1. Thegpostanesthesiagcaregunitg(PACU)gnursegtransportsgtheginpatientgsurgicalgpatientgtogthegmedical-surgicalfloor.gBeforegleavinggthegfloor,gthegmedical-
surgicalgnursegobtainsgagcompletegsetgofgvitalgsigns. gWhatgisgthegrationalegforgthisgnursingg action?
a. Thisgisgdonegtogcompletegthegfirstgactiongingaghead-to-toeg assessment.
Thisgisgdonegtogcomparegandgmonitorgforgvitalgsigngvariationgduring
b. transport.
Thisgisgdonegtogensuregthatgthegmedical-surgicalgnursegchecksgongthe
c. postoperativegpatient.
Thisgisgdonegtogfollow ghospitalgpolicygandgproceduregforgcaregofgthe
d. surgicalgpatient.
ANS:gB
BeforegthegPACUgnursegleavesgthegacutegcaregarea,gthegstaffgnursegassuminggcaregforgthegpatientgtakesgag completegsetgofgvitalgsignsgtogcomparegwithgPACUgfindings. gMinorgvitalgsigngvariationsgnormallygoccurgafter
transportinggthegpatient.gThegPACUgnursegreviewsgthegpatient’sginformationgwithgthegmedical-
surgicalgnurse,gincludinggthegsurgicalgandgPACUgcourse,gphysiciangorders,gandgthegpatient’sgcondition. gWhilegvitalgsignsgmaygorgmaygnotgbegthegfirstgactiongingaghead-to-
toegassessment,gthisgisgnotgthegrationalegforgthisgsituation.gWhilegfollowinggpolicygorgascertaininggthatgthegfloorgnursegchecksgongthegpatientgareggoodgreasonsgforgsafegcare,gtheygaregnotgthegbestgrationalegforgobtaininggvitalgsig
ns.
2. Thegnursegisgcaringgforgagpatientgwhogwillgundergogagremovalgofgaglungglobe.gWhichglevelgofgcaregwillgthepatientgrequiregimmediatelygpostgprocedure?
a. Acutegcare—medical-surgicalgunit
b. Acutegcare—intensivegcaregunit
c. Ambulatorygsurgery
d. Ambulatorygsurgery—extendedgstay
ANS:gB
Patientsgundergoinggextensivegsurgerygandgrequiringganesthesiagofglonggdurationgrecovergslowly.gIfgagpatientgisgundergoinggmajorgsurgerygsuchgasgagproceduregongtheglung,gagstaygingtheghospitalgandgspecificallygingthegintensiv
egcaregunitgisgrequiredgtogmonitorgforgpotentialgrisksgtogwell-being.gThisgpatientgwouldgrequiregmoregcaregthangcangbegprovidedgongagmedical-
surgicalgunit.gItgisgnotgappropriategforgthisgtypegofgpatientgtoggoghomegaftergthegproceduregorgtogstaygingangextendedgstaygareagofgangambulatorygsurgerygareagbecausegofgthegcomplexitygandg associatedgrisks.
,3. Thegnursegisgcaringgforgaggroupgofgpatients.gWhichgpatientgwillgthegnursegseegfirst?
a. Agpatientgwhoghadgcataractgsurgerygisg coughing.
Agpatientgwhoghadgvasculargrepairgofgthegrightgleggisgnotgdoinggrightgleg
b. exercises.
Agpatientgaftergkneegsurgerygisgwearinggintermittentgpneumatic
c. compressiongdevicesgandgreceivinggheparin.
326
, A gpatientgaftergsurgeryghasgvitalgsignsgtakengeveryg15gminutesgtwice,
d. everyg30gminutesgtwice,ghourlygforg2ghoursgthengeveryg4g hours.
ANS:gA
Forgpatientsgwhoghaveghadgeye,gintracranial,gorgspinalgsurgery,gcoughinggmaygbegcontraindicatedgbecausegofgthegpotentialgincreasegingintraoculargorgintracranialgpressure. gThegnursegwillgneedgtogseegthisgpatientgfirstgtogcontrolgthegc
oughgandgintraoculargpressure.gAllgthegrestgaregnormalgpostoperativeg patients.gLeggexercisegshouldgnotgbeg performedgongthegoperativegleggwithgvasculargsurgery.gAgpatientgaftergkneegsurgerygshouldgreceiveg heparingandg begwearinggi
ntermittentgpneumaticgcompressiongdevices;gwhilegthegnursegwillg checkgongthegpatient,gitgdoesgnotghavegtogbegfirst.gMonitoringgvitalgsignsgaftergsurgerygisgrequiredgandgthisgisgthegstandardgschedule.
4. Thegnursegdemonstratesgpostoperativegexercisesgforgagpatient.gIngwhichgordergwillgthegnurseginstructgthepatientgtogperformgthegexercises?
1. Turning
2. Breathing
3. Coughing
4. Leggexercises
a. 4,g1,g2,g3
b. 1,g2,g3,g4
c. 2,g3,g4,g1
d. 3,g1,g4,g2
ANS:gA
Thegsequencegofgexercisesgisgleggexercises,gturning,gbreathing,gandgcoughing. gMULTIPL
EgRESPONSE
1. Theg nurseg isg participatingg ing ag “time-out.”gIngwhichg activitiesgwillg theg nurseg beg involved?g (Selectgallthatg apply.)
a. Verifygthegcorrectgsite.
b. Verifygthegcorrectgpatient.
c. Verifygthegcorrectg procedure.
d. Performg“time-out”g afterg surgery.
e. Performgthegactualgmarkinggofgthegoperativegsite.
