such as bladder distention. Although hypoxemia is the most common cause, the patients oxygen
saturation is
96%. Emergence delirium is common in patients recovering from anesthesia, so there is
no need to notify the
ACP. Orientation of the patient to bed controls is needed, but is not likely to be effective unti
l the effects of
anesthesia have resolved more completely.
DIF: Cognitive Level: Analyze (analysis) REF: 357
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
10. 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?
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 patients incision in the chart.
d.
Provide hand off communication to the surgical unit charge nurse.
ANS: B
The scope of practice of UAP includes repositioning and moving patients under the supervision of a
nurse.
Providing report to another nurse, assessing and documenting the wound appearance, and clarifying
physician
orders with another nurse require registered-nurse (RN) level education and scope of pra
ctice.
DIF: Cognitive Level: Apply (application) REF: 354
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
11. A patient is transferred from the postanesthesia care unit (PACU) to the cli
nical unit. Which action by the
nurse on the clinical unit should be performed
first
?
a.
Assess the patients pain.
b.
Orient the patient to the unit.
c.
Take the patients vital signs.
d.
Read the postoperative orders.
ANS: C
Because the priority concerns after surgery are airway, breathing, and circulation, th
e vital signs are assessed
first. The other actions should take place after the vital signs are obtained and compare
d with the vital signs
before transfer.
DIF: Cognitive Level: Apply (application) REF: 350
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementa
tion
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MSC: NCLEX: Physiological Integrity
12. An older patient who had knee replacement surgery 2 days ago can only tolerate being out of
bed with
physical therapy twice a day. Which collaborative problem should the nurse identify as a
priority
for this
patient?
a.
Potential complication: hypovolemic shock
b.
Potential complication: venous thromboembolism
c.
Potential complication: fluid and electrolyte imbalance
d.
Potential complication: impaired surgical wound healing
ANS: B
The patient is older and relatively immobile, which are two risk factors for developme
nt of deep vein
thrombosis. The other potential complications are possible postoperative problems, but they
are not supported
by the data about this patient.
DIF: Cognitive Level: Apply (application) REF: 356
OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis
MSC: NCLEX: Physiological Integrity
13. A patient who is just waking up after having hip replacement surgery is agitated and confused
. Which
action should the nurse take
first
?
a.
Administer the ordered opioid.
b.
Check the oxygen (O
2
) saturation.
c.
Take the blood pressure and pulse.
d.
Apply wrist restraints to secure IV lines.
ANS: B
Emergence delirium may be caused by a variety of factors. However, the nurse should first
assess for
hypoxemia. The other actions also may be appropriate, but are not the best initial action.
DIF: Cognitive Level: Apply (application) REF: 357
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementa
tion
MSC: NCLEX: Physiological Integrity
14. A postoperative patient has not voided for 8 hours after return to the clinical unit. Which act
ion should the
nurse take
first
?
a.
Perform a bladder scan.
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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.
ANS: A
The initial action should be to assess the bladder for distention. If the bladder is disten
ded, providing the
patient with privacy (by walking with them to the bathroom) will be helpful. Because of the ri
sk for urinary
tract infection, catheterization should only be done after other measures have been trie
d without success. There
is no indication to notify the surgeon about this common postoperative problem unless all measures
to empty
the bladder are unsuccessful.
DIF: Cognitive Level: Apply (application) REF: 360-361
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementa
tion
MSC: NCLEX: Physiological Integrity
15. 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.
Whic
h action
should the nurse take
first
?
a.
Reinforce the dressing.
b.
Apply an abdominal binder.
c.
Take the patients vital signs.
d.
Recheck the dressing in 1 hour for increased drainage.
ANS: C
New bright-red drainage may indicate hemorrhage, and the nurse should initially assess th
e patients vital signs
for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital
signs. The
dressing may be changed or reinforced, based on the surgeons orders or institutional policy. The
nurse should
not wait an hour to recheck the dressing.
