POST OPERATIVE

What does progression of patients through various phases of care in a postanesthesia

care unit (PACU) primarily depend on?

a. condition of patient
b. type of anesthesia used
c. respiratory adequacy
d. type of surgical procedure
a. condition of patient
Although some surgical procedures and drug administration require more intensive
postanesthesia care, how fast and through which levels of care patients are moved depend on
the condition of the patient. A physiologically unstable outpatient may stay an extended time in
Phase I, whereas a patient requiring hospitalization but who is stable and recovering may well
be transferred quickly to an inpatient unit.
Upon admission of a patient to the PACU, the nurse's priority nursing assessment is

a. vital signs
b. surgical site
c. respiratory adequacy
d. level of consciousness
c. respiratory adequacy
Physiologic status of the patient is always prioritized with regard to airway; breathing, and
circulation, and respiratory adequacy is the first assessment priority of the patient on admission
to the PACU from the operating room. Following assessment of respiratory function,
cardiovascular, neurologic and renal function should be assessed as well as the surgical site.
How is the initial information given to the PACU nurses about the surgical patient?

a. a copy of the written operative report

b. a verbal report from the circulating nurse
c. a verbal report from the ACP
d. an explanation of the surgical procedure from the surgeon
c. a verbal report from the ACP
The admission of the patient to the PACU is a joint effort between the ACP, who is responsible
for supervising the post-anesthesia recovery of the patient, and the PACU nurse, who provides
care during anesthesia recovery. The ACP gives a verbal report that presents the details of the
surgical and anesthetic course, preoperative conditions influencing the surgical and anesthetic
outcome, and PACU treatment plans to ensure patient safety and continuity of care.
To prevent agitation during the patient's recovery from anesthesia, when should the nurse begin
orientation explanations?

a. when the patient is awake

b. when the patient first arrives in the PACU
c. when the patient becomes frightened or agitated
d. when the patient can be aroused and recognizes where he or she is
b. when the patient first arrives in the PACU
Even before patients awaken from anesthesia, their sense of hearing returns and all activities
should be explained by the nurse from the time of admission to the PACU to assist in orientation
and decrease confusion.
What is included in the routine assessment of the patient's cardiovascular function on admission
to the PACU?

a.monitoring arterial blood gases

b. ECG monitoring
c. determining fluid and electrolyte status
d. direct arterial blood pressure monitoring
b. ECG monitoring
ECG monitoring is performed on patients to assess initial cardiovascular problems during
anesthesia recovery. Fluid and electrolyte status is an indication of renal function and
determinations of arterial blood gases and direct arterial blood pressure monitoring are used
only in special cardiovascular or respiratory problems.
With what are the post-op respiratory complications of atelectasis and aspiration of
gastric contents associated?

a. hypoxemia
b. hypercapnia
c. hypoventilation
d. airway obstruction
a. hypoxemia
Hypoxemia occurs with atelectasis and aspiration as well as pulmonary edema, pulmonary
embolism, and bronchospasm. Hypercapnia is caused by decreased removal of CO2 from the
respiratory system that could occur with airway obstruction or hypoventilation. Hyperventilation
may occur with depression of central respiratory drive, poor respiratory muscle tone due to
disease or anesthesia, mechanical restriction, or pain. Airway obstruction could occur with the
tongue blocking the airway, restrained thick secretions, laryngospasm, or laryngeal edema.
To prevent airway obstruction in the post-op patient who is unconscious or
semiconscious, what will the nurse do?

a. encourage deep breathing

b. elevate the head of the bed
c. administer oxygen per mask
d. position the patient in a side-lying position
d. position the patient in a side-lying position
An unconscious or semiconscious patient should be placed in a lateral position to protect the
airway from obstruction by the tongue. Deep breathing and elevation of the head of the bed are
implemented to facilitate gas exchange when the patient is responsive. Oxygen administration is
often used but the patient must first have a patent airway.
To promote effective coughing, deep breathing, and ambulation in the post-op patient,
what is most important for the nurse to do?

