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Medical-Surgical Nursing: Critical Thinking for Collaborative Care, 5th Edition

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Test Bank Chapter 22: Interventions for Postoperative Clients MULTIPLE CHOICE 1. Which function or assessment finding in a client being admitted to the postanesthesia care unit after surgery is the best indication t ...

Test Bank Chapter 22: Interventions for Postoperative Clients MULTIPLE CHOICE 1. Which function or assessment finding in a client being admitted to the postanesthesia care unit after surgery is the best indication that the client's respiratory status does not require immediate attention? A. The client is able to talk. B. The client is alert and oriented. C. The client's oxygen saturation is 90%. D. The client's chest rises and falls rhythmically during respiration. ANS: C The client may have impaired gas exchange at the alveolar capillary level and still be able to talk and be alert and oriented. The chest may continue to rise and fall rhythmically. The definitive assessment finding that indicates whether gas exchange is effective is the degree of oxygen saturation. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Physiological Integrity 2. Which assessment finding in a postoperative client indicates to the nurse that the interventions to prevent hypovolemia need to be re-evaluated? A. The blood pressure changes from 136/80 to 122/80 mm Hg. B. The urine output decreases from 40 to 10 mL/hour. C. The client cannot count backward from 100 by threes. D. The client's temperature has changed from 100.2° to 100.4° F. ANS: B One of the most sensitive indicators of vascular volume loss is a decreased urine output in response to increased secretion of antidiuretic hormone (ADH). DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Physiological Integrity 3. The client is admitted to the postanesthesia care unit (PACU) after surgery that took place with the client in the lithotomy position. Which change in assessment findings alerts the nurse to a possible complication of this surgical position? A. The electrocardiogram (ECG) shows tall, peaked T waves and wide QRS complexes. B. The client only arouses in response to light shaking. C. The pulse pressure has increased from 28 to 40 mm Hg. D. The dorsalis pedis pulses are not palpable bilaterally

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