A
The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client?
A. Heart rate and rhythm
B. Skin integrity
C. Core body temperature
D. Airway patency
ANS: D
Rationale: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This assessment is followed by cardiovascular status and the condition of the surgical site. The core temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).
The nurse is caring for a client on the medical–surgical unit postoperative day 5. During each client assessment, the nurse evaluates the client for infection. Which of the following would be most indicative of infection?
A. Presence of an indwelling urinary catheter
B. Oral temperature of 99.5°F (37.5°C)
C. Red, warm, tender incision
D. White blood cell (WBC) count of 8,000/mL
ANS: C
Rationale: Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a client to infection, but by itself does not indicate infection. An oral temperature of 99.5°F may not signal infection in a postoperative client because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/mL.
The postanesthesia care unit nurse is caring for a client who had a hernia repair. The client's blood pressure is now 164/92 mm Hg; the client has no history of hypertension prior to surgery and preoperative blood pressure was 112/68 mm Hg. The nurse should assess for which potential causes of hypertension following surgery?
A. Dysrhythmias, blood loss, and hyperthermia
B. Electrolyte imbalances and neurologic changes
C. A parasympathetic reaction and low blood volumes
D. Pain, hypoxia, and bladder distention
ANS: D
Rationale: Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Dysrhythmias, blood loss, hyperthermia, electrolyte imbalances, and neurologic changes are not common postoperative reasons for hypertension. A parasympathetic reaction and low blood volumes would cause hypotension.
The postanesthesia care unit nurse is caring for a client who has arrived from the operating room. During the initial assessment, the nurse observes that the client's skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the client is not breathing. Which intervention is the priority?
A. Check the client's oxygen saturation level, and monitor for apnea.
B. Tilt the head back and push forward on the angle of the lower jaw.
C. Assess the arterial pulses, and place the client in the Trendelenburg position.
D. Reintubate the client, and perform a focused assessment.
ANS: B
Rationale: When a nurse finds a client who is not breathing, the priority intervention is to open the airway and treat a possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the head back and then pushes forward on the angle of the lower jaw or performs the jaw thrust method to open the airway. This is an emergency and requires the basic life support intervention of airway, breathing, and circulation assessment. Arterial pulses should be checked only after airway and breathing have been established. Reintubation and resuscitation would begin after rapidly ruling out a hypopharyngeal obstruction.
The intraoperative nurse is transferring a client from the OR to the PACU after replacement of the right knee. The client is an older adult. The nurse should prioritize which of the following actions?
A. Keeping the client sterile
B. Keeping the client restrained
C. Keeping the client warm
D. Keeping the client hydrated
ANS: C
Rationale: Special attention is given to keeping the client warm because elderly clients are more susceptible to hypothermia. It is always important for the nurse to pay attention to hydration, but hypovolemia does not occur as quickly as hypothermia. The client is never sterile, and restraints are very rarely necessary.
A client is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The client's vital signs and level of consciousness have stabilized, but the client then reports severe nausea and begins to vomit. What should the nurse do next?
A. Administer a dose of intravenous analgesic.
B. Apply a cool cloth to the client's forehead.
C. Offer the client a small amount of ice chips.
D. Turn the client to one side.
ANS: D
Rationale: Turning the client to one side allows collected fluid to escape from the side of the mouth if the client vomits. After turning the client to the side, the nurse can offer a cool cloth to the client's forehead. Ice chips can increase feelings of nausea. An analgesic is not given for nausea and vomiting.
The nurse is preparing to change a client's abdominal dressing. The nurse recognizes that the first step is to provide the client with information regarding the procedure. Which explanation should the nurse provide to the client?
A. "The dressing change is often painful, so we will give you pain medication beforehand."
B. "I will provide privacy. The dressing change should not be painful; you may look at the incision and help."
C. "The dressing change should not be painful, but you can never be sure, and infection is always a concern."
D. "The best time for a dressing change is during lunch. I will provide privacy, and it should not be painful."
ANS: B
Rationale: When having dressings changed, the client needs to be informed that the dressing change is a simple procedure with little discomfort; privacy will be provided; and the client is free to look at the incision or even assist in the dressing change itself. If the client decides to look at the incision, assurance is given that the incision will shrink as it heals and that the redness will likely fade. Dressing changes should not be painful, but giving pain medication prior to the procedure is always a good preventive measure. Telling the client that the dressing change "should not be painful, but you can never be sure, and infection is always a concern" does not offer the client any real information or options and serves only to create fear. The best time for dressing changes is when it is most convenient for the client; nutrition is important so interrupting lunch is probably a poor choice.
The nurse is caring for a client in the postanesthesia care unit after abdominal surgery. The client's blood pressure has increased, and the client is restless. The client's oxygen saturation is 97%. Which factor should the nurse first suspect as the cause for this change in status?
A. Hypothermia
B. Shock
C. Pain
D. Hypoxia
ANS: C
Rationale: An increase in blood pressure and restlessness are symptoms of pain. The client's oxygen saturation is 97%, so hypothermia, hypoxia, and shock are not likely causes of the client's restlessness.
