Question 1

In the postanesthesia care unit (PACU),a patient's vital signs are blood pressure 116/72 mm Hg,pulse 74 beats/min,respirations 12 breaths/min,and SpO? 91%. The patient is sleepy but awakens easily. Which action should the nurse take first?

Accepted Answer

The patient's borderline SpO? and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable blood pressure and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO?,indicating that transfer from the PACU to a clinical unit is not appropriate.

Question 2

A patient who had knee surgery received IV ketorolac 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which action is most effective for the nurse to take at this time?

Accepted Answer

The priority at this time is pain relief. Concomitant use of opioids and nonsteroidal antiinflammatory drugs improves pain control in postoperative patients. Patient teaching and reassurance are appropriate but should be done after the patient's pain is relieved. If the patient continues to have pain after the morphine is administered,the health care provider should be notified.

Question 3

A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate?

Accepted Answer

A T-tube normally drains dark green to bright yellow drainage so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary.

Question 4

The nurse working in the postanesthesia care unit (PACU)notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take next?

Accepted Answer

The patient assessment indicates the need for active rewarming. There is no indication of a need for acetaminophen. Opioid analgesics may help reduce shivering. Because hypothermia is common in the immediate postoperative period,there is no need to notify the anesthesia care provider unless the patient continues to be hypothermic after active rewarming.

Question 5

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient?

Accepted Answer

The patient is older and relatively immobile,which are two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems,but they are not at a high risk based on the data about this patient.

Question 6

The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU)15 minutes ago. Which action should the nurse take first?

Accepted Answer

In an unconscious postoperative patient,a likely cause of hypoxemia is airway obstruction by the tongue,and the first action is to clear the airway by maneuvers such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the patient's head will not be effective in correcting the obstruction but may help with oxygenation after the patient is awake.

Question 7

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU)is restless and shouting at the nurse. The patient's oxygen saturation is 96%,and recent laboratory results are all normal. Which action by the nurse is most appropriate?

Accepted Answer

Because the patient's assessment indicates physiologic stability,the most likely cause of the patient's agitation is emergence delirium,which will resolve as the patient wakes up more fully. The nurse should look for a cause such as bladder distention. Although hypoxemia is the most common cause,the patient's oxygen saturation is 96%. Emergence delirium is common in patients recovering from anesthesia,so there is no need to notify the ACP. Orientation of the patient to bed controls is needed but is not likely to be effective until the effects of anesthesia have resolved more completely.

Question 8

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

Accepted Answer

The calf pain,swelling,and warmth suggest that the patient has a venous thromboembolism (VTE). This will require the health care provider to order diagnostic tests,anticoagulants,or both and is most critical because a VTE could result in a pulmonary embolism. Because the stress response causes fluid retention for the first 2 to 5 days postoperatively,the difference between intake and output is expected. A temperature elevation to 100.3° F on the second postoperative day is suggestive of atelectasis and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal,and the nurse should administer the ordered analgesic before patient activities.

Question 9

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse,if observed by the experienced nurse,indicates that the orientation was successful?

Accepted Answer

The patient should initially be positioned in the lateral "recovery" position to keep the airway open and avoid aspiration. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness.

Question 10

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst,the nurse obtains an oral temperature of 100.8° F (38.2° C). Which action should the nurse take next?

Accepted Answer

A temperature of 100.8° F (38.2° C)in the first 48 hours is usually caused by atelectasis,and the nurse should have the patient deep breathe,cough,and use the incentive spirometer. This problem may be resolved by nursing intervention,and therefore notifying the health care provider is not necessary. Acetaminophen or ice packs will reduce the temperature,but it will not resolve the underlying respiratory congestion.

Question 11

Which action could the postanesthesia care unit (PACU)nurse delegate to unlicensed assistive personnel (UAP)who help to transport a patient to the clinical unit?

Accepted Answer

The scope of practice of UAP includes repositioning and moving patients under the supervision of a nurse. Providing report to another nurse,assessing and documenting the wound appearance,and clarifying physician orders with another nurse require registered-nurse (RN)level education and scope of practice.

Question 12

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?

Accepted Answer

Emergence delirium may be caused by a variety of factors. However,the nurse should first assess for hypoxemia. The other actions also may be appropriate,but are not the best initial action.

