Brunner: Medical-Surgical Nursing, 11th Edition

Test Bank

Chapter 20: Postoperative Nursing Management

Multiple Choice

1. What is the first assessment the recovery room nurse makes on a newly admitted patient?A) Heart rateB) Nail perfusionC) Core temperatureD) Patency of the airway

Ans: DChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 1Patient Needs: D-3Feedback: Patency of the airway and respiratory status should be evaluated first, followed by cardiovascular status and the condition of the surgical site.

2. In what position should an unconscious patient be placed until he or she regains consciousness?A) Side-lying with chin extendedB) Dorsal with knees slightly flexedC) ProneD) Semi-Fowler's

Ans: AChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 1Patient Needs: D-3Feedback: To maintain a patent airway and prevent choking if the patient vomits, the patient

should be maintained in a side-lying position with chin extended. Dorsal, prone, and semi-Fowler's are not recommended.

3. Upon admission to the postanesthesia care unit, a patient's blood pressure was 130/90 and the pulse was 68. After 30 minutes, the patient's blood pressure is 120/65, and the pulse is 100. The patient's skin is cold, moist, and pale. The patient is showing symptoms of which of the following?A) HypothermiaB) Hypovolemic shockC) Neurogenic shockD) Malignant hypothermia

Ans: BChapter: 20Cognitive Level: AnalysisDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 1Patient Needs: D-4Feedback: The patient is exhibiting symptoms of hypovolemic shock; therefore, the nurse should notify the patient's physician and anticipate orders for fluid and/or blood product replacement.

4. The patient is in the recovery room following chest surgery and complains of severe nausea. The nurse should first:A) Administer an analgesic.B) Apply a cool cloth to the patient's forehead.C) Offer the patient a small amount of ice chips.D) Turn the patient completely to one side.

Ans: DChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 3Patient Needs: D-1Feedback: Turning the patient completely to one side allows collected fluid to escape from the side of the mouth if the patient vomits. Ice chips can increase feelings of nausea. After turning the patient to the side, the nurse can offer a cool cloth to the patient's forehead.

5. A nurse is caring for a patient after abdominal surgery in the postanesthesia-care unit. The patient's blood pressure has increased and the patient is restless. The patient's oxygen saturation is 97%. What is the likely cause for the increase in blood pressure and restlessness?A) The patient's temperature is low.B) The patient is in shock.C) The patient is in pain.D) The patient is nauseated.

Ans: CChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 3Patient Needs: D-4Feedback: An increase in blood pressure and restlessness are symptoms of pain. The patient's oxygen saturation is 97 %, so hypothermia and shock are not likely causes of the patient's restlessness.

6. The recovery room nurse would assess the patient's respiration effectively by doing which of the following?A) Placing the palm of the hand at the patient's nose and mouth to feel the exhaled breathB) Visualizing the rise and fall of the patient's abdomenC) Placing the palm of the hand on the patient's abdomen to count the rateD) Visualizing the rise and the fall of the patient's chest

Ans: AChapter: 20Cognitive Level: ApplicationDifficulty: DifficultIntegrated Process: Nursing ProcessObjective: 1Patient Needs: D-3Feedback: The nurse should place the palm of the hand at the patient's nose and mouth to feel the exhaled breath. A patient may have an obstructed airway that would cause the abdomen or chest to rise and fall. By feeling the exhaled breath, the nurse can be sure the patient's airway is patent.

7. A 60-year-old patient is admitted into the recovery room following cataract surgery. Which of the following postoperative complications could have an adverse effect on this patient's surgery?A) PainB) VomitingC) DisorientationD) Temporary decrease in oxygen saturation

Ans: BChapter: 20Cognitive Level: ApplicationDifficulty: DifficultIntegrated Process: Nursing ProcessObjective: 3Patient Needs: D-3Feedback: The strain of vomiting can have adverse effects on the surgical area (the eye).

8. The patient is being discharged home from day surgery after a general anesthetic. What instruction should the patient be given prior to leaving the hospital?A) The patient is not to drive a vehicle.B) The patient should have a glass of brandy the first night at home to help him or her sleep.C) Eat a large meal at home.D) Do not sign important papers for the first 12 hours after surgery.

