SPC Level 2 Exam 1- Postoperative Care Adaptive Quiz
Questions With Complete Solutions
A nurse is caring for a patient who had a bowel resection 10
hours before. The patient weighs 200 pounds (91 kg) and has a
urine output of 240 cc for the past eight hours. Which action
would the nurse take?
-Encourage oral (PO) fluids.
-Continue to monitor the urine output.
-Notify the health care provider.
-Administer a 500 cc normal saline IV bolus. Correct Answers
-Notify the health care provider.
The formula for determining adequate urine output is 0.5
mL/kg/hr. This patient, weighing 91 kg, needs to have 45 cc per
hour or about 365 cc of urine in eight hours. It often takes three
to five days for the bowel to begin working post-abdominal
surgery; therefore it would be inappropriate at this time to
encourage PO fluids. Continuing to monitor the urine output,
instead of calling the health care provider, would delay
identifying and treating the cause for the low urine output. The
nurse must obtain a prescription for the normal saline bolus
before administration.
A nurse is caring for an older adult patient who had a knee
replacement the previous day and denies any pain. Which
response by the nurse would be most appropriate?
-"Excellent. You must be able to handle a lot of pain."
,-"Great. It is wise to only take the pain medication if you need
it."
-"It is important that you take pain medication. It will help you
recover more quickly."
-"Almost everyone has pain after this surgery. Are you certain
that you are not experiencing pain?" Correct Answers -"Almost
everyone has pain after this surgery. Are you certain that you are
not experiencing pain?"
Thoroughly assessing the presence of pain is imperative,
especially for those who deny any pain after surgery, especially
the elderly. Gerontology patients may hesitate about reporting
pain because of the belief that pain should be tolerated and is
inevitable postsurgery. It is not appropriate to compliment the
patient on being able to handle pain. The patient will not
develop an addiction to pain medication, so it is not appropriate
to tell the patient he or she should only take it when necessary.
The nurse should not tell the patient that pain medication will
help him or her recover quicker, because that could give the
patient false reassurance.
A patient had an estimated blood loss of 400 mL during
abdominal surgery. The patient received 300 mL of 0.9% saline
during surgery. The patient is alert but is now experiencing
hypotension postoperatively. Which intervention would the
nurse take for this patient?
-Restore circulating volume with administration of IV fluids.
-Monitor pulse and BP.
-Get an electrocardiogram (ECG) to check circulatory status.
,-Return to surgery to check for internal bleeding. Correct
Answers -Restore circulating volume with administration of IV
fluids.
The nurse would anticipate restoring circulating volume with IV
infusion. Although blood could be used to restore circulating
volume, there are no manifestations in this patient indicating a
need for blood administration. The nurse will need to do more
than monitor pulse and BP. An ECG may be done if there is no
response to the fluid administration or if there is a past history of
cardiac disease or cardiac problems were noted during surgery.
Returning to surgery to check for internal bleeding would only
be done if the patient's level of consciousness changes or the
abdomen becomes firm and distended.
A patient in the postanesthesia care unit (PACU) becomes
delirious and restless and shouts at the nurse about pain. Which
factor would the nurse consider may be a cause of this behavior?
-A new diagnosis of psychosis
-Decreased ability to tolerate pain
-Anesthetic agents used in surgery
-Overdose of analgesics Correct Answers -Anesthetic agents
used in surgery
Anesthetic agents used in surgery can cause short-term
psychotic-type behaviors that are relieved after the anesthetic
drugs have cleared the body. A new diagnosis of psychosis is
not warranted in the acute phase following surgery. The patient
may not be tolerating the pain, but the delirium, yelling, and
restlessness denote short-term psychotic-like behavior caused by
, the anesthetic agents and postoperative pain. An overdose of
pain medications would present as increased sedation and
decreased respiratory rate.
A patient is admitted to the postanesthesia care unit (PACU)
after bowel surgery and tells the nurse that he or she is going to
"throw up." Which statement by the nurse reflects a priority
nursing intervention?
-"I need to check your vital signs."
-"Let me help you turn to your side."
-"Here is a sip of ginger ale for you."
-"I can give you some anti-nausea medicine." Correct Answers
-"Let me help you turn to your side."
If the patient is nauseated and may vomit, place the patient in a
lateral recovery position to keep the airway open and reduce the
risk of aspiration if vomiting occurs. Checking vital signs does
not address the nausea. It may not be appropriate to give the
patient oral fluids immediately following bowel surgery.
Administering an antiemetic may be appropriate after turning
the patient to the side.
A patient is having elective cosmetic surgery performed on the
face. Which action is the nurse's postoperative priority for this
patient?
-Manage patient pain.
-Control the bleeding.
