2nd Edition, Ch. 16
Quiz by Darwin
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- Q1
The postanesthesia care unit (PACU) nurse determines that the patient’s Aldrete score is 9. The nurse on the postoperative unit knows that this means the:
patient is at an increased risk for postoperative respiratory complications.
patient’s condition warrants close monitoring.
patient is experiencing severe pain.
patient will soon be transferred to the postoperative unit.
60s - Q2
The patient recovering in the PACU awakes confused and disoriented. The nurse’s most appropriate intervention is to:
take vital signs.
encourage the patient to return to sleep.
say, “Your surgery is over. You are in the recovery area.”
chart, “Patient awake and disoriented.”
60s - Q3
Following abdominal surgery, the PACU nurse demonstrates the best nursing care by placing the semi-conscious patient in _____ position.
the supine
semi-Fowler’s
the lateral
Trendelenburg’s
60s - Q4
When the PACU nurse assesses diminished breath sounds in the unconscious recovering patient, the nurse should:
hyperventilate the patient with an Ambu bag.
turn the oxygen up to 3 L/min.
elevate the head of bed 45 degrees.
chart, “Diminished breath sounds in both lower lobes.”
60s - Q5
The nurse is caring for a patient during the first postoperative day. An appropriate goal to write in the nursing care plan to avoid atelectasis would be:
patient will turn, cough, and deep-breathe every 4 hours.
patient will “huff cough” every 2 hours.
patient will use the incentive spirometer twice a day.
nurse will assist the patient to ambulate in the hall three times a day.
60s - Q6
The nurse is caring for a 90-year-old postoperative patient. The nurse notes that the oxygen saturation is frequently dropping below 90%. This is most likely related to:
prolonged use of a walker.
poor fluid intake.
weakened respiratory muscles.
increased elasticity of costal cartilages.
60s - Q7
Which assessment finding on a patient who had a right total knee replacement this morning should be reported to the charge nurse immediately?
Pain at level of 8 at operative site
Capillary refill of right toe of 7 seconds
Right foot warm to touch
Swelling of right knee
60s - Q8
Antiembolic stockings are in place on the obese postsurgical patient. The nurse is aware that the standard of care in regard to antiembolic stockings is that the stockings should be:
left in place continually for the first 24 hours.
fitted tightly at the knee and ankle.
removed approximately 20 minutes every shift.
removed when ambulating.
60s - Q9
The nurse has been assigned to care for several postoperative patients. The nurse is aware that the patient most likely to develop thrombophlebitis is the patient:
with a history of blood clots who is being discharged following an outpatient cholecystectomy.
who is 6 days postoperative for total right hip replacement and has a history of left-sided stroke.
who has had major abdominal surgery and was dehydrated upon admission.
who is 2 days postoperative for hernia repair with a history of diabetes.
60s - Q10
The patient’s initial vital signs immediately on return from surgery are BP, 140/90; P, 80; R, 14; T, 98° F. One hour later the vital signs are BP, 130/84; P, 72; R, 16; T, 96.8° F. Based on these assessments, the nurse should:
add a blanket for warmth to the patient.
notify the charge nurse of probable hemorrhage.
raise the head of the bed 45 degrees.
note the assessment as normal postoperative recovery.
60s - Q11
The nurse is caring for a patient who has had spinal anesthesia. The nurse correctly questions which of the following orders?
Patient to lie flat for 6 to 8 hours.
Resume diet as tolerated.
Use incentive spirometer every hour while awake.
Notify physician immediately if headache occurs.
60s - Q12
To help seal the insertion site from the spinal anesthesia, the nurse will offer:
tea.
Jell-O.
milk.
iced water.
60s - Q13
The nurse should report to the charge nurse that a 10-hour post–abdominal surgery patient has:
vomited 20 mL of clear green fluid.
asked for pain medication twice.
not voided since surgery.
a weak cough ability.
60s - Q14
For the surgical patient who complains of excessive gas, the nurse will:
offer iced fluids.
arrange for large meal servings.
provide a straw for drinking fluids.
ambulate the patient in the hall.
60s - Q15
The postoperative patient complains of pain only 1 hour after having been medicated with an opioid, which cannot be repeated for 3 more hours. The nurse should initially:
give one half of the prescribed dose now.
contact the prescriber.
ambulate the patient in the hall.
reposition the patient.
60s