Deck 22: Nursing Management Postoperative Care

Question 1

After a new nurse has been oriented to the postanaesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse does which of the following actions?

A)Places a client in the Trendelenburg position when the blood pressure (BP) drops.
B)Assists a client to the prone position when the client is nauseated.
C)Turns an unconscious client to the side when the client arrives in the PACU.
D)Positions a newly admitted unconscious client supine with the head elevated.

Answer 1

Turns an unconscious client to the side when the client arrives in the PACU.

Question 2

The nurse is caring for a client who is recovering from anaesthesia in the postanaesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure is 112/60, with a pulse of 72 andwarm,dry skin. Which of the following actions is the most appropriate for the nurse to implement at this time?

A)Increase the rate of the IV fluid replacement.
B)Continue to take vital signs every 15 minutes.
C)Administer oxygen therapy at 100% per mask.
D)Notify the anaesthesia care provider (ACP) immediately.

Answer 2

Continue to take vital signs every 15 minutes.

Question 3

The nurse is caring for a client who is recovering from anaesthesia in the postanaesthesia care unit (PACU), and the vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The client is sleepy but awakens easily. Which of the followingactions should the nurse take at this time?

A)Place the client in a side-lying position.
B)Encourage the client to take deep breaths.
C)Prepare to transfer the client from the PACU.
D)Increase the rate of the postoperative IV fluids.

Answer 3

Encourage the client to take deep breaths.

Question 4

The nurse is caring for a client following gallbladder surgery, and the client's T-tube is draining dark green fluid. Which of the following actions should the nurse take?

A)Place the client on bed rest.
B)Notify the client's surgeon.
C)Document the colour and amount of drainage.
D)Irrigate the T-tube with sterile normal saline.

Question 5

The nurse is caring for an older adult in the postanaesthesia unit. Which of the following age-related considerations may impact postoperative recovery?

A)Increased thoracic compliance
B)Decreased ability to cough
C)Increased lung tissue
D)Decreased compliance with deep breathing and coughing

Question 6

The nurse is caring for a client who is just waking up after having a general anaesthetic and the client is agitated and confused. Which of the following actions should the nurse take first?

A)Check the O2 saturation.
B)Administer the ordered opioid.
C)Take the blood pressure and pulse.
D)Notify the anaesthesia care provider.

Question 7

The nurse is caring for a client who has begun to awaken after 30 minutes in the postanaesthesia care unit (PACU), who is restless and shouting at the nurse. The client's oxygen saturation is 99%, and recent laboratory results are all normal. Which of the following actions by the nurse is most appropriate?

A)Insert an oral or nasal airway.
B)Notify the anaesthesia care provider.
C)Orient the client to time, place, and person.
D)Be sure that the client's IV lines are secure.

Question 8

The nurse is caring for a client with abdominal surgery and on the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. Which of the following actions should the nurse implement first?

A)Reinforce the dressing.
B)Take the client's vital signs.
C)Recheck the dressing in 1 hour for increased drainage.
D)Notify the client's surgeon of a potential hemorrhage.

Question 9

The nurse is caring for a postoperative client who has not voided for 7 hours after return to the postsurgical unit. Which of the following actions should the nurse take first?

A)Notify the surgeon.
B)Assess for bladder distension.
C)Assist the client to ambulate to the bathroom.
D)Insert a straight catheter as indicated on the PRN order.

Question 10

The nurse is caring for an older-adult client who had a surgical repair of a hip fracture 2 days previously and has restrictions on ambulation. Based on this information, which of the following collaborative problems is priority for the client?

A)Potential complication: hypovolemic shock
B)Potential complication: venous thrombo-embolism
C)Potential complication: fluid and electrolyte imbalance
D)Potential complication: impaired surgical wound healing

Question 11

The nurse is caring for a client and during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 38.2°C (100.8°F). Which of the following actions should the nurse take first?

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

Question 12

After removal of the nasogastric (NG) tube on the second postoperative day, the client is placed on a clear liquid diet. Four hours later, the client complains of sharp, cramping gas pains. Which of the following actions should the nurse take?

A)Reinsert the NG tube.
B)Give the PRN IV opioid.
C)Assist the client to ambulate.
D)Place the client on NPO status.

Question 13

The nurse is caring for a client who is being transferred from the postanaesthesia care unit (PACU) to the clinical surgical unit. Which of the following actions should the nurse implement first on the clinical surgical unit?

A)Assess the client's pain.
B)Take the client's vital signs.
C)Read the postoperative orders.
D)Check the rate of the IV infusion.

Question 14

The nurse is caring for an unconscious client who was transferred to the postanaesthesia care unit (PACU) 10 minutes previously and has an oxygen saturation of 88%. Which of the following actions should the nurse take first?

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

Question 15

In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative client on the first postoperative day, which of the following actions by the nurse is most helpful?

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

Question 16

The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative client have been successful when which of the following goals has been met?

A)Client drinks 2-3 L of fluid in 24 hours.
B)Client uses the spirometer 10 times every hour.
C)Client's breath sounds are clear to auscultation.
D)Client's temperature is less than 38°C (100.4°F) orally.

Question 17

The nurse is caring for a client on the first postoperative day who is dizzy when ambulating in the room. In what order will the nurse accomplish the following activities? (All the activities are appropriate.)

A)Take the client's blood pressure (BP).
B)Place the client in the supine position.
C)Assist the client to sit.
D)Record the results.

Question 18

The nurse is caring for a client who had abdominal surgery two days previously. Which of the following information about the client is most important to communicate to the health care provider?

A)The right calf is swollen, warm, and painful.
B)The client's temperature is 37.9°C (100.2°F).
C)The 24-hour oral intake is 600 mL greater than the total output.
D)The client complains of abdominal pain at level 6 (0-10 scale).

Question 19

The nurse is caring for a client in the postoperative period who is on bed rest. Which of the following actions should the nurse implement?

A)Assist the client to the bathroom when required.
B)Implement active ROM exercise every 1-2 hours.
C)Place the client in a chair for 20 minutes TID.
D)Complete passive ROM exercises once per 12 hour shift.

Question 20

The nurse is preparing an older-adult client for discharge from the ambulatory surgical unit following left eye surgery. The client tells the nurse, "I do not know if I can take care of myself with this patch over my eye." Which of the following actionsisthemost appropriate for the nurse to implement?

A)Refer the client for home health care services.
B)Discuss the specific concerns regarding self-care.
C)Give the client written instructions regarding care.
D)Assess the client's support system for care at home.

Question 21

The nurse is caring for a client in the PACU and the client's blood pressure has dropped from an admission blood pressure of 138/84 to 100/58 with a pulse change of 68-94. SpO₂ is 98% on 3L of oxygen. In which order should the nurse take these actions?

A)Raise the IV infusion rate.
B)Assess the client's dressing.
C)Increase the oxygen flow rate.
D)Check the client's temperature.