Chapter 20: Nursing Management: Postoperative Care
Test Bank
MULTIPLE CHOICE
1. 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.
ANS: B
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
highconcentration oxygen administration.
DIF: Cognitive Level: Analyze (analysis) REF: 356 TOP: Nursing
Process: Implementation MSC: NCLEX: Physiological Integrity
2. 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.
ANS: B
The patient’s 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
blood pressure 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 to a
clinical unit is not appropriate.
DIF: Cognitive Level: Analyze (analysis) REF: 353-354
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
3. 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.
ANS: C
The patient should initially be positioned in the lateral “recovery” position to keep the airway
open and avoid aspiration. The Trendelenburg position is avoided because it increases the
work of breathing. The patient is placed supine with the head elevated after regaining
consciousness.
DIF: Cognitive Level: Apply (application) REF: 354 TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
4. 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.
ANS: B
The nurse’s initial action should be to assess exactly the patient’s concerns about self-care.
Referral to home health care and assessment of the patient’s support system may be
appropriate actions but will be based on further assessment of the patient’s concerns. Written
instructions should be given to the patient, but these are unlikely to address the patient’s stated
concern about self-care.
DIF: Cognitive Level: Apply (application) REF: 362-363 TOP: Nursing
Process: Implementation MSC: NCLEX: Physiological Integrity
5. 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.
ANS: C
Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient’s
discomfort. If distention persists, the patient may need to be placed on NPO status, but usually
this is not necessary. Morphine administration will further decrease intestinal motility. Gas
pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will
not relieve the pains.
Test Bank
MULTIPLE CHOICE
1. 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.
ANS: B
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
highconcentration oxygen administration.
DIF: Cognitive Level: Analyze (analysis) REF: 356 TOP: Nursing
Process: Implementation MSC: NCLEX: Physiological Integrity
2. 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.
ANS: B
The patient’s 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
blood pressure 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 to a
clinical unit is not appropriate.
DIF: Cognitive Level: Analyze (analysis) REF: 353-354
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
3. 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.
ANS: C
The patient should initially be positioned in the lateral “recovery” position to keep the airway
open and avoid aspiration. The Trendelenburg position is avoided because it increases the
work of breathing. The patient is placed supine with the head elevated after regaining
consciousness.
DIF: Cognitive Level: Apply (application) REF: 354 TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
4. 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.
ANS: B
The nurse’s initial action should be to assess exactly the patient’s concerns about self-care.
Referral to home health care and assessment of the patient’s support system may be
appropriate actions but will be based on further assessment of the patient’s concerns. Written
instructions should be given to the patient, but these are unlikely to address the patient’s stated
concern about self-care.
DIF: Cognitive Level: Apply (application) REF: 362-363 TOP: Nursing
Process: Implementation MSC: NCLEX: Physiological Integrity
5. 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.
ANS: C
Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient’s
discomfort. If distention persists, the patient may need to be placed on NPO status, but usually
this is not necessary. Morphine administration will further decrease intestinal motility. Gas
pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will
not relieve the pains.
