ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 22 Questions
Question 1 of 5
In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which of the following actions by the nurse is most helpful?
Correct Answer: C
Rationale: The most essential nursing action in encouraging these postoperative activities is administration of adequate analgesia to allow the patient to accomplish the activities with minimal pain. Even with motivation provided by proper teaching, positive reinforcement, and concern about complications, patients will have difficulty if there is a great deal of pain involved with these activities.
Question 2 of 5
The nurse is caring for a patient who is recovering from anaesthesia in the postanaesthesia care unit (PACU), and the vital signs are blood pressure 118/72, pulse 72, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which of the following actions should the nurse take at this time?
Correct Answer: B
Rationale: The patient's borderline SpO2 and sleepiness indicate hypoventilation. The nurse should stimulate the patient and remind the patient to take deep breaths. Placing the patient in a lateral position is needed when the patient first arrives in the PACU and is unconscious. The stable BP and pulse indicate that no changes in fluid intake are required. The patient is not fully awake and has a low SpO2, indicating that transfer from the PACU is not appropriate.
Question 3 of 5
The nurse is caring for a patient with abdominal surgery and on the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. Which of the following actions should the nurse implement first?
Correct Answer: B
Rationale: New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's 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 surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing.
Question 4 of 5
The nurse is caring for an older adult in the postanesthesia unit. Which of the following age-related considerations may impact postoperative recovery?
Correct Answer: B
Rationale: The older adult has a decrease in respiratory function, including decreased ability to cough, decreased thoracic compliance (not increased), and decreased (not increased) lung tissue. There is no noted decrease in compliance related to postoperative deep breathing and coughing.
Question 5 of 5
The nurse is caring for a patient and during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 38.2°C (100.8°F). Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: A temperature of 38.2°C (100.8°F) in the first 48 hours is usually caused by atelectasis, and the nurse should 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 evidence of wound infection does not usually occur before the third postoperative day, assessment of the incision is not likely to be useful.