[Osborn] chapter 27

Learning Outcomes [Number and Title]

Learning Outcome 1
Prioritize nursing diagnoses and interventions for the patient in
the postanesthesia care unit.
Learning Outcome 2
Discuss criteria for moving patients through the phases of
recovery.
Learning Outcome 3
Discuss the assessment, prevention, and nursing management
of common postoperative problems.
Learning Outcome 4
Develop a teaching plan for the discharge of a patient after
surgery.
Learning Outcome 5
Identify and discuss areas of future research relevant to the care
of the postoperative patient.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

1. The nurse has just received a client from the surgical area. After 30 minutes in the
recovery area, the clients vital signs are as follows: pulse 92; blood pressure 110/50;
respirations 12; pulse oximeter 86%. What should be the initial nursing response?
1.
2.
3.
4.

Stimulate the client.

Call the physician.
Ask another nurse for his or her opinion.
Place an oral airway in the client.

Correct Answer: Stimulate the client.

Rationale: The clients respirations and pulse oximeter are low. The initial response by
the nurse should be to stimulate the client to see if the pulse oximeter will increase. The
client may require frequent stimulation to improve the oxygen saturation. If the oxygen
saturation does not stay up after stimulation, the nurse may wish to advise the physician.
An oral airway may be necessary if the client is not easily aroused. It is not necessary to
ask for a second opinion.
Cognitive Level: Applying
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

2. The recovery room nurse has just received a client whose abdominal drain has an
excessive amount of sanguineous drainage. The nurse contacts the physician without
delay, recognizing that this could:
1.
2.
3.
4.

Require the client to return immediately to surgery.

Be a potential respiratory crisis.
Lead to a major wound infection.
Need further assessment.

Correct Answer: Require the client to return immediately to surgery.

Rationale: An excessive amount of sanguineous drainage in the abdominal drain may
require the client to return to surgery to explore the surgical site. While the nurse is
waiting for the surgical arrangements to be made, the clients hemodynamic status may
need to be supported. The symptoms related to the drainage are not related to respiratory
complications.
Cognitive Level: Applying
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

3. The client is just arriving in the postanesthesia care unit following general anesthesia.
The nurses top priority upon receiving the client is to:
1. Assess the clients respiratory status.
2. Assess the clients cardiac status.
3. Ask the client about pain.
4. Assess the clients IV.
Correct Answer: Assess the clients respiratory status
Rationale: The clients respiratory status will be the nurses top priority upon receiving a
client into the postanesthesia care unit because anesthesia can impact the respiratory
system. Airway, respirations, and lung sounds will comprise this assessment because
respiratory complications are the most frequent cause of complications in the
postanesthesia care unit. Cardiac status, level of consciousness, and vital signs will be the
next priority, followed by pain and eventually the status of the clients IV.
Cognitive Level: Analyzing
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

4. The client has just arrived in the recovery room. As part of the evaluation for
determining discharge from the postanesthesia recovery unit, the nurses next action will
be to:
1. Assess the client for respirations, oxygen saturation, consciousness,
circulation, and activity.
2. Assess the client for pain.
3. Assess whether the client wants the family in the recovery room.
4. Take the clients temperature.
Correct Answer: Assess the client for respirations, oxygen saturation, consciousness,
circulation, and activity.
Rationale: Assessing the clients respirations, oxygen saturation, consciousness,
circulation, and activity are all used to determine the clients progress toward discharge.
Assessing the client for pain helps the clients comfort but is not part of the discharge
criteria. The family may be allowed in the recovery room in many institutions, but their
presence is usually delayed until the client has been assessed and is arousable.
Temperature is vital to assessing hypothermia, but is not included as part of the discharge
criteria.
Cognitive Level: Analyzing
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

5. Progression through the various phases in the postanesthesia recovery unit (PACU)
depends upon:
1.
2.
3.
4.

The clients progress toward physiological homeostasis.

The severity of the procedure the client underwent.
The temperature and environment of the unit.
The attentiveness and caring of the nursing staff.

Correct Answer: The clients progress toward physiological homeostasis.

