Question 1

The nasogastric (NG)tube is removed on the second postoperative day,and the patient is placed on a clear liquid diet.Four hours later,the patient complains of sharp,cramping gas pains.What action by the nurse is the most appropriate?

Accepted Answer

A)   Reinsert the NG tube.
B)   Give the PRN IV opioid.
C)   Assist the patient to ambulate.
D)   Place the patient on NPO status. C

Question 2

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction.The nurse notices new bright-red drainage about 5 cm in diameter on the dressing.Which action should the nurse take first?

Accepted Answer

A)   Reinforce the dressing.
B)   Apply an abdominal binder.
C)   Take the patient's vital signs.
D)   Recheck the dressing in 1 hour for increased drainage. C

Question 3

The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU)15 minutes ago.Which action should the nurse take first?

Accepted Answer

A)   Elevate the patient's head.
B)   Suction the patient's mouth.
C)   Increase the oxygen flow rate.
D)   Perform the jaw-thrust maneuver. D

Question 4

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU).Which action by the new nurse,if observed by the experienced nurse,indicates that the orientation was successful?

Accepted Answer

A)   The new nurse assists a nauseated patient to a supine position.
B)   The new nurse positions an unconscious patient supine with the head elevated.
C)   The new nurse turns an unconscious patient to the side upon arrival in the PACU.
D)   The new nurse places a patient in the Trendelenburg position when the blood pressure drops.

Question 5

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago.Which information about the patient is most important to communicate to the health care provider?

Accepted Answer

A)   The right calf is swollen, warm, and painful.
B)   The patient's temperature is 100.3° F (37.9° 
C)  .
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 to 10 scale)  when ambulating.

Question 6

On admission of a patient to the postanesthesia care unit (PACU),the blood pressure (BP)is 122/72.Thirty minutes after admission,the BP falls to 114/62,with a pulse of 74 and warm,dry skin.Which action by the nurse is most appropriate?

Accepted Answer

A)   Increase the IV fluid rate.
B)   Continue to take vital signs every 15 minutes.
C)   Administer oxygen therapy at 100% per mask.
D)   Notify the anesthesia care provider (ACP)  immediately.

Question 7

A patient who is just waking up after having hip replacement surgery is agitated and confused.Which action should the nurse take first?

Accepted Answer

A)   Administer the ordered opioid.
B)   Check the oxygen (O2)  saturation.
C)   Take the blood pressure and pulse.
D)   Apply wrist restraints to secure IV lines.

Question 8

A postoperative patient has not voided for 8 hours after return to the clinical unit.Which action should the nurse take first?

Accepted Answer

A)   Perform a bladder scan.
B)   Encourage increased oral fluid intake.
C)   Assist the patient to ambulate to the bathroom.
D)   Insert a straight catheter as indicated on the PRN order.

Question 9

A patient's T-tube is draining dark green fluid after gallbladder surgery.What action by the nurse is the most appropriate?

Accepted Answer

A)   Notify the patient's surgeon.
B)   Place the patient on bed rest.
C)   Document the color and amount of drainage.
D)   Irrigate the T-tube with sterile normal saline.

Question 10

A patient's blood pressure in the postanesthesia care unit (PACU)has dropped from an admission blood pressure of 140/86 to 102/60 with a pulse change of 70 to 96.SpO2 is 92% on 3 L of oxygen.In which order should the nurse take these actions? (Put a comma and a space between each answer choice [A,B,C,D].)

Accepted Answer

A)   Increase the IV infusion rate.
B)   Assess the patient's dressing.
C)   Increase the oxygen flow rate.
D)   Check the patient's temperature.

Question 11

A postoperative patient has a nursing diagnosis of ineffective airway clearance.The nurse determines that interventions for this nursing diagnosis have been successful if which is observed?

Accepted Answer

A)   Patient drinks 2 to 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 100.4° F orally.

Question 12

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst,the nurse obtains an oral temperature of 100.8° F.Which action should the nurse take first?

Accepted Answer

A)   Have the patient use the incentive spirometer.
B)   Assess the surgical incision for redness and swelling.
C)   Administer the ordered PRN acetaminophen (Tylenol) .
D)   Ask the health care provider to prescribe a different antibiotic.

Question 13

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer.Which finding is most important for the nurse to report to the surgeon?

Accepted Answer

A)   Tympanic temperature 99.2° F (37.3° 
C)  
B)   Fine crackles audible at both lung bases
C)   Redness and swelling along the suture line
D)   200 mL sanguineous fluid in the wound drain

Question 14

In the postanesthesia care unit (PACU),a patient's vital signs are blood pressure 116/72,pulse 74,respirations 12,and SpO2 91%.The patient is sleepy but awakens easily.Which action should the nurse take first?

Accepted Answer

A)   Place the patient in a side-lying position.
B)   Encourage the patient to take deep breaths.
C)   Prepare to transfer the patient to a clinical unit.
D)   Increase the rate of the postoperative IV fluids.

Question 15

The nurse reviews the laboratory results for a patient on the first postoperative day after a hiatal hernia repair.Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing?

Accepted Answer

A)   Potassium 3.5 mEq/L
B)   Albumin level 2.2 g/dL
C)   Hemoglobin 11.2 g/dL
D)   White blood cells 11,900/µL

Question 16

A patient is transferred from the postanesthesia care unit (PACU)to the clinical unit.Which action by the nurse on the clinical unit should be performed first?

Accepted Answer

A)   Assess the patient's pain.
B)   Orient the patient to the unit.
C)   Take the patient's vital signs.
D)   Read the postoperative orders.

Question 17

A nurse assists a patient on the first postoperative day to ambulate,cough,deep breathe,and turn.Which action by the nurse is most helpful?

Accepted Answer

A)   Teach the patient to fully exhale into the incentive spirometer.
B)   Administer ordered analgesic medications before these activities.
C)   Ask the patient to state two possible complications of immobility.
D)   Encourage the patient to state the purpose of splinting the incision.

Question 18

The nurse working in the postanesthesia care unit (PACU)notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C).Which action should the nurse take?

Accepted Answer

A)   Cover the patient with a warm blanket and put on socks.
B)   Notify the anesthesia care provider about the temperature.
C)   Avoid the use of opioid analgesics until the patient is warmer.
D)   Administer acetaminophen (Tylenol)  650 mg suppository rectally.

Question 19

A patient who had knee surgery received intramuscular ketorolac (Toradol)30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale).Which action is best for the nurse to take at this time?

Accepted Answer

A)   Administer the prescribed PRN IV morphine sulfate.
B)   Notify the health care provider about the ongoing knee pain.
C)   Reassure the patient that postoperative pain is expected after knee surgery.
D)   Teach the patient that the effects of ketorolac typically last about 6 to 8 hours.

Question 20

Which action could the postanesthesia care unit (PACU)nurse delegate to unlicensed assistive personnel (UAP)who help with the transfer of a patient to the clinical unit?

Accepted Answer

A)   Clarify the postoperative orders with the surgeon.
B)   Help with the transfer of the patient onto a stretcher.
C)   Document the appearance of the patient's incision in the chart.
D)   Provide hand off communication to the surgical unit charge nurse.

Exam 16: Nursing Management: Postoperative Care

The nasogastric (NG) tube is removed on the second postoperative day,and the patient is placed on a clear liquid diet.Four hours later,the patient complains of sharp,cramping gas pains.What action by the nurse is the most appropriate?

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction.The nurse notices new bright-red drainage about 5 cm in diameter on the dressing.Which action should the nurse take first?

The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago.Which action should the nurse take first?

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU) .Which action by the new nurse,if observed by the experienced nurse,indicates that the orientation was successful?

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago.Which information about the patient is most important to communicate to the health care provider?

On admission of a patient to the postanesthesia care unit (PACU) ,the blood pressure (BP) is 122/72.Thirty minutes after admission,the BP falls to 114/62,with a pulse of 74 and warm,dry skin.Which action by the nurse is most appropriate?

A patient who is just waking up after having hip replacement surgery is agitated and confused.Which action should the nurse take first?

