Chapter 20 Nursing Management Postoperative

Question 1

1. When a client is admitted to the PACU, what are the priority interventions the nurse performs?
   a. Assess the surgical site, noting presence and character of drainage.
   b. Assess the amount of urine output and the presence of bladder distension.
   c. Assess for airway patency and quality of respirations and obtain vital signs.
   d. Review results of intraoperative laboratory values and medications received.

Answer 1

C

Question 2

2. A client is admitted to the PACU after major abdominal surgery. During the initial assessment, the client tells the nurse he thinks he is “going to throw up.” What would be the priority nursing intervention?
   a. Increase the rate of the IV fluids.
   b. Obtain vital signs, including O2 saturation.
   c. Position client in lateral recovery position.
   d. Administer antiemetic medication as ordered.

Answer 2

C

Question 3

3. After admission of the postoperative client to the clinical unit, which assessment data require the most immediate attention?
   a. O2 saturation of 85%
   b. Respiratory rate of 13/min
   c. Temperature of 38°C
   d. Blood pressure of 90/60 mm Hg

Answer 3

A

Question 4

4. A 70-kg postoperative client has an average urine output of 25 mL/hr during the first 8 hours. Given this assessment, what would the priority nursing intervention(s) be?
   a. Perform a straight catheterization to measure the amount of urine in the bladder.
   b. Notify the physician and anticipate obtaining blood work to evaluate renal function.
   c. Continue to monitor the client because this is a normal finding during this time period.
   d. Evaluate the client’s fluid volume status since surgery and obtain a bladder ultrasound.

Answer 4

D

Question 5

5. The nurse on the postoperative unit is caring for a client who had a laparoscopic partial colectomy. On postoperative day 2, the client is complaining of abdominal distension and discomfort. Which of the
   following interventions may be appropriate for this client? (Select all that apply)
   a. Increase the dose of opioids for pain relief.
   b. Insert a nasogastric tube.
   c. Reassure the client that this complication should subside in a day or two.
   d. Monitor the client’s abdominal girth by measuring for distension and auscultate the abdomen in all four quadrants.

Answer 5

B C D

Question 6

6. Discharge criteria for the Phase II client include which of the following? (Select all that apply)
   a. No nausea or vomiting
   b. Ability to drive himself or herself home
   c. No respiratory depression
   d. Written discharge instructions understood
   e. Opioid pain medication given 45 minutes ago

Answer 6

C D E