Chapter 29: Pre-Operative and Post-Operative Care Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition

Multiple Choice

1. The nurse instructs the patient about scheduled surgery involving general anesthesia and about postoperative care. Which does the nurse include during this time?

a. Determine patient cultural and religious preferences.

b. Avoid eating or drinking anything 2 hours before surgery.

c. Ask for antianxiety medication in the operating room.

d. Follow the rules for beginning to exercise after the incision has healed.

ANS: A

Patients must be asked about their cultural practices and religious beliefs that may alter their or their family caregiver’s acceptance of necessary education and procedures. A minimum time for avoiding food and drink has been set at 2 hours, but agency policies will differ. Antianxiety medications, if used, will be given in the preoperative area. Patient will begin to do light exercise, such as ambulation or physical therapy, long before the incision has healed.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Tell the patient that this surgery always leaves a scar. b. Change the operative consent form to reflect what the patient says. c. Inform the surgeon that the patient is not ready for surgery. d. Notify the surgeon of the patient’s statement before medication is given.

2. The patient is prepared for shoulder surgery and tells the preoperative nurse that the scar will be invisible after the surgery. Which action does the nurse take at this time?

ANS: D

The patient’s statement about an invisible scar is inconsistent with shoulder surgery because skin incisions always leave a scar. The inconsistent statement cues the nurse to verify the patient and the procedure on the surgical consent form and then, once patient identity is secure, address the patient’s misunderstanding and ask the surgeon to speak with him or her. The nurse avoids changing the consent form. The nurse does not know yet whether the patient is ready for surgery; he or she resolves the patient misunderstanding or misidentification first.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Ask the patient if medications will calm him or her before surgery. b. Identify specific concerns regarding the surgical experience. c. Explain to the patient that stress is easily identified and managed. d. Tell the patient that complications rarely occur with surgical procedures today.

3. The patient’s family has had many experiences with surgical complications. What information is most important for the nurse to use to understand the patient’s stress in the perioperative period?

ANS: B

The patient’s perception of the perioperative experience creates a point of reference for evaluation of the situation. Asking about fears, cultural practices, and religious beliefs allows the nurse to anticipate the patient’s and family caregiver’s priorities and adapt the plan to give appropriate instruction and support. The nurse should get more information so potential concerns can be identified. Anxiolytics can relieve stress quickly by sedating the patient but do nothing to resolve the patient’s stressor. Stressors can be difficult to identify and are usually more difficult to manage. Telling the patient that complications are rare is dismissive of the patient’s concern and does not provide any useful information.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. “I feel that you’re uneasy about discussing medications.” b. “Why don’t you want to talk about your medications?” c. “You’re avoiding me; so you must have a big secret.” d. “Don’t you think that it’s important to discuss medications?”

4. The nurse interviews a preoperative patient who evades all questions about medications taken at home. Which is the best response for the nurse to use to facilitate safe, effective nursing care?

ANS: A

The best response is to validate the nurse’s perception of the patient’s behavior in a nonthreatening manner in order to elicit more information from the patient. The nurse avoids asking a “why” question because it may make a patient feel defensive. Stating that the patient is avoiding the question has the potential to be beneficial for interviewing, but concluding that the patient has a secret may be perceived as an accusation, sarcasm, or humor and lacks professionalism. It is unlikely to elicit more information. Asking a question that implies a position that the patient hasn’t advocated (you don’t think medications are important to discuss) is judgmental and unlikely to uncover the patient’s true concerns.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. The patient’s lungs will be clear when auscultated every 2 hours. b. The nurse will manage the patient’s pain with oral morphine. c. The patient will perform coughing and deep breathing as directed. d. The patient will ambulate 4 hours after surgery.

5. The nurse determines that the patient is at risk for atelectasis caused by pain from back surgery 3 hours ago. Which is the best goal for the nurse to help the patient achieve?

ANS: A

This goal is appropriate for the patient, objective, attainable, and specific. Goals are for patient actions or outcomes, not the nurse. Performing coughing and deep breathing as directed is vague. Early mobility is critical after surgery, however; the patient may not be allowed up so soon after back surgery and that goal is not as specific as the respiratory outcome.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Use sterile gloves to provide care to this patient. b. Remove latex products from the patient’s room. c. Inform the surgeon about the patient’s hypersensitivity to latex. d. Gather additional information about potential allergies.

6. A nurse admits a patient to ambulatory surgery. The patient’s history includes multiple surgeries over the last 10 years. In addition, when the patient wears antiembolism stockings or has tape on the skin, a rash develops. Which action does the nurse take initially?

ANS: D

A rash or other local response when items touch the skin could potentially alert the nurse to latex allergy. The nurse would continue assessing allergies. Sterile gloves are not needed for routine care. Removing latex products from the room is premature. The nurse does not yet know if the patient has a latex allergy, so notifying the surgeon is also premature.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Begin coughing and deep breathing when the patient is ready. b. Take a deep breath, hold it for 10 seconds, and exhale slowly. c. Support the incision when doing these exercises. d. Perform coughing and deep breathing every four hours.

7. The nurse instructs the patient about postoperative coughing and deep-breathing exercises following abdominal surgery. Which technique does the nurse teach the patient to facilitate cooperation?

ANS: C

The nurse engages the patient in postoperative coughing and deep breathing by instructing him or her to splint the incision similar to when the patient is turning. By holding the incision, the patient stabilizes the edges of the wound and puts less stress on the incision. The nurse does not allow the patient to decide when and if coughing and deep breathing are done. He or she involves the patient actively. Simply taking a deep breath and holding it before exhaling does not clear secretions from the respiratory tract. Coughing and deep breathing (or use of a device such as a spirometer) are done every 1–2 hours.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Avoid any fluids by mouth until the patient begins passing gas. b. Flex and rotate the ankles several times every hour while awake. c. Rest quietly to allow the maximum action of the opioid analgesics. d. Stay positioned on either side with pillows between the legs.

8. A patient will be on bed rest for several days after extensive surgery. Which activity does the nurse teach the patient to prevent complications from decreased perfusion?

ANS: B

The nurse instructs the patient to perform ankle flexion and rotation to promote venous return from the lower extremities, which helps prevent thromboembolic complications and increases arterial perfusion to provide oxygen for the tissues while the patient is not ambulating. Passing gas has no correlation to decreased perfusion in the patient’s lower extremities. Pain needs to be controlled, but this has little to do with potential impaired tissue perfusion in the lower extremities. Placing pillows between the legs when positioned on the side provides comfort and is a passive method of preventing compression of the lower leg by the upper one. This is not the most effective way of preventing decreased perfusion to the lower extremities.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Bring the preoperative medications prepared by the nurse to the patient. b. Administer a preoperative enema to the patient. c. Instruct the patient to arrange for a ride home and a companion after surgery. d. Reinforce preoperative teaching related to the patient’s postoperative diet.

9. The nurse plans assignments for the staff in an ambulatory surgery center. Which assignment can the nurse delegate to nursing assistive personnel (NAP)?

ANS: B

The nurse delegates administering the preoperative enema to the NAP because this is within the scope of practice for this person. Handling medications is a nursing responsibility and cannot be delegated. Patient teaching remains a nursing responsibility because it involves assessment, planning, and evaluation components.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. “They prevent any chance of blood clots after surgery.” b. “They are required since you will be on bed rest.” c. “They are connected to a pump and improve circulation.” d. “They help improve circulation and reduce the risk of blood clots in your legs.”

10. The patient asks why preoperative application of compression stockings has been ordered. Which response by the nurse is most appropriate?

ANS: D

The purpose of compression stockings is to promote circulation during periods of immobilization, reducing the risk of an embolism. They cannot prevent any chance of blood clots because blood clots can develop in other body areas for other reasons. They are usually used for patients on bed rest or with limited mobility, but that doesn’t explain the purpose of them. The devices connected to a pump to promote circulation in the lower extremities are called sequential compression devices.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Asks the patient to estimate the fluid volume. b. Instructs the patient to dress and return home. c. Notifies the anesthesiologist and surgeon. d. Changes or delays surgery for several hours.

11. The nurse admits a patient for ambulatory surgery. The patient tells the nurse that he or she skipped breakfast but drank a cup of coffee and some juice. Which does the nurse implement next?

