When a patient is admitted to the PACU, what are the priority interventions the nurse
performs?
a. Assess the surgical site, no tine presence and character of drainage
b. Assess the amount of urine output and the presence of bladder distention
c. Assess for airway potency and quality of expirations, and obtain vital signs.
d. Review results of intraoperative laboratory values and medications received.
Give this one a try later!
c. Assess for airway potency and quality of expirations, and obtain vital
signs.
Rationale: Assessment in the postanesthesia care unit (PACU) begins with
evaluation of the airway, breathing, and circulation (ABC) status of the
patient. Identification of inadequate oxygenation and ventilation or
respiratory compromise necessitates prompt intervention.
, 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 would be to:
a. increase the rate of IV fluids
b. obtain vital signs, including O2 saturation
c. position patient in lateral recovery position
d. administer antiemetic medication as ordered
Give this one a try later!
c. position patient in lateral recovery position
Rationale: If the patient is nauseated and may vomit, place the patient in a
lateral recovery position to keep the airway open and reduce the risk of
aspiration if vomiting occurs.
When assessing a patient's surgical dressing on the first postoperative day, the nurse
notes new, bright-red drainage about 5 cm in diameter. In response to this finding,
what should the nurse do first?
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.
Give this one a try later!
c. Assess the patient's blood pressure and heart rate.
The first action by the nurse is to gather additional assessment data to form
a more complete clinical picture. The nurse can then report all of the
findings. Continued reassessment will be done. Agency policy determines
whether the nurse may change the dressing for the first time or simply
reinforce it.
performs?
a. Assess the surgical site, no tine presence and character of drainage
b. Assess the amount of urine output and the presence of bladder distention
c. Assess for airway potency and quality of expirations, and obtain vital signs.
d. Review results of intraoperative laboratory values and medications received.
Give this one a try later!
c. Assess for airway potency and quality of expirations, and obtain vital
signs.
Rationale: Assessment in the postanesthesia care unit (PACU) begins with
evaluation of the airway, breathing, and circulation (ABC) status of the
patient. Identification of inadequate oxygenation and ventilation or
respiratory compromise necessitates prompt intervention.
, 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 would be to:
a. increase the rate of IV fluids
b. obtain vital signs, including O2 saturation
c. position patient in lateral recovery position
d. administer antiemetic medication as ordered
Give this one a try later!
c. position patient in lateral recovery position
Rationale: If the patient is nauseated and may vomit, place the patient in a
lateral recovery position to keep the airway open and reduce the risk of
aspiration if vomiting occurs.
When assessing a patient's surgical dressing on the first postoperative day, the nurse
notes new, bright-red drainage about 5 cm in diameter. In response to this finding,
what should the nurse do first?
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.
Give this one a try later!
c. Assess the patient's blood pressure and heart rate.
The first action by the nurse is to gather additional assessment data to form
a more complete clinical picture. The nurse can then report all of the
findings. Continued reassessment will be done. Agency policy determines
whether the nurse may change the dressing for the first time or simply
reinforce it.
