Ch 18 quiz

Which description illustrates the beginning of the postoperative period?
a. Completion of the surgical procedure and arousal of the patient from anesthesia
b. discharge planning initiated in the preoperative setting
c. closure of the patient’s surgical incision
*d. completion of the surgical procedure and transfer of the patient to the post anesthesia care unit (PACU) or intensive care unit*

What is the primary purpose of a PACU?
a. follow-through on the surgeon’s postoperative orders
*b. ongoing critical evaluation and stabilization of the patient*
c. prevention of lengthened hospital stay
d. arousal of patient following the use of conscious sedation

A patient develops respiratory distress after having a left total hip replacement. The patient develops labored breathing and a pulse oximetry reading is 83% on 2 L nasal cannula. Which intervention is appropriate for unlicensed personnel to perform?
a. assess change in patient’s respiratory status.
b. order necessary medications to be administered
c. intubate the patient for maintenance of airway and assisted breathing
*d. take vital signs*

Which signs/symptoms are considered postoperative complications? (select all that apply)
a. sedation
b. pain at the surgical site
*c. pulmonary embolism*
*d. hypothermia*
*e. wound evisceration*

If a patient experiences a wound dehiscence, which description illustrates what is happening with the wound?
a. purulent drainage is present at incision site because of infection
b. extreme pain is present at incision site
*c. a partial or complete separation of outer layers is present at incision site*
d. the inner and outer layers of the incision are separated

A patient who is 2 days postoperative abdominal surgery states, “I coughed and heard something pop.” The nurse’s immediate assessment reveals an opened incision with a portion of large intestine protruding. Which statements apply to this clinical situation? (Select all that apply)
a. Incision dehiscence has occurred
*b. This is an emergency situation.*
*c. The wound must be kept moist with normal saline-soaked sterile dressings*
d. This is an urgent situation
*e. Incision evisceration has occurred*

In the PACU, the nurse assesses that a patient is bleeding profusely from an abdominal incision. What actions, in order or priority, does the nurse perform? (Select in order of priority)
a. The surgeon is paged
b. The nurse applied pressure to the dressing
c. unlicensed assistive personnel (UAP) are asked to get additional dressing supplies
d. a complete blood count is ordered

*b, c, a, d*

The nurse transfers a patient to the PACU who had an inciosn and drainage of an abscess in the right groin with general anesthesia. Blood pressure is 80/47 mmHG, heart rate 117/min in sinus tachycardia, respiratory rate 28/min, pulse oximeter reading is 93% on oxygen at 3 L nasal cannula, temp is 38.5 C. The Jackson Pratt drain has 70 mL of a cream-colored output. Normal saline is infusion at 150 mL/hr. The surgeon sends order to bolus the patient with 500 mL IV over 1 hour of normal saline, draw two sets of blood cultures, and culture drainage from the Jackson pratt drain. The patient has a history of vulvar cancer and had a needle biopsy of the right groin 1 week ago. In addition, the patient has a history of hypertension and is taking lisinopril 5 mg PO daily. The patient has known drug allergies. The patient is a full code. Using SBAR reporting method, indicate the appropriate responses for this case.
a. Situation: Nurse transfers a patent to the PACU who had an incision and drainage for an abscess in the right join with general anesthesia.
b. Background: Patient had an abscess in the right groin. History of vulvar cancer, had a needle biopsy of right groin 1 week ago, and hypertension treated with lisinopril 5 mg PO daily. NKA. Pt is a full code.
c. Assessment: Blood pressure is 80/47 mmHg, HR 117/min in sinus tachycardia, respiratory rate 28/min, pulse oximeter reading 93% on oxygen at 3 L nasal cannula, temp 38.5 C. Jackson-Pratt drain has cream-colored output, 70 mL.
d. Recommendation: Surgeon sending orders to bolus patient with 500 mL IV over 1 hour of normal saline, draw two sets of blood cultures, and culture drainage from Jackson-Pratt drain.