Question 13

An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse,"I don't know if I can take care of myself once I'm home." Which action by the nurse is most appropriate?

Accepted Answer

The nurse's initial action should be to assess exactly the patient's concerns about self-care. Referral to home health care and assessment of the patient's support system may be appropriate actions but will be based on further assessment of the patient's concerns. Written instructions should be given to the patient,but these are unlikely to address the patient's stated concern about self-care.

Question 14

On admission of a patient to the postanesthesia care unit (PACU),the blood pressure (BP)is 122/72 mm Hg. Thirty minutes after admission,the BP is 114/62,with a pulse of 74 and warm,dry skin. Which action by the nurse is most appropriate?

Accepted Answer

A slight drop in postoperative BP with a normal pulse and warm,dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia or cool,clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP,increased fluids,and high-concentration oxygen administration.

Question 15

A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed?

Accepted Answer

One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as crackles,so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not always improve breath sounds. Elevated temperature may occur with atelectasis,but a normal or near-normal temperature does not always indicate resolution of respiratory problems.

Question 16

The nasogastric (NG)tube is removed on the second postoperative day,and the patient is placed on a clear liquid diet. Four hours later,the patient complains of frequent,cramping gas pains. What action by the nurse is the most appropriate?

Accepted Answer

Ambulation encourages peristalsis and the passing of flatus,which will relieve the patient's discomfort. If distention persists,the patient may need to be placed on NPO status,but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon,and reinsertion of the NG tube will not relieve the pains.

Question 17

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first?

Accepted Answer

New bright-red drainage may indicate hemorrhage,and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced,based on the surgeon's orders or agency policy. The nurse should not wait an hour to recheck the dressing.

Question 18

A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first?

Accepted Answer

The initial action should be to assess the bladder for distention. If the bladder is distended,providing the patient with privacy (by walking with the patient to the bathroom)will be helpful. Because of the risk for urinary tract infection,catheterization should only be done after other measures have been tried without success. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful.

Question 19

Which action by the nurse will be most helpful to a patient who is expected to ambulate,deep breathe,and cough on the first postoperative day?

Accepted Answer

An important nursing action to encourage these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching,positive reinforcement,concern about complications,and with rest and sleep,patients will have difficulty if there is a great deal of pain involved with these activities.

Question 20

A patient is transferred from the postanesthesia care unit (PACU)to the clinical unit. Which action by the nurse on the clinical unit should be performed first?

Accepted Answer

Because the priority concerns after surgery are airway,breathing,and circulation,the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer.

Quiz 19: Postoperative Care

In the postanesthesia care unit (PACU) ,a patient's vital signs are blood pressure 116/72 mm Hg,pulse 74 beats/min,respirations 12 breaths/min,and SpO? 91%. The patient is sleepy but awakens easily. Which action should the nurse take first?

A patient who had knee surgery received IV ketorolac 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale) . Which action is most effective for the nurse to take at this time?

A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate?

The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C) . Which action should the nurse take next?

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient?

The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first?

A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 96%,and recent laboratory results are all normal. Which action by the nurse is most appropriate?

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about the patient is most important to communicate to the health care provider?

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU) . Which action by the new nurse,if observed by the experienced nurse,indicates that the orientation was successful?

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst,the nurse obtains an oral temperature of 100.8° F (38.2° C) . Which action should the nurse take next?

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help to transport a patient to the clinical unit?

A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?

An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse,"I don't know if I can take care of myself once I'm home." Which action by the nurse is most appropriate?

On admission of a patient to the postanesthesia care unit (PACU) ,the blood pressure (BP) is 122/72 mm Hg. Thirty minutes after admission,the BP is 114/62,with a pulse of 74 and warm,dry skin. Which action by the nurse is most appropriate?

A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed?

The nasogastric (NG) tube is removed on the second postoperative day,and the patient is placed on a clear liquid diet. Four hours later,the patient complains of frequent,cramping gas pains. What action by the nurse is the most appropriate?

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first?

A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first?

Which action by the nurse will be most helpful to a patient who is expected to ambulate,deep breathe,and cough on the first postoperative day?

A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first?