Question 1

Following gallbladder surgery, a patient has a T-tube with thick, dark green drainage. When the patient asks about the tube and the drainage, the best response by the nurse is

Accepted Answer

A T-tube is placed in the common bile duct after a cholecystectomy and drains green to bright yellow drainage. The T-tube does not drain blood or other fluid from the surgical site. The T-tube does not empty the duodenum or small bowel.

Question 2

While assessing patients for complications during recovery from anesthesia, the nurse recognizes that the patient who is at the greatest risk for developing postoperative hypothermia is a

Accepted Answer

The 48-year-old patient is at greatest risk because of the length the surgery and anesthesia. The 34-year-old patient is having a minor surgery under local anesthesia, which will be low risk for hypothermia. Older patients are frequently at higher risk, but the 62- and 68-year-old patients are having shorter surgeries and less exposure to anesthesia.

Question 3

Postoperatively a patient is receiving low-molecular-weight heparin (LMWH). When administering this drug, the nurse

Accepted Answer

The purpose of LMWH is prevention of thromboembolism such as deep vein thrombosis. LMWH is given subcutaneously. Baseline aPTT testing and blood testing are not needed for the LMWH, which has a predictable, dose-related impact on coagulation.

Question 4

After a new nurse has been oriented to the PACU, the charge nurse will evaluate that the orientation has been successful when the new nurse

Accepted Answer

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.

Question 5

A patient becomes restless and agitated while beginning to regain consciousness in the PACU, and the SpO₂ is 88%. The nurse should first

Accepted Answer

The most common cause of postoperative hypoxemia is atelectasis, and having the patient deep breathe will open the alveoli and correct the drop in oxygen saturation. Suctioning, listening to lung sounds, and checking for NG patency may be done if the hypoxemia is not corrected with deep breathing.

Question 6

A patient's blood pressure in the PACU has dropped from an admission blood pressure of 138/84 to 110/78 with a pulse change of 68 to 84. The first action indicated by the nurse is to

Accepted Answer

The first nursing action is to increase the oxygen flow rate to maximize oxygenation of hypoperfused organs. The next action should be to increase the IV infusion rate. Finally, the nurse should assess the patient for possible causes of the vital sign changes, such as bleeding or rewarming.

Question 7

A postoperative patient has not voided for 7 hours after return to the postsurgical unit. Initially the nurse should

Accepted Answer

The initial action should be to assess the bladder for distension. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Catheterization should only be done after other measures have been tried without success, because of the risk for urinary tract infection. There is no indication to notify the health care provider about this common postoperative problem unless all measures to empty the bladder are unsuccessful.

Question 8

In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which action by the nurse is most helpful?

Accepted Answer

The most essential nursing action in encouraging 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, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities.

Question 9

On admission of a patient to the postanesthesia care unit (PACU) from surgery, the nurse should first assess the

Accepted Answer

The first priority is to assess the airway and breathing status. The surgical dressing, level of consciousness (LOC), and IV fluids are lower in priority during the initial assessment.

Question 10

While caring for a postoperative patient on the second postoperative day, which information about the patient is most important to communicate to the health care provider?

Accepted Answer

The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require health care provider orders for diagnostic tests and anticoagulants. 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 suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities.

Question 11

An 83-year-old patient had a surgical repair of a hip fracture and has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for the patient as potential complication:

Accepted Answer

The patient is older and relatively immobile, two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems but are not supported by the data about this patient.

Question 12

The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when the

Accepted Answer

One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or wheezes, 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 improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems.

Question 13

The nasogastric (NG) tube is removed on the second postoperative day for a patient who had abdominal surgery. A clear liquid diet is ordered. Four hours later, the patient complains of abdominal distention and sharp, cramping gas pains. The most appropriate nursing action is to

Accepted Answer

Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient's discomfort. If distension persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine 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.

Question 14

When a patient is transferred from the PACU to the clinical surgical unit, the first action by the nurse on the surgical unit should be to

Accepted Answer

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.

Question 15

While caring for a patient with abdominal surgery the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this finding, the nurse should initially

Accepted Answer

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 orders or institutional policy. The nurse should not wait an hour to recheck the dressing.

Question 16

A 42-year-old patient is recovering from anesthesia in the PACU. On admission to the PACU the blood pressure (BP) was 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

Accepted Answer

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.

Question 17

When a postoperative patient in the PACU complains of pain at the abdominal incision site, the nurse should

Accepted Answer

In the immediate postoperative period, a reduced dose of opioid may be given to treat pain and prevent problems such as hypoventilation, but the scope of nursing practice does not permit nurses to administer a dose (such as half the ordered dose) that has not been ordered by the anesthesiologist or other provider. The nurse will need to consult with the ACP about an appropriate dose of medication. Analgesic orders on the postoperative orders are intended for use once the patient is stable and is transferred to the clinical nursing unit. Although opioid analgesics may decrease respiratory effort, patients who are having abdominal pain may have improvements in respiratory effort with appropriate analgesia.

