Nokea
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.
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The nurse is caring for an older-adult patient who had a surgical repair of a hip fracture 2 days previously and has restrictions on ambulation. Based on this information, which of the following collaborative problems is priority for the patient?
- A. Potential complication: hypovolemic shock
- B. Potential complication: venous thromboembolism
- C. Potential complication: fluid and electrolyte imbalance
- D. Potential complication: impaired surgical wound healing
Correct Answer: B
Rationale: The patient is older and relatively immobile, two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient.
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.
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.
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 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.