Chapter 19 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 19

Question 1

Type: MCSA

The nurse has just received a patient from the surgical area. After 30 minutes in the recovery area, the patients 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 patients 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 patients 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 patients respirations and pulse oximeter are low. The nurses 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 patients 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 nurses 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 nurses priority intervention?

1. Assess the patients respiratory status.

2. Assess the patients IV.

3. Ask the patient about pain.

4. Assess the patients cardiac status.

Correct Answer: 1

Rationale 1: The patients respiratory status will be the nurses 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 patients IV is important, but it is not the highest priority.

Rationale 3: The patients pain level is important, but it is not the highest priority.

Rationale 4: The patients 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 nurses next action?

1. Assess the patients 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 patients temperature.

Correct Answer: 1

Rationale 1: Assessments of the patients 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 patients 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

Question 5

Type: MCSA

Progression through the various phases in the postanesthesia recovery unit (PACU) depends on which factor?

1. The severity of the procedure the patient underwent

2. The attentiveness and caring of the nursing staff

3. The temperature and environment of the unit

4. The patients progress toward physiological homeostasis

Correct Answer: 4

Rationale 1: The severity of the procedure is not the determining factor in the patients progression through PACU.

Rationale 2: While attentive and caring nursing staff may make the PACU experience more pleasant, this attention is not the determining factor in the patients progression.

Rationale 3: The temperature and environment of the unit may make the PACU experience more or less comfortable, but they are not the determining factor in the patients progression.

Rationale 4: The patients recovery and progress through the various phases in the PACU depend on how quickly the patient returns to physiological homeostasis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-2

Question 6

Type: MCSA

A patient is being evaluated for discharge from the postanesthesia care unit. The patient had a preoperative baseline blood pressure of 124/80. Currently, the patient is moving all four extremities voluntarily, has a respiratory rate of 11, and rouses when her name is called. Which other assessment would mandate that the patient stay in postanesthesia care until more stable?

1. The patient has vomited once since admission.

2. The patients blood pressure is 120/76.

3. The patient has had no pain since admission to the unit.

4. The patients pulse oximeter measures 92% on oxygen.

Correct Answer: 4

Rationale 1: The current incomplete PADS score is 6. A single episode of vomiting is not significant.

Rationale 2: A blood pressure of 120/76 is within 20% of baseline, scoring a 2. Added to the current incomplete PADS score of 6, the patients score is 8, which is sufficient for discharge to a hospital unit.

Rationale 3: The patient currently has an incomplete PADS score of 6. Having no pain is not a reason to keep the patient in the PACU.

Rationale 4: The patients current incomplete PADS score is 6. The missing component is O2 saturation. The reading of 92% on oxygen earns a score of 1, bringing the total PADS score to 7. A PADS score of 7 requires that the patient stay in the PACU.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 19-2

Question 7

Type: MCSA

A 75-year-old patient is received into the postanesthesia recovery room (PACU) following a 6-hour abdominal surgery. The patients hemodynamic status is stable. Based on knowledge of the patients surgery and the common postoperative complications the patient might be at risk for, the recovery room nurse would perform which interventions?

1. Keep the room temperature at 70 degrees, consider supplemental oxygen, and provide warm blankets.

2. Consider increasing the IV fluids, assess for urine output, and monitor the oxygen saturation.

3. Assess the patients blood pressure more frequently than for younger clients and provide oxygen.

4. Provide postoperative instructions to avoid straining and eat a low-fiber diet.

Correct Answer: 1

Rationale 1: This patient is at risk for hypothermia based on age, the length of the surgery, and the likelihood of intra-operative irrigants to the abdomen. The nurses role will be to minimize the risk for hypothermia by providing warm blankets, keeping the room at 70 degrees, and, if the core temperature drops, considering the provision of supplemental oxygen.

Rationale 2: The IV rate does not need to be increased at this time because the patient is hemodynamically stable. The urine output would

be automatically monitored, but the nurse would not anticipate a problem with it because the patient is hemodynamically stable.

Rationale 3: The patients hemodynamic status is stable; therefore, the blood pressure is stable. Increased frequency of blood pressure monitoring is not necessary.

Rationale 4: Because the patient was in surgery for 6 hours, postoperative instructions to avoid straining and eat a low-fiber diet are not applicable at this time.

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 8

Type: MCSA

The nurse assesses a patient in the postanesthesia recovery unit and finds a BP of 88/50, pulse 116, and respirations of 20. What assessment data will the nurse collect next?

