When a patient is admitted to the PACU, what are the priority interventions the nurse performs? Show
a. assess the surgical site, noting presence and character of drainage c. assess for airway patency and quality of respirations and obtain vital signs A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to throw up. A priority nursing intervention is to a. increase the rate of the IV fluids c. position patient in lateral recovery position After admission of the postoperative patient to the clinical unit, which assessment data require the most immediate attention? a. O2 saturation of 85% a. O2 saturation of 85%
A 70 kg postoperative patient has an average urine output of 25 ml/hr during the first 8 hrs. The priority nursing interventions given this assessment would be to a. perform a straight catheterization to measure the amount of urine in the bladder d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound Discharge criteria for Phase 2 patient include: select all that apply: a. no nausea or vomiting c. no respiratory depression Which patient would be at highest risk for hypothermia after surgery? a. A 42-yr-old patient who had a laparoscopic appendectomy b. A 38-yr-old patient who had a lumpectomy for breast cancer c. A 20-yr-old patient with an open reduction of a fractured radius d. A 75-yr-old patient with repair of a femoral neck fracture after a fall d. A 75-yr-old patient with repair of a femoral neck fracture after a fall The nurse is positioning a patient after a surgical procedure. What is the best position unless contraindicated, for this patient to be placed in to prevent respiratory complications? a. Supine b. Lateral c. Semi-Fowler's d. High-Fowler's b. Lateral A postoperative patient has a bronchial obstruction resulting from retained secretions and an oxygen saturation of 87%. What condition does the nurse suspect is occurring? a. Atelectasis b. Bronchospasm c. Hypoventilation d. Pulmonary embolism a. Atelectasis An older adult patient who had surgery is displaying manifestations of delirium. What priority action would benefit this patient? a. Check the chart for intraoperative complications. b. Check which medications were used for anesthesia. c. Check the effectiveness of the analgesics received. d. Check the preoperative assessment for previous delirium or dementia. d. Check the preoperative assessment for previous delirium or dementia. A patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression? a. Increased respiratory rate b. Decreased oxygen saturation c. Increased carbon dioxide pressure d. Frequent premature ventricular contractions (PVCs) c. Increased carbon dioxide pressure The PACU nurse has received a patient, and all the following assessments are included in the initial assessment. In which order should the nurse perform the following actions for the patient with no complications? a. Surgical site E,G,C,B,D,A,F The nurse is caring for a Native American patient 2 days after a thoracotomy for tumor resection. What would be the most appropriate action if the patient does not report any pain? a. Contact the health care provider. b. Identify possible reasons for denial of pain. c. Administer the prescribed pain medication. d. Assess the renal and liver function test results. b. Identify possible reasons for denial of pain. The nurse is providing discharge teaching to a patient who has had a laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the patient, indicates an understanding of the discharge instructions? a. "I will have someone stay with me for 24 hours in case I feel dizzy." b. "I should wait for the pain to be severe before taking the medication." c. "Because I did not have general anesthesia, I will be able to drive home." d. "It is expected after this surgery to have a temperature up to 102.4º F." a. "I will have someone stay with me for 24 hours in case I feel dizzy." In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes? a. Administering adequate analgesics to promote relief or control of pain b. Asking the patient to demonstrate the postoperative exercises every 1 hour c. Giving the patient positive feedback when the activities are performed correctly d. Warning the patient about possible complications if the activities are not performed a. Administering adequate analgesics to promote relief or control of pain A patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply.)? a. Vital signs baseline or stable a. Vital signs baseline or stable The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? a. Assess the patient's pain. b. Assess the patient's vital signs. c. Check the rate of the IV infusion. d. Check the physician's postoperative orders. b. Assess the patient's vital signs. A nurse is caring for an unconscious patient who has just been admitted to the postanesthesia care unit after abdominal hysterectomy. How should the nurse position the patient? a. Left lateral position with head supported on a pillow b. Prone position with a pillow supporting the abdomen c. Supine position with head of bed elevated 30 degrees d. Semi-Fowler's position with the head turned to the right a. Left lateral position with head supported on a pillow In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can the nurse delegate to the unlicensed assistive personnel (UAP)? a. Monitor the patient's pain. b. Do the admission vital signs. c. Assist the patient to take deep breaths and cough. d. Change the dressing when there is excess drainage. c. Assist the patient to take deep breaths and cough. A patient is having elective cosmetic surgery performed on the face and will be staying in the facility for 24 hours after surgery. What is the nurse's postoperative priority for this patient? a. Manage patient pain. b. Control the bleeding. c. Maintain fluid balance. d. Manage oxygenation status. d. Manage oxygenation status. When assessing a patient's surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. What is the priority action by the nurse? a. Recheck in 1 hour for increased drainage. b. Notify the surgeon of a potential hemorrhage. c. Assess the patient's blood pressure and heart rate. d. Remove the dressing and assess the surgical incision. c. Assess the patient's blood pressure and heart rate. The patient donated a kidney, and early ambulation is included in the plan of care, but the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? a. "Early walking keeps your legs limber and strong." b. "Early ambulation will help you be ready to go home." c. "Early ambulation will help you get rid of your syncope and pain." d. "Early walking is the best way to prevent postoperative complications." d. "Early walking is the best way to prevent postoperative complications." A patient having abdominal surgery had an estimated blood loss of 400 mL and received 300 mL of 0.9% normal saline. Postoperatively, the patient's blood pressure is 70/48 mm Hg. What treatment does the nurse anticipate administering? a. Blood administration b. IV fluid administration c. An ECG to check circulatory status d. Return to surgery to check for internal bleeding b. IV fluid administration A patient becomes restless and agitated in the postanesthesia care unit (PACU) as he begins to regain consciousness. The first action the nurse should take is to a. Turn the patient to a lateral position. d. Check the patient's oxygen saturation with pulse oximetry. What are the priority assessments for post operative clients?Routine post anaesthetic observations should include:. HR, RR, SpO2, BP and Temperature.. Neurological Assessment (AVPU, Michigan sedation score or formal GCS as indicated). Pain Score.. Assessment of Wound Sites / Dressings.. Presence of drains and patency of same.. What are the priority nursing assessments for a postoperative patient?ESSENTIAL POSTOPERATIVE OBSERVATIONS. Airway patency.. Respiratory status (rate and oxygen saturation). Cardiovascular status (blood pressure and pulse). Circulatory status (strict fluid balance and central venous pressure where available). Temperature.. Haemorrhage/drainage volumes/ vomiting/fluid balance.. Mental state.. What are 3 priority assessments of the PACU nurse?To PACU. Assess air exchange status and note patient's skin color.. Verify patient identity. The nurse must also know the type of operative procedure performed and the name of the surgeon responsible for the operation.. Neurologic status assessment. ... . Cardiovascular status assessment. ... . Operative site examination.. When a client is admitted to the Postanesthesia care unit after surgery How frequently will the nurse plan to assess the blood pressure?Conclusions: Based on these results, the best times to take post-operative vitals to ensure deviations are detected are: every 15 minutes for 30 minutes upon admission, 1.5 hours after admission, 4 hours after admission, and then every 4 hours for 20 hours.
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Which assessment is a priority in the Postanesthesia care unit during the first few minutes after a patient is admitted for an emergency appendectomy?
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