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Chapter 19: Management: Postoperative Care (Med Surg I)

Terms in this set (25)

1. On admission of a patient to the postanesthesia care unit (PACU), the blood
pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a
pulse of 74 and warm, dry skin. Which action by the nurse ismost appropriate?
a. Increase the IV fluid rate.
b. Continue to take vital signs every 15 minutes.
c. Administer oxygen therapy at 100% per mask.
d. Notify the anesthesia care provider (ACP) immediately.
ANS: B
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 and/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.
2. In the postanesthesia care unit (PACU), a patients vital signs are blood pressure
116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens
easily. Which action should the nurse take first?
a. Place the patient in a side-lying position.
b. Encourage the patient to take deep breaths.
c. Prepare to transfer the patient to a clinical unit.
d. Increase the rate of the postoperative IV fluids.
ANS: B
The patients borderline SpO2 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 SpO2, indicating that
transfer from the PACU to a clinical unit is not appropriate.
3. 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?
a. The new nurse assists a nauseated patient to a supine position.
b. The new nurse positions an unconscious patient supine with the head
elevated.
c. The new nurse turns an unconscious patient to the side upon arrival in
the PACU.
d. The new nurse places a patient in the Trendelenburg position when the
blood pressure drops.
ANS: C
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.
4. An older patient is being discharged from the ambulatory surgical unit following
left eye surgery. The patient tells the nurse, I do not know if I can take care of myself
with this patch over my eye. Which action by the nurse is most appropriate?
a. Refer the patient for home health care services.
b. Discuss the specific concerns regarding self-care.
c. Give the patient written instructions regarding care.
d. Assess the patients support system for care at home.
ANS: B
The nurses initial action should be to assess exactly the patients concerns about self-
care. Referral to home health care and assessment of the patients support system may
be appropriate actions but will be based on further assessment of the patients
concerns. Written instructions should be given to the patient, but these are unlikely to
address the patients stated concern about self-care.
5. 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 sharp,
cramping gas pains. What action by the nurse is the mostappropriate?
a. Reinsert the NG tube.
b. Give the PRN IV opioid.
c. Assist the patient to ambulate.
d. Place the patient on NPO status.
ANS: C
Ambulation encourages peristalsis and the passing of flatus, which will relieve the
patients 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.
6. A patients T-tube is draining dark green fluid after gallbladder surgery. What action
by the nurse is the most appropriate?
a. Notify the patients surgeon.
b. Place the patient on bed rest.
c. Document the color and amount of drainage.
d. Irrigate the T-tube with sterile normal saline.
ANS: C
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.
7. A nurse assists a patient on the first postoperative day to ambulate, cough, deep
breathe, and turn. Which action by the nurse is most helpful?
a. Teach the patient to fully exhale into the incentive spirometer.
b. Administer ordered analgesic medications before these activities.
c. Ask the patient to state two possible complications of immobility.
d. Encourage the patient to state the purpose of splinting the incision.
ANS: B
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, and concern about complications, patients will have difficulty if there
is a great deal of pain involved with these activities. When using an incentive
spirometer, the patient should be taught to inhale deeply, rather than exhale into the
spirometer to promote lung expansion and prevent atelectasis.
8. 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?
a. Patient drinks 2 to 3 L of fluid in 24 hours.
b. Patient uses the spirometer 10 times every hour.
c. Patients breath sounds are clear to auscultation.
d. Patients temperature is less than 100.4 F orally.
ANS: C
One characteristic of ineffective airway clearance is the presence of adventitious
breath sounds such as rhonchi or 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 improve breath sounds in all patients.
Elevated temperature may occur with atelectasis, but a normal or near-normal
temperature does not always indicate resolution of respiratory problems.
9. A patient who has begun to awaken after 30 minutes in the postanesthesia care unit
(PACU) is restless and shouting at the nurse. The patients oxygen saturation is 96%,
and recent laboratory results are all normal. Which action by the nurse is most
appropriate?
a. Increase the IV fluid rate.
b. Assess for bladder distention.
c. Notify the anesthesia care provider (ACP).
d. Demonstrate the use of the nurse call bell button.
ANS: B
Because the patients assessment indicates physiologic stability, the most likely cause
of the patients 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 patients 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.
