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The nurse is caring for a patient following gallbladder surgery, and the patient's T-tube is draining dark green fluid. Which of the following actions should the nurse take?
- A. Place the patient on bed rest.
- B. Notify the patient's surgeon.
- C. Document the colour and amount of drainage.
- D. Irrigate the T-tube with sterile normal saline.
Correct Answer: C
Rationale: A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and colour of the drainage is needed. The other actions are not necessary.
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The nurse is caring for a patient in the PACU and the patient's blood pressure has dropped from an admission blood pressure of 138/84 to 100/58 with a pulse change of 68-94. SpO2 is 98% on 3 L of oxygen. In which order should the nurse take these actions?
- A. Raise the IV infusion rate.
- B. Assess the patient's dressing.
- C. Increase the oxygen flow rate.
- D. Check the patient's temperature.
Correct Answer: C,A,B,D
Rationale: The first nursing action should be to increase the oxygen flow rate. Since the most common cause of hypotension is volume loss, the IV rate should be increased next. Because hemorrhage is a common cause of postoperative volume loss, the nurse should check the dressing. Finally, the patient should be assessed for vasodilation caused by rewarming.
The nurse is caring for a patient who is recovering from anaesthesia in the postanaesthesia care unit (PACU), and the vital signs are blood pressure 118/72, pulse 72, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which of the following actions should the nurse take at this time?
- A. Place the patient in a side-lying position.
- B. Encourage the patient to take deep breaths.
- C. Prepare to transfer the patient from the PACU.
- D. Increase the rate of the postoperative IV fluids.
Correct Answer: B
Rationale: The patient's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable BP and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU is not appropriate.
The nurse is caring for a patient who is being transferred from the postanesthesia care unit (PACU) to the clinical surgical unit. Which of the following actions should the nurse implement first on the clinical surgical unit?
- A. Assess the patient's pain.
- B. Take the patient's vital signs.
- C. Read the postoperative orders.
- D. Check the rate of the IV infusion.
Correct Answer: B
Rationale: Because the priority concerns after surgery are airway, breathing, and circulation, the vital signs are assessed first. The other actions should take place after the vital signs are obtained and compared with the vital signs before transfer.
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 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.