A postoperative patient has not voided for 8 hours after return to the clinical unit.Which action should the nurse take first?

A patient's T-tube is draining dark green fluid after gallbladder surgery.What action by the nurse is the most appropriate?

A postoperative patient has a nursing diagnosis of ineffective airway clearance.The nurse determines that interventions for this nursing diagnosis have been successful if which is observed?

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst,the nurse obtains an oral temperature of 100.8° F.Which action should the nurse take first?

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer.Which finding is most important for the nurse to report to the surgeon?

In the postanesthesia care unit (PACU) ,a patient's vital signs are blood pressure 116/72,pulse 74,respirations 12,and SpO₂ 91%.The patient is sleepy but awakens easily.Which action should the nurse take first?

The nurse reviews the laboratory results for a patient on the first postoperative day after a hiatal hernia repair.Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing?

A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit.Which action by the nurse on the clinical unit should be performed first?

A nurse assists a patient on the first postoperative day to ambulate,cough,deep breathe,and turn.Which action by the nurse is most helpful?

The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C) .Which action should the nurse take?

A patient who had knee surgery received intramuscular ketorolac (Toradol) 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale) .Which action is best for the nurse to take at this time?

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit?

Exam 16: Nursing Management: Postoperative Care

The nasogastric (NG) tube is removed on the second postoperative day,and the patient is placed on a clear liquid diet.Four hours later,the patient complains of sharp,cramping gas pains.What action by the nurse is the most appropriate?

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction.The nurse notices new bright-red drainage about 5 cm in diameter on the dressing.Which action should the nurse take first?

The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago.Which action should the nurse take first?

An experienced nurse orients a new nurse to the postanesthesia care unit (PACU) .Which action by the new nurse,if observed by the experienced nurse,indicates that the orientation was successful?

The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago.Which information about the patient is most important to communicate to the health care provider?

On admission of a patient to the postanesthesia care unit (PACU) ,the blood pressure (BP) is 122/72.Thirty minutes after admission,the BP falls to 114/62,with a pulse of 74 and warm,dry skin.Which action by the nurse is most appropriate?

A patient who is just waking up after having hip replacement surgery is agitated and confused.Which action should the nurse take first?

A postoperative patient has not voided for 8 hours after return to the clinical unit.Which action should the nurse take first?

A patient's T-tube is draining dark green fluid after gallbladder surgery.What action by the nurse is the most appropriate?

A postoperative patient has a nursing diagnosis of ineffective airway clearance.The nurse determines that interventions for this nursing diagnosis have been successful if which is observed?

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst,the nurse obtains an oral temperature of 100.8° F.Which action should the nurse take first?

The nurse assesses a patient on the second postoperative day after abdominal surgery to repair a perforated duodenal ulcer.Which finding is most important for the nurse to report to the surgeon?

In the postanesthesia care unit (PACU) ,a patient's vital signs are blood pressure 116/72,pulse 74,respirations 12,and SpO2 91%.The patient is sleepy but awakens easily.Which action should the nurse take first?

The nurse reviews the laboratory results for a patient on the first postoperative day after a hiatal hernia repair.Which finding would indicate to the nurse that the patient is at increased risk for poor wound healing?

A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit.Which action by the nurse on the clinical unit should be performed first?

A nurse assists a patient on the first postoperative day to ambulate,cough,deep breathe,and turn.Which action by the nurse is most helpful?

The nurse working in the postanesthesia care unit (PACU) notes that a patient who has just been transported from the operating room is shivering and has a temperature of 96.5° F (35.8° C) .Which action should the nurse take?

A patient who had knee surgery received intramuscular ketorolac (Toradol) 30 minutes ago and continues to complain of pain at a level of 7 (0 to 10 scale) .Which action is best for the nurse to take at this time?

Which action could the postanesthesia care unit (PACU) nurse delegate to unlicensed assistive personnel (UAP) who help with the transfer of a patient to the clinical unit?

In the postanesthesia care unit (PACU) ,a patient's vital signs are blood pressure 116/72,pulse 74,respirations 12,and SpO₂ 91%.The patient is sleepy but awakens easily.Which action should the nurse take first?