The nurse is caring for a client who has just been transferred to the PACU from the
OR. What is the highest nursing priority?
A. Assessing for hemorrhage
B. Maintaining a patent airway
C. Managing the client's pain
D. Assessing vital signs every 30 minutes
ANS: B
Rationale: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Assessing for hemorrhage and assessing vital signs are also important, but constitute lower priorities. Pain management is important but only after the client has been stabilized.
22. A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? Select all that apply.
A. Absence of pain
B. Stable blood pressure
C. Ability to tolerate oral fluids
D. Sufficient oxygen saturation
E. Adequate respiratory function
ANS: B, D, E
Rationale: A client remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level compared with baseline. Clients can be released from PACU before resuming oral intake. Pain is often present at discharge from the PACU and can be addressed in other inpatient settings.
The perioperative nurse is preparing to discharge a client home from day surgery performed under general anesthesia. Which instruction should the nurse give the client prior to the client leaving the hospital?
A. Do not drive yourself home.
B. Take an over-the-counter (OTC) sleeping pill for 2 nights.
C. Attempt to eat a large meal at home to aid wound healing.
D. Remain in bed for the first 48 hours’ postoperative.
ANS: A
Rationale: During this time, the client should not drive a vehicle and should eat only as tolerated. Although recovery time varies depending on the type and extent of surgery and the client's overall condition, instructions usually advise limited activity for 24 to 48 hours. However, complete bed rest is contraindicated in most cases. The nurse does not normally make OTC recommendations for hypnotics.
A client is 2 hours’ postoperative with an indwelling urinary catheter. The last hourly urine output recorded for this client was 10 mL. The tubing of the catheter is confirmed to be patent. What should the nurse do?
A. Irrigate the catheter with 30 mL normal saline.
B. Notify the health care provider and continue to monitor the hourly urine output.
C. Decrease the intravenous fluid rate and massage the client's abdomen.
D. Have the client sit in high-Fowler position.
ANS: B
Rationale: If the client has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 25 mL/hr are reported. The urine output should continue to be monitored hourly by the nurse. Irrigation would not be warranted because it is known that the catheter is patent. There is no need to place the client in high-Fowler position (sitting straight up), which would likely be uncomfortable 2 hours’ postoperative.
The nurse is caring for an older adult client in the postanesthesia care unit. The client begins to awaken and responds to their name, but is confused, restless, and agitated. Which principle should guide the nurse's subsequent assessment?
A. Postoperative confusion in older adults is an indication of impaired oxygenation or possibly a stroke during surgery.
B. Confusion, restlessness, and agitation are expected postoperative findings in older adults, and they will diminish in time.
C. Postoperative confusion is common in the older adult client, but it could also indicate a significant blood loss.
D. Confusion, restlessness, and agitation indicate an underlying cognitive deficit such as dementia.
ANS: C
Rationale: Postoperative confusion is common in the older adult client, but it could also indicate blood loss and the potential for hypovolemic shock; it is a critical symptom for the nurse to identify. Despite being common, it is not considered to be an expected finding. Postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery, but blood loss is more likely. A new onset of confusion, restlessness, and agitation does not necessarily suggest an underlying cognitive disorder.
The nurse is caring for a client who is postoperative day 2 following a colon resection. While turning the client, wound dehiscence with evisceration occurs. What should be the nurse's first response?
A. Return the client to the previous position and call the health care provider.
B. Place saline-soaked sterile dressings on the wound.
C. Assess the client's blood pressure and pulse.
D. Pull the dehiscence closed using gloved hands.
ANS: B
Rationale: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the health care provider and take the client's vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.
The nurse is discharging a client home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the client and the caregiver. What else should the nurse do before discharging the client from the facility? Select all that apply.
A. Provide all discharge instructions in writing.
B. Provide the surgeon's contact information.
C. Give prescriptions to the client.
D. Irrigate the client's incision and perform a sterile dressing change.
E. Administer a bolus dose of an opioid analgesic.
ANS: A, B, C
Rationale: Before discharging the client, the nurse provides written instructions, prescriptions, and the surgeon's telephone number. Administration of an opioid would necessitate further monitoring to ensure safety. A dressing change would not normally be ordered on the day of surgery.
The nurse is caring for a 78-year-old client who has had an outpatient cholecystectomy. The nurse is getting the client up for the first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the client do?
A. Sit in a chair for 10 minutes prior to ambulating.
B. Drink plenty of fluids to increase circulating blood volume.
C. Stand upright for 2 to 3 minutes prior to ambulating.
D. Perform range-of-motion exercises for each joint.
ANS: C
Rationale: Older adults are at an increased risk for orthostatic hypotension secondary to age-related changes in vascular tone. The client should sit up and then stand for 2 to 3 minutes before ambulating to alleviate orthostatic hypotension. The nurse should assess the client's ability to mobilize safely, but full assessment of range of motion in all joints is not normally necessary. Sitting in a chair and increasing fluid intake are insufficient to prevent orthostatic hypotension and consequent falls.
The nurse is caring for a client who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear external pneumatic compression stockings. The nurse should explain that refusing to wear external pneumatic compression stockings increases the risk of which postsurgical complication?