-Maintain fluid balance.
Questions With Complete Solutions
A nurse is caring for a patient who had a bowel resection 10
hours before. The patient weighs 200 pounds (91 kg) and has a
urine output of 240 cc for the past eight hours. Which action
would the nurse take?
-Encourage oral (PO) fluids.
-Continue to monitor the urine output.
-Notify the health care provider.
-Administer a 500 cc normal saline IV bolus. Correct Answers
-Notify the health care provider.
The formula for determining adequate urine output is 0.5
mL/kg/hr. This patient, weighing 91 kg, needs to have 45 cc per
hour or about 365 cc of urine in eight hours. It often takes three
to five days for the bowel to begin working post-abdominal
surgery; therefore it would be inappropriate at this time to
encourage PO fluids. Continuing to monitor the urine output,
instead of calling the health care provider, would delay
identifying and treating the cause for the low urine output. The
nurse must obtain a prescription for the normal saline bolus
before administration.
A nurse is caring for an older adult patient who had a knee
replacement the previous day and denies any pain. Which
response by the nurse would be most appropriate?
-"Excellent. You must be able to handle a lot of pain."
,-"Great. It is wise to only take the pain medication if you need
it."
-"It is important that you take pain medication. It will help you
recover more quickly."
-"Almost everyone has pain after this surgery. Are you certain
that you are not experiencing pain?" Correct Answers -"Almost
everyone has pain after this surgery. Are you certain that you are
not experiencing pain?"
Thoroughly assessing the presence of pain is imperative,
especially for those who deny any pain after surgery, especially
the elderly. Gerontology patients may hesitate about reporting
pain because of the belief that pain should be tolerated and is
inevitable postsurgery. It is not appropriate to compliment the
patient on being able to handle pain. The patient will not
develop an addiction to pain medication, so it is not appropriate
to tell the patient he or she should only take it when necessary.
The nurse should not tell the patient that pain medication will
help him or her recover quicker, because that could give the
patient false reassurance.
A patient had an estimated blood loss of 400 mL during
abdominal surgery. The patient received 300 mL of 0.9% saline
during surgery. The patient is alert but is now experiencing
hypotension postoperatively. Which intervention would the
nurse take for this patient?
-Restore circulating volume with administration of IV fluids.
-Monitor pulse and BP.
-Get an electrocardiogram (ECG) to check circulatory status.
,-Return to surgery to check for internal bleeding. Correct
Answers -Restore circulating volume with administration of IV
fluids.
The nurse would anticipate restoring circulating volume with IV
infusion. Although blood could be used to restore circulating
volume, there are no manifestations in this patient indicating a
need for blood administration. The nurse will need to do more
than monitor pulse and BP. An ECG may be done if there is no
response to the fluid administration or if there is a past history of
cardiac disease or cardiac problems were noted during surgery.
Returning to surgery to check for internal bleeding would only
be done if the patient's level of consciousness changes or the
abdomen becomes firm and distended.
A patient in the postanesthesia care unit (PACU) becomes
delirious and restless and shouts at the nurse about pain. Which
factor would the nurse consider may be a cause of this behavior?
-A new diagnosis of psychosis
-Decreased ability to tolerate pain
-Anesthetic agents used in surgery
-Overdose of analgesics Correct Answers -Anesthetic agents
used in surgery
Anesthetic agents used in surgery can cause short-term
psychotic-type behaviors that are relieved after the anesthetic
drugs have cleared the body. A new diagnosis of psychosis is
not warranted in the acute phase following surgery. The patient
may not be tolerating the pain, but the delirium, yelling, and
restlessness denote short-term psychotic-like behavior caused by
, the anesthetic agents and postoperative pain. An overdose of
pain medications would present as increased sedation and
decreased respiratory rate.
A patient is admitted to the postanesthesia care unit (PACU)
after bowel surgery and tells the nurse that he or she is going to
"throw up." Which statement by the nurse reflects a priority
nursing intervention?
-"I need to check your vital signs."
-"Let me help you turn to your side."
-"Here is a sip of ginger ale for you."
-"I can give you some anti-nausea medicine." Correct Answers
-"Let me help you turn to your side."
If the patient is nauseated and may vomit, place the patient in a
lateral recovery position to keep the airway open and reduce the
risk of aspiration if vomiting occurs. Checking vital signs does
not address the nausea. It may not be appropriate to give the
patient oral fluids immediately following bowel surgery.
Administering an antiemetic may be appropriate after turning
the patient to the side.
A patient is having elective cosmetic surgery performed on the
face. Which action is the nurse's postoperative priority for this
patient?
-Manage patient pain.
-Control the bleeding.
-Maintain fluid balance.
