Nokea
After a new nurse has been oriented to the postanaesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse does which of the following actions?
- A. Places a patient in the Trendelenburg position when the blood pressure (BP) drops.
- B. Assists a patient to the prone position when the patient is nauseated.
- C. Turns an unconscious patient to the side when the patient arrives in the PACU.
- D. Positions a newly admitted unconscious patient supine with the head elevated.
Correct Answer: C
Rationale: The patient should initially be positioned in the lateral 'recovery' position to keep the airway open and avoid aspiration. The prone position is not usually used and would make it difficult to assess the patient's respiratory effort and cardiovascular status. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness.
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The nurse is caring for a patient in the postoperative period who is on bed rest. Which of the following actions should the nurse implement?
- A. Assist the patient to the bathroom when required.
- B. Implement active ROM exercise every 1-2 hours.
- C. Place the patient in a chair for 20 minutes TID.
- D. Complete passive ROM exercises once per 12 hour shift.
Correct Answer: B
Rationale: When confined to bed, patients should alternately flex and extend all joints 10-12 times every 1-2 hours while awake. The muscular contraction produced by these exercises and by ambulation facilitates venous return from the lower extremities. A patient on bed rest is not to be assisted up to the bathroom or placed in a chair. If passive ROM exercise were to be completed, the frequency would be every 1-2 hours, not once per 12 hour shift.
The nurse is caring for a postoperative patient who has not voided for 7 hours after return to the postsurgical unit. Which of the following actions should the nurse take first?
- A. Notify the surgeon.
- B. Assess for bladder distension.
- C. Assist the patient to ambulate to the bathroom.
- D. Insert a straight catheter as indicated on the PRN order.
Correct Answer: B
Rationale: The initial action should be to assess the bladder for distension. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Catheterization should only be done after other measures have been tried without success because of the risk for urinary tract infection. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful.
After removal of the nasogastric (NG) tube on the second postoperative day, the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. Which of the following actions should the nurse take?
- A. Reinsert the NG tube.
- B. Give the PRN IV opioid.
- C. Assist the patient to ambulate.
- D. Place the patient on NPO status.
Correct Answer: C
Rationale: Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient's discomfort. If distension persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains.
The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when which of the following goals has been met?
- A. Patient drinks 2-3 L of fluid in 24 hours.
- B. Patient uses the spirometer 10 times every hour.
- C. Patient's breath sounds are clear to auscultation.
- D. Patient's temperature is less than 38°C (100.4°F) orally.
Correct Answer: C
Rationale: One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or wheezes, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory condition.
The nurse is caring for a patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU), who is restless and shouting at the nurse. The patient's oxygen saturation is 99%, and recent laboratory results are all normal. Which of the following actions by the nurse is most appropriate?
- A. Insert an oral or nasal airway.
- B. Notify the anesthesia care provider.
- C. Orient the patient to time, place, and person.
- D. Be sure that the patient's IV lines are secure.
Correct Answer: D
Rationale: Because the patient's assessment indicates physiological stability, the most likely cause of the patient's agitation is emergence delirium, which will resolve as the patient wakes up more fully. The nurse should ensure patient safety through interventions such as raising the bed rails and securing IV lines. Emergence delirium is common in patients recovering from anaesthesia, so there is no need to notify the anaesthesiologist. Insertion of an airway is not needed because the oxygen saturation is good. Orientation of the patient is needed but is not likely to be effective until the effects of anaesthesia have resolved more completely.