Chapter 05: Care of Postoperative Patients deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

MULTIPLE CHOICE 1. The post-anesthesia care unit (PACU) nurse determines that the patient’s Aldrete score is 9. Which statement correctly describes the meaning of this score? a. The patient is at an increased risk for postoperative respiratory complications. b. The patient’s condition warrants close monitoring. c. The patient is experiencing severe pain. d. The patient will soon be transferred to the postoperative unit. ANS: D The Aldrete scoring system is a method of determining readiness for a surgery patient to be transferred from PACU to the postoperative unit. Scores are given for activity, respiration, circulation, consciousness, skin color, and oxygen saturation. A score of 9 or 10 indicatesreadiness for transfer. PTS: 1 DIF: Cognitive Level: Application REF: 81 OBJ: 5 (clinical) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 2. The nurse is caring for a patient recovering in the PACU. The patient awakens confused and disoriented. What actionshould the nurse take first? a. Take the patient’s vital signs. b. Encourage the patient to return to sleep. c. Reorient and reassure the patient. d. Document that the patient is awake and disoriented. ANS: C The patient should be reoriented and assured when awaking from anesthesia. PTS:1 DIF: Cognitive Level: Comprehension REF: 81 OBJ:1(theory) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. The PACU nurse is caring for a semiconscious patient immediately following abdominal surgery. The nurse correctly places the patient in which position? a. Supine b. Semi-Fowler c. Lateral d. Trendelenburg ANS: C Aspiration is a high-risk complication during this phase of recovery and can best be prevented by placing the unconscious orsemiconscious patient on the side with head turned to the side. PTS: 1 DIF: Cognitive Level: Application REF: 83 OBJ: 6 (clinical) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 4. The PACU nurse is caring for an unconscious patient. Assessment reveals diminished breath sounds bilaterally. Which action should the nurse take? a. Hyperventilate the patient with an Ambu bag. b. Increase bi-nasal oxygen to 3 L/min. c. Elevate the head of bed 45 degrees. d. Document “diminished breath sounds in both lower lobes.”