Chapter 20: Postoperative Care Flashcards
A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action would the nurse take?
a. Increase the postoperative IV fluid rate.
b. Notify the anesthesia care provider (ACP).
c. Continue to take vital signs every 15 minutes.
d. Administer oxygen therapy at 100% per mask.
c. Continue to take vital signs every 15 minutes.
In the postanesthesia care unit (PACU), a patient‘s vital signs are blood pressure 116/72 mm Hg, pulse 74 beats/min, respirations 12 breaths/min, and SpO2 91%. the patient is sleepy but awakens easily. Which action would the nurse take?
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.
An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse would indicate that the orientation was successful?
a. The new nurse assists a nauseated patient to a supine position.
b. The new nurse places a sleeping patient supine with the head elevated.
c. The new nurse positions an unconscious patient on the side upon arrival from
surgery.
d. The new nurse places a patient in the Trendelenburg position for a low blood pressure.
c. The new nurse positions an unconscious patient on the side upon arrival from surgery.
An older adult patient is being discharged from the ambulatory surgical unit after left eye surgery. The patient tells the nurse, “I don’t know if I can take care of myself once I‘m home.” Which action would the nurse implement first?
a. Assess the patient‘s home support system.
b. Discuss patient concerns regarding self-care.
c. Refer the patient for home health care services.
d. Provide written instructions for the patient‘s care.
b. Discuss patient concerns regarding self-care.
On the second postoperative day, the patient‘s nasogastric (NG) tube is removed and the patient begins drinking clear liquids. Four hours later, the
patient reports frequent, cramping gas pains. Which action would the nurse take?
a. Reinsert theNG tube.
b. Assist the patient to ambulate.
c. Place the patient on NPO status.
d. Give the prescribed PRN IV opioid.
b. Assist the patient to ambulate.
A patient‘s T-tube is draining dark green fluid after gallbladder surgery. Which action would the nurse take?
a. Notify the patient‘s surgeon.
b. Place the patient on bed rest.
c. Irrigate the T-tube with sterile saline.
d. Document the drainage characteristics.
d. Document the drainage characteristics.
Which action by the nurse will be most helpful to a patient who is expected to ambulate, deep breathe, and cough on the first postoperative day?
a. Schedule the activity to begin after the patient has taken a nap.
b. Administer prescribed analgesic medications before the activities.
c. Ask the patient to state two possible complications of immobility.
d. Encourage the patient to repeat back the purpose of splinting the incision.
b. Administer prescribed analgesic medications before the activities.
Which data on the patient‘s second postoperative day would indicate that interventions to remove secretions from the patient‘s airway have been successful?
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 100.2F orally.
c. Patient‘s breath sounds are clear to auscultation.
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 96%, and recent laboratory results are normal. Which action would the nurse take?
a. Increase theIV fluid rate.
b. Assess for bladder distention.
c. Notify the anesthesia care provider (ACP).
d. Demonstrate how to use the call bell button.
b. Assess for bladder distention.
Which action could the postanesthesia care unit (PACU) nurse delegate to assistive personnel (AP) during transfer of a patient to the clinical unit?
a. Help to slide the patient onto a stretcher.
b. Clarify postoperative orders with the surgeon.
c. Document the appearance of the patient‘s incision.
d. Provide hand-off communication to the surgical unit nurse.
a. Help to slide the patient onto a stretcher.
A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action would the nurse on the clinical unit perform first?
a. Ask the patient about pain.
b. Orient the patient to the unit.
c. Assess the patient‘s vital signs.
d. Read the postoperative orders.
c. Assess the patient‘s vital signs.
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 potential complication would the nurse identify as a priority for this patient?
a. Hypovolemic shock
b. Venous thromboembolism
c. Fluid and electrolyte imbalance
d. Impaired surgical wound healing
b. Venous thromboembolism
A patient who is just waking up after having hip replacement surgery is agitated and confused.
Which action would the nurse take first?
a. Administer the prescribed 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.
