NUR 313 Exam 2 Practice Questions With Complete
Solutions
A patient's blood pressure (BP) increases from 110/76 mg Hg to
160/90 mm Hg 2 hours after a surgical procedure. Which action
would the nurse take first?
Assess pain level.
Decrease the IV fluid rate.
Reassess the BP in 15 minutes.
Restart the patient's antihypertensive medication. Correct
Answers Assess pain level.
A postoperative patient has absence of breath sounds on the left
lung and an oxygen saturation of 86%. Which intervention
would the nurse take to maintain adequate oxygen saturation?
Select all that apply.
Administer diuretics.
Allow delayed ambulation.
Instruct shallow breathing.
Encourage incentive spirometry.
Provide humidified oxygen therapy. Correct Answers
Encourage incentive spirometry.
Provide humidified oxygen therapy.
in which position would the nurse place a patient who is still
drowsy from anesthesia and has been vomiting? Correct
Answers lateral recovery position
In which position would the nurse place a postoperative,
conscious patient in order to prevent respiratory problems?
Correct Answers supine position with head elevated
,The nurse is developing a care plan for the postoperative patient
in order to prevent complications and promote ambulation,
coughing, deep breathing, and turning. Which action is the most
important for the nurse to provide to achieve these desired
outcomes?
Explain easily the rationale for these activities.
Have family in the room for support and encouragement.
Warn about pneumonia and clotting if the actions are not
completed.
Administer enough analgesics to promote relative freedom from
pain. Correct Answers Administer enough analgesics to
promote relative freedom from pain
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 Correct Answers
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. Correct Answers Assist
in emptying the patient's bladder.
Which action would the nurse take first for a surgical patient
postoperative day 1 who is reporting severe pain?
Administer morphine.
Reposition to side lying.
Offer a backrub.
Apply an icepack. Correct Answers Administer morphine.
Which action would the nurse take for a patient who has not
voided 8 hours after having surgery?
Encourage oral (PO) fluid intake.
Use a straight catheter to assess for retention.
Palpate the suprapubic area for bladder distention.
Check the medical record to determine the type of anesthetic
given. Correct Answers Palpate the suprapubic area for bladder
distention.
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. Correct Answers
Obtain the patient's vital signs.
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 Correct Answers Respiratory rate of
8
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." Correct Answers
"It is the best way to prevent complications."
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 Correct Answers Atelectasis
Which criterion must a patient meet in order to be discharged
from the PACU phase 1 to the clinical unit? Select all that apply.
No nausea or vomiting
No respiratory depression
Oxygen saturation above 90%
Written discharge instruction understood
Patient reports pain level of 4 on a 1-10 scale Correct Answers
No respiratory depression
Oxygen saturation above 90%
Solutions
A patient's blood pressure (BP) increases from 110/76 mg Hg to
160/90 mm Hg 2 hours after a surgical procedure. Which action
would the nurse take first?
Assess pain level.
Decrease the IV fluid rate.
Reassess the BP in 15 minutes.
Restart the patient's antihypertensive medication. Correct
Answers Assess pain level.
A postoperative patient has absence of breath sounds on the left
lung and an oxygen saturation of 86%. Which intervention
would the nurse take to maintain adequate oxygen saturation?
Select all that apply.
Administer diuretics.
Allow delayed ambulation.
Instruct shallow breathing.
Encourage incentive spirometry.
Provide humidified oxygen therapy. Correct Answers
Encourage incentive spirometry.
Provide humidified oxygen therapy.
in which position would the nurse place a patient who is still
drowsy from anesthesia and has been vomiting? Correct
Answers lateral recovery position
In which position would the nurse place a postoperative,
conscious patient in order to prevent respiratory problems?
Correct Answers supine position with head elevated
,The nurse is developing a care plan for the postoperative patient
in order to prevent complications and promote ambulation,
coughing, deep breathing, and turning. Which action is the most
important for the nurse to provide to achieve these desired
outcomes?
Explain easily the rationale for these activities.
Have family in the room for support and encouragement.
Warn about pneumonia and clotting if the actions are not
completed.
Administer enough analgesics to promote relative freedom from
pain. Correct Answers Administer enough analgesics to
promote relative freedom from pain
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 Correct Answers
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. Correct Answers Assist
in emptying the patient's bladder.
Which action would the nurse take first for a surgical patient
postoperative day 1 who is reporting severe pain?
Administer morphine.
Reposition to side lying.
Offer a backrub.
Apply an icepack. Correct Answers Administer morphine.
Which action would the nurse take for a patient who has not
voided 8 hours after having surgery?
Encourage oral (PO) fluid intake.
Use a straight catheter to assess for retention.
Palpate the suprapubic area for bladder distention.
Check the medical record to determine the type of anesthetic
given. Correct Answers Palpate the suprapubic area for bladder
distention.
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. Correct Answers
Obtain the patient's vital signs.
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 Correct Answers Respiratory rate of
8
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." Correct Answers
"It is the best way to prevent complications."
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 Correct Answers Atelectasis
Which criterion must a patient meet in order to be discharged
from the PACU phase 1 to the clinical unit? Select all that apply.
No nausea or vomiting
No respiratory depression
Oxygen saturation above 90%
Written discharge instruction understood
Patient reports pain level of 4 on a 1-10 scale Correct Answers
No respiratory depression
Oxygen saturation above 90%
