Exam 22: Nursing Management Postoperative Care

The nurse is caring for a client who is recovering from anaesthesia in the postanaesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure is 112/60, with a pulse of 72 andwarm,dry skin. Which of the following actions is the most appropriate for the nurse to implement at this time?

The nurse is caring for a client 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.)

The nurse is caring for a client following gallbladder surgery, and the client's T-tube is draining dark green fluid. Which of the following actions should the nurse take?

The nurse is caring for a client who is being transferred from the postanaesthesia care unit (PACU) to the clinical surgical unit. Which of the following actions should the nurse implement first on the clinical surgical unit?

The nurse is caring for an older-adult client 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 client?

In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative client on the first postoperative day, which of the following actions by the nurse is most helpful?

The nurse is caring for a client who had abdominal surgery two days previously. Which of the following information about the client is most important to communicate to the health care provider?

The nurse is caring for a client 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?

The nurse is caring for a client with abdominal surgery and on the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. Which of the following actions should the nurse implement first?

After removal of the nasogastric (NG) tube on the second postoperative day, the client is placed on a clear liquid diet. Four hours later, the client complains of sharp, cramping gas pains. Which of the following actions should the nurse take?

The nurse is caring for a client in the PACU and the client'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 3L of oxygen. In which order should the nurse take these actions?

The nurse is caring for a client who has begun to awaken after 30 minutes in the postanaesthesia care unit (PACU), who is restless and shouting at the nurse. The client's oxygen saturation is 99%, and recent laboratory results are all normal. Which of the following actions by the nurse is most appropriate?

The nurse is caring for a client in the postoperative period who is on bed rest. Which of the following actions should the nurse implement?

The nurse is caring for a client who is just waking up after having a general anaesthetic and the client is agitated and confused. Which of the following actions should the nurse take first?

The nurse is preparing an older-adult client for discharge from the ambulatory surgical unit following left eye surgery. The client tells the nurse, "I do not know if I can take care of myself with this patch over my eye." Which of the following actionsisthemost appropriate for the nurse to implement?

The nurse is caring for a client who is recovering from anaesthesia in the postanaesthesia care unit (PACU), and the vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The client is sleepy but awakens easily. Which of the followingactions should the nurse take at this time?

The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative client have been successful when which of the following goals has been met?

After a new nurse has been oriented to the postanaesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse does which of the following actions?

The nurse is caring for an older adult in the postanaesthesia unit. Which of the following age-related considerations may impact postoperative recovery?

The nurse is caring for a postoperative client who has not voided for 7 hours after return to the postsurgical unit. Which of the following actions should the nurse take first?