1. A postoperative patient is complaining of incisional pain. An order has been given for morphine every 4 to 6 hours as needed (PRN). What should the nurse assess first?
a. Assess for the presence of bowel sounds.
b.
...
1. A postoperative patient is complaining of incisional pain. An order has been given for morphine every 4 to 6 hours as needed (PRN). What should the nurse assess first?
a. Assess for the presence of bowel sounds.
b. Assess pupillary reaction.
c. Ask the patient’s family if she is having pain.
d. Determine when the patient last received pain medication. ANS: D
Verifying the time of the last dose decreases the risk of a dose of medication being given too soon.
DIF: Cognitive Level: Application REF: p. 277 OBJ: 9 TOP: Acute Pain KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2. A nurse is caring for a postoperative patient. What should the nurse ask when assessing for the complication of malignant hyperthermia?
a. “Do you think you might have a fever?”
b. “Do you currently have an infection?”
c. “Has anyone in your family ever had problems with general anesthesia?”
d. “Have you ever had any type of malignancy?” ANS: C
Malignant hyperthermia is a life-threatening complication that occurs in response to certain drugs. Susceptibility to this response is inherited.
DIF: Cognitive Level: Application REF: p. 268 OBJ: 7
TOP: General Anesthesia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk
3. A patient who had a hysterectomy yesterday has not been allowed food or drink by mouth (NPO). The physician has now ordered the patient’s diet to be clear liquids. What should the nurse assess prior to providing this patient with clear liquids?
a. Feelings of hunger
b. Bowel sounds
c. Positive Homans sign
d. Gag reflex ANS: B
The absence of bowel sounds would contraindicate a diet of clear liquids.
DIF: Cognitive Level: Application REF: p. 283 OBJ: 7 | 8 TOP: Postoperative Nursing Implementations
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
4. Which technique should a nurse implement when changing a postoperative dressing?
a. Enteric isolation
b. Aseptic technique
c. Clean technique
d. Respiratory isolation ANS: B
The aseptic technique is important to reduce the risk of infection.
DIF: Cognitive Level: Comprehension REF: p. 281 OBJ: 9
TOP: Postoperative Risk for Infection KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
5. A nurse is caring for a postoperative patient who has had spinal anesthesia. Which assessment is a priority for this patient?
a. Complaints of a headache
b. Pulse rate of 78 beats/min
c. Voided 300 mL
d. Blood pressure of 126/78 mm Hg ANS: A
One complication of spinal anesthesia is postspinal headache, which is caused by the leaking of cerebrospinal fluid at the puncture site.
DIF: Cognitive Level: Application REF: p. 267 OBJ: 7
TOP: Regional Anesthesia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. What should a nurse ensure that a postoperative patient implement to best prevent deep vein thrombosis (DVT)?
a. Splint the incision.
b. Cough and deep breathe every 2 hours.
c. Regularly remove antiembolism stockings.
d. Ambulate frequently. ANS: D
DVT is best prevented by early and frequent ambulation of the patient.
DIF: Cognitive Level: Application REF: p. 272 OBJ: 7
TOP: Postoperative Complications KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. During a nurse’s preoperative assessment, the nurse notices that a patient is extremely anxious. The patient’s blood pressure is 142/92 mm Hg, the heart rate is 104 beats/min, and respirations are 32 breaths/min. What nursing action should be implemented?
a. Give the preoperative medicine early to help calm the patient.
b. Call the surgical department and cancel the surgery.
c. Notify the anesthesiologist or surgeon.
d. Instruct the patient on possible postoperative complications. ANS: C
When significant fear is associated with surgical complications, sometimes surgery is postponed until the anxiety level is reduced.
