Chapter 16: Care of Postoperative Patients Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9edition

MULTIPLE CHOICE 1. A client has arrived in the postoperative unit. What action by the circulating nurse takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report ANS: D Hand-offs are a critical time in client care, and poor communication during this time can lead to serious errors. The postoperative nurse and circulating nurse participate in hand-off report as the priority. Assessing fluid losses and dressings can be done together as part of the report. Ensuring the client is warm is a lower priority. DIF: Applying/Application REF: 271 KEY: Postoperative nursing| communication| hand-off communication| SBAR MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 2. The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96 F (35.6 C) ANS: C The respiratory rate is the most critical vital sign for any client who has undergone general anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too low and indicates respiratory depression. The nurse should assess this client first. A blood pressure of 100/50 mm Hg is slightly low and may be within that clients baseline. A pulse of 118 beats/min is slightly fast, which could be due to several causes, including pain and anxiety. A temperature of 96 F is slightly low and the client needs to be warmed. But none of these other vital signs take priority over the respiratory rate. DIF: Applying/Application REF: 272 KEY: Postoperative nursing| nursing assessment| sedation| respiratory system MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate? a. Assess other indicators of oxygenation. b. Call the Rapid Response Team. c. Notify the anesthesia provider. d. Prepare to intubate the client. ANS: A If a postoperative clients oxygen saturation (SaO2) drops below 95% (or the clients baseline), the nurse should notify the anesthesia provider. If the SaO2 drops by 10% or more, the nurse should call the Rapid Response Team. Since this is approximately a 3% drop, the nurse should further assess the client. Intubation (if the client is not intubated already) is not warranted. DIF: Applying/Application REF: 273 KEY: Postoperative nursing| nursing assessment| respiratory assessment| oxygen saturation MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential