Chapter 19: Postoperative Care

Chapter 19: Postoperative Care

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 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 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.

 

DIF:    Cognitive Level: Analyze (analysis)                                  REF:   337

TOP:   Nursing Process: Implementation     MSC:  NCLEX: Physiological Integrity

 

2. 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.

 

DIF:    Cognitive Level: Analyze (analysis)                                  REF:   333

OBJ:   Special Questions: Prioritization      TOP:   Nursing Process: Implementation

MSC:  NCLEX: Physiological Integrity

 

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 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 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.

 

DIF:    Cognitive Level: Apply (application)           REF:               336

TOP:   Nursing Process: Evaluation            MSC:  NCLEX: Safe and Effective Care Environment

 

4. An older patient is being discharged from the ambulatory surgical unit following 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?

a.	Provide written instructions for the care.
b.	Assess the patient’s home support system.
c.	Discuss specific concerns regarding self-care.
d.	Refer the patient for home health care services.

 

 

ANS:  C

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 should be given to the patient, but these are unlikely to address the patient’s stated concern about self-care.

 

DIF:    Cognitive Level: Analyze (analysis)                                  REF:   344

TOP:   Nursing Process: Implementation     MSC:  NCLEX: Physiological Integrity