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The nurse is caring for a patient on the first postoperative day who is dizzy when ambulating in the room. In what order will the nurse accomplish the following activities? (All the activities are appropriate.)
- A. Take the patient's blood pressure (BP).
- B. Place the patient in the supine position.
- C. Assist the patient to sit and repeat 5 minutes later.
- D. Record the results.
Correct Answer: B,A,C,D
Rationale: The first priority for the patient with syncope is to prevent a fall, so the patient should be placed in the supine position. Assessment of the BP will determine whether the dizziness is due to orthostatic hypotension, which occurs because of hypovolemia. After taking BP, the patient is assisted to the sitting position and the BP is rechecked in 1-3 minutes. Because this is a common postoperative problem that is usually resolved through nursing measures such as increasing fluid intake and making position changes more slowly, there is no need to notify the health care provider and the nurse is to record the results of the assessment.
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In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which of the following actions by the nurse is most helpful?
- A. Discuss the complications of immobility and poor cough effort.
- B. Teach the patient the purpose of respiratory care and ambulation.
- C. Administer ordered analgesic medications before these activities.
- D. Give the patient positive reinforcement for accomplishing these activities.
Correct Answer: C
Rationale: The most essential nursing action in encouraging these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities.
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 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.
The nurse is caring for a patient who is just waking up after having a general anaesthetic and the patient is agitated and confused. Which of the following actions should the nurse take first?
- A. Check the O2 saturation.
- B. Administer the ordered opioid.
- C. Take the blood pressure and pulse.
- D. Notify the anaesthesia care provider.
Correct Answer: A
Rationale: Emergence delirium may be caused by a variety of factors. However, the nurse should first assess for hypoxemia. The other actions also may be appropriate, but are not the best initial action.
The nurse is caring for a patient who is recovering from anaesthesia in the postanaesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure is 112/60, with a pulse of 72 and warm, dry skin. Which of the following actions is the most appropriate for the nurse to implement at this time?
- A. Increase the rate of the IV fluid replacement.
- B. Continue to take vital signs every 15 minutes.
- C. Administer oxygen therapy at 100% per mask.
- D. Notify the anaesthesia care provider (ACP) immediately.
Correct Answer: B
Rationale: A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anaesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration.