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 an 82-year-old female patient in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurses subsequent assessment?
Correct Answer: C
Rationale: Postoperative confusion is common in the older adult patient, but it could also indicate blood loss and the potential for hypovolemic shock; it is a critical symptom for the nurse to identify. Despite being common, it is not considered to be an expected finding. Postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery, but blood loss is more likely. A new onset of confusion, restlessness, and agitation does not necessarily suggest an underlying cognitive disorder.
Question 2 of 5
An adult patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the patient may be at risk for what?
Correct Answer: A
Rationale: The patient with a hemorrhage presents with hypotension; rapid, thready pulse; disorientation; restlessness; oliguria; and cold, pale skin. Aspiration would manifest in airway disturbance. Hypertension or dysrhythmias would be less likely to cause pallor and cool skin. An infection would not be present at this early postoperative stage.
Question 3 of 5
The nursing instructor is discussing postoperative care with a group of nursing students. A student nurse asks, Why does the patient go to the PACU instead of just going straight up to the postsurgical unit? What is the nursing instructors best response?
Correct Answer: B
Rationale: The PACU provides care for the patient while he or she recovers from the effects of anesthesia. The patient must be oriented, have stable vital signs, and show no evidence of hemorrhage or other complications. Patients will sometimes recover in the ICU, but this is considered an extension of the PACU. The PACU does allow the patient to recover from anesthesia, but the environment is calm and quiet as patients are initially disoriented and confused as they begin to awaken and reorient. Patients are not usually placed in the medicalsurgical unit for recovery and, although hospitals are occasionally short of beds, the PACU is not used for patient triage. Incisions are very rarely modified in the immediate postoperative period.
Question 4 of 5
The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention?
Correct Answer: B
Rationale: When a nurse finds a patient who is not breathing, the priority intervention is to open the airway and treat a possible hypopharyngeal obstruction.
To treat the possible airway obstruction, the nurse tilts the head back and then pushes forward on the angle of the lower jaw or performs the jaw thrust method to open the airway. This is an emergency and requires the basic life support intervention of airway, breathing, and circulation assessment. Arterial pulses should be checked only after airway and breathing have been established. Reintubation and resuscitation would begin after rapidly ruling out a hypopharyngeal obstruction.
Question 5 of 5
The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer. Which of the following statements by the patient indicates that teaching has been effective?
Correct Answer: D
Rationale: Optimal nutritional status is important for wound healing; the patient should eat plenty of fruits and vegetables and not reduce protein intake.
To avoid impeding circulation to the area, the bandage should be secure but not tight. If the patients foot feels cold, circulation is impaired, which inhibits wound healing.