Chapter 17. Priorities for the Postoperative Patient Flashcards
- 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.
- 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.
- 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.
- 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 ismost 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.
- 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.
- 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.
- 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.
A
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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
