Hesi, The Post-Anesthesia Care Unit (PACU),
Mr. Potter UPDATED ACTUAL Exam
Questions and CORRECT Answers
You know that nursing care in PACU is multifaceted and involves:
- monitoring the patient's physiological status
- intervening to ensure uneventful recovery from anesthesia and surgery
- providing a safe environment for the patient experiencing limitations in physical, mental, and
emotional function
- preventing or promptly treating complications in the immediate post-anesthesia period
- upholding the patient's rights to dignity, privacy, and confidentiality
- utilizing high tech equipment so health care costs will be justified - CORRECT
ANSWER - A. monitoring the patient's physiological status
B. intervening to ensure uneventful recovery from anesthesia and surgery
C. providing a safe environment for the patient experiencing limitations in physical, mental, and
emotional function
D. preventing or promptly treating complications in the immediate post-anesthesia period
E. upholding the patient's rights to dignity, privacy, and confidentiality
The nurse anesthetist gives you Mr. Potter's record, and prepares to give you a verbal report. You
know that her verbal report should include:
- Mr. Potter's height and weight
- The name of the surgical procedure Mr. Potter had
- Mr. Potter's relevant health history
- Anesthetic agents and other drugs that were administered to Mr. Potter
- Mr. Potter's estimated blood loss during surgery
- Mr. Potter's religious preference
- Mr. Potter's fluid status and IV therapy - CORRECT ANSWER - B. The name of the
surgical procedure Mr. Potter had
,C. Mr. Potter's relevant health history
D. Anesthetic agents and other drugs that were administered to Mr. Potter
E. Mr. Potter's estimated blood loss during surgery
G. Mr. Potter's fluid status and IV therapy
In providing care for Mr. Potter, your first step is to:
- assess your patient
- analyze patient data
- plan care
- intervene
- evaluate care - CORRECT ANSWER - A. assess your patient
Mr. Potter is a new patient. Data collection takes priority.
In PACU, many assessments and interventions are done simultaneously. However, the most
critical, high-priority assessment to be done with Mr. Potter is his:
- operative site
- skin integrity
- pulse
- airway
- blood pressure - CORRECT ANSWER - D. airway
The nurse's initial priority when admitting a patient to PACU is to determine and insure the
adequacy of the patient's airway and breathing. The patient's airway should be assessed for
patency. Respiratory rate, rhythm, and quality should be determined. Breath sounds should be
auscultated as soon as possible. Since Mr. Potter has an oral endotracheal (ET) tube in place, you
assess for the presence of bilateral breath sounds, since the ET tube may have become dislodged
during transport to PACU. Mr. Potter is breathing spontaneously at 16 regular, deep breaths per
minute through the oral ET tube. You attach Mr. Potter to monitoring equipment that measures
his arterial oxygen saturation continuously by pulse oximetry (SpO2). His current SpO2 is 97%.
, You attach 35% oxygen to Mr. Potter's ET tube via T-tube at 8 liters per minute, per protocol, to
prevent desaturation.
What TWO assessments are your next priorities?
- Operative site
- Skin color
- Skin integrity
- Pulse
- Blood pressure
- Orientation - CORRECT ANSWER - D. Pulse
E. Blood pressure
After assessing a patient's airway and breathing, the adequacy of circulation should be
determined. The patient's pulse should be checked. You attach Mr. Potter to monitoring
equipment that monitors his heart rate and rhythm. Mr. Potter's heart rhythm is regular at a rate
of 68 beats per minute. His baseline preop pulse rate was 76.
After assessing a patient's airway and breathing, the adequacy of circulation should be assessed.
BP should be determined. BP reflects the adequacy of circulation and cardiac output. You attach
Mr. Potter to monitoring equipment that will monitor his BP noninvasively. His noninvasive BP
is 158/84. Mr. Potter's baseline preoperative BP was 150/90.
Since Mr. Potter is a smoker, he has increased risk associated with surgery and anesthesia. You
are aware that cigarette smoking can be responsible for which of the following in the immediate
postoperative period?
- Dehydration
- Difficulty in clearing secretions
- Cardiac dysrhythmias - CORRECT ANSWER - B. Difficulty in clearing secretions
C. Cardiac dysrhythmias
Smokers usually have a reduced vital capacity of the lungs. Vital capacity is the maximum
amount of air that can be exhaled after a maximum inhalation. When vital capacity is reduced,
deep breathing, coughing, and clearing of secretions is more difficult and less effective. Clearing
Mr. Potter UPDATED ACTUAL Exam
Questions and CORRECT Answers
You know that nursing care in PACU is multifaceted and involves:
- monitoring the patient's physiological status
- intervening to ensure uneventful recovery from anesthesia and surgery
- providing a safe environment for the patient experiencing limitations in physical, mental, and
emotional function
- preventing or promptly treating complications in the immediate post-anesthesia period
- upholding the patient's rights to dignity, privacy, and confidentiality
- utilizing high tech equipment so health care costs will be justified - CORRECT
ANSWER - A. monitoring the patient's physiological status
B. intervening to ensure uneventful recovery from anesthesia and surgery
C. providing a safe environment for the patient experiencing limitations in physical, mental, and
emotional function
D. preventing or promptly treating complications in the immediate post-anesthesia period
E. upholding the patient's rights to dignity, privacy, and confidentiality
The nurse anesthetist gives you Mr. Potter's record, and prepares to give you a verbal report. You
know that her verbal report should include:
- Mr. Potter's height and weight
- The name of the surgical procedure Mr. Potter had
- Mr. Potter's relevant health history
- Anesthetic agents and other drugs that were administered to Mr. Potter
- Mr. Potter's estimated blood loss during surgery
- Mr. Potter's religious preference
- Mr. Potter's fluid status and IV therapy - CORRECT ANSWER - B. The name of the
surgical procedure Mr. Potter had
,C. Mr. Potter's relevant health history
D. Anesthetic agents and other drugs that were administered to Mr. Potter
E. Mr. Potter's estimated blood loss during surgery
G. Mr. Potter's fluid status and IV therapy
In providing care for Mr. Potter, your first step is to:
- assess your patient
- analyze patient data
- plan care
- intervene
- evaluate care - CORRECT ANSWER - A. assess your patient
Mr. Potter is a new patient. Data collection takes priority.
In PACU, many assessments and interventions are done simultaneously. However, the most
critical, high-priority assessment to be done with Mr. Potter is his:
- operative site
- skin integrity
- pulse
- airway
- blood pressure - CORRECT ANSWER - D. airway
The nurse's initial priority when admitting a patient to PACU is to determine and insure the
adequacy of the patient's airway and breathing. The patient's airway should be assessed for
patency. Respiratory rate, rhythm, and quality should be determined. Breath sounds should be
auscultated as soon as possible. Since Mr. Potter has an oral endotracheal (ET) tube in place, you
assess for the presence of bilateral breath sounds, since the ET tube may have become dislodged
during transport to PACU. Mr. Potter is breathing spontaneously at 16 regular, deep breaths per
minute through the oral ET tube. You attach Mr. Potter to monitoring equipment that measures
his arterial oxygen saturation continuously by pulse oximetry (SpO2). His current SpO2 is 97%.
, You attach 35% oxygen to Mr. Potter's ET tube via T-tube at 8 liters per minute, per protocol, to
prevent desaturation.
What TWO assessments are your next priorities?
- Operative site
- Skin color
- Skin integrity
- Pulse
- Blood pressure
- Orientation - CORRECT ANSWER - D. Pulse
E. Blood pressure
After assessing a patient's airway and breathing, the adequacy of circulation should be
determined. The patient's pulse should be checked. You attach Mr. Potter to monitoring
equipment that monitors his heart rate and rhythm. Mr. Potter's heart rhythm is regular at a rate
of 68 beats per minute. His baseline preop pulse rate was 76.
After assessing a patient's airway and breathing, the adequacy of circulation should be assessed.
BP should be determined. BP reflects the adequacy of circulation and cardiac output. You attach
Mr. Potter to monitoring equipment that will monitor his BP noninvasively. His noninvasive BP
is 158/84. Mr. Potter's baseline preoperative BP was 150/90.
Since Mr. Potter is a smoker, he has increased risk associated with surgery and anesthesia. You
are aware that cigarette smoking can be responsible for which of the following in the immediate
postoperative period?
- Dehydration
- Difficulty in clearing secretions
- Cardiac dysrhythmias - CORRECT ANSWER - B. Difficulty in clearing secretions
C. Cardiac dysrhythmias
Smokers usually have a reduced vital capacity of the lungs. Vital capacity is the maximum
amount of air that can be exhaled after a maximum inhalation. When vital capacity is reduced,
deep breathing, coughing, and clearing of secretions is more difficult and less effective. Clearing
