Chapter 19 Medical Surgical Nursing Preparation For Practice 2nd Edition

Chapter 19  Medical Surgical Nursing Preparation For Practice 2nd Edition

Complete Chapter Questions And Answers
 

Sample Questions

Question 1
Type: MCSA
The nurse has just received a patient from the surgical area. After 30 minutes in the recovery area, the patient’s vital signs are: pulse 92; blood pressure 110/50; respirations 12; and pulse oximeter 86%. What should be the initial nursing response?
1. Call the physician.
2. Ask another nurse for his or her opinion.
3. Stimulate the patient.
4. Place an oral airway in the patient.
Correct Answer: 3
Rationale 1: The patient’s respirations and pulse oximeter are low. Notifying the physician is not the initial nursing response indicated, although it may be necessary if other interventions do not improve ventilation.
Rationale 2: The patient’s respirations and pulse oximeter are low. It is not necessary to ask for a second opinion. The nursing assessment is correct and the intervention is standard.
Rationale 3: The patient’s respirations and pulse oximeter are low. The nurse’s initial response should be to stimulate the patient to see if the pulse oximeter will increase. The patient may require frequent stimulation to improve the oxygen saturation.
Rationale 4: The patient’s respirations and pulse oximeter are low, but there is no indication that an oral airway is needed at this time. If the correct initial intervention does not improve oxygenation, an oral airway may be considered.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 19-3

Question 2
Type: MCSA
The recovery room nurse has just received a patient whose abdominal drain has an excessive amount of sanguineous drainage. The nurse contacts the physician without delay, recognizing that the drainage could indicate which critical situation?
1. A major wound infection
2. Need for further assessment
3. A potential respiratory crisis
4. Need to return immediately to surgery
Correct Answer: 4
Rationale 1: A wound infection would not develop so rapidly.
Rationale 2: Further assessment is probably necessary, but this is not the nurse’s major concern.
Rationale 3: Wound drainage is not indicative of an imminent respiratory crisis.
Rationale 4: An excessive amount of sanguineous drainage in the abdominal drain may require returning the patient to surgery so that the surgical site may be explored.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 19-3

Question 3
Type: MCSA
A patient is just arriving in the postanesthesia care unit following general anesthesia. What is the nurse’s priority intervention?
1. Assess the patient’s respiratory status.
2. Assess the patient’s IV.
3. Ask the patient about pain.
4. Assess the patient’s cardiac status.
Correct Answer: 1
Rationale 1: The patient’s respiratory status will be the nurse’s top priority because anesthesia can impact the respiratory system. Respiratory complications are the most frequent complications in the postanesthesia care unit.
Rationale 2: The status of the patient’s IV is important, but it is not the highest priority.
Rationale 3: The patient’s pain level is important, but it is not the highest priority.
Rationale 4: The patient’s cardiac status is important, but it is not the highest priority.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 19-1

Question 4
Type: MCSA
A patient has just arrived in the recovery room. As part of the evaluation for determining discharge from the postanesthesia recovery unit, what will be the nurse’s next action?
1. Assess the patient’s respirations, oxygen saturation, consciousness, circulation, and activity.
2. Assess whether the patient wants the family in the recovery room.
3. Assess the patient for pain.
4. Take the patient’s temperature.
Correct Answer: 1
Rationale 1: Assessments of the patient’s respirations, oxygen saturation, consciousness, circulation, and activity are used to determine progress toward discharge.
Rationale 2: The family may be allowed in the recovery room in many institutions, but their presence is usually delayed until the patient has been assessed and is arousable.
Rationale 3: Assessing for pain helps the patient’s comfort but is not part of the discharge criteria.
Rationale 4: Temperature is vital to assessing hypothermia, but it is not one of the discharge criteria.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 19-2