Test bank for lewis medical surgical nursing 12th edition

Test Bank For Lewis's Medical-Surgical Nursing, 12th Edition by Mariann M. Harding, Jeffrey Kwong, Debra Hagler Chapter 20: Postoperative Care Harding: Lewis’s Medical-Surgical Nursing, 12th Edition MULTIPLE CHOICE 1. A patient is admitted to the postanesthesia care unit (PACU) with a blood pressure (BP) 122/72 mm Hg. Thirty minutes after admission, theBP is 114/62, with a pulse of 74 and warm, dry skin. Which action would thenurse take? A. Increase thepostoperative IV fluid rate. B. Notify theanesthesia care provider (ACP). C. Continue to take vital signs every 15 minutes. D. Administer oxygen therapy at 100% per mask. ANS: C A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to theresidual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and theneed for notification of theACP, increased fluids, and high-concentration oxygen administration. 2. In thepostanesthesia care unit (PACU), a patient‘s vital signs are blood pressure 116/72 mm Hg, pulse 74 beats/min, respirations 12 breaths/min, and SpO2 91%. thepatient is sleepy but awakens easily. Which action would thenurse take? A. Place thepatient in a side-lying position. B. Encourage thepatient to take deep breaths. C. Prepare to transfer thepatient to a clinical unit. D. Increase therate of thepostoperative IV fluids. ANS: B The patient‘s borderline SpO2 and sleepiness indicate hypoventilation. thenurse would stimulate thepatient and remind thepatient to take deep breaths. Placing thepatient in a lateral position is needed when thepatient first arrives in thePACU and is unconscious. thestable blood pressure and pulse indicate that no changes in fluid intake are required. thepatient is not fully awake and has a low SpO2, indicating that transfer from thePACU to a clinical unit is not appropriate. 3. An experienced nurse orients a new nurse to thepostanesthesia care unit (PACU). Which action by thenew nurse would indicate that theorientation was successful? A. The new nurse assists a nauseated patient to a supine position. B. The new nurse places a sleeping patient supine with thehead elevated. C. The new nurse positions an unconscious patient on theside upon arrival from surgery. D. The new nurse places a patient in theTrendelenburg position for a low blood pressure. ANS: C The patient would initially be placed in thelateral “recovery” position to keep theairway open and avoid aspiration. Avoid theTrendelenburg position because it increases thework of breathing. thepatient is placed supine with thehead elevated after regaining consciousness. 4. An older adult patient is being discharged from theambulatory surgical unit after left eye surgery. thepatient tells thenurse, “I don‘t know if I can take care of myself once I‘m home.” Which action would thenurse implement first? A. Assessthepatient‘s home support system. B. Discuss patient concerns regarding self-care. C. Refer thepatient for home health care services. D. Provide written instructionsfor thepatient‘s care. ANS: B The nurse‘s initial action would be to assess exactly thepatient‘s concerns about self-care. Referral to home health care and assessment of thepatient‘s support system may be appropriate actions but will be based on further assessment of thepatient‘s concerns. Written instructions for care would be given to thepatient, but these may not address thepatient‘s stated concern about self-care. 5. On thesecond postoperative day, thepatient‘s nasogastric (NG) tube is removed and thepatient begins drinking clear liquids. Four hours later, thepatient reports frequent, cramping gas pains. Which action would thenurse take? A. Reinsert theNG tube. B. Assist thepatient to ambulate. C. Place thepatient on NPO status. D. Give theprescribed PRN IV opioid. ANS: B Ambulation encourages peristalsis and thepassing of flatus, which will relieve thepatient‘s discomfort. If distention persists, thepatient may need to be placed on NPO status, but usually this is not necessary. Opioid administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in thecolon, and reinsertion of theNG tube will not relieve thepains. 6. A patient‘s T-tube is draining dark green fluid after gallbladder surgery. Which action would thenurse take? A. Notify thepatient‘s surgeon. B. Place thepatient on bed rest. C. Irrigate theT-tube with sterile saline. D. Document thedrainage characteristics. ANS: D A T-tube normally drains dark green to bright yellow drainage so no action other than to document theamount and color of thedrainage is needed. theother actions are not necessary. 7. Which action by thenurse will be most helpful to a patient who is expected to ambulate, deep breathe, and cough on thefirst postoperative day? A. Schedule theactivity to begin after thepatient has taken a nap. B. Administer prescribed analgesic medications before theactivities. C. Ask thepatient to state two possible complications of immobility. D. Encourage thepatient to repeat back thepurpose of splinting theincision. ANS: B An important nursing action to encourage these postoperative activities is administration of adequate analgesia to allow thepatient to accomplish theactivities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, concern about complications, and with rest and sleep, patients will have difficulty if there is a great deal of pain involved with these activities. 8. Which data on thepatient‘s second postoperative day would indicate that interventions to remove secretions from thepatient‘s airway have been successful? A. Patient drinks 2 to 3 L of fluid in 24 hours. B. Patient uses thespirometer 10 times every hour. C. Patient‘s breath sounds are clear to auscultation. D. Patient‘s temperature is less than 100.2F orally. ANS: C One characteristic of airway secretions is thepresence of adventitious breath sounds such as crackles, so clear breath sounds are an indication of resolution of theproblem. Spirometer use and increased fluid intake are interventions to improve airway clearance but they are not evidence of improvement. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems. 9. A patient who has begun to awaken after 30 minutes in thepostanesthesia care unit (PACU) is restless and shouting at thenurse. thepatient‘s oxygen saturation is 96%, and recent laboratory results are normal. Which action would thenurse take? A. Increase theIV fluid rate. B. Assess for bladder distention. C. Notify theanesthesia care provider (ACP). D. Demonstrate how to use thecall bell button. ANS: B Because thepatient‘s assessment indicates physiologic stability, themost likely cause of thepatient‘s agitation is emergence delirium, which will resolve as thepatient wakes up more fully. thenurse would look for a cause such as bladder distention. Although hypoxemia is themost common cause, thepatient‘s oxygen saturation is 96%. Emergence delirium is common in patients recovering from anesthesia, so there is no need to notify theACP. Orientation of thepatient to bed controls is needed but is not likely to be effective until theeffects of anesthesia have resolved more completely. 10. Which action could thepostanesthesia care unit (PACU) nurse delegate to assistive personnel (AP) during transfer of a patient to theclinical unit? A. Help to slide thepatient onto a stretcher. B. Clarify postoperative orders with thesurgeon. C. Document theappearance of thepatient‘s incision. D. Provide hand-off communication to thesurgical unit nurse. ANS: A The scope of practice of AP includes repositioning and moving patients under thesupervision of a nurse. Providing report to another nurse, assessing and documenting thewound appearance, and clarifying physician orders with another nurse require registered nurse (RN) level education and scope of practice. 11. A patient is transferred from thepostanesthesia care unit (PACU) to theclinical unit. Which action would thenurse on theclinical unit perform first? A. Ask thepatient about pain. B. Orient thepatient to theunit. C. Assessthepatient‘s vital signs. D. Read thepostoperative orders. ANS: C Because thepriority concerns after surgery are airway, breathing, and circulation, thevital signs are assessed first. theother actions would take place after thevital signs are obtained and compared with thevital signs before transfer. 12. An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which potential complication would thenurse identify as a priority for this patient? A. Hypovolemic shock B. Venous thromboembolism C. Fluid and electrolyte imbalance D. Impaired surgical wound healing ANS: B The patient is older and relatively immobile, which are two risk factors for development of deep vein thrombosis. theother potential complications are possible postoperative problems, but they are not at a high risk based on thedata about this patient. 13. A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action would thenurse take first? A. Administer theprescribed opioid. B. Check theoxygen (O2)saturation. C. Take theblood pressure and pulse. D. Applywrist restraints to secure IV lines. ANS: B Emergence delirium may be caused by a variety of factors. thenurse would first assess for hypoxemia. theother actions also may be appropriate, but are not thebest initial action. 