Rationale: The clients recovery and progress through the various phases while in the
PACU depends on how quickly the client returns to physiological homeostasis. The other
answer choices do not determine the clients progress.
Cognitive Level: Applying
Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

6. A client is being evaluated for discharge from the postanesthesia care unit. The clients
blood pressure has been 120/76 with a preoperative baseline of 124/80. This client has
moderate bleeding and is vomiting every 20 minutes. Which other assessment would
mandate the client stay in postanesthesia care until more stable?
1. Moderate pain
2. Blood pressure 120/76
3. Able to ambulate
4. Pulse oximeter 93%
Correct Answer: Moderate pain
Rationale: This client who is experiencing moderate bleeding and frequent vomiting
would receive a score of 8 on the PAD. If the client also complained of moderate pain,
the PAD score would fall to 7, which would require the client to stay longer in the unit. A
blood pressure of 120/76 is within 20% of baseline, the ability to ambulate, and a 93%
pulse oximeter reading would all indicate the client is stable enough to discharge.
Cognitive Level: Analyzing
Nursing Process: Evaluating
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

7. A postoperative client arrives in the recovery room. The nurse knows which of the
following assessments best indicates adequate circulation?
1. Radial pulses 2+, capillary refill of 2 seconds, pink, awake and alert, heart rate
of 88, oxygen saturation of 94%
2. Pedal pulses weak, capillary refill > 3 seconds, oxygen saturation of 91%,
respiratory rate of 10, ashen
3. Pedal pulses 2+, capillary refill of 4 seconds, pale, awake and alert, heart rate
of 110
4. Popliteal pulses weak, drowsy, respiratory rate 24, color pale, skin cool
Correct Answer: Radial pulses 2+, capillary refill of 2 seconds, pink, awake and alert,
heart rate of 88, oxygen saturation of 94%
Rationale: Peripheral pulses, capillary refill less than 3 seconds, oxygen saturation greater
than 93%, and clients color are good indicators of adequate circulation and respiratory
effort. Clients with impaired gas exchange or decreased cardiac output will likely have
evidence of hypoxemialow oxygen saturation, decreased capillary refill, and weak
pulses or tachycardia.
Cognitive Level: Analyzing
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

8. A 75-year-old client is received into the postanesthesia recovery room (PACU)

following a 6-hour abdominal surgery. The clients hemodynamic status is stable. Based
upon the nurses knowledge of this clients surgery and the common postoperative
complications this client might be at risk for, the recovery room nurse would provide
which of the following interventions?
1. Keep the room temperature at 70 degrees, consider supplemental oxygen, and
provide warm blankets.
2. Assess the clients blood pressure more frequently than for younger clients
and provide oxygen.
3. Consider increasing the IV fluids, assess for urine output, and monitor the
oxygen saturation.
4. Provide postoperative instructions to avoid straining and to eat a low-fiber
diet.
Correct Answer: Keep the room temperature at 70 degrees, consider supplemental
oxygen, and provide warm blankets.
Rationale: This client is at risk for hypothermia based upon the clients age, the length of
surgery, and the likelihood of intra-operative irrigants to the abdomen. Therefore, the
nurses role will be to minimize the risk for hypothermia by providing warm blankets,
keeping the room at 70 degrees, and, if the core temperature drops, considering the
provision of supplemental oxygen. The clients hemodynamic status is stable; therefore,
the blood pressure is stable. Oxygen may be needed if the client is hypothermic. The IV
rate does not need to be increased at this time because the client is hemodynamically
stable. The urine output would be automatically monitored, but the nurse would not
anticipate a problem with it since the client is hemodynamically stable. Since the client
was in surgery for 6 hours, the postoperative instructions to avoid straining and eat a lowfiber diet are not applicable to the question.
Cognitive Level: Analyzing
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

9. The nurse assesses a client in the postanesthesia recovery unit and finds a BP of 88/50,
pulse 116, and respirations of 20. What other assessment data will the nurse want to
collect first?
1. Pulse oximeter reading
2. Pain assessment
3. Whether the client is nauseated
4. Urine output
Correct Answer: Pulse oximeter reading
Rationale: With a BP of 88/50, pulse of 116, and respirations of 20, the nurse will want to
check the pulse oximeter reading next to determine whether there is hypoxia. A pain
assessment will help determine if the cause of tachycardia may be pain; however, the
blood pressure would not typically be low. Pain, in this instance, is secondary to
hypoxemia, if present. Urine output is another indicator of perfusion when the blood
pressure is low, but would not be the first priority assessment. Nausea is important to
assess, but respiratory status is a first priority.
Cognitive Level: Analyzing
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

10. The purpose of a call by the ambulatory care unit nurse to the client after discharge is
to:
1. Minimize client complications and ensure client safety.
2. Determine if the client understood the discharge instructions.
3. Let the client know the nurse cares about him or her.
4. Assist the health care provider in checking on the client.
Correct Answer: Minimize client complications and ensure client safety.
Rationale: The ambulatory care unit nurse contacts the client after discharge to ensure the
client correctly understands the discharge instructions and to answer any questions the
client may have. This helps increase client safety and minimizes client complications.
The other answer choices may be benefits of the call, but are not the purpose.
Cognitive Level: Applying
Nursing Process: Evaluation
Client Need: Health Promotion and Maintenance
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