ANS: A

The nurse obtains additional information from the patient before collaborating with the surgical team so he or she can present a complete picture of the patient’s consumption. Drinking fluids before surgery increases this risk of aspiration of gastric contents. The nurse notifies the surgical team and collaborates with them to decide about rescheduling, delaying, or proceeding with the patient’s procedure. The nurse does not change or delay the surgery independently. This is a collaborative effort within the patient’s surgical team.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Call the laboratory to get the test results. b. Collaborate with the surgeon. c. Draw a stat pregnancy test. d. Ask the patient if she is pregnant.

12. The nurse prepares the patient for surgery to begin in 1 hour, but the pregnancy test included in the preoperative orders written yesterday is not in the medical record. Which action does the nurse implement first?

ANS: A

The nurse should first find out if the test results are available before doing anything else. If the results cannot be found, the nurse obtains a blood specimen for a stat pregnancy test because the provider ordered one before surgery and the order is still valid. If the results have not been found after the specimen for the pregnancy test is drawn and sent to the lab, the nurse notifies the surgeon about the situation. The nurse avoids sending the patient to surgery on the basis of her verbal report because she may be unaware of a pregnancy or she may be concealing the truth.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. The patient is complaining of a pounding headache. b. There is a bruise on the patient’s left anterior chest. c. The patient uses continuous positive airway pressure (CPAP) at home. d. The blood pressure is 20 mm Hg higher than baseline.

13. The nurse assesses a patient before hip surgery. Which piece of information is most critical for the nurse to report to the surgeon before surgery?

ANS: C

The nurse reports the use of CPAP since this may indicate that the patient has obstructive sleep apnea, which poses a risk after surgery. The headache could potentially result from anxiety or hypoglycemia and should be reported, but not as the priority. A bruise on the patient’s chest is not near the operative area. The elevated blood pressure could be a result of preoperative anxiety.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. The patient’s father died during surgery last year. b. The patient was exposed to chickenpox 8 weeks ago. c. The serum hemoglobin level is 13.5 g/dL. d. The patient’s weight is 136 pounds; height is 5 feet 6 inches.

14. The nurse assesses a patient before surgery. Which piece of patient information requires follow-up nursing interventions?

ANS: A

The patient’s risk for developing chickenpox is past. The serum hemoglobin level is fine for surgery. The data indicate a normal weight for the patient’s height. The nurse will follow up on the cause of the father’s death to determine if malignant hyperthermia was involved. This is an inherited, life-threatening emergency.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Document what the patient just said. b. Order the missed medication in a parenteral form. c. Notify the patient’s surgeon. d. Ask the patient why he or she didn’t take it.

15. While being prepared for surgery, the patient tells the nurse about forgetting to take the ordered antibiotics in preparation for the surgery. What action by the nurse is most appropriate?

ANS: C

The nurse must alert the surgeon of the patient’s lack of compliance regarding taking the ordered antibiotics so the surgeon can decide whether to continue or postpone the operation and what needs to occur if the operation proceeds. The nurse will document what the patient said, but it is more critical to alert the surgeon. The CDC has identified prophylactic antibiotics, as recommended, to be crucial in preventing surgical site infections. The nurse cannot order a medication, even though the patient said that the surgeon has ordered it, because there is no order available; nor can the nurse change the medication route of administration. Asking a “why” question is nontherapeutic because it puts the patient in a defensive position.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. The nurse provides information about the risks and benefits of the procedure. b. Informed consent only describes the details of the surgery itself. c. The nurse verifies it is complete and consistent with patient’s understanding. d. The nurse obtains consent after administration of any preoperative medication.

16. The nurse is explaining the purpose and procedure regarding informed consent to a nursing student. What information is included in the explanation?

ANS: C

The nurse’s role is to verify the patient’s signature and verify that it is complete and consistent with the patient’s understanding. The nurse must know the policies of the agency regarding what to do if the patient later states a lack of understanding. The informed consent states what is being done by whom and includes contingency plans, risks, and benefits. The nurse can help the patient understand the information, but the nurse does not provide it. The health care provider who performs the procedure provides informed consent and includes details about the procedure. The patient is potentially incompetent after receiving preoperative medication such as sedatives and opioids; thus the nurse verifies that the consent is in order before administering preoperative medication. However, medications such as prophylactic antibiotics would not alter the patient’s ability to consent.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. A 10-year history of smoking a pack of cigarettes per day b. A reddened, swollen, and painful calf c. An upper respiratory infection last month d. A low-normal serum hemoglobin level

17. The nurse assesses a patient before knee surgery. Which assessment finding reported by the nurse will most likely require the surgery to be delayed?