10. Which action could the postanesthesia care unit (PACU) nurse delegate to
unlicensed assistive personnel (UAP) who help with the transfer of a patient to the
clinical unit?
a. Clarify the postoperative orders with the surgeon.
b. Help with the transfer of the patient onto a stretcher.
c. Document the appearance of the patients incision in the chart.
d. Provide hand off communication to the surgical unit charge nurse.
ANS: B
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.
11. 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?
a. Assess the patients pain.
b. Orient the patient to the unit.
c. Take the patients vital signs.
d. Read the postoperative orders.
ANS: C
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.
12. 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?
a. Potential complication: hypovolemic shock
b. Potential complication: venous thromboembolism
c. Potential complication: fluid and electrolyte imbalance
d. Potential complication: impaired surgical wound healing
ANS: B
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 supported by the data about this patient.
13. A patient who is just waking up after having hip replacement surgery is agitated
and confused. Which action should the nurse take first?
a. Administer the ordered opioid.
b. Check the oxygen (O2) saturation.
c. Take the blood pressure and pulse.
d. Apply wrist restraints to secure IV lines.
ANS: B
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.
14. A postoperative patient has not voided for 8 hours after return to the clinical unit.
Which action should the nurse take first?
a. Perform a bladder scan.
b. Encourage increased oral fluid intake.
c. Assist the patient to ambulate to the bathroom.
d. Insert a straight catheter as indicated on the PRN order.
ANS: A
The initial action should be to assess the bladder for distention. If the bladder is
distended, providing the patient with privacy (by walking with them 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.
15. 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. Reinforce the dressing.
b. Apply an abdominal binder.
c. Take the patients vital signs.
d. Recheck the dressing in 1 hour for increased drainage.
ANS: C
New bright-red drainage may indicate hemorrhage, and the nurse should initially
assess the patients 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 surgeons orders or institutional policy. The nurse should not
wait an hour to recheck the dressing.
16. 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.
Which action should the nurse take first?
a. Have the patient use the incentive spirometer.
b. Assess the surgical incision for redness and swelling.
c. Administer the ordered PRN acetaminophen (Tylenol).
d. Ask the health care provider to prescribe a different antibiotic.
ANS: A
A temperature of 100.8 F in the first 48 hours is usually caused by atelectasis, and the
nurse should have the patient cough and deep breathe. This problem may be resolved
by nursing intervention, and therefore notifying the health care provider is not
necessary. Acetaminophen will reduce the temperature, but it will not resolve the
underlying respiratory congestion. Because a wound infection does not usually occur
before the third postoperative day, a wound infection is not a likely source of the
elevated temperature.
17. 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. Elevate the patients head.
b. Suction the patients mouth.
c. Increase the oxygen flow rate.
d. Perform the jaw-thrust maneuver.
ANS: D
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 patients head will
not be effective in correcting the obstruction but may help with oxygenation after the
patient is awake.
18. 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?
a. The right calf is swollen, warm, and painful.
b. The patients temperature is 100.3 F (37.9 C).
c. The 24-hour oral intake is 600 mL greater than the total output.
d. The patient complains of abdominal pain at level 6 (0 to 10 scale) when
ambulating.
ANS: A
The calf pain, swelling, and warmth suggest that the patient has a deep vein
thrombosis, which will require the health care provider to order diagnostic tests and/or
anticoagulants. 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 suggests 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.
19. A patient who had knee surgery received intramuscular ketorolac (Toradol) 30
minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale). Which
action is best for the nurse to take at this time?
a. Administer the prescribed PRN IV morphine sulfate.
b. Notify the health care provider about the ongoing knee pain.
c. Reassure the patient that postoperative pain is expected after knee
surgery.
d. Teach the patient that the effects of ketorolac typically last about 6 to 8
hours.
ANS: A
The priority at this time is pain relief. Concomitant use of opioids and nonsteroidal
antiinflammatory drugs (NSAIDs) improves pain control in postoperative patients.
Patient teaching and reassurance are appropriate, but should be done after the patients
pain is relieved. If the patient continues to have pain after the morphine is
administered, the health care provider should be notified.
