Medical Surgical Nursing Concepts & Practice 3rd Edition by Susan C. deWit, Candice K. Kumagai Test Bank

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Medical Surgical Nursing Concepts & Practice 3rd Edition by Susan C. deWit, Candice K. Kumagai Test Bank

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Chapter 05: Care of Postoperative Patients
deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition

MULTIPLE CHOICE

1. The postanesthesia care unit (PACU) nurse determines that the patients Aldrete score is 9. Which statement correctly describes the meaning of this score?
a. The patient is at an increased risk for postoperative respiratory complications.
b. The patients condition warrants close monitoring.
c. The patient is experiencing severe pain.
d. The patient will soon be transferred to the postoperative unit.

ANS: D
The Aldrete scoring system is a method of determining readiness for a surgery patient to be transferred from PACU to the postoperative unit. Scores are given for activity, respiration, circulation, consciousness, skin color, and oxygen saturation. A score of 9 or 10 indicates readiness for transfer.

PTS: 1 DIF: Cognitive Level: Application REF: 81
OBJ: 5 (clinical) TOP: Immediate Postoperative Care
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

2. The nurse is caring for a patient recovering in the PACU. The patient awakens confused and disoriented. What action should the nurse take first?
a. Take the patients vital signs.
b. Encourage the patient to return to sleep.
c. Reorient and reassure the patient.
d. Document that the patient is awake and disoriented.

ANS: C
The patient should be reoriented and assured when awaking from anesthesia.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 81
OBJ: 1 (theory) TOP: Immediate Postoperative Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

3. The PACU nurse is caring for a semiconscious patient immediately following abdominal surgery. The nurse correctly places the patient in which position?
a. Supine
b. Semi-Fowler
c. Lateral
d. Trendelenburg

ANS: C
Aspiration is a high-risk complication during this phase of recovery and can best be prevented by placing the unconscious or semiconscious patient on the side with head turned to the side.

PTS: 1 DIF: Cognitive Level: Application REF: 83
OBJ: 6 (clinical) TOP: Immediate Postoperative Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

4. The PACU nurse is caring for an unconscious patient. Assessment reveals diminished breath sounds bilaterally. Which action should the nurse take?
a. Hyperventilate the patient with an Ambu bag.
b. Increase bi-nasal oxygen to 3 L/min.
c. Elevate the head of bed 45 degrees.
d. Document diminished breath sounds in both lower lobes.

ANS: D
Mild atelectasis is an expected sign after anesthesia for the first 48 hours after surgery. This finding is considered a normal finding while the patient is in the PACU and would require no further intervention unless other signs and symptoms, such as decreased oxygen saturation, were present.

PTS: 1 DIF: Cognitive Level: Application REF: 83, 91
OBJ: 4 (theory) TOP: Immediate Postoperative Care
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. The nurse is caring for a patient during the first postoperative day. Which goal works to prevent atelectasis and is most appropriate for the nursing care plan?
a. Patient will turn, cough, and deep-breathe every 4 hours.
b. Patient will huff-cough every 2 hours.
c. Patient will use the incentive spirometer twice a day.
d. Patient will resume diet as soon as possible.

ANS: B
Bi-hourly coughing will help prevent atelectasis. The patient should turn, cough, and deep-breathe every 2 hours, and the incentive spirometer should ideally be used every hour. Resuming diet does not prevent atelectasis, and as soon as possible is not a measurable amount.

PTS: 1 DIF: Cognitive Level: Analysis REF: 91, Table 5-2
OBJ: 3 (theory) TOP: Maintenance of Ventilation
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

6. The nurse is caring for a 90-year-old postoperative patient whose oxygen saturation is frequently dropping below 90%. Which age-related change is most likely related to this finding?
a. Prolonged use of a walker
b. Poor fluid intake
c. Weakened respiratory muscles
d. Increased elasticity of costal cartilages

ANS: C
Age-related changes that interfere with respiration in the older adult are weakened respiratory muscles and calcified costal cartilages.

PTS: 1 DIF: Cognitive Level: Application REF: 83, Older Adult Care Points
OBJ: 4 (theory) TOP: Maintenance of Ventilation
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

7. Which assessment finding on a patient who had a right total knee replacement this morning should be reported to the charge nurse immediately?
a. Pain level of 8 at operative site
b. Capillary refill of right toe of 7 seconds
c. Right foot warm to touch
d. Swelling of right knee

ANS: B
Capillary refills should be brisk, less than 3 seconds. Pain and swelling are expected at this early postoperative time. A warm foot is a normal finding.

PTS: 1 DIF: Cognitive Level: Application REF: 84
OBJ: 5 (clinical) TOP: Maintenance of Circulation
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

8. Anti-embolic stockings are in place on the obese postsurgical patient. Which statement accurately describes the standard of care in regard to anti-embolic stockings?
a. The stockings should remain in place continually for the first 24 hours.
b. The stockings should fit tightly at the knee and ankle.
c. The stockings should be removed approximately 20 minutes every shift.
d. The stockings should be removed when ambulating.

ANS: C
Stockings should be removed approximately 20 minutes each shift for skin care.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 84
OBJ: 1 (theory) TOP: Maintenance of Circulation
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

9. The nurse has been assigned to care for several postoperative patients. Which patient is most likely to develop thrombophlebitis?
a. A patient status post outpatient cholecystectomy with a history of blood clots.
b. A patient who is 6 days postoperative for total right hip replacement with a history of left-sided stroke.
c. A patient who underwent major abdominal surgery and was dehydrated upon admission.
d. A patient who is 2 days postoperative for hernia repair with a history of diabetes.

ANS: B
Although all of these patients are at varying degrees of risk for thrombophlebitis, the hip replacement surgery places a patient at high risk for thrombophlebitis due to limited mobility, especially after the fifth postoperative day. This patient is at even higher risk of thrombophlebitis because of a history of left-sided stroke.

PTS: 1 DIF: Cognitive Level: Analysis REF: 84
OBJ: 5 (theory) TOP: Maintenance of Circulation
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

10. The patients initial vital signs immediately on return from surgery include: blood pressure (BP) of 140/90; pulse (P) of 80; respirations (R) of 14; and temperature (T) of 98 F. One hour later the vital signs are: BP of 130/84; P of 72; R of 16; and T of 96.8 F. What action should the nurse take next?
a. Add a blanket for warmth to the patient.
b. Notify the charge nurse of a probable hemorrhage.
c. Raise the head of the bed 45 degrees.
d. Document the assessment findings.

ANS: D
These findings are normal. The nurse should document the normal recovery assessment and continue to monitor. There is no indication of chilling, hemorrhage, or respiratory distress, which respectively would require blanket application, charge nurse notification, or raising the head of the bed.

PTS: 1 DIF: Cognitive Level: Analysis
REF: 82, Assignment Considerations OBJ: 5 (clinical)
TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. The nurse is caring for a patient who has had spinal anesthesia. The nurse correctly questions which order?
a. Patient to lie flat for 6 to 8 hours.
b. Resume diet as tolerated.
c. Use incentive spirometer every hour while awake.
d. Notify physician immediately if headache occurs.

ANS: D
One of the goals during the postoperative period is to prevent or treat spinal headache. The headache can be treated with nursing interventions such as keeping the patient flat if a headache is reported and increasing fluid intake. If the headache becomes severe or does not improve, the physician could be notified. Lying flat for 6 to 8 hours reduces the risk of spinal headache and allows time for feeling to return to the legs; full diets can usually be resumed; and an incentive spirometer will reduce the chance of respiratory complications resulting from spinal anesthetic effects.

PTS: 1 DIF: Cognitive Level: Analysis REF: 85
OBJ: 6 (clinical) TOP: Prevention of Injury
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

12. The nurse is caring for a patient who had spinal anesthesia. Which drink is the best choice for the nurse to offer the patient?
a. Tea
b. Orange juice
c. Milk
d. Water

ANS: A
Caffeinated beverages like tea or coffee increase the vascular pressure and help seal the punctured area. Orange juice, milk, or water would not achieve the same goal.

PTS: 1 DIF: Cognitive Level: Application REF: 85
OBJ: 5 (theory) TOP: Prevention of Injury
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

13. When caring for a 10-hour postabdominal surgery patient, which finding the nurse should report to the charge nurse?
a. 20 mL of clear green emesis
b. Pain level of 5/10
c. No urine output since surgery
d. A weak cough ability

ANS: C
The postsurgical patient should void in 4 to 8 hours after surgery. Scant emesis, moderate pain, and a weak cough are expected findings after abdominal surgery and do not require immediate report to the charge nurse.

PTS: 1 DIF: Cognitive Level: Application REF: 85
OBJ: 5 (clinical) TOP: Immediate Postoperative Care
KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

14. The nurse is caring for a surgical patient who complains of excessive gas. Which action should the nurse take?
a. Offer iced fluids.
b. Arrange for large meal servings.
c. Provide a straw for drinking fluids.
d. Ambulate the patient in the hall.

