurse is caring for a semiconscious patient immediately following abdominal surgery.The nurse correctly places the patient in which position?

A) Supine
B) Semi-Fowler
C) Lateral
D) Trendelenburg

Question 14

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 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

Question 15

The nurse is caring for a patient who has had spinal anesthesia.The nurse correctly questions which order?

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 16

The postanesthesia care unit (PACU)nurse determines that the patient's Aldrete score is 9.Which statement correctly describes the meaning of this score?

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

Question 17

Which action is most important for the nurse to take prior to ambulating the postsurgical patient for the first time?

A) Raise the head of the bed.
B) Dangle the patient's legs over side of bed.
C) Offer the patient some fluids.
D) Apply a gait belt to the patient.

Question 18

The PACU nurse is caring for an unconscious patient.Assessment reveals diminished breath sounds bilaterally.Which action should the nurse take?

A) Hyperventilate the patient with an Ambu bag.
B) Increase bi-nasal oxygen to 3 L/min.
C) Elevate the head of bed 45 degrees.
D) Document "diminished breath sounds in both lower lobes."

Question 19

The nurse educates the postsurgical patient about which potential effect of smoking on postsurgical recovery?

A) Increased probability of hemorrhage
B) Increased blood pressure
C) Delayed healing
D) Increased need for pain medication

Question 20

The nurse is educating the patient about vitamins and wound healing.The nurse explains that which vitamin will enhance wound healing the most?

A) Vitamin A
B) Vitamin B
C) Vitamin C
D) Vitamin E

Question 21

When providing written discharge instructions,which information should the nurse include?

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 22

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 23

The nurse is performing a neurological assessment on a patient who was just transferred from the PACU following abdominal surgery.Which action(s)correctly demonstrate(s)knowledge of a neurological assessment?

A) Asking the patient to spell his name.
B) Asking the patient to identify 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 patient's pupils for response to light.

Question 24

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 intervention(s)?

A) Administering prophylactic antibiotic therapy 48 hours following surgery.
B) Encouraging the older 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 anti-embolic stockings are removed during bathing.
E) Assisting the patient with incentive spirometer every 4 hours.

Question 25

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

Question 26

Following an outpatient procedure for which the patient received general anesthesia,which finding(s)indicate(s)to the nurse that the patient is ready to be discharged?

A) The patient ambulates to the bathroom with minimal assistance.
B) The patient cannot read and voice an understanding of discharge instructions.
C) The patient has been awake for 2 hours.
D) The patient is able to empty the bladder.
E) The patient plans to drive home.

Question 27

The nurse is performing the Aldrete scoring system.Which factor(s)must be assessed?

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 ounces of broth,and 120 mL of water.In addition,750 mL of intravenous 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