nur 116 - Davis Advantage / Edge - Postoperative Care

A patient's family is in the waiting room outside the postanesthesia care unit (PACU). What is the priority of the PACU nurse? Make contact with the family every hour. Encourage the family to leave the area and wait at home. Ask the surgeon to speak with the family. Take them coffee and make them comfortable.

Make contact with the family every hour. Rationale: The nurse should inform the family when the patient arrives in the PACU and make contact every hour. Test Taking Tips: Communication is the priority.

The post-anesthesia care unit nurse should administer pain medications based on which assessment findings in a patient who remains very drowsy? Select all that apply. Restlessness Relaxed jaw Pupil dilation Heart rate of 118 beats/minute Respiratory rate of 10 breaths/minute

Restlessness Heart rate of 118 beats/minute

Which of these situations are important for the nurse to include in hand-off from the PACU to the inpatient unit? Select all that apply. Surgical procedure Surgical complications Admitting diagnosis Current vital signs Pre-surgical blood work

Surgical procedure Surgical complications Current vital signs

The registered nurse is teaching about levels of postanesthesia care unit (PACU) care to a nursing student while caring for a patient who is transferred from the operating room to the PACU. Which statement made by the nursing student indicates effective understanding? "I will transfer the patient to phase II when the patient is on a mechanical ventilator." "I will transfer the patient to phase II when the pulse rate is 55 beats/min." "I will transfer the patient to phase II when the pain score is 2." "I will transfer the patient with heavy bleeding to phase III."

"I will transfer the patient to phase II when the pain score is 2." Rationale: The pain score of 2 indicates minimal pain, which can be easily controlled. Score 0 may not be possible, so the patient can be transferred to phase II in this condition. Test Taking Tips: Look for the answer that shows the patient is stable.

Which health-care professional accompanies the patient who is transferred from the operating room to the postanesthesia care unit (PACU) after surgery? Physician assistant Anesthesia provider Surgical technologist Operating room technician

Anesthesia provider Rationale: Operating room technician, also known as a scrub, ensures the functioning of the equipment in the operating room. Test Taking Tips: The anesthesia provider manages the airway.

Monitoring for potential complications in the PACU should include: Assessing level of consciousness Assessing vital signs Monitoring urine output Determining last bowel movement Medicating for pain and nausea Checking glucose level

Assessing level of consciousness Assessing vital signs Monitoring urine output Medicating for pain and nausea Checking glucose level CORRECT. Nursing actions appropriate when monitoring a client for potential complications in the PACU include assessing level of consciousness, assessing vital signs, monitoring urine output, medication for pain and nausea and glucose level. Determining the client's last bowel movement is not necessary.

What should be the immediate nursing intervention when a patient is transferred to the postanesthesia care unit (PACU) after surgery? Assessing the vital signs Providing IV fluids Administering acetaminophen Administering metoclopramide

Assessing the vital signs Rationale: Any change in vital signs may indicate complications. So, the patient should be connected to a monitor first, and vital signs should be assessed immediately upon admission to the PACU. Test Taking Tips: Assessment is the priority.vvvv

Family care in the PACU entails: Making contact every 30 minutes Communicating plans for transfer or discharge Allowing visitation per hospital policy Providing discharge instructions Restricting family visitation unless the client is unstable Teaching family about prevention of postoperative complications

Communicating plans for transfer or discharge Allowing visitation per hospital policy Providing discharge instructions CORRECT. Caring for the family of the client in the PACU is an important nursing responsibility. The nurse should communicate plans for transfer or discharge, allow visitation per hospital policy, and provide discharge instructions. The nurse should ideally make contact with the family every hour, not every 30 minutes, when providing care to a client in the PACU and teaching should be with the patient, not the family in the PACU.

