Podcast
Questions and Answers
The nurse is caring for a postoperative patient in the PACU. Which of the following is a standard discharge criterion before transferring the patient to the surgical unit?
The nurse is caring for a postoperative patient in the PACU. Which of the following is a standard discharge criterion before transferring the patient to the surgical unit?
- Oxygen saturation is 88% on room air
- Patient reports pain of 7/10
- Patient is alert and oriented x2
- Stable vital signs for at least 30 minutes (correct)
Which assessment finding requires immediate intervention in a postoperative patient?
Which assessment finding requires immediate intervention in a postoperative patient?
- Pain level of 5/10
- Slightly elevated temperature (99.5°F/37.5°C)
- Urine output of 25 mL/hr (correct)
- Absence of bowel sounds
A nurse is caring for a patient who underwent abdominal surgery. What is the primary reason for encouraging early ambulation?
A nurse is caring for a patient who underwent abdominal surgery. What is the primary reason for encouraging early ambulation?
- Reducing the need for pain medication
- Preventing atelectasis (correct)
- Enhancing wound healing
- Decreasing the risk of anemia
A patient who had spinal anesthesia reports a severe headache when sitting up. What is the nurse's priority action?
A patient who had spinal anesthesia reports a severe headache when sitting up. What is the nurse's priority action?
A nurse is monitoring a patient who had surgery 6 hours ago. Which assessment finding requires immediate intervention?
A nurse is monitoring a patient who had surgery 6 hours ago. Which assessment finding requires immediate intervention?
A postoperative patient receiving IV morphine reports severe nausea and vomiting. What should the nurse do first?
A postoperative patient receiving IV morphine reports severe nausea and vomiting. What should the nurse do first?
The nurse is assessing a patient who had an abdominal surgery 2 days ago. The patient reports “something just popped” at the incision site. What is the nurse's priority action?
The nurse is assessing a patient who had an abdominal surgery 2 days ago. The patient reports “something just popped” at the incision site. What is the nurse's priority action?
A postoperative patient with a PCA pump has a respiratory rate of 7 breaths per minute. What is the priority nursing action?
A postoperative patient with a PCA pump has a respiratory rate of 7 breaths per minute. What is the priority nursing action?
A patient with a history of deep vein thrombosis (DVT) had knee replacement surgery. Which interventions should the nurse include in the care plan? (Select all that apply.)
A patient with a history of deep vein thrombosis (DVT) had knee replacement surgery. Which interventions should the nurse include in the care plan? (Select all that apply.)
The nurse is preparing discharge instructions for a postoperative patient. Which statements should be included? (Select all that apply.)
The nurse is preparing discharge instructions for a postoperative patient. Which statements should be included? (Select all that apply.)
The nurse is assessing a patient for postoperative complications. Which findings suggest a possible pulmonary embolism? (Select all that apply.)
The nurse is assessing a patient for postoperative complications. Which findings suggest a possible pulmonary embolism? (Select all that apply.)
The nurse is evaluating the effectiveness of postoperative pain management. Which findings suggest that pain control is inadequate? (Select all that apply.)
The nurse is evaluating the effectiveness of postoperative pain management. Which findings suggest that pain control is inadequate? (Select all that apply.)
The nurse is assessing a postoperative patient who had an abdominal surgery. Which vital sign change is expected due to the normal stress response within the first 48 hours post-op?
The nurse is assessing a postoperative patient who had an abdominal surgery. Which vital sign change is expected due to the normal stress response within the first 48 hours post-op?
A nurse is preparing to transfer a postoperative patient from the PACU to a surgical unit. What should the nurse ensure before transport?
A nurse is preparing to transfer a postoperative patient from the PACU to a surgical unit. What should the nurse ensure before transport?
A postoperative patient is at risk for atelectasis. Which intervention is most effective in preventing this complication?
A postoperative patient is at risk for atelectasis. Which intervention is most effective in preventing this complication?
The nurse is monitoring a postoperative patient for signs of infection. Which findings suggest a developing infection?
The nurse is monitoring a postoperative patient for signs of infection. Which findings suggest a developing infection?
A postoperative patient with opioid analgesia has respiratory depression. What is the priority nursing action?
A postoperative patient with opioid analgesia has respiratory depression. What is the priority nursing action?
A nurse is reviewing postoperative bowel care with a patient who had a colorectal surgery. Which teaching point is most important?
A nurse is reviewing postoperative bowel care with a patient who had a colorectal surgery. Which teaching point is most important?
A postoperative patient suddenly reports severe dyspnea and chest pain. What is the nurse's priority action?
A postoperative patient suddenly reports severe dyspnea and chest pain. What is the nurse's priority action?
The nurse is caring for a postoperative patient with a wound vacuum-assisted closure (VAC) device. What assessment finding would require immediate intervention?
The nurse is caring for a postoperative patient with a wound vacuum-assisted closure (VAC) device. What assessment finding would require immediate intervention?
The nurse is reinforcing discharge education for a postoperative patient. What should be included? (Select all that apply.)
The nurse is reinforcing discharge education for a postoperative patient. What should be included? (Select all that apply.)
The nurse is planning postoperative interventions for a patient with a high risk of developing venous thromboembolism (VTE). Which interventions are appropriate? (Select all that apply.)
The nurse is planning postoperative interventions for a patient with a high risk of developing venous thromboembolism (VTE). Which interventions are appropriate? (Select all that apply.)
A postoperative patient is reluctant to use the incentive spirometer. What action is most effective in increasing adherence?
A postoperative patient is reluctant to use the incentive spirometer. What action is most effective in increasing adherence?
A nurse is evaluating the effectiveness of early ambulation in a postoperative patient. Which finding indicates success?
A nurse is evaluating the effectiveness of early ambulation in a postoperative patient. Which finding indicates success?
The nurse is evaluating a postoperative patient's pain management. Which finding suggests inadequate pain control? (Select all that apply.)
The nurse is evaluating a postoperative patient's pain management. Which finding suggests inadequate pain control? (Select all that apply.)
The nurse is monitoring a postoperative patient for complications. Which findings indicate a possible paralytic ileus? (Select all that apply.)
The nurse is monitoring a postoperative patient for complications. Which findings indicate a possible paralytic ileus? (Select all that apply.)
Flashcards
PACU Discharge Criteria
PACU Discharge Criteria
Stable vital signs, adequate oxygenation, and responsiveness
Why encourage early ambulation?
Why encourage early ambulation?
Early ambulation improves lung expansion, reducing risks like atelectasis and pneumonia.
Spinal Headache Relief
Spinal Headache Relief
A spinal headache occurs due to CSF leakage; lying flat relieves symptoms by reducing spinal pressure.
Priority for low Respiratory Rate w/ PCA
Priority for low Respiratory Rate w/ PCA
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DVT prevention post-op
DVT prevention post-op
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Post-op discharge instructions
Post-op discharge instructions
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Signs of pulmonary embolism (PE)
Signs of pulmonary embolism (PE)
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Signs of Inadequate pain control
Signs of Inadequate pain control
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Post-op temperature elevation
Post-op temperature elevation
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Severe post-op dyspnea and chest pain
Severe post-op dyspnea and chest pain
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Study Notes
- Postoperative nursing care involves critical thinking, application, and analysis skills
Knowledge Level
- Standard discharge criteria for a postoperative patient in the PACU include stable vital signs for at least 30 minutes, adequate oxygenation, and responsiveness
- Immediate intervention is required for a postoperative patient if urine output is below 30 mL/hr, because it suggests potential hypovolemia or kidney dysfunction
Comprehension Level
- Encouraging early ambulation for a patient who underwent abdominal surgery prevents atelectasis and pneumonia by improving lung expansion
- A patient reporting a severe headache when sitting up after spinal anesthesia could be experiencing CSF leakage, nurses should encourage the patient to lie flat to reduce spinal pressure
Application Level
- Hypotension, indicated by a blood pressure of 90/50 mmHg six hours after surgery, requires immediate intervention due to potential hypovolemia or internal bleeding
- Prioritize positioning a postoperative patient receiving morphine in a side-lying position if they report nausea and vomiting to prevent aspiration, then administer antiemetics
Analysis Level
- "Something just popped" at the incision site of a patient 2 days post-abdominal surgery indicates wound dehiscence or evisceration, requiring covering the site with a sterile, saline-soaked dressing for emergency intervention
- Administer naloxone to a postoperative patient with a PCA pump and a respiratory rate of 7 breaths per minute experiencing respiratory depression from opioids, requiring immediate reversal
Synthesis Level
- Include early ambulation, compression stockings, and increased fluid intake in the care plan for a knee replacement patient with a history of DVT for interventions to reduce DVT risk, while avoiding leg crossing and calf massage
- Discharge instructions for postoperative patients should include increasing protein intake, avoiding soaking the incision, and reporting redness or purulent drainage from the wound
Evaluation Level
- Sudden shortness of breath, chest pain, and coughing up blood in a postoperative patient suggest a possible pulmonary embolism
- Refusing movement, facial grimacing, and guarding at the surgical site suggest inadequate postoperative pain control
Knowledge Level
- A slight increase in temperature is an expected vital sign change within the first 48 hours post-abdominal surgery due to the normal stress response in postoperative patient, while persistent fever indicates infection
- Oxygen saturation should be stable before transferring a postoperative patient from the PACU, to ensure safe discharge
Comprehension Level
- Encouraging deep breathing and incentive spirometry is the most effective intervention for preventing atelectasis in a postoperative patient, to help re-expand alveoli
- Purulent wound drainage is a key finding that suggests a developing infection in a postoperative patient
Application Level
- A postoperative patient with opioid analgesia who has respiratory depression requires naloxone to be administered to reverse the opioid-induced respiratory depression
- Teaching hydration and stool softeners helps prevent constipation and straining, reducing stress on the surgical site after colorectal surgery
Analysis Level
- Dyspnea and chest pain are symptoms of pulmonary embolism that requires checking the patient's oxygen saturation
- Sudden cessation of drainage from a postoperative patient with a wound VAC device requires immediate intervention, indicating a blockage in the VAC system
Synthesis Level
- Discharge education for a postoperative patient should include calling the provider if the incision becomes red or swollen, taking pain medication as prescribed, and reporting a temperature over 101°F
- Interventions to prevent venous thromboembolism (VTE) in a high-risk postoperative patient include encouraging ambulation, applying sequential compression devices, and administering prescribed anticoagulants
Evaluation Level
- To increase adherence, demonstrate and practice proper incentive spirometer technique for a postoperative patient who is reluctant to use it which is most effective in increasing adherence
- Increased oxygen saturation indicates successful early ambulation in a postoperative patient, early ambulation improves oxygenation and prevents complications
Final Complex Questions
- Refusing movement, elevated vitals, and guarding indicate poor pain control in a postoperative patient for pain management
- Abdominal distention, absent bowel sounds, and nausea indicate a possible paralytic ileus in a postoperative patient
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