Chapter 20: Nursing Management: Postoperative Care

Chapter 20: Nursing Management: Postoperative Care

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE
1. A 42-year-old patient is recovering from anesthesia in the postanesthesia care unit
(PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes
after admission, the blood pressure falls to 112/60, with a pulse of 72 and warm, dry skin.
The most appropriate action by the nurse at this time is to
a. increase the rate of the IV fluid replacement.
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.
DIF: Cognitive Level: Analysis REF: 373
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
2. During recovery from anesthesia in the postanesthesia care unit (PACU), a patient’s vital
signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The patient is
sleepy but awakens easily. Which action should the nurse take at this time?
a. Place the patient in a side-lying position.
b. Encourage the patient to take deep breaths.
c. Prepare to transfer the patient from the PACU.
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 BP 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 is not
appropriate.
DIF: Cognitive Level: Analysis REF: 369 | 371
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
3. After a new nurse has been oriented to the postanesthesia care unit (PACU), the charge
nurse will evaluate that the orientation has been successful when the new nurse
Test Bank 20-2
a. places a patient in the Trendelenburg position when the blood pressure (BP) drops.
b. assists a patient to the prone position when the patient is nauseated.
c. turns an unconscious patient to the side when the patient arrives in the PACU.
d. positions a newly admitted unconscious patient supine with the head elevated.
ANS: C
The patient should initially be positioned in the lateral “recovery” position to keep the
airway open and avoid aspiration. The prone position is not usually used and would make
it difficult to assess the patient’s respiratory effort and cardiovascular status. 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: Application REF: 371 TOP: Nursing Process:
Evaluation
MSC: NCLEX: Safe and Effective Care Environment
4. A 75-year-old is to be 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.” The most appropriate nursing action is to
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 patient’s support system for care at home.
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 should be given to the patient, but these are unlikely to address the
patient’s stated concern about self-care.
DIF: Cognitive Level: Application REF: 380
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity