A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) ...

A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.)
 
  a. Blood glucose: 120 mg/dL
  b. Hemoglobin: 7.8 mg/dL
  c. pH: 7.68
  d. Potassium: 2.9 mEq/L
  e. Sodium: 142 mEq/L

Question 2

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.)
 
  a. All phases require the client to be in the hospital.
  b. Phase I care may last for several days in some clients.
  c. Phase I requires intensive care unit monitoring.
  d. Phase II ends when the client is stable and awake.
  e. Vital signs may be taken only once a day in phase III.

Question 3

A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.)
 
  a. Apply stimulation to the contralateral leg.
  b. Assess the client's willingness to try meditation.
  c. Elevate the client's operative leg and apply ice.
  d. Reduce the noise level in the client's environment.
  e. Turn the TV on loudly to distract the client.

Question 4

A registered nurse (RN) is watching a nursing student change a dressing and perform care around a Penrose drain. What action by the student warrants intervention by the RN?
 
  a. Cleaning around the drain per agency protocol
  b. Placing a new sterile gauze under the drain
  c. Securing the drain's safety pin to the sheets
  d. Using sterile technique to empty the drain

Question 5

A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection.
 
  What should the nurse assess next?
 
  a.
  Cognitive status
  b.
  Family stress
  c.
  Nutrition status
  d.
  Psychosocial status

Question 6

A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?
 
  a. Assess the client's blood pressure.
  b. Perform hand hygiene and apply gloves.
  c. Reinforce the dressing with a clean one.
  d. Remove the dressing to assess the wound.