A nurse is monitoring the urinary drainage from a patient who returned to the unit a few hours ago from the post anesthesia care unit (PACU) following a surgical procedure. The urine total is 54 mL for the last 2 hours. The most appropriate nursing action is to:

irrigate the indwelling urinary catheter.

notify the surgeon of the findings.

increase the flow rate of the IV for 10 to 15 minutes.

apply manual pressure to the patient's bladder.

Answer and Explanation

The Correct Answer is B

A. Irrigate the indwelling urinary catheter. There is no indication that the catheter is obstructed. Catheter irrigation should only be performed if there is a suspected blockage (e.g., absent urine output, blood clots).

B. Notify the surgeon of the findings. Urine output of less than 30 mL per hour is concerning for decreased renal perfusion, possibly due to hypovolemia or other postoperative complications. The provider should be notified for further evaluation and intervention.

C. Increase the flow rate of the IV for 10 to 15 minutes. Increasing IV fluids may help improve urine output, but it should only be done based on a provider’s order and after assessing the patient’s volume status.

D. Apply manual pressure to the patient's bladder. This action is inappropriate unless the patient has urinary retention, which should be confirmed through assessment before attempting bladder compression

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Correct Answer is C

Explanation

A. That vomiting might be an expected symptom. Vomiting can occur post-surgery, particularly if anesthesia was used, but this is not an expected or desired symptom. The education plan should focus on advising the patient about managing nausea if it occurs, rather than presenting vomiting as an expected outcome.

B. Limiting wine intake for 12 hours. Alcohol intake should be avoided after surgery, but the specific restriction may vary depending on the procedure and type of anesthesia used. The recommendation is usually to avoid alcohol for at least 24 hours, not just 12 hours. Therefore, this is not an ideal choice for the education plan.

C. Not driving or making important decisions for 24 hours. After same-day surgery, the effects of anesthesia can last for several hours, impairing the patient's cognitive and motor abilities. It is important to educate the patient to avoid driving or making significant decisions for at least 24 hours after surgery to prevent accidents and errors.

D. Reporting temperatures greater than 99°F. A temperature greater than 99°F may not be a significant concern post-surgery. Generally, a fever above 100.4°F (38°C) would be more concerning. The patient should be instructed to report a higher fever, but a temperature of 99°F alone is usually not an alarming sign.

A. head of bed at 45 degrees with head and neck midline. B. side lying. C. supine. D. head of bed at 30 degrees with head and neck midline.

Correct Answer is B

Explanation

A. Head of bed at 45 degrees with head and neck midline. Although the head of the bed at 45 degrees can be appropriate for some patients, it is not the best position to maintain a patent airway for a drowsy postoperative patient. This position can lead to airway obstruction, especially if the patient is drowsy.

B. Side lying. The side-lying position is the best choice for a patient who is drowsy and requires verbal stimulation to remain aroused. This position prevents aspiration and ensures that the airway remains patent by allowing any secretions or fluids to drain from the mouth. It is especially useful in the postoperative period to prevent airway obstruction.

C. Supine. The supine position is not ideal for a drowsy postoperative patient, as it can increase the risk of airway obstruction. The tongue may fall back and obstruct the airway, particularly if the patient is drowsy.

D. Head of bed at 30 degrees with head and neck midline. Although elevating the head of the bed at 30 degrees is common, it is not the best choice for a drowsy patient at risk for airway obstruction. Side-lying would be more effective in preventing aspiration and maintaining the airway.

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A nurse is monitoring the urinary drainage from a patient who returned to the unit a few hours ago from the post anesthesia care unit (PACU) following a surgical procedure. The urine total is 54 mL for the last 2 hours. The most appropriate nursing action is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is ready for discharge following same day surgery. The education plan for this patient includes:

Correct Answer is C

Explanation

A patient who has returned to the surgical nursing unit from the post-anesthesia care unit (PACU) is drowsy and requires verbal stimulation to remain aroused. The best position to maintain an airway for this patient is:

Correct Answer is B

Explanation

After the surgery, the patient is transferred to the PACU. Functions of the nurse in the PACU are to

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