Chapter 18

Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking
for Collaborative Care, 6h Edition

Test Bank
Chapter 18: Care of Postoperative Patients
MULTIPLE CHOICE
1. Which function or assessment finding in a client being admitted to the postanesthesia
care unit after surgery is the best indication that the client's respiratory status does not
require immediate attention?
A. The client is able to talk.
B. The client is alert and oriented.
C. The client's oxygen saturation is 90%.
D. The client's chest rises and falls rhythmically during respiration.
ANS: C
The client may have impaired gas exchange at the alveolar capillary level and still be able
to talk and be alert and oriented. The chest may continue to rise and fall rhythmically.
The definitive assessment finding that indicates whether gas exchange is effective is the
degree of oxygen saturation.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Physiological Integrity
2. Which assessment finding in a postoperative client indicates to the nurse that the
interventions to prevent hypovolemia need to be re-evaluated?
A. The blood pressure changes from 136/80 to 122/80 mm Hg.
B. The urine output decreases from 40 to 10 mL/hour.
C. The client cannot count backward from 100 by threes.
D. The client's temperature has changed from 100.2 to 100.4 F.
ANS: B
One of the most sensitive indicators of vascular volume loss is a decreased urine output
in response to increased secretion of antidiuretic hormone (ADH).
3. The client is admitted to the postanesthesia care unit (PACU) after surgery that took
place with the client in the lithotomy position. Which change in assessment findings
alerts the nurse to a possible complication of this surgical position?
A. The electrocardiogram (ECG) shows tall, peaked T waves and wide QRS complexes.
B. The client only arouses in response to light shaking.
C. The pulse pressure has increased from 28 to 40 mm Hg.
D. The dorsalis pedis pulses are not palpable bilaterally.
ANS: D
The lithotomy position can compromise the client's peripheral circulation in the lower
extremities.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
4. In checking the neurologic status of the client just admitted to the PACU, the nurse
notes that the right eye pupil is dilated more than the left pupil. What is the nurses
best first action?
A. Check the client's chart to compare these findings to the client's baseline neurologic
assessment.
B. Raise the head of the bed up to a 30-degree angle and administer oxygen.
C. Test the client's deep tendon reflexes on all four extremities.
D. Notify the physician and document the finding.
ANS: A
Any abnormal neurologic assessment finding discovered postoperatively should be
compared to the client's preoperative neurologic status. Unequal pupil size is a relatively
common assessment finding in otherwise healthy adults.
TOP: Nursing Process Step: Assessment
5. Which client is at greatest risk for respiratory complications after surgery under
general anesthesia?
A.
B.
C.
D.
65-year-old woman taking a calcium channel blocker for hypertension

55-year-old man with chronic allergic rhinitis
45-year-old woman with diabetes mellitus type 1
35-year-old man who smokes two packs of cigarettes daily
ANS: D
Cigarette smoking greatly increases the risk for pulmonary problems following general
anesthesia because the cilia of the mucous membranes may be absent or hypoactive, the
lining of the airways may be hypertrophied, and the alveoli may be less compliant. Age
and gender are not significant in this case.
6. One hour after admission to the PACU, the postoperative client has become very
restless. What is the nurses best first action?
A. Ask the client if he or she is having pain.
B. Check the client's oxygen saturation level.
C. Document the finding as the only action.
D. Explain to the client that he or she is in the recovery room after surgery.
ANS: B
The most common causes of restlessness in the immediate postoperative period are
hypoxemia and pain. Although pain control is very important, determining the adequacy
of ventilation in this case has higher priority.
TOP: Nursing Process Step: Assessment /Implementation/Intervention
7. The postoperative client's arterial blood gas values are pH 7.22, HCO3 21 mEq/L,
PCO2 65 mm Hg, and PO2 58 mm Hg. What is the nurses best first action?
A. Notify the physician.
B. Assess the client's airway.