Handoff communication between OR and PACU staff: Occurs with two members of the OR team Includes a detailed health history assessment by system Details the procedure performed Includes medications received during surgery, including pain medications Includes all laboratory results since admission Patient identification with one identifier

Details the procedure performed Includes medications received during surgery, including pain medications CORRECT. The handoff communication that occurs between OR and PACU staff will includes the use of two identifiers, significant medical history, details of the procedure performed and medications received during surgery, including pain medications and anesthesia. Additional information should include significant labs, fluid intake and blood loss, IVs, home medications, and the plan of care. The handoff communication should occur with three members of the OR team (anesthesia, surgical team member, and OR nurse) and should also include a summary of pertinent health history information and pertinent laboratory results only.

What postoperative assessment is for possible complications? Assessment of type of IV fluids running Assessment of the smell of the urine Fingerstick glucose level Auscultation of bowel sounds

Fingerstick glucose level Rationale: Hypo- and hyperglycemia are possible complications during the postoperative phase. Test Taking Tips: They must understand the discharge instructions.

A nurse is recovering a patient in the postanesthesia care unit (PACU). The nurse notes that the patient is restless, tachycardic, and has facial grimacing. What action should the nurse take? 13861 Assess the urine output. Medicate for pain. Notify the surgeon. Reposition the patient.

Medicate for pain. Rationale: The nurse should assess for physiological symptoms associated with pain, including restlessness, facial grimacing, or moaning. Test Taking Tips: Consider non-verbal cues.

The nurse has received a patient from the operating room to the postanesthesia care unit. After assessing the vital signs, what are the priority assessments? Select all that apply. Monitor for nausea and vomiting. Monitor urine output. Check for bleeding of the surgical site and drains. Monitor for sign of malignant hyperthermia. Address physiological signs of pain.

Monitor for nausea and vomiting. Monitor urine output. Check for bleeding of the surgical site and drains. Monitor for sign of malignant hyperthermia. Address physiological signs of pain. Rationale: Nausea and vomiting places the patient at risk for aspiration and is a priority. Rationale: Urine output helps to tell the nurse about fluid status. Rationale: Excess bleeding at the surgical site could require the patient to return to the operating room. Rationale: Malignant hyperthermia is a life-threatening condition and a priority. Rationale: Since the patient cannot verbalize pain, physiological signs need to be evaluated. Test Taking Tips: All answers may be correct in a multiple response item.

Which findings would a nurse most likely observe during phase II of the postoperative period? Select all that apply. Client responds to painful stimuli Normal oxygen saturation rate Blood pressure stabilization Client verbalizes pain 9/10 on 0-10 scale Client has minimal nausea

Normal oxygen saturation rate Blood pressure stabilization Client has minimal nausea

The client is prescribed patient-controlled analgesia pump for pain control. What important education is needed? To continue to push the button for the best pain control. Only the patient can push the button, no one else. The medication is delivered intramuscularly. NSAIDS are commonly delivered via this route.

Only the patient can push the button, no one else.

What is a common laboratory test done postoperatively? Select all that apply. PT/PTT BUN, creatinine Glucose Hematocrit/hemoglobin Liver function tests

PT/PTT BUN, creatinine Glucose Hematocrit/hemoglobin

The nurse is performing a postsurgical dressing assessment in the postanesthesia care unit. The dressing is noted in this image. Place the steps in order that the nurse needs to take. Document the event. Reinforce the dressing. Notify the provider. Empty and measure the drains.

Reinforce the dressing. Empty and measure the drains. Notify the provider. Document the event. Rationale: Bleeding is a concern and may require the patient to return to surgery. When a lot of blood is evident through the dressing, the nurse reinforces the dressing, empties and measures the drains, and notifies the provider. After orders are received, the event is documented. Test Taking Tips: Assess before contacting the provider.

During phase I of the postoperative period, the nurse notices that the client's surgical dressing contains an area of bright, red bleeding. Which action should the nurse take first? Assess the client's temperature. Notify the anesthesiologist. Reinforce the surgical dressing. Measure urinary output for the past hour.

