Health and Healing IV test 1 DURHAM college Questions
With Complete Solutions
The nurse is caring for a patient who is recovering from
anaesthesia in the postanaesthesia care unit (PACU). On
admission to the PACU, the blood pressure (BP) is 124/70.
Thirty minutes after admission, the blood pressure is 112/60,
with a pulse of 72 and warm, dry skin. Which of the following
actions is the most appropriate for the nurse to implement at this
time?
a. Increase the rate of the IV fluid replacement.
b. Continue to take vital signs every 15 minutes.
c. Administer oxygen therapy at 100% per mask.
d. Notify the anaesthesia care provider (ACP) immediately
b. Continue to take vital signs every 15 minutes.
The nurse is caring for a patient who is recovering from
anaesthesia in the postanaesthesia care unit (PACU), and the
vital signs are blood pressure 118/72, pulse 76, respirations 12,
and SpO2 91%. The patient is sleepy but awakens easily. Which
of the following actions 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.
b. Encourage the patient to take deep breaths.
,After a new nurse has been oriented to the postanaesthesia care
unit (PACU), the charge nurse will evaluate that the orientation
has been successful when the new nurse does which of the
following actions?
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.
c. Turns an unconscious patient to the side when the patient
arrives in the PACU.
The nurse is preparing an older-adult patient for discharge from
the ambulatory surgical unit following left eye surgery. The
patient tells the nurse, "I do not know if I can take care of myself
with this patch over my eye." Which of the following actions is
the most appropriate for the nurse to implement?
a. Refer the patient for home health care services.
b. Discuss the specific concerns regarding self-care.
c. Give the patient written instructions regarding care.
d. Assess the patient's support system for care at home.
b. Discuss the specific concerns regarding self-care.
After removal of the nasogastric (NG) tube on the second
postoperative day, the patient is placed on a clear liquid diet.
Four hours later, the patient complains of sharp, cramping gas
,pains. Which of the following actions should the nurse take?
a. Reinsert the NG tube.
b. Give the PRN IV opioid.
c. Assist the patient to ambulate.
d. Place the patient on NPO status.
c. Assist the patient to ambulate.
The nurse is caring for a patient following gallbladder surgery,
and the patient's T-tube is draining dark green fluid. Which of
the following actions should the nurse take?
a. Place the patient on bed rest.
b. Notify the patient's surgeon.
c. Document the colour and amount of drainage.
d. Irrigate the T-tube with sterile normal saline.
c. Document the colour and amount of drainage.
In intervening to promote ambulation, coughing, deep breathing,
and turning by a postoperative patient on the first postoperative
day, which of the following actions by the nurse is most helpful?
a. Discuss the complications of immobility and poor cough
effort.
b. Teach the patient the purpose of respiratory care and
ambulation.
c. Administer ordered analgesic medications before these
activities.
d. Give the patient positive reinforcement for accomplishing
these activities.
c. Administer ordered analgesic medications before these
activities.
, The nurse evaluates that the interventions for the nursing
diagnosis of ineffective airway clearance in a postoperative
patient have been successful when which of the following goals
has been met?
a. Patient drinks 2-3 L of fluid in 24 hours.
b. Patient uses the spirometer 10 times every hour.
c. Patient's breath sounds are clear to auscultation.
d. Patient's temperature is less than 38C (100.4F) orally.
c. Patient's breath sounds are clear to auscultation.
The nurse is caring for a patient who has begun to awaken after
30 minutes in the postanaesthesia care unit (PACU), who is
restless and shouting at the nurse. The patient's oxygen
saturation is 99%, and recent laboratory results are all normal.
Which of the following actions by the nurse is most appropriate?
a. Insert an oral or nasal airway.
b. Notify the anaesthesia care provider.
c. Orient the patient to time, place, and person.
d. Be sure that the patient's IV lines are secure.
d. Be sure that the patient's IV lines are secure.
The nurse is caring for an older adult in the postanaesthesia unit.
Which of the following agerelated considerations may impact
postoperative recovery?
a. Increased thoracic compliance
b. Decreased ability to cough
c. Increased lung tissue
d. Decreased compliance with deep breathing and coughing
b. Decreased ability to cough
With Complete Solutions
The nurse is caring for a patient who is recovering from
anaesthesia in the postanaesthesia care unit (PACU). On
admission to the PACU, the blood pressure (BP) is 124/70.
Thirty minutes after admission, the blood pressure is 112/60,
with a pulse of 72 and warm, dry skin. Which of the following
actions is the most appropriate for the nurse to implement at this
time?
a. Increase the rate of the IV fluid replacement.
b. Continue to take vital signs every 15 minutes.
c. Administer oxygen therapy at 100% per mask.
d. Notify the anaesthesia care provider (ACP) immediately
b. Continue to take vital signs every 15 minutes.
The nurse is caring for a patient who is recovering from
anaesthesia in the postanaesthesia care unit (PACU), and the
vital signs are blood pressure 118/72, pulse 76, respirations 12,
and SpO2 91%. The patient is sleepy but awakens easily. Which
of the following actions 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.
b. Encourage the patient to take deep breaths.
,After a new nurse has been oriented to the postanaesthesia care
unit (PACU), the charge nurse will evaluate that the orientation
has been successful when the new nurse does which of the
following actions?
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.
c. Turns an unconscious patient to the side when the patient
arrives in the PACU.
The nurse is preparing an older-adult patient for discharge from
the ambulatory surgical unit following left eye surgery. The
patient tells the nurse, "I do not know if I can take care of myself
with this patch over my eye." Which of the following actions is
the most appropriate for the nurse to implement?
a. Refer the patient for home health care services.
b. Discuss the specific concerns regarding self-care.
c. Give the patient written instructions regarding care.
d. Assess the patient's support system for care at home.
b. Discuss the specific concerns regarding self-care.
After removal of the nasogastric (NG) tube on the second
postoperative day, the patient is placed on a clear liquid diet.
Four hours later, the patient complains of sharp, cramping gas
,pains. Which of the following actions should the nurse take?
a. Reinsert the NG tube.
b. Give the PRN IV opioid.
c. Assist the patient to ambulate.
d. Place the patient on NPO status.
c. Assist the patient to ambulate.
The nurse is caring for a patient following gallbladder surgery,
and the patient's T-tube is draining dark green fluid. Which of
the following actions should the nurse take?
a. Place the patient on bed rest.
b. Notify the patient's surgeon.
c. Document the colour and amount of drainage.
d. Irrigate the T-tube with sterile normal saline.
c. Document the colour and amount of drainage.
In intervening to promote ambulation, coughing, deep breathing,
and turning by a postoperative patient on the first postoperative
day, which of the following actions by the nurse is most helpful?
a. Discuss the complications of immobility and poor cough
effort.
b. Teach the patient the purpose of respiratory care and
ambulation.
c. Administer ordered analgesic medications before these
activities.
d. Give the patient positive reinforcement for accomplishing
these activities.
c. Administer ordered analgesic medications before these
activities.
, The nurse evaluates that the interventions for the nursing
diagnosis of ineffective airway clearance in a postoperative
patient have been successful when which of the following goals
has been met?
a. Patient drinks 2-3 L of fluid in 24 hours.
b. Patient uses the spirometer 10 times every hour.
c. Patient's breath sounds are clear to auscultation.
d. Patient's temperature is less than 38C (100.4F) orally.
c. Patient's breath sounds are clear to auscultation.
The nurse is caring for a patient who has begun to awaken after
30 minutes in the postanaesthesia care unit (PACU), who is
restless and shouting at the nurse. The patient's oxygen
saturation is 99%, and recent laboratory results are all normal.
Which of the following actions by the nurse is most appropriate?
a. Insert an oral or nasal airway.
b. Notify the anaesthesia care provider.
c. Orient the patient to time, place, and person.
d. Be sure that the patient's IV lines are secure.
d. Be sure that the patient's IV lines are secure.
The nurse is caring for an older adult in the postanaesthesia unit.
Which of the following agerelated considerations may impact
postoperative recovery?
a. Increased thoracic compliance
b. Decreased ability to cough
c. Increased lung tissue
d. Decreased compliance with deep breathing and coughing
b. Decreased ability to cough
