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Flashcards in Ch.20 MD Deck (23):
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 is most 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.

b.
Continue to take vital signs every 15 minutes.

2

In the postanesthesia care unit (PACU), a patient’s 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.

b.
Encourage the patient to take deep breaths.

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.

c.
The new nurse turns an unconscious patient to the side upon arrival in the PACU.

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 patient’s support system for care at home.

b.
Discuss the specific concerns regarding 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 most appropriate?
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

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

c.
Document the color and amount of drainage.

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.

b.
Administer ordered analgesic medications before these activities.

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.
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

(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?
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.

b.
Assess for bladder distention.

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 patient’s incision in the chart.
d.
Provide hand off communication to the surgical unit charge nurse.

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

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 patient’s pain.
b.
Orient the patient to the unit.
c.
Take the patient’s vital signs.
d.
Read the postoperative orders.

c.
Take the patient’s vital signs.

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

b.
Potential complication: venous thromboembolism

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.

b.
Check the oxygen (O2) saturation.

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.

a.
Perform a bladder scan.

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 patient’s vital signs.
d.
Recheck the dressing in 1 hour for increased drainage.

c.
Take the patient’s vital signs.

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.

a.
Have the patient use the incentive spirometer.

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 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

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 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 to 10 scale) when ambulating.

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

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.

a.
Administer the prescribed PRN IV morphine sulfate.

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.

a.
Cover the patient with a warm blanket and put on socks.

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/µL

b.
Albumin level 2.2 g/dL

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

d.
200 mL sanguineous fluid in the wound drain

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 100°F (37.8°C) on the first postoperative day after chest surgery
d.
Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) administration

a.
Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating