b. Explain the rationale for these activities.
c. Provide adequate and regular pain medication.
d. Use an incentive spirometer to motivate the patient.
9. While assessing a patient in the PACU, the nurse finds that the patient's blood pressure is below the preoperative baseline. The nurse determines that the patient has residual vasodilating effects of anesthesia when what is assessed?
a. A urinary output >30 mL/hr b. An oxygen saturation of 88%
c. A normal pulse with warm, dry, pink skin d. A narrowing pulse pressure with normal pulse
10. Priority Decision: A patient in the PACU has emergence delirium manifested by agitation and thrashing. What should the nurse assess the patient for first?
a. Hypoxemia b. Neurologic injury c. Distended bladder d. Cardiac dysrhythmias
11. The PACU nurse applies warm blankets to a postoperative patient who is shivering and has a body temperature of 96.0° F (35.6° C). What treatment may also be used to treat the patient?
a. Oxygen therapy b. Vasodilating drugs c. Antidysrhythmic drugs d. Analgesics or sedatives
12. Which patient is ready for discharge from Phase I PACU care to the clinical unit?
a. Arouses easily, pulse is 112 bpm, respiratory rate is 24, dressing is saturated, SpO2 is 88%
b. Awake, vital signs stable, dressing is dry and intact, no respiratory depression, SpO2 is 92%
c. Difficult to arouse, pulse is 52, respiratory rate is 22, dressing is dry and intact, SpO2 is 91%
d. Arouses, blood pressure (BP) higher than preoperative and respiratory rate is 10, no excess bleeding, SpO2 is 90%
13. For which nursing diagnoses or collaborative problems common in postoperative patients has ambulation been found to be an appropriate intervention (select all that apply)?
a. Impaired skin integrity related to incision
b. Impaired mobility related to decreased muscle strength c. Risk for aspiration related to decreased level of consciousness
d. Ineffective airway clearance related to decreased respiratory excursion
e. Constipation related to decreased physical activity and impaired gastrointestinal (GI) motility f. Venous thromboembolism related to dehydration, immobility, vascular manipulation, or injury 14. A patient who had major surgery is experiencing emotional stress as well as physiologic stress
from the effects of surgery. What can this stress cause?
a. Diuresis b. Hyperkalemia c. Fluid retention
d. Impaired blood coagulation
15. In addition to ambulation, which nursing intervention could be implemented to prevent or treat the postoperative complication of syncope?
a. Monitor vital signs after ambulation.
b. Do not allow the patient to eat before ambulation.
c. Slowly progress to ambulation with slow changes in position.
d. Have the patient deep breathe and cough before getting out of bed.
16. Which tubes drain gastric contents (select all that apply)?
a. T-tube b. Penrose
c. Nasogastric tube d. Indwelling catheter e. Gastrointestinal tube
17. Which drainage is drained with a Hemovac?
a. Bile b. Urine
c. Gastric contents d. Wound drainage
18. Priority Decision: The nurse notes drainage on the surgical dressing when the patient is
transferred from the PACU to the clinical unit. In what order of priority should the nurse perform the following actions? Number the options with 1 for the first action and 5 for the last action.
_____ a. Reinforce the surgical dressing.
_____ b. Change the dressing and assess the wound as ordered.
_____ c. Notify the surgeon of excessive drainage type and amount.
_____ d. Recall the report from PACU for the number and type of drains in use.
_____ e. Note and record the type, amount, and color and odor of the drainage.
19. Thirty-six hours postoperatively, a patient has a temperature of 100° F (37.8° C).What is the most likely cause of this temperature elevation?
a. Dehydration b. Wound infection
c. Lung congestion and atelectasis d. Normal surgical stress response
20. The health care provider has ordered IV morphine q2-4hr PRN for a patient following major abdominal surgery. When should the nurse plan to administer the morphine?
a. Before all planned painful activities
b. Every 2 to 4 hours during the first 48 hours
c. Every 4 hours as the patient requests the medication
d. After assessing the nature and intensity of the patient's pain
21. What should be included in the instructions given to the postoperative patient before discharge?
a. Need for follow-up care with home care nurses b. Directions for maintaining routine postoperative diet c. Written information about self-care during recuperation d. Need to restrict all activity until surgical healing is complete
Case Study
Postoperative Patient
(©szefei/iStock/Thinkstock)
Patient Profile
S.B., a 63-yr-old alert and oriented woman, is admitted to the PACU following a cystoscopy for recurrent bladder infections and recent hematuria. The procedure was scheduled as outpatient surgery and was performed under IV sedation.
Postoperative Orders
• Vital signs per routine
• Discontinue IV before discharge
• Patient to void before discharge
• Ciprofloxacin (Cipro) 500 mg PO q6hr for 10 days
• Acetaminophen 300 mg/codeine 30 mg (Tylenol #3) 1 or 2 tabs q3-4hr PRN for pain
• Patient to call office to schedule follow-up appointment Discussion Questions
Using a separate sheet of paper, answer the following questions:
1. Priority Decision: What priority nursing actions will be required to progress S.B. toward discharge?
2. Safety: What precautions will be required in ambulating S.B. after surgery?
3. What problems may interfere with discharging S.B. home in a timely manner?
4. How will the nurse determine that S.B.is ready to be discharged?
5. Patient-Centered Care: What are the unique needs of discharging this patient home as compared to discharging this patient to a clinical unit?
6. Priority Decision: Based on the data presented, what are the priority nursing diagnoses? Are there any collaborative problems?
S E C T I O N 4
Problems Related to Altered Sensory Input
OUTLINE
20 Assessment of Visual and Auditory Systems 21 Visual and Auditory Problems
22 Assessment of Integumentary System 23 Integumentary Problems
24 Burns