Marian University • Indianapolis IN Nsg 331 - Summer/Fall
2025 CH 19 EAQ Postoperative Care Questions With
Complete Solutions
A nurse cares for a patient with acute pulmonary edema. What
findings would the nurse expect to assess?
a. Vertigo and headache
b. Palpitations and nausea
c. Anxiety and distended neck veins
d. Dry, hacking cough and chest pain Correct Answers ANS: C
The patient experiencing acute pulmonary edema would most
likely experience anxiety related to hypoxia. Distended neck
veins would be present because of decreased cardiac output
resulting in right-sided heart congestion, causing blood to back
up into the neck veins. Vertigo and headaches, and palpitations
and nausea, may be present but are not as distinct and common
as anxiety, distended neck veins, and shortness of breath. The
cough associated with pulmonary edema will be moist and
productive. In severe cases, this may present as pink and frothy
sputum. Chest pain may also be present.
A nurse is assisting a postoperative patient with ambulation.
What benefits of early ambulation should the nurse explain to
the patient? Select all that apply.
a. It stimulates circulation.
,b. It improves muscle tone.
c. It promotes venous stasis.
d. It decreases vital capacity.
e. It prevents thrombus embolism. Correct Answers ANS: A B
E
Early ambulation is the most significant general nursing measure
to prevent postoperative complications. Early ambulation
increases muscle tone and strength and promotes venous return.
This is turn improves circulation, which prevents formation of
thrombus in the blood vessels. Early ambulation increases vital
capacity by promoting lung expansion, and prevents venous
stasis.
A nurse is caring for a patient who had a bowel resection 10
hours before. The patient weighs 200 pounds (91 kg) and has a
urine output of 240 cc for the past eight hours. What action
should the nurse take?
a. Encourage oral (PO) fluids
b. Continue to monitor the urine output
c. Notify the primary health care provider
d. Administer a 500 cc normal saline intravenous (IV) bolus
Correct Answers ANS: C
,The formula for determining adequate urine output is 0.5
mL/kg/hr. This patient, weighing 91 kg, needs to have 45 cc per
hour or about 365 cc of urine in eight hours. It often takes three
to five days for the bowel to begin working postabdominal
surgery; therefore, it would be inappropriate at this time to
encourage PO fluids. Continuing to monitor the urine output,
instead of calling the primary health care provider, would delay
identifying and treating the cause for the low urine output. The
nurse must obtain a prescription for the normal saline bolus
before administration.
A nurse is caring for an older adult patient, who had a knee
replacement the previous day. The patient denies any pain.
Which response by the nurse would be most appropriate?
a. "Excellent. You must be able to handle a lot of pain."
b. "Great. It is wise to only take the pain medication if you need
it."
c. "It is important that you take pain medication. It will help you
recover quicker."
d. "Almost everyone has pain after this surgery. Are you certain
that you are not experiencing pain?" Correct Answers ANS: D
Thoroughly assessing the presence of pain is imperative,
especially for those who deny any pain after surgery, especially
the elderly. Gerontology patients may hesitate about reporting
pain because of the belief that pain should be tolerated and is
, inevitable postsurgery. It is not appropriate to compliment the
patient on being able to handle pain. The patient will not
develop an addiction to pain medication, so it is not appropriate
to tell the patient he or she should only take it when necessary.
The nurse should not tell the patient that pain medication will
help him or her recover quicker, because that could give the
patient false reassurance.
A nurse is providing postoperative care for a patient who has
undergone exploratory abdominal surgery. Which nursing
interventions would help prevent post-operative atelectasis?
a. Medicating the patient with a narcotic analgesic as prescribed
b. Providing an abdominal binder to help the patient in
ambulation
c. Encouraging use of an incentive spirometer at least every hour
d. Turning the patient from one side to the other at least every 2
to 4 hours Correct Answers ANS: C
Use of an incentive spirometer after surgery encourages the
patient to take deep, slow breaths, which facilitates the opening
of terminal airways, mobilizes secretions, and prevents
postoperative atelectasis. The patient should be instructed to
perform 10 repetitions every hour. Narcotic analgesics, use of an
abdominal binder for ambulation, and frequent turning in bed
may indirectly support recovery and prevention of complications
postoperatively. However, these interventions do not specifically
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