Question 18

A 75-year-old patient 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

Accepted Answer

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.

Question 19

During recovery from anesthesia in the PACU, a patient's vital signs for the past hour have been blood pressure 112/82, 110/82, 112/80, 114/82; pulse 76, 78, 78, 80; and respirations 22, 24, 24, 26; her SpO₂ is 90%. The patient is sleepy but awakens easily and is oriented when spoken to. Her surgical dressing is dry and intact. The most appropriate action by the nurse is to

Accepted Answer

The patient's borderline SpO₂ and sleepiness indicate that 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.

Question 20

When caring for a patient during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 100.8° F. Which action is appropriate for the nurse to take first?

Accepted Answer

A temperature of 100.8° F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because evidence of wound infection does not usually occur before the third postoperative day, assessment of the incision is not likely to be useful.

Quiz 20: Nursing Management: Postoperative Care

Following gallbladder surgery, a patient has a T-tube with thick, dark green drainage. When the patient asks about the tube and the drainage, the best response by the nurse is

While assessing patients for complications during recovery from anesthesia, the nurse recognizes that the patient who is at the greatest risk for developing postoperative hypothermia is a

Postoperatively a patient is receiving low-molecular-weight heparin (LMWH) . When administering this drug, the nurse

After a new nurse has been oriented to the PACU, the charge nurse will evaluate that the orientation has been successful when the new nurse

A patient becomes restless and agitated while beginning to regain consciousness in the PACU, and the SpO₂ is 88%. The nurse should first

A patient's blood pressure in the PACU has dropped from an admission blood pressure of 138/84 to 110/78 with a pulse change of 68 to 84. The first action indicated by the nurse is to

A postoperative patient has not voided for 7 hours after return to the postsurgical unit. Initially the nurse should

In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which action by the nurse is most helpful?

On admission of a patient to the postanesthesia care unit (PACU) from surgery, the nurse should first assess the

While caring for a postoperative patient on the second postoperative day, which information about the patient is most important to communicate to the health care provider?

An 83-year-old patient had a surgical repair of a hip fracture and has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for the patient as potential complication:

The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when the

The nasogastric (NG) tube is removed on the second postoperative day for a patient who had abdominal surgery. A clear liquid diet is ordered. Four hours later, the patient complains of abdominal distention and sharp, cramping gas pains. The most appropriate nursing action is to

When a patient is transferred from the PACU to the clinical surgical unit, the first action by the nurse on the surgical unit should be to

While caring for a patient with abdominal surgery the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this finding, the nurse should initially

A 42-year-old patient is recovering from anesthesia in the PACU. On admission to the PACU the blood pressure (BP) was 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

When a postoperative patient in the PACU complains of pain at the abdominal incision site, the nurse should

A 75-year-old patient 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

When caring for a patient during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 100.8° F. Which action is appropriate for the nurse to take first?

Quiz 20: Nursing Management: Postoperative Care

Following gallbladder surgery, a patient has a T-tube with thick, dark green drainage. When the patient asks about the tube and the drainage, the best response by the nurse is

While assessing patients for complications during recovery from anesthesia, the nurse recognizes that the patient who is at the greatest risk for developing postoperative hypothermia is a

Postoperatively a patient is receiving low-molecular-weight heparin (LMWH) . When administering this drug, the nurse

After a new nurse has been oriented to the PACU, the charge nurse will evaluate that the orientation has been successful when the new nurse

A patient becomes restless and agitated while beginning to regain consciousness in the PACU, and the SpO2 is 88%. The nurse should first

A patient's blood pressure in the PACU has dropped from an admission blood pressure of 138/84 to 110/78 with a pulse change of 68 to 84. The first action indicated by the nurse is to

A postoperative patient has not voided for 7 hours after return to the postsurgical unit. Initially the nurse should

In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which action by the nurse is most helpful?

On admission of a patient to the postanesthesia care unit (PACU) from surgery, the nurse should first assess the

While caring for a postoperative patient on the second postoperative day, which information about the patient is most important to communicate to the health care provider?

An 83-year-old patient had a surgical repair of a hip fracture and has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for the patient as potential complication:

The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when the

The nasogastric (NG) tube is removed on the second postoperative day for a patient who had abdominal surgery. A clear liquid diet is ordered. Four hours later, the patient complains of abdominal distention and sharp, cramping gas pains. The most appropriate nursing action is to

When a patient is transferred from the PACU to the clinical surgical unit, the first action by the nurse on the surgical unit should be to

While caring for a patient with abdominal surgery the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this finding, the nurse should initially

A 42-year-old patient is recovering from anesthesia in the PACU. On admission to the PACU the blood pressure (BP) was 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

When a postoperative patient in the PACU complains of pain at the abdominal incision site, the nurse should

A 75-year-old patient 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

When caring for a patient during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 100.8° F. Which action is appropriate for the nurse to take first?

A patient becomes restless and agitated while beginning to regain consciousness in the PACU, and the SpO₂ is 88%. The nurse should first