A postoperative patient has not voided for 8 hours after return to unit. Which action would the nurse take first?
a. Perform a bladder scan.
b. Insert a straight catheter.
c. Encourage increased oral fluid intake.
d. Assist the patient to ambulate to the bathroom.
a. Perform a bladder scan.
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 would the nurse take first?
a. Reinforce the dressing.
b. Apply an abdominal binder.
c. Take the patient‘s vital signs.
d. Plan to recheck the dressing in 1 hour.
c. Take the patient‘s vital signs.
On the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, a patient has an oral temperature of 100.8F (38.2C). Which action would the nurse take?
a. Place ice packs in thepatient‘s axillae.
b. Have the patient use the incentive spirometer.
c. Request a prescription for acetaminophen suppositories.
d. Ask the health care provider to change the antibiotic prescription.
b. Have the patient use the incentive spirometer.
An unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action would the nurse take first?
a. Suction the patient‘s mouth.
b. Increase the oxygen flow rate.
c. Perform the jaw-thrust maneuver.
d. Elevate the patient‘s head on two pillows.
c. Perform the jaw-thrust maneuver.
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 patient‘s temperature is 100.3F (37.9C).
b. The patient‘s calf is swollen and warm to touch.
c. The patient reports abdominal pain when ambulating.
d. The patient has fluid intake 600 mL greater than the output.
b. The patient‘s calf is swollen and warm to touch.
A patient who had knee surgery received IV ketorolac 30 minutes ago and continues to report pain at a level of 7 (0 to 10 scale). Which action would the nurse take?
a. Administer the prescribed PRN IV morphine sulfate.
b. Notify the health care provider about the ongoing pain.
c. Teach the patient that effects of ketorolac last 6 to 8 hours.
d. Reassure the patient that pain is expected after knee surgery.
a. Administer the prescribed PRN IV morphine sulfate.
A patient who has just been transported from the operating room to the postanesthesia care unit (PACU) is shivering and has a temperature of 96.8F (36C). Which action would the nurse take?
a. Notify the anesthesia care provider.
b. Cover the patient with warm blankets.
c. Hold opioid analgesics until the patient is warmer.
d. Give acetaminophen 650 mg suppository rectally.
b. Cover the patient with warm blankets.
Which finding would indicate to the nurse that a postoperative patient is at increased risk for poor wound healing?
a. Potassium 3.5 mEq/L
b. Albumin level 2.2 g/dL
c. Hemoglobin 10.2 g/dL
d. White blood cells 11,900/L
b. Albumin level 2.2 g/dL
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 99.2F (37.3C)
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
After receiving change-of-shift report about these postoperative patients, which patient would the nurse assess first?
a. Patient who had abdominal surgery 3 days ago and whose wound edges may be 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 100F (37.8C) on the first day after chest surgery
d. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) was given
a. Patient who had abdominal surgery 3 days ago and whose wound edges may be separating
An awake patient who has a history of smoking has just arrived on the surgical unit from the postanesthesia care unit. Which action would the nurse take first?
a. Auscultate for adventitious breath sounds.
b. Obtain the temperature and apply warm blankets.
c. Teach the patient about harmful effects of smoking.
d. Ask the health care provider to prescribe a nicotine patch.
a. Auscultate for adventitious breath sounds.
Name this phase of postanesthesia care.
- care during the immediate postanesthesia period
- ECG and more intense monitoring
phase I
Name this phase of postanesthesia care.
- ambulatory surgery patients
- fast-tracking
phase II
Name this phase of postanesthesia care.
- the patient may be delayed from progressing out of the PACU
phase III
What is the first sense to return to the unconscious patient who has just gotten out of surgery?
hearing
T/F
Cardiac complications pose the greatest risk to patients in the postanesthesia and immediate postoperative period.
false; pulmonary
__________ is commonly caused by the patient’s tongue and is most pronounced when supine and extremely sleepy.
a. atelectasis
b. hypoxemia
c. airway obstruction
d. hypoventilation
c. airway obstruction
