An older patient is being discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, I do not know if I can take care of myself with this patch over my eye. Which action by the nurse is most appropriate?
a. Refer the patient for home health care services.
b. Discuss the specific concerns regarding self-care.
c. Give the patient written instructions regarding care.
d. Assess the patient's support system for care at home.
Question 2A patient's T-tube is draining dark green fluid after gallbladder surgery. What action by the nurse is the most appropriate?
a. Notify the patient's surgeon.
b. Place the patient on bed rest.
c. Document the color and amount of drainage.
d. Irrigate the T-tube with sterile normal saline.
Question 3In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72, pulse 74, respirations 12, and SpO2 91. The patient is sleepy but awakens easily. Which action should the nurse take first?
a. Place the patient in a side-lying position.
b. Encourage the patient to take deep breaths.
c. Prepare to transfer the patient to a clinical unit.
d. Increase the rate of the postoperative IV fluids.
Question 4An experienced nurse orients a new nurse to the postanesthesia care unit (PACU). Which action by the new nurse, if observed by the experienced nurse, indicates that the orientation was successful?
a. The new nurse assists a nauseated patient to a supine position.
b. The new nurse positions an unconscious patient supine with the head elevated.
c. The new nurse turns an unconscious patient to the side upon arrival in the PACU.
d. The new nurse places a patient in the Trendelenburg position when the blood pressure drops.
Question 5On admission of a patient to the postanesthesia care unit (PACU), the blood pressure (BP) is 122/72. Thirty minutes after admission, the BP falls to 114/62, with a pulse of 74 and warm, dry skin. Which action by the nurse is most appropriate?
a. Increase the IV fluid rate.
b. Continue to take vital signs every 15 minutes.
c. Administer oxygen therapy at 100 per mask.
d. Notify the anesthesia care provider (ACP) immediately.
Question 6Which actions will the nurse include in the surgical time-out procedure before surgery (select all that apply)?
a. Check for placement of IV lines.
b. Have the surgeon identify the patient.
c. Have the patient state name and date of birth.
d. Verify the patient identification band number.
e. Ask the patient to state the surgical procedure.
f. Confirm the hospital chart identification number.
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