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Flashcards in Ch. 20 MJ Deck (18):
1

A 42-year-old patient is recovering from anesthesia in the postanesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure falls to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at this time is to

a. increase the rate of the IV fluid replacement.

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.

b. continue to take vital signs every 15 minutes.

2

During recovery from anesthesia in the postanesthesia care unit (PACU), a patient’s vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take at this time?

a. Place the patient in a side-lying position.

b. Encourage the patient to take deep breaths.

c. Prepare to transfer the patient from the PACU.

d. Increase the rate of the postoperative IV fluids.

b. Encourage the patient to take deep breaths.

3

After a new nurse has been oriented to the postanesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse

a. places a patient in the Trendelenburg position when the blood pressure (BP) drops.

b. assists a patient to the prone position when the patient is nauseated.

c. turns an unconscious patient to the side when the patient arrives in the PACU.

d. positions a newly admitted unconscious patient supine with the head elevated.

c. turns an unconscious patient to the side when the patient arrives in the PACU.

4

A 75-year-old is to be 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.” The most appropriate nursing action is to

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 patient’s support system for care at home.

b. discuss the specific concerns regarding self-care.

5

After removal of the nasogastric (NG) tube on the second postoperative day, the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. Which action should the nurse take?

a. Reinsert the NG tube.

b. Give the PRN IV opioid.

c. Assist the patient to ambulate.

d. Place the patient on NPO status

c. Assist the patient to ambulate.

6

Following gallbladder surgery, a patient’s T-tube is draining dark green fluid. Which action should the nurse take?

a. Place the patient on bed rest.

b. Notify the patient’s surgeon.

c. Document the color and amount of drainage.

d. Irrigate the T-tube with sterile normal saline.

c. Document the color and amount of drainage.

7

In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which action by the nurse is most helpful?

a. Discuss the complications of immobility and poor cough effort.

b. Teach the patient the purpose of respiratory care and ambulation.

c. Administer ordered analgesic medications before these activities.

d. Give the patient positive reinforcement for accomplishing these activities.

c. Administer ordered analgesic medications before these activities.

8

The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when the

a. patient drinks 2 to 3 L of fluid in 24 hours.

b. patient uses the spirometer 10 times every hour.

c. patient’s breath sounds are clear to auscultation.

d. patient’s temperature is less than 100.4° F orally.

c. patient’s breath sounds are clear to auscultation.

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 patient’s oxygen saturation is 99%, and recent lab results are all normal. Which action by the nurse is most appropriate?

a. Insert an oral or nasal airway.

b. Notify the anesthesia care provider.

c. Orient the patient to time, place, and person.

d. Be sure that the patient’s IV lines are secure.

d. Be sure that the patient’s IV lines are secure.

10

Which action should the postanesthesia care unit (PACU) nurse delegate to nursing assistive personnel (NAP) who help with the transfer of a patient to the surgical unit?

a. Help with the transfer of the patient onto a stretcher.

b. Give a verbal report to the surgical unit charge nurse.

c. Document the appearance of the patient’s incision in the chart.

d. Ensure that the receiving nurse understands the postoperative orders.

a. Help with the transfer of the patient onto a stretcher.

11

When a patient is transferred from the postanesthesia care unit (PACU) to the clinical surgical unit, the first action by the nurse on the surgical unit should be to

a. assess the patient’s pain.

b. take the patient’s vital signs.

c. read the postoperative orders.

d. check the rate of the IV infusion.

b. take the patient’s vital signs.

12

An 83-year-old who had a surgical repair of a hip fracture 2 days previously has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for the patient as

a. potential complication: hypovolemic shock.

b. potential complication: venous thromboembolism.

c. potential complication: fluid and electrolyte imbalance.

d. potential complication: impaired surgical wound healing

b. potential complication: venous thromboembolism.

13

A patient who is just waking up after having a general anesthetic is agitated and confused. Which action should the nurse take first?

a. Check the O2 saturation.

b. Administer the ordered opioid.

c. Take the blood pressure and pulse.

d. Notify the anesthesia care provider.

a. Check the O2 saturation.

14

A postoperative patient has not voided for 7 hours after return to the postsurgical unit. Which action should the nurse take first?

a. Notify the surgeon.

b. Perform a bladder scan.

c. Assist the patient to ambulate to the bathroom.

d. Insert a straight catheter as indicated on the PRN order.

b. Perform a bladder scan.

15

While caring for a patient with abdominal surgery the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this finding, the nurse should first

a. reinforce the dressing.

b. take the patient’s vital signs.

c. recheck the dressing in 1 hour for increased drainage.

d. notify the patient’s surgeon of a potential hemorrhage.

b. take the patient’s vital signs.

16

When caring for a patient during the second postoperative day after abdominal surgery, 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. Notify the patient’s health care provider about the fever.

a. Have the patient use the incentive spirometer.

17

The nurse notes that the oxygen saturation is 88% in an unconscious patient who was transferred to the postanesthesia care unit (PACU) 10 minutes previously. Which action should the nurse take first?

a. Elevate the patient’s head.

b. Suction the patient’s mouth.

c. Increase the oxygen flow rate.

d. Perform the jaw-thrust maneuver

d. Perform the jaw-thrust maneuver

18

While caring for a patient who had abdominal surgery on the second postoperative day, 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 patient’s 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 (0-10 scale).

a. The right calf is swollen, warm, and painful.