DIF: Cognitive Level: Apply (application) REF: 355
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementa
tion
MSC: NCLEX: Physiological Integrity
16. 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 ta
ke
first
?
a.
Have the patient use the incentive spirometer.
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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.
ANS: A
A temperature of 100.8 F in the first 48 hours is usually caused by atelectasis, and the nurse sh
ould have the
patient cough and deep breathe. This problem may be resolved by nursing intervention, and
therefore notifying
the health care provider is not necessary. Acetaminophen will reduce the temperature
, but it will not resolve the
underlying respiratory congestion. Because a wound infection does not usually occur before the third
postoperative day, a wound infection is not a likely source of the elevated temperature.
DIF: Cognitive Level: Apply (application) REF: 359
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementa
tion
MSC: NCLEX: Physiological Integrity
17. The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transf
erred from
surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action should the nurse ta
ke
first
?
a.
Elevate the patients head.
b.
Suction the patients mouth.
c.
Increase the oxygen flow rate.
d.
Perform the jaw-thrust maneuver.
ANS: D
In an unconscious postoperative patient, a likely cause of hypoxemia is airway obstruction by the to
ngue, and
the first action is to clear the airway by maneuvers such as the jaw thrust or chin lif
t. Increasing the oxygen
flow rate and suctioning are not helpful when the airway is obstructed by the tongue. Elevating the
patients
head will not be effective in correcting the obstruction but may help with oxygenation after th
e patient is
awake.
DIF: Cognitive Level: Apply (application) REF: 351 | 352 | 323
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementa
tion
MSC: NCLEX: Physiological Integrity
18. The nurse assesses a patient who had a total abdominal hysterectomy 2 days ago. Which
informa
tion about
the patient is
most
important to communicate to the health care provider?
a.
The right calf is swollen, warm, and painful.
b.
The patients temperature is 100.3 F (37.9 C).
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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.
ANS: A
The calf pain, swelling, and warmth suggest that the patient has a deep vein thrombosis, which
will require the
health care provider to order diagnostic tests and/or anticoagulants. Because the stre
ss response causes fluid
retention for the first 2 to 5 days postoperatively, the difference between intake and output is
expected. A
temperature elevation to 100.3 F on the second postoperative day suggests atelectasis, and the
nurse should
have the patient deep breathe and cough. Pain with ambulation is normal, and the nurse should
administer the
ordered analgesic before patient activities.
DIF: Cognitive Level: Apply (application) REF: 363
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessme
nt
MSC: NCLEX: Physiological Integrity
19. A patient who had knee surgery received intramuscular ketorolac (Toradol) 30 minutes ago an
d 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?
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.
ANS: A
The priority at this time is pain relief. Concomitant use of opioids and nonsteroidal antii
nflammatory drugs
(NSAIDs) improves pain control in postoperative patients. Patient teaching and reass
urance are appropriate,
but should be done after the patients pain is relieved. If the patient continues to have pain afte
r the morphine is
administered, the health care provider should be notified.
DIF: Cognitive Level: Apply (application) REF: 358
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementa
tion
MSC: NCLEX: Safe and Effective Care Environment
20. The nurse working in the postanesthesia care unit (PACU) notes that a patient who has ju
st 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.
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.
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d.
Administer acetaminophen (Tylenol) 650 mg suppository rectally.
ANS: A
The patient assessment indicates the need for active rewarming. There is no indica
tion of a need for
acetaminophen. Opioid analgesics may help reduce shivering. Because hypothermia is common in
the
immediate postoperative period, there is no need to notify the anesthesia care provider, unle
ss the patient
continues to be hypothermic after active rewarming.
DIF: Cognitive Level: Apply (application) REF: 359
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
21. 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 fo
r poor wound healing?
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/L
ANS: B
Because proteins are needed for an appropriate inflammatory response and wound healing, the lo
w serum
albumin level (normal level 3.5 to 5.0 g/dL) indicates a risk for poor wound healing. The potassium
level is
normal. Because a small amount of blood loss is expected with surgery, the hemoglobin level is
not indicative
of an increased risk for wound healing. WBC count is expected to increase after surgery as
a part of the normal
inflammatory response.