a. teach the patient controlled breathing

b. explain the rationale for these activities
c. provide adequate and regular pain meds
d. use an incentive spirometer to motivate the patient
c. provide adequate and regular pain meds
Incisional pain is often the greatest deterrent to patient participation in effective ventilation and
ambulation and adequate and regular analgesic medications should be provided to encourage
these activities. Controlled breathing may help the patient to manage pain but does not promote
coughing and deep breathing. Explanations and use of an incentive spirometer help to gain
patient participation but are more effective if pain is controlled.
While assessing a patient in the PACU, the nurse finds that the patient's blood pressure
is below the pre-op baseline. The nurse determines that the patient has residual
vasodilating effects of anesthesia when what is assessed?

a. a urinary output >30 mL/hr

b. an oxygen saturation of 88%
c. a normal pulse with warm, dry, pink skin
d. a narrowing pulse pressure with normal pulse
c. a normal pulse with warm, dry, pink skin
Hypotension with normal pulse and skin assessment is typical of residual vasodilating effects of
anesthesia and requires continued observation. An oxygen saturation of 88% indicates
hypoxemia, whereas a narrowing pulse pressure accompanies hypoperfusion. A urinary output
>30 mL/hr is desirable and indicates normal renal function.
A patient in the PACU has emergence delirium manifested by agitation and thrashing.
What should the nurse assess for first in the patient?

a. hypoxemia
b. neurologic injury
c. distended bladder
d. cardiac dysrhythmias
a. hypoxemia
The most common cause of emergence delirium is hypoxemia and initial assessment should
evaluate respiratory function. When hypoxemia is ruled out, other causes, such as distended
bladder, pain, and fluid and electrolyte disturbances, should be considered. Delayed awakening
may result from neurologic injury and cardiac dysrhythmias most often result from specific
respiratory, electrolyte, or cardiac problems.
The PACU nurse applies warm blankets to a post-op patient who is shivering and has a
body temperature of 96 degrees Fahrenheit. What treatment also may be used to treat the
patient?

a. oxygen
b. vasodilating drugs
c. antidysrhythmic drugs
d. analgesics or sedatives
a. oxygen
(The most common cause of emergence delirium is hypoxemia and initial assessment should
evaluate respiratory function. When hypoxemia is ruled out, other causes, such as distended
bladder, pain, and fluid and electrolyte disturbances, should be considered. Delayed awakening
may result from neurologic injury and cardiac dysrhythmias most often result from specific
respiratory, electrolyte, or cardiac problems.) balik
Which patient is ready for discharge from Phase 1 PACU care to the clinical unit?

a. arouses easily, pulse is 112 bpm, respiratory rate is 24, dressing is saturated, SaO2 is 88%
b. difficult to arouse, pulse is 52, respiratory rate is 22, dressing is dry and intact, SaO2 is 91%
c. awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92%
d. arouses, blood pressure higher than pre-op and respiratory rate is 10 no excess bleeding,
SaO2 is 90%
c. awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92%
On initial assessment in PACU the airway, breathing, and circulation (ABC) status is assessed
using a standardized tool that usually includes consciousness, respiration, oxygen saturation,
circulation, and activity. Increased or decreased respiratory rate, hypertension, and a SaO2
below 90% indicate inadequate oxygenation that will be treated or managed in the PACU before
discharging the patient to the next phase.
For which nursing diagnoses or collaborative problems common in post-op patients has
ambulation been found to be an appropriate intervention (SELECT ALL THAT APPLY)

a. impaired skin integrity r/t incision

b. impaired mobility r/t decreased muscle strength
c. risk for aspiration r/t decreased muscle strength
d. ineffective airway clearance r/t decreased respiratory excursion
e. constipation r/t decreased physical activity and impaired GI motility
f. venous thromboembolism r/t dehydration, immobility, vascular manipulation, or injury
b. impaired mobility r/t decreased muscle strengthd. ineffective airway clearance r/t decreased
respiratory excursion
e. constipation r/t decreased physical activity and impaired GI motility
f. venous thromboembolism r/t dehydration, immobility, vascular manipulation, or injury
These problems are improved with ambulation. Other collaborative problems could be potential
complications: urinary retention, atelectasis, and pneumonia.
A patient who had major surgery is experiencing emotional stress as well as physiologic
stress from the effects of surgery. What can this stress cause?