DIF: Cognitive Level: Analysis REF: p. 259 OBJ: 3
TOP: Preoperative Anxiety KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
8. A nurse is performing a postoperative assessment on a patient who has just returned from a hernia repair. The patient’s blood pressure is 90/60 mm Hg, and the apical pulse is 108 beats/min. What should be the nurse’s first action?
a. Check the dressing for bleeding.
b. Notify the registered nurse (RN).
c. Document the vital signs.
d. Increase the rate of infusion of intravenous fluids. ANS: A
A decrease in blood pressure and tachycardia could indicate postoperative bleeding. The first action of the nurse should be to check the dressing and then report to the RN.
DIF: Cognitive Level: Application REF: p. 270 OBJ: 8
TOP: Postoperative Complications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
9. A postoperative patient who has no previous medical conditions is difficult to arouse when transferred to the surgical unit from the postanesthesia care unit. A nurse monitors the pulse oximeter and gets a reading of 85%. What should be the nurse’s next action?
a. Assess the pulse oximeter reading again in 1 hour.
b. Arouse the patient, have him cough, and encourage deep breathing.
c. Administer a dose of pain medication.
d. Suction fluid from the oral cavity. ANS: B
If the pulse oximeter reading is less than 90%, the patient should be aroused and encouraged to take deep breaths. The patient’s respirations may not be adequate as a result of the effects of anesthesia.
DIF: Cognitive Level: Application REF: p. 271 OBJ: 8 TOP: Hypoxia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
10. A nurse has completed giving discharge instructions to a patient after a hernia repair. What verbalization by the patient should lead the nurse to determine that the patient understands the instructions?
a. Go back to work tomorrow.
b. Do not change the dressing until he sees his physician in 2 weeks.
c. Ignore changes in the size of his abdomen.
d. Report fever, redness, swelling, or increased pain at the incision site. ANS: D
The patient should report any signs and symptoms of infection (e.g., fever, redness, swelling, pain).
DIF: Cognitive Level: Comprehension REF: p. 284 OBJ: 10
TOP: Discharge Planning KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
11. A nurse should include the proper use of an incentive spirometer in teaching a preoperative patient. What postoperative assessment of this patient would reveal that the incentive spirometry teaching has been effective?
a. Adventitious breath sounds
b. Expiratory wheezing
c. Thick, green respiratory secretions
d. Clear breath sounds ANS: D
An incentive spirometer is used to promote lung expansion, which opens airways, reduces atelectasis, and stimulates coughing to clear secretions.
DIF: Cognitive Level: Comprehension REF: p. 281 OBJ: 8
TOP: Impaired Gas Exchange KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
12. The suprapubic area of a postoperative patient is distended. The patient states that he has not voided since surgery approximately 9 hours ago. What should be the nurse’s first action?
a. Notify the head nurse or physician.
b. Insert a catheter and document insertion.
c. Seat the patient on the side of the bed to try to void.
d. Prepare the patient to return to surgery. ANS: C
The patient should be encouraged to try to void in a natural position before other measures are taken. Seated on the bedside or on a bedside commode may make urination easier.
DIF: Cognitive Level: Application REF: p. 283 OBJ: 9
TOP: Postoperative Urinary Retention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
13. Which modification should the nurse implement when caring for a postoperative patient after cataract surgery?
a. Early ambulation is not necessary.
b. Remove the dressing immediately.
c. Omit instructions relative to coughing.
d. Omit use of an incentive spirometer for deep breathing. ANS: C
There are only a few instances in which coughing is contraindicated. They include surgeries for hernias, cataracts, and brain surgery.
DIF: Cognitive Level: Application REF: p. 282 OBJ: 7
TOP: Postoperative Complications KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
14. When obtaining a patient’s signature on the surgical consent form, the patient seems confused about the procedure to be performed. What is the most appropriate response by the nurse?
a. Tell the patient to talk to the physician after he or she gets to the surgical department.
b. Ask the patient to go ahead and sign the consent.
c. Ask the patient what the physician told him and then call the physician if necessary.
d. Encourage the patient to ask his family what the physician told them. ANS: C
[Show More]
