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A postoperative client has the following orders: IV lactated Ringer's 125 mL/hr, NG tube to low continuous suction, Replace NG output every 4 hours with normal saline over 4 hours, Morphine sulfate 2 mg IV push every hour as needed for pain, NPO, Up in chair tonight. At 1600 (4:00 PM) the nurse measures the nasogastric (NG) output from noon to be 200 mL. What is the client's total IV rate for the next 4 hours? (Record your answer using a whole number.) mL/hr
- A. 150 mL/hr
- B. 175 mL/hr
- C. 200 mL/hr
- D. 225 mL/hr
Correct Answer: B
Rationale: The total IV rate is calculated as the baseline IV rate (125 mL/hr) plus the NG output replacement (200 mL over 4 hours = 50 mL/hr). Thus, 125 mL/hr + 50 mL/hr = 175 mL/hr.
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An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states 'She needs to get back to her old self.' What response by the nurse is best?
- A. Everyone comes out of surgery differently.
- B. Let's just give her some more time, okay?
- C. She may have had a stroke during surgery.
- D. Older people take longer to wake up.
Correct Answer: D
Rationale: Due to age-related changes, older adults may take longer to metabolize anesthetic agents and pain medications, leading to delayed recovery of cognitive status. The nurse should educate the family on this common occurrence. The other responses either lack specific information or suggest rare complications without evidence.
A postoperative client reports discomfort but denies serious pain and does not want medication. What action by the nurse is best to promote comfort?
- A. Assess the client's pain on a 0-to-10 scale
- B. Reposition the client gently
- C. Offer a warm blanket
- D. Encourage deep breathing exercises
Correct Answer: B
Rationale: Repositioning the client can help alleviate discomfort without medication, addressing the client's immediate needs. Assessing pain is important but does not directly promote comfort. Offering a blanket or encouraging breathing exercises may help but are less specific to addressing discomfort.
A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which medication and dose does the nurse prepare to administer?
- A. Flumazenil (Romazicon) 0.2 to 1 mg
- B. Flumazenil (Romazicon) 2 to 10 mg
- C. Flumazenil (Romazicon) 3 to 15 mg
- D. Naloxone (Narcan) 0.4 to 2 mg
Correct Answer: A
Rationale: Flumazenil is a benzodiazepine antagonist used to reverse the effects of midazolam. The correct dose is 0.2 to 1 mg. Naloxone is an opioid antagonist and would not be appropriate for reversing benzodiazepine-induced respiratory depression.
A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.)
- A. Administer antibiotics for 72 hours.
- B. Dispose of dressings properly.
- C. Ensure a sterile environment in the operating room.
- D. Perform proper hand hygiene.
- E. Remove and replace wet dressings.
Correct Answer: B,D,E
Rationale: Proper disposal of soiled dressings, performing hand hygiene, and removing wet dressings reduce infection risk. Prophylactic antibiotics are typically stopped after 24 hours if no infection is present, and the operating room environment is not the nurse's responsibility on the postoperative unit.
A nurse entering the postoperative area learns which principles about the postoperative period? (Select all that apply.)
- A. All phases require the client to be in the hospital.
- B. Phase I involves immediate recovery in the PACU.
- C. Phase II ends when the client is stable and awake.
- D. Phase III involves extended recovery at home.
- E. Phase III ends when the client is fully recovered.
Correct Answer: B,D,E
Rationale: Phase I occurs in the PACU for immediate recovery, Phase II ends when the client is stable and awake, and Phase III involves extended recovery, often at home. Not all phases require hospitalization, and Phase III does not necessarily end with full recovery but with ongoing recovery at home.