Chapter 16 Postoperative Nursing Management
1. The recovery room nurse is admitting a patient from the OR following the patient's successful
splenectomy. What is the first assessment that the nurse should perform on this newly
admitted patient?
A) Heart rate and rhythm
B) Skin integrity
C) Core body temperature
D) Airway patency
Ans: D
Feedback:
The primary objective in the immediate postoperative period is to maintain ventilation
and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and
ventilation is reduced. This assessment is followed by cardiovascular status and the condition
of the surgical site. The core temperature would be assessed after the airway, cardiovascular
status, and wound (skin integrity).
2. An adult patient is in the recovery room following a nephrectomy performed for the
treatment of renal cell carcinoma. The patient's vital signs and level of consciousness
stabilized, but the patient then complains of severe nausea and begins to retch. What should
the nurse do next?
A) Administer a dose of IV analgesic.
B) Apply a cool cloth to the patient's forehead.
C) Offer the patient a small amount of ice chips. D) Turn the patient completely to one
side.
Ans: D
Feedback:
,Turning the patient completely to one side allows collected fluid to escape from the side of
the mouth if the patient vomits. After turning the patient to the side, the nurse
can offer a cool cloth to the patient's forehead. Ice chips can increase feelings of nausea. An
analgesic is not administered for nausea and vomiting.
3. The perioperative nurse is preparing to discharge a female patient home from day
surgery performed under general anesthetic. What instruction should the nurse give the
patient prior to the patient leaving the hospital?
A) The patient should not drive herself home.
B) The patient should take an OTC sleeping pill for 2 nights.
C) The patient should attempt to eat a large meal at home to aid wound healing.
D) The patient should remain in bed for the first 48 hours postoperative. Ans: A
Feedback:
Although recovery time varies, depending on the type and extent of surgery and the
patient's overall condition, instructions usually advise limited activity for 24 to 48 hours.
Complete bedrest is contraindicated in most cases, however. During this time, the patient
should not drive a vehicle and should eat only as tolerated. The nurse does not normally make
OTC recommendations for hypnotics.
4. The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy.
The nurse is getting him up for his first walk postoperatively. To decrease the potential
for orthostatic hypotension and consequent falls, what should the nurse have the patient do?
A)
Sit in a chair for 10 minutes prior to ambulating.
B) Drink plenty of fluids to increase circulating blood volume.
C) Stand upright for 2 to 3 minutes prior to ambulating. D) Perform range-of-motion
exercises for each joint. Ans: C
Feedback:
,Older adults are at an increased risk for orthostatic hypotension secondary to age- related
changes in vascular tone. The patient should sit up and then stand for 2 to 3 minutes before
ambulating to alleviate orthostatic hypotension. The nurse should assess the patient's ability
to mobilize safely, but full assessment of range of motion in all joints is not normally
necessary. Sitting in a chair and increasing fluid intake are insufficient to prevent orthostatic
hypotension and consequent falls.
5. The perioperative nurse is providing care for a patient who is recovering on the
postsurgical unit following a transurethral prostate resection (TUPR). The patient is reluctant
to ambulate, citing the need to recover in bed. For what complication is the patient most at
risk?
A) Atelectasis
B) Anemia
C) Dehydration
D) Peripheral edema
Ans: A
Feedback:
Atelectasis occurs when the postoperative patient fails to move, cough, and breathe deeply.
With good nursing care, this is an avoidable complication, but reduced mobility greatly
increases the risk. Anemia occurs rarely and usually in situations where the patient loses a
significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively
may result in dehydration and peripheral edema, but the patient is most at risk for atelectasis.
6. The nurse is caring for a patient on the medicalñsurgical unit postoperative day 5.
During each patient assessment, the nurse evaluates the patient for infection. Which of
the following would be most indicative of infection? A) Presence of an indwelling urinary
catheter
B) Rectal temperature of 99.5∫F (37.5∫C) C) Red, warm, tender incision
, D) White blood cell (WBC) count of 8,000/mL Ans: C
Feedback:
Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a
postoperative infection. The presence of any invasive device predisposes a patient to
infection, but by itself does not indicate infection. An oral temperature of 99.5∫F may not
signal infection in a postoperative patient because of the inflammatory process. A normal
WBC count ranges from 4,000 to 10,000/mL.
