Question 1

Which nursing action is appropriate when providing care to a patient who is exhibiting low oxygen saturation levels in the postanesthesia care unit (PACU).

Accepted Answer

Monitoring breath sounds is an appropriate nursing action in a patient exhibiting low oxygen saturation levels in the PACU as it can help identify any potential respiratory complications. Administering heparin and assessing for malignant hyperthermia are not appropriate actions for this particular situation. Holding prescribed opioid analgesics may also be appropriate but it would depend on the individual patient’s condition and assessment findings.

Question 2

The postanesthesia care nurse is providing care to a patient with fluid volume overload who is experiencing cardiac dysrhythmias.Which laboratory test should the nurse monitor for this patient?

Accepted Answer

Serum potassium levels should be monitored for a patient with fluid volume overload and cardiac dysrhythmias as an imbalance in potassium levels can contribute to the development of dysrhythmias. Serum glucose levels, prothrombin time, and blood urea nitrogen levels are not directly related to the cardiac dysrhythmias seen in this patient.

Question 3

The patient arrives at the surgeon's office one week after surgery to have the sutures removed.Which classification would the nurse use when documenting care for this patient?

Accepted Answer

The presence of sutures indicates that the patient has already undergone surgery, making the appropriate classification for documenting care "postoperative." "Preoperative" refers to care provided before surgery, "intraoperative" refers to care provided during surgery, and "perioperative" refers to care provided throughout the entire surgical experience (before, during, and after).

Question 4

The nurse is caring for a patient with a drain connected to a portable drainage suction device shaped like a grenade made of plastic.Which term will the nurse use when describing this system during end-of-shift report?

Accepted Answer

The described device is a Jackson-Pratt drain, which is a closed wound drainage system shaped like a grenade and used to remove fluids from a surgical site.

Question 5

Which is the priority initial assessment for a patient who is admitted to the postanesthesia care unit (PACU)?

Accepted Answer

The priority initial assessment for a patient who is admitted to the PACU is to assess their respirations. This is because patients who have undergone anesthesia are at risk for respiratory depression and airway obstruction, which can lead to hypoxia and other complications. Monitoring and managing the patient's respirations is therefore essential to their safety and wellbeing. Once the patient's respiratory status has been stabilized, other vital signs like heart rate, blood pressure, and temperature can be assessed and managed accordingly.

Question 6

The medical-surgical nurse is providing care to a postoperative patient who is experiencing an elevated temperature.Which laboratory value should the nurse monitor to gather more information?

Accepted Answer

White blood cell (WBC) count is the most appropriate laboratory value to monitor when a patient is experiencing an elevated temperature as it can indicate the presence of an infection. The normal range for WBC count is 4,500 to 11,000 cells/mm³. An elevated WBC count could indicate an infection, inflammation, or an immune response. Other laboratory values (platelet count, serum glucose, RBC count) may provide important information for certain conditions, but they are not as directly related to an elevated temperature.

Question 7

The nurse is providing care to a postoperative patient who is experiencing pain.The patient rates the pain at a 4 on a 1 to 10 numeric pain assessment scale.Which prescribed medication should the nurse administer to this patient?

Accepted Answer

Based on the patient's pain rating of 4 out of 10, which falls into the mild to moderate pain range, ibuprofen would be the appropriate medication to administer. Fentanyl and morphine are typically reserved for severe pain, while hydromorphone is more commonly used for moderate to severe pain.

Question 8

Which nursing action is appropriate when providing care to a patient who is exhibiting symptoms of a venous thromboembolism (VTE)?

Accepted Answer

Administering heparin is the appropriate nursing action for a patient who is exhibiting symptoms of VTE as it is the first-line medication for preventing and treating blood clots. Monitoring breath sounds may be appropriate for other conditions, but it is not related to VTE. Holding prescribed opioid analgesics and assessing for malignant hyperthermia are also not necessary for VTE.

Question 9

The nurse is providing care to a patient in the postanesthesia care unit (PACU)who lost a large amount of blood during a surgical procedure.Which assessment finding should the nurse monitor this patient for based on the current data?

Accepted Answer

Tachycardia is a common response to blood loss as the body tries to compensate for decreased blood volume by increasing heart rate. Bradypnea, hypothermia, and hypertension are not commonly associated with blood loss.

Question 10

Which nursing action is appropriate when providing care to a patient who is difficult to arouse in the postanesthesia care unit (PACU)?

Accepted Answer

The answer of Which nursing action is appropriate when providing...

Question 11

The nurse is assessing a patient's postoperative wound and finds it has separated from the suture line with extrusion of the bowel through the opening.When documenting this finding,which term will the nurse use?

Accepted Answer

Wound evisceration is when the wound separates and the internal organs or tissues protrude through the opening. A, B, and D do not accurately describe this specific finding.

Question 12

Which patient finding would indicate the need for further monitoring rather than discharge home after an outpatient surgical procedure?

Accepted Answer

The answer of Which patient finding would indicate the need...

Question 13

The postoperative patient displays sudden chest pain,shortness of breath,cyanosis,tachycardia,and low blood pressure.The nurse suspects which postoperative complication?

Accepted Answer

The sudden onset of chest pain, shortness of breath, cyanosis, tachycardia, and low blood pressure are signs of a pulmonary embolism, which is a serious postoperative complication that occurs due to a blood clot blocking a blood vessel in the lungs. Prompt intervention is necessary to prevent further complications. The other options, pneumonia, atelectasis, and hypovolemia, may also cause some of these symptoms, but they are not typically acute and may present with other symptoms as well.

