Ch. 16 PostOp

Question 1

The recovery room nurse is admitting a patient from the OR following the patient’s successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted patient?

A. Heart rate and rhythm
B. Skin integrity
C. Core body temperature
D. Airway patency

Answer 1

D. Airway patency

Question 2

An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patient’s vital signs and LOC stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next?

A. Administer a dose of IV analgesia
B. Apply a cool cloth to the patient’s forehead
C. Offer the patient a small amount of ice chips
D. Turn the patient completely to one side

Answer 2

D. Turn the patient completely to one side

Question 3

The peri-operative nurse is preparing to discharge a female patient home from day surgery performed under general anesthetic. What instruction should the nurse give the patient prior to the patient leaving the hospital?

A. The patient should not drive herself home
B. The patient should take an OTC sleeping pill for 2 nights
C. The patient should attempt to eat a large meal at home to aid wound healing
D. The patient should remain in bed for the first 48 hours postop

Answer 3

A. The patient shouldn’t drive herself home

Question 4

The nurse is caring for a 78-year old man who has had an outpatient cholecystemctomy. The nurse is getting him up for his first walk postop. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do?

A. Sit in a chair for 10 minutes prior to ambulating
B. Drink plenty of fluids to increase circulating blood volume
C. Stand upright for 2 to 3 minutes prior to ambulating
D. Perform ROM exercises for each joint

Answer 4

C. Stand upright for 2 to 3 minutes prior to ambulating

Question 5

The perioperative nurse is providing care for a patient who is recovering on the post surgical unit following a transurethral prostate resection (TUPR). The patient is reluctant to ambulate, citing the need to recover in bed. For what complication is the patient most at risk?

A. Atelectasis
B. Anemia
C. Dehydration
D. Peripheral edema

Answer 5

A. Atelectasis

Question 6

The nurse is caring for a patient on the medical/surgical unit postop day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection?

A. Presence of an indwelling urinary catheter
B. Rectal temperature of 99.5 F (37.5 C)
C. Red, warm, tender incision
D. WBC count of 8000/mL

Answer 6

C. Red, warm, tender incision

Question 7

The nurse is preparing to change a patient’s abdominal dressing. The nurse recognizes the first step is to provide the patient with information regarding the procedure. Which of the following explanations should the nurse provide to the patient?

A. The dressing change is often painful, and we will be giving you pain. Medication prior to the procedure so you don’t have to worry
B. During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to
C. The dressing change should not be painful, but you can never be sure, and infection is always a concern
D. The best time for doing a dressing change is during lunch so we’re not interrupted. I will provide privacy, and it shouldn’t be painful

Answer 7

B. During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to

Question 8

A patient is 2 hours postop with a foley in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the foley is patent. What should the nurse do?

A. Irrigate the foley with 30 mL normal saline
B. Notify the physician and continue to monitor the hourly urine output closely
C. Decrease the IV fluid rate and massage the patient’s abdomen
D. Have the patient sit in high-fowler’s position

Answer 8

B. Notify the physician and continue to monitor the hourly urine output closely

Question 9

The nurse is caring for a 79-year old man who has returned to the post-surgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what post surgical complication?

A. Sepsis
B. Infection
C. Pulmonary embolism
D. Hematoma

Answer 9

C. Pulmonary embolism

Question 10

The nurse admits a patient to the PACU with a BP of 132/90 mmHg and a pulse of 68 bpm. After 30 minutes, the patient’s blood pressure is 94/47 mmHg, and the pulse is 110. The nurse documents that the patient’s skin is cold, moist, and pale. Of what is the patient showing signs?

A. Hypothermia
B. Hypovolemic shock
C. Neurogenic shock
D. Malignant hyperthermia

Answer 10

B. Hypovolemic shock

Question 11

The PACU nurse is caring for a male patient who had a hernia repair. The patient’s blood pressure is now 164/92 mmHg; he has no history of HTN prior to surgery and his preop BP was 112/68 mmHg. The nurse should assess for what potential causes of HTN following surgery?

A. Dysrhythmias, blood loss, and hyperthermia
B. Electrolyte imbalances and neurologic changes
C. A parasympathetic reaction and low blood volumes
D. Pain, hypoxia, or bladder distention

Answer 11

D. Pain, hypoxia, or bladder distention

Question 12

The nurse is caring for a patient after abdominal surgery in the PACU. The patient’s blood pressure has increased the patient is restless. The patient’s oxygen saturation is 97%. What cause for this change in status should the nurse first suspect?

A. The patient is hypothermic
B. The patient is in shock
C. The patient is in pain
D. The patient is hypoxic

Answer 12

C. The patient is in pain

Question 13

The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and residues the wound. You are aware that the wound will not heal by what means?

A. Late intention
B. Second intention
C. Third intention
D. First intention

Answer 13

C. Third intention

Question 14

The nurse is caring for an 82-year old female patient in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurses subsequent assessment?

