Lewis: Medical-Surgical
Nursing~Chapter 20 (Postoperative
Care)
A 42-year-old patient is recovering from anesthesia in the
postanesthesia
(PACU). care unit
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,The
skin. drymost appropriate action by the nurse at this
time is to:
a. increase the rate of the IV fluid
replacement.
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. correct answers
Answer: b.
continue 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 ongoingHypotension with tachycardia and/or cool, clammy skin
monitoring.
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 postanesthesia care unit (PACU), a l
patients
signs arevita
blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%.
The
is patient
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.
c. Prepare to transfer the patient from the
PACU.
d. Increase the rate of the postoperative IV fluids. correct answers
Answer: b. the patient to take deep
Encourage
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
a patient
lateral in
position is needed when the patient first arrives in the
PACU and is The stable BP and pulse indicate that no changes in fluid
unconscious.
intake areThe patient is not fully awake and has a low SpO2, indicating
required.
that transfer
from the PACU is not
appropriate.
After a new nurse has been oriented to the postanesthesia care unit
(PACU),nurse
charge the 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)
b. drops.
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
thepositions
d. PACU. a newly admitted unconscious patient supine with the
head elevated.
correct answers 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 keepopen
airway the and avoid aspiration. The prone position is not usually used
and would
make it difficult to assess the patients respiratory effort and cardiovascular
status. The
Trendelenburg position is avoided because it increases the work of
breathing.
patient The supine with the head elevated after regaining
is placed
consciousness.
A 75-year-old is to be discharged from the ambulatory surgical unit
followingThe
surgery. left patient
eye tells the nurse, I do not know if I can take care of
myselfover
patch withmy thiseye. The most appropriate nursing
action is to:
a. refer the patient for home health care
services.
b. discuss the specific concerns regarding
self-care.
c. give the patient written instructions
regarding
d. assess the care.patients support system for care at home. correct answers
Answer:the
discuss b. specific concerns regarding
self-care.
The nurses initial action should be to assess exactly the patients concerns
aboutReferral
care. self- to home health care and assessment of the patients support
system
be may
appropriate actions but will be based on further assessment of the
patientsinstructions
Written concerns. should be given to the patient, but these are unlikely to
address
patients thestated concern about self-
care.
After removal of the nasogastric (NG) tube on the second postoperative day,
theplaced
is patient on a clear liquid diet. Four hours later, the patient
complainsgas
cramping of sharp,
pains. Which action should the
nurse take?
a. Reinsert the NG
tube.
b. Give the PRN IV
opioid.
c. Assist the patient to
d. Place the patient on NPO status. correct answers Answer: c. Assist the
ambulate.
patient to
ambulat
e.
Ambulation encourages peristalsis and the passing of flatus, which will
relieve the
patients discomfort. If distention persists, the patient may need to be
placed on
status, butNPO 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 of the NG tube will not relieve the
reinsertion
pains.
Nursing~Chapter 20 (Postoperative
Care)
A 42-year-old patient is recovering from anesthesia in the
postanesthesia
(PACU). care unit
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,The
skin. drymost appropriate action by the nurse at this
time is to:
a. increase the rate of the IV fluid
replacement.
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. correct answers
Answer: b.
continue 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 ongoingHypotension with tachycardia and/or cool, clammy skin
monitoring.
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 postanesthesia care unit (PACU), a l
patients
signs arevita
blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%.
The
is patient
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.
c. Prepare to transfer the patient from the
PACU.
d. Increase the rate of the postoperative IV fluids. correct answers
Answer: b. the patient to take deep
Encourage
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
a patient
lateral in
position is needed when the patient first arrives in the
PACU and is The stable BP and pulse indicate that no changes in fluid
unconscious.
intake areThe patient is not fully awake and has a low SpO2, indicating
required.
that transfer
from the PACU is not
appropriate.
After a new nurse has been oriented to the postanesthesia care unit
(PACU),nurse
charge the 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)
b. drops.
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
thepositions
d. PACU. a newly admitted unconscious patient supine with the
head elevated.
correct answers 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 keepopen
airway the and avoid aspiration. The prone position is not usually used
and would
make it difficult to assess the patients respiratory effort and cardiovascular
status. The
Trendelenburg position is avoided because it increases the work of
breathing.
patient The supine with the head elevated after regaining
is placed
consciousness.
A 75-year-old is to be discharged from the ambulatory surgical unit
followingThe
surgery. left patient
eye tells the nurse, I do not know if I can take care of
myselfover
patch withmy thiseye. The most appropriate nursing
action is to:
a. refer the patient for home health care
services.
b. discuss the specific concerns regarding
self-care.
c. give the patient written instructions
regarding
d. assess the care.patients support system for care at home. correct answers
Answer:the
discuss b. specific concerns regarding
self-care.
The nurses initial action should be to assess exactly the patients concerns
aboutReferral
care. self- to home health care and assessment of the patients support
system
be may
appropriate actions but will be based on further assessment of the
patientsinstructions
Written concerns. should be given to the patient, but these are unlikely to
address
patients thestated concern about self-
care.
After removal of the nasogastric (NG) tube on the second postoperative day,
theplaced
is patient on a clear liquid diet. Four hours later, the patient
complainsgas
cramping of sharp,
pains. Which action should the
nurse take?
a. Reinsert the NG
tube.
b. Give the PRN IV
opioid.
c. Assist the patient to
d. Place the patient on NPO status. correct answers Answer: c. Assist the
ambulate.
patient to
ambulat
e.
Ambulation encourages peristalsis and the passing of flatus, which will
relieve the
patients discomfort. If distention persists, the patient may need to be
placed on
status, butNPO 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 of the NG tube will not relieve the
reinsertion
pains.
