PV 19 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 by the nurse is most appropriate?
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.
ANS: C
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 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 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 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 patient’s 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 places a sleeping patient supine with the head elevated.
c. The new nurse positions an unconscious patient on the side upon arrival in the
PACU.
d. The new nurse places a patient in the Trendelenburg position for a low blood
pressure.
ANS: C
The patient should initially be placed in the lateral “recovery” position to keep the airway
open and avoid aspiration. Avoid the Trendelenburg position because it increases the work of
breathing. The patient is placed supine with the head elevated after regaining consciousness.
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 by the nurse is most appropriate to 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.
ANS: B
The nurse’s initial action should be to assess exactly the patient’s concerns about self-care.
Referral to home health care and assessment of the patient’s support system may be
appropriate actions but will be based on further assessment of the patient’s concerns. Written
instructions for care should be given to the patient, but these are unlikely to address the
patient’s stated concern about 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. What action by the nurse is the most appropriate?
a. Reinsert the NG tube.
b. Assist the patient to ambulate.
c. Place the patient on NPO status.
d. Give the prescribed PRN IV opioid.
ANS: B
Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient’s
discomfort. If distention persists, the patient may need to be placed on NPO status, but usually
this is not necessary. Opioid 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 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. Irrigate the T-tube with sterile saline.
d. Document the drainage characteristics.
ANS: D
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.
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 discuss the purpose of splinting the incision.
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, concern about
complications, and with rest and sleep, patients will have difficulty if there is a great deal of
pain involved with these activities.
A postoperative patient has ineffective airway clearance. Which data would indicate to the
nurse that interventions for this patient problem 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 100.2° F orally.
ANS: C
One characteristic of ineffective airway clearance is the presence of adventitious breath
sounds such as 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 always improve breath sounds. 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 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.
ANS: B
Because the patient’s assessment indicates physiologic stability, the most likely cause of the
patient’s 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 patient’s 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 to transport a patient to the clinical unit?
a. Help to transfer the patient onto a stretcher.
b. Clarify postoperative orders with the surgeon.
c. Document the appearance of the patient’s incision in the chart.
d. Provide hand-off communication to the surgical unit charge nurse.
ANS: A
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 patient’s pain.
b. Orient the patient to the unit.
c. Take the patient’s 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 potential complication should 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
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 at a high risk based on 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 prescribed 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. Insert a straight catheter.
c. Encourage increased oral fluid intake.
d. Assist the patient to ambulate to the bathroom.
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 the patient 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 of a fluid volume
deficit.
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. Plan to recheck the dressing in 1 hour.
ANS: C
New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the
patient’s 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
surgeon’s instructions or agency policy. The nurse should not wait an hour to recheck the
dressing.
On the second postoperative day after abdominal surgery for removal of a large pancreatic
cyst, a patient has an oral temperature of 100.8° F (38.2° C). Which action should the nurse
take next?
a. Place ice packs in the patient’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.
ANS: B
A temperature of 100.8° F (38.2° C) in the first 48 hours is usually caused by atelectasis, and
the nurse should have the patient deep breathe, cough, and use the incentive spirometer.
Nursing intervention may resolve this problem, and therefore notifying the health care
provider is not necessary. Acetaminophen or ice packs will reduce the temperature, but it will
not resolve the underlying respiratory congestion.
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 should the nurse take
first?
a. Suction the patient’s mouth.
b. Increase the oxygen flowrate.
c. Perform the jaw-thrust maneuver.
d. Elevate the patient’s head on two pillows.
ANS: C
In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by
the tongue, and the first action is to clear the airway by maneuvers such as the jaw thrust or
chin lift. Increasing the oxygen flowrate and suctioning are not helpful when the airway is
obstructed by the tongue. Elevating the patient’s head will not be effective in correcting the
obstruction but may help with oxygenation after the patient is awake.
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 100.3° F (37.9° C).
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.
ANS: B
The calf pain, swelling, and warmth suggest that the patient has a venous thromboembolism
(VTE). This will require the health care provider to prescribe diagnostic tests, anticoagulants,
or both and is most critical because a VTE could result in a pulmonary embolism. Because the
stress response causes fluid retention for the first 2 to 5 days postoperatively, the difference
between intake and output is expected. A temperature elevation to 100.3° F on the second
postoperative day is suggestive of atelectasis, and the nurse should have the patient deep
breathe and cough. Pain with ambulation is normal, and the nurse should administer the
prescribed analgesic before patient activities.
