Test Bank Postoperative Care Lewis: Medical-Surgical Nursing, 10th Edition,100% CORRECT
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Course
NURSING 119
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NURSING 119
Test Bank Postoperative Care Lewis: Medical-Surgical Nursing, 10th Edition
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. W...
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Test Bank Postoperative Care Lewis: Medical-Surgical Nursing, 10th
Edition
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.
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.
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.
5. The nasogastric (NG) tube is removed on the second postoperative day, and the
patient is placed on a clear liquid diet. Four hours later, the patient complains of
frequent, cramping gas pains. What action by the nurse is the most appropriate?
a. Reinsert the NG tube. c. Assist the patient to ambulate.
b. Give the PRN IV opioid. d. Place the patient on NPO status.
ANS: C
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. 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.
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