Ignatavicius Chapter 16: Care of Postoperative Patients questions with correct answers

1. The nurse is caring for a client who had surgery 24 hours ago. He is alert and oriented when awakened and reports pain, but goes back to sleep when not being stimulated. He is on patient-controlled analgesia (PCA). What is the nurse's next action? a. Push the PCA control for the client. b. Discontinue the PCA immediately. c. Assess the client's respiratory status. d. Keep the client awake as much as possible. Answer ANS: C The client should be assessed further before action is taken. If the client cannot stay awake 24 hours after surgery, there may be other problems. The nurse should assess respiratory rate and depth and lung sounds, as well as oxygen status. The nurse should never push the PCA for the client, and pain should be assessed before decisions are made and interventions taken. 2. Postoperatively, a client has a heart rate of 120 beats/min, with dysrhythmias noted on the ECG monitor and a respiratory rate of 34 breaths/min, and is very difficult to arouse. Which action by the nurse is most appropriate? a. Accompany the client to the postanesthesia care unit (PACU). b. Keep the client in the surgical suite. c. Call a code or the Rapid Response Team. d. Transfer the client to the intensive care unit (ICU). Answer ANS: D Clients in critical condition are transferred from the operating room directly to the ICU. This client is not stable with elevated heart and respiratory rates, dysrhythmias, and difficulty in arousal.