1. Pain assessment

2. Urine output

3. Pulse oximeter reading

4. Whether the patient is nauseated

Correct Answer: 3

Rationale 1: A pain assessment will help determine if the cause of tachycardia may be pain; however, the blood pressure would not typically be low. Pain, in this instance, is secondary to hypoxemia, if present.

Rationale 2: Urine output is another indicator of perfusion when the blood pressure is low, but it would not be the priority assessment.

Rationale 3: With a BP of 88/50, pulse of 116, and respirations of 20, the nurse will want to check the pulse oximeter reading next to determine whether there is hypoxia.

Rationale 4: Nausea is important to assess but is not the first priority.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-3

Question 9

Type: MCSA

What is the purpose of a call by the ambulatory care unit nurse to the patient on the day after discharge?

1. To minimize patient complications and ensure patient safety

2. To let the patient know the nurse cares about him or her

3. To assist in collecting discharge data for the health care provider

4. To meet federal and regulatory requirements

Correct Answer: 1

Rationale 1: The ambulatory care unit nurse contacts the patient after discharge to ensure the patient correctly understands the discharge instructions and to answer any questions the patient may have. This helps increase patient safety and minimizes complications.

Rationale 2: This may be a benefit of the call but is not its purpose.

Rationale 3: This may be a benefit of the call but is not its purpose.

Rationale 4: Some accrediting bodies may have such requirements, but this is not the purpose of the call.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 19-4

Question 10

Type: MCSA

The recovery room nurse is preparing to discharge a 24-year-old patient to home following ambulatory surgery. Which discharge instructions provided by the nurse would be the most comprehensive?

1. Verbal and written instructions to the patient and family regarding the wound, activity and diet restrictions, new medications, pain management, potential complications, and process for reaching the health care provider if needed

2. Written instructions to manage the wound, instructions to resume activities slowly, methods for pain control, and information on whom to contact in 2 days

3. Verbal and written instructions to the family regarding the patients activity levels, diet, potential problems, and medications

4. Verbal instructions to restrict all activities, diet restrictions, pain management, and circumstances that require contacting the health care provider

Correct Answer: 1

Rationale 1: The patient and family should be provided discharge instructions verbally and in writing that include: wound management; restrictions on activity, diet, and bathing; new medications; pain management; the follow-up appointment; the postoperative progress the patient can expect; and complications that require contacting the health care provider.

Rationale 2: This set of discharge instruction does not include verbal instructions and instructions to the family, and it leaves out essential content.

Rationale 3: This set of discharge instructions does not provide information for the patient. It also omits some essential information.

Rationale 4: This set of discharge instructions omits written instructions as well as some essential information.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-4

Question 11

Type: MCSA

A patient is preparing for discharge to home. The nurse has provided discharge instructions regarding activities. Which instruction is most helpful to the patient?

1. You may complete activities as tolerated.

2. Be sure to rest throughout the day.

3. You can start exercising in 7 days if there are no signs of wound infection.

4. You can bathe normally.

Correct Answer: 3

Rationale 1: Activities as tolerated is not specific information.

Rationale 2: Rest through the day does not offer specific guidelines.

Rationale 3: Patients find discharge instructions most helpful when they are specific. These instructions are specific, giving the patient exact details.

Rationale 4: Bathing normally is up to interpretation of the patient. This statement does not offer the specific information required.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-4

Question 12

Type: MCSA

A nurse notices that patients who ambulate within the first 12 hours of surgery have fewer postoperative complications. Which approach would provide validation for the nurses belief that early ambulation reduces postoperative complications?

1. Correlation of postoperative complications with the patients activity

2. Modification of the patients activity based on the surgical severity

3. Discussion of postoperative complications with a physical therapist

4. Adjustment of the patients medications related to their activity levels

Correct Answer: 1

Rationale 1: Research designed to validate whether early ambulation decreases postoperative complications must correlate the patients activity with the development of postoperative complications.

Rationale 2: Modification of the patients activity based on the severity of surgery will not validate the correlation between early ambulation and postoperative complications.

Rationale 3: Discussion with therapists regarding patients postoperative complications will not validate the correlation between early ambulation and postoperative complications.

Rationale 4: Adjustment of the patients medications based upon the activity levels will not validate the correlation between early ambulation and postoperative complications.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 19-5

Question 13

Type: MCSA

The nurse wonders which nursing interventions increase patients competence in managing their own recovery after discharge. Which intervention might be appropriate to help determine this?

1. The nurse will discuss the patients discharge with the health care provider.

2. The nurse will measure the patients ability to ambulate without dyspnea.

3. The nurse will provide the patient with 4 hours of uninterrupted sleep while in the inpatient facility.

4. The nurse will adjust patient teaching to allow for cultural diversity.

Correct Answer: 4

Rationale 1: Discussing the patients discharge with other health care providers does not address the question of patient competence, but it may provide some insight into how to manage interventions for the patient.