ANS:gA,g B,g C
surgicalgnursegobtainsgagcompletegsetgofgvitalgsigns. gWhatgisgthegrationalegforgthisgnursingg action?
a. Thisgisgdonegtogcompletegthegfirstgactiongingaghead-to-toeg assessment.
Thisgisgdonegtogcomparegandgmonitorgforgvitalgsigngvariationgduring
b. transport.
Thisgisgdonegtogensuregthatgthegmedical-surgicalgnursegchecksgongthe
c. postoperativegpatient.
Thisgisgdonegtogfollow ghospitalgpolicygandgproceduregforgcaregofgthe
d. surgicalgpatient.
ANS:gB
BeforegthegPACUgnursegleavesgthegacutegcaregarea,gthegstaffgnursegassuminggcaregforgthegpatientgtakesgag completegsetgofgvitalgsignsgtogcomparegwithgPACUgfindings. gMinorgvitalgsigngvariationsgnormallygoccurgafter
transportinggthegpatient.gThegPACUgnursegreviewsgthegpatient’sginformationgwithgthegmedical-
surgicalgnurse,gincludinggthegsurgicalgandgPACUgcourse,gphysiciangorders,gandgthegpatient’sgcondition. gWhilegvitalgsignsgmaygorgmaygnotgbegthegfirstgactiongingaghead-to-
toegassessment,gthisgisgnotgthegrationalegforgthisgsituation.gWhilegfollowinggpolicygorgascertaininggthatgthegfloorgnursegchecksgongthegpatientgareggoodgreasonsgforgsafegcare,gtheygaregnotgthegbestgrationalegforgobtaininggvitalgsig
ns.
2. Thegnursegisgcaringgforgagpatientgwhogwillgundergogagremovalgofgaglungglobe.gWhichglevelgofgcaregwillgthepatientgrequiregimmediatelygpostgprocedure?
a. Acutegcare—medical-surgicalgunit
b. Acutegcare—intensivegcaregunit
c. Ambulatorygsurgery
d. Ambulatorygsurgery—extendedgstay
ANS:gB
Patientsgundergoinggextensivegsurgerygandgrequiringganesthesiagofglonggdurationgrecovergslowly.gIfgagpatientgisgundergoinggmajorgsurgerygsuchgasgagproceduregongtheglung,gagstaygingtheghospitalgandgspecificallygingthegintensiv
egcaregunitgisgrequiredgtogmonitorgforgpotentialgrisksgtogwell-being.gThisgpatientgwouldgrequiregmoregcaregthangcangbegprovidedgongagmedical-
surgicalgunit.gItgisgnotgappropriategforgthisgtypegofgpatientgtoggoghomegaftergthegproceduregorgtogstaygingangextendedgstaygareagofgangambulatorygsurgerygareagbecausegofgthegcomplexitygandg associatedgrisks.
,3. Thegnursegisgcaringgforgaggroupgofgpatients.gWhichgpatientgwillgthegnursegseegfirst?
a. Agpatientgwhoghadgcataractgsurgerygisg coughing.
Agpatientgwhoghadgvasculargrepairgofgthegrightgleggisgnotgdoinggrightgleg
b. exercises.
Agpatientgaftergkneegsurgerygisgwearinggintermittentgpneumatic
c. compressiongdevicesgandgreceivinggheparin.
326
, A gpatientgaftergsurgeryghasgvitalgsignsgtakengeveryg15gminutesgtwice,
d. everyg30gminutesgtwice,ghourlygforg2ghoursgthengeveryg4g hours.
ANS:gA
Forgpatientsgwhoghaveghadgeye,gintracranial,gorgspinalgsurgery,gcoughinggmaygbegcontraindicatedgbecausegofgthegpotentialgincreasegingintraoculargorgintracranialgpressure. gThegnursegwillgneedgtogseegthisgpatientgfirstgtogcontrolgthegc
oughgandgintraoculargpressure.gAllgthegrestgaregnormalgpostoperativeg patients.gLeggexercisegshouldgnotgbeg performedgongthegoperativegleggwithgvasculargsurgery.gAgpatientgaftergkneegsurgerygshouldgreceiveg heparingandg begwearinggi
ntermittentgpneumaticgcompressiongdevices;gwhilegthegnursegwillg checkgongthegpatient,gitgdoesgnotghavegtogbegfirst.gMonitoringgvitalgsignsgaftergsurgerygisgrequiredgandgthisgisgthegstandardgschedule.
4. Thegnursegdemonstratesgpostoperativegexercisesgforgagpatient.gIngwhichgordergwillgthegnurseginstructgthepatientgtogperformgthegexercises?
1. Turning
2. Breathing
3. Coughing
4. Leggexercises
a. 4,g1,g2,g3
b. 1,g2,g3,g4
c. 2,g3,g4,g1
d. 3,g1,g4,g2
ANS:gA
Thegsequencegofgexercisesgisgleggexercises,gturning,gbreathing,gandgcoughing. gMULTIPL
EgRESPONSE
1. Theg nurseg isg participatingg ing ag “time-out.”gIngwhichg activitiesgwillg theg nurseg beg involved?g (Selectgallthatg apply.)
a. Verifygthegcorrectgsite.
b. Verifygthegcorrectgpatient.
c. Verifygthegcorrectg procedure.
d. Performg“time-out”g afterg surgery.
e. Performgthegactualgmarkinggofgthegoperativegsite.
ANS:gA,g B,g C