A. Sepsis
B. Infection
C. Pulmonary embolism
D. Hematoma
ANS: C
Rationale: Clients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of external pneumatic compression stockings significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection or sepsis would not be affected by external pneumatic compression stockings. A hematoma or bruise would not be affected by external pneumatic compression stockings unless the stockings were placed directly over the hematoma.
A client has just been admitted to the postanesthesia care unit following abdominal surgery. As the client begins to awaken, the client is uncharacteristically restless. The nurse checks the skin, and it is cold, moist, and pale. The nurse is concerned the client may be at risk for which condition?
A. Hemorrhage and shock
B. Aspiration
C. Postoperative infection
D. Hypertension and dysrhythmias
ANS: A
Rationale: The client with a hemorrhage presents with hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin. Aspiration would manifest in airway disturbance. Hypertension or dysrhythmias would be less likely to cause pallor and cool skin. An infection would not be present at this early postoperative stage.
The PACU nurse is caring for an adult client who had a left lobectomy. The nurse is assessing the client frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply.
A. Hypotension
B. Hypervolemia
C. Heart murmurs
D. Dysrhythmias
E. Hypertension
ANS: A, D, E
Rationale: The primary cardiovascular complications seen in the PACU include hypotension and shock, hemorrhage, hypertension, and dysrhythmias. Heart murmurs are not adverse reactions to surgery. Hypervolemia is not a common cardiovascular complication seen in the PACU, though fluid balance must be vigilantly monitored.
24. A client is being asked to choose between an ambulatory surgical center and a hospital-based surgical unit. What guidance should the nurse provide?
A. "Clients who go to ambulatory surgery centers are more independent."
B. "Clients admitted to the hospital for surgery usually have multiple health needs."
C. "In most cases, only emergency and trauma clients are admitted to the hospital."
D. "Clients who have surgery in the hospital are those who need to have anesthesia given."
ANS: B
Rationale: Clients admitted to the hospital have multiple needs and stay for a short period of time. Clients who have surgery in ambulatory centers do not necessarily have greater independence. It is not true that only trauma and emergency surgeries are done in the hospital. Ambulatory centers can administer anesthesia.
The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk?
A. Atelectasis
B. Anemia
C. Dehydration
D. Peripheral edema
ANS: A
Rationale: Atelectasis occurs when the postoperative client fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia occurs rarely and usually in situations where the client loses a significant amount of blood or continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the client is most at risk for atelectasis
10. The nurse admits a client to the postanesthesia care unit with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the client's blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the client's skin is cold, moist, and pale. This client is showing signs of what potential issue?
A. Hypothermia
B. Hypovolemic shock
C. Neurogenic shock
D. Malignant hyperthermia
ANS: B
Rationale: The client is exhibiting symptoms of hypovolemic shock; therefore, the nurse should notify the client's health care provider and anticipate orders for fluid and/or blood product replacement. Neurogenic shock does not normally result in tachycardia, and malignant hyperthermia would rarely present at this stage in the operative experience. Hypothermia does not cause hypotension and tachycardia.
A presurgical client asks, "Why will I go to the postanesthesia care unit (PACU) instead of just going straight up to the postsurgical unit?" Which response by the nurse would be best?
A. "It allows recovery from anesthesia in a stimulating environment to facilitate awakening and reorientation."
B. "It allows us to observe you until you're oriented and have stable vital signs and no complications."
C. "The medical–surgical unit is short of beds, and the PACU is an excellent place to triage clients."
D. "The surgeon likely will need to reinforce or alter the your incision in the hours following surgery."
ANS: B
Rationale: The PACU provides care for the client while the client recovers from the effects of anesthesia. The client must be oriented, have stable vital signs, and show no evidence of hemorrhage or other complications. The PACU does allow the client to recover from anesthesia, but the environment is calm and quiet, as clients are initially disoriented and confused as they begin to awaken and reorient. Clients are not usually placed in the medical-surgical unit for recovery and, although hospitals are occasionally short of beds, the PACU is not used for client triage. Incisions are very rarely modified in the immediate postoperative period.
A postoperative client rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the client is experiencing a hemorrhage. What should be the nurse's first action?
A. Stay with the client and promptly notify the health care provider.
B. Attempt to determine the cause of hemorrhage.
C. Begin resuscitation.
D. Put the client in the Trendelenburg position.
ANS: B
Rationale: Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures, but these require notifying the health care provider. The nurse should stay with the client. Resuscitation is not necessarily required. The Trendelenburg position would be contraindicated.
The nurse just received a postoperative client from the postanesthesia care unit to the medical–surgical unit. The client had surgery for a left hip replacement. Which concern should the nurse prioritize for this client in the first few hours on the unit?
A. Beginning early ambulation
B. Maintaining clean dressings on the surgical site
C. Closely monitoring neurologic status
D. Resuming normal oral intake
ANS: C
Rationale: In the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability, incisional pain, surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding are primary concerns. A client who has had total hip replacement does not ambulate during the first few hours on the unit. Dressings are assessed but may have some drainage on them. Oral intake will take more time to resume.