ANS: B

Calf pain, tenderness, and swelling are consistent with clinical indicators of a deep vein thrombosis or an infection; thus the surgery most likely will be rescheduled after resolution of these findings. The history of smoking is important but most likely will not delay the operation. The patient should be fully recovered from an uncomplicated upper respiratory infection last month. Low-normal hemoglobin is sufficient to clear the patient for surgery.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Tighten the thighs pushing the knee into the bed 5 times every 1–2 hours. b. Cough and deep breathe every time you change position. c. Use your hands to splint your incision because they are cleaner than the pillow is. d. Reposition in bed every 4 hours.

18. The nurse provides instructions about postoperative exercises to the patient who is scheduled for a laparotomy. What does the nurse include in patient teaching?

ANS: A

Quadriceps setting is an exercise to help improve circulation and consists of tightening the thighs and pressing the knee down toward the bed. This should be done 5 times every 1–2 hours. The patient should cough and deep breathe every 1–2 hours; the post-surgical pain may keep the patient from changing position frequently. A pillow, blanket, or the hands can help splint the incision. The patient should be mobilized soon after the operation and does not need a specific turning schedule.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Position the head to maintain a patent airway. b. Elevate the affected hand higher than the level of the heart. c. Monitor the circulatory status in the operative hand. d. Measure the core body temperature.

19. The nurse admits the patient to the postanesthesia care unit (PACU) after minor hand surgery with minimal sedation and regional anesthesia. Which action by the nurse is priority?

ANS: A

Although the patient did not receive general anesthesia, the nurse’s priority is maintaining t he airway because short-acting benzodiazepines and opioids used during conscious sedation potentially depress respirations. If the patient is very lethargic, he or she may have trouble maintaining the airway and require temporary support. After establishing a stable airway, breathing, and circulation, the nurse elevates the hand according to the provider’s preference while assessing it. Monitoring the circulatory status in the hand that was operated on is essential but not a priority. Checking the temperature is important but is not the priority.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

20. The nurse is caring for a patient who had an ovarian cyst removed under general anesthesia a. The patient will cough and deep breathe every hour for 48 hours. b. The patient will have bowel sounds within 24 hours after surgery. c. The patient will exercise the feet and ankles 3 times this shift. d. The patient will ambulate tonight and 3 times tomorrow.

12 hours ago. Which is the most important goal for this patient?

ANS: D

The most important goal for this patient is ambulation because it promotes lung expansion, restoration of peristalsis, peripheral perfusion, venous return, and tissue integrity and thereby decreases atelectasis and prevents pneumonia, constipation, thromboembolic events, skin breakdown, and infection. The patient should not cough and deep breathe every hour for 48 hours. She must be allowed to sleep. Establishing bowel sounds within 24 hours after surgery is an unrealistic goal. Ankle and foot exercises promote perfusion and venous return, which help to prevent circulatory problems, but ambulation is best.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Apply warm blankets to stop the shivering. b. Administer medication to relax the muscles. c. Give the patient antipyretics to reduce the fever. d. Tell the patient that shivering is to be expected after surgery.

21. The nurse is caring for a shivering patient immediately after back surgery under general anesthesia. Which nursing intervention is most suitable for this patient?

ANS: A

To warm the patient, the nurse applies warm blankets or a warming device to eliminate shivering because shivering consumes massive amounts of oxygen in skeletal muscle. If the patient has a respiratory or cardiovascular problem, shivering potentially aggravates it significantly. Medication is not indicated for shivering unless it becomes unresolved. The patient may have a fever causing shivering, but it is more likely to be from the cold operating room, impaired thermoregulation from anesthesia, or open body cavities that lose heat. There is also no data on the patient’s temperature. Telling the patient that this is expected does nothing to relieve the shivering.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Reposition the patient on the side. b. Give the ordered antiemetic. c. Prepare to insert a nasogastric (NG) tube. d. Apply oxygen at 10 L/min by face mask.

