Chapter 16: Care of Postoperative Patients Questions And Answers
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Course
Care Of Postoperative Patients
Institution
Care Of Postoperative Patients
A client has arrived in the postoperative unit. What action by the circulating nurse takes priority?
a. Assessing fluid and blood output
b. Checking the surgical dressings
c. Ensuring the client is warm
d. Participating in hand-off report - ANS ANS: D
Hand-offs are a critical tim...
Chapter 16: Care of Postoperative Patients
Questions And Answers
A client has arrived in the postoperative unit. What action by the circulating nurse takes priority?
a. Assessing fluid and blood output
b. Checking the surgical dressings
c. Ensuring the client is warm
d. Participating in hand-off report - ANS ANS: D
Hand-offs are a critical time in client care, and poor communication during this time can lead to
serious errors. The postoperative nurse and circulating nurse participate in hand-off report as
the priority. Assessing fluid losses and dressings can be done together as part of the report.
Ensuring the client is warm is a lower priority.
DIF: Applying/Application REF: 257
KEY: Postoperative nursing| communication| hand-off communication| SBAR
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative
clients. Which client should the nurse assess first?
a. Client with a blood pressure of 100/50 mm Hg
b. Client with a pulse of 118 beats/min
c. Client with a respiratory rate of 6 breaths/min
d. Client with a temperature of 96° F (35.6° C) - ANS ANS: C
The respiratory rate is the most critical vital sign for any client who has undergone general
anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too
low and indicates respiratory depression. The nurse should assess this client first. A blood
pressure of 100/50 mm Hg is slightly low and may be within that client's baseline. A pulse of 118
beats/min is slightly fast, which could be due to several causes, including pain and anxiety. A
temperature of 96° F is slightly low and the client needs to be warmed. But none of these other
vital signs take priority over the respiratory rate.
DIF: Applying/Application REF: 258
KEY: Postoperative nursing| nursing assessment| sedation| respiratory system
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%.
What action by the nurse is most appropriate?
, a. Assess other indicators of oxygenation.
b. Call the Rapid Response Team.
c. Notify the anesthesia provider.
d. Prepare to intubate the client. - ANS ANS: A
If a postoperative client's oxygen saturation (SaO2) drops below 95% (or the client's baseline),
the nurse should notify the anesthesia provider. If the SaO2 drops by 10% or more, the nurse
should call the Rapid Response Team. Since this is approximately a 3% drop, the nurse should
further assess the client. Intubation (if the client is not intubated already) is not warranted.
Ten hours after surgery, a postoperative client reports that the antiembolism stockings and
sequential compression devices itch and are too hot. The client asks the nurse to remove them.
What response by the nurse is best?
a. "Let me call the surgeon to see if you really need them."
b. "No, you have to use those for 24 hours after surgery."
c. "OK, we can remove them since you are stable now."
d. "To prevent blood clots you need them a few more hours." - ANS ANS: D
According to the Surgical Care Improvement Project (SCIP), any prophylactic measures to
prevent thromboembolic events during surgery are continued for 24 hours afterward. The nurse
should explain this to the client. Calling the surgeon is not warranted. Simply telling the client he
or she has to wear the hose and compression devices does not educate the client. The nurse
should not remove the devices.
DIF: Understanding/Comprehension REF: 260
KEY: Postoperative nursing| Surgical Care Improvement Project (SCIP)| venous
thromboembolism prevention| thromboembolic events| core measures| quality improvement
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the
client's bed. The client's blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What
action by the nurse is best?
a. Call the Rapid Response Team.
b. Increase the IV fluid rate.
c. Lower the head of the bed.
d. Nothing; this is expected. - ANS ANS: C
A client who had epidural or spinal anesthesia may become hypotensive when the head of the
bed is raised. If this occurs, the nurse should lower the head of the bed to its original position.
The Rapid Response Team is not needed, nor is an increase in IV rate.
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