11. The recovery room nurse is preparing to discharge a 24-year-old client to home
following the clients ambulatory surgery. Which of the following discharge instructions
provided by the nurse is the most comprehensive?
1. Verbal and written instructions to the client and family regarding the clients
wound, activity and diet restrictions, new medications, pain management,
potential complications, and process for reaching the health care provider if
needed
2. Verbal instructions to restrict all activities, diet restrictions, pain management, and
circumstances that require contacting the health care provider
3. Written instructions to manage the wound, instructions to resume activities
slowly, methods for pain control, and information on whom to contact in 2 days
4. Verbal and written instructions to the family regarding the clients activity, diet,
potential problems, and medications
Correct Answer: Verbal and written instructions to the client and family regarding the
clients wound, activity and diet restrictions, new medications, pain management,
potential complications, and process for reaching the health care provider if needed
Rationale: The client and family need to be provided discharge instructions verbally and
in writing that include: wound management; restrictions on activity, diet, and bathing;
new medications; pain management; the follow-up appointment; the postoperative
progress the client can expect; and complications that require the contact of the health
care provider.
Cognitive Level: Analyzing
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

12. A client is preparing for discharge to home. The nurse has provided discharge
instructions regarding activities. Which of the following instructions is most helpful to
the client?
1. You can start exercising in 7 days if there are no signs of wound infection.
2. You may complete activities as tolerated.
3. Be sure to rest throughout the day.
4. You can bathe normally.
Correct Answer: You can start exercising in 7 days if there are no signs of wound
infection.
Rationale: Clients find discharge instructions most helpful when they are specific. The
instructions You can start exercising in 7 days if there are no signs of wound infection
is the most specific, giving the client exact details. The other answer choices of
completing activities as tolerated, resting throughout the day, and bathing normally are
not specific and could leave the client with room for faulty interpretation.
Cognitive Level: Analyzing
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

13. A nurse noticed that clients who ambulated within the first 12 hours of surgery had
fewer postoperative complications. Which of the following approaches would provide
validation for the nurses belief that early ambulation decreases postoperative
complications?
1.
2.
3.
4.

Correlation of postoperative complications with the clients activity

Discussion of postoperative complications with physical therapist
Adjustment of the clients medications related to their activity levels
Modification of the clients activity based upon the surgical severity

Correct Answer: Correlate postoperative complications with the clients activity

Rationale: Research designed to validate whether early ambulation decreases
postoperative complications must correlate clients activity with the development of
postoperative complications. Discussion with therapists regarding clients postoperative
complications, adjustment of the clients medications based upon the activity levels, and
modification of the clients activity based upon the severity of the surgery will not
validate the correlation between early ambulation and postoperative complications.
Cognitive Level: Analyzing
Nursing Process: Evaluation
Client Need: Health Promotion and Maintenance
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

14. The nurse wonders which nursing interventions increase clients competence in
managing their own recovery after discharge. Which intervention might be appropriate to
help determine this?
1. The nurse will adjust client teaching to allow for cultural diversity.
2. The nurse will provide the client with 4 hours of uninterrupted sleep while in
the inpatient facility.
3. The nurse will measure the clients ability to ambulate without dyspnea.
4. The nurse will discuss the clients discharge with the health care provider.
Correct Answer: The nurse will adjust client teaching to allow for cultural diversity.
Rationale: Interventions involved in a research project to help determine client
competence in managing their own recovery after discharge must address the topic for
validation. Adjusting client teaching to allow for cultural diversity would help determine
whether this intervention would impact the clients competence. Providing the client with
uninterrupted sleep will not address the question of client competence in managing their
own recovery after discharge. The ability to ambulate without dyspnea could determine
how far the client can ambulate, but does not address the research question. Discussing
the clients discharge with other health care providers does not address the question of
client competence, but may provide some insight into how to manage interventions for
the client.
Cognitive Level: Analyzing
Nursing Process: Evaluation
Client Need: Health Promotion and Maintenance
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

15. Attempting to better understand the discharge instructions needed by a client could be
a potential research study. An anticipated result of such a study might provide insight
into:
1. Ways clients might better manage their own recovery
2. How the nurse might provide care while in the hospital
3. When the client should be discharged
4. Decreased hospitalizations
Correct Answer: Ways clients might better manage their own recovery
Rationale: A study looking at the discharge instructions needed by a client could provide
insight into ways clients might better manage their own recovery. As a secondary impact,
there may be information on ways to decrease hospitalization; however, that would not be
the primary focus. When the client should be discharged and how the nurse could provide
care while in the hospital would not be a focus of the research study.
Cognitive Level: Analyzing
Nursing Process: Evaluating
Client Need: Health Promotion and Maintenance
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.