Lewis: Medical-Surgical Nursing~Chapter 20
A 42-year-old patient is recovering from anesthesia in the postanesthesia care unit (PACU). On admission
to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure falls
to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at this time
is to:
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 anesthesia care provider (ACP) immediately. - (correct Answer) - Answer: b. continue to take
vital signs every 15 minutes.
A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to
the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia
and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification
of the ACP, increased fluids, and high-concentration oxygen administration.
During recovery from anesthesia in the postanesthesia care unit (PACU), a patients vital signs are blood
pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily.
Which action 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. - (correct Answer) - Answer: b. Encourage the patient
to take deep breaths.
The patients borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the
patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed
when the patient first arrives in the PACU and is unconscious. The stable BP and pulse indicate that no
changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that
transfer from the PACU is not appropriate.
After a new nurse has been oriented to the postanesthesia care unit (PACU), the charge nurse will
, evaluate that the orientation has been successful when the new nurse:
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. - (correct Answer) -
Answer: c. turns an unconscious patient to the side when the patient arrives in the PACU.
The patient should initially be positioned in the lateral recovery position to keep the airway open and
avoid aspiration. The prone position is not usually used and would make it difficult to assess the patients
respiratory effort and cardiovascular status. The Trendelenburg position is avoided because it increases
the work of breathing. The patient is placed supine with the head elevated after regaining consciousness.
A 75-year-old is to be discharged 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. The most
appropriate nursing action is to:
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 patients support system for care at home. - (correct Answer) - Answer: b. discuss the
specific concerns regarding self-care.
The nurses initial action should be to assess exactly the patients concerns about self-care. Referral to
home health care and assessment of the patients support system may be appropriate actions but will be
based on further assessment of the patients concerns. Written instructions should be given to the
patient, but these are unlikely to address the patients stated concern about 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 action
should the nurse take?
a. Reinsert the NG tube.
b. Give the PRN IV opioid.
A 42-year-old patient is recovering from anesthesia in the postanesthesia care unit (PACU). On admission
to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure falls
to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at this time
is to:
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 anesthesia care provider (ACP) immediately. - (correct Answer) - Answer: b. continue to take
vital signs every 15 minutes.
A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to
the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia
and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification
of the ACP, increased fluids, and high-concentration oxygen administration.
During recovery from anesthesia in the postanesthesia care unit (PACU), a patients vital signs are blood
pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily.
Which action 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. - (correct Answer) - Answer: b. Encourage the patient
to take deep breaths.
The patients borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the
patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed
when the patient first arrives in the PACU and is unconscious. The stable BP and pulse indicate that no
changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that
transfer from the PACU is not appropriate.
After a new nurse has been oriented to the postanesthesia care unit (PACU), the charge nurse will
, evaluate that the orientation has been successful when the new nurse:
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. - (correct Answer) -
Answer: c. turns an unconscious patient to the side when the patient arrives in the PACU.
The patient should initially be positioned in the lateral recovery position to keep the airway open and
avoid aspiration. The prone position is not usually used and would make it difficult to assess the patients
respiratory effort and cardiovascular status. The Trendelenburg position is avoided because it increases
the work of breathing. The patient is placed supine with the head elevated after regaining consciousness.
A 75-year-old is to be discharged 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. The most
appropriate nursing action is to:
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 patients support system for care at home. - (correct Answer) - Answer: b. discuss the
specific concerns regarding self-care.
The nurses initial action should be to assess exactly the patients concerns about self-care. Referral to
home health care and assessment of the patients support system may be appropriate actions but will be
based on further assessment of the patients concerns. Written instructions should be given to the
patient, but these are unlikely to address the patients stated concern about 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 action
should the nurse take?
a. Reinsert the NG tube.
b. Give the PRN IV opioid.