Rationale 2: The ability to ambulate without dyspnea could determine how far the patient can ambulate, but it does not address the research question.

Rationale 3: Providing the patient with uninterrupted sleep will not address the question of patients competence in managing their own recovery after discharge.

Rationale 4: Interventions involved in a research project to help determine patients competence in managing their own recovery after discharge must address the topic for validation. Adjusting teaching to allow for cultural diversity would help determine whether this intervention would impact patients competence.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 19-5

Question 14

Type: MCSA

A potential research study focuses on identifying topics essential for inclusion in patients discharge instructions. Such a study might provide insight into which question?

1. How can hospitalizations be reduced?

2. When should the patient be discharged?

3. In what ways can patients better manage their own recovery?

4. How might the nurse improve care provided in the hospital?

Correct Answer: 3

Rationale 1: As a secondary impact, there may be information on ways to reduce hospitalization; however, that would not be the primary focus.

Rationale 2: When the patient should be discharged would not be a focus of the research study.

Rationale 3: A study looking at the discharge instructions needed by a patient could provide insight into ways patients might better manage their own recovery.

Rationale 4: How the nurse could improve care provided in the hospital would not be a focus of the research study.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 19-5

Question 15

Type: MCMA

The nurse is preparing to discharge a patient who has had outpatient surgery. Which criteria would make the patient eligible for discharge?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Stable vital signs for 1 hour

2. No nausea or dizziness

3. Acceptable level of pain

4. Ability to void

5. Stated readiness to go home

Correct Answer: 1,2,3,4

Rationale 1: The patient should have stable vital signs for at least 1 hour before discharge to home.

Rationale 2: The patient should be able to tolerate oral fluids and have returned to baseline neurologic status before discharge to home.

Rationale 3: The patients pain should be acceptable or be controlled to an acceptable level before discharge to home.

Rationale 4: The patient should be able to void before discharge to home.

Rationale 5: The patients readiness to go home is not a criterion for discharge after outpatient surgery.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-2

Question 16

Type: MCSA

The nurse is caring for a patient recovering from surgery conducted in the previous 24 hours. What should the nurse do to assist this patient with pain control?

1. Administer prescribed analgesics around the clock.

2. Administer prescribed analgesics when the patient requests something for pain.

3. Assist the patient to a more comfortable position to reduce the amount of pain.

4. Offer the patient a back rub to reduce the amount of pain.

Correct Answer: 1

Rationale 1: Established, persistent, severe pain is more difficult to treat than pain at its onset. Postoperative analgesics should be administered at regular intervals around the clock to maintain a therapeutic blood level.

Rationale 2: Administering analgesics as needed (prn) lowers the therapeutic level; delays in medication administration further increase pain intensity. As needed administration of analgesics is not recommended in the first 36 to 48 hours postoperatively.

Rationale 3: The nurse could help the patient into a more comfortable position to reduce the pain; however, the nurse should also provide the patient with the prescribed analgesics.

Rationale 4: The nurse could offer the patient a back rub to reduce the amount of pain; however, the nurse should also provide the patient with the prescribed analgesics.

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 17

Type: MCSA

An elderly surgical patient is having an epidural catheter inserted for pain control. The nurse tells the patient that this method of pain medication has which benefit?

1. Earlier return of bowel function

2. Faster wound healing

3. Earlier ambulation

4. Improved appetite

Correct Answer: 1

Rationale 1: Patient-controlled epidural analgesia is associated with faster return of gastrointestinal function.

Rationale 2: Patient-controlled epidural analgesia does not speed up wound healing in the elderly patient.

Rationale 3: Patient-controlled epidural analgesia does not lead to earlier ambulation in the elderly patient.

Rationale 4: Patient-controlled epidural analgesia does not improve appetite in the elderly patient.

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 18

Type: MCMA

An elderly postoperative patient is given metoclopramide (Reglan) for nausea. Which assessment finding would indicate this patient is experiencing a possible adverse reaction to this medication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Involuntary muscle movements

2. Sedation

3. Dry mouth

4. Breakthrough vomiting

5. Hypotension

Correct Answer: 1,2

Rationale 1: Antiemetics such as metoclopramide (Reglan) can cause an extrapyramidal reaction. The patient would demonstrate involuntary muscle movements, muscle tone changes, and abnormal posturing.

Rationale 2: Metoclopramide can cause mild sedation.

