Chapter 19: Postoperative Care Lewis:
Medical-Surgical Nursing, 10th Edition
A nurse assists a patient on the primary postoperative day to ambulate, cough, deep breathe,
and turn. Which action by way of the nurse is most beneficial?
A. Teach the patient to fully exhale into the incentive spirometer.
B. Administer ordered analgesic medications before those activities.
C. Ask the patient to nation two possible complications of immobility.
D. Encourage the affected person to kingdom the cause of splinting the incision. - ANS-ANS: B
An vital nursing action to inspire those postoperative activities is administration of ok analgesia
to allow the affected person to accomplish the activities with minimal ache. Even with motivation
provided with the aid of proper teaching, high-quality reinforcement, and challenge
approximately headaches, patients will have problem if there is a excellent deal of pain worried
with those sports. When the use of an incentive spirometer, the patient must gain knowledge of
to inhale deeply, as opposed to exhale into the spirometer to promote lung enlargement and
save you atelectasis
A affected person is transferred from the postanesthesia care unit (PACU) to the clinical unit.
Which motion by way of the nurse on the scientific unit should be done first?
A. Assess the affected person's pain.
B. Orient the patient to the unit.
C. Take the patient's crucial symptoms.
D. Read the postoperative orders. - ANS-ANS: C
Because the concern worries after surgery are airway, breathing, and movement, the crucial
signs are assessed first. The different movements need to take region after the vital signs and
symptoms are received and compared with the essential signs earlier than transfer
A affected person who had knee surgical operation obtained intramuscular ketorolac (Toradol)
30 minutes ago and keeps to complain of pain at a level of 7 (0 to ten scale). Which movement
is satisfactory for the nurse to take presently?
A. Administer the prescribed PRN IV morphine sulfate.
B. Notify the health care issuer about the continuing knee pain.
C. Reassure the patient that postoperative pain is predicted after knee surgical treatment.
D. Teach the affected person that the outcomes of ketorolac generally remaining about 6 to 8
hours. - ANS-ANS: A
The priority at the moment is ache comfort. Concomitant use of opioids and nonsteroidal
antiinflammatory tablets (NSAIDs) improves pain manipulate in postoperative sufferers. Patient
coaching and reassurance are appropriate, however ought to be accomplished after the affected
, person's ache is relieved. If the affected person continues to have ache after the morphine is
run, the fitness care company need to be notified
A affected person who has started to evoke after 30 minutes inside the postanesthesia care unit
(PACU) is stressed and shouting on the nurse. The patient's oxygen saturation is ninety six%,
and latest laboratory effects are all ordinary. Which action via the nurse is maximum
appropriate?
A. Increase the IV fluid fee.
B. Assess for bladder distention.
C. Notify the anesthesia care provider (ACP).
D. Demonstrate the usage of the nurse name bell button. - ANS-ANS: B
Because the patient's assessment shows physiologic balance, the most possibly purpose of the
patient's agitation is emergence delirium, as a way to resolve as the patient wakes up extra
completely. The nurse must search for a cause which includes bladder distention. Although
hypoxemia is the most commonplace cause, the affected person's oxygen saturation is ninety
six%. Emergence delirium is common in sufferers recovering from anesthesia, so there is no
want to inform the ACP. Orientation of the patient to bed controls is needed, but is not probable
to be powerful until the outcomes of anesthesia have resolved greater absolutely
A patient who is simply waking up after having hip alternative surgical operation is agitated and
stressed. Which motion should the nurse take first?
A. Administer the ordered opioid.
B. Check the oxygen (O2) saturation.
C. Take the blood pressure and pulse.
D. Apply wrist restraints to comfy IV traces. - ANS-ANS: B
Emergence delirium may be because of an expansion of factors. However, the nurse must first
investigate for hypoxemia. The other actions also may be appropriate, but are not the pleasant
initial motion
A patient's blood stress within the postanesthesia care unit (PACU) has dropped from an
admission blood stress of one hundred forty/86 to 102/60 with a pulse exchange of 70 to 96.
SpO2 is 92% on 3 L of oxygen. In which order have to the nurse take these moves? (Put a
comma and a area among each solution preference [A, B, C, D].)
a. Increase the IV infusion fee.
B. Assess the affected person's dressing.
C. Increase the oxygen drift fee.
D. Check the affected person's temperature - ANS-ANS:
A, C, B, D
The first nursing motion ought to be to increase the IV infusion rate. Because the maximum
commonplace purpose of hypotension is volume loss, the IV price should be increased. The
subsequent movement need to be to increase the oxygen glide charge to maximize oxygenation
of hypoperfused organs. Because hemorrhage is a not unusual purpose of postoperative
quantity loss, the nurse should test the dressing. Finally, the affected person's temperature need
to be assessed to decide the consequences of vasodilation due to rewarming.
