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Chapter 05: Care of Postoperative Patients
deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition
MULTIPLE CHOICE
1. The postanesthesia care unit (PACU) nurse determines that the patient’s Aldrete score is 9.
Which statement correctly describes the meaning of this score?
a. The patient is at an increased risk for postoperative respiratory complications.
b. The patient’s condition warrants close monitoring.
c. The patient is experiencing severe pain.
d. The patient will soon be transferred to the postoperative unit.
ANS: D
The Aldrete scoring system is a method of determining readiness for a surgery patient to be
transferred from PACU to the postoperative unit. Scores are given for activity, respiration,
circulation, consciousness, skin color, and oxygen saturation. A score of 9 or 10 indicates
readiness for transfer.
PTS: 1 DIF: Cognitive Level: Application REF: 81 OBJ: 5 (clinical) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
2. The nurse is caring for a patient recovering in the PACU. The patient awakens confused and
disoriented. What action should the nurse take first?
a. Take the patient’s vital signs.
b. Encourage the patient to return to sleep.
c. Reorient and reassure the patient.
d. Document that the patient is awake and disoriented.
ANS: C
The patient should be reoriented and assured when awaking from anesthesia.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 81 OBJ: 1 (theory) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
3. The PACU nurse is caring for a semiconscious patient immediately following abdominal
surgery. The nurse correctly places the patient in which position?
a. Supine
b. Semi-Fowler
c. Lateral
d. Trendelenburg
ANS: C
Aspiration is a high-risk complication during this phase of recovery and can best be prevented
by placing the unconscious or semiconscious patient on the side with head turned to the side.
PTS: 1 DIF: Cognitive Level: Application REF: 83 OBJ: 6 (clinical) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
4. The PACU nurse is caring for an unconscious patient. Assessment reveals diminished breath
sounds bilaterally. Which action should the nurse take?
a. Hyperventilate the patient with an Ambu bag.
b. Increase bi-nasal oxygen to 3 L/min.
c. Elevate the head of bed 45 degrees.
d. Document “diminished breath sounds in both lower lobes.”
ANS: D
Mild atelectasis is an expected sign after anesthesia for the first 48 hours after surgery. This
finding is considered a normal finding while the patient is in the PACU and would require no
further intervention unless other signs and symptoms, such as decreased oxygen saturation,
were present.
PTS: 1 DIF: Cognitive Level: Application REF: 83, 91 OBJ: 4 (theory) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. The nurse is caring for a patient during the first postoperative day. Which goal works to
prevent atelectasis and is most appropriate for the nursing care plan?
a. Patient will turn, cough, and deep-breathe every 4 hours.
b. Patient will “huff-cough” every 2 hours.
c. Patient will use the incentive spirometer twice a day.
d. Patient will resume diet as soon as possible.
ANS: B
Bi-hourly coughing will help prevent atelectasis. The patient should turn, cough, and deep-
breathe every 2 hours, and the incentive spirometer should ideally be used every hour.
Resuming diet does not prevent atelectasis, and as soon as possible is not a measurable
amount.
PTS: 1 DIF: Cognitive Level: Analysis REF: 91, Table 5- OBJ: 3 (theory) TOP: Maintenance of Ventilation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
6. The nurse is caring for a 90-year-old postoperative patient whose oxygen saturation is
frequently dropping below 90%. Which age-related change is most likely related to this
finding?
a. Prolonged use of a walker
b. Poor fluid intake
c. Weakened respiratory muscles
d. Increased elasticity of costal cartilages
ANS: C
Although all of these patients are at varying degrees of risk for thrombophlebitis, the hip
replacement surgery places a patient at high risk for thrombophlebitis due to limited mobility,
especially after the fifth postoperative day. This patient is at even higher risk of
thrombophlebitis because of a history of left-sided stroke.
PTS: 1 DIF: Cognitive Level: Analysis REF: 84 OBJ: 5 (theory) TOP: Maintenance of Circulation KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
10. The patient’s initial vital signs immediately on return from surgery include: blood pressure
(BP) of 140/90; pulse (P) of 80; respirations (R) of 14; and temperature (T) of 98° F. One hour
later the vital signs are: BP of 130/84; P of 72; R of 16; and T of 96.8° F. What action should
the nurse take next?
a. Add a blanket for warmth to the patient.
b. Notify the charge nurse of a probable hemorrhage.
c. Raise the head of the bed 45 degrees.
d. Document the assessment findings.
ANS: D
These findings are normal. The nurse should document the normal recovery assessment and
continue to monitor. There is no indication of chilling, hemorrhage, or respiratory distress,
which respectively would require blanket application, charge nurse notification, or raising the
head of the bed.
PTS: 1 DIF: Cognitive Level: Analysis REF: 82, Assignment Considerations OBJ: 5 (clinical) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. The nurse is caring for a patient who has had spinal anesthesia. The nurse correctly questions
which order?
a. Patient to lie flat for 6 to 8 hours.
b. Resume diet as tolerated.
c. Use incentive spirometer every hour while awake.
d. Notify physician immediately if headache occurs.
ANS: D
One of the goals during the postoperative period is to prevent or treat spinal headache. The
headache can be treated with nursing interventions such as keeping the patient flat if a
headache is reported and increasing fluid intake. If the headache becomes severe or does not
improve, the physician could be notified. Lying flat for 6 to 8 hours reduces the risk of spinal
headache and allows time for feeling to return to the legs; full diets can usually be resumed;
and an incentive spirometer will reduce the chance of respiratory complications resulting from
spinal anesthetic effects.
PTS: 1 DIF: Cognitive Level: Analysis REF: 85 OBJ: 6 (clinical) TOP: Prevention of Injury KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
12. The nurse is caring for a patient who had spinal anesthesia. Which drink is the best choice for
the nurse to offer the patient?
a. Tea
b. Orange juice
c. Milk
d. Water
ANS: A
Caffeinated beverages like tea or coffee increase the vascular pressure and help seal the
punctured area. Orange juice, milk, or water would not achieve the same goal.
PTS: 1 DIF: Cognitive Level: Application REF: 85 OBJ: 5 (theory) TOP: Prevention of Injury KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
13. When caring for a 10-hour postabdominal surgery patient, which finding the nurse should
report to the charge nurse?
a. 20 mL of clear green emesis
b. Pain level of 5/
c. No urine output since surgery
d. A weak cough ability
ANS: C
The postsurgical patient should void in 4 to 8 hours after surgery. Scant emesis, moderate pain,
and a weak cough are expected findings after abdominal surgery and do not require immediate
report to the charge nurse.
PTS: 1 DIF: Cognitive Level: Application REF: 85 OBJ: 5 (clinical) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
14. The nurse is caring for a surgical patient who complains of excessive gas. Which action should
the nurse take?
a. Offer iced fluids.
b. Arrange for large meal servings.
c. Provide a straw for drinking fluids.
d. Ambulate the patient in the hall.
ANS: D
Ambulation, eating small meals, drinking tepid drinks, and avoiding the use of straws help
eliminate gas.
PTS: 1 DIF: Cognitive Level: Application REF: 86 OBJ: 6 (clinical) TOP: Promotion of Gastrointestinal Function KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
18. When the postoperative patient refuses to cough due to incisional pain, which action should
the nurse take first?
a. Encourage deep breathing instead of coughing.
b. Splint the abdomen with a pillow.
c. Explain the importance of controlled coughing.
d. Administer pain medication.
ANS: B
Giving pain medication and explaining the importance of coughing may be effective, but the
best initial action would be splinting the incision with a pillow. Deep breathing should be done
in addition to, not in place of, coughing.
PTS: 1 DIF: Cognitive Level: Application REF: 91, Table 5- OBJ: 7 (clinical) TOP: Maintenance of Ventilation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
19. The nurse is educating the patient about vitamins and wound healing. The nurse explains that
which vitamin will enhance wound healing the most?
a. Vitamin A
b. Vitamin B
c. Vitamin C
d. Vitamin E
ANS: C
Vitamin C helps with the production of collagen, which restores damaged tissues.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 88 OBJ: 6 (clinical) TOP: Promotion of Wound Healing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
20. The nurse is caring for a patient following abdominal surgery. The patient asks the nurse when
he will be able to eat a normal diet. Which response is best?
a. “It will depend on how well you tolerate advancing from a clear liquid diet.”
b. “We will have to wait until your surgeon orders a regular diet for you.”
c. “Most patients are able to eat regular foods within 2 to 3 days following abdominal
surgery.”
d. “Once you have bowel sounds and are passing gas, you may have clear liquids, and
your diet will be advanced based upon your tolerance.”