Rationale 3: Dry mouth postoperatively is likely due to NPO status, not to administration of metoclopramide.

Rationale 4: Breakthrough vomiting is not an indication of an adverse reaction.

Rationale 5: Hypotension is not an adverse effect of metoclopramide.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 19-3

Question 19

Type: MCSA

The nurse is assisting a postoperative patient in using an incentive spirometer. Which postoperative complication is the nurse attempting to avoid?

1. Atelectasis

2. Deep vein thrombosis

3. Hemorrhage

4. Pulmonary embolism

Correct Answer: 1

Rationale 1: Promoting lung expansion and systemic oxygenation of tissues is a goal in preventing atelectasis. Nursing care includes assisting with incentive spirometry.

Rationale 2: Deep vein thrombosis is not related to incentive spirometer use.

Rationale 3: Hemorrhage is not related to incentive spirometer use.

Rationale 4: Pulmonary embolism is not related to incentive spirometer use.

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 20

Type: MCSA

The nurse has conducted assessment of a patient who had surgery for a ruptured appendix 3 days ago. The patient complains of nausea, the abdomen is firm, and bowel sounds are rare in all quadrants. The nurse discusses these assessment findings with the health care provider due to concern regarding development of which condition?

1. Paralytic ileus

2. Dehydration

3. Intestinal obstruction

4. Hyperkalemia

Correct Answer: 1

Rationale 1: Three days after surgery, a distended abdomen with hypoactive bowel sounds may indicate paralytic ileus. Nausea is also indicative of ileus.

Rationale 2: Dehydration would not manifest as a distended abdomen and hypoactive bowel sounds.

Rationale 3: Intestinal obstruction may cause similar findings, but as this patient has just had surgery, it is not the condition of primary concern.

Rationale 4: Increased potassium levels would not manifest as distention of the abdomen and hypoactive bowel sounds.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-3

Question 21

Type: MCMA

The surgical unit has developed a new fast-track system whereby patients are transferred from the operating room to PACU phase II. The nurse anticipates that which patients would benefit from this change?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A healthy 50-year-old patient with an uncomplicated cataract surgery

2. A 20-year-old basketball player who had arthroscopic repair of the knee

3. A 65-year-old woman who had a hysterectomy for uterine cancer

4. A 40-year-old man who had coronary bypass surgery

5. A 5-year-old whose tonsils and adenoids were removed

Correct Answer: 1,2,5

Rationale 1: Fast-tracking is used for patients with short anesthesia times who have minimally invasive procedures.

Rationale 2: Fast-tracking is used for patients with short anesthesia times who have minimally invasive procedures.

Rationale 3: Fast-tracking is not used for high-risk patients.

Rationale 4: Fast-tracking is not used for high-risk patients. In some hospitals, this patient might be admitted directly to the ICCU.

Rationale 5: Fast-tracking is used for patients with short anesthesia times who have minimally invasive procedures.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 19-1

Question 22

Type: MCSA

A patient recovering from surgery reports a pain level of 6 on a 0 to10 pain scale but refuses additional pain medication to avoid becoming addicted. The nurses response should focus on which concept?

1. The patient may not understand the importance of treating pain.

2. The patient may already have an addiction problem.

3. The patient might benefit from a placebo dose.

4. The physician should be notified to discuss pain management.

Correct Answer: 1

Rationale 1: Patients might fear addiction or physical dependence on pain medications, especially opioids, postoperatively. The nurse should discuss the importance of treating pain but should honor any cultural considerations.

Rationale 2: The patient who already has an addiction problem is more likely to request more medication, not refuse it.

Rationale 3: The patient is verbalizing pain, so administration of a placebo is unethical and does not honor the patients right to pain management.

Rationale 4: It is within the scope of the nurses practice to review and make decisions with the patient regarding safe use of pain medications that have been ordered by the physician. The physician does not need to be called at this time unless the nurses interventions are unsuccessful.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-1

Question 23

Type: MCSA

Which finding would the PACU nurse evaluate as indicating the patient is progressing toward maintaining his own airway?

1. The patient snores while breathing.

2. The patient is fighting the oral airway.

3. The patient requires suctioning every 15 minutes.

4. The patients oxygen saturation is below 90% on room air.

Correct Answer: 2

Rationale 1: Snoring is an indication of airway obstruction.

Rationale 2: As the patient becomes more alert and able to maintain an airway, he may fight the presence of an artificial airway.

Rationale 3: A patient who requires frequent suctioning is not clearing his own airway.

