ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 22 Questions
Question 1 of 5
The nurse is caring for a patient who is recovering from anaesthesia in the postanaesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure is 112/60, with a pulse of 72 and warm, dry skin. Which of the following actions is the most appropriate for the nurse to implement at this time?
Correct Answer: B
Rationale: A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates normal response to the residual effects of anaesthesia and requires only ongoing monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased fluids, and high-concentration oxygen administration.
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
After a new nurse has been oriented to the postanaesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse does which of the following actions?
Correct Answer: C
Rationale: The patient should initially be positioned in the lateral 'recovery' position to keep the airway open and avoid aspiration. The prone position is not usually used and would make it difficult to assess the patient's respiratory effort and cardiovascular status. The Trendelenburg position is avoided because it increases the work of breathing. The patient is placed supine with the head elevated after regaining consciousness.
Question 4 of 5
The nurse is preparing an older-adult patient for discharge from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, 'I do not know if I can take care of myself with this patch over my eye.' Which of the following actions is the most appropriate for the nurse to implement?
Correct Answer: B
Rationale: The nurse's initial action should be to assess exactly the patient's concerns about self-care. Referral to home health care and assessment of the patient's support system may be appropriate actions but will be based on further assessment of the patient's concerns. Written instructions should be given to the patient, but these are unlikely to address the patient's stated concern about self-care.
Question 5 of 5
After removal of the nasogastric (NG) tube on the second postoperative day, the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Ambulation encourages peristalsis and the passing of flatus, which will relieve the patient's discomfort. If distension persists, the patient may need to be placed on NPO status, but usually this is not necessary. Morphine administration will further decrease intestinal motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion of the NG tube will not relieve the pains.