MULTIPLE CHOICE

1. The nurse is caring for a client who had surgery 24 hours ago. He is alert and oriented when awakened and reports pain, but goes back to sleep when not being stimulated. He is on patient-controlled analgesia (PCA). What is the nurse’s next action?

a.            Push the PCA control for the client.

b.            Discontinue the PCA immediately.

c.             Assess the client’s respiratory status.

d.            Keep the client awake as much as possible.

ANS: C

The client should be assessed further before action is taken. If the client cannot stay awake 24 hours after surgery, there may be other problems. The nurse should assess respiratory rate and depth and lung sounds, as well as oxygen status. The nurse should never push the PCA for the client, and pain should be assessed before decisions are made and interventions taken.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

2. Postoperatively, a client has a heart rate of 120 beats/min, with dysrhythmias noted on the ECG monitor and a respiratory rate of 34 breaths/min, and is very difficult to arouse. Which action by the nurse is most appropriate?

a.            Accompany the client to the postanesthesia care unit (PACU).

b.            Keep the client in the surgical suite.

c.             Call a code or the Rapid Response Team.

d.            Transfer the client to the intensive care unit (ICU).

ANS: D

Clients in critical condition are transferred from the operating room directly to the ICU. This client is not stable with elevated heart and respiratory rates, dysrhythmias, and difficulty in arousal.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)

3. A client has been transferred to the postanesthesia care unit (PACU). Which action does the receiving nurse perform first?

a.            Complete a nursing assessment sheet.

b.            Change the client’s arm band.

c.             Enter client data into the computer.

d.            Participate in a hand-off report.

ANS: D

After the surgery is completed, the circulating nurse and the anesthesia provider accompany the client to the PACU. A hand-off report that meets National Patient Safety Goal 2 requires effective communication between health care professionals.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)

MSC: Integrated Process: Communication and Documentation

4. The nurse is performing a hand-off report in the PACU. What is the best action for the nurse to perform during the hand-off report?

a.            Write all information on a chart and hand it to the nurse who will assume care of the client.

b.            Follow the nurse assigned to the new client and give a verbal report that does not interrupt care.

c.             Focus on the report and sit with the nurse receiving the client to give a detailed report.

d.            Finish the report quickly so the nurse can assume care of the client.

ANS: C

The hand-off report is a time when errors can potentially occur. The nurse should sit with the receiving nurse to give report. That way, both nurses will be focused on the report. Simply handing the information to the new nurse does not ensure that he or she will read or understand it. Following the accepting nurse around and giving report while he or she provides care for other clients would be distracting. The hand-off nurse should not hurry through this report and should provide a report that allows for two-way communication between nurses.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Continuity of Care)

MSC: Integrated Process: Communication and Documentation

5. The nurse reviews the initial postanesthesia care unit (PACU) flow record and notes that the client is alert and oriented 3 when stimulated, pulse is 88 per minute and regular, respirations are 12 per minute and unlabored, and oxygen saturation is 95% on 2 LPM of nasal oxygen. What is the nurse’s priority action at this time?

a.            Examine the surgical site; obtain blood pressure and temperature.

b.            Suction the client and assess anterior and posterior lung sounds.

c.             Assess urinary output, the IV site, and the client’s pain.

d.            Turn the client and perform chest physiotherapy.

ANS: A

Initial assessment on the client entering the PACU that should be recorded on the flow chart record includes level of consciousness, temperature, pulse, respirations, oxygen saturation, and blood pressure. In addition, the nurse should examine the surgical area for bleeding. These items were missing from the initial assessment.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Assessment)

6. A client who has just been transferred to the postanesthesia care unit (PACU) from surgery is very restless and confused. What is the nurse’s first action?

a.            Orient the client and remain with him or her.

b.            Call the surgeon for an intraoperative report.

c.             Notify the physician on call.

d.            Assess the client’s level of pain.

ANS: A

The client who is not oriented is at risk of falling. The nurse should remain with the client to ensure safety, and should assign another staff member to the client if care has to be given to others. The client should not be left alone.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention)

MSC: Integrated Process: Nursing Process (Implementation)