Chapter 22--Postoperative Nursing Management

Chapter 22--Postoperative Nursing Management MULTIPLE CHOICE 1. The nurse in the postanesthesia recovery room documents a client’s vital signs and current status and then covers the clipboard with a blank sheet of ...

Chapter 22--Postoperative Nursing Management MULTIPLE CHOICE 1. The nurse in the postanesthesia recovery room documents a client’s vital signs and current status and then covers the clipboard with a blank sheet of paper. The nurse’s actions are to support which of the following? 1. HIPAA laws 2. Postsurgical care expectations 3. The surgeon’s expectations 4. The anesthesiologist’s expectations PTS: 1 DIF: Analyze REF: Ethics in Practice: HIPAA: Implications for Perioperative Care 2. The nurse, caring for a postoperative client, will assess vital signs: 1. every 15 minutes for the first hour. 2. every 20 minutes for the first hour. 3. every 30 minutes for the first hour. 4. not important at this point. PTS: 1 DIF: Apply REF: Postoperative Physiological Stabilization 3. The nurse, caring for a postoperative client, will apply supplemental oxygen because: 1. the client needs it. 2. of anesthetic gasses in the lungs. 3. it helps control blood pressure. 4. it helps with wound healing. PTS: 1 DIF: Analyze REF: Postoperative Physiological Stabilization 4. A client recovering from anesthesia in the care unit has an artificial airway. The nurse knows the purpose of an artificial airway is to: 1. keep the mouth open. 2. keep the tongue from blocking the airway. 3. keep the client from vomiting. 4. allow the client to talk. PTS: 1 DIF: Analyze REF: Postoperative Physiological Stabilization 5. The nurse, caring for a client recovering from surgery, is monitoring the urine output and will notify the surgeon if the output falls below: 1. 10 mL/hr. 2. 20 mL/hr. 3. 30 mL/hr. 4. 50 mL/hr. PTS: 1 DIF: Apply REF: Postoperative Physiological Stabilization 6. The nurse assesses an area of drainage on the dressing of a postanesthesia care client’s surgical wound. Which of the following should the nurse do? 1. Call the surgeon right away. 2. Cover the dressing with a new dressing. 3. Circle the area and mark it with the date and time. 4. Pass it off to the next shift. PTS: 1 DIF: Apply REF: Wound Stabilization 7. The nurse coaches a postoperative client to utilize a breathing device that prevents the complication of atelectasis. This device would be a(n): 1. IPPB. 2. blow bottles. 3. incentive spirometer. 4. postural drainage. PTS: 1 DIF: Apply REF: Nursing Care Beyond Transfer 8. Which of the following nursing interventions would be appropriate after a wound evisceration? 1. Place the client in high-Fowler’s position. 2. Give the client fluids to prevent shock. 3. Push the organs back inside and tape up the wound. 4. Apply a sterile saline-soaked dressing and cover. PTS: 1 DIF: Apply REF: Anticipating Complications 9. The nurse should instruct the postoperative client that antiembolic stockings are used to: 1. keep the legs warm. 2. serve as a nonslip slipper. 3. promote venous return. 4. make it easier to ambulate after surgery. PTS: 1 DIF: Apply REF: Recovery Milestones Beyond the Day of Surgery 10. The nurse is planning to teach a postoperative client about discharge medication. Which of these nursing interventions would best assist the client in learning? 1. Withhold any pain medication so that the client can concentrate better. 2. Schedule the teaching after physical therapy so the client will be relaxed. 3. Place the client in a comfortable position and have the patient use the bathroom. 4. Plan the teaching at night right before bed so that the client can sleep on the new information given. PTS: 1 DIF: Apply REF: Box 22-4 Discharge Teaching Tips 11. The nurse is instructing a family member on how to change a client’s postoperative wound dressing at home. Which of the following should be included in these instructions? 1. Wear gloves to remove the old dressing. 2. Wear sterile gloves to apply the new dressing. 3. Clean hands prior to applying the new dressing. 4. Reposition the new dressing after application. . PTS: 1 DIF: Apply REF: Patient and Family Teaching 12. Which of the following should the nurse do when caring for an elderly postoperative client? 1. Allow rest periods between activities. 2. Address the client by the first name. 3. Assess for confusion if the client takes a long time to complete a task. 4. Avoid eye contact. PTS: 1 DIF: Apply REF: Respecting Our Differences: Postoperative Considerations for the Older Adult 13. The nurse is instructing a postoperative client regarding signs of complications. Which of the following should be included in these instructions? 1. Notify the physician with a body temperature greater than 99°F. 2. Expect the pain level to increase. 3. Report a change in drainage or increase in bleeding. 4. Dizziness and fainting is an expected side effect of anesthesia. PTS: 1 DIF: Apply REF: Patient and Family Teaching MULTIPLE RESPONSE 1. When a client is brought from the surgical suite to the postanesthesia care unit, the nurse will conduct a rapid head-to-toe visual assessment. Which of the following statuses will be assessed during the initial assessment? (Select all that apply.) 1. Surgical site 2. Vital signs 3. Respiratory stability 4. Circulatory stability 5. Range of motion of lower extremities 6. Bowel sounds PTS: 1 DIF: Apply REF: Postoperative Physiological Stabilization 2. The postanesthesia care unit nurse is caring for clients with different types of wound drains. Which are the most common types of drains? (Select all that apply.) 1. Plantar drain 2. Penrose drain 3. Davol 4. Hemovac 5. Ostomy appliance 6. Chest tube collection device PTS: 1 DIF: Analyze REF: Table 22-2 Wound Drains 3. The nurse, determining if a client is ready to be discharged from the postanesthesia care unit, utilizes the Aldrete System which assesses which of the following? (Select all that apply.) 1. Activity 2. Respiration 3. Circulation 4. Consciousness 5. Oxygen saturation 6. Appetite PTS: 1 DIF: Apply REF: Assessment Needs and Criteria for Discharge from PACU 4. A postoperative client is being transferred from the stretcher to the bed. Which of the following transfer techniques will be used to safety relocate this client? (Select all that apply.) 1. Use a padded transfer board. 2. Locate an extra transfer person on the side of the stretcher. 3. Lock the wheels on both the stretcher and the bed. 4. Keep the bed anchored against the back wall. 5. Slide the client first to the edge of the stretcher. 6. Use the count of five to move the client. PTS: 1 DIF: Apply REF: Box 22-1 Transfer Principles: Body Mechanics and Immediate Patient Comfort 5. The nurse is preparing instructions for a postoperative client. When planning these instructions, the nurse needs to take into consideration which three types of learning? (Select all that apply.) 1. Individual 2. Affective 3. Computerized 4. Psychomotor 5. Group 6. Cognitive PTS: 1 DIF: Analyze REF: Teaching/Learning Principles for the Postoperative Patient