14. A postoperative patient has not voided for 8 hours after return to theclinical unit. Which action would thenurse take first? A. Perform a bladder scan. B. Insert a straight catheter. C. Encourage increased oral fluid intake. D. Assist thepatient to ambulate to thebathroom. ANS: A The initial action should be to assess thebladder for distention. If thebladder is distended, providing thepatient with privacy (by walking with thepatient to thebathroom) will be helpful. Because of therisk for urinary tract infection, catheterization should only be done after other measures have been tried without success. There is no indication of a fluid volume deficit. 15. The nurse is caring for a patient thefirst postoperative day following a laparotomy for a small bowel obstruction. thenurse notices new bright-red drainage about 5 cm in diameter on thedressing. Which action would thenurse take first? A. Reinforce thedressing. B. Apply an abdominal binder. C. Take thepatient‘s vital signs. D. Plan to recheck thedressing in 1 hour. ANS: C New bright-red drainage may indicate hemorrhage, and thenurse should initially assess thepatient‘s vital signs for tachycardia and hypotension. thesurgeon should then be notified of thedrainage and thevital signs. thedressing may be changed or reinforced, based on thesurgeon‘s instructions or agency policy. thenurse should not wait an hour to recheck thedressing. 16. On thesecond postoperative day after abdominal surgery for removal of a large pancreatic cyst, a patient has an oral temperature of 100.8F (38.2C). Which action would thenurse take? A. Place ice packs in thepatient‘s axillae. B. Have thepatient use theincentive spirometer. C. Request a prescription for acetaminophen suppositories. D. Ask thehealth care provider to change theantibiotic prescription. ANS: B A temperature of 100.8F (38.2C) in thefirst 48 hours is usually caused by atelectasis, and thenurse should have thepatient deep breathe, cough, and use theincentive spirometer. Nursing intervention may resolve this problem, and therefore notifying thehealth care provider is not necessary. Acetaminophen or ice packs will reduce thetemperature, but it will not resolve theunderlying respiratory congestion. 17. An unconscious patient who was transferred from surgery to thepostanesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action would thenurse take first? A. Suction thepatient‘s mouth. B. Increase theoxygen flowrate. C. Perform thejaw-thrust maneuver. D. Elevate thepatient‘s head on two pillows. ANS: C In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by thetongue, and thefirst action is to clear theairway by maneuvers such as thejaw thrust or chin lift. Increasing theoxygen flowrate and suctioning are not helpful when theairway is obstructed by thetongue. Elevating thepatient‘s head will not be effective in correcting an obstruction but may help with oxygenation after thepatient is awake. 18. The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which information about thepatient is most important to communicate to thehealth care provider? A. The patient‘s temperature is 100.3F (37.9C). B. The patient‘s calf is swollen and warm to touch. C. The patient reports abdominal pain when ambulating. D. The patient has fluid intake 600 mL greater than theoutput. ANS: B The calf pain, swelling, and warmth suggest that thepatient has a venous thromboembolism (VTE). This will require thehealth care provider to prescribe diagnostic tests, anticoagulants, or both and is most critical because a VTE could result in a pulmonary embolism. Because thestress response causes fluid retention for thefirst 2 to 5 days postoperatively, thedifference between intake and output is expected. A temperature elevation to 100.3F on thesecond postoperative day is suggestive of atelectasis, and thenurse should have thepatient deep breathe and cough. Pain with ambulation is normal, and thenurse should administer theprescribed analgesic before patient activities. 19. A patient who had knee surgery received IV ketorolac 30 minutes ago and continues to report pain at a level of 7 (0 to 10 scale). Which action would thenurse take? A. Administer theprescribed PRN IV morphine sulfate. B. Notify thehealth care provider about theongoing pain. C. Teach thepatient that effects of ketorolac last 6 to 8 hours. D. Reassure thepatient that pain is expected after knee surgery. ANS: A The priority at this time is pain relief. Concomitant use of opioids and nonsteroidal antiinflammatory drugs improves pain control in postoperative patients. Patient teaching and reassurance are appropriate but should be done after thepatient‘s pain is relieved. If thepatient continues to have pain after themorphine is administered, notify thehealth care provider. 20. A patient who has just been transported from theoperating room to thepostanesthesia care unit (PACU) is shivering and has a temperature of 96.8F (36C). Which action would thenurse take? A. Notify theanesthesia care provider. B. Cover thepatient with warm blankets. C. Hold opioid analgesics until thepatient is warmer. D. Give acetaminophen 650 mg suppository rectally. ANS: B The patient assessment indicates theneed for rewarming. There is no indication of a need for acetaminophen. Opioid analgesics may help reduce shivering. Because hypothermia is common and expected in theimmediate postoperative period, there is no need to notify theanesthesia care provider unless thepatient continues to be hypothermic after rewarming measures. 21. Which finding would indicate to thenurse that a postoperative patient is at increased risk for poor wound healing? A. Potassium 3.5 mEq/L B. Albumin level 2.2 g/dL C. Hemoglobin 10.2 g/dL D. White blood cells 11,900/L ANS: B Because adequate nutrition including proteins are needed for an appropriate inflammatory response and wound healing, thelow serum albumin level (normal level, 3.5 to 5.0 g/dL) indicates a risk for poor wound healing. thepotassium level is normal. Because a small amount of blood loss is expected with surgery, thehemoglobin level is not indicative of an increased risk for wound healing. WBC count is expected to increase after surgery as a part of thenormal inflammatory response. 22. The nurse assesses a patient on thesecond postoperative day after abdominal surgery to repair a perforated duodenal ulcer. Which finding is most important for thenurse to report to thesurgeon? A. Tympanic temperature 99.2F (37.3C) B. Fine crackles audible at both lung bases C. Redness and swelling along thesuture line D. 200 mLsanguineous fluid in thewound drain ANS: D Wound drainage should decrease and change in color from sanguineous to serosanguineous by thesecond postoperative day. thecolor and amount of drainage for this patient are abnormal and should be reported. Redness and swelling along thesuture line and a slightly elevated temperature are normal signs of postoperative inflammation. Atelectasis is common after surgery. thenurse should have thepatient cough and deep breathe, but there is no urgent need to notify thesurgeon. 23. After receiving change-of-shift report about these postoperative patients, which patient would thenurse assess first? A. Patient who had abdominal surgery 3 days ago and whose wound edges may be separating B. Patient who has 30 mL of sanguineous drainage in thewound drain 10 hours after hip replacement surgery C. Patient who has bibasilar crackles and a temperature of 100F (37.8C) on thefirst day after chest surgery D. Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen (Vicodin) was given ANS: A The patient‘s history and assessment suggests possible wound dehiscence, which would be reported immediately to thesurgeon. Although theinformation about theother patients indicates a need for ongoing assessment and possible intervention, thedata do not suggest any acute complications. Small amounts of red drainage are common in thefirst postoperative hours. Bibasilar crackles and a slightly elevated temperature are common after surgery, although thenurse will need to have thepatient deep breathe and cough. Oral medications typically take more than 15 minutes for effective pain relief. 24. An awake patient who has a history of smoking has just arrived on thesurgical unit from thepostanesthesia care unit. Which action would thenurse take first? A. Auscultate for adventitious breath sounds. B. Obtain thetemperature and apply warm blankets. C. Teach thepatient about harmful effects of smoking. D. Ask thehealth care provider to prescribe a nicotine patch. ANS: A The nurse would first ensure a patent airway and check for breathing quality in a responsive patient. Temperature can be assessed and hypothermia addressed after a patent airway and breathing have been established. theimmediate postoperative period is not theoptimal time for patient teaching about theharmful effects of smoking. Requesting a nicotine patch may be appropriate but is not a priority at this time.