ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 19 : Postoperative Nursing Management Questions
Question 1 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 2 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.
Question 3 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 4 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 5 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.