1.The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgicalfloor.
Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this
nursing action?
a. This is done to complete the first action in a head-to-toe assessment.
This is done to compare and monitor for vital sign variation during
b. transport.
This is done to ensure that the medical-surgical nurse checks on the
c. postoperative patient.
This is done to follow hospital policy and procedure for care of the
d. surgical patient.
ANS: B
Before the PACU nurse leaves the acute care area, the staff nurse assuming care for the patient takes a complete set of vital
signs to compare with PACU findings. Minor vital sign variations normally occur after
,transporting the patient. The PACU nurse reviews the patient’s information with the medical-surgical nurse, including the
surgical and PACU course, physician orders, and the patient’s condition. While vital signs may or may not be the first action
in a head-to-toe assessment, this is not the rationale for this situation. While following policy or ascertaining that the floor
nurse checks on the patient are good reasons for safe care, they are not the best rationale for obtaining vital signs.
2. The nurse is caring for a patient who will undergo a removal of a lung lobe. Which level of care will thepatient require
immediately post procedure?
a. Acute care—medical-surgical unit
b. Acute care—intensive care unit
c. Ambulatory surgery
d. Ambulatory surgery—extended stay
ANS: B
Patients undergoing extensive surgery and requiring anesthesia of long duration recover slowly. If a patient is undergoing
major surgery such as a procedure on the lung, a stay in the hospital and specifically in the intensive care unit is required
to monitor for potential risks to well-being. This patient would require more care than can be provided on a medical-
surgical unit. It is not appropriate for this type of patient to go home after the procedure or to stay in an extended stay
area of an ambulatory surgery area because of the complexity and associated risks.
, 3. The nurse is caring for a group of patients. Which patient will the nurse see first?
a. A patient who had cataract surgery is coughing.
A patient who had vascular repair of the right leg is not doing right leg
b. exercises.
A patient after knee surgery is wearing intermittent pneumatic
c. compression devices and receiving heparin.
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Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this
nursing action?
a. This is done to complete the first action in a head-to-toe assessment.
This is done to compare and monitor for vital sign variation during
b. transport.
This is done to ensure that the medical-surgical nurse checks on the
c. postoperative patient.
This is done to follow hospital policy and procedure for care of the
d. surgical patient.
ANS: B
Before the PACU nurse leaves the acute care area, the staff nurse assuming care for the patient takes a complete set of vital
signs to compare with PACU findings. Minor vital sign variations normally occur after
,transporting the patient. The PACU nurse reviews the patient’s information with the medical-surgical nurse, including the
surgical and PACU course, physician orders, and the patient’s condition. While vital signs may or may not be the first action
in a head-to-toe assessment, this is not the rationale for this situation. While following policy or ascertaining that the floor
nurse checks on the patient are good reasons for safe care, they are not the best rationale for obtaining vital signs.
2. The nurse is caring for a patient who will undergo a removal of a lung lobe. Which level of care will thepatient require
immediately post procedure?
a. Acute care—medical-surgical unit
b. Acute care—intensive care unit
c. Ambulatory surgery
d. Ambulatory surgery—extended stay
ANS: B
Patients undergoing extensive surgery and requiring anesthesia of long duration recover slowly. If a patient is undergoing
major surgery such as a procedure on the lung, a stay in the hospital and specifically in the intensive care unit is required
to monitor for potential risks to well-being. This patient would require more care than can be provided on a medical-
surgical unit. It is not appropriate for this type of patient to go home after the procedure or to stay in an extended stay
area of an ambulatory surgery area because of the complexity and associated risks.
, 3. The nurse is caring for a group of patients. Which patient will the nurse see first?
a. A patient who had cataract surgery is coughing.
A patient who had vascular repair of the right leg is not doing right leg
b. exercises.
A patient after knee surgery is wearing intermittent pneumatic
c. compression devices and receiving heparin.
326