Rationale 4: One of the reasons a patients oxygen saturation is low could be the inability to maintain an open airway.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-2

Question 24

Type: MCMA

The PACU nurse is assessing a postoperative patients intravenous fluids. Which assessments should be documented?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Location of the intravenous catheter

2. The length of time the catheter has been in place

3. The type of IV fluid infusing

4. The rate fluid is infusing

5. The type of IV catheter present

Correct Answer: 1,3,4,5

Rationale 1: The nurse should note the location of the IV catheter.

Rationale 2: The nurse should note the condition of the catheter but is not responsible for documenting the length of time the catheter has been in place.

Rationale 3: The nurse should document the type of fluid being infused as well as any additives to the base fluid.

Rationale 4: The nurse should note the rate IV fluid is infusing.

Rationale 5: The nurse should record the type of IV catheter presentfor example, peripheral or PICC.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-1

Question 25

Type: FIB

A child who weighs 30 kg is in the PACU. The nurse would collaborate with the childs health care provider if the childs urine output was less than ______ mL per hour.

Standard Text:

Correct Answer: 15

Rationale : The nurse would become concerned if the childs urine output was less than 0.05 mL/kg/hr. 0.05 x 30 = 15.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 19-3

Question 26

Type: MCMA

A nurse in the PACU is administering an IV fluid bolus to an unconscious patient whose urine output has been less than 10 mL per hour for the last 2 hours. Which findings would indicate that this patient is having an adverse reaction to this treatment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient develops crackles in the bilateral lung bases.

2. The patients respiratory rate and depth increases.

3. The patients oxygen concentration rises.

4. The patients urine output increases.

5. The patients incisional pain increases.

Correct Answer: 1,2

Rationale 1: Crackles are an indicator of fluid overload. The patient is not tolerating the fluid bolus.

Rationale 2: The patient may respond with shortness of breath. In the unconscious patient, this may manifest as an increase in respiratory rate and depth.

Rationale 3: The adverse effect would be a decrease in oxygen concentration.

Rationale 4: This is the desired effect of a fluid bolus.

Rationale 5: Fluid volume status does not affect incisional pain.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 19-3

Question 27

Type: MCMA

A patient in the PACU is nauseated and has vomited. Which nursing actions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Administer an antiemetic per protocol or order.

2. Raise the head of the patients bed.

3. Place a cool washcloth on the patients forehead or neck.

4. Offer the patient a small amount of ice chips.

5. Offer the patient sips of tea or coffee.

Correct Answer: 1,3,4

Rationale 1: Antiemetic medications are often required to treat postoperative nausea and vomiting.

Rationale 2: Elevation of the head often triggers nausea.

Rationale 3: Application of a cool washcloth may help avert nausea.

Rationale 4: Ice chips may help to moisten the mouth and throat and avert nausea.

Rationale 5: The patient should not be given liquids that could be aspirated.

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 28

Type: FIB

A patient who is being prepared for discharge after surgery becomes dizzy and weak when getting up to go the bathroom. The nurse would document that this patient has orthostatic hypotension if the patients heart rate increases by _______beats per minute when moving from the lying to standing position.

Standard Text:

Correct Answer: 10

Rationale : The postoperative patient may have dehydration, which will result in orthostatic hypotension. The heart rate drops by 10 beats per minute and the blood pressure drops by 10 mmHg when the patient moves from the lying to standing position.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 19-3

Question 29

Type: FIB

The PACU nurse is using the postanesthetic scoring system to determine if a patient is ready to be discharged home after a same-day surgery. The nurse would determine the patient to be ready when the score reaches _______.

Standard Text:

Correct Answer: 9

Rationale : If the patient is being discharged to a hospital unit, the PACU nurse would determine readiness for discharge when the score reaches 8. As this patient is being discharged to home, the score should be 9.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 19-2

Question 30

Type: MCMA

A nurse is providing care to a patient who had surgery 5 days ago. Today the patients right calf is red, warm, swollen, and painful. Which interventions should the nurse implement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Measure the circumference of both calves and compare the readings.

2. Place the patient on bed rest.

3. Collaborate with the patients primary health care provider.

4. Place a pillow under the patients knee on the affected side.

5. Palpate for pedal pulses bilaterally.

Correct Answer: 1,2,3,5

Rationale 1: It is important to measure both calves. This establishes a baseline measurement and also compares the unaffected calf with the affected calf.

Rationale 2: The patient should be maintained on bed rest until further treatment is done.

Rationale 3: The nurse should discuss this finding with the primary health care provider. The patient may be experiencing a deep vein thrombosis.

Rationale 4: Pressure under the knee should be avoided.

Rationale 5: The nurse should assess and compare the quality of the pedal pulses bilaterally.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 19-3

 

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