ANS: D
Ambulation, eating small meals, drinking tepid drinks, and avoiding the use of straws help eliminate gas.

PTS: 1 DIF: Cognitive Level: Application REF: 86
OBJ: 6 (clinical) TOP: Promotion of Gastrointestinal Function
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

15. The postoperative patient complains of pain only 1 hour after having been medicated with an opioid, which cannot be repeated for three more hours. What action should the nurse take?
a. Give one-half of the prescribed dose now.
b. Contact the prescriber.
c. Ambulate the patient in the hall.
d. Reposition the patient.

ANS: D
Repositioning the patient is the best initial remedy.

PTS: 1 DIF: Cognitive Level: Application REF: 87
OBJ: 7 (clinical) TOP: Promotion of Comfort
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

16. Which action is most important for the nurse to take prior to ambulating the postsurgical patient for the first time?
a. Raise the head of the bed.
b. Dangle the patients legs over side of bed.
c. Offer the patient some fluids.
d. Apply a gait belt to the patient.

ANS: A
The initial intervention prior to the first ambulation is to raise the head of the bed to gradually change the patients posture. The nurse should then sit the patient on the side of the bed and allow the legs to dangle over the side with the feet on the floor of a footstool. After a few minutes, the nurse should slowly assist the patient to stand and then assist the patient to walk. The nurse should use a gait belt and request additional assistance if the patient is very weak.

PTS: 1 DIF: Cognitive Level: Application REF: 87
OBJ: 5 (theory) TOP: Promotion of Rest and Activity
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

17. The nurse educates the postsurgical patient about which potential effect of smoking on postsurgical recovery?
a. Increased probability of hemorrhage
b. Increased blood pressure
c. Delayed healing
d. Increased need for pain medication

ANS: C
Smoking delays healing because it causes a decrease in hemoglobin; hemoglobin carries oxygen to cells and tissues, which is necessary for wound healing.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 88
OBJ: 4 (theory) TOP: Factors Interfering with Wound Healing
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

18. When the postoperative patient refuses to cough due to incisional pain, which action should the nurse take first?
a. Encourage deep breathing instead of coughing.
b. Splint the abdomen with a pillow.
c. Explain the importance of controlled coughing.
d. Administer pain medication.

ANS: B
Giving pain medication and explaining the importance of coughing may be effective, but the best initial action would be splinting the incision with a pillow. Deep breathing should be done in addition to, not in place of, coughing.

PTS: 1 DIF: Cognitive Level: Application REF: 91, Table 5-2
OBJ: 7 (clinical) TOP: Maintenance of Ventilation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

19. The nurse is educating the patient about vitamins and wound healing. The nurse explains that which vitamin will enhance wound healing the most?
a. Vitamin A
b. Vitamin B
c. Vitamin C
d. Vitamin E

ANS: C
Vitamin C helps with the production of collagen, which restores damaged tissues.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 88
OBJ: 6 (clinical) TOP: Promotion of Wound Healing
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

20. The nurse is caring for a patient following abdominal surgery. The patient asks the nurse when he will be able to eat a normal diet. Which response is best?
a. It will depend on how well you tolerate advancing from a clear liquid diet.
b. We will have to wait until your surgeon orders a regular diet for you.
c. Most patients are able to eat regular foods within 2 to 3 days following abdominal surgery.
d. Once you have bowel sounds and are passing gas, you may have clear liquids, and your diet will be advanced based upon your tolerance.

ANS: D
Although the diet order originates with the physician, the nurse must ensure that bowel sounds are present and the patient is able to pass flatus before any type of diet can be given to the patient. Most surgeons will write an order to advance the diet as tolerated once these findings occur. Every patient responds differently based upon their body and the type of surgery, so stating that most patients eat regular foods within 2 to 3 days is inaccurate.

PTS: 1 DIF: Cognitive Level: Application REF: 86
OBJ: 3 (theory) TOP: Postoperative Diet
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

21. The nurse is performing a neurological assessment on a patient who was just transferred from the PACU following abdominal surgery. Which action(s) correctly demonstrate(s) knowledge of a neurological assessment? (Select all that apply.)
a. Asking the patient to spell his name.
b. Asking the patient to identify where he is.
c. Noting if the patient can identify the sensation of touch.
d. Asking the patient to move his arms and legs.
e. Assessing the patients pupils for response to light.

ANS: B, C, D, E
The level of consciousness, orientation, sensory status, motor skills, and pupillary responses are all integral components of the neurological assessment. Asking the patient to spell his name is not an assessment of neurological status, particularly immediately following surgery.