A. PostOp confusion in older adults is an indication of impaired oxygenation or possibly a stroke during surgery.
B. Confusion, restlessness, and agitation are expected postoperative findings in older adults and they will diminish in time
C. PostOp confusion is common in the older adult patient, but it could also indicate a significant blood loss
D. Confusion, restlessness, and agitation indicate an underlying cognitive deification such as dementia

Answer 14

C. PostOp confusion is common in the older adult patient, but it could also indicate a significant blood loss

Question 15

An adult patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the patient may be at risk for what?

A. Hemorrhage and shock
B. Aspiration
C. PostOp infection
D. HTN and dysrhythmias

Answer 15

A. Hemorrhage and shock

Question 16

The nursing instructor is discussing postop care with a group of nursing students. A student nurse asks, why does the patient go to the PACU instead of just going straight up to the post surgical unit. What is the nursing instructor’s best response?

A. The PACU allows the patient to recover from anesthesia in a stimulating environment to facilitate awakening and reorientation
B. The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications
C. Frequently, patients are placed in the medical/surgical unit to recover, but hospitals are usually short of beds, and the PACU is an excellent place to triage patients
D. Patients remain in the PACU for a predetermined time because the surgeon will often need to reinforce or alter the patient’s incision in the hours following surgery

Answer 16

B. The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications

Question 17

The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patient’s skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention?

A. Check the patient’s oxygen saturation level, continue to monitor for apnea, and perform a focused assessment
B. Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw
C. Assess the arterial pulses, and place the patient in Trendelenburg position
D. Re-intubate the patient

Answer 17

B. Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw

Question 18

The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer. Which of the following statements by the patient indicates that teaching has been effective?

A. I’ll make sure to limit my intake of protein
B. I’ll make sure that the bandage is wrapped tightly
C. My foot should feel cool or cold while my leg’s healing
D. I’ll eat plenty of fruits and vegetables

Answer 18

D. I’ll eat plenty of fruits and vegetables

Question 19

The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority?

A. Assessing for hemorrhage
B. Maintaining a patent airway
C. Managing the patient’s pain
D. Assessing vital signs every 30 minutes

Answer 19

B. Maintaining a patent airway

Question 20

The nurse is caring for a patient who is postop day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurse’s first response?

A. Return the patient to his previous position and call the physician
B. Place saline-soaked sterile dressings on the wound
C. Assess the patient’s blood pressure and pulse
D. Pull the dehiscence closed during gloved hands

Answer 20

B. Place saline-soaked sterile dressings on the wound

Question 21

The PACU nurse is caring for a 45-year old male patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? SATA.

A. Hypotension
B. Hypervolemia
C. Heart murmurs
D. Dysrhythmias
E. HTN

Answer 21

A. Hypotension
D. Dysrhythmias
E. HTN

Question 22

A postop patient rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be the nurse’s first action?

A. Leave and promptly notify the physician
B. Quickly attempt to determine the cause of hemorrhage
C. Begin resuscitation
D. Put the patient in the Trendelenberg position

Answer 22

B. Quickly attempt to determine the cause of hemorrhage

Question 23

The intraoperative nurse is transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year old woman. The nurse should prioritize which of the following actions?

A. Keeping the patient sterile
B. Keeping the patient restrained
C. Keeping the patient warm
D. Keeping the patient hydrated

Answer 23

C. Keeping the patient warm

Question 24

A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? SATA.

A. Absence of pain
B. Stable BP
C. Ability to tolerate oral fluids
D. Sufficient oxygen saturation
E. Adequate respiratory function

Answer 24

B. Stable blood pressure
D. Sufficient oxygen saturation
E. Adequate respiratory function

Question 25

The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? SATA. A. Provide all discharge instruction in writing B. Provide the nurse’s or surgeon’s contract information C. Give prescriptions to the patient D. Irrigate the patient’s incision and perform a sterile dressing change E. Administer a bolus dose of an opioid analgesic

Answer 25

A. Provide all discharge instruction in writing B. Provide the nurse’s or surgeon’s contact information C. Give prescriptions to the patient

Question 26

The nursing instructor is discussing the difference between ambulatory surgical centers and hospital-based surgical units. A student asks why some patients have surgery in the hospital and others are sent to ambulatory surgery centers. What is the instructor’s best response? A. Patients who go to ambulatory surgery centers are more independent than patients admitted to the hospital B. Patients admitted to the hospital for surgery usually have multiple health needs C. In most cases, only emergency and trauma patients are admitted to the hospital D. Patients who have surgery in the hospital are those who need to have anesthesia administered

Answer 26

B. Patients admitted to the hospital for surgery usually have multiple health needs

Question 27

The nurse just received a postop patient from the PACU to the medical/surgical unit. The patient is an 84-year old woman who had surgery for a left hip replacement. Which of the following concerns should the nurse prioritize for this patient in the first few hours on the unit? A. Beginning early ambulation B. Maintaining clean dressings on the surgical site C. Close monitoring of neurologic status D. Resumption of normal oral intake

Answer 27

C. Close monitoring of neurologic status

Question 28

The nurse’s aid notifies the nurse that a patient has decreased oxygen saturation levels. The nurse assesses the patient and finds that he is tachypnic, has crackles on auscultation, and his sputum is frothy and pink. The nurse should suspect what complication? A. Pulmonary embolism B. Atelectasis C. Laryngospasm D. Flash pulmonary edema

Answer 28

D. Flash pulmonary edema

Question 29

The nurse is performing the shift assessment of a post surgical patient. The nurse finds his mental status, LOC, speech, and orientation are intact and at baseline, but the patient tells you he is very anxious. What should the nurse do next? A. Assess the patient’s oxygen levels B. Administer anti anxiety medications C. Page the patient’s physician D. Initiate a social work referral

Answer 29

A. Assess the patient’s oxygen levels

Question 30

The nurse is creating the POC for a patient who is status post surgery for reduction of a femur fracture. What is the most important short-term goal for this patient? A. Relief of pain B. Adequate respiratory function C. Resumption of activities of ADLs D. Unimpaired wound healing

Answer 30

B. Adequate respiratory function

Question 31

You are caring for a 71-year old patient who is 4 days postop for bilateral inguinal hernias. The patient has a history of congestive heart failure and peptic ulcer disease. The patient is highly reluctant to ambulate and will not drink fluids except for hot tea with her meals. The nurse’s aide reports to you that this patient’s vital signs are slightly elevated and that she has a non-productive cough. When you assess the patient, you auscultate crackles at the base of the lungs. What would you suspect is wrong with your patient? A. Pulmonary embolism B. Hypervolemia C. Hypostatic pulmonary congestion D. Malignant hyperthermia

Answer 31

C. Hypostatic pulmonary congestion

Question 32

The nurse is admitting a patient to the medical/surgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia? A. Encourage the patient to eat a balanced diet that is high in protein B. Encourage the patient to limit his activity for the first 72 hours C. Encourage the patient to take his medications as ordered D. Encourage the patient to use the IS every 2 hours

Answer 32

D. Encourage the patient to use the IS every 2 hours

Question 33

A surgical patient has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). The nurse should know that the requirements for safe and effective use of PCA include what? A. A clear understanding of the need to self-dose B. An understanding of how to adjust the medication dosage C. A caregiver who can administer the medication as ordered D. An expectation of infrequent need for analgesia

Answer 33

A. A clear understanding of the need to self-dose

Question 34

A patient underwent an open bowel resection 2 days ago and the nurse’s most recent assessment of the patient’s abdominal incision reveals that it is dehiscence. What factor should the nurse suspect may have caused the dehiscence? A. The patient’s surgical dressing was changed yesterday and today B. The patient has vomited three times in the past 12 hours C. The patient has begun voiding on the commode instead of a bedpan D. The patient used PCA until this morning

Answer 34

B. The patient has vomited three times in the past 12 hours

Question 35

The dressing surrounding a mastectomy patient’s Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion? A. Describe the appearance of the dressing in the electronic health record B. Photograph the patient’s abdomen for later comparison using a smartphone C. Trace the outline of the drainage on the dressing for future comparison D. Remove and weigh the dressing, reply it, and then repeat in 8 hours

Answer 35

C. Trace the outline of the drainage on the dressing for future comparison

Question 36

The nurse is caring for a postop patient who needs daily dressing changes. The patient is 3 days postop and is schedule for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patient’s possible readiness to learn how to change her dressing? SATA. A. The patient wants you to teach a family member to do dressing changes B. The patient expresses interest in the dressing change C. The patient is willing to look at the incision during a dressing change D. The patient expresses dislike of the surgical wound E. The patient assists in the opening the packages of dressing material for the nurse

Answer 36

B. The patient expresses interest in the dressing change C. The patient is willing to look at the incision during a dressing change E. The patient assists in the opening the packages of dressing material for the nurse

Question 37

The nursing instructor is talking with a group of medical/surgical students about DVT. A student asks what factors contribute to the formation of a DVT. What would be the instructor’s best response? A. There is a genetic link in the formation of DVT B. Hypervolemia is often present in patients who go on to develop DVT C. No known factors contribute to the formation of DVT; they just occur D. Dehydration is a contributory factor to the formation of DVT

Answer 37

D. Dehydration is a contributory factor to the formation of DVT

Question 38

The home health nurse is caring for a postop patient who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the patient’s postop day 2. During the visit, the nurse will assess for wound infection. For most patients, what is the earliest postop day that a wound infection becomes evident? A. Day 9 B. Day 7 C. Day 5 D. Day 3

Answer 38

C. Day 5

Question 39

The nurse is caring for an 88-year old patient who is recovering from an ileac-femoral bypass graft. The patient is a day 2 postop and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills, What should the nurse suspect is the problem with the patient? A. Postoperative delirium B. Postoperative dementia C. Senile dementia D. Senile confusion

Answer 39

A. Postoperative delirium

Question 40

The surgeon’s pre-operative assessment of a patient has identified that the patient is at a high risk for venous thromboembolism. Once the patient is admitted to the post surgical unit, what intervention should the nurse prioritize to reduce the patient’s risk of developing this complication? A. Maintain the head of the bed at 45 degrees or higher B. Encourage early ambulation C. Encourage oral fluid intake D. Perform passive ROM exercises every 8 hours

Answer 40

B. Encourage early ambulation