ANS: D
Although the diet order originates with the physician, the nurse must ensure that bowel sounds
are present and the patient is able to pass flatus before any type of diet can be given to the
patient. Most surgeons will write an order to advance the diet as tolerated once these findings
occur. Every patient responds differently based upon their body and the type of surgery, so
stating that most patients eat regular foods within 2 to 3 days is inaccurate.
PTS: 1 DIF: Cognitive Level: Application REF: 86 OBJ: 3 (theory) TOP: Postoperative Diet
KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE
21. The nurse is performing a neurological assessment on a patient who was just transferred from
the PACU following abdominal surgery. Which action(s) correctly demonstrate(s) knowledge
of a neurological assessment? ( Select all that apply. )
a. Asking the patient to spell his name.
b. Asking the patient to identify where he is.
c. Noting if the patient can identify the sensation of touch.
d. Asking the patient to move his arms and legs.
e. Assessing the patient’s pupils for response to light.
ANS: B, C, D, E
The level of consciousness, orientation, sensory status, motor skills, and pupillary responses
are all integral components of the neurological assessment. Asking the patient to spell his
name is not an assessment of neurological status, particularly immediately following surgery.
PTS: 1 DIF: Cognitive Level: Application REF: 80 OBJ: 5 (clinical) TOP: Neurologic Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
22. The nurse is performing the Aldrete scoring system. Which factor(s) must be assessed? ( Select
all that apply. )
a. Activity
b. Circulation
c. Presence of wound drainage
d. Level of consciousness
e. O 2 saturation
ANS: A, B, D, E
The Aldrete scoring system requires that the nurse assess activity, circulation, respiration, level
of consciousness, and oxygen saturation.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 81 OBJ: 1 (theory) TOP: Aldrete Scoring System KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
23. Following an outpatient procedure for which the patient received general anesthesia, which
finding(s) indicate(s) to the nurse that the patient is ready to be discharged? ( Select all that
apply. )
a. The patient ambulates to the bathroom with minimal assistance.
b. The patient cannot read and voice an understanding of discharge instructions.
c. The patient has been awake for 2 hours.
d. The patient is able to empty the bladder.
e. The patient plans to drive home.
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care COMPLETION
26. The nurse in the PACU performs postsurgical assessments on the newly admitted patient every
_________ minutes.
ANS:
fifteen
The staff in PACU make postoperative assessments every 15 minutes on the newly admitted
patient.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 82, Focused Assessment OBJ: 5 (theory) TOP: Immediate Postoperative Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
27. The nurse assesses the musty odor coming from the wound drainage as being indicative of an
infection by a(n) ____________ organism, such as Pseudomonas or Staphylococcus.
ANS:
aerobic
A musty odor from the wound drainage is indicative of an infection by an aerobic
microorganism such as Pseudomonas or Staphylococcus.
PTS: 1 DIF: Cognitive Level: Application REF: 89 OBJ: 4 (theory) TOP: Wound Infection KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
28. A postsurgical patient consumed a cup of ice chips filled to the 120-mL mark, 2 ounces of
broth, and 120 mL of water. In addition, 750 mL of intravenous fluids were infused. The
patient voided 650 mL and vomited 100 mL.
What is the total intake for this patient? ________ mL
What is the total output for this patient? ________ mL
ANS:
One cup of ice is equal to one-half cup of water. Therefore, 120 mL of ice is 60 mL of intake.
One ounce is equal to 30 mL, so 2 ounces equals 60 mL. Therefore, the combined intake is
990 mL and the combined output is 750 mL.
PTS: 1 DIF: Cognitive Level: Application REF: 86, Clinical Cues OBJ: 6 (clinical) TOP: Intake and Output
KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
