NUR 313 EXAM 2 PRACTICE QUESTIONS
Which condition would the nurse be concerned about for a postoperative patient who
has bronchial obstruction from retained secretions and an oxygen saturation of 87%?
Pulmonary embolism
Bronchospasm
Hypoventilation
Atelectasis - Answer -Atelectasis
Which assessment finding indicates that the postoperative patient is experiencing
hypoventilation?
Rales in bilateral lower lung fields
Blood pressure reading of 96/58
Respiratory rate of 8
Capillary refill is 3 seconds - Answer -Respiratory rate of 8
Which instruction would the nurse provide to help prevent atelectasis in a patient
recovering from abdominal surgery?
"Support the incision with a folded blanket and try to cough up some mucus."
"Take rapid, shallow breaths every hour to prevent pain."
"Lay flat to prevent coughing as it can cause the sutures to rupture."
"Avoid liquids as it will cause you to need to use the bathroom frequently." - Answer -
"Support the incision with a folded blanket and try to cough up some mucus."
Which factor would the nurse include when assessing pain in the postoperative patient?
Select all that apply. One, some, or all responses may be correct.
Location
Intensity
Room temperature
Quality
Changes in vital signs - Answer -Location
Intensity
Quality
Changes in vital signs
Which priority action would the nurse take after noting new, bright red drainage about 5
cm in diameter on a patient's surgical dressing on the first postoperative day?
Recheck in 1 hour for increased drainage.
Assess the patient's blood pressure and heart rate.
Remove the dressing and assess the surgical incision.
Notify the surgeon of a potential hemorrhage. - Answer -Assess the patient's blood
pressure and heart rate.
, Which priority treatment would the nurse anticipate for a patient who had abdominal
surgery with an estimated blood loss of 400 mL, received 300 mL of 0.9% normal
saline, and has a blood pressure of 70/48?
IV fluid administration
Blood administration
An ECG to check circulatory status
Return to surgery to check for internal bleeding - Answer -IV fluid administration
Which benefit would the nurse describe to a postoperative patient as the most important
reason for early ambulation in the postoperative period?
"It will help you be ready to go home."
"It keeps your legs limber and strong."
"It will help you be free from your pain."
"It is the best way to prevent complications." - Answer -"It is the best way to prevent
complications."
What information would the PACU nurse expect to receive during the handoff report in
Phase I? Select all that apply. One, some, or all responses may be correct.
Patient's allergies
Anesthetic agents
Last dose of opioid administration
Result of laboratory tests
Number of staff in the operating room - Answer -Patient's allergies
Anesthetic agents
Last dose of opioid administration
Result of laboratory tests
Which action would the nurse perform when caring for a postoperative patient who is
hypertensive?
Administer an antipyretic.
Apply a continuous cardiac monitor.
Hold analgesics medications.
Assist in emptying the patient's bladder. - Answer -Assist in emptying the patient's
bladder.
Which action would the nurse take initially upon the patient's arrival to the surgical floor
from the postanesthesia care unit?
Obtain the patient's vital signs.
Assess the patient's pain.
Check the rate of the IV infusion.
Review the surgeon's postoperative orders. - Answer -Obtain the patient's vital signs.
Which action would the nurse take first for a surgical patient postoperative day 1 who is
reporting severe pain?
Administer morphine.
Which condition would the nurse be concerned about for a postoperative patient who
has bronchial obstruction from retained secretions and an oxygen saturation of 87%?
Pulmonary embolism
Bronchospasm
Hypoventilation
Atelectasis - Answer -Atelectasis
Which assessment finding indicates that the postoperative patient is experiencing
hypoventilation?
Rales in bilateral lower lung fields
Blood pressure reading of 96/58
Respiratory rate of 8
Capillary refill is 3 seconds - Answer -Respiratory rate of 8
Which instruction would the nurse provide to help prevent atelectasis in a patient
recovering from abdominal surgery?
"Support the incision with a folded blanket and try to cough up some mucus."
"Take rapid, shallow breaths every hour to prevent pain."
"Lay flat to prevent coughing as it can cause the sutures to rupture."
"Avoid liquids as it will cause you to need to use the bathroom frequently." - Answer -
"Support the incision with a folded blanket and try to cough up some mucus."
Which factor would the nurse include when assessing pain in the postoperative patient?
Select all that apply. One, some, or all responses may be correct.
Location
Intensity
Room temperature
Quality
Changes in vital signs - Answer -Location
Intensity
Quality
Changes in vital signs
Which priority action would the nurse take after noting new, bright red drainage about 5
cm in diameter on a patient's surgical dressing on the first postoperative day?
Recheck in 1 hour for increased drainage.
Assess the patient's blood pressure and heart rate.
Remove the dressing and assess the surgical incision.
Notify the surgeon of a potential hemorrhage. - Answer -Assess the patient's blood
pressure and heart rate.
, Which priority treatment would the nurse anticipate for a patient who had abdominal
surgery with an estimated blood loss of 400 mL, received 300 mL of 0.9% normal
saline, and has a blood pressure of 70/48?
IV fluid administration
Blood administration
An ECG to check circulatory status
Return to surgery to check for internal bleeding - Answer -IV fluid administration
Which benefit would the nurse describe to a postoperative patient as the most important
reason for early ambulation in the postoperative period?
"It will help you be ready to go home."
"It keeps your legs limber and strong."
"It will help you be free from your pain."
"It is the best way to prevent complications." - Answer -"It is the best way to prevent
complications."
What information would the PACU nurse expect to receive during the handoff report in
Phase I? Select all that apply. One, some, or all responses may be correct.
Patient's allergies
Anesthetic agents
Last dose of opioid administration
Result of laboratory tests
Number of staff in the operating room - Answer -Patient's allergies
Anesthetic agents
Last dose of opioid administration
Result of laboratory tests
Which action would the nurse perform when caring for a postoperative patient who is
hypertensive?
Administer an antipyretic.
Apply a continuous cardiac monitor.
Hold analgesics medications.
Assist in emptying the patient's bladder. - Answer -Assist in emptying the patient's
bladder.
Which action would the nurse take initially upon the patient's arrival to the surgical floor
from the postanesthesia care unit?
Obtain the patient's vital signs.
Assess the patient's pain.
Check the rate of the IV infusion.
Review the surgeon's postoperative orders. - Answer -Obtain the patient's vital signs.
Which action would the nurse take first for a surgical patient postoperative day 1 who is
reporting severe pain?
Administer morphine.