Reinforce the surgical dressing.

The nurse in an outpatient surgical center is discharging a patient after surgery. What criteria must be met before discharge to home? The patient must verbalize that they are ready to go home. The patient has received and understands written discharge instructions and prescriptions. The patient has arranged for taxi cab for pick up. The patient is nauseated and cannot keep fluids down.

The patient has received and understands written discharge instructions and prescriptions. Rationale: A patient may be discharged go home when or he or she is voiding, walking, and drinking and eating normally; has no excess bleeding or drainage; and has received and understood written discharge instructions and prescriptions. Test Taking Tips: They must understand the discharge instructions.

During phase I of the postoperative period, the nurse will perform which priority assessments? Select all that apply. Capillary refill Auscultation of bowel sounds Vital signs Level of consciousness Airway patency

Vital signs Level of consciousness Airway patency

A patient has undergone general anesthesia during hip replacement surgery. The nurse should perform which priority assessment when the patient first arrives to the post-anesthesia care unit? Ability to ambulate safely Understanding of post-operative care Vital signs evaluation Check surgical wound

Vital signs evaluation

The nurse is managing pain for a patient in the postanesthesia care unit (PACU). Which actions are the priority? Assessing for an increase in heart rate, respirations, and blood pressure Using strong opioids for pain control Monitoring the depth of sleep Holding pain medications until the patient requests them

Assessing for an increase in heart rate, respirations, and blood pressure Rationale: Signs of pain include restlessness; sweating; dilation of pupils; increase in respiration, blood pressure, and heart rate; and piloerection. Test Taking Tips: Consider basic pain assessment.

Pain management nursing actions include: Assessing for restlessness Monitoring for decreases in HR, RR, and BP Holding pain medications until the patient is alert and oriented Administering prescribed pain medications Monitoring for facial grimacing or moaning Using a multimodal pharmacological therapy approach

Assessing for restlessness Administering prescribed pain medications Monitoring for facial grimacing or moaning Using a multimodal pharmacological therapy approach CORRECT. Pain management in the PACU includes a thorough nursing assessment and administration of prescribed analgesics. The nurse should assess for physiological symptoms associated with pain, including restlessness, facial grimacing, or moaning. He or she should also monitor for increases, not decreases, in HR, RR, and BP. The best approach to pain control is the use of multiple different types of pharmacological therapies.

Before a client is discharged home following surgery, which criteria must be met? Select all that apply. Client is accompanied by a responsible adult. Client is voiding normally. Client is eating and drinking normally. Surgical wound is clean and dry. Client verbalizes understanding of instructions.

Client is accompanied by a responsible adult. Client is voiding normally. Client is eating and drinking normally. Surgical wound is clean and dry. Client verbalizes understanding of instructions.

Immediately after surgery, the post-anesthesia care unit nurse receives a report from a member of the anesthesia care team. What information should this report contain? Select all that apply. General client report with significant history Pharmacological report including anesthesia and pain medications Procedural report Anesthetic report Discharge instruction

General client report with significant history Pharmacological report including anesthesia and pain medications Procedural report Anesthetic report

PACU phase I assessment includes: Monitoring heart rate Continuous airway monitoring Palpating a brachial pulse Assessing surgical site Monitoring blood pressure Continuous electrocardiogram monitoring

Monitoring heart rate Continuous airway monitoring Assessing surgical site Monitoring blood pressure Continuous electrocardiogram monitoring CORRECT. Nursing assessment in the PACU includes monitoring for a patent airway, assessing pulse oximetry, and monitoring blood pressure, heart rate, temperature, electrocardiogram monitor, and hemodynamic readings. Additional assessment should include neurological status, pain level, dressing assessment, condition of visible incisions, IV sites, and hydration status. Apical and peripheral pulses are palpated; however, the brachial pulse is not a noted peripheral pulse to assess when monitoring vital signs in this setting.