Clinical Note: A postoperative patient in the PACU has had an open reduction internal fixation of a left fractured femur. Vital signs are blood pressure 87/49, HR 100/min sinus rhythm, respiration 22, temp 98.3. The Foley has a total amount of 110mL of clear, yellow urine in the last 4 hours. Which body systems have been assessed by the nurse? (select all that apply)
*a. respiratory*
*b. cardiovascular*
c. neurovascular
d. integumentary
*e. renal/urinary*

Clinical Note: A patient cared for in the PACU has had a colostomy placed for treatment of Crohn’s disease. The nurse assesses that an abdominal dressing is 25% saturated with serosanguinous drainage and notes that the incision is intact. An IV is infusing D LR at 100 mL/hr through a 20-g peripheral IV access. Ausculation of abdomen reveals hypoactive bowel sounds in all 4 quadrants, abdomen soft, and no dissension. Foley is in place and draining yellow urine with sediment, 375 mL output in foley bag. Which body systems have been assessed by the nurse? (select all)
*a. renal/urinary*
*b. gastrointestinal*
c. respiratory
*e. integumentary*

A 49 year old patient is in the PACU following a frontal craniotomy for repair of a ruptured cerebral aneurysm. The nurse assesses that the patient’s eyes open on verbal stimulation. Pupils are equal, reactive, to light, and prompt 3 mm. The patient’s hand grasps are equal and strong. When the nurse asks the patient to state name, the patient states name correctly. The patient has had one episode of nausea and vomiting. Incision edges are dry and approximated with sutures. Lungs are slightly diminished per auscultation and the nurse observes the patient is using abdominal accessory muscles to breathe. Which body systems has the nurse assessed? (select all)
a. cardiovascular
*b. gastrointestinal*
*c. neurologic*
*d. integumentary*
*e. respiratory*

Eyes open on command

symmetrical chest wall expansion

foley catheter to facilitate drainage
fluid and electrolyte balance, integumentary

absent dorsalis pedis pulsations

use of accessory muscles

large amount of sanguineous drainage

Negative Homans’ sign

IV infusion of dextrose 5% Ringer’s lactate
fluid and electrolye balance

States name when asked

Rounded, firm abdomen

exhalation felt from nose or mouth

decreased blood pressure
cardiovascular, fluid and electrolyte balance

wound edges approximated

dry mucous membranes
fluid and electrolyte balance

fluid and electrolyte balance, neurologic, gastrointestinal

pupils constrict equally

sternal retraction

nasogastric tube in place


dullness over symphysis pubis

fluid and electrolyte balance, integumentary

faint heart sounds
cardiovascular, fluid and electrolyte balance

wound dressing dry

absent bowel sounds

vesicular crackles
respiratory, cardiovascular, fluid and electrolyte balance

hand grips equal

simultaneous apical and radial pulsations



a patient arrives in the PACU. Which action does the nurse perform first?
*a. assess for patent airway and adequate gas exchange*
b. rate the patient’s pain using the 0-10 pain assessment scale
c. position the patient in a supine position to prevent aspiration
d. calculate the PCA pump maximum dose per hour to avoid an overdose

A patient arrives at the PACU and the nurse notes a respiratory rate of 10 with sternal retractions. The report from anesthesia personnel indicates that the patient had received fentanyl during surgery. Place in sequential order, using the number 1 to 7, the nursing interventions to be performed
a. monitor the patient for effects of anesthetic for at least 1 hour 7
b. have suction available appropriate to the patient’s available airway 3
c. closely monitor vital signs and pulse oximetry readings until the patient responds 4
d. do no leave the patient unattended until he or she is able to respond fully. 5
e. observe for significant reversal of anesthesia. 6
f. administer oxygen as ordered, monitoring pulse oximetry 2
g. maintain an open airway through positioning and suction as needed.1

The nurse is teaching incisional care to a patient who has been discharged after abdominal surgery. Which instructions does the nurse include?
a. do not rub or touch the incision site
*b. practice proper hand washing*
c. clean the incision site two times a day with soap and water
d. splint the incisional site as often as needed for comfort

Which intervention for post surgical care of a patient is correct?
a. When positioning the patient, use the knee hatch of the bed to bend the knees and relieve pressure
b. gentle massage on the lower legs and calves helps promote venous blood return to the heart
c. encourage bed rest for 3 days after surgery to prevent complications
*d. the patient should splint the surgical wound for support and comfort when getting out of bed.*

The morning after a patients lower led surgery, the nurse notes that the dressing is wet from drainage. The surgeon has not yet been in to see the patient on rounds. What does the nurse do about the dressing?
a. removes the dressing and puts on a dry, sterile dressing
*b. reinforces the dressing by adding dry, sterile dressing material on top of the existing dressing*
c. applies dry, sterile dressing material directly to the wound, then retakes the original dressing
d. does nothing to the dressing but calls the surgeon to evaluate the patient immediately