Ans: AChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 2Patient Needs: D-3Feedback: Postoperative discharge instructions should include the following: Do not sign important papers, drive, or drink alcohol for 24 to 48 hours following general anesthetic.

9. Which of the following is the most serious problem encountered in the surgical patient?A) Pulmonary complicationsB) Deep vein thrombosisC) Malignant hyperthermiaD) Nausea and vomiting

Ans: AChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 3Patient Needs: D-3Feedback: Pulmonary complications are among the most frequent and serious problems encountered by the surgical patient.

10. A nurse is assessing a 2-day postoperative patient following chest surgery. The patient is reluctant to ambulate, has a nonproductive cough, and has crackles at the base of the lung. The nurse determines that the patient is most likely exhibiting symptoms of static pulmonary secretions. What should the nurse's primary interventions for this entail?A) Send a sputum sample for culture and sensitivity testing.B) Encourage leg exercises every 2 hours.C) Turn the patient and encourage deep breathing every 2 hours.D) Decrease the patient's intake of fluids.

Ans: CChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 1Patient Needs: D-3Feedback: When the patient is reluctant to ambulate, has a nonproductive cough, and has crackles at the base of the lung, he is most likely exhibiting symptoms of static pulmonary secretions. The patient should be encouraged to turn every 2 hours and take deep breaths to prevent pneumonia.

11. The patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output for the patient was 10 mL. The tubing of the Foley is patent. The nurse should:A) Irrigate the Foley with 30 mL of normal saline.B) Notify the physician, and continue to closely monitor the hourly urine output.C) Decrease the IV fluid rate.D) Have the patient sit in high-Fowler's position.

Ans: B

Chapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 1Patient Needs: D-3Feedback: If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30 mL/h are reported. The nurse should continue to monitor urine output hourly.

12. A 78-year-old patient is getting up for the first walk postoperatively. To decrease the potential for orthostatic hypotension, the nurse should plan to have the patient:A) Sit in a chair for 10 minutes prior to ambulating.B) Encourage the patient to drink plenty of fluids to increase circulating blood volume.C) Stand upright for 2 to 3 minutes prior to ambulating.D) Sit upright on the side of the bed for 15 minutes prior to ambulating.

Ans: CChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 4Patient Needs: D-3Feedback: Older adults are at an increased risk for orthostatic hypotension secondary to age-related changes in vascular tone. The patient should sit up and stand in 2 to 3 minutes to alleviateorthostatic hypotension.

13. A nurse is caring for an adult patient on the first postoperative day following removal of a bullet due to a gunshot wound. The nurse should plan the instructions for wound care for this patient based on the wound class status called:A) CleanB) Clean-contaminatedC) Contaminated-dirtyD) Dirty

Ans: DChapter: 20Cognitive Level: ApplicationDifficulty: Moderate

Integrated Process: Nursing ProcessObjective: 5Patient Needs: D-3Feedback: The teaching should include special emphasis on signs of infection because this type of wound is considered dirty. Dirty wounds are due to trauma or foreign bodies, such as gunshot wounds.

14. The nurse has completed discharge teaching with a patient related to signs and symptoms of infection. Which statement would indicate the patient needs additional teaching?A) I should notify my physician if my dressing has a foul odor.B) I should not have swelling and pain to the wound.C) It is normal for the edges of the wound to be slightly raised.D) Red streaks in the skin near the wound are normal and will disappear.

Ans: DChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Teaching/LearningObjective: 7Patient Needs: D-3Feedback: A foul odor, temperature elevation, and red streaks near the wound are signs of infection. The patient needs further teaching if he or she thinks red streaks in the skin are normal.

15. A patient is 1 day postoperative following abdominal surgery. The patient calls the nurse to the room because she feels something gave way on her incision. The nurse assesses the incision and discovers that the wound is open with a loop of intestine protruding from the wound. What action should the nurse take?A) Cover the wound with sterile gauze soaked in normal saline and call the physician.B) Cover the wound with Steri-Strips.C) Apply an abdominal pad over the wound.D) Pour Betadine into the wound and call the physician.

Ans: AChapter: 20Cognitive Level: ApplicationDifficulty: DifficultIntegrated Process: Nursing ProcessObjective: 3Patient Needs: D-4

Feedback: When the disruption of a wound occurs, the patient is placed in low-Fowler's positionand instructed to lie quietly. The wound is covered in gauze soaked in sterile normal saline and the physician is called.

16. The patient has returned from recovery and been on the unit for 1 hour. The patient's vital signs have been stable. How often should the nurse be assessing the patient's vital signs?A) Every 5 minutesB) Every 15 minutesC) Every 4 hoursD) Every 30 minutes

Ans: DChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 2Patient Needs: D-3Feedback: Unless indicated more frequently, the pulse, blood pressure, and respirations are recorded every 15 minutes for the first hour, every 30 minutes for the next 2 hours, and every 4 hours for the next 24 hours.

17. The nurse is evaluating a postoperative patient for infection. Which sign or symptom would be most indicative of infection?A) Presence of an indwelling urinary catheterB) Rectal temperature of 100 F (37.8 C)C) Red, warm, tender incisionD) White blood cell (WBC. count of 8,000/ml

Ans: CChapter: 20Cognitive Level: AnalysisDifficulty: DifficultIntegrated Process: Nursing ProcessObjective: 3Patient Needs: A-2Feedback: Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative infection. The presence of any invasive device predisposes a patient to infection but alone doesn't indicate infection. A rectal temperature of 100 F would be a normal expectation in a postoperative patient because of the inflammatory process. A normal WBC

count ranges from 4000 to 10,000/mL.

18. A patient who undergoes a surgical procedure that requires the use of general anesthesia is most at risk for:A) AtelectasisB) AnemiaC) DehydrationD) Peripheral edema

Ans: AChapter: 20Cognitive Level: AnalysisDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 3Patient Needs: D-3Feedback: Atelectasis occurs when the postoperative patient fails to move, cough, and breathe deeply. With good nursing care, this is an avoidable complication. Anemia occurs rarely and usually in situations where the patient loses a significant amount of blood or if he continues bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema, but the patient is most at risk for atelectasis.

19. A patient has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to:A) Call the physician.B) Place saline-soaked sterile dressings on the wound.C) Take a blood pressure and pulse.D) Pull the dehiscence closed.

Ans: BChapter: 20Cognitive Level: AnalysisDifficulty: EasyIntegrated Process: Nursing ProcessObjective: 3Patient Needs: D-4Feedback: The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Then the nurse should call the physician and take the patient's vital signs. The dehiscence needs to be surgically closed; the nurse should never try to close it.

20. To assess the effectiveness of incentive spirometry, the nurse can use a pulse oximeter to monitor the patient's:A) Oxygen saturationB) Hemoglobin levelC) Partial pressure of carbon dioxide (PaCO2)D) Partial pressure of oxygen (PaO2)

Ans: AChapter: 20Cognitive Level: AnalysisDifficulty: EasyIntegrated Process: Nursing ProcessObjective: 2Patient Needs: D-3Feedback: Oxygen saturation obtained by pulse oximeter is the least invasive method of monitoring the patient during a procedure. The patient must receive an arterial stick to monitor the partial pressures of carbon dioxide (PaCO2) and oxygen (PaO2). Trends are more important todetermine effectiveness of treatment.

21. The nurse is caring for a patient who just had surgery. What is the nurse's highest priority?A) Assessing for hemorrhageB) Maintaining a patent airwayC) Managing the patient's painD) Assessing vital signs every 15 minutes

Ans: BChapter: 20Cognitive Level: AnalysisDifficulty: DifficultIntegrated Process: Nursing ProcessObjective: 1Patient Needs: D-3Feedback: The priority concern is the patient's airway, as demonstrated by the ABC principle: A = Airway, B = Breathing, C = Circulation. Assessing for hemorrhage and vital sign assessment are also important but constitute second and third priorities. Pain management is important but only after the patient has been stabilized.

22. The nurse is teaching a patient with a leg ulcer about tissue repair and wound healing. Whichof the following statements by the patient indicates that teaching has been effective?A) "I'll limit my intake of protein."B) "I'll make sure that the bandage is wrapped tightly."C) "My foot should feel cold."D) "I'll eat plenty of fruits and vegetables."

Ans: DChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Teaching/LearningObjective: 5Patient Needs: B-2Feedback: For effective tissue healing, adequate intake of protein and vitamins A, B complex, C,D, E, and K are needed. To provide these nutrients, the patient should eat a high-protein diet withplenty of fruits and vegetables. To avoid impeding circulation to the area, the bandage should be secure but not tight. If the patient's foot feels cold, circulation is impaired, which inhibits wound healing.

23. The postanesthesia-care unit (PACU) nurse is caring for a patient who has arrived from the operating room and is still unconscious. During the initial assessment, the nurse notices that the patient's skin is blue and dusky, so she looks, listens, and feels for breathing. She determines the patient is not breathing. The priority intervention is to:A) Check an oxygen saturation rate, continue to monitor for apnea, and perform a focused assessment.B) Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw.C) Check the arterial pulses and place the patient in the Trendelenburg position.D) Call a code blue and then get a rapid intubation kit and prepare to reintubate.

Ans: BChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 1Patient Needs: A-2Feedback: When a nurse finds a patient who is not breathing, the priority intervention is to open the airway and treat the possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the head back, pushes forward on the angle of the lower jaw, or performs the jaw thrust method to open the airway. Option A is incorrect; this is an emergency

and requires the basic life support intervention of airway, breathing, and circulation assessment. Option C is incorrect; arterial pulses should be checked only after airway and breathing have been established. Option D is incorrect; calling a code blue is appropriate in this case and the patient may need to be reintubated, but the nurse should never leave the patient without an airway to get a rapid intubation kit and prepare for reintubation.

24. A student nurse asks the postanesthesia care unit (PACU) nurse, Why does the patient cometo the PACU prior to the medical-surgical unit? The PACU nurse explains to the student nurse that:A) The PACU allows the patient to recover from anesthesia in a stimulating environment to facilitate awakening and reorientation.B) The PACU allows the patient to recover from the effects of anesthesia; the patients stay in PACU until they are oriented, have stable vital signs, and are without complications.C) Frequently, patients are recovered in the medical-surgical unit, but hospitals are usually short of beds and the PACU is an excellent place to triage patients.D) The medical-surgical unit is frequently very busy and unable accept the patient from surgery, so the patients are observed and monitored in PACU until a bed is available.

Ans: BChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Teaching/LearningObjective: 2Patient Needs: A-1Feedback: The PACU provides care for patients while they recover from the effects of anesthesia; the patient must be oriented, have stable vital signs, and show no evidence of hemorrhage or other complications. Patients will sometimes be recovered in the intensive care unit, but this is considered an extension of the PACU. Option A is incorrect; the PACU does allow the patient to recover from anesthesia, but the environment is calm and quiet, as patients are initially disoriented and confused when they begin to awaken and reorient. Option C is incorrect; patients are not usually recovered in the medical-surgical unit. Although hospitals are occasionally short of beds, the PACU should not be used for patient triage. Option D is incorrect;in an emergency, the medical-surgical unit may be unable to accept patients from surgery. In this case, patients are observed and monitored in the PACU until a bed is available, but this is the exception to the rule.

25. A nurse is caring for a 38-year-old patient in the postanesthesia care unit (PACU) following abdominal surgery; as the patient begins to awaken he is restless and asking for a drink of water. The nurse checks his skin and finds it is cold, moist, and pale. The nurse is concerned the

patient may be at risk for:A) Hemorrhage and shockB) Loss of airway and hypotensionC) Pain and anxietyD) Hypertension and dysrhythmias

Ans: AChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 3Patient Needs: A-1Feedback: Hemorrhage is a complication of surgery that can result in death; when blood loss is extreme, the patient usually presents as apprehensive, restless, and thirsty. The skin is cold, moist, and pale. Option B is incorrect; the patient is asking for a drink of water so loss of airway is unlikely and no evidence is provided in the question that it is related to hypotension such as blood pressure. Options C and D are incorrect; there is no evidence based on the information provided in the question that the patient is in pain or having anxiety, hypertension, ordysrhythmias.

26. A nurse is caring for an 82-year-old woman in the postanesthesia care unit (PACU). The woman begins to awaken and responds to her name but is confused, restless, and agitated. The nurse is aware that:A) Postoperative confusion indicates an oxygen problem or possibly a stroke during surgery.B) Confusion, restlessness, and agitation are normal postoperative findings and will diminish in time.C) Postoperative confusion is common in the elderly, but it could also indicate a significant blood loss.D) Confusion, restlessness, and agitation indicate inadequate pain management; analgesics will help.

Ans: CChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 4Patient Needs: A-1Feedback: Postoperative confusion is common in the elderly, but it could also indicate blood loss and the potential for hypovolemic shock; it is a critical symptom for the nurse to identify. Option A is a good answer, postoperative confusion is an indication of an oxygen problem or possibly a stroke during surgery, but blood loss is more likely. Option B is incorrect; restlessness

and agitation are never normal postoperative findings. Option D is incorrect; confusion, restless, and agitation may indicate inadequate pain management, but pain could be assessed by report of pain, splinting of the affected area, and vital signs.

27. A man returns to the emergency department (ED) after receiving 10 stitches for a knife wound while cleaning fish. The wound is now infected. The stitches are removed and the wound is cleaned and packed with gauze. The ED instructs the man to return the next day to remove the packing and resuture the wound. The nurse is aware that the wound will now heal by:A) Late intentionB) Second intentionC) Third intentionD) First intention

Ans: CChapter: 20Cognitive Level: ApplicationDifficulty: EasyIntegrated Process: Nursing ProcessObjective: 5Patient Needs: A-1Feedback: Third-intention healing, or secondary suture, is used for deep wounds that either havenot been sutured early or that the suture break down and are re-sutured later, which is what happened in this case. Secondary suture brings the two opposing granulation surfaces back together; however, this usually results in a deeper and wider scar. These wounds are also packed postoperatively with moist gauze and covered with a dry sterile dressing. Option A is incorrect; late intention is a term that sounds good but is used simply to distract the unsure test-taker. This technique is frequently used by test writers. Option B is incorrect; second intention is when the wound is left open and the wound is filled will granular tissue. Option D is incorrect; first-intention wounds are made aseptically with a minimum of tissue destruction.

28. A student nurse is going to be changing an abdominal dressing; the first step is to provide thepatient with information regarding the procedure. Which of the following represents the best planfor completing this task?A) The dressing change is often painful; we will be giving you pain medication prior to the procedure so you do not have to worry.B) During the dressing change, I will provide privacy at a time of your choosing; it should not be painful. You can look at the incision and help with the procedure if you want to.C) The dressing change should not be painful but you can never be sure; infection is always a concern.D) The best time for doing a dressing change is during lunch so we are not interrupted; I will

provide privacy, and it should not be painful.

Ans: BChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Teaching/LearningObjective: 6Patient Needs: A-2Feedback: The patient needs to be informed that changing dressings is a simple procedure with little discomfort, privacy will be provided, and he is free to look at the incision or even assist in the dressing change itself. If the patient decides to look at the incision, assurance is given that theincision will shrink as it heals and that the redness will likely fade. Option A is incorrect; dressing changes should not be painful, but giving pain medication prior to the procedure is always a good preventative measure. Option C is incorrect. Telling the patient that the dressing change should not be painful but you can never be sure; infection is always a concern does not offer the patient any real information or options and serves only to create fear. Option D is incorrect; the best time for dressing change is when it is most convenient for the patient. Nutrition is important, but interrupting lunch is probably a poor choice.

29. A nurse is caring for a patient who has had major abdominal surgery. The postsurgical nurse is aware that the postoperative plan of care should include:A) Providing passive range of motion, assisting the patient with coughing and deep breathing as needed, and increasing mobility by helping the patient sit on the side of the bed every day.B) Assessing bowel sound every 8 hours, offering medications as ordered, and allowing the patient privacy and security.C) Managing the patient's pain, working with the patient to cough and deep breathe every 2 hours, turning the patient frequently, exercising, and ambulating as early as possible.D) Allowing the patient to visit with family, allowing time for rest and reflection, and then have the nursing assistant provide a sponge bath while the nurse begins the discharge teaching process.

Ans: CChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 7Patient Needs: A-1Feedback: Postsurgical patients need to cough and deep breathe to expel the remaining anesthesia. Pain management allows the patient to increase activity. With major abdominal surgery, distention can be avoided by having the patient turn frequently, exercise, and ambulate as early as possible. Option A is incorrect; providing passive range of motion is only used when

patients are unable to move body parts for themselves, which would not be the case for a patient who has had abdominal surgery. Assisting the patient with coughing and deep breathing is important; helping the patient sit on the side of the bed should be followed by standing and a short walk on postoperative day one. Option B is incorrect; assessing bowel sounds, providing medications as ordered, and allowing patient privacy and security are all important but they are not the key postsurgical assessments and interventions. Option D is incorrect; allowing the patient to visit with family is important but patient stays in the hospital are short and self-care activity is critical for patient success. Instructing the nursing assistant to provide a sponge bath does not promote self-care. If the patient is not mobile, discharge teaching will be unnecessary.

30. A 79-year-old man who has returned to the medical-surgical unit following abdominal surgery is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse explains that refusing to wear the stocking places him at significant risk for:A) SepsisB) InfectionC) Pulmonary embolismD) Hematoma

Ans: CChapter: 20Cognitive Level: ApplicationDifficulty: EasyIntegrated Process: Teaching/LearningObjective: 1Patient Needs: A-1Feedback: Patients who have surgery that limit mobility are at an increased high risk for pulmonary embolism secondary to deep vein thrombosis. The use of an external pneumatic compression stocking significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. Options A and B are incorrect; the risk of infection or sepsis would not be affected by a pneumatic compression stocking. Option D is incorrect; a hematoma or bruise would not be affected by an external pneumatic compression stocking unless the stocking was placed directly over the hematoma.

31. A nurse is completing the discharge instructions for a 75-year-old widower who is living alone and is leaving the hospital following hip replacement surgery. The measurable outcome that should guide the patient's discharge plan of care should be the patient's ability to:A) Be responsible for herselfB) Meet developmental way pointsC) Demonstrate self-care abilitiesD) Provide evidence of follow-through on the plan of care

Ans: CChapter: 20Cognitive Level: ApplicationDifficulty: EasyIntegrated Process: Nursing ProcessObjective: 2Patient Needs: A-1Feedback: Patients must be able to demonstrate self-care abilities to be safe at home following surgery. Reduced hospital lengths of stay and diminished home health care resources have increased the level of performance needed for patients to safely perform their own self-care. Options A and D are incorrect; to be responsible for herself and to provide evidence of follow-through on the plan of care are not measurable outcomes. Option B is incorrect; to meet developmental way points is not a defined outcome related to hip replacement surgery.

32. A nurse in the postanesthesia care unit (PACU) is caring for a 56-year-old male patient who had a hernia repair. The patient's blood pressure is now 164/92, he had no history of hypertensionprior to surgery, and his preoperative blood pressure was 112/68. The nurse knows that hypertension following surgery is often related to:A) Dysrhythmias, blood loss, and hyperthermiaB) Electrolyte imbalances and neurologic changesC) A parasympathetic reaction and low blood volumesD) Pain, hypoxia, or bladder distention, which all cause sympathetic stimulation

Ans: DChapter: 20Cognitive Level: ApplicationDifficulty: ModerateIntegrated Process: Nursing ProcessObjective: 2Patient Needs: D-4Feedback: Hypertension is common in the immediate postoperative period secondary to sympathetic nervous system stimulation from pain, hypoxia, or bladder distention. Options A andB are incorrect; dysrhythmias, blood loss, hyperthermia, electrolyte imbalances, and neurologic changes are not common postoperative reasons for hypertension. Option D is incorrect; a parasympathetic reaction and low blood volumes would cause hypotension.