PTS: 1 DIF: Cognitive Level: Application REF: 80
OBJ: 5 (clinical) TOP: Neurologic Assessment
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

22. The nurse is performing the Aldrete scoring system. Which factor(s) must be assessed? (Select all that apply.)
a. Activity
b. Circulation
c. Presence of wound drainage
d. Level of consciousness
e. O2 saturation

ANS: A, B, D, E
The Aldrete scoring system requires that the nurse assess activity, circulation, respiration, level of consciousness, and oxygen saturation.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 81
OBJ: 1 (theory) TOP: Aldrete Scoring System
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

23. Following an outpatient procedure for which the patient received general anesthesia, which finding(s) indicate(s) to the nurse that the patient is ready to be discharged? (Select all that apply.)
a. The patient ambulates to the bathroom with minimal assistance.
b. The patient cannot read and voice an understanding of discharge instructions.
c. The patient has been awake for 2 hours.
d. The patient is able to empty the bladder.
e. The patient plans to drive home.

ANS: A, D
The criteria for discharge from day surgery are the ability to ambulate unassisted and to empty the bladder. Following general anesthetic, a responsible person may receive the discharge instructions and a written copy should be provided to the patient; being awake for 2 hours is not discharge criteria; and patients cannot drive any distance after general anesthesia.

PTS: 1 DIF: Cognitive Level: Application REF: 81
OBJ: 5 (theory) TOP: Day Surgery KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance

24. When providing written discharge instructions, which information should the nurse include? (Select all that apply.)
a. When to resume normal activity
b. Signs and symptoms to report
c. A list of probable complications
d. The telephone number of the surgeons office
e. The need to delay driving and decision making

ANS: A, B, D, E
The discharge instructions should include information about when to resume activity, signs and symptoms to report, contact information about the surgeon, and the need to delay driving and decision making.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 95-96, Patient Teaching
OBJ: 9 (clinical) TOP: Discharge Instructions
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

25. The nurse is caring for a patient 48 hours after mastectomy surgery. The nurse is teaching the nursing student about Core Measures. The nursing student correctly implements which Core Measure intervention(s)? (Select all that apply.)
a. Administering prophylactic antibiotic therapy 48 hours following surgery.
b. Encouraging the older patient to use the call light attached to her when ambulating to the bathroom.
c. Asking the patient to rate her pain on a pain scale.
d. Ensuring that anti-embolic stockings are removed during bathing.
e. Assisting the patient with incentive spirometer every 4 hours.

ANS: B, D
Core Measures for postsurgical patients, issued by The Joint Commission, address prevention of falls and antithrombosis therapy, which are demonstrated by encouraging use of the call light and anti-embolic stockings that may be removed during skin care. Core Measures state that prophylactic antibiotics should be discontinued within 24 hours after surgery. The pain scale and incentive spirometer are not Core Measure guidelines. In addition, use of the incentive spirometry should occur more often than every 4 hours.

PTS: 1 DIF: Cognitive Level: Application REF: 84
OBJ: 6 (clinical) TOP: Core Measures
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

COMPLETION

26. The nurse in the PACU performs postsurgical assessments on the newly admitted patient every _________ minutes.

ANS:

15
fifteen

The staff in PACU make postoperative assessments every 15 minutes on the newly admitted patient.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 82, Focused Assessment
OBJ: 5 (theory) TOP: Immediate Postoperative Care
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

27. The nurse assesses the musty odor coming from the wound drainage as being indicative of an infection by a(n) ____________ organism, such as Pseudomonas or Staphylococcus.

ANS:
aerobic

A musty odor from the wound drainage is indicative of an infection by an aerobic microorganism such as Pseudomonas or Staphylococcus.

PTS: 1 DIF: Cognitive Level: Application REF: 89
OBJ: 4 (theory) TOP: Wound Infection
KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

28. A postsurgical patient consumed a cup of ice chips filled to the 120-mL mark, 2 ounces of broth, and 120 mL of water. In addition, 750 mL of intravenous fluids were infused. The patient voided 650 mL and vomited 100 mL.
What is the total intake for this patient? ________ mL
What is the total output for this patient? ________ mL

ANS:
990; 750

One cup of ice is equal to one-half cup of water. Therefore, 120 mL of ice is 60 mL of intake. One ounce is equal to 30 mL, so 2 ounces equals 60 mL. Therefore, the combined intake is 990 mL and the combined output is 750 mL.

PTS: 1 DIF: Cognitive Level: Application REF: 86, Clinical Cues
OBJ: 6 (clinical) TOP: Intake and Output
KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

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