LEWIS: MEDICAL-SURGICAL NURSING
LEWIS: MEDICAL-SURGICAL NURSING (POSTOPERATIVE CARE) EXAM QUESTIONS AND
ANSWERS GRADED A+!!
A 42-year-old patient is recovering from anesthesia in the post anesthesia care
unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty
minutes after admission, the blood pressure falls to 112/60, with a pulse of 72
and warm, dry skin. The most appropriate action by the nurse at this time is to:
a. increases the rate of the IV fluid replacement.
b. continues to take vital signs every 15 minutes.
c. administers oxygen therapy at 100% per mask.
d. notifies the anesthesia care provider (ACP) immediately. Answer >>> b.
continues to take vital signs every 15 minutes.
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 and/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.
During recovery from anesthesia in the post anesthesia care unit (PACU), a
patient’s vital signs are blood pressure 118/72, pulse 76, respirations 12, and
SpO2 91%. The patient is sleepy but awakens easily. Which action should the
nurse take at this time?
a. Place the patient in a side-lying position.
b. Encourage the patient to take deep breaths.
, LEWIS: MEDICAL-SURGICAL NURSING
c. Prepare to transfer the patient from the PACU.
d. Increase the rate of the postoperative IV fluids. Answer >>> b. Encourage the
patient to take deep breaths.
The patients 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 BP 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 is not appropriate.
After a new nurse has been oriented to the post anesthesia care unit (PACU), the
charge nurse will evaluate that the orientation has been successful when the new
nurse:
a. places a patient in the Trendelenburg position when the blood pressure (BP)
drops.
b. assists a patient to the prone position when the patient is nauseated.
c. turns an unconscious patient to the side when the patient arrives in the PACU.
d. positions a newly admitted unconscious patient supine with the head elevated.
Answer >>> c. turns an unconscious patient to the side when the patient arrives in
the PACU.
The patient should initially be positioned in the lateral recovery position to keep
the airway open and avoid aspiration. The prone position is not usually used and
would make it difficult to assess the patient’s respiratory effort and
cardiovascular status. The Trendelenburg position is avoided because it increases
the work of breathing. The patient is placed supine with the head elevated after
regaining consciousness.
LEWIS: MEDICAL-SURGICAL NURSING (POSTOPERATIVE CARE) EXAM QUESTIONS AND
ANSWERS GRADED A+!!
A 42-year-old patient is recovering from anesthesia in the post anesthesia care
unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty
minutes after admission, the blood pressure falls to 112/60, with a pulse of 72
and warm, dry skin. The most appropriate action by the nurse at this time is to:
a. increases the rate of the IV fluid replacement.
b. continues to take vital signs every 15 minutes.
c. administers oxygen therapy at 100% per mask.
d. notifies the anesthesia care provider (ACP) immediately. Answer >>> b.
continues to take vital signs every 15 minutes.
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 and/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.
During recovery from anesthesia in the post anesthesia care unit (PACU), a
patient’s vital signs are blood pressure 118/72, pulse 76, respirations 12, and
SpO2 91%. The patient is sleepy but awakens easily. Which action should the
nurse take at this time?
a. Place the patient in a side-lying position.
b. Encourage the patient to take deep breaths.
, LEWIS: MEDICAL-SURGICAL NURSING
c. Prepare to transfer the patient from the PACU.
d. Increase the rate of the postoperative IV fluids. Answer >>> b. Encourage the
patient to take deep breaths.
The patients 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 BP 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 is not appropriate.
After a new nurse has been oriented to the post anesthesia care unit (PACU), the
charge nurse will evaluate that the orientation has been successful when the new
nurse:
a. places a patient in the Trendelenburg position when the blood pressure (BP)
drops.
b. assists a patient to the prone position when the patient is nauseated.
c. turns an unconscious patient to the side when the patient arrives in the PACU.
d. positions a newly admitted unconscious patient supine with the head elevated.
Answer >>> c. turns an unconscious patient to the side when the patient arrives in
the PACU.
The patient should initially be positioned in the lateral recovery position to keep
the airway open and avoid aspiration. The prone position is not usually used and
would make it difficult to assess the patient’s respiratory effort and
cardiovascular status. The Trendelenburg position is avoided because it increases
the work of breathing. The patient is placed supine with the head elevated after
regaining consciousness.