22. The nurse is caring for the patient who is vomiting after arriving in the PACU. Which action does the nurse implement first?

ANS: A

Surgical patients can vomit for several reasons and the nurse’s priority is to ensure the patient maintains a patent airway. This is accomplished by turning the patient to the side if allowed and having suction equipment available. After ensuring the patient’s airway is protected, the nurse can give antiemetic medications. An NG tube is not warranted at this time. Oxygen will not benefit the patient if the patient’s airway is lost, plus putting a face mask on the patient will increase the risk of aspiration.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Notify the surgeon. b. Continue to document the output. c. Irrigate the Hemovac with sterile saline. d. Attach a larger Hemovac drain.

23. The patient had shoulder surgery 2 hours ago, and the Hemovac drain is filling at a continuous rate, requiring the nurse to empty it frequently. Which does the nurse do first?

ANS: A

The nurse calls the surgeon because the amount of drainage varies with a procedure and the nurse needs to know a specific amount for this patient and surgery so the patient can be monitored appropriately. The nurse also uses critical thinking to determine that the amount of drainage is more than expected because the drain needs to be emptied frequently. The surgeon may need to take the patient back to surgery if a problem exists. The nurse should continue to monitor and document the drainage but that is not the priority. Because the volume of drainage is large, the more important action is to call the surgeon. Surgical drains are not designed for irrigation. The Hemovac is an integrated unit that includes the drainage container and attached drain that is placed in the surgical site at the conclusion of a procedure; to change a Hemovac, the provider replaces the tubing and container. This is not with the nursing role.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Every 5 minutes b. Every 5–15 minutes c. Every 15–30 minutes d. Every 30 minutes to 1 hour

24. The nurse is caring for the patient after general anesthesia. How often does the nurse perform routine patient assessment and documentation in the postanesthesia care unit (PACU)?

ANS: B

The nurse assesses the patient every 5–15 minutes in the PACU because he or she is recovering from general anesthesia and suppression of several vital functions, including maintaining an airway, breathing, and the gag reflex. If adverse responses are occurring, a patient could need reassessment every 5 minutes or less, but usually every 5–15 minutes is sufficient. Assessing at intervals of 30 minutes or more is dangerous because complications develop quickly and subtly, leaving the patient exposed to risks for extended periods.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. At discharge from the postanesthesia care unit (PACU) b. After discharge to home and before complete recovery c. Between induction for surgery and arrival in the PACU d. After discharge from the PACU and before discharge to home

25. At what point in the surgical recovery process does the nurse need to ambulate the hospitalized patient for the first time?

ANS: D

Unless the patient is being discharged from ambulatory surgery, the nurse needs to ambulate the patient for the first time on the surgical unit after discharge from the PACU and before discharge to home because postoperative ambulation is critically important to prevent postoperative complications. Unless the patient is discharged to home, he or she remains on bed rest until after the transfer to a surgical unit for continuing postoperative care. Ambulation on the surgical unit depends on many factors, although the nurse will encourage the patient to do so as much as possible. The patient is likely to be groggy from anesthesia and affected by pain medication, making ambulation dangerous at that time. The nurse owes a duty to the patient to ambulate before discharge to home unless it is contraindicated. Surgery occurs between induction and arrival in the PACU.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Administer supplemental oxygen. b. Place the patient in a supine position. c. Perform oropharyngeal suctioning. d. Prepare for endotracheal intubation.

26. The patient in the PACU is coughing up white mucus after having been intubated for surgery. What action would be most appropriate for the nurse to maintain a patent airway?

ANS: C

In the immediate postoperative period, patients frequently have pulmonary secretions from mechanical ventilation during surgery. The nurse suctions the patient as necessary to help remove the secretions from the airway. Supplemental oxygen is ineffective therapy to clear an airway. The supine position is contraindicated for patients in the immediate postoperative period unless the patient is hypotensive. The nurse avoids preparing for endotracheal intubation unless the patient develops respiratory failure.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. It helps to maintains venous return. b. It helps prevent atelectasis and pneumonia. c. It prevents any type of respiratory infection. d. It strengthens the lungs for recovery.

