Lewis: Medical-Surgical Nursing, 8th Edition QUESTIONS WITH ANSWERS 2021/22

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A 42-year-old patient is recovering from anesthesia in the postanesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pre... ssure falls to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at this time is to a. increase the rate of the IV fluid replacement. 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. ANS: B A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration. 2. During recovery from anesthesia in the postanesthesia care unit (PACU), a patient’s vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take at this time? a. Place the patient in a side-lying position. b. Encourage the patient to take deep breaths. c. Prepare to transfer the patient from the PACU. d. Increase the rate of the postoperative IV fluids. ANS: B The patient’s borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable BP and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU is not appropriate. 3. After a new nurse has been oriented to the postanesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse a. places a patient in the Trendelenburg position when the blood pressure (BP) drops. b. assists a patient to the prone position when the patient is nauseated. c. turns an unconscious patient to the side when the patient arrives in the PACU. d. positions a newly admitted unconscious patient supine with the head elevated. ANS: C The patient should initially be positioned in the lateral “recovery” position to keep the airway open and avoid aspiration. The prone position is not usually used and would make it difficult to assess the patient’s respiratory effort and cardiovascular status. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness. 4. A 75-year-old is to be discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, “I do not know if I can take care of myself with this patch over my eye.” The most appropriate nursing action is to a. refer the patient for home health care services. b. discuss the specific concerns regarding self-care. c. give the patient written instructions regarding care. d. assess the patient’s support system for care at home. ANS: B The nurse’s initial action should be to assess exactly the patient’s concerns about selfcare. Referral to home health care and assessment of the patient’s support system may be appropriate actions but will be based on further assessment of the patient’s concerns. Written instructions should be given to the patient, but these are unlikely to address the patient’s stated concern about self-care. 5. After removal of the nasogastric (NG) tube on the second postoperative day, the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. Which action should the nurse take? a. Reinsert the NG tube. b. Give the PRN IV opioid. c. Assist the patient to ambulate. d. Place the patient on NPO status. ANS: C Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient’s discomfort. If distention persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains. 6. Following gallbladder surgery, a patient’s T-tube is draining dark green fluid. Which action should the nurse take? a. Place the patient on bed rest. b. Notify the patient’s surgeon. c. Document the color and amount of drainage. d. Irrigate the T-tube with sterile normal saline. ANS: C A T-tube normally drains dark green to bright yellow drainage, so no action other than to document the amount and color of the drainage is needed. The other actions are not necessary [Show More]

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