20. 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?
a. Cover the patient with a warm blanket and put on socks.
b. Notify the anesthesia care provider about the temperature.
c. Avoid the use of opioid analgesics until the patient is warmer.
d. Administer acetaminophen (Tylenol) 650 mg suppository rectally.
ANS: A
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.
21. The nurse reviews the laboratory results for a patient on the first postoperative day
after a hiatal hernia repair. Which finding would indicate to the nurse that the patient
is at increased risk for poor wound healing?
a. Potassium 3.5 mEq/L
b. Albumin level 2.2 g/dL
c. Hemoglobin 11.2 g/dL
d. White blood cells 11,900/L
ANS: B
Because proteins are needed for an appropriate inflammatory response and wound
healing, the low serum albumin level (normal level 3.5 to 5.0 g/dL) indicates a risk for
poor wound healing. The potassium level is normal. Because a small amount of blood
loss is expected with surgery, the hemoglobin level is not indicative of an increased
risk for wound healing. WBC count is expected to increase after surgery as a part of
the normal inflammatory response.
22. The nurse assesses a patient on the second postoperative day after abdominal
surgery to repair a perforated duodenal ulcer. Which finding is most important for the
nurse to report to the surgeon?
a. Tympanic temperature 99.2 F (37.3 C)
b. Fine crackles audible at both lung bases
c. Redness and swelling along the suture line
d. 200 mL sanguineous fluid in the wound drain
ANS: D
Wound drainage should decrease and change in color from sanguineous to
serosanguineous by the second postoperative day. The color and amount of drainage
for this patient are abnormal and should be reported. Redness and swelling along the
suture line and a slightly elevated temperature are normal signs of postoperative
inflammation. Atelectasis is common after surgery. The nurse should have the patient
cough and deep breathe, but there is no urgent need to notify the surgeon.
23. After receiving change-of-shift report about these postoperative patients, which
patient should the nurse assess first?
a. Obese patient who had abdominal surgery 3 days ago and whose wound
edges are separating
b. Patient who has 30 mL of sanguineous drainage in the wound drain 10
hours after hip replacement surgery
c. Patient who has bibasilar crackles and a temperature of 100F (37.8C) on
the first postoperative day after chest surgery
d. Patient who continues to have incisional pain 15 minutes after
hydrocodone and acetaminophen (Vicodin) administration
ANS: A
The patients history and assessment suggests possible wound dehiscence, which
should be reported immediately to the surgeon. Although the information about the
other patients indicates a need for ongoing assessment and/or possible intervention,
the data do not suggest any acute complications. Small amounts of red drainage are
common in the first postoperative hours. Bibasilar crackles and a slightly elevated
temperature are common after surgery, although the nurse will need to have the
patient cough and deep breathe. Oral medications typically take more than 15 minutes
for effective pain relief.
1. While ambulating in the room, a patient complains of feeling dizzy. In what order
will the nurse accomplish the following activities? (Put a comma and a space between
each answer choice [A, B, C, D].)
a. Have the patient sit down in a chair.
b. Give the patient something to drink.
c. Take the patients blood pressure (BP).
d. Notify the patients health care provider.
ANS:
A, C, B, D
The first priority for the patient with syncope is to prevent a fall, so the patient should
be assisted to a chair. Assessment of the BP will determine whether the dizziness is
due to orthostatic hypotension, which occurs because of hypovolemia. Increasing the
fluid intake will help prevent orthostatic dizziness. Because this is a common
postoperative problem that is usually resolved through nursing measures such as
increasing fluid intake and making position changes more slowly, there is no urgent
need to notify the health care provider.
2. A patients blood pressure in the postanesthesia care unit (PACU) has dropped from
an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96.
SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions?
(Put a comma and a space between each answer choice [A, B, C, D].)
a. Increase the IV infusion rate.
b. Assess the patients dressing.
c. Increase the oxygen flow rate.
d. Check the patients temperature..
ANS:
A, C, B, D
The first nursing action should be to increase the IV infusion rate. Because the most
common cause of hypotension is volume loss, the IV rate should be increased. The
next action should be to increase the oxygen flow rate to maximize oxygenation of
hypoperfused organs. Because hemorrhage is a common cause of postoperative
volume loss, the nurse should check the dressing. Finally, the patients temperature
should be assessed to determine the effects of vasodilation caused by rewarming
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