1.

A 67-year-old male patient is admitted to the postanesthesia care

unit (PACU) after abdominal surgery. Which assessment, if made by
the nurse, is the best indicator of respiratory depression?

Increased respiratory rate

Decreased oxygen saturation
Increased carbon dioxide pressure
Frequent premature ventricular contractions (PVCs)

Increased carbon dioxide pressure

Transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a

sensitive indicator of respiratory depression. Increased CO2 pressures
would indicate respiratory depression. Clinical manifestations of
inadequate oxygenation include increased respiratory rate,
dysrhythmias (e.g., premature ventricular contractions), and decreased
oxygen saturation.

2.The nurse is caring for a 54-year-old unconscious female patient

who has just been admitted to the postanesthesia care unit after
abdominal hysterectomy. How should the nurse position the patient?

Left lateral position with head supported on a pillow

Prone position with a pillow supporting the abdomen
Supine position with head of bed elevated 30 degrees
Semi-Fowler's position with the head turned to the right

Left lateral position with head supported on a pillow

The unconscious patient should be placed in the lateral "recovery"

position to keep the airway open and reduce the risk of aspiration.
Once conscious, the patient is usually returned to a supine position
with the head of the bed elevated to maximize expansion of the thorax
by decreasing the pressure of the abdominal contents on the
diaphragm.
3.Which patient would be at highest risk for hypothermia after
surgery?

A 42-year-old patient who had a laparoscopic appendectomy

A 38-year-old patient who had a lumpectomy for breast cancer
A 20-year-old patient with an open reduction of a fractured radius
A 75-year-old patient with repair of a femoral neck fracture after a fall

A 75-year-old patient with repair of a femoral neck fracture after a fall

Patients at highest risk for hypothermia are those who are older,
debilitated, or intoxicated. Also, long surgical procedures and
prolonged anesthetic administration place the patient at increased risk
for hypothermia.

4.The nurse is providing discharge teaching to a 51-year-old female

patient who has had a laparoscopic cholecystectomy at an ambulatory
surgery center. Which statement, if made by the patient, indicates an
understanding of the discharge instructions?

"I will have someone stay with me for 24 hours in case I feel dizzy."
"I should wait for the pain to be severe before taking the medication."
"Because I did not have general anesthesia, I will be able to drive
home."
"It is expected after this surgery to have a temperature up to 102.4o
F."

"I will have someone stay with me for 24 hours in case I feel dizzy."

The nurse must assess understanding of discharge instructions and the

ability of the patient and caregiver to provide for home care needs.
The patient must be accompanied by a responsible adult caregiver.
The patient may not drive after receiving anesthetics or sedatives. The
patient should understand how to manage pain, and pain medication
should be taken before the pain becomes severe. The patient should
understand symptoms to be reported, such as a fever.
5.The nurse cares for a 72-year-old Native American male patient 2
days after a thoracotomy for tumor resection. What would be the most
appropriate action if the patient does not report any pain?

Contact the health care provider.

Identify possible reasons for denial of pain.
Administer the prescribed pain medication.
Assess the renal and liver function test results.

Identify possible reasons for denial of pain.

1.Unless contraindicated by the surgical procedure, which position is

preferred for the unconscious patient immediately postoperative?

Supine
Lateral
Semi-Fowler's
High-Fowler's

Lateral
2. The nurse is working on a surgical floor and is preparing to receive
a postoperative patient from the postanesthesia care unit (PACU).
What should the nurse's initial action be upon the patient's arrival?

Assess the patient's pain.

Assess the patient's vital signs.
Check the rate of the IV infusion.
Check the physician's postoperative orders.

Assess the patient's vital signs.

The highest priority action by the nurse is to assess the physiologic

stability of the patient. This is accomplished in part by taking the
patient's vital signs. The other actions can then take place in rapid
sequence.
3. When assessing a patient's surgical dressing on the first
postoperative day, the nurse notes new, bright-red drainage about 5
cm in diameter. In response to this finding, what should the nurse do
first?

Recheck in 1 hour for increased drainage.

Notify the surgeon of a potential hemorrhage.
Assess the patient's blood pressure and heart rate.
Remove the dressing and assess the surgical incision.

Assess the patient's blood pressure and heart rate.

The first action by the nurse is to gather additional assessment data to

form a more complete clinical picture. The nurse can then report all of
the findings. Continued reassessment will be done. Agency policy
determines whether the nurse may change the dressing for the first
time or simply reinforce it.

4.In planning postoperative interventions to promote repositioning,

ambulation, coughing, and deep breathing, which action should the
nurse recognize will best enable the patient to achieve the desired
outcomes?

Administering adequate analgesics to promote relief or control of pain

Asking the patient to demonstrate the postoperative exercises every 1

hour
Giving the patient positive feedback when the activities are performed
correctly
Warning the patient about possible complications if the activities are
not performed

Administering adequate analgesics to promote relief or

control of pain
5. Bronchial obstruction by retained secretions has contributed to a
postoperative patient's recent pulse oximetry reading of 87%. Which
health problem is the patient probably experiencing?

Atelectasis
Bronchospasm
Hypoventilation
Pulmonary embolism

Atelectasis

The most common cause of postoperative hypoxemia is atelectasis,

which may be the result of bronchial obstruction caused by retained
secretions or decreased respiratory excursion. Bronchospasm involves
the closure of small airways by increased muscle tone, whereas
hypoventilation is marked by an inadequate respiratory rate or depth.
Pulmonary emboli do not involve blockage by retained secretions.