The health care provider removed a patient’s original surgical dressing 2 days after surgery and is discharging the patient home on daily dressing changes. Which actions does the nuse take for this patient’s discharge teaching? (select all )
*a. ask the patients family or significant other to observe the dressing change*
b. ask the UAP to get dressing supplies for the patient
*c. instruct that the drainage will appear serosanguinous*
d. instruct the patient to go to the ED for problems related to dressing changes
*e. have the case manager arrange for a home health nurse to ensure that dressing changes are done and there are no complication of infection*

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions?
a. postural drainage
b. cupping the chest
c. nasotracheal suctioning
*d. frequent changes of position*

What is the priority nursing intervention for a client during the immediate postoperative period?
a. monitorying vital signs
b. observing for hemorrhage
*c. maintaining a patent airway*
d. recording intake and output

A nurse in the postanethesia care unit (PACU) observes that after an abdominal cholecystectomy a client has serosanguineous drainage on the abdominal dressing. What is the next nursing action?
a. change the dressing
*b. reinforce the dressing*
c. replace the tape with montogomery ties
d. support the incision with an abdominal binder

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus?
a. decreased blood supply
*b. impaired neural functioning*
c. perforation of the bowel wall
d. obstruction of the bowel lumen

A client experiences abdominal distention following surgery. Which nursing actions are appropriate. Select all that apply
*a. encouraging ambulation*
b. giving sips of ginger ale
*c. auscultating bowel sounds*
d. providing a straw for drinking
e. offering the prescribed opiod analgesic

A nurse is applying a dressing to a client’s surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated?
a. dialysis
b. osmosis
c. diffusion
*d. capillarity*

A nurse is preparing to change a client’s dressing. What is the reason for using surcial asepsis during this procedure?
A. keeps the area free of microorganisms

When assessing an obese client, a nurse observes dehiscenece of the abdominal surgical wound with eviscerations. The nurse places the client in the low fowler psosition with the knees slightly ben and encourages the client to lie still. What is the next nursing action?q
d. cover the wound with a sterile towel moistened with normal saline

While caring for a client with a portable wound drainage system, a nurse observes that the collection container is half full and empties it. What is the next nursing intervention?
d. compress the container before closing the port

A nurse in the surgical intensive care unit is caring fora client with a large surgical incision. What medication does the nurse anticipate will be prescribed for this client?
d. ascorbic acid (ascorbicap)

a client reports severe pain 2 days after surgery. Which initial action should the nurse take after assessing the character of the pain?
b. obtain the vital signs

After abdominal surgery a client reports pain. What action should the nurse take first?
d. determine the characteristics of the pain

A client is extubated in the postanesthesia care unit after surgery. for which common response should the nurse be alert when monitoring the client for acute respiratory distress?
a. restlessness

In the immediate postoperative period after a gastrectomy, the chlient’s nasogastric tube is draining a light-red liquid. For how long should the nurse expect this type of drainage?
c. 10 to 12 hourse

A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis?
d. diminished breath sounds on auscultation

On which concern should the nurse focus when caring for a client after abdominal surgery?
a. identifying signs of bleeding

After an abdominal c holecystectomy, a client has a T-tube attached to a collection device. On the day of surgery, at 1030 pm, 300 mL of bile is emptied from the collection bag. At 630 am the next day, the bag contains 60 mL of bile. What should the nurse consider in response to this information?
c. mechanical problems may have developed with the T-tube.

A nurse is providing discharge teaching for a client who is postoperative following a rhinoplasty using general anesthesia. Which of the following instructions should the nurse include? Use cool compresses on your eyes, nose, and face A nurse is planning …

A perioperative nurse is preparing a patient for surgery for treatment of a ruptured spleen as the result of an automobile crash. The nurse knows that this type of surgery belongs in what category? Major, emergency A nurse is preparing …

A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following assessment data indicates the client is at an increased risk for infection? Long term use of corticosteroids A nurse is assessing …

My OR day consisted of a hernia repair, a colonoscopy, and a hemorroidectomy. The role of the surgeon was to come in and perform the surgery. The anesthesiologist induced anesthesia, and monitored the patients heart and respirations and other vitals …

When caring for a postsurgical patient, the nurse observes that the client has hemorrhaged and is in hypovolemic shock. Which of the following nursing interventions will manage and minimize hemorrhage and shock? Reinforcing dressing or applying pressure if bleeding is …

Which description illustrates the beginning of the postop period? Completion of the surgical procedure and transfer of the patient to the postanesthesia care unit or intensive care unit What is the primary purpose of a PACU? Ongoing critical evaluation and …

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