Medical-Surgical Nursing, 10th Edition
A nurse assists a patient on the primary postoperative day to ambulate, cough, deep breathe,
and turn. Which action by way of the nurse is most beneficial?
A. Teach the patient to fully exhale into the incentive spirometer.
B. Administer ordered analgesic medications before those activities.
C. Ask the patient to nation two possible complications of immobility.
D. Encourage the affected person to kingdom the cause of splinting the incision. - ANS-ANS: B
An vital nursing action to inspire those postoperative activities is administration of ok analgesia
to allow the affected person to accomplish the activities with minimal ache. Even with motivation
provided with the aid of proper teaching, high-quality reinforcement, and challenge
approximately headaches, patients will have problem if there is a excellent deal of pain worried
with those sports. When the use of an incentive spirometer, the patient must gain knowledge of
to inhale deeply, as opposed to exhale into the spirometer to promote lung enlargement and
save you atelectasis
A affected person is transferred from the postanesthesia care unit (PACU) to the clinical unit.
Which motion by way of the nurse on the scientific unit should be done first?
A. Assess the affected person's pain.
B. Orient the patient to the unit.
C. Take the patient's crucial symptoms.
D. Read the postoperative orders. - ANS-ANS: C
Because the concern worries after surgery are airway, breathing, and movement, the crucial
signs are assessed first. The different movements need to take region after the vital signs and
symptoms are received and compared with the essential signs earlier than transfer
A affected person who had knee surgical operation obtained intramuscular ketorolac (Toradol)
30 minutes ago and keeps to complain of pain at a level of 7 (0 to ten scale). Which movement
is satisfactory for the nurse to take presently?
A. Administer the prescribed PRN IV morphine sulfate.
B. Notify the health care issuer about the continuing knee pain.
C. Reassure the patient that postoperative pain is predicted after knee surgical treatment.
D. Teach the affected person that the outcomes of ketorolac generally remaining about 6 to 8
hours. - ANS-ANS: A
The priority at the moment is ache comfort. Concomitant use of opioids and nonsteroidal
antiinflammatory tablets (NSAIDs) improves pain manipulate in postoperative sufferers. Patient
coaching and reassurance are appropriate, however ought to be accomplished after the affected
, person's ache is relieved. If the affected person continues to have ache after the morphine is
run, the fitness care company need to be notified
A affected person who has started to evoke after 30 minutes inside the postanesthesia care unit
(PACU) is stressed and shouting on the nurse. The patient's oxygen saturation is ninety six%,
and latest laboratory effects are all ordinary. Which action via the nurse is maximum
appropriate?
A. Increase the IV fluid fee.
B. Assess for bladder distention.
C. Notify the anesthesia care provider (ACP).
D. Demonstrate the usage of the nurse name bell button. - ANS-ANS: B
Because the patient's assessment shows physiologic balance, the most possibly purpose of the
patient's agitation is emergence delirium, as a way to resolve as the patient wakes up extra
completely. The nurse must search for a cause which includes bladder distention. Although
hypoxemia is the most commonplace cause, the affected person's oxygen saturation is ninety
six%. Emergence delirium is common in sufferers recovering from anesthesia, so there is no
want to inform the ACP. Orientation of the patient to bed controls is needed, but is not probable
to be powerful until the outcomes of anesthesia have resolved greater absolutely
A patient who is simply waking up after having hip alternative surgical operation is agitated and
stressed. Which motion should the nurse take first?
A. Administer the ordered opioid.
B. Check the oxygen (O2) saturation.
C. Take the blood pressure and pulse.
D. Apply wrist restraints to comfy IV traces. - ANS-ANS: B
Emergence delirium may be because of an expansion of factors. However, the nurse must first
investigate for hypoxemia. The other actions also may be appropriate, but are not the pleasant
initial motion
A patient's blood stress within the postanesthesia care unit (PACU) has dropped from an
admission blood stress of one hundred forty/86 to 102/60 with a pulse exchange of 70 to 96.
SpO2 is 92% on 3 L of oxygen. In which order have to the nurse take these moves? (Put a
comma and a area among each solution preference [A, B, C, D].)
a. Increase the IV infusion fee.
B. Assess the affected person's dressing.
C. Increase the oxygen drift fee.
D. Check the affected person's temperature - ANS-ANS:
A, C, B, D
The first nursing motion ought to be to increase the IV infusion rate. Because the maximum
commonplace purpose of hypotension is volume loss, the IV price should be increased. The
subsequent movement need to be to increase the oxygen glide charge to maximize oxygenation
of hypoperfused organs. Because hemorrhage is a not unusual purpose of postoperative
quantity loss, the nurse should test the dressing. Finally, the affected person's temperature need
to be assessed to decide the consequences of vasodilation due to rewarming.