Question 14

Which laboratory test should the postanesthesia care nurse monitor for a patient who is having difficulty regaining consciousness after a surgical procedure?

Accepted Answer

Monitoring serum glucose is important when a patient is having difficulty regaining consciousness, as low blood sugar levels can lead to confusion and impaired consciousness. High blood sugar levels may also be indicative of an underlying condition that could be contributing to the patient's symptoms. Monitoring serum potassium, prothrombin time, and blood urea nitrogen would not necessarily provide relevant information in this situation.

Question 15

Upon receiving the patient from the postanesthesia care unit,which nursing action is the priority?

Accepted Answer

The priority nursing action upon receiving a patient from the postanesthesia care unit is to assess the patient's vital signs, monitor for signs of complications, and ensure the patient's airway is stable. This will help prevent any potential adverse outcomes and ensure the patient's safety. Applying clean linens and assembling equipment can wait until after the initial assessment is complete. Notifying the family may be important for the patient's emotional well-being, but it is not the priority nursing action.

Question 16

How many providers from the operating room (OR)should participate in the hand-off communication that occurs with the postanesthesia care (PACU)nurse prior to patient transfer?

Accepted Answer

The answer of How many providers from the operating room...

Question 17

Which is the priority laboratory test that the postanesthesia care nurse should monitor closely for an older adult patient with renal disease who retained fluid during a surgical procedure?

Accepted Answer

For an older adult patient with renal disease who retained fluid during a surgical procedure, the priority laboratory test that the postanesthesia care nurse should monitor closely is the blood urea nitrogen (BUN) level. BUN measures the amount of nitrogen in the blood that comes from urea, a waste product of protein breakdown in the liver. In patients with renal disease, fluid retention can lead to increased nitrogen and urea in the blood, which can indicate renal dysfunction. Therefore, close monitoring of BUN levels is crucial in identifying and managing any postoperative complications related to renal function. Serum glucose, serum potassium, and prothrombin (PT) time are also important parameters to monitor in the postoperative period, but they are not the priority in this specific patient population.

Question 18

Which laboratory test should the postanesthesia care nurse monitor closely for a patient who is prescribed warfarin in the treatment of atrial fibrillation?

Accepted Answer

Warfarin is an anticoagulant medication that acts by inhibiting the synthesis of vitamin K-dependent clotting factors in the liver. Therefore, the PT time is the laboratory test that monitors the patient's response to warfarin therapy. The PT measures the time it takes for blood to clot and is expressed as an international normalized ratio (INR). The ideal target INR for a patient receiving warfarin for atrial fibrillation is 2.0-3.0. The postanesthesia care nurse should monitor the PT/INR closely to assess the patient's anticoagulant status and adjust the warfarin dose as needed based on the therapeutic range.

Question 19

The postanesthesia care unit (PACU)nurse is providing care for a patient who is exhibiting hypothermia.Which nursing action is appropriate?

Accepted Answer

Hypothermia is a potential complication of anesthesia and surgery, and it can cause respiratory depression, hypotension, and other adverse events. Providing warm blankets or warming devices can help regulate the patient's body temperature and prevent further complications. Monitoring breath sounds and checking serum glucose levels are important aspects of postoperative care but do not directly address hypothermia. Holding opioid analgesics may be necessary if the patient experiences respiratory depression or other adverse effects, but it does not address the underlying cause of hypothermia.

Question 20

In the ongoing postoperative period,the nurse independently determines,within the protocols of the hospital,the need for which provision of care?

Accepted Answer

The nurse can determine the appropriate interval for postoperative assessments based on the patient's condition and hospital protocol. However, the type of diet, activity level, and intravenous solutions should be prescribed by the physician and/or dietician and are not within the nurse's independent scope of practice.

Quiz 17: Priorities for the Postoperative Patient

Which nursing action is appropriate when providing care to a patient who is exhibiting low oxygen saturation levels in the postanesthesia care unit (PACU) .

The postanesthesia care nurse is providing care to a patient with fluid volume overload who is experiencing cardiac dysrhythmias.Which laboratory test should the nurse monitor for this patient?

The patient arrives at the surgeon's office one week after surgery to have the sutures removed.Which classification would the nurse use when documenting care for this patient?

The nurse is caring for a patient with a drain connected to a portable drainage suction device shaped like a grenade made of plastic.Which term will the nurse use when describing this system during end-of-shift report?

Which is the priority initial assessment for a patient who is admitted to the postanesthesia care unit (PACU) ?

The medical-surgical nurse is providing care to a postoperative patient who is experiencing an elevated temperature.Which laboratory value should the nurse monitor to gather more information?

The nurse is providing care to a postoperative patient who is experiencing pain.The patient rates the pain at a 4 on a 1 to 10 numeric pain assessment scale.Which prescribed medication should the nurse administer to this patient?

Which nursing action is appropriate when providing care to a patient who is exhibiting symptoms of a venous thromboembolism (VTE) ?

The nurse is providing care to a patient in the postanesthesia care unit (PACU) who lost a large amount of blood during a surgical procedure.Which assessment finding should the nurse monitor this patient for based on the current data?

Which nursing action is appropriate when providing care to a patient who is difficult to arouse in the postanesthesia care unit (PACU) ?