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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.
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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.
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 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.
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 patient who had abdominal surgery two days previously. Which of the following information about the patient is most important to communicate to the health care provider?
- A. The right calf is swollen, warm, and painful.
- B. The patient's temperature is 37.9°C (100.2°F).
- C. The 24-hour oral intake is 600 mL greater than the total output.
- D. The patient complains of abdominal pain at level 6 (0-10 scale).
Correct Answer: A
Rationale: The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which will require health care provider orders for diagnostic tests and anticoagulants. Because the stress response causes fluid retention for the first 2-5 days postoperatively, the difference between intake and output is expected. A temperature elevation to 37.9°C (100.2°F) on the second postoperative day suggests atelectasis, and the nurse should have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should administer the ordered analgesic before patient activities.