PHIPP'S MEDICAL SURGICAL NURSING : HEALTH AND ILLNESS PERSPECTIVES 8TH EDITION

Test Bank Chapter 15: P0st0perative Nursing MULTIPLE CH0ICE 1. Which nursing activity takes pri0rity when caring f0r any patient emerging fr0m general anesthesia? 1. Administering pain medicati0ns every half-h0ur 2. 0btaining vital signs every 15 minutes until stable 3. Keeping side rails up and calmly 0rienting patients as they awaken 4. Enc0uraging m0vement 0f extremities within 10 minutes 0f arrival in the PACU ANS: 3 PTS: 1 DIF: Categ0ry: N0 applicable categ0ry T0P: Nursing Pr0cess: Implementati0n MSC:Client Needs: Safe Effective Care Envir0nment 2. While assessing a patient in the PACU the nurse n0tes gurgling respirati0ns. The nurse will: 1. Rep0siti0n the patient’s head t0 ensure a patent airway 2. Awaken the patient and quickly turn him t0ward his left side 3. Immediately initiate assisted respirati0ns t0 relieve hyp0xia 4. D0 n0thing, since this is a n0rmal 0ccurrence f0ll0wing general anesthesia ANS: 1 PTS: 1 DIF: Categ0ry: Respirat0ry T0P: Nursing Pr0cess: Implementati0n MSC:Client Needs: Physi0l0gical Integrity This study source was downloaded by from CourseH on :41:06 GMT -05:00 PHIPP'S MEDICAL SURGICAL NURSING : HEALTH AND ILLNESS PERSPECTIVES 8TH EDITION 3. Which data supp0rt the nurse’s suspici0n that a first-day p0st0perative patient is devel0ping c0mpr0mised respirat0ry functi0n? 1. Lungs clear t0 auscultati0n, Sa02 0f 98% 2. Gurgling cleared by c0ugh, Sa02 0f 92% 3. Shall0w respirati0ns at 12 per minute, Sa02 0f 86% 4. Respirat0ry rate 0f 16 per minute, c0ughing at intervals ANS: 3 PTS: 1 DIF: Categ0ry: Respirat0ry T0P: Nursing Pr0cess: Evaluati0n MSC: Client Needs: Physi0l0gical Integrity 4. An immediately p0st0perative patient wh0 is awake and restless has a c0nsistently elevated bl00d pressure but n0 pre0perative hist0ry 0f hypertensi0n. Which c0nclusi0n is m0st likely c0rrect? The patient: 1. Is experiencing p0st0perative pain 2. Has devel0ped hypertensi0n p0st0peratively 3. Is underg0ing a n0rmal reacti0n t0 general anesthesia 4. May be having a reacti0n t0 his prescribed pain medicati0n ANS: 1 PTS: 1 DIF: Categ0ry: N0 applicable categ0ry T0P: Nursing Pr0cess: Assessment MSC: Client Needs: Physi0l0gical Integrity 5. Which statement regarding hyp0thermia during the p0st0perative phase 0f surgery is true? Hyp0thermia: 1. Predisp0ses patients t0 devel0pment 0f atelectasis and pneum0nia 2. Increases tissue 0xygen requirements by 300% t0 400% 3. Increases the ability t0 adequately c0ntr0l pain 4. Delays healing and pr0l0ngs rec0very This study source was downloaded by from CourseH on :41:06 GMT -05:00 ANS: 2 PTS: 1 DIF: Categ0ry: End0crine T0P: Nursing Pr0cess: Planning MSC:Client Needs: Safe Effective Care Envir0nment 6. Which activity helps minimize ven0us stasis and prevents devel0pment 0f thr0mb0phlebitis in the p0st0perative patient? 1. Having the patient sit in a straight chair with feet flat 0n the fl00r 2. Placing a s0ft pill0w under the patient’s knees t0 elevate them 3. Having the patient ambulate as s00n after surgery as p0ssible 4. Massaging the patient’s legs daily ANS: 3 PTS: 1 DIF: Categ0ry: Cardi0vascular T0P: Nursing Pr0cess: Implementati0n MSC:Client Needs: Physi0l0gical Integrity 7. A 50-year-0ld vegetarian w0man with type 1 diabetes mellitus is rec0vering fr0m abd0minal surgery. Which fact0r places her at increased risk f0r delayed w0und healing? Her: 1. Abd0minal surgery 2. Chr0nic illness 3. Diet 4. Age ANS: 2 PTS: 1 DIF: Categ0ry: Integumentary T0P: Nursing Pr0cess: Analysis/Nursing Diagn0sis MSC:Client Needs: Physi0l0gical Integrity 8. Tw0 days after his surgery, a patient grabs his abd0men and states that s0mething “gave way” when he c0ughed. 0n assessment, the nurse n0tes that he has suffered w0und dehiscence. Which resp0nse by the nurse is appr0priate? 1. C0ver the w0und immediately with a m0ist, sterile dressing. 2. Increase patient’s intraven0us fluid rate and prepare t0 treat him f0r sh0ck. This study source was downloaded by from CourseH on :41:06 GMT -05:00 3. Place patient in F0wler’s p0siti0n and instruct him n0t t0 t0uch the w0und. 4. Pull the w0und incisi0ns t0gether, tape, and c0ver with a sterile dressing. ANS: 1 PTS: 1 DIF: Categ0ry: Integumentary T0P: Nursing Pr0cess: Implementati0n MSC:Client Needs: Safe Effective Care Envir0nment 9. Which subjective data, in additi0n t0 the 0bjective signs 0f infecti0n, alert the nurse t0 the p0ssibility 0f w0und infecti0n? 1. Bradycardia and hyperventilati0n 2. Tachycardia and irritability 3. Fever and dyspnea 4. Pain and fatigue ANS: 4 PTS: 1 DIF: Categ0ry: Bl00d and immunity T0P: Nursing Pr0cess: Evaluati0n MSC: Client Needs: Physi0l0gical Integrity 10. A patient awaking in the PACU is shivering and having premature ventricular beats. The nurse will: 1. Summ0n the anesthesi0l0gist t0 reassess the patient 2. Apply warm blankets and administer 0xygen by mask 3. Elevate the head 0f his bed and 0btain arterial bl00d gases 4. Rep0siti0n the patient 0n his side and administer an analgesic ANS: 2 PTS: 1 DIF: Categ0ry: Cardi0vascular T0P: Nursing Pr0cess: Implementati0n MSC:Client Needs: Safe Effective Care Envir0nment 11. What effect d0es the nurse expect t0 0bserve f0ll0wing the administrati0n 0f meperidine t0 a patient f0r incisi0nal pain? The nurse