Question 1

After a new nurse has been oriented to the postanaesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse does which of the following actions?

Accepted Answer

The client 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 client's respiratory effort and cardiovascular status. The Trendelenburg position is avoided because it increases the work of breathing. The client is placed supine with the head elevated after regaining consciousness.

Question 2

The nurse is caring for a client who is recovering from anaesthesia in the postanaesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure is 112/60, with a pulse of 72 andwarm,dry skin. Which of the following actions is the most appropriate for the nurse to implement at this time?

Accepted Answer

A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anaesthesia 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 3

The nurse is caring for a client who is recovering from anaesthesia in the postanaesthesia care unit (PACU), and the vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The client is sleepy but awakens easily. Which of the followingactions should the nurse take at this time?

Accepted Answer

The client's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the client and remind the client to take deep breaths. Placing the client in a lateral position is needed when the client first arrives in the PACU and is unconscious. The stable BP and pulse indicate that no changes in fluid intake are required. The client is not fully awake and has a low SpO2, indicating that transfer from the PACU is not appropriate.

Question 4

The nurse is caring for a client following gallbladder surgery, and the client's T-tube is draining dark green fluid. Which of the following actions should the nurse take?

Accepted Answer

A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and colour of the drainage is needed. The other actions are not necessary.

Question 5

The nurse is caring for an older adult in the postanaesthesia unit. Which of the following age-related considerations may impact postoperative recovery?

Accepted Answer

The older adult has a decrease in respiratory function, including decreased ability to cough, decreased thoracic compliance (not increased), and decreased (not increased) lung tissue. There is no noted decrease in compliance related to postoperative deep breathing and coughing.

Question 6

The nurse is caring for a client who is just waking up after having a general anaesthetic and the client is agitated and confused. Which of the following actions should the nurse take first?

Accepted Answer

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.

Question 7

The nurse is caring for a client who has begun to awaken after 30 minutes in the postanaesthesia care unit (PACU), who is restless and shouting at the nurse. The client's oxygen saturation is 99%, and recent laboratory results are all normal. Which of the following actions by the nurse is most appropriate?

Accepted Answer

Because the client's assessment indicates physiological stability, the most likely cause of the client's agitation is emergence delirium, which will resolve as the client wakes up more fully. The nurse should ensure client safety through interventions such as raising the bed rails and securing IV lines. Emergence delirium is common in clients recovering from anaesthesia, so there is no need to notify the anaesthesiologist. Insertion of an airway is not needed because the oxygen saturation is good. Orientation of the client is needed but is not likely to be effective until the effects of anaesthesia have resolved more completely.

Question 8

The nurse is caring for a client with abdominal surgery and on the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. Which of the following actions should the nurse implement first?

Accepted Answer

New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the client'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 9

The nurse is caring for a postoperative client who has not voided for 7 hours after return to the postsurgical unit. Which of the following actions should the nurse take first?

Accepted Answer

The initial action should be to assess the bladder for distension. If the bladder is distended, providing the client 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 surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful.

Question 10

The nurse is caring for an older-adult client who had a surgical repair of a hip fracture 2 days previously and has restrictions on ambulation. Based on this information, which of the following collaborative problems is priority for the client?

Accepted Answer

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

Question 11

The nurse is caring for a client and during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 38.2°C (100.8°F). Which of the following actions should the nurse take first?

Accepted Answer

A temperature of 38.2°C (100.8°F) in the first 48 hours is usually caused by atelectasis, and the nurse should have the client 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.

Question 12

After removal of the nasogastric (NG) tube on the second postoperative day, the client is placed on a clear liquid diet. Four hours later, the client complains of sharp, cramping gas pains. Which of the following actions should the nurse take?

Accepted Answer

Ambulation encourages peristalsis and the passing of flatus, which will relieve the client's discomfort. If distension persists, the client 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 13

The nurse is caring for a client who is being transferred from the postanaesthesia care unit (PACU) to the clinical surgical unit. Which of the following actions should the nurse implement first on the clinical surgical unit?

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 14

The nurse is caring for an unconscious client who was transferred to the postanaesthesia care unit (PACU) 10 minutes previously and has an oxygen saturation of 88%. Which of the following actions should the nurse take first?

Accepted Answer

In an unconscious postoperative client, a likely cause of hypoxemia is airway obstruction by the tongue, and the first action is to clear the airway by manoeuvres such as the jaw thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the client's head will not be effective in correcting the obstruction but may help with oxygenation after the client is awake.

Question 15

In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative client on the first postoperative day, which of the following actions 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 client to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, clients will have difficulty if there is a great deal of pain involved with these activities.

Question 16

The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative client have been successful when which of the following goals has been met?

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 clients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems.

Question 17

The nurse is caring for a client on the first postoperative day who is dizzy when ambulating in the room. In what order will the nurse accomplish the following activities? (All the activities are appropriate.)

Accepted Answer

The first priority for the client with syncope is to prevent a fall, so the client should be placed in the supine position. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. After taking BP, the client is assisted to the sitting position and the BP is rechecked in 1-3 minutes.
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 need to notify the health care provider and the nurse is to record the results of the assessment.

Question 18

The nurse is caring for a client who had abdominal surgery two days previously. Which of the following information about the client is most important to communicate to the health care provider?

Accepted Answer

The calf pain, swelling, and warmth suggest that the client 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 2-5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 37.9°C (100.2°F) on the second postoperative day suggests atelectasis, and the nurse should have the client deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before client activities.

Question 19

The nurse is caring for a client in the postoperative period who is on bed rest. Which of the following actions should the nurse implement?

Accepted Answer

When confined to bed, clients should alternately flex and extend all joints 10-12 times every 1-2 hours while awake. The muscular contraction produced by these exercises and by ambulation facilitates venous return from the lower extremities. A client on bed rest is not to be assisted up to the bathroom or placed in a chair. If passive ROM exercise were to be completed, the frequency would be every 1-2 hours, not once per 12 hour shift.

Question 20

The nurse is preparing an older-adult client for discharge from the ambulatory surgical unit following left eye surgery. The client tells the nurse, "I do not know if I can take care of myself with this patch over my eye." Which of the following actionsisthemost appropriate for the nurse to implement?

Accepted Answer

The nurse's initial action should be to assess exactly the client's concerns about self-care. Referral to home health care and assessment of the client's support system may be appropriate actions but will be based on further assessment of the client's concerns.
Written instructions should be given to the client, but these are unlikely to address the client's stated concern about self-care.

Quiz 22: Nursing Management Postoperative Care

After a new nurse has been oriented to the postanaesthesia care unit (PACU) , the charge nurse will evaluate that the orientation has been successful when the new nurse does which of the following actions?