C. Increase the oxygen flow rate.
D. Document the finding as the only action.
ANS: B
The arterial blood gas values indicate acute respiratory acidosis. The client does need
oxygen; however, if the airway is not patent, increasing the oxygen flow rate will be of
minimal benefit. The best first action is to ensure a patent airway, and then apply oxygen.
TOP: Nursing Process Step: Implementation/Intervention
8. Two hours after abdominal surgery, the nurse auscultates the client's abdomen. No
bowel sounds are present. What is the nurses best first action?
A. Position the client on the right side with the bed flat.
B. Check the dressing and apply an abdominal binder.
C. Palpate the bladder and measure abdominal girth.
ANS: D
Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that
should be documented. No intervention specific to this finding is needed at this time.
9. Calculate the actual amount of nasogastric (NG) tube drainage during an 8-hour shift
(3 PM to 11 PM) from the client who has a drainage container with 200 mL marked
at 3 PM and 840 mL at 11 PM, and who received NG irrigations (flushings) of 60 mL
three times during the 8-hour shift.
A. 840 mL
B. 660 mL
C. 460 mL
D. 420 mL
ANS: C
The initial volume of 200 mL is subtracted from the 840 mL, leaving 640 mL. The
irrigation fluid is not drainage and also must be subtracted (60 3 = 180 mL). The total
drainage from this client's NG tube during the 8-hour shift was 460 mL (640 180 = 460
mL).
10. The client who is 24 hours postoperative from abdominal surgery has light brown
fluid with small particles that look like coffee grounds in the NG tube drainage. What
is the nurses best action?
A. Notify the physician.
B. Irrigate the tube with normal saline.
C. Clamp the tube and advance it 1 to 2 inches.
ANS: A
This type of drainage indicates possible gastrointestinal bleeding and should be explored
further as soon as possible.
11. When changing the client's abdominal dressing on the second postoperative day, the
nurse notes crusting on about half of the suture line and oozing of a small amount of
serosanguineous drainage. What is the nurses best action?
A. Clean the suture line gently and apply new dressings.
B. Gently remove the crusts and culture the material beneath.
C. Remove the sutures or staples in the area where crusts have formed.
D. Apply a binder over the incision and notify the surgeon.
ANS: A
Serosanguineous drainage and a small amount of crusting are normal incision findings on
the second postoperative day.
12. The client is 4 days postoperative from a bowel resection and has a large abdominal
incision. When the nurse enters the client's room, he tells her that he felt the incision
pop when he coughed just a moment ago. What is the nurses best response?
A. It is good that you are coughing and deep breathing to prevent lung complications.
B. That is a normal feeling in the incision whenever you are moving.
C. Be sure to splint the incision with a pillow or your hands when you cough.
D. Lie down flat on the bed and let me examine your incision.
ANS: D
Although wound dehiscence is not a common complication after surgery, it is usually
painless and felt as a "popping" or "splitting" sensation. Any client report of such a
sensation should be immediately investigated to avoid evisceration.
13. When a nurse checks a postoperative client for pain relief 30 minutes after the client
started patient-controlled analgesia (PCA) with morphine, the client is sleeping and
has a respiratory rate of 8 breaths/minute. What is the nurses best first action?
A. Attempt to arouse the client by calling his or her name and lightly shaking the
client's arm.
B. Administer oxygen by mask and apply an apnea monitor.
C. Document the finding as the only action.
D. Notify the physician immediately.
ANS: A
Many clients experience some degree of respiratory depression with opioid analgesics. If
the client can be aroused with minimally intrusive techniques and increases the rate of
respiration spontaneously, no further intervention is required.
14. Which precaution or issue should the nurse reinforce to the postoperative client about
correct use of the patient-controlled analgesia (PCA) device?
A. Push the button when you feel the pain beginning rather than waiting until the pain
is at its worst.
B. Push the button every 15 minutes whether you feel pain at that time or not.
C. Instruct your family or visitors to press the button for you when you are sleeping.
D. Try to go as long as you possibly can before you press the button.
ANS: A
Clients should be instructed to push the button to release medication when pain begins
rather than waiting until the pain becomes so great that the dose administered by the
pump cannot control the pain.
15. The nurse empties 80 mL of sanguineous drainage from the Jackson-Pratt drain in the
client's hip after hip surgery. What other actions regarding the drain should the nurse
take?
A. Flush the tubing with urokinase to ensure patency.
B. Compress and close the drain to ensure suction.
C. Advance the tubing inch from the insertion site.
D. Clamp the drain for 2 hours and release the clamp for 2 hours.
ANS: B
The Jackson-Pratt drain removes fluid from the wound through closed suction. The drain
must be compressed and closed to create suction as it slowly re-expands.
DIF:
Cognitive Level: Application or higher

16. Which maneuver or technique should the nurse avoid to prevent pulmonary emboli in
a postoperative client?
A. Application of elastic wraps to the lower extremities
B. Measuring calf circumference every shift
C. Calf muscle massage
D. Early ambulation
ANS: C
Although massaging the calf and compressing the muscles can help prevent the formation
of deep vein thrombosis, this practice is avoided because it can stimulate the movement
of any clots that may have formed in the leg veins.
DIF: Cognitive Level: Comprehension
17. The client is postoperative from surgery performed to determine whether a growth in
her colon is cancerous. She asks the nurse what the pathology report shows. The
pathology report indicates that the growth is benign. What is the nurses best
response?
A. Congratulations! The growth was not cancerous.
B. You will have to wait for your doctor to tell you the results.
C. You shouldn't worry. Most tumors of this sort are benign.
D. I will call your doctor to let her know you are awake and are concerned about the
results.
ANS: D
Unless there are specific orders to tell the client the pathology results, the surgeon is the
person to explain them to the client.
MSC: Client Needs Category: Psychosocial Integrity

18. The postoperative client is receiving butorphanol tartrate (Stadol) IM for pain control.
Which intervention or precaution should the nurse employ specifically for this drug?
A. Assessing bowel sounds in all four quadrants
B. Performing neurologic checks every 2 hours
C. Assessing the client for drug dependence
D. Assessing blood pressure every 2 hours
ANS: B
Butorphanol tartrate can increase intracranial pressure.
19. The client returning to the clinic for a follow-up visit 3 weeks after abdominal surgery
is concerned because she can feel small, uneven lumps under the suture line of the
incision. What is the nurses best response?
A. Avoid touching those areas because you may dislodge the blood clots that keep
your incision from bleeding.
B. What you are feeling is growth of new tissue proceeding at different rates in the
incision.
C. Those are the deep stitches the surgeon placed, and they will eventually be absorbed
and disappear.
D. Keep the incision covered for as long as those lumps can be felt.
ANS: B
Tissue healing and growth of new cells proceed at different rates along the incision.
Small, firm lumps are usually new blood vessels or new collagen bases. They eventually
smooth out without intervention when the scar is mature.
MSC: Client Needs Category: Psychosocial Integrity/Physiological Integrity

20. What dietary modifications should the nurse teach to the client who is going home
with an extensive wound after surgery?
A. Drink at least 4 L of fluid every day.
B. Eating dietary fiber can help prevent constipation.
C. Be sure you are getting adequate amounts of vitamin C in your diet.
D. Try to lose weight so that you don't put too much strain on the incision.
ANS: C
Vitamin C promotes wound healing.
DIF: Cognitive Level: Comprehension
21. As part of the report, the nurse of the medical surgical unit was told that the clients
Foley catheter had been empty prior to leaving the PACU/recovery room. Two hours
later, the nurse notes that the clients output is 30 mL. What is the nurses best first
action?
A. Measure and compare total output with total intake.
B. Document the finding as the only action.
C. Increase the rate of IV fluids by 50 mL/hour.
D. Notify the surgeon immediately.
ANS: A
Fluid balance is affected by a variety of factors, including length of fasting before
surgery, fluid loss during the surgical procedure, and the amount of fluids or blood given
during surgery. Postoperatively, intake (IV fluid, oral intake) must be measured against
output from insensible fluid loss, diaphoresis, wound drainage, or drainage in tubes such
as an NG tube or Jackson-Pratt drain. Once this information is gathered concerning the
clients total intake and output, the nurse determines whether to call the physician.
COMPLETION
1. Partial or complete separation of the outer layers of a wound is known as
____________________, whereas ____________________ is the total separation of
all wound layers and protrusion of all wound layers.
ANS:
dehiscence, evisceration
Rationale: These complications typically occur 5 to 10 days after surgery and are seen
more often in obese clients, those with diabetes, or those who are using steroids. The
nurse must be able to use the correct terminology when reporting the occurrence of one
of these complications to the physician. Evisceration is a surgical emergency, whereas
dehiscence may be initially treated with nonsurgical interventions.
DIF: Cognitive Level: Knowledge
OTHER
1. Which of the following is associated with increased risk of postoperative nausea and
vomiting? (Select all that apply.)
A. Older adult
B.
Raising the head of the bed
C.
Obese client
D.
Abdominal surgery
E.
History of motion sickness
F.
Head and neck surgery
G.
Type of anesthesia used
H.
Position during surgery
ANS:
C, D, E, G
Rationale: Awareness of factors that can increase nausea and vomiting will enable the
nurse to institute precautionary measures to prevent nausea and vomiting from occurring.
DIF: Cognitive Level: Knowledge
TOP: Nursing Process Step: Intervention

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Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking

for Collaborative Care, 6h Edition

65-year-old woman taking a calcium channel blocker for hypertension

B. Assess the client's airway.

Cognitive Level: Application or higher

TOP: Nursing Process Step: Implementation/Intervention

MSC: Client Needs Category: Psychosocial Integrity

MSC: Client Needs Category: Psychosocial Integrity/Physiological Integrity

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