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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.
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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.
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 and during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 38.2°C (100.8°F). Which of the following actions should the nurse take first?
- A. Have the patient use the incentive spirometer.
- B. Assess the surgical incision for redness and swelling.
- C. Administer the ordered PRN acetaminophen.
- D. Notify the patient's health care provider about the fever.
Correct Answer: A
Rationale: A temperature of 38.2°C (100.8°F) in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because evidence of wound infection does not usually occur before the third postoperative day, assessment of the incision is not likely to be useful.
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.