a. diuresis
b. hyperkalemia
c. fluid retention
d. impaired blood coagulation
c. fluid retention
The stress response causes fluid retention during the first 1 to 3 days postoperatively and fluid
overload is possible during this time. Fluid retention results from secretion and release of
antidiuretic hormone (ADH) and adrenocorticotropic hormone (ACTH) by the pituitary and
activation of the renin-angiotensin-aldosterone system (RAAS). ACTH stimulates that adrenal
cortex to secrete cortisol and aldosterone. The RAAS increases aldosterone release, which also
increases fluid retention. Aldosterone causes renal potassium loss with possible hypokalemia
and blood coagulation is enhanced by cortisol.
In addition to ambulation, which nursing intervention could be implemented to prevent or
treat the post-op complication of syncope?

a. monitor vital signs after ambulation

b. do not allow the patient to eat before ambulation
c. slowly progress to ambulation with slow changes in position
d. have the patient deep breathe and cough before getting out of bed
c. slowly progress to ambulation with slow changes in position
Slow progression to ambulation by slowly changing the patient's position will help to prevent
syncope. Monitoring vital signs after walking will not prevent or treat syncope. Monitor the
patient's pulse and blood pressure (BP) before, during, and after position changes. Elevate the
patient's head, then slowly have the patient dangle, then stand by the bed to help determine if
the patient is safe for walking. Eating will not have an effect on syncope. Deep breathing and
coughing will not decrease syncope, although it will prevent respiratory complications.
Which tubes drain gastric contents (SELECT ALL THAT APPLY)?

a. T-tube
b. hemovac
c. nasogastric tube
d. indwelling catheter
e. gastrointestinal tube
c. nasogastric tube
e. gastrointestinal tube
The nasogastric tube and gastrointestinal tube drain gastric contents. The T-tube drains bile, the
Hemovac drains blood from the surgical site, and the indwelling catheter drains urine form the
bladder.
Which drainage is drained with a Hemovac?

a. bile
b. urine
c. gastric contents
d. wound drainage
d. wound drainage
Bile is drained by a T-tube, urine is drained by an indwelling urinary catheter, and gastric
contents are drained by a nasogastric tube or a gastrointestinal tube.
Thirty-six hours post-op a patient has a temperature of 100 degrees Fahrenheit. What is the
most likely cause of this temperature elevation?

a. dehydration
b. wound infection
c. lung congestion and atelectasis
d. normal surgical stress response
d. normal surgical stress response
The nurse must be aware of drains, if used, and the type of surgery to help predict the expected
drainage. Dressings over surgical sites are initially removed by the surgeon unless otherwise
specified and should not be changed, although reinforcing the dressing is appropriate. Some
drainage is expected for most surgical wounds and the drainage should be evaluated and
recorded to establish a baseline for continuing assessment. The surgeon should be notified of
excessive drainage. Dressings will then be changed as ordered with assessment for infection
being done as well.
The health care provider has ordered IV morphine q2-4hr PRN for a patient following major
abdominal surgery. When should the nurse plan to administer the morphine?

a. before all planned painful activities

b. every 2 to 4 hours during the first 48 hours
c. every 4 hours as the patient requests the medication
d. after assessing the nature and intensity of the patient's pain
d. after assessing the nature and intensity of the patient's pain
Before administering all analgesic medication, the nurse should first assess the nature and
intensity of the patient's pain to determine if the pain is expected, prior doses of the medication
have been effective, and any undesirable side effects are occurring. The administration of PRN
analgesic medication is based on the nursing assessment. If possible, pain medication should
be in effect during painful activities but activities may be scheduled around medication
administration.
What should be included in the instructions given to the post-op patient before discharge?

a. need for follow-up care with home care nurses

b. directions for maintaining routine post-op diet
c. written information about self-care during recuperation
d. need to restrict all activity until surgical healing is complete
c. All postoperative patients need discharge instructions regarding what to expect and what self-
care can be assumed during recovery. Diet, activities, follow-up care, symptoms to report, and
instructions about medications are individualized to the patient.
THIS SET IS OFTEN SAVED IN THE SAME FOLDER AS...
PRE OPERATIVE CARE

Which procedures are done for curative purposes (select all that apply)?
a. Gastroscopy
b. Rhinoplasty
c. Tracheotomy
d. Hysterectomy
e. Herniorrhaphy
d. Hysterectomy
e. Herniorrhaphy

Hysterectomy and herniorrhaphy are done to eliminate and repair pathologic conditions.
2. A patient is scheduled for a hemorrhoidectomy at an ambulatory surgery center. An
advantage of performing surgery at an ambulatory center is a decreased need for
a. diagnostic studies and preoperative medications.
b. preoperative and postoperative teaching by the nurse.
c. psychologic support to alleviate fears of pain and discomfort.
d. preoperative nursing assessment related to possible risks and complications.
a. diagnostic studies and preoperative medications.

Ambulatory surgery is usually less expensive and more convenient, generally involving fewer
diagnostic studies, fewer preoperative and postoperative medications, and leads susceptibility
to HAIs.
Patient-Centered Care: A patient who is being admitted to the surgical unit for hysterectomy
paces the floor, repeatedly saying, "I just want this over." What should the nurse do to promote a
positive surgical outcome for the patient?
a. Ask the patient what her specific concerns are about the surgery.
b. Redirect the patient's attention to the necessary preoperative preparations.
c. Reassure the patient that the surgery will be over soon and she will be fine.
d. Tell the patient she should not be so anxious because she is having a common, safe surgery.
a. Ask the patient what her specific concerns are about the surgery.

Excessive anxiety and stress can affect the surgical recovery and the nurse's roe in
psychologically preparing the patient for surgery is to asses for potential stressors that could
negatively affect surgery. Specific fears should be identified and addressed by the nurse by
listening and explaining planned postoperative care.

Many herbal products that are commonly taken cause surgical problems. Which herbs listed
below should the nurse teach the patient to avoid before surgery to prevent an increase in
bleeding for the surgical patient (select all that apply)?
a. Garlic
b. Fish oil
c. Valerian
d. Vitamin E
e. Astragalus
f. Ginkgo biloba
a. Garlic
b. Fish oil
d. Vitamin E
f. Ginkgo biloba

Garlic, fish oil, vitamin E, and ginkgo blob may increase bleeding for the surgical patient.
Priority Decision: When the nurse asks a preoperative patient about allergies, the patient reports
a history of seasonal environmental allergies and allergies to a variety of fruits. What should the
nurse do next?
a. Note this information int he patient's record as hay fever and food allergies.
b. Place an allergy alert wristband that identifies the specific allergies on the patient.
c. Ask the patient to describe the nature and severity of any allergic responses experienced
from these agents.
d. Notify the anesthesia care provider (ACP) because the patient may have an increased risk for
allergies to anesthetics.
c. Ask the patient to describe the nature and severity of any allergic responses experienced
from these agents.

Risk factors for latex allergies include a history of hay fever and allergies to foods such as
avocados, kiwi, bananas, potatoes, peaches, and apricots. When a patient identifies such
allergies, the patient should be further questioned about exposure to latex and specific reactions
to allergens. A history of any allergic responsiveness increases the risk for hypersensitivity
reactions to drugs used during anesthesia, but the hay fever and fruit allergies are specifically
related to latex allergy.
During a preoperative review of systems, the patient reveals a history of renal disease. This
finding suggests the need for which preoperative diagnostic studies?
a. ECG and chest x-ray
b. Serum glucose and CBC
c. ABGs and coagulation tests
d. BUN, serum creatinine, and electrolytes
d. BUN, serum creatinine, and electrolytes

BUN, serum creatinine, and electrolytes are used to assess renal function and should be
evaluated before surgery.
During a preoperative physical examination, the nurse is alerted to the possibility of
compromised respiratory function during or after surgery in a patient with which problem?
a. Obesity
b. Dehydration
c. Enlarged liver
d. Decreased peripheral pulses
a. Obesity

Obesity, as well as spinal, chest, and airway deformities, may compromise respiratory function
during and after surgery.
What type of procedural information should be given to a patient in preparation for ambulatory
surgery (select all that apply)?
a. How pain will be controlled
b. Any fluid and food restrictions
c. Characteristics of monitoring equipment
d. What odors and sensations may be experienced
e. Technique and practice of coughing and deep breathing, if appropriate
a. How pain will be controlled
b. Any fluid and food restrictions
e. Technique and practice of coughing and deep breathing, if appropriate

