Chapter 05 Care of Postoperative Surgical Patients

Chapter 05  Care of Postoperative Surgical Patients

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. The postanesthesia care unit (PACU) nurse determines that the patient’s Aldrete score is 9. The nurse on the postoperative unit knows that this means the:
a.
patient is at an increased risk for postoperative respiratory complications.
b.
patient’s condition warrants close monitoring.
c.
patient is experiencing severe pain.
d.
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 indicates readiness for transfer.

DIF: Cognitive Level: Application REF: 82 OBJ: 2 (theory)
TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

2. The patient recovering in the PACU awakes confused and disoriented. The nurse’s most appropriate intervention is to:
a.
take vital signs.
b.
encourage the patient to return to sleep.
c.
say, “Your surgery is over. You are in the recovery area.”
d.
chart, “Patient awake and disoriented.”

ANS: C
The patient should be reoriented and assured when awaking from anesthesia.

DIF: Cognitive Level: Comprehension REF: 82 OBJ: 1 (theory)
TOP: Immediate Postoperative Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

3. Following abdominal surgery, the PACU nurse demonstrates the best nursing care by placing the semi-conscious patient in _____ position.
a.
the supine
b.
semi-Fowler’s
c.
the lateral
d.
Trendelenburg’s

ANS: C
Aspiration is a high-risk complication during this phase of recovery and can best be prevented by placing the unconscious patient on the side with head turned to the side.

DIF: Cognitive Level: Application REF: 84 OBJ: 1 (theory)
TOP: Immediate Postoperative Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

4. When the PACU nurse assesses diminished breath sounds in the unconscious recovering patient, the nurse should:
a.
hyperventilate the patient with an Ambu bag.
b.
turn the oxygen up to 3 L/min.
c.
elevate the head of bed 45 degrees.
d.
chart, “Diminished breath sounds in both lower lobes.”

ANS: D
Mild atelectasis is an expected sign after anesthesia for the first 48 hours after surgery. This would be considered a normal finding while the patient is in the PACU and would require no further intervention unless other signs and symptoms, such as decreased oxygen saturation, were present.

DIF: Cognitive Level: Application REF: 84 OBJ: 4 (theory)
TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. The nurse is caring for a patient during the first postoperative day. An appropriate goal to write in the nursing care plan to avoid atelectasis would be:
a.
patient will turn, cough, and deep-breathe every 4 hours.
b.
patient will “huff cough” every 2 hours.
c.
patient will use the incentive spirometer twice a day.
d.
nurse will assist the patient to ambulate in the hall three times a day.

ANS: B
Bi-hourly coughing will help prevent atelectasis. The patient should turn, cough, and deep-breathe every 2 hours; and the incentive spirometer should ideally be used every hour. The nurse assisting the patient to ambulate is an intervention, not a goal.

DIF: Cognitive Level: Analysis REF: 92 | Table 5-2
OBJ: 3 (theory) TOP: Maintenance of Ventilation
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

6. The nurse is caring for a 90-year-old postoperative patient. The nurse notes that the oxygen saturation is frequently dropping below 90%. This is most likely related to:
a.
prolonged use of a walker.
b.
poor fluid intake.
c.
weakened respiratory muscles.
d.
increased elasticity of costal cartilages.

ANS: C
Age-related changes that interfere with respiration in the older adult are weakened respiratory muscles and calcified costal cartilages.

DIF: Cognitive Level: Application REF: 84 | Elder Care Points
OBJ: 4 (theory) TOP: Maintenance of Ventilation
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease