Chapter 22Postoperative Nursing Management My Nursing Test Banks

Chapter 22Postoperative Nursing Management

MULTIPLE CHOICE

1.The nurse in the postanesthesia recovery room documents a clients vital signs and current status and then covers the clipboard with a blank sheet of paper. The nurses actions are to support which of the following?

1.

HIPAA laws

2.

Postsurgical care expectations

3.

The surgeons expectations

4.

The anesthesiologists expectations

ANS: 1

In order to protect client privacy and confidentiality with HIPAA laws, written information is to be covered so that casual observers cannot violate the law. Blank sheets should be placed over clipboards to obstruct viewing. The nurse is not covering the clipboard because of postsurgical care expectations. This action is not a surgeon or anesthesiologists expectation.

PTS:1DIF:Analyze

REF:Ethics in Practice: HIPAA: Implications for Perioperative Care

2.The nurse, caring for a postoperative client, will assess vital signs:

1.

every 15 minutes for the first hour.

2.

every 20 minutes for the first hour.

3.

every 30 minutes for the first hour.

4.

not important at this point.

ANS: 1

Vital signs are performed every 15 minutes for the first hour and may be done more often if the client is less stable. Vital sign assessment is extremely important and should be done more frequently than every 20 or 30 minutes.

PTS: 1 DIF: Apply REF: Postoperative Physiological Stabilization

3.The nurse, caring for a postoperative client, will apply supplemental oxygen because:

1.

the client needs it.

2.

of anesthetic gasses in the lungs.

3.

it helps control blood pressure.

4.

it helps with wound healing.

ANS: 2

Postoperative clients require supplemental oxygen because they may still be retaining anesthetic gasses in the lungs. The client will not be able to state that they need oxygen. Oxygen will not control blood pressure nor will it help with wound healing.

PTS: 1 DIF: Analyze REF: Postoperative Physiological Stabilization

4.A client recovering from anesthesia in the care unit has an artificial airway. The nurse knows the purpose of an artificial airway is to:

1.

keep the mouth open.

2.

keep the tongue from blocking the airway.

3.

keep the client from vomiting.

4.

allow the client to talk.

ANS: 2

The artificial airway ensures that the tongue does not block the upper airway. An artificial airway may or may not keep the mouth open. An artificial airway will not prevent the client from vomiting and is not used to facilitate client communication.

PTS: 1 DIF: Analyze REF: Postoperative Physiological Stabilization

5.The nurse, caring for a client recovering from surgery, is monitoring the urine output and will notify the surgeon if the output falls below:

1.

10 mL/hr.

2.

20 mL/hr.

3.

30 mL/hr.

4.

50 mL/hr.

ANS: 3

With proper renal function, the kidneys will produce a minimum of 30 mL of urine per hour. A urine output of 10 or 20 mL/hr should be reported to the physician. A urine output of 50 mL/hr does not need to be reported.

PTS: 1 DIF: Apply REF: Postoperative Physiological Stabilization

6.The nurse assesses an area of drainage on the dressing of a postanesthesia care clients surgical wound. Which of the following should the nurse do?

1.

Call the surgeon right away.

2.

Cover the dressing with a new dressing.

3.

Circle the area and mark it with the date and time.

4.

Pass it off to the next shift.

ANS: 3

If any drainage is showing on the dressing, the nurse is to circle the area and mark it with the date and time. The surgeon does not need to be phoned unless excessive bleeding or hematoma formation has occurred. The dressing does not need to be covered with a new dressing. The nurse should not pass this finding off to the next shift.

PTS:1DIF:ApplyREF:Wound Stabilization

7.The nurse coaches a postoperative client to utilize a breathing device that prevents the complication of atelectasis. This device would be a(n):

1.

IPPB.

2.

blow bottles.

3.

incentive spirometer.

4.

postural drainage.

ANS: 3

An incentive spirometer assists the patient with deep breathing exercises that can help prevent atelectasis. A client would not use an intermittent positive pressure breathing device without the presence of a nurse and/or respiratory therapist. Blow bottles are not a medical device used to prevent atelectasis. Postural drainage is a technique used to drain secretions from the lung lobes.

PTS: 1 DIF: Apply REF: Nursing Care Beyond Transfer

8.Which of the following nursing interventions would be appropriate after a wound evisceration?

1.

Place the client in high-Fowlers position.

2.

Give the client fluids to prevent shock.

3.

Push the organs back inside and tape up the wound.

4.

Apply a sterile saline-soaked dressing and cover.

ANS: 4

The nurse is to cover the wound with a sterile saline-soaked dressing and maintain it until the client is taken to surgery. High-Fowlers position will not help with wound evisceration. Providing fluids would be contraindicated since the client will be returning to surgery. The nurse should not manipulate the exposed organs.

PTS: 1 DIF: Apply REF: Anticipating Complications

9.The nurse should instruct the postoperative client that antiembolic stockings are used to:

1.

keep the legs warm.

2.

serve as a nonslip slipper.

3.

promote venous return.

4.

make it easier to ambulate after surgery.

ANS: 3

Surgery may result in swelling that could impede blood return. Antiembolic stockings will aid in blood return and reduce lower extremity edema postoperatively. These stockings are not used to keep the legs warm, serve as a nonslip slipper, nor make it easier to ambulate after surgery.

PTS: 1 DIF: Apply REF: Recovery Milestones Beyond the Day of Surgery

10.The nurse is planning to teach a postoperative client about discharge medication. Which of these nursing interventions would best assist the client in learning?

1.

Withhold any pain medication so that the client can concentrate better.

2.

Schedule the teaching after physical therapy so the client will be relaxed.

3.

Place the client in a comfortable position and have the patient use the bathroom.

4.

Plan the teaching at night right before bed so that the client can sleep on the new information given.

