Deck 22: Nursing Management: Postoperative Care

Question 1

Postoperatively,a patient is receiving low-molecular weight heparin.What should the nurse do when administering this drug?

A) Explain that the drug will help prevent clot formation in the legs.
B) Administer the dose with meals to prevent gastrointestinal irritation and bleeding.
C) Check the results of the partial thromboplastin time before administration.
D) Inform the patient that blood will be drawn every 6 hours to monitor the prothrombin time.

Answer 1

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

Question 2

Which of the following is an integumentary system clinical manifestation of inadequate oxygenation?

A) Muscle twitching
B) Use of accessory muscles
C) Hypotension
D) Prolonged capillary refill

Answer 2

Prolonged capillary refill

Question 3

A patient is one day postoperative for abdominal surgery and has an indwelling catheter.Which of the following amounts represents the normal daily range of urine volume?

A) 200 to 400 mL
B) 500 to 700 mL
C) 800 to 1000 mL
D) 1500 to 2000 mL

Answer 3

500 to 700 mL

Question 4

Following gallbladder surgery,a patient has a T-tube with thick,dark green drainage.When the patient asks about the tube and the drainage,what is the nurse's best response?

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

Question 5

A patient who had bowel surgery 2 days ago has orders for morphine sulphate 4 mg IV every 2 hours and a clear liquid diet.The patient tells the nurse that she feels distended and has gas pains.What is the most appropriate intervention in response to the patient's complaint?

A) Obtain an order for a laxative.
B) Withhold all oral fluid and food.
C) Assist the patient to ambulate in the hall.
D) Administer the prescribed morphine sulphate.

Question 6

During planning to promote ambulation,coughing,deep breathing,and turning in a postoperative patient,which of the following does the nurse know will help ensure that the desired outcomes will most readily be met?

A) The patient understands the rationale for these activities.
B) The patient receives praise when the activities are completed.
C) The patient receives enough analgesics to promote relative freedom from pain.
D) The patient is warned about complications that can occur without the activities.

Question 7

To maintain the airway and promote respiratory function,in which preferred position should the nurse place unconscious patients in the PACU?

A) Prone
B) Lateral
C) Dorsal recumbent
D) Supine with the head of the bed elevated

Question 8

Which of the following is a possible cause for a temperature of 36.1°C in a patient at 8 hours postoperative abdominal surgery?

A) Surgical stress response
B) Lung congestion,atelectasis
C) Effects of anaesthesia
D) Phlebitis

Question 9

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

A) Call the physician.
B) Palpate and percuss the bladder.
C) Ambulate the patient to the bathroom.
D) Check the postoperative orders for catheterization orders.

Question 10

While caring for a postoperative patient,what should the nurse expect that a physiological response to stress during the first 2 to 5 days postoperatively will result in?

A) Tachycardia
B) Hyperventilation
C) Fluid retention with decreased urinary output
D) An elevation of body temperature to 38.3°C

Question 11

On admission of a patient to the postanaesthesia care unit (PACU)from surgery,the nurse should place the highest priority on assessing which of the following?

A) The condition of the surgical site
B) The patient's level of consciousness
C) The adequacy of respiratory function
D) The status of fluid and electrolyte balance

Question 12

The nurse is documenting the daily amount that was collected in a patient's T-tube.Which one of the following daily totals would be considered normal?

A) 100 mL
B) 250 mL
C) 500 mL
D) 1000 mL

Question 13

Which of the following is an ambulatory surgery discharge criterion?

A) Voided at least three times
B) No IV narcotics for last 30 minutes
C) Had at least one bowel movement
D) Oxygen saturation 88%

Question 14

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

A) Administer analgesics as written in the patient's postoperative orders.
B) Administer half of the postoperative dose of analgesic ordered for the patient.
C) Tell the patient that pain medication cannot be given until transfer to the postoperative clinical unit.
D) Consult with the anaesthesiologist to determine an effective,reduced dose of an analgesic for the patient.

Question 15

During recovery from anaesthesia in the PACU,a patient's vital signs for the past hour have been as follows: blood pressure 112/82,110/82,112/80,and 114/82 mm Hg;pulse 76,78,78,and 80 beats/min;and respirations 22,24,24,and 26 breaths/min;her SpO₂ is 90%.She is sleepy but awakens easily and is oriented when spoken to.Her surgical dressing is dry and intact.What is the most appropriate nursing action?

A) Position the patient in a lateral position.
B) Encourage the patient to take deep breaths.
C) Check the patient's temperature,and apply warm blankets.
D) Notify the anaesthesiologist that the patient is ready for discharge from the PACU.

Question 16

When a patient is transferred from the PACU to the clinical surgical unit,what is the first nursing action on the surgical unit?

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

Question 17

A patient's blood pressure in the PACU has dropped from an admission blood pressure of 138/84 to 110/78 mm Hg,with a pulse change of 68 to 84 beats/min.What is the first nursing action to be performed?

A) Administer oxygen.
B) Assess for a full bladder.
C) Auscultate the patient's lungs.
D) Check the patient's temperature.

Question 18

A 42-year-old patient is recovering from anaesthesia in the PACU following a hysterectomy.Her preoperative blood pressure was 120/68 mm Hg,and on admission to the PACU,her blood pressure was 124/70 mm Hg.Thirty minutes after admission,her blood pressure is 112/60 mm Hg.Her pulse is 72 beats/min,and her skin is warm and dry.What is the most appropriate nursing action at this time?

A) Administer oxygen therapy per mask.
B) Notify the anaesthesiologist immediately.
C) Increase the rate of the patient's intravenous (IV)fluid replacement.
D) Continue to monitor the patient,taking vital signs every 15 minutes.

Question 19

A 70-year-old patient becomes restless and agitated as he begins to regain consciousness in the PACU,and his SpO₂ is 88%.What is the most common cause of hypoxemia during anaesthesia recovery that the nurse bases her knowledge on to intervene?

A) Atelectasis
B) Bronchospasm
C) Pulmonary edema
D) Aspiration of gastric contents

Question 20

While assessing patients for complications during recovery from anaesthesia,the nurse recognizes that which of the following patients is at the greatest risk for developing postoperative hypothermia?

A) A 78-year-old female patient undergoing a vaginal hysterectomy under general anaesthesia
B) A 58-year-old male patient undergoing repair of a knee cartilage under general anaesthesia
C) A 68-year-old female patient with diabetes undergoing a great toe amputation under local anaesthesia
D) A 72-year-old male patient undergoing bowel resection for colon cancer under general anaesthesia