Lewis Chapter 19: Postoperative Care

When a patient is admitted to the PACU, what are the priority interventions the nurse performs?
a. Assess the surgical site, no tine presence and character of drainage
b. Assess the amount of urine output and the presence of bladder distention
c. Assess for airway potency and quality of expirations, and obtain vital signs.
d. Review results of intraoperative laboratory values and medications received.

c. Assess for airway potency and quality of expirations, and obtain vital signs.

Rationale: Assessment in the postanesthesia care unit (PACU) begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Identification of inadequate oxygenation and ventilation or respiratory compromise necessitates prompt intervention.

A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to "throw up." A priority nursing intervention would be to:
a. increase the rate of IV fluids
b. obtain vital signs, including O2 saturation
c. position patient in lateral recovery position
d. administer antiemetic medication as ordered

c. position patient in lateral recovery position

Rationale: If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs.

After admission of the postoperative patient to the clinical unit, which assessment data require the most immediate attention?
a. Oxygen saturation of 85%
b. Respiratory rate of 13/min
c. Temperature of 100.4F
d. Blood pressure of 90/60 mmHg

a. Oxygen saturation of 85%

Rationale: During the initial assessment, identify signs of inadequate oxygenation and ventilation. Pulse oximetry monitoring is initiated because it provides a noninvasive means of assessing the adequacy of oxygenation. Pulse oximetry may indicate low oxygen saturation (<90% to 92%) with respiratory compromise. This necessitates prompt intervention.

A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to:
a. perform a straight catheterization to measure the amount of urine in the bladder
b. notify the physician and anticipate obtaining blood work to evaluate renal function
c. continue to monitor the patient because this is a normal finding during this time period
d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound

d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound

Rationale: Because of the possibility of infection associated with catheterization, the nurse should first try to validate that the bladder is full. The nurse should consider fluid intake during and after surgery and should determine bladder fullness by percussion, by palpation, or by a portable bladder ultrasound study to assess the volume of urine in the bladder and avoid unnecessary catheterization.

Discharge criteria for the Phsae II patient include (select all that apply):
a. no nausea or vomiting
b. ability to drive self home
c. no respiratory depression
d. written discharge instructions understood
e. opioid pain medication given 45 minutes ago

c, d, & e

Rationale: Phase II discharge criteria that must be met include the following: all PACU discharge criteria (Phase I) met; no intravenous opioid drugs administered for the past 30 minutes; patient's ability to void (if appropriate with regard to surgical procedure or orders); patient's ability to ambulate if it is not contraindicated; presence of a responsible adult to accompany or drive patient home; and written discharge instructions given and understood.

Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately postoperative?
a. Supine
b. Lateral
c. Semi-Fowler's
d. High-Fowler's

b. Lateral

Unless contraindicated by the surgical procedure, the unconscious patient is positioned in a lateral "recovery" position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated.

The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival?
a. Assess the patient's pain.
b. Assess the patient's vital signs.
c. Check the rate of the IV infusion.
d. Check the physician's postoperative orders.

b. Assess the patient's vital signs.

The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient's vital signs. The other actions can then take place in rapid sequence.

When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. In response to this finding, what should the nurse do first?
a. Recheck in 1 hour for increased drainage.
b. Notify the surgeon of a potential hemorrhage.
c. Assess the patient's blood pressure and heart rate.
d. Remove the dressing and assess the surgical incision.

c. Assess the patient's blood pressure and heart rate.

The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes?
a. Administering adequate analgesics to promote relief or control of pain
b. Asking the patient to demonstrate the postoperative exercises every 1 hour
c. Giving the patient positive feedback when the activities are performed correctly
d. Warning the patient about possible complications if the activities are not performed

a. Administering adequate analgesics to promote relief or control of pain

Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.

Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which health problem is the patient probably experiencing?
a. Atelectasis
b. Bronchospasm
c. Hypoventilation
d. Pulmonary embolism

a. Atelectasis

The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.

In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)?
a. Monitor the patient's pain.
b. Do the admission vital signs.
c. Assist the patient to take deep breaths and cough.
d. Change the dressing when there is excess drainage.

c. Assist the patient to take deep breaths and cough.

The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The LPN or RN will monitor and treat the patient's pain and change the dressings.

The patient had abdominal surgery. The estimated blood loss was 400 mL. The patient received 300 mL of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient?
a. Blood administration
b. Restoring circulating volume
c. An ECG to check circulatory status
d. Return to surgery to check for internal bleeding

b. Restoring circulating volume

The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, or there is a past history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient's level of consciousness changes or the abdomen becomes firm and distended.

The patient donated a kidney, and early ambulation is included in her plan of care. But the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation?
a. "Early walking keeps your legs limber and strong."
b. "Early ambulation will help you be ready to go home."
c. "Early ambulation will help you get rid of your syncope and pain."
d. "Early walking is the best way to prevent postoperative complications."

d. "Early walking is the best way to prevent postoperative complications."

The best rationale is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and VTE, speeds wound healing, and increases vital capacity and maintains normal respiratory function. These things help the patient be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management should always occur before walking.

An older patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this new patient?
a. Check his chart for intraoperative complications.
b. Check which medications were used for anesthesia.
c. Check the effectiveness of the analgesics he has received.
d. Check his preoperative assessment for previous delirium or dementia.

d. Check his preoperative assessment for previous delirium or dementia.

If the patient's ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications, and pain will be assessed as these can all contribute to delirium.

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)?
a. Vital signs baseline or stable
b. Minimal nausea and vomiting
c. Wants to go to the bathroom at home
d. Responsible adult taking patient home
e. Comfortable after IV opioid 15 minutes ago

a, b, & d

Ambulatory surgery discharge criteria includes meeting Phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria includes a responsible adult driving patient, no IV opioid drugs for last 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.

A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient?
a. Manage patient pain.
b. Control the bleeding.
c. Maintain fluid balance.
d. Manage oxygenation status.

d. Manage oxygenation status.

The nurse's priority is to manage the patient's oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.