DIF: Cognitive Level: Apply (application) REF: 173
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
22. The nurse assesses a patient on the second postoperative day after abdominal surgery to re
pair a perforated
duodenal ulcer. Which finding is
most
important for the nurse to report to the surgeon?
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
ANS: D
Wound drainage should decrease and change in color from sanguineous to serosanguineous by the
second
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postoperative day. The color and amount of drainage for this patient are abnormal and should be
reported.
Redness and swelling along the suture line and a slightly elevated temperature are norma
l signs of
postoperative inflammation. Atelectasis is common after surgery. The nurse should hav
e the patient cough and
deep breathe, but there is no urgent need to notify the surgeon.
DIF: Cognitive Level: Apply (application) REF: 361
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessme
nt
MSC: NCLEX: Safe and Effective Care Environment
23. After receiving change-of-shift report about these postoperative patients, which pat
ient should the nurse
assess
first
?
a.
Obese patient who had abdominal surgery 3 days ago and whose wound edges are separating
b.
Patient who has 30 mL of sanguineous drainage in the wound drain 10 hours after hip replacement
surgery
c.
Patient who has bibasilar crackles and a temperature of 100F (37.8C) on the first posto
perative day
after chest surgery
d.
Patient who continues to have incisional pain 15 minutes after hydrocodone and acetaminophen
(Vicodin) administration
ANS: A
The patients history and assessment suggests possible wound dehiscence, which should be reporte
d
immediately to the surgeon. Although the information about the other patients indicates a need
for ongoing
assessment and/or possible intervention, the data do not suggest any acute complications. Sma
ll amounts of red
drainage are common in the first postoperative hours. Bibasilar crackles and a slightl
y elevated temperature are
common after surgery, although the nurse will need to have the patient cough and deep breathe.
Oral
medications typically take more than 15 minutes for effective pain relief.
DIF: Cognitive Level: Analyze (analysis) REF: 361
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessme
nt
MSC: NCLEX: Safe and Effective Care Environment
OTHER
1. While ambulating in the room, a patient complains of feeling dizzy. In what order will the nurs
e accomplish
the following activities?
(Put a comma and a space between each answer choice [A, B, C, D].)
a. Have the patient sit down in a chair.
b. Give the patient something to drink.
c. Take the patients blood pressure (BP).
d. Notify the patients health care provider.
ANS:
A, C, B, D
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The first priority for the patient with syncope is to prevent a fall, so the patient should be
assisted to a chair.
Assessment of the BP will determine whether the dizziness is due to orthostatic
hypotension, which occurs
because of hypovolemia. Increasing the fluid intake will help prevent orthostatic dizzines
s. Because this is a
common postoperative problem that is usually resolved through nursing measures such as increas
ing fluid
intake and making position changes more slowly, there is no urgent need to notify the health care
provider.
DIF: Cognitive Level: Apply (application) REF: 357
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementa
tion
MSC: NCLEX: Physiological Integrity
2. A patients blood pressure in the postanesthesia care unit (PACU) has dropped from an admis
sion blood
pressure of 140/86 to 102/60 with a pulse change of 70 to 96. SpO
2
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].)
a. Increase the IV infusion rate.
b. Assess the patients dressing.
c. Increase the oxygen flow rate.
d. Check the patients temperature.
ANS:
A, C, B, D
The first nursing action should be to increase the IV infusion rate. Because the most comm
on cause of
hypotension is volume loss, the IV rate should be increased. The next action should be to increase
the oxygen
flow rate to maximize oxygenation of hypoperfused organs. Because hemorrhage is a common
cause
of
postoperative volume loss, the nurse should check the dressing. Finally, the patients temperat
ure should be
assessed to determine the effects of vasodilation caused by rewarming.
DIF: Cognitive Level: Analyze (analysis) REF: 355-356
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementa
tion
MSC: NCLEX: Physiological Integrity