1. The postanesthesia care unit (PACU) nurse transports the inpatient surgical
patient to the medical-surgical floor. Before leaving the floor, the medical-surgical
nurse obtains a complete set of vital signs. What is the rationale for this nursing
action?
a. This is done to complete the first ...
1 the postanesthesia care unit pacu nurse transports the inpatient surgical patient to the medical surgical floor before leaving the floor
the medical surgical nurse obtains a complete set of vit
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Voorbeeld van de inhoud
ATI PN LEADERSHIP
ATI PN MANAGEMENT
LEADERSHIP MANAGEMENT PROCTORED
PROCTORED EXAMEXAM
1. The postanesthesia care unit (PACU) nurse transports the inpatient surgical
patient to the medical-surgical floor. Before leaving the floor, the medical-surgical
nurse obtains a complete set of vital signs. What is the rationale for this nursing
action?
a. This is done to complete the first action in a head-to-toe assessment.
This is done to compare and monitor for vital sign variation during
b. transport.
This is done to ensure that the medical-surgical nurse checks on the
c. postoperative patient.
This is done to follow hospital policy and procedure for care of the
d. surgical patient.
ANS: B
Before the PACU nurse leaves the acute care area, the staff nurse assuming care for
the patient takes a complete set of vital signs to compare with PACU findings.
Minor vital sign variations normally occur after transporting the patient. The
PACU nurse reviews the patient’s information with the medical-surgical nurse,
including the surgical and PACU course, physician orders, and the patient’s
condition. While vital signs may or may not be the first action in a head-to-toe
assessment, this is not the rationale for this situation. While following policy or
ascertaining that the floor nurse checks on the patient are good reasons for safe
care, they are not the best rationale for obtaining vital signs.
2. The nurse is caring for a patient who will undergo a removal of a lung lobe.
Which level of care will the patient require immediately post procedure?
a. Acute care—medical-surgical unit
b. Acute care—intensive care unit
c. Ambulatory surgery
d. Ambulatory surgery—extended stay
325
,ANS: B
325
, A&E I Comprehensive Testbank
Patients undergoing extensive surgery and requiring anesthesia of long
duration recover slowly. If a patient is undergoing major surgery such as a
procedure on the lung, a stay in the hospital and specifically in the intensive
care unit is required to monitor for potential risks to well-being. This patient
would require more care than can be provided on a medical-surgical unit. It is
not appropriate for this type of patient to go home after the procedure or to
stay in an extended stay area of an ambulatory surgery area because of the
complexity and associated risks.
3. The nurse is caring for a group of patients. Which patient will the nurse see
first?
a. A patient who had cataract surgery is coughing.
A patient who had vascular repair of the right leg is not doing right leg
b. exercises.
A patient after knee surgery is wearing intermittent pneumatic
c. compression devices and receiving heparin.
A patient after surgery has vital signs taken every 15 minutes twice,
d. every 30 minutes twice, hourly for 2 hours then every 4 hours.
ANS: A
For patients who have had eye, intracranial, or spinal surgery, coughing may
be contraindicated because of the potential increase in intraocular or
intracranial pressure. The nurse will need to see this patient first to control the
cough and intraocular pressure. All the rest are normal postoperative patients.
Leg exercise should not be performed on the operative leg with vascular
surgery. A patient after knee surgery should receive heparin and be wearing
intermittent pneumatic compression devices; while the nurse will check on the
patient, it does not have to be first. Monitoring vital signs after surgery is
required and this is the standard schedule.
4. The nurse demonstrates postoperative exercises for a patient. In which
order will the nurse instruct the patient to perform the exercises?
1. Turning
2. Breathing
3. Coughing
4. Leg exercises
3
a. 4, 1, 2, 3
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