RNSG2504 Study Guide — Part 3: Postoperative Nursing Care 2026 | Questions & Complete Solutions
(ACC)
1. The Postoperative Period
• Begins immediately after surgery and continues until discharge.
• Primary nurse role: maintain airway/ventilation, support perfusion, monitor fluid/electrolytes,
promote comfort, prevent infection, and ensure safety.
• Patient moves through different levels of care: PACU → clinical unit → home or rehab.
2. Phases of Postanesthesia Care
Phase I
o Location: PACU (immediately post-op). o Intense monitoring: ECG, BP, O₂
sat, ventilation, pain, drains.
o Goal: Stabilize patient for transfer.
Phase II
o Location: Ambulatory surgery setting or step-down unit.
o Focus: Preparing for discharge, self-care teaching, pain control.
Extended Observation
o Location: Clinical unit or observation area. o Goal: Transition to home
or self-care with ongoing recovery support.
3. PACU Admission Handoff
• Joint handoff between ACP, OR RN, PACU RN.
• Includes:
, o Patient info (name, age, procedure, surgeon). o Type of
anesthesia, reversal agents used.
o Tubes, drains, catheters, IV lines.
o Fluid totals (input, blood loss, urine output). o Intra-op
complications/events.
o Pain management plan, NPO status.
📌 Nursing role: Ensure interactive handoff → ask questions, clarify orders.
4. Initial PACU Assessment
• Airway: Patency, artificial airways (ET tube, nasal airway, LMA).
• Breathing: RR/quality, breath sounds, O₂ sat, capnography.
• Circulation: ECG, BP, cap refill, skin color/temp, pulses.
• Neuro: LOC, orientation, pupils, sensory/motor status.
• GU: Urine output (≥0.5 mL/kg/hr).
• Surgical site: Dressing, drains, bleeding.
• Pain: Location, intensity (0–10 scale).
📌 Priority = Airway, Breathing, Circulation (always assess in that order).
5. Post-op Complications
Respiratory
• Airway obstruction: Tongue falling back → reposition, jaw thrust.
• Hypoxemia: PaO₂ < 60 mmHg → most common cause = atelectasis.
• Hypoventilation: ↓ RR from opioids or anesthesia.
• Aspiration: If protective reflexes not back yet.
• Pneumonia, PE, bronchospasm.
Prevention: Positioning, O₂ therapy, deep breathing/coughing, incentive spirometry, early ambulation.
(ACC)
1. The Postoperative Period
• Begins immediately after surgery and continues until discharge.
• Primary nurse role: maintain airway/ventilation, support perfusion, monitor fluid/electrolytes,
promote comfort, prevent infection, and ensure safety.
• Patient moves through different levels of care: PACU → clinical unit → home or rehab.
2. Phases of Postanesthesia Care
Phase I
o Location: PACU (immediately post-op). o Intense monitoring: ECG, BP, O₂
sat, ventilation, pain, drains.
o Goal: Stabilize patient for transfer.
Phase II
o Location: Ambulatory surgery setting or step-down unit.
o Focus: Preparing for discharge, self-care teaching, pain control.
Extended Observation
o Location: Clinical unit or observation area. o Goal: Transition to home
or self-care with ongoing recovery support.
3. PACU Admission Handoff
• Joint handoff between ACP, OR RN, PACU RN.
• Includes:
, o Patient info (name, age, procedure, surgeon). o Type of
anesthesia, reversal agents used.
o Tubes, drains, catheters, IV lines.
o Fluid totals (input, blood loss, urine output). o Intra-op
complications/events.
o Pain management plan, NPO status.
📌 Nursing role: Ensure interactive handoff → ask questions, clarify orders.
4. Initial PACU Assessment
• Airway: Patency, artificial airways (ET tube, nasal airway, LMA).
• Breathing: RR/quality, breath sounds, O₂ sat, capnography.
• Circulation: ECG, BP, cap refill, skin color/temp, pulses.
• Neuro: LOC, orientation, pupils, sensory/motor status.
• GU: Urine output (≥0.5 mL/kg/hr).
• Surgical site: Dressing, drains, bleeding.
• Pain: Location, intensity (0–10 scale).
📌 Priority = Airway, Breathing, Circulation (always assess in that order).
5. Post-op Complications
Respiratory
• Airway obstruction: Tongue falling back → reposition, jaw thrust.
• Hypoxemia: PaO₂ < 60 mmHg → most common cause = atelectasis.
• Hypoventilation: ↓ RR from opioids or anesthesia.
• Aspiration: If protective reflexes not back yet.
• Pneumonia, PE, bronchospasm.
Prevention: Positioning, O₂ therapy, deep breathing/coughing, incentive spirometry, early ambulation.
