Chapter 16: Care of Postoperative Patients Examination Questions
and Answers 2025 Updated Version.
Terms in this set (19)
ANS: D
Hand-offs are a critical time in client care, and poor communication
A client has arrived in the during this time can lead to serious errors. The postoperative nurse
postoperative unit. What action and circulating nurse participate in hand-off report as the priority.
by the circulating nurse takes Assessing fluid losses and dressings can be done together as part of
priority? the report. Ensuring the client is warm is a lower priority.
a. Assessing fluid and blood output
b. Checking the surgical dressings
DIF: Applying/Application REF: 257
c. Ensuring the client is warm
KEY: Postoperative nursing| communication| hand-off
d. Participating in hand-off report
communication| SBAR MSC: Integrated Process:
Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment:
Management of
Care
, ANS: C
The respiratory rate is the most critical vital sign for any client who
The postanesthesia care unit has undergone general anesthesia or moderate sedation, or has
(PACU) charge nurse notes vital received opioid analgesia. This respiratory rate is too low and
signs on four indicates respiratory depression. The nurse should
postoperative clients. Which client assess this client first. A blood pressure of 100/50 mm Hg is slightly
should the nurse assess first? low and may be within that client's baseline. A pulse of 118
a. Client with a blood pressure of beats/min is slightly fast, which could be due to several causes,
100/50 mm Hg including pain and anxiety. A temperature of 96° F is slightly low
b. Client with a pulse of 118 beats/min
and the client needs to be warmed. But none of these other
c. Client with a respiratory
vital signs take priority over the respiratory rate.
rate of 6 breaths/min
d. Client with a temperature of 96° F
DIF: Applying/Application REF: 258
(35.6° C) 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
ANS: A
If a postoperative client's oxygen saturation (SaO2) drops below 95%
A postoperative nurse is caring for (or the client's baseline), the nurse should notify the anesthesia
a client whose oxygen provider. If the SaO2 drops by 10% or more, the nurse should call
saturation dropped from the Rapid Response Team. Since this is approximately a 3% drop,
98% to 95%. What action by the the nurse should further assess the client. Intubation (if the client is
nurse is most appropriate? not
a. Assess other indicators of intubated already) is not warranted.
oxygenation.
b. Call the Rapid Response Team.
DIF: Applying/Application REF: 259
c. Notify the anesthesia provider.
KEY: Postoperative nursing| nursing assessment| respiratory
d. Prepare to intubate the client.
assessment| oxygen saturation
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
Ten hours after surgery, a ANS: D
postoperative client reports According to the Surgical Care Improvement Project (SCIP), any prophylactic
that the antiembolism measures to prevent thromboembolic events during surgery are continued for
24
stockings and sequential
hours afterward. The nurse should explain this to the client. Calling
and Answers 2025 Updated Version.
Terms in this set (19)
ANS: D
Hand-offs are a critical time in client care, and poor communication
A client has arrived in the during this time can lead to serious errors. The postoperative nurse
postoperative unit. What action and circulating nurse participate in hand-off report as the priority.
by the circulating nurse takes Assessing fluid losses and dressings can be done together as part of
priority? the report. Ensuring the client is warm is a lower priority.
a. Assessing fluid and blood output
b. Checking the surgical dressings
DIF: Applying/Application REF: 257
c. Ensuring the client is warm
KEY: Postoperative nursing| communication| hand-off
d. Participating in hand-off report
communication| SBAR MSC: Integrated Process:
Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment:
Management of
Care
, ANS: C
The respiratory rate is the most critical vital sign for any client who
The postanesthesia care unit has undergone general anesthesia or moderate sedation, or has
(PACU) charge nurse notes vital received opioid analgesia. This respiratory rate is too low and
signs on four indicates respiratory depression. The nurse should
postoperative clients. Which client assess this client first. A blood pressure of 100/50 mm Hg is slightly
should the nurse assess first? low and may be within that client's baseline. A pulse of 118
a. Client with a blood pressure of beats/min is slightly fast, which could be due to several causes,
100/50 mm Hg including pain and anxiety. A temperature of 96° F is slightly low
b. Client with a pulse of 118 beats/min
and the client needs to be warmed. But none of these other
c. Client with a respiratory
vital signs take priority over the respiratory rate.
rate of 6 breaths/min
d. Client with a temperature of 96° F
DIF: Applying/Application REF: 258
(35.6° C) 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
ANS: A
If a postoperative client's oxygen saturation (SaO2) drops below 95%
A postoperative nurse is caring for (or the client's baseline), the nurse should notify the anesthesia
a client whose oxygen provider. If the SaO2 drops by 10% or more, the nurse should call
saturation dropped from the Rapid Response Team. Since this is approximately a 3% drop,
98% to 95%. What action by the the nurse should further assess the client. Intubation (if the client is
nurse is most appropriate? not
a. Assess other indicators of intubated already) is not warranted.
oxygenation.
b. Call the Rapid Response Team.
DIF: Applying/Application REF: 259
c. Notify the anesthesia provider.
KEY: Postoperative nursing| nursing assessment| respiratory
d. Prepare to intubate the client.
assessment| oxygen saturation
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
Ten hours after surgery, a ANS: D
postoperative client reports According to the Surgical Care Improvement Project (SCIP), any prophylactic
that the antiembolism measures to prevent thromboembolic events during surgery are continued for
24
stockings and sequential
hours afterward. The nurse should explain this to the client. Calling
