The nurse is monitoring a postoperative patient in the Phase I postanesthesia care unit
(PACU). Discharge criteria for the Phase I patient include which of the following?
Select all that apply.
1. No nausea or vomiting
2. No respiratory depression
3. Oxygen saturation above 90%
4. Written discharge instructions understood
5. Patient reports pain level of 4 on a 1 to 10 scale
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2, 3, 5. Discharge criteria from Phase I are listed in Table 20-8 and include:
oxygen saturation above 90%; no respiratory depression; and pain
controlled or tolerable. Nausea and vomiting should be minimal.
Understanding written discharge instructions are part of Phase II discharge
criteria.
, The nurse finds that a postoperative patient has not voided for 8 hours. Which are the
most appropriate early nursing actions? Select all that apply.
1. Reassure the patient regarding the ability to void.
2. Scan the bladder with a portable ultrasound.
3. Obtain a prescription and catheterize the patient.
4. Use techniques like pouring warm water over the perineum.
5. Help the patient to use a bedside commode.
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1, 4, 5. It is very important that the patient voids within 6-8 hours
postoperatively. The nurse should reassure the patient regarding the ability
to void and help the patient using techniques like providing privacy and
pouring warm water over the perineum. The patient should be helped to
use a bedside commode if comfortable. If these early measures fail, then
the nurse should scan the bladder to assess bladder fullness and
catheterize the patient as per the prescription.
The postanesthesia care unit (PACU) nurse has received a patient and all of 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?
Correct
1. Airway
2. Breathing
3. Circulation
4. Neurologic
5. Gastrointestinal
6. Output
7. Surgical Site
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(PACU). Discharge criteria for the Phase I patient include which of the following?
Select all that apply.
1. No nausea or vomiting
2. No respiratory depression
3. Oxygen saturation above 90%
4. Written discharge instructions understood
5. Patient reports pain level of 4 on a 1 to 10 scale
Give this one a try later!
2, 3, 5. Discharge criteria from Phase I are listed in Table 20-8 and include:
oxygen saturation above 90%; no respiratory depression; and pain
controlled or tolerable. Nausea and vomiting should be minimal.
Understanding written discharge instructions are part of Phase II discharge
criteria.
, The nurse finds that a postoperative patient has not voided for 8 hours. Which are the
most appropriate early nursing actions? Select all that apply.
1. Reassure the patient regarding the ability to void.
2. Scan the bladder with a portable ultrasound.
3. Obtain a prescription and catheterize the patient.
4. Use techniques like pouring warm water over the perineum.
5. Help the patient to use a bedside commode.
Give this one a try later!
1, 4, 5. It is very important that the patient voids within 6-8 hours
postoperatively. The nurse should reassure the patient regarding the ability
to void and help the patient using techniques like providing privacy and
pouring warm water over the perineum. The patient should be helped to
use a bedside commode if comfortable. If these early measures fail, then
the nurse should scan the bladder to assess bladder fullness and
catheterize the patient as per the prescription.
The postanesthesia care unit (PACU) nurse has received a patient and all of 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?
Correct
1. Airway
2. Breathing
3. Circulation
4. Neurologic
5. Gastrointestinal
6. Output
7. Surgical Site
Give this one a try later!
