NURSING CARE FOR PREOPERATIVE AND
POSTOPERATIVE FINAL PAPER TESTED
QUESTIONS WITH COMPLETE ANSWER
KEY
●● A patient is admitted to the PACU after major abdominal surgery.
During the initial assessment the patient tells the nurse he thinks he is
going to "throw up." A priority nursing intervention would be to:
a. increase the rate of IV fluids
b. obtain vital signs, including O2 saturation
c. position patient in lateral recovery position
d. administer antiemetic medication as ordered
Answer: c. position patient in lateral recovery position
Rationale: If the patient is nauseated and may vomit, place the patient in
a lateral recovery position to keep the airway open and reduce the risk of
aspiration if vomiting occurs.
●● After admission of the postoperative patient to the clinical unit,
which assessment data require the most immediate attention?
a. Oxygen saturation of 85%
b. Respiratory rate of 13/min
c. Temperature of 100.4F
,d. Blood pressure of 90/60 mmHg
Answer: a. Oxygen saturation of 85%
Rationale: During the initial assessment, identify signs of inadequate
oxygenation and ventilation. Pulse oximetry monitoring is initiated
because it provides a noninvasive means of assessing the adequacy of
oxygenation. Pulse oximetry may indicate low oxygen saturation (<90%
to 92%) with respiratory compromise. This necessitates prompt
intervention.
●● A 70-kg postoperative patient has an average urine output of 25
mL/hr during the first 8 hours. The priority nursing intervention(s) given
this assessment would be to:
a. perform a straight catheterization to measure the amount of urine in
the bladder
b. notify the physician and anticipate obtaining blood work to evaluate
renal function
c. continue to monitor the patient because this is a normal finding during
this time period
d. evaluate the patient's fluid volume status since surgery and obtain a
bladder ultrasound
Answer: d. evaluate the patient's fluid volume status since surgery and
obtain a bladder ultrasound
Rationale: Because of the possibility of infection associated with
catheterization, the nurse should first try to validate that the bladder is
,full. The nurse should consider fluid intake during and after surgery and
should determine bladder fullness by percussion, by palpation, or by a
portable bladder ultrasound study to assess the volume of urine in the
bladder and avoid unnecessary catheterization.
●● Discharge criteria for the Phsae II patient include (select all that
apply):
a. no nausea or vomiting
b. ability to drive self home
c. no respiratory depression
d. written discharge instructions understood
e. opioid pain medication given 45 minutes ago
Answer: c, d, & e
Rationale: Phase II discharge criteria that must be met include the
following: all PACU discharge criteria (Phase I) met; no intravenous
opioid drugs administered for the past 30 minutes; patient's ability to
void (if appropriate with regard to surgical procedure or orders);
patient's ability to ambulate if it is not contraindicated; presence of a
responsible adult to accompany or drive patient home; and written
discharge instructions given and understood.
●● Unless contraindicated by the surgical procedure, which position is
preferred for the unconscious patient immediately postoperative?
a. Supine
, b. Lateral
c. Semi-Fowler's
d. High-Fowler's
Answer: b. Lateral
Unless contraindicated by the surgical procedure, the 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.
●● The nurse is working on a surgical floor and is preparing to receive a
postoperative patient from the postanesthesia care unit (PACU). What
should the nurse's initial action be upon the patient's arrival?
a. Assess the patient's pain.
b. Assess the patient's vital signs.
c. Check the rate of the IV infusion.
d. Check the physician's postoperative orders.
Answer: b. Assess the patient's vital signs.
The highest priority action by the nurse is to assess the physiologic
stability of the patient. This is accomplished in part by taking the
patient's vital signs. The other actions can then take place in rapid
sequence.
POSTOPERATIVE FINAL PAPER TESTED
QUESTIONS WITH COMPLETE ANSWER
KEY
●● A patient is admitted to the PACU after major abdominal surgery.
During the initial assessment the patient tells the nurse he thinks he is
going to "throw up." A priority nursing intervention would be to:
a. increase the rate of IV fluids
b. obtain vital signs, including O2 saturation
c. position patient in lateral recovery position
d. administer antiemetic medication as ordered
Answer: c. position patient in lateral recovery position
Rationale: If the patient is nauseated and may vomit, place the patient in
a lateral recovery position to keep the airway open and reduce the risk of
aspiration if vomiting occurs.
●● After admission of the postoperative patient to the clinical unit,
which assessment data require the most immediate attention?
a. Oxygen saturation of 85%
b. Respiratory rate of 13/min
c. Temperature of 100.4F
,d. Blood pressure of 90/60 mmHg
Answer: a. Oxygen saturation of 85%
Rationale: During the initial assessment, identify signs of inadequate
oxygenation and ventilation. Pulse oximetry monitoring is initiated
because it provides a noninvasive means of assessing the adequacy of
oxygenation. Pulse oximetry may indicate low oxygen saturation (<90%
to 92%) with respiratory compromise. This necessitates prompt
intervention.
●● A 70-kg postoperative patient has an average urine output of 25
mL/hr during the first 8 hours. The priority nursing intervention(s) given
this assessment would be to:
a. perform a straight catheterization to measure the amount of urine in
the bladder
b. notify the physician and anticipate obtaining blood work to evaluate
renal function
c. continue to monitor the patient because this is a normal finding during
this time period
d. evaluate the patient's fluid volume status since surgery and obtain a
bladder ultrasound
Answer: d. evaluate the patient's fluid volume status since surgery and
obtain a bladder ultrasound
Rationale: Because of the possibility of infection associated with
catheterization, the nurse should first try to validate that the bladder is
,full. The nurse should consider fluid intake during and after surgery and
should determine bladder fullness by percussion, by palpation, or by a
portable bladder ultrasound study to assess the volume of urine in the
bladder and avoid unnecessary catheterization.
●● Discharge criteria for the Phsae II patient include (select all that
apply):
a. no nausea or vomiting
b. ability to drive self home
c. no respiratory depression
d. written discharge instructions understood
e. opioid pain medication given 45 minutes ago
Answer: c, d, & e
Rationale: Phase II discharge criteria that must be met include the
following: all PACU discharge criteria (Phase I) met; no intravenous
opioid drugs administered for the past 30 minutes; patient's ability to
void (if appropriate with regard to surgical procedure or orders);
patient's ability to ambulate if it is not contraindicated; presence of a
responsible adult to accompany or drive patient home; and written
discharge instructions given and understood.
●● Unless contraindicated by the surgical procedure, which position is
preferred for the unconscious patient immediately postoperative?
a. Supine
, b. Lateral
c. Semi-Fowler's
d. High-Fowler's
Answer: b. Lateral
Unless contraindicated by the surgical procedure, the 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.
●● The nurse is working on a surgical floor and is preparing to receive a
postoperative patient from the postanesthesia care unit (PACU). What
should the nurse's initial action be upon the patient's arrival?
a. Assess the patient's pain.
b. Assess the patient's vital signs.
c. Check the rate of the IV infusion.
d. Check the physician's postoperative orders.
Answer: b. Assess the patient's vital signs.
The highest priority action by the nurse is to assess the physiologic
stability of the patient. This is accomplished in part by taking the
patient's vital signs. The other actions can then take place in rapid
sequence.