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 is most effective 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 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.
ANS: A
The priority at this time is pain relief. Concomitant use of opioids and nonsteroidal
antiinflammatory drugs improves pain control in postoperative patients. Patient teaching and
reassurance are appropriate but should be done after the patient’s pain is relieved. If the
patient continues to have pain after the morphine is administered, notify the health care
provider.
A patient who has just been transported from the operating room to the postanesthesia care
unit (PACU) is shivering and has a temperature of 96.5° F (35.8° C). Which action should the
nurse take next?
a. Notify the anesthesia care provider.
b. Cover the patient with a warm blanket.
c. Hold opioid analgesics until the patient is warmer.
d. Give acetaminophen 650 mg suppository rectally.
ANS: B
The patient assessment indicates the need for active rewarming. There is no indication of a
need for acetaminophen. Opioid analgesics may help reduce shivering. Because hypothermia
is common and expected in the immediate postoperative period, there is no need to notify the
anesthesia care provider unless the patient continues to be hypothermic after active
rewarming.
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/μL
ANS: B
Because proteins are needed for an appropriate inflammatory response and wound healing, the
low serum albumin level (normal level, 3.5 to 5.0 g/dL) indicates a risk for poor wound
healing. The potassium level is normal. Because a small amount of blood loss is expected with
surgery, the hemoglobin level is not indicative of an increased risk for wound healing. WBC
count is expected to increase after surgery as a part of the normal inflammatory response.
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
ANS: D
Wound drainage should decrease and change in color from sanguineous to serosanguineous
by the second postoperative day. The color and amount of drainage for this patient are
abnormal and should be reported. Redness and swelling along the suture line and a slightly
elevated temperature are normal signs of postoperative inflammation. Atelectasis is common
after surgery. The nurse should have the patient cough and deep breathe, but there is no urgent
need to notify the surgeon.
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) was given.
ANS: A
The patient’s history and assessment suggests possible wound dehiscence, which should be
reported immediately to the surgeon. Although the information about the other patients
indicates a need for ongoing assessment and possible intervention, the data do not suggest any
acute complications. Small amounts of red drainage are common in the first postoperative
hours. Bibasilar crackles and a slightly elevated temperature are common after surgery,
although the nurse will need to have the patient deep breathe and cough. Oral medications
typically take more than 15 minutes for effective pain relief.
While ambulating in the room, a patient reports feeling dizzy. In what order will the nurse
accomplish the following activities? (Put a comma and a space between each answer choice
[A, B, C, D].)
a. Have the patient sit down in a chair.
b. Give the patient something to drink.
c. Take the patient’s blood pressure (BP).
d. Inform the patient’s health care provider.
ANS:
A, C, B, D
The first priority for the patient with syncope is to prevent a fall, so the patient should be
assisted to a chair. Assessment of the BP will determine whether the dizziness is due to
orthostatic hypotension, which occurs because of hypovolemia. Increasing the fluid intake
will help prevent orthostatic dizziness. Because this is a common postoperative problem that
is usually resolved through nursing measures such as increasing fluid intake and making
position changes more slowly, there is no urgent need to inform the health care provider.
A patient’s blood pressure in the postanesthesia care unit (PACU) has dropped from an
admission blood pressure of 140/86 to 102/60 mm Hg with a pulse change of 70 to 96
beats/min. SpO2 is 92% on 3 L of oxygen. In which order should the nurse take these actions?
(Put a comma and a space between each answer choice [A, B, C, D].)
a. Increase the IV infusion rate.
b. Assess the patient’s dressing.
c. Increase the oxygen flowrate.
d. Check the patient’s temperature.
ANS:
A, C, B, D
The first nursing action should be to increase the IV infusion rate. Because the most common
cause of hypotension is volume loss, the IV rate should be increased. The next action should
be to increase the oxygen flowrate to maximize oxygenation of hypoperfused organs. Because
hemorrhage is a common cause of postoperative volume loss, the nurse should check the
dressing. Finally, the patient’s temperature should be assessed to determine the effects of
vasodilation caused by rewarming.
