A client has arrived in the postoperative unit. What action by the circulating nurse takes priority?
a. Assessing fluid and blood output
b. Checking the surgical dressings
c. Ensuring the client is warm
d. Participating in hand-off report
The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which
client should the nurse assess first?
a. Client with a blood pressure of 100/50 mm Hg
b. Client with a pulse of 118 beats/min
c. Client with a respiratory rate of 6 breaths/min
d. Client with a temperature of 96 F (35.6 C)
A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action
by the nurse is most appropriate?
a. Assess other indicators of oxygenation.
b. Call the Rapid Response Team.
c. Notify the anesthesia provider.
d. Prepare to intubate the client.
Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best?
a. Let me call the surgeon to see if you really need them.
b. No, you have to use those for 24 hours after surgery.
c. OK, we can remove them since you are stable now.
d. To prevent blood clots you need them a few more hours.
A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the clients bed. The
clients blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best?
a. Call the Rapid Response Team.
b. Increase the IV fluid rate.
c. Lower the head of the bed.
d. Nothing; this is expected.
A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most
a. Allow the client to rest.
b. Auscultate lung sounds.
c. Document the episode.
d. Encourage the client to eat dry toast.
A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by
the PACU nurse takes priority?
d. Cardiac rhythm
A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which
IV-push medication and dose does the nurse prepare to administer?
a. Flumazenil (Romazicon) 0.2 to 1 mg
b. Flumazenil (Romazicon) 2 to 10 mg
c. Naloxone (Narcan) 0.4 to 2 mg
d. Naloxone (Narcan) 4 to 20 mg
A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not
want medication. What action by the nurse is best to promote comfort?
a. Assess the clients pain on a 0-to-10 scale.
b. Assist the client into a position of comfort.
c. Have the client sit up in a recliner.
d. Tell the client when pain medication is due.
A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and
manage a drain at home. What instruction by the nurse is most important?
a. Be sure you keep all your postoperative appointments.
b. Call your surgeon if you have any questions at home.
c. Eat a diet high in protein, iron, zinc, and vitamin C.
d. Wash your hands before touching the drain or dressing.
An older adult has been transferred to the postoperative inpatient unit after surgery. The family is
concerned that the client is not waking up quickly and states She needs to get back to her old self! What
response by the nurse is best?
a. Everyone comes out of surgery differently.
b. Lets just give her some more time, okay?
c. She may have had a stroke during surgery.
d. Sometimes older people take longer to wake up.
A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of
blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?
a. Assess the clients blood pressure.
b. Perform hand hygiene and apply gloves.
c. Reinforce the dressing with a clean one.
d. Remove the dressing to assess the wound.
A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and
respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen
saturation, and shows no signs of infection. What should the nurse assess next?
a. Cognitive status
b. Family stress
c. Nutrition status
d. Psychosocial status
A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose
drain. What action by the student warrants intervention by the RN?
a. Cleaning around the drain per agency protocol
b. Placing a new sterile gauze under the drain
c. Securing the drains safety pin to the sheets
d. Using sterile technique to empty the drain
A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select
all that apply.)
a. All phases require the client to be in the hospital.
b. Phase I care may last for several days in some clients.
c. Phase I requires intensive care unit monitoring.
d. Phase II ends when the client is stable and awake.
e. Vital signs may be taken only once a day in phase III.
A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube.
What laboratory values would warrant intervention by the nurse? (Select all that apply.)
a. Blood glucose: 120 mg/dL
b. Hemoglobin: 7.8 mg/dL
c. pH: 7.68
d. Potassium: 2.9 mEq/L
e. Sodium: 142 mEq/L
A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history
of acute confusion after a previous operation. What interventions does the nurse include on the clients plan of
care to minimize the potential for this occurring? (Select all that apply.)
a. Allow family and friends to visit as the client desires.
b. Ask the client about coping techniques frequently used.
c. Instruct the nursing assistant to ensure the client is bathed.
d. Place the client in a room secluded at the end of the hall.
e. Provide the client with uninterrupted periods of sleep
A postoperative client is being discharged with a prescription for oxycodone hydrochloride with
acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.)
a. Check all over-the-counter medications for acetaminophen.
b. Do not take more pills each day than you are prescribed.
c. Eat a diet that is high in fiber and drink lots of water.
d. If this gives you diarrhea, loperamide (Imodium) can help.
e. You shouldnt drive while you are taking this medication.
A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort
interventions can the nurse provide? (Select all that apply.)
a. Apply stimulation to the contralateral leg.
b. Assess the clients willingness to try meditation.
c. Elevate the clients operative leg and apply ice.
d. Reduce the noise level in the clients environment.
e. Turn the TV on loudly to distract the client.
A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection.
What actions are best to achieve this goal? (Select all that apply.)
a. Administering antibiotics for 72 hours
b. Disposing of dressings properly
c. Leaving draining wounds open to air
d. Performing proper hand hygiene
e. Removing and replacing wet dressings
A postoperative client has the following orders:
IV lactated Ringers 125 mL/hr
NG tube to low continuous suction
Replace NG output every 4 hours with normal saline over 4 hours
Morphine sulfate 2 mg IV push every hour as needed for pain
Up in chair tonight
At 1600 (4:00 PM), the nurse measures the nasogastric (NG) output from noon to be 200 mL. What is the
clients total IV rate for the next 4 hours? (Record your answer using a whole number.) _____ mL/hr
200 mL of NG output 4 hours = 50 mL/hr.
125 mL/hr + 50 mL/hr = 175 mL/hr.