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The nurse is caring for a patient with abdominal surgery and on the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. Which of the following actions should the nurse implement first?
- A. Reinforce the dressing.
- B. Take the patient's vital signs.
- C. Recheck the dressing in 1 hour for increased drainage.
- D. Notify the patient's surgeon of a potential hemorrhage.
Correct Answer: B
Rationale: New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing.
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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.
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 an older adult in the postanesthesia unit. Which of the following age-related considerations may impact postoperative recovery?
- A. Increased thoracic compliance
- B. Decreased ability to cough
- C. Increased lung tissue
- D. Decreased compliance with deep breathing and coughing
Correct Answer: B
Rationale: The older adult has a decrease in respiratory function, including decreased ability to cough, decreased thoracic compliance (not increased), and decreased (not increased) lung tissue. There is no noted decrease in compliance related to postoperative deep breathing and coughing.
The nurse is preparing an older-adult patient for discharge from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, 'I do not know if I can take care of myself with this patch over my eye.' Which of the following actions is the most appropriate for the nurse to implement?
- A. Refer the patient for home health care services.
- B. Discuss the specific concerns regarding self-care.
- C. Give the patient written instructions regarding care.
- D. Assess the patient's support system for care at home.
Correct Answer: B
Rationale: The nurse's initial action should be to assess exactly the patient's concerns about self-care. Referral to home health care and assessment of the patient's support system may be appropriate actions but will be based on further assessment of the patient's concerns. Written instructions should be given to the patient, but these are unlikely to address the patient's stated concern about self-care.