Chapter 20: Nursing Management: Postoperative Care
(LEWIS) /Questions And Answers
Quiz :On admission of a patient to the postanesthesia care unit (PACU), the
blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to
114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is
most appropriate?
a. Increase the IV fluid rate.
b. Continue to take vital signs every 15 minutes.
c. Administer oxygen therapy at 100% per mask.
d. Notify the anesthesia care provider (ACP) immediately. - √Answer :B
Quiz :In the postanesthesia care unit (PACU), a patient's vital signs are blood
pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy
but awakens easily. Which action should the nurse take first?
a. Place the patient in a side-lying position.
b. Encourage the patient to take deep breaths.
c. Prepare to transfer the patient to a clinical unit.
d. Increase the rate of the postoperative IV fluids. - √Answer :B
Quiz :An experienced nurse orients a new nurse to the postanesthesia care
unit (PACU). Which action by the new nurse, if observed by the experienced
nurse, indicates that the orientation was successful?
a. The new nurse assists a nauseated patient to a supine position.
b. The new nurse positions an unconscious patient supine with the head
elevated.
c. The new nurse turns an unconscious patient to the side upon arrival in the
PACU.
d. The new nurse places a patient in the Trendelenburg position when the
blood pressure drops. - √Answer :C
Quiz :An older patient is being discharged from the ambulatory surgical unit
following left eye surgery. The patient tells the nurse, "I do not know if I can
take care of myself with this patch over my eye." Which action by the nurse is
most appropriate?
a. Refer the patient for home health care services.
b. Discuss the specific concerns regarding self-care.
c. Give the patient written instructions regarding care.
d. Assess the patient's support system for care at home. - √Answer :B
, Quiz :The nasogastric (NG) tube is removed on the second postoperative day,
and the patient is placed on a clear liquid diet. Four hours later, the patient
complains of sharp, cramping gas pains. What action by the nurse is the most
appropriate?
a. Reinsert the NG tube.
b. Give the PRN IV opioid.
c. Assist the patient to ambulate.
d. Place the patient on NPO status. - √Answer :C
Quiz :A patient's T-tube is draining dark green fluid after gallbladder surgery.
What action by the nurse is the most appropriate?
a. Notify the patient's surgeon.
b. Place the patient on bed rest.
c. Document the color and amount of drainage.
d. Irrigate the T-tube with sterile normal saline. - √Answer :C
Quiz :A nurse assists a patient on the first postoperative day to ambulate,
cough, deep breathe, and turn. Which action by the nurse is most helpful?
a. Teach the patient to fully exhale into the incentive spirometer.
b. Administer ordered analgesic medications before these activities.
c. Ask the patient to state two possible complications of immobility.
d. Encourage the patient to state the purpose of splinting the incision. -
√Answer :B
Quiz :A postoperative patient has a nursing diagnosis of ineffective airway
clearance. The nurse determines that interventions for this nursing diagnosis
have been successful if which is observed?
a. Patient drinks 2 to 3 L of fluid in 24 hours.
b. Patient uses the spirometer 10 times every hour.
c. Patient's breath sounds are clear to auscultation.
d. Patient's temperature is less than 100.4° F orally. - √Answer :C
Quiz :A patient who has begun to awaken after 30 minutes in the
postanesthesia care unit (PACU) is restless and shouting at the nurse. The
patient's oxygen saturation is 96%, and recent laboratory results are all
normal. Which action by the nurse is most appropriate?
a. Increase the IV fluid rate.
b. Assess for bladder distention.
c. Notify the anesthesia care provider (ACP).
d. Demonstrate the use of the nurse call bell button. - √Answer :B
(LEWIS) /Questions And Answers
Quiz :On admission of a patient to the postanesthesia care unit (PACU), the
blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to
114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is
most appropriate?
a. Increase the IV fluid rate.
b. Continue to take vital signs every 15 minutes.
c. Administer oxygen therapy at 100% per mask.
d. Notify the anesthesia care provider (ACP) immediately. - √Answer :B
Quiz :In the postanesthesia care unit (PACU), a patient's vital signs are blood
pressure 116/72, pulse 74, respirations 12, and SpO2 91%. The patient is sleepy
but awakens easily. Which action should the nurse take first?
a. Place the patient in a side-lying position.
b. Encourage the patient to take deep breaths.
c. Prepare to transfer the patient to a clinical unit.
d. Increase the rate of the postoperative IV fluids. - √Answer :B
Quiz :An experienced nurse orients a new nurse to the postanesthesia care
unit (PACU). Which action by the new nurse, if observed by the experienced
nurse, indicates that the orientation was successful?
a. The new nurse assists a nauseated patient to a supine position.
b. The new nurse positions an unconscious patient supine with the head
elevated.
c. The new nurse turns an unconscious patient to the side upon arrival in the
PACU.
d. The new nurse places a patient in the Trendelenburg position when the
blood pressure drops. - √Answer :C
Quiz :An older patient is being discharged from the ambulatory surgical unit
following left eye surgery. The patient tells the nurse, "I do not know if I can
take care of myself with this patch over my eye." Which action by the nurse is
most appropriate?
a. Refer the patient for home health care services.
b. Discuss the specific concerns regarding self-care.
c. Give the patient written instructions regarding care.
d. Assess the patient's support system for care at home. - √Answer :B
, Quiz :The nasogastric (NG) tube is removed on the second postoperative day,
and the patient is placed on a clear liquid diet. Four hours later, the patient
complains of sharp, cramping gas pains. What action by the nurse is the most
appropriate?
a. Reinsert the NG tube.
b. Give the PRN IV opioid.
c. Assist the patient to ambulate.
d. Place the patient on NPO status. - √Answer :C
Quiz :A patient's T-tube is draining dark green fluid after gallbladder surgery.
What action by the nurse is the most appropriate?
a. Notify the patient's surgeon.
b. Place the patient on bed rest.
c. Document the color and amount of drainage.
d. Irrigate the T-tube with sterile normal saline. - √Answer :C
Quiz :A nurse assists a patient on the first postoperative day to ambulate,
cough, deep breathe, and turn. Which action by the nurse is most helpful?
a. Teach the patient to fully exhale into the incentive spirometer.
b. Administer ordered analgesic medications before these activities.
c. Ask the patient to state two possible complications of immobility.
d. Encourage the patient to state the purpose of splinting the incision. -
√Answer :B
Quiz :A postoperative patient has a nursing diagnosis of ineffective airway
clearance. The nurse determines that interventions for this nursing diagnosis
have been successful if which is observed?
a. Patient drinks 2 to 3 L of fluid in 24 hours.
b. Patient uses the spirometer 10 times every hour.
c. Patient's breath sounds are clear to auscultation.
d. Patient's temperature is less than 100.4° F orally. - √Answer :C
Quiz :A patient who has begun to awaken after 30 minutes in the
postanesthesia care unit (PACU) is restless and shouting at the nurse. The
patient's oxygen saturation is 96%, and recent laboratory results are all
normal. Which action by the nurse is most appropriate?
a. Increase the IV fluid rate.
b. Assess for bladder distention.
c. Notify the anesthesia care provider (ACP).
d. Demonstrate the use of the nurse call bell button. - √Answer :B
