LEWIS MEDICAL SURGICAL NURSING 2026
CLINICAL CARE PRACTICE SET ANSWERS
FULL SOLUTION
◉ During recovery from anesthesia in the postanesthesia care unit
(PACU), a patients vital signs are blood pressure 118/72, pulse 76,
respirations 12, and SpO2 91%. The patient is sleepy but awakens
easily. Which action should the nurse take at this time?
a. Place the patient in a side-lying position.
b. Encourage the patient to take deep breaths.
c. Prepare to transfer the patient from the PACU.
d. Increase the rate of the postoperative IV fluids.
Answer: Answer: b. Encourage the patient to take deep breaths.
The patients borderline SpO2 and sleepiness indicate
hypoventilation. The nurse should 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 the PACU and is
unconscious. The stable BP 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 the PACU is not appropriate.
, ◉ After a new nurse has been oriented to the postanesthesia care
unit (PACU), the charge nurse will evaluate that the orientation has
been successful when the new nurse:
a. places a patient in the Trendelenburg position when the blood
pressure (BP) drops.
b. assists a patient to the prone position when the patient is
nauseated.
c. turns an unconscious patient to the side when the patient arrives
in the PACU.
d. positions a newly admitted unconscious patient supine with the
head elevated.
Answer: Answer: c. turns an unconscious patient to the side when
the patient arrives in the PACU.
The patient should initially be positioned in the lateral recovery
position to keep the airway open and avoid aspiration. The prone
position is not usually used and would make it difficult to assess the
patients respiratory effort and cardiovascular status. The
Trendelenburg position is avoided because it increases the work of
breathing. The patient is placed supine with the head elevated after
regaining consciousness.
◉ A 75-year-old is to be discharged from the ambulatory surgical
unit following left eye surgery. The patient tells the nurse, I do not
CLINICAL CARE PRACTICE SET ANSWERS
FULL SOLUTION
◉ During recovery from anesthesia in the postanesthesia care unit
(PACU), a patients vital signs are blood pressure 118/72, pulse 76,
respirations 12, and SpO2 91%. The patient is sleepy but awakens
easily. Which action should the nurse take at this time?
a. Place the patient in a side-lying position.
b. Encourage the patient to take deep breaths.
c. Prepare to transfer the patient from the PACU.
d. Increase the rate of the postoperative IV fluids.
Answer: Answer: b. Encourage the patient to take deep breaths.
The patients borderline SpO2 and sleepiness indicate
hypoventilation. The nurse should 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 the PACU and is
unconscious. The stable BP 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 the PACU is not appropriate.
, ◉ After a new nurse has been oriented to the postanesthesia care
unit (PACU), the charge nurse will evaluate that the orientation has
been successful when the new nurse:
a. places a patient in the Trendelenburg position when the blood
pressure (BP) drops.
b. assists a patient to the prone position when the patient is
nauseated.
c. turns an unconscious patient to the side when the patient arrives
in the PACU.
d. positions a newly admitted unconscious patient supine with the
head elevated.
Answer: Answer: c. turns an unconscious patient to the side when
the patient arrives in the PACU.
The patient should initially be positioned in the lateral recovery
position to keep the airway open and avoid aspiration. The prone
position is not usually used and would make it difficult to assess the
patients respiratory effort and cardiovascular status. The
Trendelenburg position is avoided because it increases the work of
breathing. The patient is placed supine with the head elevated after
regaining consciousness.
◉ A 75-year-old is to be discharged from the ambulatory surgical
unit following left eye surgery. The patient tells the nurse, I do not