27. After instructing the patient in using the incentive spirometer (IS), the nurse instructs nursing assistive personnel (NAP) to encourage the patient to use it. What does the nurse provide to the NAP as a rationale for using the IS after surgery?

ANS: B

Using the IS involves inhaling; as the lungs fill with air, alveoli that collapse in surgery pop open from expansion of the chest wall. In addition, IS promotes airway clearance by stimulating coughing and gas exchange as secretions are removed from the lungs. This helps prevent atelectasis and pneumonia. Inhalation does promote venous return to the heart, but this is not the reason for using an IS with postoperative patients. Incentive spirometry cannot prevent any type of respiratory infection from occurring. The IS is not intended to strengthen the lungs.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. The pain level is 2 on a scale of 0–10 after an analgesic. b. The patient is voiding an average of 45 mL/hr. c. Bowel sounds are inaudible in all quadrants. d. The patient performs breathing exercises every 6–8 hours.

28. The nurse assesses the patient on the first postoperative day after major abdominal surgery. Which is the most important patient outcome that requires follow-up interventions by the nurse?

ANS: D

Increasing the frequency of breathing exercises is important because breathing is a vital function. The patient decreases the risk of atelectasis and pneumonia after surgery with frequent coughing, deep breathing, incentive spirometry, and ambulation. A pain level of 2 is within normal limits for a postoperative patient requiring routine postoperative nursing care. The urine output is normal. Inaudible bowel sounds after major abdominal surgery for up to the first 48 hours or so would be expected.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Notify the surgeon of the findings. b. Assess the patient for drug abuse. c. Administer pain medication. d. Assess the patient’s cardiac history.

29. A patient on the post-surgical nursing unit has rhinorrhea, muscle aching, and profuse sweating. What action by the nurse is most appropriate?

ANS: B

Symptoms of opioid withdrawal include rhinorrhea, muscle aching, sweating, nausea, diarrhea, dysphoric mood, lacrimation, dilated pupils, piloerection, yawning, fever, and insomnia. The nurse would assess the patient for a history of drug abuse. After completing the assessment, the nurse would notify the surgeon. Pain medication is not warranted at this time. Although sweating may be seen in cardiac disorders, the other signs are not, so the nurse would first assess for drug abuse.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Score 0 b. Score 4 c. Score 8 d. Score 10

30. The nurse has assessed the Aldrete score on four patients in PACU. Which patient is the most appropriate to transfer to the post-surgical nursing unit?

ANS: D

The Aldrete score for postanesthesia monitoring ranges from 0 to 10, with 10 being the optimal score. A patient with a score of 10 is able to move all four extremities, breathe and cough freely, has a BP within 20 mm Hg of preoperative baseline, is fully awake, and maintains his or her oxygen saturation >92% on room air. The patient whose score is 0 is apneic and unresponsive, among other things. A score of 4 does not demonstrate readiness for transfer yet. A score of 8 is good, but 10 is better.

N

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment

Multiple Response

1. The student nurse has learned about complications from general anesthesia. Which of the following are included? (Select all that apply.)

a. Hypotension b. Dysrhythmias c. Hallucinations d. Increased intraocular pressure e. Edema of the face and throat

ANS: A, B, C

Some complications of general anesthesia include hypotension, heart rhythm abnormalities, and hallucinations. Increased intraocular pressure can be seen with neuromuscular blocking agents. Edema of the face and throat can occur with local anesthesia allergies.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Perform assessments and procedures guided by a child’s developmental level. b. Dehydration is not as likely to occur in children due to lower fluid volume. c. Temperature management is a priority in children due to immature thermoregulation d. The older patient may need more time to learn information and practice skills. e. The older adult’s liver and kidney function does not influence drug action.

2. What does the student nurse learn about age-related differences in surgical patients? (Select all that apply).

ANS: A, C, D

For pediatric patients, use the child’s developmental level to help plan the best way to perform assessments and procedures. Children are more vulnerable to fluid volume deficits because of their higher percentage of body fluids. Temperature management is a priority as children’s immature thermoregulatory systems often lead to temperature variations. Kidney and liver function decline with age, so drug metabolism, action, and excretion are all affected.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment