Chapter 20: Postoperative Care Harding: Lewis’s Medical-Surgical Nursing, 12th Edition

MULTIPLE CHOICE 1. A patient is admitted to the post-anesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. 30 minutes after admission, the BP is 114/62, with a pulse of 74 and warm, dry skin. Which action would the nurse take? a. Increase the postoperative IV fluid rate. b. Notify the anesthesia care provider (ACP). c. Continue to take vital signs every 15 minutes. d. Administer oxygen therapy at 100% per mask. ANS: C 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 or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration. DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 2. In the post anesthesia care unit (PACU), a patient‘s vital signs are blood pressure 116/72 mm Hg, pulse 74 beats/min, respirations 12 breaths/min, and SpO2 91%. The patient is sleepy but awakens easily. Which action would the nurse take? 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 would 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 thePACU 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 thePACU to a clinical unit is not appropriate. DIF:CognitiveLevel: Apply (Application) TOP: Nursing Process: Implementation MSC:NCLEX: Physiological Integrity 3. An experienced nurse orients a new nurse to the post anesthesia care unit (PACU). Which action by the new nurse would indicate that the orientation was successful? a. The new nurse assists a nauseated patient to a supine position. b. The new nurse places a sleeping patient supine with the head elevated. c. The new nurse positions an unconscious patient on the side upon arrival from surgery. d. The new nurse places a patient in the Trendelenburg position for a low blood pressure. ANS: C The patient would initially be placed in the lateral “recovery” position to keep the airway open and avoid aspiration. Avoid the Trendelenburg position because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness. DIF: Cognitive Level: Apply (Application) TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 4. An older adult patient is being discharged from the ambulatory surgical unit after left eye surgery. The patient tells the nurse, “I don‘t know if I can take care of myself once I‘m home.” Which action would the nurse implement first? a. Assess the patient’s home support system. b. Discuss patient concerns regarding self-care. c. Refer the patient for home health care services. d. Provide written instructions for the patient’s care.