Procedural information includes what will be done for surgical preparation, including what to
bring and what to wear to surgery center, length and type of food and fluid restrictions, physical
preparation required, pain control, need for coughing and deep breathing (if appropriate), and
procedures done before and during surgery (such as vital signs, IV lines, and how anesthesia is
administered).
The nurse asks a preoperative patient to sign a surgical consent form as specified by the
surgeon and then signs the form after the patient does so. By this action, what is the nurse
doing?
a. Witnessing the patient's signature
b. Obtaining informed consent from the patient for the surgery
c. Verifying that the consent for surgery is truly voluntary and informed
d. Ensuring that the patient is mentally competent to sign he consent form
a. Witnessing the patient's signature

The HCP is ultimate responsible for obtaining informed consent. However, the nurse may be
responsible for obtaining and witnessing the patient's signature on the consent form.
When the nurse prepares to administer a preoperative medication to a patient, the patient tells
the nurse that she really does not understand what the surgeon plans to do.
a. What action should be taken by the nurse?

b. What condition of informed consent hast not been met in this situation?
a. The nurse should notify the surgeon because the patient needs further explanation of the
planned surgery.

b. Clear understanding of the information.

A patient scheduled for hip replacement surgery int he early afternoon is NPO but receives and
ingests a breakfast tray with clear liquids on the morning of surgery. What response does the
nurse expect when the ACP is notified?
a. Surgery will be done as scheduled.
b. Surgery will be rescheduled for the following day.
c. Surgery will be postponed for 8 hours after the fluid intake.
d. A nasogastric tube will be inserted to remove the fluids from the stomach.
a. Surgery will be done as scheduled.

The preoperative fasting recommendations of the American Society of Anesthesiology indicate

that clear liquids may be taken up to 2 hours before surgery fro healthy patients undergoing
elective procedures.
What is the rationale for using preoperative checklists on the day of surgery?
a. The patient is correctly identified and preoperative medications administered.
b. All preoperative orders and procedures have been carried out and documented.
c. Voiding is the last procedure before the patient is transported to the operating room.
d. Patients' families have been informed as to where they can accompany and wait for patients.
b. All preoperative orders and procedures have been carried out and documented.

The rationale for use of preoperative checklists is to ensure that the many preparations and
precautions performed before surgery have been completed and documented.
A common reason that a nurse may need extra time when preparing older adults for surgery is
their
a. ineffective coping
b. limited adaptation to stress
c. diminished vision and hearing
d. meed to include caregivers in activities.
c. diminished vision and hearing

One of the major reasons that older adults need increased time preoperatively is the presence
of impaired vision and hearing that slows understanding of preoperative instructions and
preparation for surgery. Thought processes and cognitive abilities may also be impaired in some
older adults.
The nurse is reviewing the laboratory results for a preoperative patient. Which study result
should be brought to the attention of the surgeon immediately?
a. Serum K+ of 3.8 mEq/L
b. Hemoglobin of 15 g/dL
c. Blood glucose of 100 mg/dL
d. White blood cell (WBC) count of 18,500/uL
d. White blood cell (WBC) count of 18,500/uL

The elevated WBC count may indicate infection. The surgeon will probably postpone the
surgery until the cause of the elevated WBC count has been found.
The nurse is preparing a patient for transport to the operating room. The patient is scheduled for
a right knee arthroscopy. What actions should the nurse take at this time (select all hat apply)?
a. Ensure that the patient has voided.
b. Verify that the informed consent is signed.
c. Complete preoperative nursing documentation.
d. Verify that the right knee is marked with indelible marker,
e. Ensure that the H&P, diagnostic reports, and vital signs are on the chart.
a. Ensure that the patient has voided.
b. Verify that the informed consent is signed.
c. Complete preoperative nursing documentation.
d. Verify that the right knee is marked with indelible marker,
e. Ensure that the H&P, diagnostic reports, and vital signs are on the chart.

All of these actions that are needed to ensure that the patient is ready for surgery. In addition,
the nurse should verify that the identification band and allergy band (if applicable) are on; the
patient is not wearing any cosmetics; nail polish has been removed; valuables have been
removed and secured and prosthetics, such as eyeglasses, have been removed and secured.

ADULT HEALTH ASSESSMENT