ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 19 : Postoperative Nursing Management Questions
Question 1 of 5
The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority?
Correct Answer: B
Rationale: The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Assessing for hemorrhage and assessing vital sign are also important, but constitute second and third priorities. Pain management is important but only after the patient has been stabilized.
Question 2 of 5
The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurses first response?
Correct Answer: B
Rationale: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection.
Then the nurse should call the physician and take the patients vital signs. The dehiscence needs to be surgically closed, so the nurse should never try to close it.
Question 3 of 5
The PACU nurse is caring for a 45-year-old male patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply.
Correct Answer: A,D,E
Rationale: The primary cardiovascular complications seen in the PACU include hypotension and shock, hemorrhage, hypertension, and dysrhythmias. Heart murmurs are not adverse reactions to surgery. Hypervolemia is not a common cardiovascular complication seen in the PACU, though fluid balance must be vigilantly monitored.
Question 4 of 5
A postoperative patient rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be the nurses first action?
Correct Answer: B
Rationale: Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures. Resuscitation is not necessarily required and the nurse must not leave the patient. The Trendelenberg position would be contraindicated.
Question 5 of 5
The intraoperative nurse is transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year-old woman. The nurse should prioritize which of the following actions?
Correct Answer: C
Rationale: Special attention is given to keeping the patient warm because elderly patients are more susceptible to hypothermia. It is all important for the nurse to pay attention to hydration, but hypovolemia does not occur as quickly as hypothermia. The patient is never sterile and restraints are very rarely necessary.