ANS: 3

Placing the client in a comfortable position and having him use the bathroom will allow him to concentrate on the learning to take place. The client will not be able to concentrate on the instructions if he is in pain. The client may be tired after physical therapy and would not want to engage in instruction at this time. Waiting until night to conduct instruction is also not a good time considering the client may be fatigued from activities throughout the day and needs to rest.

PTS: 1 DIF: Apply REF: Box 22-4 Discharge Teaching Tips

11.The nurse is instructing a family member on how to change a clients postoperative wound dressing at home. Which of the following should be included in these instructions?

1.

Wear gloves to remove the old dressing.

2.

Wear sterile gloves to apply the new dressing.

3.

Clean hands prior to applying the new dressing.

4.

Reposition the new dressing after application.

ANS: 3

If the client is to change the dressing at home, there is no need to wear gloves when the old dressing is removed. Clean hands are sufficient to apply the new dressing. Sterile gloves are not needed to apply the new dressing. Once the new dressing has been placed over the wound, it should be left alone and not repositioned.

PTS: 1 DIF: Apply REF: Patient and Family Teaching

12.Which of the following should the nurse do when caring for an elderly postoperative client?

1.

Allow rest periods between activities.

2.

Address the client by the first name.

3.

Assess for confusion if the client takes a long time to complete a task.

4.

Avoid eye contact.

ANS: 1

Caring for an elderly postoperative client, the nurse should allow rest periods between activities, avoid using the clients first name, not mistake slow activity for confusion, and maintain eye contact and full attention.

PTS:1DIF:Apply

REF: Respecting Our Differences: Postoperative Considerations for the Older Adult

13.The nurse is instructing a postoperative client regarding signs of complications. Which of the following should be included in these instructions?

1.

Notify the physician with a body temperature greater than 99F.

2.

Expect the pain level to increase.

3.

Report a change in drainage or increase in bleeding.

4.

Dizziness and fainting is an expected side effect of anesthesia.

ANS: 3

Signs and symptoms of postoperative complications include fever, usually greater than 100 or 101F; sudden change in pain; change in drainage or bleeding; dizziness and fainting. The client should not be instructed to notify the physician with a body temperature of 99F. Pain level should not increase once discharged. Dizziness and fainting should be reported immediately.

PTS: 1 DIF: Apply REF: Patient and Family Teaching

MULTIPLE RESPONSE

1.When a client is brought from the surgical suite to the postanesthesia care unit, the nurse will conduct a rapid head-to-toe visual assessment. Which of the following statuses will be assessed during the initial assessment? (Select all that apply.)

1.

Surgical site

2.

Vital signs

3.

Respiratory stability

4.

Circulatory stability

5.

Range of motion of lower extremities

6.

Bowel sounds

ANS: 1, 2, 3, 4

When a client is admitted to the postanesthesia care unit, the initial head-to-toe assessment includes surgical site, vital signs, respiratory stability, and circulatory stability. Range of motion of the lower extremities and bowel sounds are not a part of the initial head-to-toe assessment.

PTS: 1 DIF: Apply REF: Postoperative Physiological Stabilization

2.The postanesthesia care unit nurse is caring for clients with different types of wound drains. Which are the most common types of drains? (Select all that apply.)

1.

Plantar drain

2.

Penrose drain

3.

Davol

4.

Hemovac

5.

Ostomy appliance

6.

Chest tube collection device

ANS: 2, 3, 4

The most common types of wound drains include the Penrose, Davol, and Hemovac. An ostomy appliance is not a postoperative wound drain. A chest tube collection device is not a postoperative wound drain.

PTS: 1 DIF: Analyze REF: Table 22-2 Wound Drains

3.The nurse, determining if a client is ready to be discharged from the postanesthesia care unit, utilizes the Aldrete System which assesses which of the following? (Select all that apply.)

1.

Activity

2.

Respiration

3.

Circulation

4.

Consciousness

5.

Oxygen saturation

6.

Appetite

ANS: 1, 2, 3, 4, 5

The Aldrete System is used to assess readiness for discharge from the postanesthesia care unit and uses a numeric scoring system that measures stability with activity, respiration, circulation, consciousness, and oxygen saturation. Appetite is not assessed with the Aldrete System.

PTS:1DIF:Apply

REF:Assessment Needs and Criteria for Discharge from PACU

4.A postoperative client is being transferred from the stretcher to the bed. Which of the following transfer techniques will be used to safety relocate this client? (Select all that apply.)

1.

Use a padded transfer board.

2.

Locate an extra transfer person on the side of the stretcher.

3.

Lock the wheels on both the stretcher and the bed.

4.

Keep the bed anchored against the back wall.

5.

Slide the client first to the edge of the stretcher.

6.

Use the count of five to move the client.

ANS: 1, 3, 5

Techniques to safely transfer a client from a stretcher to a bed include: use a padded transfer board; lock the wheels on both the stretcher and the bed; slide the client first to the edge of the stretcher. An extra transfer person should be located on the side of the bed and not on the side of the stretcher. The head of the bed should be placed about a foot from the wall. The transfer will usually commence on the count of three.

PTS:1DIF:Apply

REF: Box 22-1 Transfer Principles: Body Mechanics and Immediate Patient Comfort

5.The nurse is preparing instructions for a postoperative client. When planning these instructions, the nurse needs to take into consideration which three types of learning? (Select all that apply.)

1.

Individual

2.

Affective

3.

Computerized

4.

Psychomotor

5.

Group

6.

Cognitive

ANS: 2, 4, 6

There are three types of learning: 1) cognitive, 2) affective, and 3) psychomotor. Individual, computerized, and group are strategies or approaches to providing instruction.

PTS:1DIF:Analyze

REF:Teaching/Learning Principles for the Postoperative Patient

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