Fundamentals Proctored Exam
There are discharge criteria for clients in the postanesthesia care unit (PACU) regardless of the
type of anesthesia used and additional criteria for specific types of anesthesia. Which is the
criterion specific for the client who has received spinal anesthesia? - ANS Motor and sensory
function returns
A client is admitted to the postanesthesia care unit. Which nursing action is most important
during the client's stay in this unit? - ANS Suctioning mucus from respiratory passages
A postoperative client is transferred back to the surgical unit with an abdominal dressing and a
Penrose drain. Which is the most important nursing action associated with caring for a client
with a Penrose drain? - ANS Changing the soiled dressing carefully
A client has abdominal surgery. Which should the nurse do to best assess for a sign of
postoperative ileus in this client after surgery? - ANS Identify the time of the first bowel
movement
Four days after abdominal surgery, while being transferred from a bed to a chair, a client says to
a nurse, "My incision feels funny all of a sudden." Which should the nurse do first? - ANS Place
the client in the low-Fowler position
Which factor places a client at the highest risk for postoperative nausea and vomiting after
receiving general anesthesia? - ANS Obesity
On the second postoperative day after an above-the-knee amputation, the client's elastic
dressing accidentally comes off. Which should the nurse do first? - ANS Wrap the residual limb
with an elastic compression bandage
A nurse is caring for a postoperative client. Which action is effective in preventing postoperative
urinary tract infections? - ANS Drinking an adequate amount of fluid d4. increasing the intake of
citrus fruit juices
A client received conscious sedation during a colonoscopy. Which should the nurse expect
regarding the client's experience with this procedure? - ANS Client will be sleepy but able to
follow verbal commands
Which client having emergency surgery should the nurse anticipate to be at the highest risk for
postoperative mortality? - ANS Individual who has alcoholism
A nurse is caring for a client who had an abdominal hysterectomy. Which intervention best
prevents postoperative thrombophlebitis? - ANS Leg exercises 10 times per hour when awake
An obese client has abdominal surgery for removal of the gallbladder. Which should the nurse
be most concerned about if exhibited by the client? - ANS Shallow breathing
A client arrives in the postanesthesia care unit. Which is the most important information that the
nurse needs to know? - ANS Type and extent of the surgery
Which client responses best support the decision to discharge the client from the
postanesthesia care unit? - ANS Sao, of 95%, vita signs stable for 30 minutes, active gag reflex
How many days after surgery should the nurse anticipate that a postoperative client will begin to
exhibit signs and symptoms of a wound infection if it should occur? - ANS Third day
A nurse is assessing a client who had spinal anesthesia. For which common response should
the nurse assess the client? - ANS Headache
A hospitalized client who has been receiving medications via a variety of routes for several days
is scheduled for surgery at 10 a.m. Which should the nurse plan to do on the day of surgery? -
ANS Obtain directions from the primary health care provider regarding the medications
There are discharge criteria for clients in the postanesthesia care unit (PACU) regardless of the
type of anesthesia used and additional criteria for specific types of anesthesia. Which is the
criterion specific for the client who has received spinal anesthesia? - ANS Motor and sensory
function returns
A client is admitted to the postanesthesia care unit. Which nursing action is most important
during the client's stay in this unit? - ANS Suctioning mucus from respiratory passages
A postoperative client is transferred back to the surgical unit with an abdominal dressing and a
Penrose drain. Which is the most important nursing action associated with caring for a client
with a Penrose drain? - ANS Changing the soiled dressing carefully
A client has abdominal surgery. Which should the nurse do to best assess for a sign of
postoperative ileus in this client after surgery? - ANS Identify the time of the first bowel
movement
Four days after abdominal surgery, while being transferred from a bed to a chair, a client says to
a nurse, "My incision feels funny all of a sudden." Which should the nurse do first? - ANS Place
the client in the low-Fowler position
Which factor places a client at the highest risk for postoperative nausea and vomiting after
receiving general anesthesia? - ANS Obesity
On the second postoperative day after an above-the-knee amputation, the client's elastic
dressing accidentally comes off. Which should the nurse do first? - ANS Wrap the residual limb
with an elastic compression bandage
A nurse is caring for a postoperative client. Which action is effective in preventing postoperative
urinary tract infections? - ANS Drinking an adequate amount of fluid d4. increasing the intake of
citrus fruit juices
A client received conscious sedation during a colonoscopy. Which should the nurse expect
regarding the client's experience with this procedure? - ANS Client will be sleepy but able to
follow verbal commands
Which client having emergency surgery should the nurse anticipate to be at the highest risk for
postoperative mortality? - ANS Individual who has alcoholism
A nurse is caring for a client who had an abdominal hysterectomy. Which intervention best
prevents postoperative thrombophlebitis? - ANS Leg exercises 10 times per hour when awake
An obese client has abdominal surgery for removal of the gallbladder. Which should the nurse
be most concerned about if exhibited by the client? - ANS Shallow breathing
A client arrives in the postanesthesia care unit. Which is the most important information that the
nurse needs to know? - ANS Type and extent of the surgery
Which client responses best support the decision to discharge the client from the
postanesthesia care unit? - ANS Sao, of 95%, vita signs stable for 30 minutes, active gag reflex
How many days after surgery should the nurse anticipate that a postoperative client will begin to
exhibit signs and symptoms of a wound infection if it should occur? - ANS Third day
A nurse is assessing a client who had spinal anesthesia. For which common response should
the nurse assess the client? - ANS Headache
A hospitalized client who has been receiving medications via a variety of routes for several days
is scheduled for surgery at 10 a.m. Which should the nurse plan to do on the day of surgery? -
ANS Obtain directions from the primary health care provider regarding the medications
