REVIEW

QUESTIONS

ROBERT C. REA, RN

The nurse is assessing a client recovering

from anesthesia. Which of the following is
an early indicator of hypoxemia?
a.
b.
c.
d.

Somnolence.
Restlessness.
Chills.
Urgency.

A client arrives from surgery to the

postanesthesia care unit. Which of the
following respiratory assessments should
the nurse complete first?
a.
b.
c.
d.

Oxygen saturation.
Respiratory rate.
Breath sounds.
Airway flow.

Which of the following nursing interventions

is most important in preventing
postoperative complications?
a.
b.
c.
d.

Progressive diet planning.

Pain management.
Bowel and elimination monitoring.
Early ambulation.

A client who is scheduled for an open

cholecystectomy has a 20-pack-year history
of smoking. For which postoperative
complication is the client most at risk?
a.
b.
c.
d.

Deep vein thrombosis.

Atelectasis and pneumonia.
Delayed wound healing.
Prolonged immobility.

Eight hours after surgery, a client has a

distended bladder and is unable to void.
Which of the following interventions is
contraindicated?
a.
b.
c.
d.

Facilitate voiding by normal position.

Pour running water over perineum.
Insert an indwelling urinary catheter.
Insert a straight catheter every 4 hours.

ANSWERS AND
RATIONALES
ROBERT C. REA, RN

The nurse is assessing a client recovering

from anesthesia. Which of the following is
an early indicator of hypoxemia?
a.
b.
c.
d.

Somnolence.
Restlessness.
Chills.
Urgency.

Rationale: One of the earliest signs of hypoxia

is restlessness and agitation. Decreased level
of consciousness and somnolence are later
signs of hypoxia. Chills can be related to the
anesthetic agent used but are not indicative of
hypoxia. Urgency is not related to hypoxia.

A client arrives from surgery to the

postanesthesia care unit. Which of the
following respiratory assessments should
the nurse complete first?
a.
b.
c.
d.

Oxygen saturation.
Respiratory rate.
Breath sounds.
Airway flow.

Rationale: Airway flow is always the first

assessment. Once the nurse establishes that
the client has a patent airway, the pulse
oximeter is applied to measure the oxygen
saturation, the respiratory rate is counted,
and the breath sounds are auscultated

Which of the following nursing interventions is most

important in preventing postoperative
complications?
a.
b.
c.
d.

Progressive diet planning.

Pain management.
Bowel and elimination monitoring.
Early ambulation.

Rationale: Early ambulation is the most significant

general nursing measure to prevent postoperative
complications and has been advocated for more than
40 years. Walking the client increases vital capacity
and maintains normal respiratory functioning,
stimulates circulation, prevents venous stasis,
improves gastrointestinal and genitourinary function,
increases muscle tone, and increases wound healing.
The client should maintain a healthy diet, manage
pain, and have regular bowel movements. However,

A client who is scheduled for an open

cholecystectomy has a 20-pack-year history of
smoking. For which postoperative complication is
the client most at risk?
a.
b.
c.
d.

Deep vein thrombosis.

Atelectasis and pneumonia.
Delayed wound healing.
Prolonged immobility.

Rationale: The client who has a significant cigarette

smoking history and an operative manipulation close to the
diaphragm (the gallbladder is against the liver) is at
increased risk for atelectasis and pneumonia.
Postoperatively this client will be reluctant to deep-breathe
because of pain, in addition to having residual lung damage
from smoking. Therefore, the client is at greater-thanaverage risk for pulmonary complications. The client does
not have an increased risk of prolonged immobility (unless
slowed by a respiratory problem), deep vein thrombosis (as
long as the client performs leg exercises), or delayed

Eight hours after surgery, a client has a distended

bladder and is unable to void. Which of the
following interventions is contraindicated?
a.
b.
c.
d.

Facilitate voiding by normal position.

Pour running water over perineum.
Insert an indwelling urinary catheter.
Insert a straight catheter every 4 hours.

Rationale: An indwelling urinary catheter increases

the risk of urinary tract infection because
microbes ascend the catheter and travel to the
bladder. The nurse should try to facilitate the
clients ability to void by using the sitting position
for a woman or the standing position for a man
and by running warm water over the perineum. If
such conservative methods fail, the nurse should
obtain an order to catheterize the client every 4
hours using a small French straight catheter until