NUR 243 Chapter 19 Post-op Evolve
UPDATED ACTUAL Questions and
CORRECT Answers
Which patient would be at highest risk for hypothermia after surgery?
A. A 42-yr-old patient who had a laparoscopic appendectomy
B. A 38-yr-old patient who had a lumpectomy for breast cancer
C. A 20-yr-old patient with an open reduction of a fractured radius
D. A 75-yr-old patient with repair of a femoral neck fracture after a fall - CORRECT ANSWER -D.
Rational: Patients at highest risk for hypothermia are those who are older, debilitated, or intoxicated.
Also, long surgical procedures and prolonged anesthetic administration increase the patient's risk for
hypothermia.
The nurse is positioning a patient after a surgical procedure. What is the best position unless
contraindicated, for this patient to be placed in to prevent respiratory complications?
A. Supine
B. Lateral
C. Semi-Fowler's
D. High-Fowler's - CORRECT ANSWER -B.
Rational: Unless contraindicated by the surgical procedure, an unconscious patient is positioned in a
lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of
aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with
the head of the bed elevated.
A postoperative patient has a bronchial obstruction resulting from retained secretions and an oxygen
saturation of 87%. What condition does the nurse suspect is occurring?
A. Atelectasis
, B. Bronchospasm
C. Hypoventilation
D. Pulmonary embolism - CORRECT ANSWER -A.
Rational: The most common cause of postoperative hypoxemia is atelectasis, which may be the result of
bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm
involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an
inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.
An older adult patient who had surgery is displaying manifestations of delirium. What priority action
would benefit this patient?
A. Check the chart for intraoperative complications.
B. Check which medications were used for anesthesia.
C. Check the effectiveness of the analgesics received.
D. Check the preoperative assessment for previous delirium or dementia. - CORRECT ANSWER -
D.
Rational: If the patient's ABCs are okay, it is important to first know if the patient was mentally alert
without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications
and pain will be assessed as these can all contribute to delirium.
A postoperative patient is transferred from the postanesthesia unit to the medical-surgical nursing floor.
The nurse notes that the patient has an order for D5 ½NS to infuse at 125 mL/hr. Until an IV pump is
available, the nurse regulates the IV at what flow rate in drops (gtt)/min, noting that the tubing has a drop
factor of 10 drops/mL?
______ gtt/min - CORRECT ANSWER -125 mL/hr × 10 gtt/mL = 1250 gtt/hr
1250 gtt ÷ 60 min = 20.83 gtt/min
A patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment,
if made by the nurse, is the best indicator of respiratory depression?
UPDATED ACTUAL Questions and
CORRECT Answers
Which patient would be at highest risk for hypothermia after surgery?
A. A 42-yr-old patient who had a laparoscopic appendectomy
B. A 38-yr-old patient who had a lumpectomy for breast cancer
C. A 20-yr-old patient with an open reduction of a fractured radius
D. A 75-yr-old patient with repair of a femoral neck fracture after a fall - CORRECT ANSWER -D.
Rational: Patients at highest risk for hypothermia are those who are older, debilitated, or intoxicated.
Also, long surgical procedures and prolonged anesthetic administration increase the patient's risk for
hypothermia.
The nurse is positioning a patient after a surgical procedure. What is the best position unless
contraindicated, for this patient to be placed in to prevent respiratory complications?
A. Supine
B. Lateral
C. Semi-Fowler's
D. High-Fowler's - CORRECT ANSWER -B.
Rational: Unless contraindicated by the surgical procedure, an unconscious patient is positioned in a
lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of
aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with
the head of the bed elevated.
A postoperative patient has a bronchial obstruction resulting from retained secretions and an oxygen
saturation of 87%. What condition does the nurse suspect is occurring?
A. Atelectasis
, B. Bronchospasm
C. Hypoventilation
D. Pulmonary embolism - CORRECT ANSWER -A.
Rational: The most common cause of postoperative hypoxemia is atelectasis, which may be the result of
bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm
involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an
inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.
An older adult patient who had surgery is displaying manifestations of delirium. What priority action
would benefit this patient?
A. Check the chart for intraoperative complications.
B. Check which medications were used for anesthesia.
C. Check the effectiveness of the analgesics received.
D. Check the preoperative assessment for previous delirium or dementia. - CORRECT ANSWER -
D.
Rational: If the patient's ABCs are okay, it is important to first know if the patient was mentally alert
without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications
and pain will be assessed as these can all contribute to delirium.
A postoperative patient is transferred from the postanesthesia unit to the medical-surgical nursing floor.
The nurse notes that the patient has an order for D5 ½NS to infuse at 125 mL/hr. Until an IV pump is
available, the nurse regulates the IV at what flow rate in drops (gtt)/min, noting that the tubing has a drop
factor of 10 drops/mL?
______ gtt/min - CORRECT ANSWER -125 mL/hr × 10 gtt/mL = 1250 gtt/hr
1250 gtt ÷ 60 min = 20.83 gtt/min
A patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment,
if made by the nurse, is the best indicator of respiratory depression?
