ch27.doc

[Osborn] chapter 27

Learning Outcomes [Number and Title] Learning Outcome 1 Prioritize nursing diagnoses and interventions for the patient in

the postanesthesia care unit.Learning Outcome 2 Discuss criteria for moving patients through the phases of

recovery.Learning Outcome 3 Discuss the assessment, prevention, and nursing management

of common postoperative problems.Learning Outcome 4 Develop a teaching plan for the discharge of a patient after

surgery.Learning Outcome 5 Identify and discuss areas of future research relevant to the care

of the postoperative patient.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.

1. The nurse has just received a client from the surgical area. After 30 minutes in the recovery area, the client’s vital signs are as follows: pulse 92; blood pressure 110/50; respirations 12; pulse oximeter 86%. What should be the initial nursing response?

1. Stimulate the client.2. Call the physician.3. Ask another nurse for his or her opinion.4. Place an oral airway in the client.

Correct Answer: Stimulate the client.

Rationale: The client’s respirations and pulse oximeter are low. The initial response by the nurse should be to stimulate the client to see if the pulse oximeter will increase. The client may require frequent stimulation to improve the oxygen saturation. If the oxygen saturation does not stay up after stimulation, the nurse may wish to advise the physician. An oral airway may be necessary if the client is not easily aroused. It is not necessary to ask for a second opinion.

Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Physiological IntegrityLO: 1


2. The recovery room nurse has just received a client whose abdominal drain has an excessive amount of sanguineous drainage. The nurse contacts the physician without delay, recognizing that this could:

1. Require the client to return immediately to surgery.2. Be a potential respiratory crisis.3. Lead to a major wound infection.4. Need further assessment.

Correct Answer: Require the client to return immediately to surgery.

Rationale: An excessive amount of sanguineous drainage in the abdominal drain may require the client to return to surgery to explore the surgical site. While the nurse is waiting for the surgical arrangements to be made, the client’s hemodynamic status may need to be supported. The symptoms related to the drainage are not related to respiratory complications.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 1


3. The client is just arriving in the postanesthesia care unit following general anesthesia. The nurse’s top priority upon receiving the client is to:

1. Assess the client’s respiratory status.2. Assess the client’s cardiac status.3. Ask the client about pain.4. Assess the client’s IV.

Correct Answer: Assess the client’s respiratory status

Rationale: The client’s respiratory status will be the nurse’s top priority upon receiving a client into the postanesthesia care unit because anesthesia can impact the respiratory system. Airway, respirations, and lung sounds will comprise this assessment because respiratory complications are the most frequent cause of complications in the postanesthesia care unit. Cardiac status, level of consciousness, and vital signs will be the next priority, followed by pain and eventually the status of the client’s IV.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Physiological IntegrityLO: 1


4. The client has just arrived in the recovery room. As part of the evaluation for determining discharge from the postanesthesia recovery unit, the nurse’s next action will be to:

1. Assess the client for respirations, oxygen saturation, consciousness, circulation, and activity.

2. Assess the client for pain.3. Assess whether the client wants the family in the recovery room.4. Take the client’s temperature.

Correct Answer: Assess the client for respirations, oxygen saturation, consciousness, circulation, and activity. Rationale: Assessing the client’s respirations, oxygen saturation, consciousness, circulation, and activity are all used to determine the client’s progress toward discharge. Assessing the client for pain helps the client’s comfort but is not part of the discharge criteria. The family may be allowed in the recovery room in many institutions, but their presence is usually delayed until the client has been assessed and is arousable. Temperature is vital to assessing hypothermia, but is not included as part of the discharge criteria.

Cognitive Level: AnalyzingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 2


5. Progression through the various phases in the postanesthesia recovery unit (PACU) depends upon:

1. The client’s progress toward physiological homeostasis. 2. The severity of the procedure the client underwent.3. The temperature and environment of the unit.4. The attentiveness and caring of the nursing staff.

Correct Answer: The client’s progress toward physiological homeostasis. Rationale: The client’s recovery and progress through the various phases while in the PACU depends on how quickly the client returns to physiological homeostasis. The other answer choices do not determine the client’s progress.

Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Health Promotion and MaintenanceLO: 2


6. A client is being evaluated for discharge from the postanesthesia care unit. The client’s blood pressure has been 120/76 with a preoperative baseline of 124/80. This client has moderate bleeding and is vomiting every 20 minutes. Which other assessment would mandate the client stay in postanesthesia care until more stable?

1. Moderate pain2. Blood pressure 120/763. Able to ambulate4. Pulse oximeter 93%

Correct Answer: Moderate pain

Rationale: This client who is experiencing moderate bleeding and frequent vomiting would receive a score of 8 on the PAD. If the client also complained of moderate pain, the PAD score would fall to 7, which would require the client to stay longer in the unit. A blood pressure of 120/76 is within 20% of baseline, the ability to ambulate, and a 93% pulse oximeter reading would all indicate the client is stable enough to discharge.

Cognitive Level: AnalyzingNursing Process: EvaluatingClient Need: Physiological Integrity LO: 2


7. A postoperative client arrives in the recovery room. The nurse knows which of the following assessments best indicates adequate circulation?

1. Radial pulses 2+, capillary refill of 2 seconds, pink, awake and alert, heart rate of 88, oxygen saturation of 94%

2. Pedal pulses weak, capillary refill > 3 seconds, oxygen saturation of 91%, respiratory rate of 10, ashen

3. Pedal pulses 2+, capillary refill of 4 seconds, pale, awake and alert, heart rate of 110

4. Popliteal pulses weak, drowsy, respiratory rate 24, color pale, skin cool

Correct Answer: Radial pulses 2+, capillary refill of 2 seconds, pink, awake and alert, heart rate of 88, oxygen saturation of 94%

Rationale: Peripheral pulses, capillary refill less than 3 seconds, oxygen saturation greater than 93%, and client’s color are good indicators of adequate circulation and respiratory effort. Clients with impaired gas exchange or decreased cardiac output will likely have evidence of hypoxemia—low oxygen saturation, decreased capillary refill, and weak pulses or tachycardia.



8. A 75-year-old client is received into the postanesthesia recovery room (PACU) following a 6-hour abdominal surgery. The client’s hemodynamic status is stable. Based upon the nurse’s knowledge of this client’s surgery and the common postoperative complications this client might be at risk for, the recovery room nurse would provide which of the following interventions?

1. Keep the room temperature at 70 degrees, consider supplemental oxygen, and provide warm blankets.

2. Assess the client’s blood pressure more frequently than for younger clients and provide oxygen.

3. Consider increasing the IV fluids, assess for urine output, and monitor the oxygen saturation.

4. Provide postoperative instructions to avoid straining and to eat a low-fiber diet.

Correct Answer: Keep the room temperature at 70 degrees, consider supplemental oxygen, and provide warm blankets. Rationale: This client is at risk for hypothermia based upon the client’s age, the length of surgery, and the likelihood of intra-operative irrigants to the abdomen. Therefore, the nurse’s role will be to minimize the risk for hypothermia by providing warm blankets, keeping the room at 70 degrees, and, if the core temperature drops, considering the provision of supplemental oxygen. The client’s hemodynamic status is stable; therefore, the blood pressure is stable. Oxygen may be needed if the client is hypothermic. The IV rate does not need to be increased at this time because the client is hemodynamically stable. The urine output would be automatically monitored, but the nurse would not anticipate a problem with it since the client is hemodynamically stable. Since the client was in surgery for 6 hours, the postoperative instructions to avoid straining and eat a low-fiber diet are not applicable to the question.

Cognitive Level: AnalyzingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 3


9. The nurse assesses a client in the postanesthesia recovery unit and finds a BP of 88/50, pulse 116, and respirations of 20. What other assessment data will the nurse want to collect first?

1. Pulse oximeter reading2. Pain assessment3. Whether the client is nauseated4. Urine output

Correct Answer: Pulse oximeter reading

Rationale: With a BP of 88/50, pulse of 116, and respirations of 20, the nurse will want to check the pulse oximeter reading next to determine whether there is hypoxia. A pain assessment will help determine if the cause of tachycardia may be pain; however, the blood pressure would not typically be low. Pain, in this instance, is secondary to hypoxemia, if present. Urine output is another indicator of perfusion when the blood pressure is low, but would not be the first priority assessment. Nausea is important to assess, but respiratory status is a first priority.



10. The purpose of a call by the ambulatory care unit nurse to the client after discharge is to:

1. Minimize client complications and ensure client safety.2. Determine if the client understood the discharge instructions.3. Let the client know the nurse cares about him or her.4. Assist the health care provider in checking on the client.

Correct Answer: Minimize client complications and ensure client safety. Rationale: The ambulatory care unit nurse contacts the client after discharge to ensure the client correctly understands the discharge instructions and to answer any questions the client may have. This helps increase client safety and minimizes client complications. The other answer choices may be benefits of the call, but are not the purpose.

Cognitive Level: ApplyingNursing Process: EvaluationClient Need: Health Promotion and MaintenanceLO: 4


11. The recovery room nurse is preparing to discharge a 24-year-old client to home following the client’s ambulatory surgery. Which of the following discharge instructions provided by the nurse is the most comprehensive?

1. Verbal and written instructions to the client and family regarding the client’s wound, activity and diet restrictions, new medications, pain management, potential complications, and process for reaching the health care provider if needed

2. Verbal instructions to restrict all activities, diet restrictions, pain management, and circumstances that require contacting the health care provider

3. Written instructions to manage the wound, instructions to resume activities slowly, methods for pain control, and information on whom to contact in 2 days

4. Verbal and written instructions to the family regarding the client’s activity, diet, potential problems, and medications

Correct Answer: Verbal and written instructions to the client and family regarding the client’s wound, activity and diet restrictions, new medications, pain management, potential complications, and process for reaching the health care provider if needed

Rationale: The client and family need to be provided discharge instructions verbally and in writing that include: wound management; restrictions on activity, diet, and bathing; new medications; pain management; the follow-up appointment; the postoperative progress the client can expect; and complications that require the contact of the health care provider.

Cognitive Level: AnalyzingNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 4


12. A client is preparing for discharge to home. The nurse has provided discharge instructions regarding activities. Which of the following instructions is most helpful to the client?

1. “You can start exercising in 7 days if there are no signs of wound infection.”2. “You may complete activities as tolerated.”3. “Be sure to rest throughout the day.”4. “You can bathe normally.”

Correct Answer: “You can start exercising in 7 days if there are no signs of wound infection.”

Rationale: Clients find discharge instructions most helpful when they are specific. The instructions “You can start exercising in 7 days if there are no signs of wound infection” is the most specific, giving the client exact details. The other answer choices of completing activities as tolerated, resting throughout the day, and bathing normally are not specific and could leave the client with room for faulty interpretation.

Cognitive Level: AnalyzingNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 4


13. A nurse noticed that clients who ambulated within the first 12 hours of surgery had fewer postoperative complications. Which of the following approaches would provide validation for the nurse’s belief that early ambulation decreases postoperative complications?

1. Correlation of postoperative complications with the clients’ activity2. Discussion of postoperative complications with physical therapist3. Adjustment of the clients’ medications related to their activity levels4. Modification of the clients’ activity based upon the surgical severity

Correct Answer: Correlate postoperative complications with the clients’ activity Rationale: Research designed to validate whether early ambulation decreases postoperative complications must correlate clients’ activity with the development of postoperative complications. Discussion with therapists regarding clients’ postoperative complications, adjustment of the clients medications based upon the activity levels, and modification of the clients’ activity based upon the severity of the surgery will not validate the correlation between early ambulation and postoperative complications.

Cognitive Level: AnalyzingNursing Process: EvaluationClient Need: Health Promotion and MaintenanceLO: 5


14. The nurse wonders which nursing interventions increase clients’ competence in managing their own recovery after discharge. Which intervention might be appropriate to help determine this?

1. The nurse will adjust client teaching to allow for cultural diversity.2. The nurse will provide the client with 4 hours of uninterrupted sleep while in

the inpatient facility.3. The nurse will measure the client’s ability to ambulate without dyspnea.4. The nurse will discuss the client’s discharge with the health care provider.

Correct Answer: The nurse will adjust client teaching to allow for cultural diversity. Rationale: Interventions involved in a research project to help determine client competence in managing their own recovery after discharge must address the topic for validation. Adjusting client teaching to allow for cultural diversity would help determine whether this intervention would impact the client’s competence. Providing the client with uninterrupted sleep will not address the question of client competence in managing their own recovery after discharge. The ability to ambulate without dyspnea could determine how far the client can ambulate, but does not address the research question. Discussing the client’s discharge with other health care providers does not address the question of client competence, but may provide some insight into how to manage interventions for the client.

Cognitive Level: AnalyzingNursing Process: EvaluationClient Need: Health Promotion and MaintenanceLO: 5


15. Attempting to better understand the discharge instructions needed by a client could be a potential research study. An anticipated result of such a study might provide insight into:

1. Ways clients might better manage their own recovery2. How the nurse might provide care while in the hospital3. When the client should be discharged4. Decreased hospitalizations

Correct Answer: Ways clients might better manage their own recovery

Rationale: A study looking at the discharge instructions needed by a client could provide insight into ways clients might better manage their own recovery. As a secondary impact, there may be information on ways to decrease hospitalization; however, that would not be the primary focus. When the client should be discharged and how the nurse could provide care while in the hospital would not be a focus of the research study.

Cognitive Level: AnalyzingNursing Process: EvaluatingClient Need: Health Promotion and MaintenanceLO: 5


Documents

ch27.doc