1. The recovery room nurse is admitting a patient from the OR following the patient's successful
splenectomy. What is the first assessment that the nurse should perform on this newly
admitted patient?
A) Heart rate and rhythm
B) Skin integrity
C) Core body temperature
D) Airway patency
Ans: D
Feedback:
The primary objective in the immediate postoperative period is to maintain ventilation
and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and
ventilation is reduced. This assessment is followed by cardiovascular status and the condition
of the surgical site. The core temperature would be assessed after the airway, cardiovascular
status, and wound (skin integrity).
2. An adult patient is in the recovery room following a nephrectomy performed for the
treatment of renal cell carcinoma. The patient's vital signs and level of consciousness
stabilized, but the patient then complains of severe nausea and begins to retch. What should
the nurse do next?
A) Administer a dose of IV analgesic.
B) Apply a cool cloth to the patient's forehead.
C) Offer the patient a small amount of ice chips. D) Turn the patient completely to one
side.
Ans: D
Feedback:
,Turning the patient completely to one side allows collected fluid to escape from the side of
the mouth if the patient vomits. After turning the patient to the side, the nurse
can offer a cool cloth to the patient's forehead. Ice chips can increase feelings of nausea. An
analgesic is not administered for nausea and vomiting.
3. The perioperative nurse is preparing to discharge a female patient home from day
surgery performed under general anesthetic. What instruction should the nurse give the
patient prior to the patient leaving the hospital?
A) The patient should not drive herself home.
B) The patient should take an OTC sleeping pill for 2 nights.
C) The patient should attempt to eat a large meal at home to aid wound healing.
D) The patient should remain in bed for the first 48 hours postoperative. Ans: A
Feedback:
Although recovery time varies, depending on the type and extent of surgery and the
patient's overall condition, instructions usually advise limited activity for 24 to 48 hours.
Complete bedrest is contraindicated in most cases, however. During this time, the patient
should not drive a vehicle and should eat only as tolerated. The nurse does not normally make
OTC recommendations for hypnotics.
4. The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy.
The nurse is getting him up for his first walk postoperatively. To decrease the potential
for orthostatic hypotension and consequent falls, what should the nurse have the patient do?
A)
Sit in a chair for 10 minutes prior to ambulating.
B) Drink plenty of fluids to increase circulating blood volume.
C) Stand upright for 2 to 3 minutes prior to ambulating. D) Perform range-of-motion
exercises for each joint. Ans: C
Feedback:
,Older adults are at an increased risk for orthostatic hypotension secondary to age- related
changes in vascular tone. The patient should sit up and then stand for 2 to 3 minutes before
ambulating to alleviate orthostatic hypotension. The nurse should assess the patient's ability
to mobilize safely, but full assessment of range of motion in all joints is not normally
necessary. Sitting in a chair and increasing fluid intake are insufficient to prevent orthostatic
hypotension and consequent falls.
5. The perioperative nurse is providing care for a patient who is recovering on the
postsurgical unit following a transurethral prostate resection (TUPR). The patient is reluctant
to ambulate, citing the need to recover in bed. For what complication is the patient most at
risk?
A) Atelectasis
B) Anemia
C) Dehydration
D) Peripheral edema
Ans: A
Feedback:
Atelectasis occurs when the postoperative patient fails to move, cough, and breathe deeply.
With good nursing care, this is an avoidable complication, but reduced mobility greatly
increases the risk. Anemia occurs rarely and usually in situations where the patient loses a
significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively
may result in dehydration and peripheral edema, but the patient is most at risk for atelectasis.
6. The nurse is caring for a patient on the medicalñsurgical unit postoperative day 5.
During each patient assessment, the nurse evaluates the patient for infection. Which of
the following would be most indicative of infection? A) Presence of an indwelling urinary
catheter
B) Rectal temperature of 99.5∫F (37.5∫C) C) Red, warm, tender incision
, D) White blood cell (WBC) count of 8,000/mL Ans: C
Feedback:
Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a
postoperative infection. The presence of any invasive device predisposes a patient to
infection, but by itself does not indicate infection. An oral temperature of 99.5∫F may not
signal infection in a postoperative patient because of the inflammatory process. A normal
WBC count ranges from 4,000 to 10,000/mL.
